Welcome back to the Healing Pain Podcast with Dr. Cormac Ryan
In this episode, we are exploring the outcomes of the Pain Neuroscience Education and what to do about the partial reconceptualization of pain. If you’re not familiar with the term reconceptualization of pain, it can be defined by three key concepts. The first is that the pain does not provide a measure of the state of tissues. The second is that pain is modulated by many factors across somatic, psychological and social domains. Finally, the relationship between pain and tissue becomes less predictable as pain persists. Pain Neuroscience Education, Pain Neurophysiology Education, explain the pain. Pain education is all different types of terms that relate to educational interventions for patients with chronic pain.
Pain Neuroscience Education assists patients to reconceptualize their pain away from the biomedical model towards a more biopsychosocial understanding by explaining pain biology. It’s what we do here on the show. To help us understand the partial reconceptualization of pain is Dr. Cormac Ryan. He’s a Professor of Clinical Rehabilitation at Teesside University in the United Kingdom. He has earned both a Masters in Physiotherapy and a PhD, where he explored the relationship between physical activity and chronic lower back pain. Ryan has published over 60 peer-reviewed journal articles and it has obtained over $1 million in research funding.
His research interests are primarily in the era of chronic pain and its impact on patients and developing new interventions to help patients better manage their condition. He has a particular interest in the area of Pain Neuroscience Education as an intervention for patients with chronic pain. You will learn what we mean by the partial reconceptualization of pain. Is a partial reconceptualization a success or a failure? What things we can do to maximize reconceptualization and where the research needs to go next with regards to Pain Neuroscience Education? Dr.
Ryan has also provided an interactive diagram and guide to explain the pain to patients with chronic musculoskeletal pain. Whether you’re a practitioner or you’re someone who’s looking to overcome pain, this is something you’re going to want to download and read through thoroughly. To download this diagram, all you have to do is text the word, 164Download, to the number 44222 or you can open up a new browser on your computer and type in the URL, www.IntegrativePainScienceInstitute.com/164download. I enjoyed this episode and I know you’re going to enjoy it as much as I did. Let’s get ready and let’s meet Dr. Cormac Ryan.
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Is Partial Reconceptualization Of Pain A Success Or A Failure? With Dr. Cormac Ryan
Cormac, thanks for joining us for this episode. It’s great to have you here.
Joe, it is great to be here.
I’ve been wanting to have you on for a while because the topic of pain neuroscience education explaining pain. Pain biology education is one that’s on the tip of everyone’s tongue, especially in the worlds of physiotherapy, but it spills over into other professions as well. As people can tell from the topic or the headline of this episode, we’re talking about the reconceptualization of pain, which is a very important topic and a great place for us to start. Can you explain in essence to us what the reconceptualization of pain means for people? Can you define that and why is it important in the treatment of pain?
Pain reconceptualization is something that was coined from my perspective by Moseley in 2007. He put forward four pillars of what pain reconceptualization should include. They were things like moving away from seeing pain as an accurate marker of tissue damage toward seeing it as an indicator of the sensory system, feeling that something’s not quite right. Moving away from this idea that the issue is in the tissues that its damage related. Other things like appreciating that when we look at acute pain and the classic public understanding of the relationship between tissue injury and pain that the association between pain and injury, it becomes much less clear as we move into chronicity and chronic pain.
Those were some of the components of pain reconceptualization that mostly put forward is a key component of the mechanism of effect by which something like Pain Neuroscience Education might work. That by helping patients to reconceptualize, by helping them to understand the biology involved, that in turn may help with classic clinical outcomes like pain function and quality of life. We’ve looked at this issue of pain reconceptualization. How do you investigate it? How you do potentially measure and indeed does it change? Can you change it? If you do, does that appear to be the mechanism of effect or not? We’ve explored these things by in all means have we answered these questions.
