David S. Butler

The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain

OBJECTIVE To evaluate the evidence for the effectiveness of neuroscience education (NE) for pain, disability, anxiety, and stress in chronic musculoskeletal (MSK) pain. DATA SOURCES Systematic searches were conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect, and Web of Science. Secondary searching (PEARLing) was undertaken, whereby reference lists of the selected articles were reviewed for additional references not identified in the primary search. STUDY SELECTION All experimental studies including randomized controlled trials (RCTs), nonrandomized clinical trials, and case series evaluating the effect of NE on pain, disability, anxiety, and stress for chronic MSK pain were considered for inclusion. Additional limitations: studies published in English, published within the last 10 years, and patients older than 18 years. No limitations were set on specific outcome measures of pain, disability, anxiety, and stress. DATA EXTRACTION Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach. DATA SYNTHESIS Methodological quality was assessed by 2 reviewers using the Critical Review Form-Quantitative Studies. This review includes 8 studies comprising 6 high-quality RCTs, 1 pseudo-RCT, and 1 comparative study involving 401 subjects. Most articles were of good quality, with no studies rated as poor or fair. Heterogeneity across the studies with respect to participants, interventions evaluated, and outcome measures used prevented meta-analyses. Narrative synthesis of results, based on effect size, established compelling evidence that NE may be effective in reducing pain ratings, increasing function, addressing catastrophization, and improving movement in chronic MSK pain. CONCLUSIONS For chronic MSK pain disorders, there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance.

Fifteen Years of Explaining Pain: The Past, Present, and Future

The pain field has been advocating for some time for the importance of teaching people how to live well with pain. Perhaps some, and maybe even for many, we might again consider the possibility that we can help people live well without pain. Explaining Pain (EP) refers to a range of educational interventions that aim to change ones understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself. It draws on educational psychology, in particular conceptual change strategies, to help patients understand current thought in pain biology. The core objective of the EP approach to treatment is to shift ones conceptualization of pain from that of a marker of tissue damage or disease to that of a marker of the perceived need to protect body tissue. Here, we describe the historical context and beginnings of EP, suggesting that it is a pragmatic application of the biopsychosocial model of pain, but differentiating it from cognitive behavioral therapy and educational components of early multidisciplinary pain management programs. We attempt to address common misconceptions of EP that have emerged over the last 15 years, highlighting that EP is not behavioral or cognitive advice, nor does it deny the potential contribution of peripheral nociceptive signals to pain. We contend that EP is grounded in strong theoretical frameworks, that its targeted effects are biologically plausible, and that available behavioral evidence is supportive. We update available meta-analyses with results of a systematic review of recent contributions to the field and propose future directions by which we might enhance the effects of EP as part of multimodal pain rehabilitation. Perspective: EP is a range of educational interventions. EP is grounded in conceptual change and instructional design theory. It increases knowledge of pain-related biology, decreases catastrophizing, and imparts short-term reductions in pain and disability. It presents the biological information that justifies a biopsychosocial approach to rehabilitation.

Preoperative education addressing postoperative pain in total joint arthroplasty: Review of content and educational delivery methods.

Objective: Evaluate content and educational delivery methods of preoperative education in total joint arthroplasties of the hip and knee (THA and TKA) addressing postoperative pain. Data sources: Systematic searches conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect, and Web of Science. Secondary searching (pearling) was undertaken. Data extraction: Data were extracted utilizing the participants, interventions, comparisons, and outcomes approach. Study selection: All randomized controlled trials (RCTs) evaluating the effect of preoperative education on postoperative pain in THA and TKA surgery were considered for inclusion. Limitations: Studies published in English; published within the last 20 years and patients over the age of 18. No limitations were set on specific outcome measures of pain. Data synthesis: This review included 13 RCTs involving a total of 1,017 subjects who underwent THA or TKA. Educational delivery methods comprised verbal one-on-one or group education sessions, delivered within 4 weeks of surgery lasting an average of 30 minutes, and accompanied by other written materials. The educational content centered on descriptions of preoperative preparation, hospital stay, surgical procedure, immediate/intermediate experiences, expectations following surgery, rehabilitation, encouragement/reassurance, and answering common question associated with the surgical experience. Conclusions: Preoperative education centered on a biomedical model of anatomy and pathoanatomy as well as procedural information has limited effect in reducing postoperative pain after THA and TKA surgeries. Preoperative educational sessions that aim to increase patient knowledge of pain science may be more effective in managing postoperative pain.

