A Protocol for Pain Neuroscience Education

A Protocol for Pain Neuroscience EducationCase study: applying the model to a patient with chronic low back painDeborah Guthmann, SPTUniversity of North Carolina at Chapel HillDoctorate of Physical Therapy ProgramDecember 4, 2018BackgroundWhat is pain?Former theories described the mechanization of pain like a telephone wire communicating onset, duration, location, and quality of noxious stimuli directly to areas of the brain which bring awareness of painful sensations.ADDIN F1000_CSL_CITATION<~#@#~>[{"First":false,"Last":false,"author":[{"family":"Louw","given":"Adriaan"},{"family":"Puenteduera","given":"Emilio"}],"authorYearDisplayFormat":false,"citation-label":"5563251","collection-editor":[{"given":"OPTP"}],"id":"5563251","invisible":false,"issued":{"date-parts":[["2013"]]},"publisher":"International Spine and Pain Institute","suppress-author":false,"title":"Therapeutic Neuroscience Education: teaching patients about pain","type":"book"}]1 This model determined that pain and illness are because of anatomical pathophysiology. When proponents of this model could not find physical pathology corresponding ?with the patient’s presentation, pain became ‘non-organic’ or an illness of the mind.ADDIN F1000_CSL_CITATION<~#@#~>[{"First":false,"Last":false,"author":[{"family":"Louw","given":"Adriaan"},{"family":"Puenteduera","given":"Emilio"}],"authorYearDisplayFormat":false,"citation-label":"5563251","collection-editor":[{"given":"OPTP"}],"id":"5563251","invisible":false,"issued":{"date-parts":[["2013"]]},"publisher":"International Spine and Pain Institute","suppress-author":false,"title":"Therapeutic Neuroscience Education: teaching patients about pain","type":"book"}]1 This model has failed to help patients, which is evident by the continued rise in chronic pain and unsuccessful treatments. Though the literature varies widely in estimates of chronic pain, estimates range from 15-64%, with some studies citing that 25.3 million adults in the US experience chronic pain daily.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/10669817.2017.1323699","First":false,"Last":false,"PMCID":"PMC5498797","PMID":"28694679","abstract":"In recent years, there has been an increased interest in pain neuroscience education (PNE) in physical therapy. There is growing evidence for the efficacy of PNE to decrease pain, disability, fear-avoidance, pain catastrophization, limited movement, and health care utilization in people struggling with pain. PNE teaches people in pain more about the biology and physiology of their pain experience including processes such as central sensitization, peripheral sensitization, allodynia, inhibition, facilitation, neuroplasticity and more. PNE's neurobiological model often finds itself at odds with traditional biomedical models used in physical therapy. Traditional biomedical models, focusing on anatomy, pathoanatomy, and biomechanics have been shown to have limited efficacy in helping people understand their pain, especially chronic pain, and may in fact even increase a person's pain experience by increasing fear-avoidance and pain catastrophization. An area of physical therapy where the biomedical model is used a lot is manual therapy. This contrast between PNE and manual therapy has seemingly polarized followers from each approach to see PNE as a 'hands-off' approach even having clinicians categorize patients as either in need of receiving PNE (with no hands-on), or hands-on with no PNE. In this paper, we explore the notion of PNE and manual therapy co-existing. PNE research has shown to have immediate effects of various clinical signs and symptoms associated with central sensitization. Using a model of sensitization (innocuous, noxious, and allodynia), we argue that PNE can be used in a manual therapy model, especially treating someone where the nervous system has become increasingly hypervigilant. Level of Evidence: VII.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Nijs","given":"Jo"},{"family":"Puentedura","given":"Emilio J"}],"authorYearDisplayFormat":false,"citation-label":"4209200","container-title":"The Journal of manual & manipulative therapy","container-title-short":"J. Man. Manip. Ther.","id":"4209200","invisible":false,"issue":"3","issued":{"date-parts":[["2017","7"]]},"journalAbbreviation":"J. Man. Manip. Ther.","page":"160-168","suppress-author":false,"title":"A clinical perspective on a pain neuroscience education approach to manual therapy.","type":"article-journal","volume":"25"},{"DOI":"10.1016/j.jpain.2010.07.002","First":false,"Last":false,"PMID":"20797916","abstract":"UNLABELLED: A cross-sectional, Internet-based survey was conducted in a nationally representative sample of United States (US) adults to estimate the point prevalence of chronic pain and to describe sociodemographic correlates and characteristics of chronic pain. The survey was distributed to 35,718 members (aged 18 years and older) of a Web-enabled panel that is representative of the US population, and 27,035 individuals responded. Crude and weighted prevalence estimates were calculated and stratified by age, sex, and type of chronic pain. The weighted point-prevalence of chronic pain (defined as chronic, recurrent, or long-lasting pain lasting for at least 6 months) was 30.7% (95% CI, 29.8-31.7). Prevalence was higher for females (34.3%) than males (26.7%) and increased with age. The weighted prevalence of primary chronic lower back pain was 8.1% and primary osteoarthritis pain was 3.9%. Half of respondents with chronic pain experienced daily pain, and average (past 3 months) pain intensity was severe (≥ 7 on a scale ranging from 0 to 10) for 32%. Multiple logistic regression analysis identified low household income and unemployment as significant socioeconomic correlates of chronic pain. Chronic pain is prevalent among US adults and is related to indicators of poorer socioeconomic status. PERSPECTIVE: The results of this cross-sectional Internet-based survey suggest a considerable burden of chronic pain in US adults. Chronic pain, experienced by about a third of the population, was correlated with indicators of poorer socioeconomic status. Primary chronic pain was most commonly attributed to lower back pain, followed by osteoarthritis pain. Copyright ? 2010 American Pain Society. Published by Elsevier Inc. All rights reserved.","author":[{"family":"Johannes","given":"Catherine B"},{"family":"Le","given":"T Kim"},{"family":"Zhou","given":"Xiaolei"},{"family":"Johnston","given":"Joseph A"},{"family":"Dworkin","given":"Robert H"}],"authorYearDisplayFormat":false,"citation-label":"1756312","container-title":"The Journal of Pain","container-title-short":"J. Pain","id":"1756312","invisible":false,"issue":"11","issued":{"date-parts":[["2010","11"]]},"journalAbbreviation":"J. Pain","page":"1230-1239","suppress-author":false,"title":"The prevalence of chronic pain in United States adults: results of an Internet-based survey.","type":"article-journal","volume":"11"}]2,3 In recent years, this “telephone wire” theory has been replaced with a biopsychosocial model of pain. This model understands that the human experience is modulated by biological, social, and psychosocial domains. Context heavily impacts the output of the central nervous system. Pain occurs when the brain perceives a threat, which is impacted by context, and determines that action is needed. Pain is not merely something a tissue experiences and informs the brain, rather it is a “multiple system output activated by the brain based on perceived threat.”ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/S1356-689X(03)00051-1","First":false,"Last":false,"PMID":"12909433","abstract":"This paper presents an approach to rehabilitation of pain patients. The fundamental principles of the approach are (i) pain is an output of the brain that is produced whenever the brain concludes that body tissue is in danger and action is required, and (ii) pain is a multisystem output that is produced when an individual-specific cortical pain neuromatrix is activated. When pain becomes chronic, the efficacy of the pain neuromatrix is strengthened via nociceptive and non-nociceptive mechanisms, which means that less input, both nociceptive and non-nociceptive, is required to produce pain. The clinical approach focuses on decreasing all inputs that imply that body tissue is in danger and then on activating components of the pain neuromatrix without activating its output. Rehabilitation progresses to increase exposure to threatening input across sensory and non-sensory domains.","author":[{"family":"Moseley","given":"G L"}],"authorYearDisplayFormat":false,"citation-label":"612467","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"612467","invisible":false,"issue":"3","issued":{"date-parts":[["2003","8"]]},"journalAbbreviation":"Man. Ther.","page":"130-140","suppress-author":false,"title":"A pain neuromatrix approach to patients with chronic pain.","type":"article-journal","volume":"8"}]4 Many areas of the brain are involved with processing and are unique to every individual, thus necessitating that treatment of patients be highly variable and personalized. Acute pain, therefore, is a protective output from the central nervous system (CNS) to prevent use of potentially injured structures and to bring awareness to cause(s) of threat. It can be termed nociceptive pain and it is understood to have proportionate and clear aggravating and easing factors.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/S1356-689X(03)00051-1","First":false,"Last":false,"PMID":"12909433","abstract":"This paper presents an approach to rehabilitation of pain patients. The fundamental principles of the approach are (i) pain is an output of the brain that is produced whenever the brain concludes that body tissue is in danger and action is required, and (ii) pain is a multisystem output that is produced when an individual-specific cortical pain neuromatrix is activated. When pain becomes chronic, the efficacy of the pain neuromatrix is strengthened via nociceptive and non-nociceptive mechanisms, which means that less input, both nociceptive and non-nociceptive, is required to produce pain. The clinical approach focuses on decreasing all inputs that imply that body tissue is in danger and then on activating components of the pain neuromatrix without activating its output. Rehabilitation progresses to increase exposure to threatening input across sensory and non-sensory domains.","author":[{"family":"Moseley","given":"G L"}],"authorYearDisplayFormat":false,"citation-label":"612467","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"612467","invisible":false,"issue":"3","issued":{"date-parts":[["2003","8"]]},"journalAbbreviation":"Man. Ther.","page":"130-140","suppress-author":false,"title":"A pain neuromatrix approach to patients with chronic pain.","type":"article-journal","volume":"8"}]4 Chronic pain is pain that lasts beyond normal tissue healing times; now often termed nociplastic pain. This pain is disproportionate and often incorporates both peripheral and central sensitivity.