Since the Cartesian model and the understanding of ‘a nervous system’, there has been a dualistic approach of pain. Especially in Western societies, a strong focus on ‘the bodily part’ of pain still exists today, as many (Western) healthcare professionals are of the opinion that pain needs a bodily onset. In a recent study we found that 80% of healthy participants believe that for pain to occur an injury is a prerequisite (Booy et al. 2017). Therefore new paradigms on pain are warranted.
Melzack and Wall (1965) described the ‘gate control theory’ leading to our current knowledge about central sensitization processes in our nervous system. This process of central sensitization is acting as a continuous loop mechanism combined of bottom up and top down mechanisms. Beside nociceptive and neuropathic information, emotional factors are essential in this pain loop. Emotional factors can be linked to psychological diagnoses such a depression, fear or anxiety, inadequate perceptions, catastrophizing, post-traumatic stress disorders or sleep disorders, and also to processes where behavioral and social factors interfere, such as classical conditioning and social learning processes.
This has led, especially within the field op physical therapy, to a biopsychosocial view on persisting pain (Wijma et al. 2016). In the pain treatment, pain neuroscience education (PNE) is integrated and has shown to be of great value on different outcome (Louw et al. 2016). PNE is a cognitive approach focusing on changing illness perception of patients by explaining persisting pain from a neurophysiological standpoint (central sensitization) instead of a biomedical point of view (posture, crushed nerves, disc problems, muscle weakness etc.). This process is a solid neurophysiological explanation of persistent pain in which the explanation leads to reassurance of negative illness perceptions. PNE can lead to pain reduction as well as behavioral changes, although not in every patient (Malfliet et al. 2017).
Till now, in many situations, PNE is a treatment primarily focusing on cognitive changes, primarily perceptions about the cause of pain, treatment expectations, (physical) coping and understanding of pain. Following these cognitive changes, behavioral programs as graded exposure and/or graded activity can be applied. The next step in PNE is however to make a broader connection to the contributing factors of central sensitization. These contributing factors are mainly also other psychosocial factors. Pain neuroscience education therefore can be the Cartesian bridge connecting body and mind, aiming to also illuminate other contributing psychosocial factors.
In the assessment and treatment of persisting pain, a psychologists understanding of the neurophysiology of pain, is therefore essential. To reach the next level of pain neuroscience education we need more transdisciplinary collaboration where physical therapists and physicians collaborate with psychologists aiming at patient centred pain care and a more successful pain neuroscience education and pain treatment worldwide.
Paul van Wilgen
2017 Pain in Motion
References and further reading:
Booy S, de Blois W, Beetsma AJ, van der Noord R, Van Wilgen CP. Effects of an online paineducation tool on the knowledge and perceptions of pain in healthy volunteers and physical therapy students. Groningen 2017; unpublished data.
Wijma AJ, van Wilgen CP, Meeus M, Nijs J. Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education. Physiotherapy theory and practice. 2016;32(5):368-84
Louw A, Zimney, Puentedura EJ, Diener I, . The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother theory pract 2016;32(55);332-55.
Malfliet A, Van Oosterwijck J, Meeus M, Cagnie B, Danneels L, Dolphens M, Buyl R, Nijs J. Kinesiophobia and maladaptive coping strategies prevent improvements in pain catastrophizing following pain neuroscience education in fibromyalgia/chronic fatigue syndrome: An explorative study. Physiother. Theory Pract. DOI: 10.1080/09593985.2017.1331481