James Watson, a PhD student in Teeside University, NHS physiotherapist and PPA member, discusses his first paper as a lead author "Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis" which was recently published in The Journal of Pain. You can find him on Twitter @ThePainGuide
The research and methods
Chronic pain is a leading cause of disability worldwide (Goldberg and McGee, 2011). Pain neuroscience education (PNE) is a treatment used in the management of chronic pain that aims to change an individual’s understanding of their pain to be less threatening which may help them in their rehabilitation (Moseley, 2007). The most contemporary systematic review on heterogeneous chronic musculoskeletal pain concluded PNE is effective for improving pain, function, psychosocial factors, pain knowledge, movement and healthcare usage (Louw et al. 2016). This is partly supported by two recently published meta-analysis on people with chronic low back pain where PNE was concluded to be effective for improving pain and disability, but not for psychosocial factors (Wood and Hendrick, 2018; Tegner et al. 2018). However, to date all PNE reviews have several methodological limitations. Furthermore, no review has conducted a meta-analysis on PNE in a heterogeneous sample of individuals with chronic pain or undertaken a synthesis of qualitative studies on PNE. To address these gaps in the literature we undertook a mixed-methods systematic review and meta-analysis to investigate the effectiveness and experiences of PNE in adults with chronic musculoskeletal pain.
Twelve randomised controlled trials (RCTs) (n = 755 participants) and four qualitative studies (n = 50 participants) met the inclusion criteria. There were enough studies (≥5) who measured pain, disability, pain catastrophising and kinesiophobia for these outcomes to be pooled in a meta-analysis. Outcomes were assessed in the short (<3 months), medium (≥3-6 months) and long (≥12 months) term. There were insufficient studies reporting outcomes in the long term to pool data. We set the minimal clinically important difference as 10% in line with recent NICE low back pain guidelines. Table 1 is the modified summary of findings table which outlines the quantitative findings of the meta-analysis.
The findings and discussion
Narrative of quantitative findings
PNE group ~6/100 better than control
PNE may result in little to no difference in pain score in the short term.
PNE group ~6/100 better than control
The evidence is very uncertain about the effect of PNE on pain score in the medium term.
PNE group ~4/100 better than control
PNE probably results in a small possibly unimportant effect in disability score in the short term.
PNE group ~8/100 better than control
PNE probably results in a small possibly unimportant effect in disability score in the medium term.
Pain catastrophising ST
PNE group ~3/52 better than control
PNE probably results in a small possibly unimportant effect in pain catastrophising score in the short term
Pain catastrophising MT
PNE group ~5.3/52 better than control
PNE probably reduces pain catastrophising score in the medium term slightly.
PNE group ~14/100 better than control
PNE probably reduces kinesiophobia score in the short term slightly.
Table 1 Legend: Summary of findings table for meta-analysis of PNE versus control for adults with chronic musculoskeletal pain. ST, short-term. MT, medium term. RCT, randomised controlled trial.
Meta-regressions revealed clinically relevant greater effects for pain (short and medium term), disability (medium term), and pain catastrophizing (short and medium term) when PNE was combined with another intervention compared with PNE delivered in isolation. These findings align with previous meta-analysis (Wood and Hendrick 2018; Yun, 2017) and narrative reviews (Moseley and Butler, 2015; Louw et al 2016). We also found greater effects for disability and pain catastrophising in the medium term when longer durations of PNE were delivered however the effect was small and of questionable clinical relevance.
Two synthesised findings were generated from 23 qualitative study findings extracted from 4 qualitative studies. Both synthesised findings were rated on ConQual as ‘low’. The synthesised findings below have been coloured to highlight the different components.
- Synthesised finding 1:
- Synthesised finding 2:
It was difficult to verify from the information available if the components included within the synthesised findings were included within the RCTs included in this review. Only two components were clearly identified within the RCTs. The skill of the HCP delivering PNE was mentioned in 6 RCTs, and monitoring progress towards reconceptualisation was mentioned in 4 RCTs. I recommend that future quantitative studies are needed to investigate if using the components outlined in the two synthesised findings improve clinical outcomes.
Synthesised finding 2 suggests that when individuals reconceptualise their pain it can improve their ability to cope. Quantitatively we found PNE to produce reductions in kinesiophobia and pain catastrophising which suggest that these individuals may feel less threatened by their pain. This less threatened state may itself be an easier place to be in and thus cope. It may also shift priority from pain control (leading to avoidance, deconditioning and negative affect) towards priority to valued life goals (leading to reconditioning and positive affect) as illustrated by the fear-avoidance model (Vlaeyen, Crombez and Linton, 2016). They may also be more open to other interventions like exercise which previously were avoided due to fear of damage. Furthermore, learning principles of graded exposure is commonly included within PNE and this may show people how to engage in their valued activities whilst avoiding the boom-bust and fear-avoidance cycles. As individuals become better at pacing and graded exposure, they may engage more in valued life goals/exercise and thus their function may improve.
Top tips for clinical practice
- Curiosity - Cultivate your curiosity about the individual’s story, listening to understand, not simply to reply.
- The powerful pause - When you feel like you want to speak, pause for five seconds. Give space for the individual to make sense of their own story.
- Whole context - See the whole person, in their context. (Checkout figure 1 from O’Sullivan et al. (2018) for a framework here)
- Relevance – Reflect on how you can make your language, questions, explanations, advice and exercises relevant to the individual.
- Checking in – Check your shared understanding of the take away message from the consultation by asking “Describe how you will explain your consultation findings to your family, or significant other when you get home”.
You can find the full text article HERE.
- Goldberg, D.S. and McGee, S.J., 2011. Pain as a global public health priority. BMC public health, 11(1), p.770.
- Louw, A., Zimney, K., Puentedura, E.J. and Diener, I., 2016. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physiotherapy theory and practice, 32(5), pp.332-355.
- Moseley, G.L., 2007. Reconceptualising pain according to modern pain science. Physical therapy reviews, 12(3), pp.169-178.
- Vlaeyen JW, Crombez G, Linton SJ, 2016. The fear-avoidance model of pain. Pain 157:1588-1589.
- Wood, L. and Hendrick, P.A., 2019. A systematic review and meta‐analysis of pain neuroscience education for chronic low back pain: Short‐and long‐term outcomes of pain and disability. European Journal of Pain, 23(2), pp.234-249.
Additional references can be found in the reference section of the paper here.