You have two key papers so far on this topic of the Partial Reconceptualization of Pain. One is in 2018 in The Journal of Pain Research and Management. That article is called Pain Reconceptualization after Pain Neurophysiology Education in Adults with Chronic Low Back Pain: A Qualitative Study. You have one in October 2019 from The Journal of Pain looking at The Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis. You’ve gone into the data pretty deeply on it. I’m curious, as PTs, everyone’s excited about pain education and reconceptualization of pain. How did you wake up one morning and say, “I’m curious to know how much of this conceptualizes the idea of this partial reconceptualization of pain or patchy as you mentioned in one of your studies?”
The term partial and patchy is something that we’ve used quite a lot probably we’ve looked at the amount of reconceptualization that we’ve seen in the patients involved in our studies. My interest in Pain Neuroscience Education goes back a long way, right back to my PhD, in 2008. I found that a fascinating and interesting approach to treatment. It wasn’t until much later in my career that I began to become interested in more qualitative research and began to be more interested in the potential mechanism of the effect of Pain Neuroscience Education. There was a lot in the literature looking at can we change patients’ understanding of their pain?
There is quite a bit in the literature to say that, “Yes, we can.” People were then taking back evidence to suggest that we were helping them to reconceptualize. That using a questionnaire to test knowledge was for testing a change in almost a belief system. We weren’t sure. We could see the logic and we felt that it was a good place to start to begin to explore this area. We felt that you could only explore this issue qualitatively when looking at an issue of reconceptualization. That was very much due to the way when talking to patients, how would they hold that you’ll understand of something? Often completely conflicting understandings of the same thing. In one breath, they may say something like, “My pain is due to this heightened sensitivity of my neural system.”
In a flash say, “My primary problem is this bulging disc.” It was that dualistic completely competing in different viewpoints, which we felt couldn’t be captured in a questionnaire. The questionnaire you were looking for is a consistency of viewpoint. There was either a right way or a wrong way of looking at something and you’re looking to capture. For example, people are more fearful of something due to their back pain such as the Tampa Scale of Kinesiophobia and the Fear-Avoidance Beliefs Questionnaire. They all tap into a single construct where it’s clear that you’re looking for answers at a certain time. People hold a mixed viewpoint on such a complex issue as reconceptualization. We felt that only by talking to people qualitatively, could we explore what people were thinking?
That’s what we began to do. We undertook a series of three qualitative studies in our systematic review. We only found four qualitative studies that met our inclusion criteria, three of which were ours. That’s a big limitation in the literature. If you’ve only got one center, one group talking about this, you’re going to get a very biased-free and narrow view on something. I would hope that more and more quals work will be done in the field of Pain Neuroscience Education. It desperately needs it. Those three series of three studies began to explore this idea of how the patients think about their pain following Pain Neuroscience Education.
The first study was led by Victoria Robinson, who’s a colleague of ours down at The James Cook University Hospital, which our neighboring hospital here at Teesside University. It was with ten patients with chronic pain. We simply interviewed them after they had gone through a two-hour PNE session. We asked them to explain what they thought was causing their pain and what they felt about PNE as an intervention. That’s where we first coined this term, partial and patchy reconceptualization. We found that there were some who were completely unmoved. When you asked, what do you think is the cause of your pain? The medical reason that they gave beforehand was identical to the medical reason they gave after that very much biomechanical, “It is the fault of my disc,” for example.
In that case, there was no reconceptualization?
Absolutely.
Out of that study, it’s a bit of a smaller study, but I appreciate this work because you do hear people say, and I get people who read my blogs and they email me and they say, “I have a large herniated disc at L4, L5 and an L5-S1. I had an MRI but from reading your blog, I think my nervous system is too sensitive or ‘out of whack.’” They’re using the exact language that you’re mentioning. Out of the twelve in that study, three have no reconceptualization at all.
When it comes to quals, you don’t focus too much on the exact demand. You’re not looking for a representative generalizable sample. The idea that there were some for sure who simply have no evidence of reconceptualization but for most, it came to what you’ve described. They still held on to those previous biomechanical understandings, but they had been gone to niche into the verbalization of their problem. Some seeds of Pain Neuroscience, some tangible steps towards a less medicalized view of their condition, appreciating that it might be more to do with a sensitized nervous system. Their anxieties and their fears may be playing a role.