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/S1356-689X(03)00051-1","First":false,"Last":false,"PMID":"12909433","abstract":"This paper presents an approach to rehabilitation of pain patients. The fundamental principles of the approach are (i) pain is an output of the brain that is produced whenever the brain concludes that body tissue is in danger and action is required, and (ii) pain is a multisystem output that is produced when an individual-specific cortical pain neuromatrix is activated. When pain becomes chronic, the efficacy of the pain neuromatrix is strengthened via nociceptive and non-nociceptive mechanisms, which means that less input, both nociceptive and non-nociceptive, is required to produce pain. The clinical approach focuses on decreasing all inputs that imply that body tissue is in danger and then on activating components of the pain neuromatrix without activating its output. Rehabilitation progresses to increase exposure to threatening input across sensory and non-sensory domains.","author":[{"family":"Moseley","given":"G L"}],"authorYearDisplayFormat":false,"citation-label":"612467","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"612467","invisible":false,"issue":"3","issued":{"date-parts":[["2003","8"]]},"journalAbbreviation":"Man. Ther.","page":"130-140","suppress-author":false,"title":"A pain neuromatrix approach to patients with chronic pain.","type":"article-journal","volume":"8"}]4 Smaller and fewer inputs activate the peripheral pathways and less nociceptive messages from the peripheral system are enough to activate CNS output of pain.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/S1356-689X(03)00051-1","First":false,"Last":false,"PMID":"12909433","abstract":"This paper presents an approach to rehabilitation of pain patients. The fundamental principles of the approach are (i) pain is an output of the brain that is produced whenever the brain concludes that body tissue is in danger and action is required, and (ii) pain is a multisystem output that is produced when an individual-specific cortical pain neuromatrix is activated. When pain becomes chronic, the efficacy of the pain neuromatrix is strengthened via nociceptive and non-nociceptive mechanisms, which means that less input, both nociceptive and non-nociceptive, is required to produce pain. The clinical approach focuses on decreasing all inputs that imply that body tissue is in danger and then on activating components of the pain neuromatrix without activating its output. Rehabilitation progresses to increase exposure to threatening input across sensory and non-sensory domains.","author":[{"family":"Moseley","given":"G L"}],"authorYearDisplayFormat":false,"citation-label":"612467","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"612467","invisible":false,"issue":"3","issued":{"date-parts":[["2003","8"]]},"journalAbbreviation":"Man. Ther.","page":"130-140","suppress-author":false,"title":"A pain neuromatrix approach to patients with chronic pain.","type":"article-journal","volume":"8"}]4 As Louw would describe it, where before a patient could run five miles without soreness, now standing up is painful.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.15640/ijhs.v2n3a4","First":false,"Last":false,"author":[{"family":"Louw","given":"Adriaan"},{"family":"Puentedura","given":"Emilio J"}],"authorYearDisplayFormat":false,"citation-label":"6001490","container-title":"International Journal of Human Sciences / Uluslararas? ?nsan Bilimleri Dergisi","container-title-short":"IJHS","id":"6001490","invisible":false,"issue":"3","issued":{"date-parts":[["2014"]]},"journalAbbreviation":"IJHS","suppress-author":false,"title":"Therapeutic neuroscience education, pain, physiotherapy and the pain neuromatrix","type":"article-journal","volume":"2"}]5 This widespread hypersensitivity is characteristic of nociplastic pain and involves impaired descending inhibition and overactive descending and ascending pain pathways. Nociplastic Pain and the Orthopedic ClinicianChronic musculoskeletal pain often begins with a traumatic injury. Typically, an area is sensitive during and after tissue healing in order to protect the site of former damage. It has been noted that in one in four people, this threshold does not return to normal levels and nociplastic pain occurs. It is important to note that nociplastic pain includes both central and peripheral sensitizations. Musculoskeletal changes or degeneration, such as in osteoarthritic damage to articular cartilage, can sustain central sensitization because the continuous nociceptive messages increase the CNS’ heightened awareness and therefore sensitivity.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.math.2011.04.005","First":false,"Last":false,"PMID":"21632273","abstract":"Central sensitization provides an evidence-based explanation for many cases of 'unexplained' chronic musculoskeletal pain. Prior to commencing rehabilitation in such cases, it is crucial to change maladaptive illness perceptions, to alter maladaptive pain cognitions and to reconceptualise pain. This can be accomplished by patient education about central sensitization and its role in chronic pain, a strategy known as pain physiology education. Pain physiology education is indicated when: 1) the clinical picture is characterized and dominated by central sensitization; and 2) maladaptive illness perceptions are present. Both are prerequisites for commencing pain physiology education. Face-to-face sessions of pain physiology education, in conjunction with written educational material, are effective for changing pain cognitions and improving health status in patients with various chronic musculoskeletal pain disorders. These include patients with chronic low back pain, chronic whiplash, fibromyalgia and chronic fatigue syndrome. After biopsychosocial assessment pain physiology education comprises of a first face-to-face session explaining basic pain physiology and contrasting acute nociception versus chronic pain (Session 1). Written information about pain physiology should be provided as homework in between session 1 and 2. The second session can be used to correct misunderstandings, and to facilitate the transition from knowledge to adaptive pain coping during daily life. Pain physiology education is a continuous process initiated during the educational sessions and continued within both the active treatment and during the longer term rehabilitation program. Copyright ? 2011 Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Paul van Wilgen","given":"C"},{"family":"Van Oosterwijck","given":"Jessica"},{"family":"van Ittersum","given":"Miriam"},{"family":"Meeus","given":"Mira"}],"authorYearDisplayFormat":false,"citation-label":"1947295","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"1947295","invisible":false,"issue":"5","issued":{"date-parts":[["2011","10"]]},"journalAbbreviation":"Man. Ther.","page":"413-418","suppress-author":false,"title":"How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines.","type":"article-journal","volume":"16"}]6 Hypersensitivity is believed to play a large role in osteoarthritic discomfort. While defects in articular cartilage are present, the amount of damage found on imaging does not predict or correlate with the degree of pain experienced.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1136/bjsports-2018-099257","First":false,"Last":false,"PMID":"29886437","abstract":"BACKGROUND: Knee MRI is increasingly used to inform clinical management. Features associated with osteoarthritis are often present in asymptomatic uninjured knees; however, the estimated prevalence varies substantially between studies. We performed a systematic review with meta-analysis to provide summary estimates of the prevalence of MRI features of osteoarthritis in asymptomatic uninjured knees. METHODS: We searched six electronic databases for studies reporting MRI osteoarthritis feature prevalence (ie, cartilage defects, meniscal tears, bone marrow lesions and osteophytes) in asymptomatic uninjured knees. Summary estimates were calculated using random-effects meta-analysis (and stratified by mean age: < 40?vs ≥40 years). Meta-regression explored heterogeneity. RESULTS: We included 63 studies (5397 knees of 4751 adults). The overall pooled prevalence of cartilage defects was 24% (95% CI 15% to 34%) and meniscal tears was 10% (7% to 13%), with significantly higher prevalence with age: cartilage defect < 40 years 11% (6%to 17%) and ≥40 years 43% (29% to 57%); meniscal tear < 40 years 4% (2% to 7%) and ≥40 years 19% (13% to 26%). The overall pooled estimate of bone marrow lesions and osteophytes was 18% (12% to 24%) and 25% (14% to 38%), respectively, with prevalence of osteophytes (but not bone marrow lesions) increasing with age. Significant associations were found between prevalence estimates and MRI sequences used, physical activity, radiographic osteoarthritis and risk of bias. CONCLUSIONS: Summary estimates of MRI osteoarthritis feature prevalence among asymptomatic uninjured knees were 4%-14% in adults aged < 40 years to 19%-43% in adults ≥40 years. These imaging findings should be interpreted in the context of clinical presentations and considered in clinical decision-making. ? Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.","author":[{"family":"Culvenor","given":"Adam G"},{"family":"?iestad","given":"Britt Elin"},{"family":"Hart","given":"Harvi F"},{"family":"Stefanik","given":"Joshua J"},{"family":"Guermazi","given":"Ali"},{"family":"Crossley","given":"Kay M"}],"authorYearDisplayFormat":false,"citation-label":"5988330","container-title":"British Journal of Sports Medicine","container-title-short":"Br. J. Sports Med.","id":"5988330","invisible":false,"issued":{"date-parts":[["2018","6","9"]]},"journalAbbreviation":"Br. J. Sports Med.","suppress-author":false,"title":"Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis.","type":"article-journal"}]7 Therefore, while there may also be corresponding tissue changes, identifying chronicity as well as other signs of central and peripheral sensitization will lead to the most appropriate treatment addressing both central and peripheral components.Rehabilitation: With this is mind, rehabilitation of prolonged pain becomes more about addressing nerve sensitivity than tissue damage. Proven methods are structured around delivery of pain neuroscience? education in an effort to decrease the threat associated with pain by increasing a patient’s understanding of physiology.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/10669817.2017.1323699","First":false,"Last":false,"PMCID":"PMC5498797","PMID":"28694679","abstract":"In recent years, there has been an increased interest in pain neuroscience education (PNE) in physical therapy. There is growing evidence for the efficacy of PNE to decrease pain, disability, fear-avoidance, pain catastrophization, limited movement, and health care utilization in people struggling with pain. PNE teaches people in pain more about the biology and physiology of their pain experience including processes such as central sensitization, peripheral sensitization, allodynia, inhibition, facilitation, neuroplasticity and more. PNE's neurobiological model often finds itself at odds with traditional biomedical models used in physical therapy. Traditional biomedical models, focusing on anatomy, pathoanatomy, and biomechanics have been shown to have limited efficacy in helping people understand their pain, especially chronic pain, and may in fact even increase a person's pain experience by increasing fear-avoidance and pain catastrophization. An area of physical therapy where the biomedical model is used a lot is manual therapy. This contrast between PNE and manual therapy has seemingly polarized followers from each approach to see PNE as a 'hands-off' approach even having clinicians categorize patients as either in need of receiving PNE (with no hands-on), or hands-on with no PNE. In this paper, we explore the notion of PNE and manual therapy co-existing. PNE research has shown to have immediate effects of various clinical signs and symptoms associated with central sensitization. Using a model of sensitization (innocuous, noxious, and allodynia), we argue that PNE can be used in a manual therapy model, especially treating someone where the nervous system has become increasingly hypervigilant. Level of Evidence: VII.