Teaching People About Pain

Pain is a normal human experience. Without the ability to

experience pain, people would not survive. Living in pain, however,
is not normal.1 Pain that lasts beyond the normal healing time of
tissues is called chronic or persistent pain. Worldwide, chronic pain
is increasing. In the US alone, chronic pain has doubled in the last
15-20 years.2 With this increase, comes increased cost. Within
Medicare, a US government-based insurance, epidural steroid (pain)
injections have increased 629% in the last five years and the use of
opioids (for example, hydrocodone and oxycodone) is up 423%.1
This increase is not isolated to the US and represents a global
concern. In the shadow of this growing epidemic, we are faced with
serious questions. Why is chronic pain increasing? Why are some of
our most heroic treatments (opioids, injections, surgery,
amputations, etc.) not working? The answer to these questions is
complex and contains a variety of issues.
Over the last 10 years, our research team (International Spine and
Pain Institute; Therapeutic Neuroscience Research Group) has
explored one such potential cause and set in motion a variety of
research projects aimed at teaching people more about pain.3
Traditional medicine is strongly rooted in a biomedical model.4, 5
The biomedical model assumes that injury and pain are the same
issue; therefore, an increase in pain means increased tissue injury
and increased tissue issues lead to more pain. This model (called
the Cartesian model of pain) is over 350 years old, and it's
incorrect.1

Compounding the issue, the tissue model is then also used to teach
patients why they hurt. For example, a patient presents at the
clinician’s office with low back pain that significantly limits his
function and movement. In this scenario, the clinician grabs the
nearest spine model and explains to the patient that the reason he is
hurting is due to a “bad disc” or “certain abnormal or faulty
movement.” Now the model is set in place: correct the faulty tissue
or movement and pain will go away.6 Not only does this model not
work, but it actually increases fear and anxiety. Words like "bulging,"
"herniated," "rupture" and "tear" increase anxiety and make people
less interested in movement, which is essential for recovery. Our
research team contends that this approach contains a blatant flaw.
When people seek treatment for pain, why teach them about joints
and muscles? We should teach them about pain. This approach of
teaching people about joints when they have pain does not make
sense, and in fact does not answer the big question: Why do I
hurt?7 This is especially true when pain persists for long periods; we
know most tissues in the human body heal between 3-6 months.1 It
is now well established that ongoing pain is more due to a sensitive
nervous system. In other words, the body’s alarm system stays in
alarm mode after tissues have healed.8
Our research has shown that people in pain are interested in pain,
especially in regard to how pain works.9 Learning the biological
processes of pain is called neuroscience education (the science of
nerves). Since educating people about the science of nerves in
regards to pain has a positive therapeutic effect, we decided to use
the term Therapeutic Neuroscience Education (TNE). Based on a
large number of high-quality studies, it has been shown that
teaching people with pain more about the neuroscience of their pain
(TNE) produces some impressive immediate and long-term

changes.1, 3, 10, 11, 12, 13, 14, 15, 16

• Pain decreases
• Function improves
• Fear diminishes
• Thoughts about pain are more positive
• Knowledge of pain increases
• Movement improves
• Muscles work better
• Patients spend less money on medical tests and treatments
• The brain calms down, as seen on brain scans
• People are more willing to do much-needed exercise

How and why does this work? First, therapeutic neuroscience

education changes a patient’s perception of pain. Originally, a
patient may have believed that a certain tissue was the main cause
for their pain. With TNE, the patient understands that pain may not
correctly represent the health of the tissue, but may be due to extra-
sensitive nerves. Second, fear is eased, and the patient is more able
and willing to move and exercise.
How do we do it? This is the fun part. Every time we show people
what we do, we get nervous—it seems so simple. We have
developed a way to take very complex processes of the nerves and
brain and make them easy to understand. Once we have distilled
the information into an easy-to-understand format and paired it up
with some interesting visuals, it becomes easy for everyone to
understand. This includes patients of all ages, education levels,
ethnic groups, etc. Using interpreters, TNE can be used all around
the world.
Here's a brief example of therapeutic neuroscience education in
practice: Suzy is experiencing pain and believes her pain is due to a
bad disc. However, the pain has been there for 10 years. It is well
established that discs reabsorb between 7-9 months and completely
heal.17,18, 19, 20, 21 So, why would it still hurt? She believes (as
she has been told by clinicians) that her pain is caused by a bad
disc. Now, we start explaining complex pain issues via a
story/metaphor with the aim to change her beliefs, and then we set a
treatment plan in place based on the new, more accurate
neuroscience view of pain.
Therapist: “If you stepped on a rusted nail right now, would you want
to know about it?”
Patient: “Of course.”
Therapist: “Why?”
Patient: “Well; to take the nail out of my foot and get a tetanus shot.”
Therapist: “Exactly. Now, how do you know there’s a nail in your
foot? How does the nail get your attention?”
Therapist: “The human body contains over 400 nerves that, if strung
together, would stretch 45 miles. All of these nerves have a little bit
of electricity in them. This shows you’re alive. Does this make
sense?”
Patient: “Yes.”
Therapist: “The nerves in your foot are always buzzing with a little bit
of electricity in them. This is normal and shows….?”
Patient: “I’m alive.”
Therapist: “Yes. Now, once you step on the nail, the alarm system is
activated. Once the alarm’s threshold is met, the alarm goes off,
sending a danger message from your foot to your spinal cord and
then on to the brain. Once the brain gets the danger message, the
brain may produce pain. The pain stops you in your tracks, and you
look at your foot to take care of the issue. Does this sound right?”
 Image from: Why Do I Hurt? Louw (2013 OPTP – with
permission)