To clarify, for people who are reading this, when you’re talking about the qualitative nature of your study, you’re in essence interviewing people and documenting or listening to the language that they’re using when they reflect you what’s happening with their particular pain condition.
In study one, we interviewed people with a recording device for approximately an hour or we ask them in a semi-structured interview way to explain their pain, their understanding of it and their experience of going through PNE. After that study, we said that one of the limitations of that work was that we didn’t know what their understanding of pain was prior to going into the education session. We were making some assumptions about how much they had changed or not. In study two, which we published in Patient Education and Counseling, the primary author of this paper was Richard King, also a clinician down at James Cook University Hospital, where we interview people pre and post.
In this case, we only had seven people but it was richer data because we had those two interviews. It very much supported what we had found in the previous study, this idea of partial reconceptualization. We could track exactly what they had said at the time one at exactly what they had said at the time two. I talk about this at conferences. I liked doing some slides at the start where I put up quotes from these interviews and I ask the audience and say, “Was this someone before they have received PNE or after they’ve received PNE?” I purposely pick quotes, which are the complete opposite of what you might expect. Ones where they say, “The problem is my desk.” I say, “Was this before or after?” They all thought that was before but it was still after they received the education.
I put up one like the problem, “It has to do with my brain and the way my neural system is protecting my body.” They all naturally go, “That must be after PNE.” I said, “No. The patient came in, sat down and that was their understanding before I said a word.” It throws people because they don’t expect that. It’s such a unique thing. That’s why qualitative interviews help to explore that. The third paper was very much almost a confirmatory paper where we interviewed people before or after. We essentially found the same things. It’s nice. In the world of qualitative research, one of the markers of quality is how replicable your work case. When you do it again, do you find the same things? Which essentially is what we did, which was we encouraged.
Through your research, you’re finding that there are people who did not reconceptualize. There’s a whole rainbow of colors in the middle of varying different shades and degrees. What was interesting, there’s also one person or subject, P4 in one of your studies. You guys claim in the paper that it had advanced reconceptualization after one session, which is pretty cool because everyone’s like, “Who that person is and what happened there?” To clarify for people in one of the studies I read for you, the intervention was delivered by experience physiotherapists onto numerous consumer education courses. Specifically, it looked like from explained pain, which everyone knows about and this was delivered in a two-hour group format.
It’s definitely one of the strengths of our work, but the education was delivered by experienced clinicians, who had lots of experience at delivering PNE. Once more, we’ve published at least two service evaluations demonstrating that patients who go through that service improve the pain in Physiology Education Quiz developed by Moseley and his group. The amount of improvement is in keeping with the improvements shown in the literature. It was a nice way of providing evidence that we’re delivering this education within this fear to a pretty thorough level. Despite that, not everyone was changing the way we had hoped. Though there was absolutely this individual P4, who changed wonderfully. We’ve only begun to scratch the surface to try and explain why some people might take on these messages and some people might not. Whatever that the patient brings in with them is hugely important. Interestingly, one of the patients who changed quite a bit was a patient who would come in with a phantom limb pain. It was a complex regional pain syndrome.
It was a painful condition that ultimately it’s poorly explained by a biomechanical model because of that, they were more open to a nonbiomechanical explanation. They had heard prior to getting to the study nonmedical model explanations from healthcare professions or at least they didn’t have medical model explanations rammed down their throats above by those other healthcare professionals. That made the change all that more ready, there was the environment that had been created for the seeds that were sown could take root.
There was some priming that existed there before and once they arrived in the physiotherapist and sat through this, they obviously deepened that learning. I’m curious about that one particular and it was probably difficult for you to talk about specifics, but there is some information around health literacy and education with regard to the deepening of this type of learning with patients. Had you come across any of that in your qualitative research?
