There's a new and untested trend in physical therapy. The idea is that educating back pain patients not to be sick and to ignore their symptoms will produce miraculous results. The problem is that nobody has a clue if this works. In fact, we're just getting our first high-level trial results of this idea and as a new study shows, to no surprise, this idea wasn't effective.
What Is Pain Neuroscience Education?
Pain neuroscience education (PNE) is a theory in physical therapy circles that the pain we think we feel is really just hyperexcitable nerves, so pain really is, for the most part, all in our head (or in our perception of overactive nerves). Further, how we interpret pain signals is what determines pain, so if we conceptualize them as a sign of worse things to come, and our medical providers feed into this gloomy narrative, we are, in essence, creating our pain. The flip side to this PNE theory is if patients are educated that their back pain, for example, isn’t so bad, this will make it really not so bad.
So that back pain you woke up with this morning isn’t really back pain; you just think it is because your doctor told you that you have an irritated nerve (or some other disease or condition) in your back. All you have to do is apply the PNE model and ignore those pain signals, and, somehow, this will soothe those hyperexcitable nerves and your pain will just go away.
This, in a nutshell, is pain neuroscience education, and as mentioned earlier, we have very little research that any of this is effective. Let’s take a look at the new study.
PNE vs. Placebo on Low Back Pain
The purpose of the new study was to determine the efficacy of using intensive patient education to address low back pain. Patients were randomized into two groups: a patient education group and a placebo group. The researchers then compared how pain responded to patient education and to placebo (or no education in this case). Patient education included providing methods for patients to manage their own pain (e.g., being active, pacing, etc.) and providing detailed information on the biological, psychological, and social (biopsychosocial) aspects that contribute to pain. The placebo group participated in listening with no advice or educational methods provided.
The result? Intensive patient education was no better than placebo at reducing the intensity of low back pain. In other words, patient education did nothing to relieve pain! Nothing! In addition to the same intensity level of pain, the study also found that the attitudes of those in the patient education group after one week had changed and they were less likely to believe their intense pain was due to any serious back condition. So while the education sessions didn’t reduce their pain, they did reduce their concern about it. Understandably, this is a very dangerous attitude to have toward intense low back pain. Pain is a warning sign that shouldn’t be ignored.
This confirms what I’ve been saying right here on this blog over the past few years. PNE does not work, and the reason it doesn’t work is because pain is very real!
More on PNE and the Crazy Biopsychosocialists
Let’s review some of the prior issues I’ve raised concerning PNE and the most recent crazy biopsychosocialist re-emergence:
- PNE isn’t a fresh new approach to pain; PNE is failed chronic-pain programs from two to three decades ago that they’ve dug back up and brushed the dust off of.
- Pain has been shown to physically alter brain function, not just its psychological reaction to it, which should thoroughly discredit the PNE theory. In addition, back pain in particular has been associated with atrophy (shrinkage) in the brain.
- According to the physical therapists’ PNE model, I should ignore my own back pain due to a chronic S1 nerve issue, and treating it with orthobiologics to minimize wear and tear and enhance stability keeps me focused on the pain and makes it worse.
- The biopsychosocialists have re-emerged and are attempting to talk patients out of their pain; one example is the SI joint in the low back, which they seem to consider “bombproof” (or too tough to injure).
The upshot? Hopefully, this study takes some of the steam out of the PNE fad. When applied with common sense to those few patients who do have issues with functioning because they perseverate on their pain, that makes sense. However, when therapists try to apply it to every patient with back pain, as this study shows, that's junk science. So let's all get the memo, pain is real and we need to focus on how best to diagnose what's wrong rather than talking patients out of their pain.