Patient: “Yes.”
Therapist: “Once we remove the nail, the alarm system should…?”
Patient: “Go down.”
Therapist: “Exactly. Over the next few days, the alarm system will
calm down to its original level, so you will still feel your foot for a day
or two. This is normal and expected."
Therapist: “Here’s the important part. In one in four people, the
alarm system will activate after an injury or stressful time, but never
calm down to the original resting level. It remains extra sensitive.
With the alarm system extra sensitive and close to the “firing level,”
it does not take a lot of movement, stress or activity to activate the
alarm system. When this happens, surely you think something
MUST be wrong. Based on your examination today, I believe a large
part of your pain is due to an extra-sensitive alarm system. So,
instead of focusing of fixing tissues, we will work on a variety of
strategies to help calm down your alarm system, which will steadily
help you move more, experience less pain and return to previous
function."
 Image from: Why Do I Hurt? Louw (2013 OPTP – with
permission)

The example above is just one story/metaphor we use to teach

patients about complex processes like injury, inflammation, nerves
waking up, extra-sensitive nerves, brain processing information, pain
produced by the brain, etc. It seems quite simple, but it's complex.
The crucial part is that patients are easily able to understand the
example and better yet, the principle. Subsequently, a significant
shift occurs. Instead of only seeing pain from a “broken tissue”
perspective, they see pain from a sensitive nervous system
perspective. Simply stated, they understand they may have a pain
problem rather than a tissue problem. Now, the fun starts. If you're
the fifth therapist a chronic pain patient has seen, he or she will
likely have little hope that you will be able to help, since your
treatment will likely be the same as the others. This neuroscience
view of sensitive nerves versus tissue injury allows for a new,
understandable view of treatments aimed at easing nerve sensitivity,
such as aerobic exercise, manual therapy, relaxation, breathing,
sleep hygiene, diet and more.

When a patient learns more about pain and how pain works, their
pain eases considerably and they experience a variety of other
benefits, such as increased movement, better function and less fear.
These effects are measurable and we believe they can do more
than some of the most powerful drugs in the world, without any of
the side-effects. Look at the picture below (Louw A, et. al 2014 –
submitted for publication). It’s a brain scan we performed on a high-
level dancer experiencing significant back pain for almost two years.
She was scheduled for back surgery in two days and was nervous
and anxious.
Row 1: She was in the scanner, relaxing and watching a movie. You
will notice you there are no red "blobs."
Row 2: We asked her to move her painful back while in the scanner.
The scanner picks up activity of the brain and displays it as red
blobs. Without being too technical, the more red blobs we see, the
more pain she was experiencing. Therefore, Row 2 shows her brain
while she is having pain during spine movements.
Row 3: After Row 2’s scans (red blobs), we took her out of the
scanner and spent 20-25 minutes teaching her more about pain, as
we describe earlier. After the education session, we re-scanned her
brain doing the same painful task as performed in Row 2. This time,
however, there is significantly less activity, fewer red blobs, while
doing the same painful task as before.

This is a graphic representation of how teaching people about pain

helps ease pain. It works. Know pain; know gain.
Author
Adriaan Louw, PT, PhD, CSMT, is the co-founder and CEO of
International Spine & Pain Institute (ISPI). Adriaan earned both an
undergraduate as well as a master’s degree in research and spinal
surgery rehabilitation from the University of Stellenbosch in Cape
Town, South Africa. He is a guest lecturer/adjunct faculty at
Rockhurst University, St. Ambrose University and the University of
Las Vegas Nevada. In addition, he maintains a clinical practice and
is co-owner of The Ortho Spine and Pain Clinic in Story City, Iowa.
Adriaan has been teaching postgraduate, spinal manual therapy and
pain science classes throughout the US and internationally for 15
years. He is a Certified Spinal Manual Therapist through ISPI. In
addition, Adriaan has presented at numerous national and
international manual therapy, pain science and medical conferences
and has authored and co-authored articles, books and book
chapters related to spinal disorders and pain science. In addition,
Adriaan Louw is the co-author of a clinical guide to TNE and the
author of a series of books for patients, includingWhy Do I Hurt? and
Your Fibromyalgia Workbook. The TNE guide and the patient books
are available at OPTP. Recently, Adriaan completed his Ph.D.,
which centers on therapeutic neuroscience education and spinal
disorders.

References
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