It’s not something that we have explored in any depth, this idea of health literacy. One thing I would say about the area of recruitment of participants for this study is that it’s not very affluent. A lot of the patients were from less affluent areas. On this, one might anticipate some challenges of taking on the information, but I don’t think there were any issues being able to take on the information. The patients were well able to take on the information, but it’s a big difference between being able to take the information on and believing. There’s a beautiful quote for one particular patient and one of the three studies, where she said it was in her post-education interview. She gave a neat explanation of “I know that it could be to do with my sensitized nervous system, etc. but I don’t know whether I am not ready to accept it or willing to accept that. I can’t believe there’s not something there.” She was emotional about it. The conversation clearly showed a very intelligent lady was well able to follow the physiology but could not change her belief system that accepting her pain might not be due to our volume mechanical issue. She was aware she wasn’t ready for it and it was made her quite emotional.
That’s interesting because if you look at some of the research in the world of psychology around the idea that once there is a memory that’s been formed, you cannot change your memory. You can place new learning on top of that memory, but you can’t change that. The idea that you’re discussing that people being able to juggle if you will, that there is a biomedical component to this potential as well as the biopsychosocial variables is important. Helping people along that spectrum of moving them more and more toward that biopsychosocial understanding of pain, but maybe realizing fully that you’ll never change someone’s belief 100%. That may actually be humanly impossible, so to speak.
It’s fairly refreshing as a clinician because you feel obliged to help the person. If you feel that the best way of helping them is to explain their pain biology, then you want to do a great job. If they after her single to our section we happened reconceptualize, you might feel inside that you’ve done a bad job or you let them down. The reality is that you haven’t. It is difficult to share shift beliefs, very difficult to shift them, especially in such a short and brief time. Is partial reconceptualization, is it a win or is it lose? Should you be thinking, “At least I’ve changed the patient’s viewpoint a little, I’ve set the scene for the future?” Perhaps over time when they’ve had time to reflect on the information to test that out themselves in real life, it might lead to more. I’m very much of an opinion that partial reconceptualization is a win. If you shifted the belief system even in infinitesimal, it’s been worthwhile. It’s been useful but I’m a glass half-full guy.
I appreciate it because what you’re saying is it’s not there has been partial reconceptualization at the end. It’s that there hasn’t been partial reconceptualization, and now let’s begin to move, explore, expose and continue basically.
I couldn’t agree more. It may be that in a year’s time that patient will come back to you and go, “Can we talk a bit more about that? I’m in a place where I’m ready to talk about that.”
With some patients, that’s the best you can hope for. That’s is definitely a win.
It takes time to move through those stages of change and just because you read a study that says, “Some people partially reconceptualize within two hours,” it doesn’t necessarily mean that’s going to apply to every single patient. Let’s say your particular practice, I want to touch on some more technicalities and then I know you have some principles you can share with practitioners to help them be more effective in their care. It is like the 10,000-foot view with regard to first pain, second is kinesiophobia, third pain catastrophizing and then four disability, which is right there could be a PhD in and of itself. What is the research showing or demonstrating with regard to those four important areas of Pain Neuroscience or Explain Pain Education?
This relates very much to our mixed methods. A systematic review that we published a couple of months ago. My PhD students led on this chapter called Jamie Watson, a brilliant young researcher. He told me that apparently, it was well-received on social media. As someone who doesn’t do social media at all, I’ll have to take his word for it. It’s nice to hear that people have been interested in it. What we did in that mixed-method review was look quantitatively to RCTs that provide evidence around the outcome measures that you’ve described. We looked at qualitative studies focused more on how you might deliver optimally
Coming back to your question about what’s the evidence for those different outcome measures? What we found that with respect to pain and indeed arguably disability, there was some evidence of change in favor of PNE but the magnitude of the change was very small below what you might consider being a minimally clinically important difference. We used a 10% change as a minimally clinically important difference. We borrowed that from the nice guidelines looking at lower back pain. They are minimally clinically important. If you are not going on both 10%, then that’s probably not having a great effect on that. If you look at it in that cold way for simple pain and function, PNE probably doesn’t make a great difference based upon the literature that exists at the moment. One could argue that it’s not necessarily attempting to make those changes.
Certainly, that evidence is more in the medium or the short to medium term. There was no evidence in terms of the long-term. When I say no evidence, people hadn’t looked at that. My gut feeling is that in the longer term, you may well see clinically relevant changes in pain and function, but it takes time for the information and for the changes to occur in patients. In its most simplistic cold way of interpreting the data, PNE or Pain Neuroscience Education makes very little difference to pain and function in the short to medium term. However, if we begin to look at other technical outcomes, gut catastrophizing and kinesiophobia here, we do begin to see minimally clinically important differences in the medium to short-term.