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Nijs","given":"Jo"},{"family":"Puentedura","given":"Emilio J"}],"authorYearDisplayFormat":false,"citation-label":"4209200","container-title":"The Journal of manual & manipulative therapy","container-title-short":"J. Man. Manip. Ther.","id":"4209200","invisible":false,"issue":"3","issued":{"date-parts":[["2017","7"]]},"journalAbbreviation":"J. Man. Manip. Ther.","page":"160-168","suppress-author":false,"title":"A clinical perspective on a pain neuroscience education approach to manual therapy.","type":"article-journal","volume":"25"}]2 It explains both “biological and physiological processes” of the pain experience and deemphasizes anatomical structures.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/10669817.2017.1323699","First":false,"Last":false,"PMCID":"PMC5498797","PMID":"28694679","abstract":"In recent years, there has been an increased interest in pain neuroscience education (PNE) in physical therapy. There is growing evidence for the efficacy of PNE to decrease pain, disability, fear-avoidance, pain catastrophization, limited movement, and health care utilization in people struggling with pain. PNE teaches people in pain more about the biology and physiology of their pain experience including processes such as central sensitization, peripheral sensitization, allodynia, inhibition, facilitation, neuroplasticity and more. PNE's neurobiological model often finds itself at odds with traditional biomedical models used in physical therapy. Traditional biomedical models, focusing on anatomy, pathoanatomy, and biomechanics have been shown to have limited efficacy in helping people understand their pain, especially chronic pain, and may in fact even increase a person's pain experience by increasing fear-avoidance and pain catastrophization. An area of physical therapy where the biomedical model is used a lot is manual therapy. This contrast between PNE and manual therapy has seemingly polarized followers from each approach to see PNE as a 'hands-off' approach even having clinicians categorize patients as either in need of receiving PNE (with no hands-on), or hands-on with no PNE. In this paper, we explore the notion of PNE and manual therapy co-existing. PNE research has shown to have immediate effects of various clinical signs and symptoms associated with central sensitization. Using a model of sensitization (innocuous, noxious, and allodynia), we argue that PNE can be used in a manual therapy model, especially treating someone where the nervous system has become increasingly hypervigilant. Level of Evidence: VII.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Nijs","given":"Jo"},{"family":"Puentedura","given":"Emilio J"}],"authorYearDisplayFormat":false,"citation-label":"4209200","container-title":"The Journal of manual & manipulative therapy","container-title-short":"J. Man. Manip. Ther.","id":"4209200","invisible":false,"issue":"3","issued":{"date-parts":[["2017","7"]]},"journalAbbreviation":"J. Man. Manip. Ther.","page":"160-168","suppress-author":false,"title":"A clinical perspective on a pain neuroscience education approach to manual therapy.","type":"article-journal","volume":"25"}]2 Such education, when deeply learned and combined with movement therapy, decreases pain and disability, while improving function and quality of life.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/09593985.2016.1194646","First":false,"Last":false,"PMID":"27351541","abstract":"OBJECTIVE: Systematic review of randomized control trials (RCTs) for the effectiveness of pain neuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and healthcare utilization in individuals with chronic musculoskeletal (MSK) pain. DATA SOURCES: Systematic searches were conducted on 11 databases. 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 RCTs evaluating the effect of PNE on chronic MSK pain were considered for inclusion. Additional Limitations: Studies published in English, published within the last 20 years, and patients older than 18 years. No limitations were set on specific outcome measures. DATA EXTRACTION: Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach. DATA SYNTHESIS: Study quality of the 13 RCTs used in this review was assessed by 2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation to outcomes measurements and effectiveness. CONCLUSIONS: Current evidence supports the use of PNE for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Zimney","given":"Kory"},{"family":"Puentedura","given":"Emilio J"},{"family":"Diener","given":"Ina"}],"authorYearDisplayFormat":false,"citation-label":"2261235","container-title":"Physiotherapy Theory and Practice","container-title-short":"Physiother. Theory Pract.","id":"2261235","invisible":false,"issue":"5","issued":{"date-parts":[["2016","7"]]},"journalAbbreviation":"Physiother. Theory Pract.","page":"332-355","suppress-author":false,"title":"The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature.","type":"article-journal","volume":"32"}]8 Research shows that face-to-face, individual education sessions are more effective than delivery through groups or written material alone.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.math.2011.04.005","First":false,"Last":false,"PMID":"21632273","abstract":"Central sensitization provides an evidence-based explanation for many cases of 'unexplained' chronic musculoskeletal pain. Prior to commencing rehabilitation in such cases, it is crucial to change maladaptive illness perceptions, to alter maladaptive pain cognitions and to reconceptualise pain. This can be accomplished by patient education about central sensitization and its role in chronic pain, a strategy known as pain physiology education. Pain physiology education is indicated when: 1) the clinical picture is characterized and dominated by central sensitization; and 2) maladaptive illness perceptions are present. Both are prerequisites for commencing pain physiology education. Face-to-face sessions of pain physiology education, in conjunction with written educational material, are effective for changing pain cognitions and improving health status in patients with various chronic musculoskeletal pain disorders. These include patients with chronic low back pain, chronic whiplash, fibromyalgia and chronic fatigue syndrome. After biopsychosocial assessment pain physiology education comprises of a first face-to-face session explaining basic pain physiology and contrasting acute nociception versus chronic pain (Session 1). Written information about pain physiology should be provided as homework in between session 1 and 2. The second session can be used to correct misunderstandings, and to facilitate the transition from knowledge to adaptive pain coping during daily life. Pain physiology education is a continuous process initiated during the educational sessions and continued within both the active treatment and during the longer term rehabilitation program. Copyright ? 2011 Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Paul van Wilgen","given":"C"},{"family":"Van Oosterwijck","given":"Jessica"},{"family":"van Ittersum","given":"Miriam"},{"family":"Meeus","given":"Mira"}],"authorYearDisplayFormat":false,"citation-label":"1947295","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"1947295","invisible":false,"issue":"5","issued":{"date-parts":[["2011","10"]]},"journalAbbreviation":"Man. Ther.","page":"413-418","suppress-author":false,"title":"How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines.","type":"article-journal","volume":"16"}]6 However, written material in addition to in-person education is preferred and ‘appreciated.’ PNE should accompany pain reduction techniques (i.e. modalities, manual therapy) as well as other interventions to address all biopsychosocial factors contributing to chronicity. (see table 2)PNE ProtocolApplying this knowledge to an independent clinical experience in physical therapy school, this writer wishes to create a protocol for pain education of the chronic low back pain population. As a template for the patient interaction, the protocol will guide the reader through identification, delivery of education, and initiation of treatment. The outline first attempts to change the maladaptive belief of pain as a threat and then initiate treatment with improved motivation and compliance. The following practice guidelines were adapted from Jo Nijs’s model as outlined in his article, “How to explain central sensitization to patients with unexplained chronic musculoskeletal pain: a practice guideline.”ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.math.2011.04.005","First":false,"Last":false,"PMID":"21632273","abstract":"Central sensitization provides an evidence-based explanation for many cases of 'unexplained' chronic musculoskeletal pain. Prior to commencing rehabilitation in such cases, it is crucial to change maladaptive illness perceptions, to alter maladaptive pain cognitions and to reconceptualise pain. This can be accomplished by patient education about central sensitization and its role in chronic pain, a strategy known as pain physiology education. Pain physiology education is indicated when: 1) the clinical picture is characterized and dominated by central sensitization; and 2) maladaptive illness perceptions are present. Both are prerequisites for commencing pain physiology education. Face-to-face sessions of pain physiology education, in conjunction with written educational material, are effective for changing pain cognitions and improving health status in patients with various chronic musculoskeletal pain disorders. These include patients with chronic low back pain, chronic whiplash, fibromyalgia and chronic fatigue syndrome. After biopsychosocial assessment pain physiology education comprises of a first face-to-face session explaining basic pain physiology and contrasting acute nociception versus chronic pain (Session 1). Written information about pain physiology should be provided as homework in between session 1 and 2. The second session can be used to correct misunderstandings, and to facilitate the transition from knowledge to adaptive pain coping during daily life. Pain physiology education is a continuous process initiated during the educational sessions and continued within both the active treatment and during the longer term rehabilitation program. Copyright ? 