Welcome back to the Healing Pain Podcast with Adriaan Louw, PT, PhD
Happy New Year and welcome to this first episode of the Healing Pain Podcast in the year 2021. We are starting the year off on a strong note with one of the world’s experts with regard to pain neuroscience education. My guest is Professor Adriaan Louw. Adriaan is a physical therapist, pain scientist and author in the field of pain neuroscience, Director of the Therapeutic Neuroscience Research Group and Director of Pain Science for Evidence in Motion. His main area of research focuses on teaching patients and healthcare providers more about pain.
He has years of experience teaching pain neuroscience education to health professionals. He’s authored numerous books on the topic and published over 70 peer-reviewed papers related to pain science. In this episode, we discuss pain neuroscience education plus why it is important for both practitioners and people living with pain. What types of clinical outcomes can you expect when you deliver effective pain neuroscience education? Whether or not it should be delivered as a standalone intervention or part of a larger multimodal treatment approach coupled with other cognitive interventions such as Cognitive Behavioral Therapy, Acceptance and Commitment Therapy or mindfulness.
Throughout the interview, we discuss how you can effectively use pain neuroscience education and couple it with other cognitive interventions. If you’re interested in combining pain neuroscience education with Acceptance and Commitment Therapy, make sure to check out my latest book available on Amazon. It’s called Radical Relief: A Guide To Overcome Chronic Pain. Inside, he goes deep into the principles of Acceptance and Commitment Therapy and includes over 50 cognitive and mindful exercises you can use with your patients as well as a little bit of pain neuroscience education. Without further ado, let’s begin with the great Adriaan Louw.
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Pain Neuroscience Education Plus With Adriaan Louw, PT, PhD
Adriaan, welcome to the show. It’s great to have you here. Thanks for joining me.
Joe, it’s nice to be here.
I’m looking forward to talking to you as one of the leaders in pain education globally. It’s a real pleasure to be chatting with you. People are going to be interested in the things you have to say and the information you have to share. I had the pleasure of hearing you speak a couple of years ago at the International Association for the Study of Pain. I enjoyed the lecture. Lots of great information on pain neuroscience education and pain neurobiology. I enjoyed it as a practitioner. There’s something that you continually seated throughout that lecture. That has always stuck with me.
Throughout that lecture was a room of advanced practitioners with DPTs, PhDs and some of the world’s best are in there but you kept saying, “Please don’t use technical, high-level words and vocabulary with your patients and with the public in the delivery of pain education, if you will.” That always stuck with me because the study of pain is complex, but we want to deliver it in a way that’s easy, approachable and digestible for people. It’s appropriate that we start talking to people who have pain. In your own words, how would you describe to people living with pain why it’s important to learn about the pain? How can it help them recover and lead a better life?
It’s important for people to understand what’s going on with them. You may be waking up this morning with something wrong with your knee, you would like to know what’s going on. It’s like an old story. I’m going to know what’s wrong with me and what can I do about it? What can you do for me as a provider? How long will it take and will it get better? The reality is no matter where we look at it, when people come to us as healthcare providers, they want to have answers. We do give the answers, the problem is sometimes these answers are advanced that patients don’t understand it. It doesn’t mean it’s the fault of the patient. It’s our fault. A good example is you might as well speak a foreign language.
The language we have is complex and we try to impress people where the best evidence says take complex and make it simple where a patient, on any level, can go, “I got that.” We’re seeing it. We’re teaching middle school kids about pain where they sit there in the classroom and go, “I got that.” Why should people learn more about pain? Pain is a universal human experience. The sad reality is there are about twelve people in the world from a condition called Mendelian disorder that can process pain. Pain is important. Without it, we would be dead. It protects us. Fundamentally, we must understand it. My answer to people struggling with pain is, you should know more about pain because it’s your pain.
I would like to know what’s going on with me if I was in this position and I often do get in these positions of pain myself. We do know now from a robust bunch of research that if you learn more about your pain, you’re better for it on many levels. You’re less fearful and anxious. There are many positives that need to understand. The same thing as I would like to know what’s wrong with my car. The minute to understand what’s wrong with my car, I’m like, “What do you do about it?” That’s almost simple in some way if you will.