In terms of patients fear and anxiety and worry about their condition. We see changes that are being clear. They’re still not necessarily enormous, but they’re both a minimally clinically important difference with positive shifts, less fearful, less worrying. We don’t have that evidence in the longer term and that’s what’s lacking in the literature. People doing long-term follow-up RCTs. That’s probably where the greatest benefit will be seen. It’s a bit of a slow burner. If you think about something like TENS. The best evidence for TENS is when it’s turned on, it’s on the patients. When you remove it, it was probably not a lot going on anymore.
It’s not something that kept carrying on after. Whereas with PNE, immediate to short-term measurements, possibly not the best time to measure its effects. Probably the best time to measure its effects is a year down the line where patients had time to process it and think about it. To cut a long story short, pain and function perhaps not so much but fear and anxiety and worry, Pain Neuroscience Education can make a real impact on an important point.
Those are important outcome measures that all these studies are looking at. All the experts recommend that this type of cognitive intervention should be combined with other interventions, specifically therapeutic exercise or some type of great activity program where you’re helping people apply what they’re learning to their daily life or daily activities.
The data pull that out. It wasn’t a particularly strong effect, but there was a tendency for those studies that combined PNE with something else. They tended to have the greatest effects on it. I believe it was designed to be delivered that way and not delivered in isolation.
What’s nice about your research is it begins to culminate with some principles that you share that can help practitioners with their application of PNE and potentially, make it more effective for obviously the clinician and the patient. Can you share a couple of those principles with the practitioners who are reading?
I go back to mixed-methods systematic reviews of the future. They’re extremely powerful because they don’t focus on the numbers. They focus on how to do the work well from the perspective of the clinician and of the patients. One of the key things which seem to be important for the patient was the ability to be able to tell their story. This idea of going in and delivering education in a very bland way of living doesn’t seem to be the optimal way of delivering. Sitting down with the patient, asking them to tell you their story and giving them time to voice their concerns is an integral part of PNE. It shouldn’t be a one-way conversation.
In doing that and allowing them to tell their story, patients often identify and consistencies in their own stories, which begin to hurt the medical model, the biomechanical model in their own mind, which can help you when you’re talking about delivering Pain Neuroscience Education to them. It’ll be a prerequisite to deliver in PNE. If you’re delivering it in a cold planned way, without listening to the patient’s story, you’re going to have less of an effect. I would say that’s probably number one. Also in terms of that, probably the key thing of all of our work has been around the issue of relevance, making the education relevant to the patient and having listened to their story first will allow you or help you when you’re delivering the education to make it bespoke to that individual.
If you don’t, again you’re at risk of losing them. We talked about some of the factors which seemed to predict who would reconceptualize and who wouldn’t? Those who found the information relevant, who felt that this was talking about them and their pain or the ones who showed evidence of taking on the messages. That’s another key thing. When you’re delivering PNE, make it bespoke relevant to the patient. If you don’t, you’re at risk of losing that. As clinicians and researchers, we’re excited about all this. We love Pain Neuroscience Education. We could talk about it all day. We’re at risk of telling them lots of information, but they don’t care about it. They can’t see how it’s relevant to them. What we have to do is think, “We’ve got lots of exciting information,” but what are the bits that will help us connect with this individual which will help them take on board this information? We try and find that nugget and focus on that rather than all the other exciting things we know that we want to tell them.
Logically, it makes sense to us as professionals, but that logic doesn’t necessarily translate to the patients, not necessarily what they need at that moment.
PNE or Pain Neuroscience Education will not be for everyone for sure, but for most people, it has a place. The question is, how much of a place and how to pitch it and how to deliver it? We can learn a lot from psychology, a lot of reconceptualization literature out there and frameworks that are out there in terms of how to help people reconceptualize. All we need to do is deliver our PNE in a way that fits those frameworks and we will hopefully make the education we deliver a lot more effective and useful.