2011 Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Paul van Wilgen","given":"C"},{"family":"Van Oosterwijck","given":"Jessica"},{"family":"van Ittersum","given":"Miriam"},{"family":"Meeus","given":"Mira"}],"authorYearDisplayFormat":false,"citation-label":"1947295","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"1947295","invisible":false,"issue":"5","issued":{"date-parts":[["2011","10"]]},"journalAbbreviation":"Man. Ther.","page":"413-418","suppress-author":false,"title":"How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines.","type":"article-journal","volume":"16"}]6Step 1: Identifying the patient appropriate for pain physiology educationBefore seeing a patient, the chart evaluation can typically hint at the diagnosis of central sensitivity. Typically, patients have seen multiple providers and attempted other conservative evaluations and treatment measures before entering the clinic. Therefore, the exam should incorporate musculoskeletal assessment that clears red flags, observes general movements, and focuses on widespread nerve sensitivity through neurodynamic testing rather than specific orthopedic tests. A patient with central sensitization will present with hyper-responsiveness to movement and sensitivity to touch.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.pain.2010.09.030","First":false,"Last":false,"PMCID":"PMC3268359","PMID":"20961685","abstract":"Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization. Central sensitization manifests as pain hypersensitivity, particularly dynamic tactile allodynia, secondary punctate or pressure hyperalgesia, aftersensations, and enhanced temporal summation. It can be readily and rapidly elicited in human volunteers by diverse experimental noxious conditioning stimuli to skin, muscles or viscera, and in addition to producing pain hypersensitivity, results in secondary changes in brain activity that can be detected by electrophysiological or imaging techniques. Studies in clinical cohorts reveal changes in pain sensitivity that have been interpreted as revealing an important contribution of central sensitization to the pain phenotype in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders and post-surgical pain. The comorbidity of those pain hypersensitivity syndromes that present in the absence of inflammation or a neural lesion, their similar pattern of clinical presentation and response to centrally acting analgesics, may reflect a commonality of central sensitization to their pathophysiology. An important question that still needs to be determined is whether there are individuals with a higher inherited propensity for developing central sensitization than others, and if so, whether this conveys an increased risk in both developing conditions with pain hypersensitivity, and their chronification. Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity. We have certainly come a long way since the first discovery of activity-dependent synaptic plasticity in the spinal cord and the revelation that it occurs and produces pain hypersensitivity in patients. Nevertheless, discovering the genetic and environmental contributors to and objective biomarkers of central sensitization will be highly beneficial, as will additional treatment options to prevent or reduce this prevalent and promiscuous form of pain plasticity. Copyright ? 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.","author":[{"family":"Woolf","given":"C J"}],"authorYearDisplayFormat":false,"citation-label":"122530","container-title":"Pain","container-title-short":"Pain","id":"122530","invisible":false,"issue":"3 Suppl","issued":{"date-parts":[["2011","3"]]},"journalAbbreviation":"Pain","page":"S2-15","suppress-author":false,"title":"Central sensitization: implications for the diagnosis and treatment of pain.","type":"article-journal","volume":"152"}]9 They will have generalized decreases in pressure pain thresholds which is detected with pressure algometers or manual palpation. Subjective description of symptoms often include “burning” sensations.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.pain.2010.09.030","First":false,"Last":false,"PMCID":"PMC3268359","PMID":"20961685","abstract":"Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization. Central sensitization manifests as pain hypersensitivity, particularly dynamic tactile allodynia, secondary punctate or pressure hyperalgesia, aftersensations, and enhanced temporal summation. It can be readily and rapidly elicited in human volunteers by diverse experimental noxious conditioning stimuli to skin, muscles or viscera, and in addition to producing pain hypersensitivity, results in secondary changes in brain activity that can be detected by electrophysiological or imaging techniques. Studies in clinical cohorts reveal changes in pain sensitivity that have been interpreted as revealing an important contribution of central sensitization to the pain phenotype in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders and post-surgical pain. The comorbidity of those pain hypersensitivity syndromes that present in the absence of inflammation or a neural lesion, their similar pattern of clinical presentation and response to centrally acting analgesics, may reflect a commonality of central sensitization to their pathophysiology. An important question that still needs to be determined is whether there are individuals with a higher inherited propensity for developing central sensitization than others, and if so, whether this conveys an increased risk in both developing conditions with pain hypersensitivity, and their chronification. Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity. We have certainly come a long way since the first discovery of activity-dependent synaptic plasticity in the spinal cord and the revelation that it occurs and produces pain hypersensitivity in patients. Nevertheless, discovering the genetic and environmental contributors to and objective biomarkers of central sensitization will be highly beneficial, as will additional treatment options to prevent or reduce this prevalent and promiscuous form of pain plasticity. Copyright ? 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.","author":[{"family":"Woolf","given":"C J"}],"authorYearDisplayFormat":false,"citation-label":"122530","container-title":"Pain","container-title-short":"Pain","id":"122530","invisible":false,"issue":"3 Suppl","issued":{"date-parts":[["2011","3"]]},"journalAbbreviation":"Pain","page":"S2-15","suppress-author":false,"title":"Central sensitization: implications for the diagnosis and treatment of pain.","type":"article-journal","volume":"152"}]9 Pain is diffuse and spreading, not following dermatome or myotome patterns.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.pain.2010.09.030","First":false,"Last":false,"PMCID":"PMC3268359","PMID":"20961685","abstract":"Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization. Central sensitization manifests as pain hypersensitivity, particularly dynamic tactile allodynia, secondary punctate or pressure hyperalgesia, aftersensations, and enhanced temporal summation. It can be readily and rapidly elicited in human volunteers by diverse experimental noxious conditioning stimuli to skin, muscles or viscera, and in addition to producing pain hypersensitivity, results in secondary changes in brain activity that can be detected by electrophysiological or imaging techniques. Studies in clinical cohorts reveal changes in pain sensitivity that have been interpreted as revealing an important contribution of central sensitization to the pain phenotype in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders and post-surgical pain. The comorbidity of those pain hypersensitivity syndromes that present in the absence of inflammation or a neural lesion, their similar pattern of clinical presentation and response to centrally acting analgesics, may reflect a commonality of central sensitization to their pathophysiology. An important question that still needs to be determined is whether there are individuals with a higher inherited propensity for developing central sensitization than others, and if so, whether this conveys an increased risk in both developing conditions with pain hypersensitivity, and their chronification. Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity. We have certainly come a long way since the first discovery of activity-dependent synaptic plasticity in the spinal cord and the revelation that it occurs and produces pain hypersensitivity in patients. Nevertheless, discovering the genetic and environmental contributors to and objective biomarkers of central sensitization will be highly beneficial, as will additional treatment options to prevent or reduce this prevalent and promiscuous form of pain plasticity. Copyright ? 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.","author":[{"family":"Woolf","given":"C J"}],"authorYearDisplayFormat":false,"citation-label":"122530","container-title":"Pain","container-title-short":"Pain","id":"122530","invisible":false,"issue":"3 Suppl","issued":{"date-parts":[["2011","3"]]},"journalAbbreviation":"Pain","page":"S2-15","suppress-author":false,"title":"Central sensitization: implications for the diagnosis and treatment of pain.","type":"article-journal","volume":"152"},{"DOI":"10.1016/j.neuron.2006.09.021","First":false,"Last":false,"PMCID":"PMC1810425","PMID":"17015228","abstract":"Neuropathic pain refers to pain that originates from pathology of the nervous system. Diabetes, infection (herpes zoster), nerve compression, nerve trauma, \"channelopathies,\" and autoimmune disease are examples of diseases that may cause neuropathic pain. The development of both animal models and newer pharmacological strategies has led to an explosion of interest in the underlying mechanisms. Neuropathic pain reflects both peripheral and central sensitization mechanisms. Abnormal signals arise not only from injured axons but also from the intact nociceptors that share the innervation territory of the injured nerve. This review focuses on how both human studies and animal models are helping to elucidate the mechanisms underlying these surprisingly common disorders. The rapid gain in knowledge about abnormal signaling promises breakthroughs in the treatment of these often debilitating disorders.","author":[{"family":"Campbell","given":"James N"},{"family":"Meyer","given":"Richard A"}],"authorYearDisplayFormat":false,"citation-label":"234837","container-title":"Neuron","container-title-short":"Neuron","id":"234837","invisible":false,"issue":"1","issued":{"date-parts":[["2006","10","5"]]},"journalAbbreviation":"Neuron","page":"77-92","suppress-author":false,"title":"Mechanisms of neuropathic pain.","type":"article-journal","volume":"52"}]9,10 The patient’s pain does not have clear mechanical provocative or easing factors, and may increase with temperature, stress, emotions, or without known cause. Typically, sleep is impacted and patients will complain of fatigue and aches upon awakening. Patients may express difficulty with memory or concentration and mood swings. Nociplastic pain is often accompanied or preceded by mental health illnesses such as depression and anxiety.9 The patient will also present with maladaptive pain cognition, often with hypervigilance and altered perceptions. Outcome measures can identify psychosocial problems which contribute to the development and maintenance of chronic pain.