It’s a great way to start the episode. When I started this a couple of years ago, I approached this as a public service announcement for people living with pain and practitioners as well. I always like to touch on that aspect of it for the people. One of the reasons why you came on my radar is there was a viewpoint in the October 2020 Journal of Orthopedic and Sports Physical Therapy. The title of that viewpoint was Revisiting the Provision of Pain Neuroscience Education: An Adjunct Intervention for Patients, but a Primary Focus for Clinician Education. Viewpoints are scholarly papers that contain an opinion or perspective from someone. That’s relevant to a particular profession or topic that is out there in the field. Why did you decide to offer this viewpoint at this time?
Our understanding of pain neuroscience education, teaching people about pain, shifted in the last year. What we’ve also figured out is a lot of clinicians have either done a very bad job at presenting this content or people have misinterpreted the idea that I can sit with you and in some miraculous way, explain pain away from you and suddenly you’re like, “I’m better.” It’s way more complicated. Pain education is a good strategy but in itself, it’s limited clinically. If you look at the research, education, by itself, in any healthcare setting is not that powerful. In the United States, we’re spending $2.1 trillion on smoke cessation. We cannot print large enough from cigarette packages smoking causes cancer and people smoke. Education doesn’t change behavior as much.
It doesn’t change the pain that much for that matter. I wish I could do it but as a research team, we were looking at all the data and it became apparent that PNE or Pain Neuroscience Education isn’t that powerful. The original title was PNE doesn’t work. The editors decided not to put that in because they wanted to create it but still, people need to understand that some people think that’s what we do. Pain neuroscience education is better seen as a primer. The evidence behind movement helping pain is astronomical on every level.
You and I can have a serious conversation and I know this is an area you’re good at too that there are various forms of movement, traditional and non-traditional, but people didn’t pay more move. Why? They’re afraid, nervous or anxious. They have catastrophizing ideas related to movement. What PNE does is normalizes that then you move. What made you better? Movement, not PNE. PNE made you move. We wanted therapists and clinicians to read and understand that this thing they’ve been doing for decades of works is a means to get people to move. That was the intent behind it.
It was a way to clarify and update the research and to help provide a guide for practitioners on how to use PNE and what it’s useful for and not useful for.
It’s a right-sizing of the ship. The neat thing is I’m one of many authors. When Kory Zimney, one of my colleagues, sat and discussed this at a conference, it was one of those light bulb things we started looking at and then we contacted other well-known scientists in the area. Dr. Jo Nijs, Dr. Kathleen Sluka, Dr. Carol Courtney said, “This is what we are thinking.” They’re all like, “Yes.” We got together as a collective team and said, “This is a message that’s worthy getting out.” I don’t want clinicians to think you can bring a patient and send them at the table, explain to them how pain works and suddenly they would stand up and say, “I’m pain-free.” It doesn’t work that way. Pain is way too complex.
Without throwing the baby out with the bathwater, tell us what the advantages of PNE are with regard to clinically meaningful outcomes. I don’t know if we should break that down first into PNE as a standalone treatment and then PNE combined with what you call PNE Plus which you’re eloquently stating the purpose of PNE. The first plus we should add on should be some type of exercise movement or physical activity. As a standalone treatment, are there any advantages to it?
I believe so. We’re still in the early stages of figuring that out. We do know that PNE has a robust effect on two things, fear avoidance and catastrophization. If a patient were to come into our clinic and they had high levels of fear, which we can measure, high levels of catastrophization, which we can measure, PNE would be not a bad intervention to ease some of that. It makes it move. That’s the intent of the treatment. There’s nothing wrong doing it. I wanted clinicians to not think of it as a standalone. It’s the a-ha moment. It doesn’t work that way. If we have patients walk-in with high levels of fear of catastrophization, I would consider PNE as an intervention that brings in the idea of who does not need PNE. I’ve been interviewed about PNE and nobody ever asked me who does not need PNE.
That’s one of my questions.
