Many of you know that I am a current Fellow-in-Training in the Bellin College Orthopedic Manual Therapy program. Over the past 8 weeks, I started the program with the lumbopelvic management course and really got into the weeds on current best practice of patients with low back pain. I was really excited to tackle this topic of pain neuroscience education for a lot of reasons. This blog post is literally a copy-paste from my discussion board from the course. The 2 articles in the prompt are referenced here:
Nijs J, Meeus M, Cagnie B, Roussel NA, Dolphens M, Van Oosterwijck J, Danneels L. A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. Phys Ther. 2014 May;94(5):730-8. doi: 10.2522/ptj.20130258. Epub 2014 Jan 30. PMID: 24481595.
Brumagne S, Diers M, Danneels L, Moseley GL, Hodges PW. Neuroplasticity of Sensorimotor Control in Low Back Pain. J Orthop Sports Phys Ther. 2019 Jun;49(6):402-414. doi: 10.2519/jospt.2019.8489. PMID: 31151373
PROMPT: Describe one take home and one challenge in clinical practice after reading and reflecting on the Nijs & Brumagne articles. How will you marry the idea behind lumbar “stabilization” within the modern approach described by Nijs Brumagne?Be sure to tie in the results from the Saragiotto et al article.
How will you marry lumbar stab with modern PNE approach: For individuals with chronic pain, I do some PNE and MCE (motor control exercise), but at this point after playing with both for a long time, I have found that one of the most effective strategies for individuals with complex chronic LBP is to really dive into lifestyle modification. I regularly talk to my patients about stress, sleep, & nutrition, and ANY exercise that they enjoy and is sustainable. The Saragiotto study is just one study that found no significant difference between MCE vs. “other” exercise, which is why I just focus on getting the patient to do anything that I know they will most likely stick with.
My reasoning for this approach: we all know chronic pain is extremely complex and multi-factorial. It takes a village, literally! So, starting with a holistic health approach combined with PNE, at least in my experience, seems to be the thing that most patients respond the best to.
1 take home: Education on pain processing must be included (somehow, some way), preferably before any other exercise intervention, in individuals with chronic pain.
There is insurmountable evidence that individuals with chronic pain have altered central processing. Many of our patients want to know where their pain is coming from. I have found with chronic pain patients, that until the patient is satisfied with the “origin” of pain, they don’t respond well to exercise interventions. While I know and understand PNE very well, and have some success with it from time to time, I feel I have failed to implement it in an effective and clinically sustainable manner. It is my belief that comprehensive, multidisciplinary pain clinics with specially trained practitioners should lead the charge on this. I’ll elaborate below.
1 challenge: Implementing this treatment plan as recommended by Nijs et al, has proven to be exceptionally difficult in our current healthcare landscape. I’ll report on my top 3 barriers:
Time/Insurance
Clinical Competency
Multidisciplinary Support
I will start by saying that I am very familiar with cortical changes of the “chronically pained brain” and PNE, dating back to my final year of PT school in 2013-14. In fact, my final clinical inservice was on the multidisc treatment of individuals with chronic pain. Landstuhl Regional Medical Center (where I did my final clinical) had an intensive 5day/week x3 weeks chronic pain program for recovering servicemembers to get them back in the Middle East as soon as reasonably possible. It was pretty impressive - group PNE sessions, intense time-contingent HIIT exercise, hot yoga, group and individual CBT, acupuncture and guided self massage and meditation. Then, my first boss/clinical mentor out of PT school completed the ISPI residency and is/was a pain specialist. (Sup, Pete!) Back then, I felt that PNE was a godsend for anyone with chronic pain. I used the concepts with nearly every patient, and went “intensive” on the ones that I felt were really affected by central sensitization. Over time, my opinions on the effectiveness of the strategies have not changed, however, my opinion on the realistic application of this has.
Barrier #1: Time/Insurance
I’ve practiced in a lot of outpt settings (Army traditional clinic, Army primary care, Outpt cancer center, outpt private practice and mobile cash based). The schedule templates set for a typical outpt therapist, in my experience at least, do not allow for this type of treatment to be carried out in an efficient or effective manner. The therapist must have a VERY good understanding of these concepts, have the communication and motivational interviewing skills to implement it, and then be able to somehow manage that in a 30-45 min session (60 if you’re lucky!). If the answer to that is just to expand on the # of sessions, then your chance at following through with the whole program exponentially decreases - (reasons: patient’s don’t have time, you don’t have space on your schedule, patient’s copay is too high or has high deductible plan, patient loses patience and gives up, the list goes on...). Finally, insurance companies are WAY behind the curve as far as what a PT does. They might be flagged (and confused) depending on how you code for this. Yet another reason why I went cash-based.