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.12965/jer.130079","First":false,"Last":false,"PMCID":"PMC3884874","PMID":"24409431","abstract":"This study was conducted in order to determine the relationship among fear-avoidance beliefs, pain and disability index in patients with low back pain as well as to identify factors having an influence on fear-avoidance beliefs, pain and disability index. The subjects used in this study were 55 patients with low back pain. All subjects completed a fear-avoidance beliefs questionnaire (FABQ) which was divided into two subscales, FABQ for physical activity (FABQ-P) and FABQ for work (FABQ-W), Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ). In correlation analysis, FABQ-P appeared to show significant correlation with FABQ-W, FABQ-total, VAS and RMDQ, and all variables showed significant correlation with each other. Findings of this study suggest that screening for fear-avoidance beliefs may be useful for identification of patients at risk of psychosocial problems as well as pain intensity and physical impairment. ","author":[{"family":"Chung","given":"Eun Jung"},{"family":"Hur","given":"Young-Goo"},{"family":"Lee","given":"Byoung-Hee"}],"authorYearDisplayFormat":false,"citation-label":"5998105","container-title":"Journal of exercise rehabilitation","container-title-short":"J. Exerc. Rehabil.","id":"5998105","invisible":false,"issue":"6","issued":{"date-parts":[["2013","12","31"]]},"journalAbbreviation":"J. Exerc. Rehabil.","page":"532-535","suppress-author":false,"title":"A study of the relationship among fear-avoidance beliefs, pain and disability index in patients with low back pain.","type":"article-journal","volume":"9"}]11 The fear and avoidance questionnaire (FABQ), Oswestry Disability Index (ODI), and the Roland Morris Disability Questionnaire are frequently used to screen for fear-avoidance and impairments. High scores on these tests have been linked to poor outcomes and chronic pain.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.12965/jer.130079","First":false,"Last":false,"PMCID":"PMC3884874","PMID":"24409431","abstract":"This study was conducted in order to determine the relationship among fear-avoidance beliefs, pain and disability index in patients with low back pain as well as to identify factors having an influence on fear-avoidance beliefs, pain and disability index. The subjects used in this study were 55 patients with low back pain. All subjects completed a fear-avoidance beliefs questionnaire (FABQ) which was divided into two subscales, FABQ for physical activity (FABQ-P) and FABQ for work (FABQ-W), Visual Analog Scale (VAS), Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ). In correlation analysis, FABQ-P appeared to show significant correlation with FABQ-W, FABQ-total, VAS and RMDQ, and all variables showed significant correlation with each other. Findings of this study suggest that screening for fear-avoidance beliefs may be useful for identification of patients at risk of psychosocial problems as well as pain intensity and physical impairment. ","author":[{"family":"Chung","given":"Eun Jung"},{"family":"Hur","given":"Young-Goo"},{"family":"Lee","given":"Byoung-Hee"}],"authorYearDisplayFormat":false,"citation-label":"5998105","container-title":"Journal of exercise rehabilitation","container-title-short":"J. Exerc. Rehabil.","id":"5998105","invisible":false,"issue":"6","issued":{"date-parts":[["2013","12","31"]]},"journalAbbreviation":"J. Exerc. Rehabil.","page":"532-535","suppress-author":false,"title":"A study of the relationship among fear-avoidance beliefs, pain and disability index in patients with low back pain.","type":"article-journal","volume":"9"}]11Step 2: Education beginsOnce the physical therapist has identified nociplastic origins of symptoms, the patient should receive an explanation of the results which indicate appropriateness for a type of treatment that includes education on pain neurophysiology (treatment rationale). Pain neuroscience education (PNE) should take place over at least two sessions, face-to-face, with content based on “Explain Pain” and supplemented material from this writer’s own research. ADDIN F1000_CSL_CITATION<~#@#~>[{"First":false,"Last":false,"author":[{"family":"Louw","given":"Adriaan"},{"family":"Puenteduera","given":"Emilio"}],"authorYearDisplayFormat":false,"citation-label":"5563251","collection-editor":[{"given":"OPTP"}],"id":"5563251","invisible":false,"issued":{"date-parts":[["2013"]]},"publisher":"International Spine and Pain Institute","suppress-author":false,"title":"Therapeutic Neuroscience Education: teaching patients about pain","type":"book"}]1 Education will last 30-60 minutes per session, as proposed by Nijs and Louw.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.3109/09593985.2011.562602","First":false,"Last":false,"PMID":"21721995","abstract":"Chronic low back pain (CLBP) remains prevalent in society, and conservative treatment strategies appear to have little effect. It is proposed that patients with CLBP may have altered cognition and increased fear, which impacts their ability to move, perform exercise, and partake in activities of daily living. Neuroscience education (NE) aims to change a patient's cognition regarding their pain state, which may result in decreased fear, ultimately resulting in confrontation of pain barriers and a resumption of normal activities. A 64-year-old female with history of CLBP was the patient for this case report. A physical examination, the Numeric Pain Rating Scale (NPRS), Oswestry Disability Index (ODI), Fear-Avoidance Beliefs Questionnaire (FABQ), and Zung Depression Scale were assessed during her initial physical therapy visit, immediately after her first physical therapy session, and at 7-month follow-up. Treatment consisted of an abbreviated NE approach, exercises (range of motion, stretches, and cardiovascular), and aquatic therapy. She attended twice a week for 4 weeks, or 8 visits total. Pre-NE, the patient reported NPRS?=?9/10; ODI?=?54%; FABQ-W?=?25/42,; FABQ-PA?=?20/24, and Zung?=?58. Immediately following the 75-minute evaluation and NE session, the patient reported improvement in all four outcome measures, most notably a reduction in the FABQ-W score to 2/42 and the FABQ-PA to 1/24. At a 7-month follow-up, all outcome measures continued to be improved. NE aimed at decreasing fear associated with movement may be a valuable adjunct to movement-based therapy, such as exercise, for patients with CLBP.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Puentedura","given":"Emilio Louie"},{"family":"Mintken","given":"Paul"}],"authorYearDisplayFormat":false,"citation-label":"3516653","container-title":"Physiotherapy Theory and Practice","container-title-short":"Physiother. Theory Pract.","id":"3516653","invisible":false,"issue":"1","issued":{"date-parts":[["2012","1"]]},"journalAbbreviation":"Physiother. Theory Pract.","page":"50-62","suppress-author":false,"title":"Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: a case report.","type":"article-journal","volume":"28"},{"DOI":"10.1016/j.math.2011.04.005","First":false,"Last":false,"PMID":"21632273","abstract":"Central sensitization provides an evidence-based explanation for many cases of 'unexplained' chronic musculoskeletal pain. Prior to commencing rehabilitation in such cases, it is crucial to change maladaptive illness perceptions, to alter maladaptive pain cognitions and to reconceptualise pain. This can be accomplished by patient education about central sensitization and its role in chronic pain, a strategy known as pain physiology education. Pain physiology education is indicated when: 1) the clinical picture is characterized and dominated by central sensitization; and 2) maladaptive illness perceptions are present. Both are prerequisites for commencing pain physiology education. Face-to-face sessions of pain physiology education, in conjunction with written educational material, are effective for changing pain cognitions and improving health status in patients with various chronic musculoskeletal pain disorders. These include patients with chronic low back pain, chronic whiplash, fibromyalgia and chronic fatigue syndrome. After biopsychosocial assessment pain physiology education comprises of a first face-to-face session explaining basic pain physiology and contrasting acute nociception versus chronic pain (Session 1). Written information about pain physiology should be provided as homework in between session 1 and 2. The second session can be used to correct misunderstandings, and to facilitate the transition from knowledge to adaptive pain coping during daily life. Pain physiology education is a continuous process initiated during the educational sessions and continued within both the active treatment and during the longer term rehabilitation program. Copyright ? 2011 Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Paul van Wilgen","given":"C"},{"family":"Van Oosterwijck","given":"Jessica"},{"family":"van Ittersum","given":"Miriam"},{"family":"Meeus","given":"Mira"}],"authorYearDisplayFormat":false,"citation-label":"1947295","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"1947295","invisible":false,"issue":"5","issued":{"date-parts":[["2011","10"]]},"journalAbbreviation":"Man. Ther.","page":"413-418","suppress-author":false,"title":"How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines.","type":"article-journal","volume":"16"}]6,12 An outline of education and information provided can be found in the attached document. In general, education should cover nervous system physiology with an emphasis on pain system physiology. Acute and chronic pain definitions should be introduced as well as the central nervous system’s role in the production of pain. Discussion of contributors to central sensitivity should be included as well as methods to reduce sensitivity.Step 3: Reinforcement via homeworkOnly deep learning of pain neuroscience education will impact the pain experience.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/09593985.2016.1194646","First":false,"Last":false,"PMID":"27351541","abstract":"OBJECTIVE: Systematic review of randomized control trials (RCTs) for the effectiveness of pain neuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and healthcare utilization in individuals with chronic musculoskeletal (MSK) pain. DATA SOURCES: Systematic searches were conducted on 11 databases. 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 RCTs evaluating the effect of PNE on chronic MSK pain were considered for inclusion. Additional Limitations: Studies published in English, published within the last 20 years, and patients older than 18 years. No limitations were set on specific outcome measures. DATA EXTRACTION: Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach. DATA SYNTHESIS: Study quality of the 13 RCTs used in this review was assessed by 2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation to outcomes measurements and effectiveness. CONCLUSIONS: Current evidence supports the use of PNE for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Zimney","given":"Kory"},{"family":"Puentedura","given":"Emilio J"},{"family":"Diener","given":"Ina"}],"authorYearDisplayFormat":false,"citation-label":"2261235","container-title":"Physiotherapy Theory and Practice","container-title-short":"Physiother. Theory Pract.","id":"2261235","invisible":false,"issue":"5","issued":{"date-parts":[["2016","7"]]},"journalAbbreviation":"Physiother. Theory Pract.","page":"332-355","suppress-author":false,"title":"The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature.","type":"article-journal","volume":"32"}]8 The patient should be provided with written educational information about neurophysiology and review concepts discussed with the therapist at home, between sessions. The source used by this writer was, “Recovery Strategies: a pain guidebook,” by Dr. Greg Lehman. Step 4: Correcting, reconceptualization, and applicationOnce information is delivered, it is imperative to identify misunderstandings and correct beliefs in later sessions. “De-education” seeks to correct misbeliefs which limit patient outcomes.