I oftentimes wonder if the word pain education is an educational intervention or from one, it should be pain counseling. It is definitely part of this is counseling versus educating of two very different things. I know they have cognitively, they have some overlaps, but they are two very different things when you’re working with a patient one-on-one. Before you go, I’m a big supporter of all the research that you’ve shared. Thanks for sharing with us, but I want to make sure that you talk about the gift that you’re offering people.
As a group, again working with our colleagues at James Cook University Hospital, Victoria Robinson and Richard King. I should mention there’s a whole pile of us here who work in this area like Professor Denis Martin and Jamie Watson. We’ve got lots of PNE-based researchers. We’ve all worked to try and come up with various best ways of delivering a PNE. The paper that we have as the free gift is a paper we published in the journal that I edit, which is called Pain and Rehabilitation, which is the Journal of the Physiotherapy Chemists Association. All of our materials are readily available online. This particular article talks through an interactive diagram that was developed by Victoria and Richard, where it puts a force and then has a neural system built into it. It talks you through in a series of eight slides in terms of what you might say about the picture at different time points of what you might add as you go through the picture to help talk someone through a Pain Neuroscience Education process. It’s how they deliver it. It’s neat. There is an infinite number of ways you can deliver this education. Some groups have done it beautifully.
Like Moseley’s groups, for example. Just brilliant infographics and illustrations and all the rest. This is one more example of how you might deliver it. People can look at it and take from it their way. Does it resonate with them? This is a neat way of communicating the information. They can take it onboard all of us or a little bit of us, but what we’ve done is essentially laminate the main picture and with a little pen, you would mark on the different slide bits and then as you move from side-to-side, move on the marketing and move onto the next bit. It works really well.
Make sure to download that. It’s called a Novel Interactive Diagram to Explain Pain Neurophysiology to Patients with Chronic Musculoskeletal Pain: A Practical Guide. Cormac, it’s been great having you on the podcast and please let us know of any new work you have. We’d love to hear it and you have an open invitation to come back on and share your research. In the interim, please tell people how they can learn more about you.
I’m not a big social media person, but you can go on the Teesside University website. That’s where I work in the UK. I’ve got a webpage there where you can find about me and the various research publications that we produce as a group. If you want to contact me via email, it’s [email protected].
Cormac may not be a big social media person, but all of you reading, we need your help. Please take the link to this episode and share it with your friends and family on Facebook, LinkedIn, Twitter, Instagram or wherever you are on social. Take the link, drop it into a Facebook group where people are interested in the neurophysiology of pain and explaining pain. I want to thank Cormac for being on this episode. I will see you in the next episode.
Thank you, Joe.
Important Links:
- Dr. Cormac Ryan
- www.IntegrativePainScienceInstitute.com/164download
- Pain Reconceptualization after Pain Neurophysiology Education in Adults with Chronic Low Back Pain: A Qualitative Study
- The Journal of Pain looking at The Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis
- Novel Interactive Diagram to Explain Pain Neurophysiology to Patients with Chronic Musculoskeletal Pain: A Practical Guide
- Teesside University
- [email protected]
- https://Research.Tees.ac.uk/en/persons/cormac-ryan
About Dr. Cormac Ryan
Dr. Cormac Ryan is a Professor of Clinical Rehabilitation at Teesside University in the UK. He graduated from the University of Limerick in Ireland in 2002 with a BSc in Sports and Exercise Science and completed an MSc in Physiotherapy (pre-registration) at Queen Margaret University College, Edinburgh.
He was awarded his PhD from Glasgow Caledonian University in 2008 where he explored the relationship between physical activity and chronic lower back pain. Cormac has published over sixty peer-reviewed journal articles and obtained more the £1M in research funding. Cormac’s research interests are primarily in the area of chronic pain, its impact on patients and developing new interventions to help patients better manage the condition.
He has a particular interest in the area of pain neuroscience education as an intervention for patients with chronic pain. Cormac is the co-editor in chief of Pain and rehabilitation – the journal of the Physiotherapy Pain Association, a peer-review journal with a 20-year history.
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