If you have what we would consider no susceptive dominant, you have an ankle or you have a back the tissues that are not happy but you’re not afraid or fearful, it doesn’t make you not see the future is bright. You’re like, “It’s an ankle sprain. I’m good.” You don’t need a cognitive intervention. We need to get your ankle moving and get blood flow oxygen and life is good. We do know that PNE is not needed for people in pre-contemplation phases. If you look at the readiness of change scale, I’ve said it for a long time and there’s good data to back it.
When people come to us and pre-contemplated and those were the people with the utmost respect, they’re not ready to change yet. My brother is one of them. He’s a smoker. Every year, I visit him, smoking causes cancer and he’s like, “Forget you, whatever.” In the therapy realm, patients coming to see you and they’re like, “I’m only here so that I get my employer happy.” “I’m able to get my wife off my back,” as an example. We will teach students, “Don’t try a cognitive intervention. They’re not ready for it.
Let’s do some good movement-based stuff. Treat them with compassion, dignity, respect. As a shift, we can do those.” That’s the answer. The PNE Plus is correct. The idea is that PNE by itself is not powerful. Most treatments in general by themselves are not good standalone. You and I can speak the same language. If you manipulate somebody’s neck, that’s good but you’ve got to surely show them some exercises and stretches. I would argue the same process to work its way through. Movement, sleep hygiene, nutrition and things you are well versed in can be added to the approach.
That’s an important point. I talked to practitioners all the time about that one intervention. If you find yourself being hooked by exercise, nutrition or managed it, that will not become your mainstay. You need to step back, reflect on your own practice and skills, look at yourself and say, “Where am I being effective as a practitioner? How can I improve myself and be more effective? What’s missing from my skills as a licensed professional?” The purpose of continuing professional development is that you professionally develop throughout your career. There’s no end to that for professionals. To summarize, PNE has an impact on pain catastrophizing and kinesiophobia or fear of movement. How about pain? How about disability?
Not much. We don’t have great studies to show that it robustly changes, the minimal detectable change of pain is about 2 points on a 10-point scale. I have not seen much research to show it can do that. Think about it, the idea of pain neuroscience education normalizes the pain experience and you understand it more. To be honest, there’s a condition that we’ve alluded to it in some of our papers called Explain Pain Pain. When we teach people about pain, their pain gets worse. When I mean worse, it’s 0.01 on a 10-point scale.
It slack then it goes up and we have tracked those patients that they do better long-term. Why does it happen? It’s because they think about it. If you think about your pain, you’re more aware of it so you may rate it slightly higher. Pain doesn’t drop suddenly. The function also not which is intriguing for us. We’ve been on this incredible journey trying to find out, what does pain neuroscience education do? We know it’s fear or kinesiophobia and self-efficacy is big on this scale. Those kinds of things we’re looking at but I wish I can say robustly shifts function. It does but not as much as we wanted to.
You answered this question slightly but I want to come back to it because I’m sure professionals want to know. Is there a diagnosis, group, population or demographic that would benefit from PNE more than the other beyond those with pain catastrophizing and kinesiophobia?
It’s been studied. As I close my eyes, I can see the list. There’s a handful of the conditions that PNE is ideally designed for people with central sensitization or nociplastic pain. This is widespread sensitization of the nervous system. They do well with this approach. As they do well with any cognitive approach via CBT Acceptance and Therapy, etc. When I talk about chronic, I’m talking duration. I understand some chronic conditions start early but the longer you have pain, the more layers we started adding to this onion skins model if you will. Fear and catastrophization do well.
People that are in the readiness for change scale are ready for a shift. They’re in the preparation phase. Those kinds of patients do well. Specific diagnosis is it’s been studied extensively on things like chronic back pain, fibromyalgia, chronic fatigue syndrome and chronic whiplash-associate disorders. We’ve done it on pre-op patients for various orthopedic surgeries. That’s the bucket we would be looking at for people that tend to respond well to this.
Let’s talk about PNE Plus. As I look at all the different types of cognitive-behavioral interventions that are now bubbling up to the surface, pain neuroscience education, ACT, CBT and mindfulness. You can go down the list of things. I feel there’s been a focus on the pain. What I like about your viewpoint is you’re bringing the focus back to movement, physical activity, meaningful activities, etc., which in my opinion, should be the ultimate outcome of all this. We want the pain to go away and we want it to decrease substantially. My mom was a nurse, she worked in a hospital and I had access to people who were suffering but still living life with pain. My curiosity has always been no matter what stage of life someone is in, how do we help them engage with that life even if they have some pain. That’s what you’re saying with PNE Plus.
