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Pain Neuroscience Education (Beyond Pain and Fatigue Episode Recap)

Soph Shephard

This week on Beyond Pain and Fatigue, Soph and Ollie got stuck into a conversation about Pain Neuroscience Education (PNE) - including what it actually is, the benefits, as well as some of the potential challenges or criticisms of applying it in practice.

What is PNE?

PNE, or Pain Neuroscience Education, is an educational intervention focused on enhancing someone’s understanding of what pain is and how it works - the ‘nuts and bolts’ of pain itself. The most well known form of PNE is the Explain Pain model, which has been widely adopted by clinicians and used as the basis for many educational interventions. PNE uses modern pain science to help expand the focus from a purely tissue-based explanation of pain to one that includes biological, psychological, and social factors, where pain is explained as a protective perception or output of the nervous system in response to perceived threat to the body. Persistent pain is often explained as the pain system becoming overprotective, where pain may often not relate clearly to ongoing tissue injury or damage.

Key features of PNE discussed in the episode include:

  • Core concepts and models underpinning PNE (e.g. the Mature Organism Model of Pain)

  • Emphasizing the distinction between tissue damage and the perception of pain - while they can go hand in hand, they often aren’t as closely tied as we might think.

  • Why PNE is often needed as part of a interdisciplinary holistic approach to pain management

What Evidence Supports the Efficacy of PNE?

Soph and Ollie discuss some of the research on PNE as an isolated intervention, which has been shown to help:

  • Improve pain knowledge: PNE can helps patients understand their condition, which may reduce fear and uncertainty and open the door to additional biopsychosocial pain management approaches

  • Enhance self-efficacy and reduce pain catastrophising: PNE may help reframe and dethreaten pain, providing a greater sense of control and greater optimism for future outcomes

However, PNE has not necessarily been shown to make substantial direct improvement on pain and disability outcomes as a standalone intervention, and PNE is intended to be part of a broader management approach coupled with practical pain management strategies tailored to the person.

What Are the Potential Shortcomings or Criticisms of PNE?

While PNE has many benefits, Sophie and Ollie acknowledge its potential pitfalls, particularly when not applied well or when clinicians may not have a full understanding of the concepts underpinning PNE. Many of these are not an issue with PNE itself - rather, in how concepts may be applied or misunderstood:

  • Reductionism within PNE: Overemphasizing psychosocial factors at the expense of tissue-based issues can leave patients feeling invalidated or misunderstood. Ignoring the possibility of underlying contributing conditions or tissue based factors can limit opportunities for effective management, and conditions like hypermobility disorders can easily be missed if all people with chronic pain are put in the same bucket.

  • Neurocentric bias: Clinicians may unintentionally have too narrow a focus on the nervous system’s role in pain, which risks neglecting other biological contributors, including tissue injury or systemic factors that may require specific management.

  • Lack of tailored application: Some clinicians may approach PNE as a "one-size-fits-all" solution, leading to ineffective or overly generic educational interventions. Education is a skill like any other that needs development, and Explain Pain deliberately includes educational theory as a way of tailoring education more effectively.

  • Educational limitations: Many healthcare providers receive minimal training in pain science, leading to superficial or incomplete understanding of pain that limits how effectively they can adapt education to fit the patient’s unique circumstances.

Soph and Ollie both highlight the importance of integrating PNE into a broader clinical reasoning framework that considers both tissue-based and broader contributors to a particular person’s pain, regardless of whether pain is acute or chronic. Proper assessment and nuanced integration of PNE is essential to avoid unintended harms and missing helpful therapeutic opportunities. Interventions like manual therapy are still coherent within a modern understanding of pain - however, we might explain or understand the mechanisms behind these a bit differently in light of new evidence.

What Are the Key Concepts to Take Away?

  • All pain is complex: It’s influenced by many factors beyond just tissue injury, including other body systems, the environment, context, beliefs and understandings, and past experiences. Taking a big picture view of all possible contributing factors optimises the opportunities to support recovery.

  • Education is important - but this doesn’t mean we ‘explain pain’ at everyone: Effective PNE relies on good educational practices and is tailored to the individual’s context and goals - there’s no one size fits all and education should be carefully reasoned and implemented alongside other movement-based and other active management approaches.

  • Nuance is critical: PNE and a modern understanding of pain should integrate, not replace, evidence informed anatomical and biomedical considerations. A balanced approach ensures that all aspects of a patient’s experience are addressed.

  • Clinician skill is key: Delivering PNE effectively requires training and an up to date understanding of pain, critical thinking, and a commitment to understanding each patient’s unique experience and context.

Resources and Links

Papers

  • Louw, A., Sluka, K. A., Nijs, J., Courtney, C. A., & Zimney, K. (2021). Revisiting the provision of pain neuroscience education: an adjunct intervention for patients but a primary focus of clinician education. Journal of Orthopaedic &Amp; Sports Physical Therapy, 51(2), 57-59. https://doi.org/10.2519/jospt.2021.9804

  • Louw, A., Schuemann, T., Zimney, K., & Puentedura, E. J. (2024). Pain neuroscience education for acute pain. International Journal of Sports Physical Therapy, 19(6). https://doi.org/10.26603/001c.118179

  • Moseley, G. L., & Butler, D. S. (2015). Fifteen years of explaining pain: the past, present, and future. The Journal of Pain, 16(9), 807-813.

  • Lin, I. B., O'Sullivan, P. B., Coffin, J. A., Mak, D. B., Toussaint, S., & Straker, L. M. (2013). Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians. BMJ open, 3(4), e002654.

Websites/Links

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