Motor Imagery in People With a History of Back Pain, Current Back Pain, Both, or Neither

Introduction:There is mounting evidence that cortical maps are disrupted in chronic limb pain and that these disruptions may contribute to the problem and be a viable target for treatment. Little is known as to whether this is also the case for the most common and costly chronic pain—back pain. Objectives:To investigate the effects of back pain characteristics on the performance of left/right trunk judgment tasks, a method of testing the integrity of cortical maps. Methods:A total of 1008 volunteers completed an online left/right trunk judgment task in which they judged whether a model was rotated or laterally flexed to the left or right in a series of images. Results:Participants who had back pain at the time of testing were less accurate than pain-free controls (P=0.027), as were participants who were pain free but had a history of back pain (P<0.01). However, these results were driven by an interaction such that those with current back pain and a history of back pain were less accurate (mean [95% CI]=76% [74%-78%]) than all other groups (>84% [83%-85%]). Discussion:Trunk motor imagery performance is reduced in people with a history of back pain when they are in a current episode. This is consistent with disruption of cortical proprioceptive representation of the trunk in this group. On the basis of this result, we propose a conceptual model speculating a role of this measure in understanding the development of chronic back pain, a model that can be tested in future studies.

Left/right neck rotation judgments are affected by age, gender, handedness and image rotation.

Understanding motor imagery of the hands and feet has led to promising new treatments for neurological and chronic pain disorders. We aimed to extend this line of research to the neck with a view to developing the definitive platform study upon which clinical and experimental studies can be based. In a cross-sectional experiment with a convenience sample, volunteers were shown 40 photographs of a model with their head turned to the left or right. Images were presented in random order and orientation. Participants judged the direction of neck rotation. They also completed a left/right hand judgment task. 1361 pain-free participants volunteered. Mean ± standard deviation response time (RT) for making left/right judgments of neck rotation was 1.621 ± 0.501 s. Median accuracy was 92.5%. RT was related to age, gender, and handedness (p < 0.001). That is, RT increased with age, was greater in females than in males and was greater in left-handers than in right-handers. Accuracy reduced with age (p < 0.001), but was unaffected by gender or handedness. Judgments were more accurate when images showed a neck rotated to the right than when they showed a neck rotated to the left (p < 0.001). The magnitude of image rotation affected both response time and accuracy (p < 0.001). In general, the performance parameters established for left/right limb judgments also apply for left/right neck rotation judgments. The current work establishes the definitive normative values against which clinical and experimental groups can be compared and reveals unpredicted effects of the direction neck rotation and the orientation of the image.

Language and the pain experience

BACKGROUND AND PURPOSE People in persistent pain have been reported to pay increased attention to specific words or descriptors of pain. The amount of attention paid to pain or cues for pain (such as pain descriptors), has been shown to be a major factor in the modulation of persistent pain. This relationship suggests the possibility that language may have a role both in understanding and managing the persistent pain experience. The aim of this paper is to describe current models of neuromatrices for pain and language, consider the role of attention in persistent pain states and highlight discrepancies, in previous studies based on the McGill Pain Questionnaire (MPQ), of the role of attention on pain descriptors. The existence of a pain neuromatrix originally proposed by Melzack (1990) has been supported by emerging technologies. Similar technologies have recently allowed identification of multiple areas of involvement for the processing of auditory input and the construction of language. As with the construction of pain, this neuromatrix for speech and language may intersect with neural systems for broader cognitive functions such as attention, memory and emotion. METHOD A systematic search was undertaken to identify experimental or review studies, which specifically investigated the role of attention on pain descriptors (as cues for pain) in persistent pain patients. A total of 99 articles were retrieved from six databases, with 66 articles meeting the inclusion criteria. After duplicated articles were eliminated, the remaining 41 articles were reviewed in order to support a link between persistent pain, pain descriptors and attention. RESULTS This review revealed a diverse range of specific pain descriptors, the majority of which were derived from the MPQ. Increased attention to pain descriptors was consistently reported to be associated with emotional state as well as being a significant factor in maintaining persistent pain. However, attempts to investigate the attentional bias of specific pain descriptors highlighted discrepancies between the studies. As well as the diversity of pain descriptors used in studies, they were inconsistently categorized into domains of pain. A lack of consistent bias towards certain pain descriptors was observed, and may be explained simply by the fact that the words provided are not those which subjects themselves would use. CONCLUSION These findings suggest that the multidimensional and individual nature of the persistent pain experience may not be adequately explained by pain questionnaires such as the MPQ. Personalized pain descriptors may communicate the pain experience more appropriately, but may also contribute to an increased sensitivity of cortical pain processing areas by capturing increased attention for that individual. The language used as part of communication between therapists and people with persistent pain may provide an, as yet, unexplored adjunct strategy in management.

Development of a preoperative neuroscience educational program for patients with lumbar radiculopathy.

ABSTRACTPostoperative rehabilitation for lumbar radiculopathy has shown little effect on reducing pain and disability. Current preoperative education programs with a focus on a biomedical approach feature procedural and anatomical information, and these too have shown little effect on postoperative outcomes. This report describes the development of an evidence-based educational program and booklet for patients undergoing lumbar surgery for radiculopathy using a recently conducted systematic review of neuroscience education for musculoskeletal pain. The previous systematic review produced evidence for neuroscience education as well as best-evidence synthesis of the content and delivery methods for neuroscience education for musculoskeletal pain. These evidence statements were extracted and developed into patient-centered messages and a booklet, which was then evaluated by peer and patient review. The neuroscience educational booklet and preoperative program convey key messages from the previous systematic review aimed at reducing fear and anxiety before surgery and assist in developing realistic expectations regarding pain after surgery. Key topics include the decision to undergo surgery, pain processing, peripheral nerve sensitization, effect of anxiety and stress on pain, surgery and the nervous system, and decreasing nerve sensitization. Feedback from the evaluations of the booklet and preoperative program was favorable from all review groups, suggesting that this proposed evidence-based neuroscience educational program may be ready for clinical application.