Barrier #2: Clinical Competence
Appropriateness/Patient Selection: This one is the most concerning to me. As a new grad, I definitely looked at some imaging findings that were clinically relevant and that I should have paid closer attention to and dismissed them as “incidental findings”, because that’s what I believed to be true at the time. This was my ignorant bias after soaking myself in the PNE world; I was constantly saying “hurt does not equal harm” and “imaging isn’t necessary or isn’t related”. I was overconfident and not skilled enough to do a full systems review. What I learned over time is that it is extremely important to be absolutely sure that nothing else is at play before going down this road with the patient, and I do stand by that today.
Grit: Being a PT is a ‘tough as nails’ job: it’s busy, exhausting, and doesn’t pay enough. Working with/educating patients with chronic pain (especially in an environment where hardly any other practitioner is going to understand your approach) takes all of that to another level and I think it really takes a special person.
Entry-Level Skill?: Are we considering PNE and all that comes along with it to be an entry-level skill? I don’t think it should be. Understanding the concepts is one thing, but being SURE that the patient has had a complete work-up and that nothing else is at play is so imperative and I don’t know that every new grad would do this. This is me saying this knowing that many DPT programs are dropping back down to 2 years to help students save money. How can you possibly fit this into that curriculum? As a final note, I don’t think the science is firm enough yet for me to go all-in on the pain concepts. I think there is still a lot that we don’t know about autoimmune and neuroendocrine conditions and how they influence pain mechanisms.
Barrier #3: Multidisciplinary Support
My clinical at LRMC showed me that this PNE approach can be done WELL with outstanding multidisc support, but it is imperative to have a team that is all on the same page with the foundational concepts. Outside of that clinic in Germany, I really haven’t seen that happen. The closest I came to it was at the OU cancer center - tremendous support and funding of multidisc teamwork, but even there, the vast majority of healthcare professionals had no idea what PNE was. How can you be successful as a sole professional? I just think it is so incredibly essential to bring a patient through this process with multidisc support, especially as nearly all of these interventions are neurocognitive in nature: Brumagne’s extinction training, sensory discrimination training and cognitive training (1), Moseley’s explain pain and Louw’s TNE. This is a multidisc study that brought a whole cohort of individuals through these cognitive restructuring concepts, led by a team, but all the CBT stuff was led by a psychotherapist(4). For me, it just begs the question - are the educational strategies really for a PT to be implementing? Or would a patient be better off receiving the education from a neuropsychologist and then coming to us for the exercise/functional components, with us reiterating the concepts throughout the treatment? My opinion is this - it has to be a team approach. And unfortunately right now, most healthcare systems don’t have the time, staff or resources to erect these types of programs.
Can it change in the future? Absolutely. And I feel confident that we are headed in the right direction with time. But right now, I have found that that “PNE lite”* is the most effective model for my patients with chronic pain.
* ”PNE lite” Definition: Motivational interviewing, a light sprinkling of foundational PNE concepts, lifestyle modification encouragement (pick 1, not all) and sustainable exercise. (disclaimer: this generally fails when the other healthcare providers on the patient’s team are unaware of how chronic pain works).
References:
Brumagne S, Diers M, Danneels L, Moseley GL, Hodges PW. Neuroplasticity of Sensorimotor Control in Low Back Pain. J Orthop Sports Phys Ther. 2019 Jun;49(6):402-414. doi: 10.2519/jospt.2019.8489. PMID: 31151373.
Znidarsic J, Kirksey KN, Dombrowski SM, Tang A, Lopez R, Blonsky H, Todorov I, Schneeberger D, Doyle J, Libertini L, Jamie S, Segall T, Bang A, Barringer K, Judi B, Ehrman JP, Roizen MF, Golubić M. "Living Well with Chronic Pain": Integrative Pain Management via Shared Medical Appointments. Pain Med. 2021 Feb 4;22(1):181-190. doi: 10.1093/pm/pnaa418. PMID: 33543263; PMCID: PMC7861469