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/10669817.2017.1323699","First":false,"Last":false,"PMCID":"PMC5498797","PMID":"28694679","abstract":"In recent years, there has been an increased interest in pain neuroscience education (PNE) in physical therapy. There is growing evidence for the efficacy of PNE to decrease pain, disability, fear-avoidance, pain catastrophization, limited movement, and health care utilization in people struggling with pain. PNE teaches people in pain more about the biology and physiology of their pain experience including processes such as central sensitization, peripheral sensitization, allodynia, inhibition, facilitation, neuroplasticity and more. PNE's neurobiological model often finds itself at odds with traditional biomedical models used in physical therapy. Traditional biomedical models, focusing on anatomy, pathoanatomy, and biomechanics have been shown to have limited efficacy in helping people understand their pain, especially chronic pain, and may in fact even increase a person's pain experience by increasing fear-avoidance and pain catastrophization. An area of physical therapy where the biomedical model is used a lot is manual therapy. This contrast between PNE and manual therapy has seemingly polarized followers from each approach to see PNE as a 'hands-off' approach even having clinicians categorize patients as either in need of receiving PNE (with no hands-on), or hands-on with no PNE. In this paper, we explore the notion of PNE and manual therapy co-existing. PNE research has shown to have immediate effects of various clinical signs and symptoms associated with central sensitization. Using a model of sensitization (innocuous, noxious, and allodynia), we argue that PNE can be used in a manual therapy model, especially treating someone where the nervous system has become increasingly hypervigilant. Level of Evidence: VII.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Nijs","given":"Jo"},{"family":"Puentedura","given":"Emilio J"}],"authorYearDisplayFormat":false,"citation-label":"4209200","container-title":"The Journal of manual & manipulative therapy","container-title-short":"J. Man. Manip. Ther.","id":"4209200","invisible":false,"issue":"3","issued":{"date-parts":[["2017","7"]]},"journalAbbreviation":"J. Man. Manip. Ther.","page":"160-168","suppress-author":false,"title":"A clinical perspective on a pain neuroscience education approach to manual therapy.","type":"article-journal","volume":"25"}]2 This step will allow patients to ask questions and make the concepts personal as the therapist discusses sensitization and contributing factors in the perspective of the patient’s unique life experiences. Tools such as the neurophysiology of pain quiz may guide this dialogue.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1097/AJP.0000000000000658","First":false,"Last":false,"PMID":"30260841","abstract":"OBJECTIVE: Educating patients about the neurobiological basis of their pain experience is now an important part of managing patients with pain disorders. The aim of this study was to evaluate the measurement properties of the Neurophysiology of Pain Questionnaire (NPQ) in a population seeking osteopathy treatment for both acute and chronic musculoskeletal pain complaints. METHODS: Patients attending the Victoria University Osteopathy Clinic for their initial osteopathy consultation were recruited consecutively. Prior to their consultation patients were invited to complete a health information questionnaire and the NPQ. The measurement properties of the NPQ were evaluated using Rasch analysis. RESULTS: Two-hundred and ninety-four patients completed the NPQ (female 57.1%, mean age 35.5?y). Over two-thirds of these patients presented with a spinal complaint and 53% of patient presentations were acute. Initial analysis suggested the NPQ responses did not fit the Rasch model. Modifications to the NPQ including removing items and removing person responses, resulted in the development of a 14-item unidimensional version of the NPQ that was and free from differential item functioning. DISCUSSION: The study provides further evidence for the validity of the NPQ total score, derived from a population seeking care for an acute or chronic musculoskeletal pain complaint. The total score is interval-level data and can be used to evaluate changes in pain knowledge pre, during and after pain education interventions. Future studies could utilize this revised version of the NPQ in longitudinal designs and also evaluate pain knowledge changes in conjunction with other objective or subjective pain measures.","author":[{"family":"Vaughan","given":"Brett"},{"family":"Mulcahy","given":"Jane"},{"family":"Fitzgerald","given":"Kylie"},{"family":"Austin","given":"Philip"}],"authorYearDisplayFormat":false,"citation-label":"6026825","container-title":"The Clinical Journal of Pain","container-title-short":"Clin. J. Pain","id":"6026825","invisible":false,"issued":{"date-parts":[["2018","9","26"]]},"journalAbbreviation":"Clin. J. Pain","suppress-author":false,"title":"Evaluating patient's understanding of pain neurophysiology: rasch analysis of the neurophysiology of pain questionnaire.","type":"article-journal"}]13 Patients should then set specific, measurable, achievable, relevant, and timely functional goals from the biopsychosocial understanding of pain under the guidance of the PT. Broad examples involve reducing stress, increasing physical activity, and improving sleep in order to de-sensitize nociceptors. Step 5: Applying pain knowledge during treatmentAfter learning about the biopsychosocial model of pain and pain physiology, the patient would benefit from reinforcement of concepts while being actively treated for nociplastic pain. Research has found that the pain experience is most impacted when PNE is combined with another treatment.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/09593985.2016.1194646","First":false,"Last":false,"PMID":"27351541","abstract":"OBJECTIVE: Systematic review of randomized control trials (RCTs) for the effectiveness of pain neuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and healthcare utilization in individuals with chronic musculoskeletal (MSK) pain. DATA SOURCES: Systematic searches were conducted on 11 databases. 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 RCTs evaluating the effect of PNE on chronic MSK pain were considered for inclusion. Additional Limitations: Studies published in English, published within the last 20 years, and patients older than 18 years. No limitations were set on specific outcome measures. DATA EXTRACTION: Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach. DATA SYNTHESIS: Study quality of the 13 RCTs used in this review was assessed by 2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation to outcomes measurements and effectiveness. CONCLUSIONS: Current evidence supports the use of PNE for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Zimney","given":"Kory"},{"family":"Puentedura","given":"Emilio J"},{"family":"Diener","given":"Ina"}],"authorYearDisplayFormat":false,"citation-label":"2261235","container-title":"Physiotherapy Theory and Practice","container-title-short":"Physiother. Theory Pract.","id":"2261235","invisible":false,"issue":"5","issued":{"date-parts":[["2016","7"]]},"journalAbbreviation":"Physiother. Theory Pract.","page":"332-355","suppress-author":false,"title":"The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature.","type":"article-journal","volume":"32"}]8 Suggested interventions for central and peripheral sensitivity involve top-down and bottom-up treatments; treatments should address central sensitivity as well as peripheral components that sustain hypersensitivity. This writer emphasized pain neuroscience education, aerobic exercise, sleep, hygiene, and goal setting. Secondary interventions include 18 interventions that address all components of the pain experience.ADDIN F1000_CSL_CITATION<~#@#~>[{"First":false,"Last":false,"author":[{"family":"Louw","given":"Adriaan"},{"family":"Puenteduera","given":"Emilio"}],"authorYearDisplayFormat":false,"citation-label":"5563251","collection-editor":[{"given":"OPTP"}],"id":"5563251","invisible":false,"issued":{"date-parts":[["2013"]]},"publisher":"International Spine and Pain Institute","suppress-author":false,"title":"Therapeutic Neuroscience Education: teaching patients about pain","type":"book"}]1 (see table 2)In this consolidatory step, it is important to continually reinforce PNE concepts in communication with the patient, explaining how each treatment relates to the pain model and addresses neuropathic processes.Case Description: Subject Description, History, and Systems ReviewHistoryMs. Camp is a 37-year-old female with a 17-year history of back pain. She works full time at the Veterans Association Hospital in respiratory care. She is a single mom with two kids, describing them as “abnormally easy” and stress-relieving components of her life. She lives with her children and dog and has a supportive family network in the area. She experienced a recent exacerbation with reports of radiating pain into her right leg and right buttock. At the time of her physical therapy evaluation, she was finishing a two-week leave of absence due to intense, disabling pain in her low back and right leg. Specific to her chief complaint, she sustained a traumatic injury 17 years ago when someone fell on her during a training exercise in the military. She describes pain since that occurrence, but imaging was negative for significant soft tissue or bony damage. She cycled through three physical therapists, multiple acupuncture trials, and a chiropractor with no sustaining relief. Her medical history is significant for depression, amenorrhea, polyarthralgia, chronic pain, anxiety, and degenerative arthritis of spine. She is currently on medication for anxiety and depression and takes pain medication and muscle relaxers intermittently. These comorbidities are known to impact patient outcomes and contribute to the diagnosis of central sensitization.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.math.2009.12.001","First":false,"Last":false,"PMID":"20036180","abstract":"Central sensitization plays an important role in the pathophysiology of numerous musculoskeletal pain disorders, yet it remains unclear how manual therapists can recognize this condition. Therefore, mechanism based clinical guidelines for the recognition of central sensitization in patients with musculoskeletal pain are provided. By using our current understanding of central sensitization during the clinical assessment of patients with musculoskeletal pain, manual therapists can apply the science of nociceptive and pain processing neurophysiology to the practice of manual therapy. The diagnosis/assessment of central sensitization in individual patients with musculoskeletal pain is not straightforward, however manual therapists can use information obtained from the medical diagnosis, combined with the medical history of the patient, as well as the clinical examination and the analysis of the treatment response in order to recognize central sensitization. The clinical examination used to recognize central sensitization entails the distinction between primary and secondary hyperalgesia.