The idea would be there are people with chronic pain starting at PhD that’s getting ready to run a marathon and physic during COVID. This is the thing that excites me. There are people that have chronic pain significant but function at high levels. That has always intrigued me. Why is that? Is it self-efficacy? Is it goals? We need to change and that’s the paradigm. What PNE Plus does is this idea of there are many ways of making a human being better and healthier be it sleep, nutrition, exercise, mindful, relaxation or breathing. Joe, the first thing I was told in PT school years ago, the first day of PT class, I was still breathing.
I remember sitting there thinking stupidest thing I’ve ever done in my whole life and years later going, “Let me tell you about breathing.” One of the coolest things you can do for somebody in pain. When you talk about professional development, how neat is it? I want clinicians to understand they have a plethora of techniques to their disposal that they already have. PNE helps people do it more willingly if you will. People always say, “I’m not a pain specialist.” You don’t have to be a pain specialist. You have to be a caring provider, for some people teach them how to sleep and get some better habits going. You may know something about nutrition, you can help them. If not, get them some help.
We have so much in our wheelhouse already. The problem we’ve had is people in pain, we have to get them to engage in those. That’s where these cognitive approaches. PNE is one. Acceptance and Commitment Therapy, motivational intervene, the list goes on and on. To move the needle somewhat so people will like, “I can do this.” The PNE Plus thing is neat. Do you know what I do in a clinic? I give people that list and I say, “Pick one.” Suddenly, our patients have a choice. The cool thing is they’ll say, “What’s mindfulness?” “Let’s tell you what it is and I’ll show you.” “What is sleep hygiene?” “Let me show you that.” We give them the choice. There’s a protocol from A to D which that’s why clinicians get tired because I have a protocol and you’re informed of my protocol. Pain shouldn’t be a protocol. There’s a human lived experience.
I want to go back to the idea of education for pain but I want to turn to DPT school. I’m curious from your own perspective, there have been guidelines by the International Association for the study of pain that some schools have adopted and some have not. If we look at exploring PNE and education programs, some of that is lacking so we need more research in that area. Do you have a suggestion for a University DPT Program, an OT program or any program with regard to should PNE be single in class? Should it be a single course? How many hours? How do we measure outcomes about professionals learning this? Do we need to have more on the PT boards? A lot of different topics there but they’ll connect to the same route, I believe.
Everybody should realize I’m biased. The good news is we cannot stop traveling from school-to-school. That would be a PT, OT, nurse practitioner, medical school, etc. There’s an enormous hunger for this content so that’s good. You and I know that whenever we introduce something new, it takes seventeen years or something to work its way unless there’s something drastic. It shifts you. I’m happy to know that PNE is filtering its way through PT schools. Every year at big conferences, people like myself and you are up on stage telling people all this so the young generations are getting exposed to it. As an academic person, the question is always what do we take out?
That’s the classic thing. The good news is PNE is working its way and I know that it’s under review for CAPT that sets a lot of the PT Guidelines for us. More schools are putting it in even if it’s not a guideline yet. It depends. It’s like manipulation. Some schools teach one minute, we covered it and checked the box. Another school does lumbopelvic and then another school does everything manip depending on the bent of the instructor. The good news is it’s moving. The guidelines from the ISP are good guidelines. We’re discussing with Kathleen Sluka and our team this idea of, should we follow-up with that study that was done years ago? Has the needle shifted? I think it has. That’s a good part.
Your question to me is, as far as the class, those are tricky. There are some data that would show that around that fifteen-hour, classically two-day, weekend seminar type of hours from Lattimer’s work has shown seem to be the optimal amount of pain science. A few years ago, the University of Wisconsin invited me. Bill Bunce was still there before we went to the APTA. They invited the faculty board meeting and they asked me, “If you had to build an ideal pain program, how would you do it?”