Preoperative education for lumbar radiculopathy: A survey of US spine surgeons

Background We sought to determine current utilization, importance, content, and delivery methods of preoperative education by spine surgeons in the United States for patients with lumbar radiculopathy. Methods An online cross-sectional survey was used to study a random sample of spine surgeons in the United States. The Spinal Surgery Education Questionnaire (SSEQ) was developed based on previous related surveys and assessed for face and content validity by an expert panel. The SSEQ captured information on demographics, content, delivery methods, utilization, and importance of preoperative education as rated by surgeons. Descriptive statistics were used to describe the current utilization, importance, content, and delivery methods of preoperative education by spine surgeons in the United States for patients with lumbar radiculopathy. Results Of 200 surgeons, 89 (45% response rate) responded to the online survey. The majority (64.2%) provide preoperative education informally during the course of clinical consultation versus a formal preoperative education session. The mean time from the decision to undergo surgery to the date of surgery was 33.65 days. The highest rated educational topics are surgical procedure (96.3%), complications (96.3%), outcomes/expectations (93.8%), anatomy (92.6%), amount of postoperative pain expected (90.1%), and hospital stay (90.1%). Surgeons estimated spending approximately 20% of the preoperative education time specifically addressing pain. Seventy-five percent of the surgeons personally provide the education, and nearly all surgeons (96.3%) use verbal communication with the use of a spine model. Conclusions Spine surgeons believe that preoperative education is important and use a predominantly biomedical approach in preparing patients for surgery. Larger studies are needed to validate these findings.

Are people who do yoga any better at a motor imagery task than those who do not

Background Yoga is a popular recreational activity in Western society and there is an abundance of literature suggesting that yoga may be beneficial for people with a chronic pain disorder. Despite consistently positive results in the literature, the mechanisms of effect are unclear. On the grounds that chronic pain is associated with disruptions of brain-grounded maps of the body, a possible mechanism of yoga is to refine these brain-grounded maps. A left/right body part judgement task is an established way of interrogating these brain-grounded maps of the body. Objective To determine if people who do regular yoga practice perform better at a left/right judgement task than people who do not. Methods Previously collected, cross-sectional data were used. Using a case–control design, participants who reported taking part in regular yoga were selected against age, gender, neck pain and arm pain-matched controls. Participants viewed 40 photographs of a model with their head turned to the left or right, and were asked to judge the direction of neck rotation. They then completed a left/right-hand judgement task. Results Of the 1737 participants, 86 of them reported regularly taking part in yoga. From the remaining participants, 86 matched controls were randomly selected from all matched controls. There was no difference between Groups (yoga and no yoga) for either response time (p=0.109) or accuracy (p=0.964). There was a difference between Tasks; people were faster (p<0.001) and more accurate (p=0.001) at making left/right neck rotation judgements than they were at making left/right-hand judgements, regardless of group. Conclusions People who do regular yoga perform no differently in a left/right judgement task than people who do not.

Dizzy people perform no worse at a motor imagery task requiring whole body mental rotation; a case-control comparison

We wanted to find out whether people who suffer from dizziness take longer than people who do not, to perform a motor imagery task that involves implicit whole body rotation. Our prediction was that people in the “dizzy” group would take longer at a left/right neck rotation judgment task but not a left/right hand judgment task, because actually performing the former, but not the latter, would exacerbate their dizziness. Secondly, we predicted that when dizzy participants responded to neck rotation images, responses would be greatest when images were in the upside down orientation; an orientation with greatest dizzy-provoking potential. To test this idea, we used a case-control comparison design. One hundred and eighteen participants who suffered from dizziness and 118 age, gender, arm pain, and neck pain-matched controls took part in the study. Participants undertook two motor imagery tasks; a left/right neck rotation judgment task and a left/right hand judgment task. The tasks were completed using the Recognise program; an online reaction time task program. Images of neck rotation were shown in four different orientations; 0°, 90°, 180°, and 270°. Participants were asked to respond to each “neck” image identifying it as either “right neck rotation” or a “left neck rotation,” or for hands, a right or a left hand. Results showed that participants in the “dizzy” group were slower than controls at both tasks (p = 0.015), but this was not related to task (p = 0.498). Similarly, “dizzy” participants were not proportionally worse at images of different orientations (p = 0.878). Our findings suggest impaired performance in dizzy people, an impairment that may be confined to motor imagery or may extend more generally.