\n \n Copyright 2009 Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Van Houdenhove","given":"Boudewijn"},{"family":"Oostendorp","given":"Rob A B"}],"authorYearDisplayFormat":false,"citation-label":"1212232","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"1212232","invisible":false,"issue":"2","issued":{"date-parts":[["2010","4"]]},"journalAbbreviation":"Man. Ther.","page":"135-141","suppress-author":false,"title":"Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice.","type":"article-journal","volume":"15"}]14 Imagery of her spine in 2015 showed normal impressions without sclerosis, erosion, lytic or blastic lesions ruling out “red flag” conditions such as radiculopathy, myelopathy, or spondylolisthesis. Though she reported falls and intermittent numbness and tingling in her legs, she denied symptoms of radiculopathy, myelopathy, cancer, systemic infection, or cardiovascular issues. Ms. Camp was chosen for this case study because her history and subjective reports are consistent with nociplastic or chronic pain with central sensitization. She also expressed motivation and willingness to comply with therapy indicating that she would not be lost to follow up. Ms. Camp verbalizes that she wants to be able to work without pain, go on road trips with her kids, be able to redecorate her home, and take her dog on walks without significant pain.In addition to patient identified goals, the writer created short- and long-term objectives based on patient needs and the education session. Goals can be found in attached document. (Table 3)Case Description: examination, evaluation, diagnosis, and prognosisOutline of procedures generallyA subjective interview was conducted first followed by gait and functional movement observations. Active ranges of motion, strength testing, and passive ranges of motion were conducted in various positions necessary for technique (see table 4). Sensation and neurodynamic testing were conducted next with palpation of nerve paths performed in sitting. Special tests were done in supine following passive ranges of motion. The last component was prone palpations of the lumbar spine as the therapist suspected it would elicit the most discomfort. Outcome measures were filled out following completion of the physical exam. Rationalization of exam components:A large portion of the patient-therapist interaction was spent on the subjective portion of the exam. Central sensitization and chronic pain is often revealed in the beliefs and daily experiences of the patient.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.math.2009.12.001","First":false,"Last":false,"PMID":"20036180","abstract":"Central sensitization plays an important role in the pathophysiology of numerous musculoskeletal pain disorders, yet it remains unclear how manual therapists can recognize this condition. Therefore, mechanism based clinical guidelines for the recognition of central sensitization in patients with musculoskeletal pain are provided. By using our current understanding of central sensitization during the clinical assessment of patients with musculoskeletal pain, manual therapists can apply the science of nociceptive and pain processing neurophysiology to the practice of manual therapy. The diagnosis/assessment of central sensitization in individual patients with musculoskeletal pain is not straightforward, however manual therapists can use information obtained from the medical diagnosis, combined with the medical history of the patient, as well as the clinical examination and the analysis of the treatment response in order to recognize central sensitization. The clinical examination used to recognize central sensitization entails the distinction between primary and secondary hyperalgesia.\n \n Copyright 2009 Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Van Houdenhove","given":"Boudewijn"},{"family":"Oostendorp","given":"Rob A B"}],"authorYearDisplayFormat":false,"citation-label":"1212232","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"1212232","invisible":false,"issue":"2","issued":{"date-parts":[["2010","4"]]},"journalAbbreviation":"Man. Ther.","page":"135-141","suppress-author":false,"title":"Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice.","type":"article-journal","volume":"15"}]14 Because Ms. Camp has seen several clinicians, received imaging, and been cleared of red flag pathologies, her reports on function and dysfunction will likely reveal more than objective information.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.math.2009.12.001","First":false,"Last":false,"PMID":"20036180","abstract":"Central sensitization plays an important role in the pathophysiology of numerous musculoskeletal pain disorders, yet it remains unclear how manual therapists can recognize this condition. Therefore, mechanism based clinical guidelines for the recognition of central sensitization in patients with musculoskeletal pain are provided. By using our current understanding of central sensitization during the clinical assessment of patients with musculoskeletal pain, manual therapists can apply the science of nociceptive and pain processing neurophysiology to the practice of manual therapy. The diagnosis/assessment of central sensitization in individual patients with musculoskeletal pain is not straightforward, however manual therapists can use information obtained from the medical diagnosis, combined with the medical history of the patient, as well as the clinical examination and the analysis of the treatment response in order to recognize central sensitization. The clinical examination used to recognize central sensitization entails the distinction between primary and secondary hyperalgesia.\n \n Copyright 2009 Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Van Houdenhove","given":"Boudewijn"},{"family":"Oostendorp","given":"Rob A B"}],"authorYearDisplayFormat":false,"citation-label":"1212232","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"1212232","invisible":false,"issue":"2","issued":{"date-parts":[["2010","4"]]},"journalAbbreviation":"Man. Ther.","page":"135-141","suppress-author":false,"title":"Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice.","type":"article-journal","volume":"15"}]14 Additionally, subjective interviewing is important for developing a therapeutic relationship with the patient. It is essential to know what a patient is doing, his/her perceptions, how pain impacts life, and how life impacts pain. Subjective interviewing also facilitates a team approach with the patient and clinician working together to make decisions.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/09593985.2016.1194648","First":false,"Last":false,"PMID":"27351690","abstract":"The interview of a patient attending physical therapy is the cornerstone of the physical examination, diagnosis, plan of care, prognosis, and overall efficacy of the therapeutic experience. A thorough, skilled interview drives the objective tests and measures chosen, as well as provides context for the interpretation of those tests and measures, during the physical examination. Information from the interview powerfully influences the treatment modalities chosen by the physical therapist (PT) and thus also impacts the overall outcome and prognosis of the therapy sessions. Traditional physical therapy focuses heavily on biomedical information to educate people about their pain, and this predominant model focusing on anatomy, biomechanics, and pathoanatomy permeates the interview and physical examination. Although this model may have a significant effect on people with acute, sub-acute or postoperative pain, this type of examination may not only gather insufficient information regarding the pain experience and suffering, but negatively impact a patient's pain experience. In recent years, physical therapy treatment for pain has increasingly focused on pain science education, with increasing evidence of pain science education positively affecting pain, disability, pain catastrophization, movement limitations, and overall healthcare cost. In line with the ever-increasing focus of pain science in physical therapy, it is time for the examination, both subjective and objective, to embrace a biopsychosocial approach beyond the realm of only a biomedical approach. A patient interview is far more than \"just\" collecting information. It also is a critical component to establishing an alliance with a patient and a fundamental first step in therapeutic neuroscience education (TNE) for patients in pain. This article highlights the interview process focusing on a pain science perspective as it relates to screening patients, establishing psychosocial barriers to improvement, and pain mechanism assessment. ","author":[{"family":"Diener","given":"Ina"},{"family":"Kargela","given":"Mark"},{"family":"Louw","given":"Adriaan"}],"authorYearDisplayFormat":false,"citation-label":"5671648","container-title":"Physiotherapy Theory and Practice","container-title-short":"Physiother. Theory Pract.","id":"5671648","invisible":false,"issue":"5","issued":{"date-parts":[["2016","7"]]},"journalAbbreviation":"Physiother. Theory Pract.","page":"356-367","suppress-author":false,"title":"Listening is therapy: Patient interviewing from a pain science perspective.","type":"article-journal","volume":"32"}]15Musculoskeletal tests used were typical of orthopedic exams and used to clear patient of both nociceptive and peripheral neurogenic sources of symptoms. While central sensitization was suspected to be the core issue, ongoing input into the nociceptic pathways contributes to prolonged pain and sensitivity.