My answer was, “You can do PNE as a standalone but it should be filtered in the whole curriculum orthopedics, neuro, amputations, pediatrics.” I’m biased, remember. According to me, this is how the world looks and if the world is flat, that’s the way it is. I would love for students to learn PNE. When I go do the neuro part, they can apply it to neuro. If you want to focus, that will drive us towards things like residencies, fellowships and aiming specifically in those directions. That’s the way more specialized training.
How does PNE improve the therapeutic relationship between a practitioner and someone living with pain? It’s a key part that we need to explore more in the research and to adopt more as professionals as well.
We are doing that research. My colleague, Dr. Kory Zimney at the University of South Dakota, defended his PhD. I’m proud of him. His whole PhD looked at this thing that what makes therapeutic interactions work especially on the PNE side. It all came down to one word which is trust. If a patient trusts you. Here’s the cool part, Joe, for the clinicians, trust is not time-contingent. The studies have shown us more time with the patient doesn’t necessarily mean more trust. You almost instantaneously, within a fraction of a second, develop trust. The question is, how do you do that? It’s being present. It’s the stuff you and I believe. I’m not looking at the computer but how you’re doing it is being here and present. What brings you here? How can I make your life better?
The whole therapeutic alliance trust, empathy and compassion. Putting that around an explanation for something that’s making you afraid and nervous. I would argue that it’s not just PNE. We’ve got to be careful because it’s a well-meaning biomedical explanation for something. If you have a problem with your shoulder but in this interaction, there’s trust, compassion, empathy, etc. How’s that? That’s a busy-end so we’re exploring it, it’s critical. I wish we spend more time screening students, the future professionals, on those skillsets as well. The compassion and empathy scales, whatever they may be. I’ve always asked academics, “How do you find the next good PT?” They have a standard list of questions. There’s something. I don’t know who they are. I would like to know who they are.
It’s always been something that’s fascinated me too. I’ve interviewed lots of physical therapist for jobs and I’ve always tried to figure out, what’s the formula during an interview to ask people to figure out are they going to be a good therapist or not? That’s true. Entering the university setting as well. The fact that delivery or PNE should change or modify thoughts and beliefs with regard to pain sometimes that only happens partially or it never happens. In your years of experience in training professionals in this technique, how do you approach a professional who maybe gets stuck on the idea that they have to change thoughts and beliefs for PNE to be effective and for them to be effective as a practitioner?
In our group, there are two ideas here. One is to look at PNE as a technique. As you walk in, I’m going to do this technique. There’s a group of us that believe that PNE is not a technique. It’s the way we do what we do. It’s almost this idea that you filter throughout your being in the clinic. I’m intrigued by that idea. Jo Nijs was known that he’s mister super bright, smart guy. We do a lot of research together. When we sit down and have one of our favorite beverages, we always talk about this and he said, “We need to change pain neuroscience education to pain neuroscience communication because it’s the way we talk to people. It’s not a technique.” That’s what the essence of this stuff is. We need to get away from the idea that it’s a technique. Would it need to become the language of clinicians? We’re now doing work with medical doctors where they use PNE with nurse practitioners and PAs and it should become the normal language we have. I’m not answering your question directly, but that may be the way we should be looking at this per se.
Another thing that I’ve been looking at more and more is what we’ve done as a profession, the PT profession since the opioid crisis started in 2016? We’ve had great marketing from APTA and many professional organizations with regards to physical therapy as an alternative to opioids and physical therapy as a way to prevent chronic pain. I haven’t seen a step into that arena yet as professionals where we’re directly involved with opioid use disorder.
I’ve stuck my thumb into people’s sides a little bit and asked them this question like, “Would you be comfortable working in an environment where you’re either directly treating someone a part of a team that’s treating opioid use disorder?” Some professionals say yes but a lot of them say no. I don’t feel prepared or educated enough to do that yet. Is PNE a way for us to start to engage in this massive problem especially in the US with regard to opioid use disorder and with the tapering strategies that are now starting to happen in various places?
