Pelvic Health Symposium

Pain Neuroscience Education:

Foundations for Treatment

Tim Zepelak, PT, DPT, OCS, TPS, CSCS, CMP, RYTPhysical Therapist at Swedish Pain Services

Board Certified Orthopedic Specialist

Certified Therapeutic Pain Specialist

September 18, 2020

Pain Classification1

1. Adapted from Stanos S, et al. Postgrad Med 2016;128(5):502-515.

2. https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=6862

Predominantly Neuropathic• Postherpetic neuralgia• Painful diabetic peripheral neuropathy• Lumbar or cervical radiculopathy• Stenosis

• Tumor-related neuropathy• Chemotherapy-induced neuropathy• Small fiber neuropathy• Persistent postoperative pain

• Multiple sclerosis pain• Post-stroke pain• Pain associated with spinal

cord injury

Predominantly Nociceptive• Osteoarthritis• Rheumatoid arthritis• Tendonitis, bursitis• Ankylosing spondylitis• Gout• Neck and back pain with structural

pathology• Tumor-related nociceptive pain• Sickle-cell disease• Inflammatory bowel disease

Predominantly Nociplastic2• Fibromyalgia• Irritable bowel syndrome• Tension-type pain• Interstitial cystitis/pelvic pain syndrome• Tempo-mandibular join disorder• Chronic fatigue syndrome• Restless leg syndrome• Neck and back pain without structural pathologyMixed pain conditions are

frequently associated with multiple pain pathophysiologies

once pain becomes chronic

Neuropathic Pain

Nociplastic Pain

Nociceptive Pain

• Identify how Pain Neuroscience Education (PNE) helps patients

reframe their pain experience to reduce fear, catastrophizing, and

discomfort while improving overall function.

• Recognize how patient knowledge can be a catalyst for treatment

• Explain the basics of pain science to patients through

understandable stories and metaphors that support positive

therapeutic outcomes.

Objectives

Why are we teaching PNE?

4

• Research has shown many benefits to

teaching patients how pain works in

their body

• Knowledge changes their thoughts,

beliefs, attitudes, and behaviors

around pain

• We do this through translating complex

neurophysiology into easy to

understand stories and metaphors

• End result: pain becomes

reconceptualized

Photo by Jeremy Bishop on Unsplash

Current evidence supports the use of pain education in the treatment of chronic pain

Pain Neuroscience Education has been shown to:

• Reduce pain***

• Improve function

• Lower disability

• Reduce fear, avoidance, and catastrophizing

• Reduce perceived threat and harm beliefs associated with pain

• Enhance movement

• Reduce healthcare utilization

• Improve self efficacy

Why are we teaching PNE?

Why are we teaching PNE?

• 43 year old female

• Ongoing chronic Lower back, hip, and pelvic pain for several years—typical pattern in our clinic

• History of multiple lower back injuries as young athlete

• Psychological evaluation reveals past trauma

• Prior hysterectomy, L 5/S1 discectomy

• Pain is limiting functional activities, sleep, sex life, and work as a community service director

Case Study

• Presents to Pain Services 4 week Functional Restoration Program

• Goal is to educate with independent self management strategies

• Interdisciplinary approach

• Coordinate care with pelvic health specialists pre/post

• Initial evaluation reveals several nociceptive contributors in addition to

general nociplastic (central sensitization) changes and kinesiophobia

• Begin with Pain Neuroscience Education to set stage for treatment,

ease fears about movement and tissue damage

Case Study

• If you were walking

along and stepped

on a nail would you

feel it?

• Of course you

would!

• How would you

know?

Louw/ISPI with permission

• Body has a living breathing alarm

system

• 400 individual nerves

• 45 miles of nerves

• Forming a complex superhighway of

communication

• At all times there is a little bit of

electricity going through them

• Activity can go up or down

Normally threat removed,

tissues heal, danger signal

ramps down

Louw/ISPI with permission

• 1:4 people the sensitivity

stays ramped up

• Shifts perspective from

“broken anatomy” to “a

sensitive alarm system”

• “Extra-protective nervous

system”

• Thinks it is doing a really

good job protecting you

from possible danger!

• Pain may not directly

equate to level of tissue

health or damage

Louw et al 2017

Louw/ISPI with permission

14

PNE Story #2: “Nosy Neighbors”

(Why Is My Pain Spreading)?

• Have you ever wondered why you now

have hip pain, pelvic pain, and mid back

pain when years ago it was just low back

pain?

• Sometimes the longer you have been in

pain other parts of your body start to “wake

up” from the sound of the “pain alarm”

going off in your lower back

• Let’s look at a story to illustrateColumbustelegram.com

• Home alarm goes off at 11 PM,

what do your neighbors do?

