The role of pain neuroscience education in the management of chronic musculoskeletal pain:a physiotherapeutic approach

Thangamani Ramalingam Alagappan,Sudipta Roy

1Department of Physiotherapy,Sarvajanik College of Physiotherapy,Gujarat 395003,India. 2Clinical psychology,Psylens center,Gujarat 395003,India.

#Thangamani Ramalingam Alagappan and Sudipta Roy are the co-first authors of this paper.

Abstract

Keywords: pain neuroscience education; chronic musculoskeletal pain; bio-psychosocial assessment; physiotherapy practice

Introduction

Chronic pain is defined as persistent nociception that lasts longer than three months. Sometimes this pain can be the sole primary complaint and requires extra attention and supportive care from expert professional service providers. The new International Classification of Diseases (ICD) categorizes chronic pain disorders into 7 different groups, including chronic musculoskeletal pain (CMP) as one of the categories [1]. In the course of an illness or injury, CMP may occur.It is, however, more than just a symptom; it is a distinct medical illness with its own medical description and classification [2].

Chronic musculoskeletal pain

According to the new ICD-11 classification, which introduces a new conceptualization of the concept of chronic musculoskeletal pain, two types of chronic musculoskeletal pain were proposed in which the primary chronic musculoskeletal pain is a condition or state of an individual not occupied by a specific classified disease as a cause.Chronic secondary musculoskeletal pain is a symptom that arises from an underlying condition in another part of the body that leads to persistent nociception due to local or systemic causes.It can be caused by inflammation, structural abnormalities, or biomechanical implications of nervous system illnesses [1, 3]. CMP is widely distributed; approximately 13.5% to 47% of the general population suffers from chronic musculoskeletal discomfort. Moreover ,the fact that the prevalence appears to have grown in recent years as a result of many variables, such as changes in exposure to environmental and other risk factors, has surely increased. And the key difficulty at the moment is to do very concentrated research to identify these risk variables and create preventive solutions[4].

Pain neuro science education (PNE)

Poor advice from healthcare professionals, especially the physiotherapists solely biomedical, in their clinical practice regarding movement, radiological findings, exercises and the benefits of electro therapeutic modalities may affect the mood and cognitive psychological dimensions of chronic musculoskeletal pain patients,leading to incorrect conceptualization of pain perceptions and enhancing fear avoidance and pain catastrophizing behaviour [5-8].Pain neuroscience education (PNE) is a cognitive-behavioral intervention that informs pain neurophysiology in order to transform maladaptive sickness beliefs, alter maladaptive pain cognition, and re-conceptualize pain beliefs [9]. PNE comes in a variety of styles,ranging from rigorous one-on-one and small group tutorial sessions to three-hour big group lectures.Pain explanation is based on conceptual change and instructional design philosophy. It improves pain-related biological knowledge, reduces catastrophizing, and provides short-term pain and disability relief. It discusses the biological evidence that supports a biopsychosocial approach to rehabilitation[6].

Bio psychosocial assessment and PNE

Psychological, social, and environmental variables all have a role in the onset, management, and treatment of chronic pain. A biopsychosocial assessment paradigm can assist in identifying the distinct contributions of several levels of physical, cognitive,emotional, behavioural, and environmental aspects to the overall clinical evaluation and conceptualization [10, 11]. A biopsychosocial approach to assessing and treating chronic pain is both clinically and economically effective [12]. Prior to PNE, a complete biopsychosocial evaluation is advised in the therapeutic context to make the therapy session more engaging and patient-centered. Using this method, the practitioner may categorise patients and personalise the course of therapy, including PNE, to individual CMP patients[13].

Current evidences on pain neuroscience education

The current evidence strongly supports the use of PNE for chronic musculoskeletal (MSK) disorders in terms of pain modulation and improving patient knowledge of pain, enhancing movement and function by changing the perception of disability, reducing psychosocial factors, and further minimising healthcare utilisation MSK [14, 15]. The patients with chronic low back pain (CLBP) who received PNE underwent varying levels of reconceptualization, which appeared to be related to the perceived benefits, such as pain,disability and psychological distress reported by the patient [16, 17].According to the current evidence,a balanced approach that combines PNE with manual therapy and physical exercise can be seen as meeting or perhaps enhancing patient expectations and refreshing or sharpening body schema maps within the brain, leading to better outcomes in patients with chronic low back pain [18]. PNE education in isolation may have low benefit, but the combination of guided purposeful exercise with PNE may have a positive influence on therapeutic outcomes [19]. A home exercise program may provide value addition in improving back performance [20]. Therefore, these concepts should be viewed through an educational lens to create a patient needs-based model of physiotherapy care [21]. When compared to normal routine sessions, multidimensional physiotherapy, including PNE, was attainable and dramatically reduced pain in the short term [22].

Conclusion

The inclusion of feasible pain neuroscience education preceded by bio psychosocial assessment sessions against the regular advice based,clinician dominated and passive physiotherapy care for chronic musculoskeletal pain management practice may produce better clinical outcomes compared to standard sessions.