I’m going to give you two answers. The first one is we have done work in that. We published a paper, a reason to go to physicians to use PNE to taper a patient single case study. We have built what to consider an anti-opioid initiative of some of the VAs in the United States where the idea of PNE process is it builds such a robust therapeutic treatment tool that engages the indigenous systems that you can taper patients. I can see if therapists are nervous and anxious. We’ve always been told don’t deal with drugs but we have to put our foot down and say, “I’m going to build this side of the scale. My doctor, nurse or PA will taper the drug on the other side. It has to get in there.”
That in itself is still a problem. One of the initiatives we’ve worked on extensively is we have built now middle school programs for PNE. We have to start upstream, Joe. Nowadays kids are tomorrow’s adults. We published a paper where we took 600 middle-school kids, train them in PNE, one group got it, one group didn’t and we track them for six months. During the school year, the kids had learned PNE use 30% less pain medicine during the school year than the other groups. How will that translate later on? We must take this to the population at large. By the time they come to us in the opioid dependence stages, that’s fine. We need to work with him. I’ll give him everything I’ve got but if we don’t change it from the beginning, we’ll never change it. We’ve got to go way upstream to change downstream.
These are difficult problems that sometimes persistent people for a long time and getting to the root of the problem early is a wise way. We use similar language with regard to physical therapists or physiotherapists who can use the mind and can engage the brain with regard to treatment but still not everyone. Some physical therapists haven’t come around to the idea of cognitive interventions in practice. Some referees don’t understand how a physical therapist can use this. They look at us as mechanistic individuals. Why is it still considered a radical idea that physical therapists can use the mind and cognitive-behavioral interventions in practice to help people?
There are multiple answers. It’s the model we follow. It’s a legacy where they relayed aid card. When I hear from therapists like, “I don’t do that. I’m not going to go that way,” I start laughing because you’re already doing it, you don’t know you’re doing it. Many people better by what I tell them but not by the technique I did. Those kinds of things. I don’t push them. I leave them be. That’s fine. Do your thing. We’ll all get there but the reluctance is the models. We need to significantly update the models we’re teaching and understanding that there’s a stigma. “It’s in my head.” “You think it’s not real.”
All pain is real. I’m a neuroscientist. We scan brains and I’m telling you, we’ve never scanned a brain and fake pain. If your patients are reading, if a provider ever makes you feel like they didn’t believe you, fire them and find somebody else because your pain is real. It’s left-over from the models we would teach for years. It’s periphrastic, left-over from years ago. For the clinicians who think they’re not doing it, I have a message for you. You’re doing it. You don’t know you’re doing it. That’s the fun part.
Adriaan, it’s been an information-packed interview and I can talk to you forever but I know you have important things to do. I appreciate you coming on and sharing your information and knowledge in this concise way. Sending the message of PNE Plus is the important message. It’s PNE and everything related to the plus should help people move and engage with their life. How can people learn more about you, your great work and all the things you have to offer?
The easiest way is our company Evidence In Motion and this is where I work. We teach classes, we do seminars, webinars and all kinds of fun stuff. If anybody wants to find anything that we’re doing, they can find me there.
I want to thank Adriaan once again for joining us on the show talking about PNE Plus. Make sure to share this episode out with your friends and colleagues on Facebook, Twitter, LinkedIn or a Facebook group where people are talking about pain neuroscience education. An important topic both for practitioners and people living with pain.
Important Links:
- Radical Relief: A Guide To Overcome Chronic Pain
- EvidenceInMotion.com
- https://www.JOSPT.org/doi/abs/10.2519/jospt.2021.9804
About Adriaan Louw, PT, PhD
Adriaan earned his undergraduate, master’s degree and PhD from the University of Stellenbosch in Cape Town, South Africa. He is an adjunct faculty member at St. Ambrose University and the University of Nevada Las Vegas, teaching pain science. Adriaan has taught throughout the US and internationally for 20 years at numerous medical, pain science and rehabilitation conferences and published over 70 peer reviewed papers related to pain science. Adriaan is a physical therapist, pain scientist and author in the field of pain neuroscience and the Director of the Therapeutic Neuroscience Research Group and Director of Pain Science for Evidence in Motion. His main areas of research focus on optimization teaching patients and healthcare providers more about pain.
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