– Wake up, check on you

• Alarm turns off: all is well

everyone goes back to sleep

• But if alarm keeps going off--

you start to have irritated

neighbors!

• In this case: pelvis, hips start

“getting grumpy” and “talking”

• Feeling pain in surrounding

areas does not always equal a

separate tissue issue or

problem

Louw/ISPI with permission

Nosy Neighbor Story

• We all have pain relieving compounds in our brain

• Called opiates: – Endorphins, dynorphins,

enkephalins, seratonin, dopamine, and many more...

• Natural occuring and similar to morphine

PNE Story #3 “Medicine Cabinet in Your Brain”

Image: Sarah Williams@army physio

• When in chronic pain these compounds “dry up”

• Your brain does this to purposefully allow in more information from the tissues about potential danger.

• But we can produce more of them

• Turning on this “faucet” of pain medicine in your brain helps block incoming “danger signals”

• How do we do it? Exercise!

• 15-30 minutes of daily aerobic exercise within THR

Medicine Cabinet in Your Brain

For Chronic Pain:• Gowans, deHueck et al., 2001

• Sim and Adams, 2002

• Goldenberg, Burckhardt et al., 2004

• Bonifazi, Suman et al., 2006

• Busch, Barber et al., 2007

• Rooks, Gautam et al., 2007

• Carville, Arendt-Nielsen et al., 2008

Post-exercise analgesia: • Koltyn, Garvin et al., 1996

• Hoffman, Shepanski et al., 2004, 2005

• Chatzitheodorou, Kabitsis et al, 2007

• Hurkmans, van der Giesen et al., 2009

• Sharma, Ryals et al., 2010

Evidence Supporting Aerobic Exercise for Chronic Pain

• Peripheral Sensitization and ion channels

• Effects of nerve pressure gradients

• Not all pain is the same

• Bioplasticity and Mechano-transduction

• Brain’s role in pain, central sensitization

• Effects of pain on brain’s other functions

• Homunculus and its role in pain

• Stress mechanisms in pain

• Role of emotions in pain

• Descending inhibition and facilitation

• “Nerve sensors”

• “Kinks in the Garden Hose”

• “Pain variance based on context stories”

• “Building a callus through exercise”

• “Brain as CEO” and “Pain Signatures”

• “Brain in a pain meeting”

• “Body maps in the brain”

• “Mountain Lion story”

• “Water cup story”

• “Spinal cord pain volume turned up and

down”

More Pain Stories and Metaphors

Neuroscience mechanism Patient story

• Of course Pain Neuroscience Education (PNE) is not a stand-alone

treatment

• We call this PNE +…

• Aerobic exercise, stretching, strengthening, taping, manual therapy,

dry needling, meditation, diaphragmatic breathing, progressive

muscle relaxation, autogenic training, proper diet, sleep hygiene,

medications, procedures, psychology, etc.

PNE +

Patient Resources

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Clinician Resources

Thank You!

Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther.

2017;25(3):160-168.

Louw A, Puentedura EJ, Diener I, Zimney KJ, Cox T. Pain neuroscience education: Which pain neuroscience education metaphor worked

best?. S Afr J Physiother. 2019;75(1):1329. Published 2019 Aug 13.

Louw A, Zimney K, O'Hotto C, Hilton S. The clinical application of teaching people about pain. Physiother Theory Pract. 2016;32(5):385-395.

Louw, A. & Puentedura, E. J. (2013). Therapeutic Neuroscience Education, Vol. 1. Minneapolis, MN: OPTP

Louw, A. et al. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy

Theory and Practice 32 (2016): 332 - 355.

Malfliet A, Kregel J, Coppieters I, et al. Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on

Chronic Spinal Pain: A Randomized Clinical Trial [published correction appears in JAMA Neurol. 2019 Mar 1;76(3):373]. JAMA Neurol.

2018;75(7):808-817

References

Moseley, G. Reconceptualising pain according to modern pain science. Physical Therapy Reviews 12 (2007): 169 - 178.

Moseley GL, Butler DS. Fifteen Years of Explaining Pain: The Past, Present, and Future. J Pain. 2015;16(9):807-813.

Rondon-Ramos A, Martinez-Calderon J, Diaz-Cerrillo JL, et al. Pain Neuroscience Education Plus Usual Care Is More Effective

Than Usual Care Alone to Improve Self-Efficacy Beliefs in People with Chronic Musculoskeletal Pain: A Non-Randomized Controlled

Trial. J Clin Med. 2020;9(7):2195. Published 2020 Jul 11.

Saracoglu I, Arik MI, Afsar E, Gokpinar HH. The effectiveness of pain neuroscience education combined with manual therapy and

home exercise for chronic low back pain: A single-blind randomized controlled trial [published online ahead of print, 2020 Aug

19]. Physiother Theory Pract. 2020;1-11.

References