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/10669817.2017.1300397","First":false,"Last":false,"PMCID":"PMC5498792","PMID":"28694674","abstract":"In last decades, knowledge of nociceptive pain mechanisms has expanded rapidly. The use of quantitative sensory testing has provided evidence that peripheral and central sensitization mechanisms play a relevant role in localized and widespread chronic pain syndromes. In fact, almost any patient suffering with a chronic pain condition will demonstrate impairments in the central nervous system. In addition, it is accepted that pain is associated with different types of trigger factors including social, physiological, and psychological. This rational has provoked a change in the understanding of potential mechanisms of manual therapies, changing from a biomechanical/medical viewpoint, to a neurophysiological/nociceptive viewpoint. Therefore, interventions for patients with chronic pain should be applied based on current knowledge of nociceptive mechanisms since determining potential drivers of the sensitization process is critical for effective management. The current paper reviews mechanisms of chronic pain from a clinical and neurophysiological point of view and summarizes key messages for clinicians for proper management of individuals with chronic pain.","author":[{"family":"Courtney","given":"Carol A"},{"family":"Fernández-de-Las-Pe?as","given":"César"},{"family":"Bond","given":"Samantha"}],"authorYearDisplayFormat":false,"citation-label":"4103307","container-title":"The Journal of manual & manipulative therapy","container-title-short":"J. Man. Manip. Ther.","id":"4103307","invisible":false,"issue":"3","issued":{"date-parts":[["2017","7"]]},"journalAbbreviation":"J. Man. Manip. Ther.","page":"118-127","suppress-author":false,"title":"Mechanisms of chronic pain - key considerations for appropriate physical therapy management.","type":"article-journal","volume":"25"},{"DOI":"10.1016/S1356-689X(03)00051-1","First":false,"Last":false,"PMID":"12909433","abstract":"This paper presents an approach to rehabilitation of pain patients. The fundamental principles of the approach are (i) pain is an output of the brain that is produced whenever the brain concludes that body tissue is in danger and action is required, and (ii) pain is a multisystem output that is produced when an individual-specific cortical pain neuromatrix is activated. When pain becomes chronic, the efficacy of the pain neuromatrix is strengthened via nociceptive and non-nociceptive mechanisms, which means that less input, both nociceptive and non-nociceptive, is required to produce pain. The clinical approach focuses on decreasing all inputs that imply that body tissue is in danger and then on activating components of the pain neuromatrix without activating its output. Rehabilitation progresses to increase exposure to threatening input across sensory and non-sensory domains.","author":[{"family":"Moseley","given":"G L"}],"authorYearDisplayFormat":false,"citation-label":"612467","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"612467","invisible":false,"issue":"3","issued":{"date-parts":[["2003","8"]]},"journalAbbreviation":"Man. Ther.","page":"130-140","suppress-author":false,"title":"A pain neuromatrix approach to patients with chronic pain.","type":"article-journal","volume":"8"}]4,16 Active and passive ROM of upper and lower quarters with emphasis to hips and lumbar movements as well as strength assessments of the lower quarter were used to observe deficits and pain patterns. Special tests for the hips were used to clear instability, impingements, and malalignments as well as quantitatively assess Camp’s sensitivity to touch and movement. Functional movements were observed as well to assess limitations in daily routine and get a better picture of how impairments manifest in dysfunction.Outcome measures selected were Roland Morris Disability Questionnaire (RMDQ), Fear and Avoidance Beliefs Questionnaire (FABQ), pain intensity scale, and body diagram. All the measures selected are commonly used in assessing a patient with suspected central sensitization.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.math.2009.12.001","First":false,"Last":false,"PMID":"20036180","abstract":"Central sensitization plays an important role in the pathophysiology of numerous musculoskeletal pain disorders, yet it remains unclear how manual therapists can recognize this condition. Therefore, mechanism based clinical guidelines for the recognition of central sensitization in patients with musculoskeletal pain are provided. By using our current understanding of central sensitization during the clinical assessment of patients with musculoskeletal pain, manual therapists can apply the science of nociceptive and pain processing neurophysiology to the practice of manual therapy. The diagnosis/assessment of central sensitization in individual patients with musculoskeletal pain is not straightforward, however manual therapists can use information obtained from the medical diagnosis, combined with the medical history of the patient, as well as the clinical examination and the analysis of the treatment response in order to recognize central sensitization. The clinical examination used to recognize central sensitization entails the distinction between primary and secondary hyperalgesia.\n \n Copyright 2009 Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Van Houdenhove","given":"Boudewijn"},{"family":"Oostendorp","given":"Rob A B"}],"authorYearDisplayFormat":false,"citation-label":"1212232","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"1212232","invisible":false,"issue":"2","issued":{"date-parts":[["2010","4"]]},"journalAbbreviation":"Man. Ther.","page":"135-141","suppress-author":false,"title":"Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice.","type":"article-journal","volume":"15"},{"DOI":"10.1016/j.math.2012.11.001","First":false,"Last":false,"PMID":"23273516","abstract":"It is well established that the biomedical model falls short in explaining chronic musculoskeletal pain. Although many musculoskeletal therapists have moved on in their thinking and apply a broad biopsychosocial view with regard to chronic pain disorders, the majority of clinicians have received a biomedical-focused training/education. Such a biomedical training is likely to influence the therapists' attitudes and core beliefs toward chronic musculoskeletal pain. Therapists should be aware of the impact of their own attitudes and beliefs on the patient's attitudes and beliefs. As patient's attitudes and beliefs influence treatment adherence, musculoskeletal therapists should be aware that focusing on the biomedical model for chronic musculoskeletal pain is likely to result in poor compliance with evidence based treatment guidelines, less treatment adherence and a poorer treatment outcome. Here, we provide clinicians with a 5-step approach toward effective and evidence-based care for patients with chronic musculoskeletal pain. The starting point entails self-reflection: musculoskeletal therapists can easily self-assess their attitudes and beliefs regarding chronic musculoskeletal pain. Once the therapist holds evidence-based attitudes and beliefs regarding chronic musculoskeletal pain, assessing patients' attitudes and beliefs will be the natural next step. Such information can be integrated in the clinical reasoning process, which in turn results in individually-tailored treatment programs that specifically address the patients' attitudes and beliefs in order to improve treatment adherence and outcome. Crown Copyright ? 2012. Published by Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Roussel","given":"Nathalie"},{"family":"Paul van Wilgen","given":"C"},{"family":"K?ke","given":"Albère"},{"family":"Smeets","given":"Rob"}],"authorYearDisplayFormat":false,"citation-label":"3515844","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"3515844","invisible":false,"issue":"2","issued":{"date-parts":[["2013","4"]]},"journalAbbreviation":"Man. Ther.","page":"96-102","suppress-author":false,"title":"Thinking beyond muscles and joints: therapists' and patients' attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment.","type":"article-journal","volume":"18"},{"First":false,"Last":false,"author":[{"family":"Louw","given":"Adriaan"},{"family":"Puenteduera","given":"Emilio"}],"authorYearDisplayFormat":false,"citation-label":"5563251","collection-editor":[{"given":"OPTP"}],"id":"5563251","invisible":false,"issued":{"date-parts":[["2013"]]},"publisher":"International Spine and Pain Institute","suppress-author":false,"title":"Therapeutic Neuroscience Education: teaching patients about pain","type":"book"}]1,14,17 Quantitative assessment of the characteristics of central sensitization such as hypersensitivity, fear of movement, impact of pain on function, and the patterns of pain guide diagnosis as well as measure change throughout treatment process. The measures selected have excellent reliability and validity with normative data specific to chronic low back pain (see table 1).Results of subjective exam:Ms. Camp notes that her low back pain radiates upwards towards her scapula and trapezius muscles bilaterally and down her right thigh and across buttock to left gluteus. She describes pain as dull with occasional shooting “lightning” down her right leg. She occasionally has pain in shoulders, headaches, and pain in her feet without knowing what initiated symptoms. She experiences a dull ache which never leaves but fluctuates in intensity. Though pain can occur spontaneously, she reports that typically repetitive motions including lifting, bending, pushing, and pulling increase her pain while physical therapy, occasional prescription pain medication, stretching, and complete rest alleviate it. She also expressed hypersensitivity to temperature, noises, and lights, verbalizing that it can bring on headaches and body aches. She expresses difficulty sleeping due to discomfort and often wakes up unrefreshed. Notably, Camp reports an average of three falls per month because her “right foot doesn’t touch the ground right” and gives out regularly. Camp says her pain is very limiting and knows that it has caused or is tied to her mental health struggles. She has withdrawn from activities she loves such as road trips, running, and interacting with her children. While she does yoga once per week typically, when her pain gets worse she withdraws from all physical activity. She believes that work makes her back pain worse and has contributed to dysfunction.Results of objective exam: Ms. Camp was pleasant, well-groomed, cheerful, and joking throughout her evaluation. Even when movements elicited symptoms, she maintained a smile. Gait observation revealed non-antalgic pattern at self-selected pace with externally rotated lower extremities and increased q-angle noted. When prompted to walk faster, she began to limp with shortened stance phase on right lower extremity due to reported instability and ache in her right low back and buttock. Camp was generally within normal limits for all active ranges of motion in shoulders, cervical, hips, lumbar spine, and soft tissue length of major muscle groups. She had some compensation with lumbar flexion and extension, using hip flexion and extension during movements. She maintained a lordotic posture throughout the exam, describing discomfort in lumbar extension as “tightness.” In supine, passive ROM revealed full motion with mild pain in her right low back at the end of hip ranges in her right lower extremity (LE). Strength testing revealed intact upper quarter strength and decreased strength in bilateral LE with non-fatiguing but weakened holds. She did not report pain with muscle testing. Special tests for hip pathology were negative though mild, concordant pain in her right low back and across glutes were reported with testing of left hip. Thomas test for hip flexor and quadricep tightness was positive on the right with lumbar extensions used as compensation for apparent deficits in hip flexor length.With the slump neurodynamic test, the patient denied pain or symptoms with either LE testing. In supine, Single Leg Raise (SLR) was positive for sensitivity at 45 degrees with a neutral bias. Palpations revealed general sensitivity across her back with grade 1-2 mobilization of thoracic and lumbar spine (posterior to anterior intervertebral mobilizations). Some hypomobility was noted with significant muscle guarding with gentle palpations making motion of the spine difficult to assess. Sensation was intact to light touch with increased sensitivity bilaterally in the common fibularis, both superficial and deep branches,Outcome measures revealed increased fear and avoidance, significant disability, and spreading pain. (see Table 5) Imaging impressions of neck and cervical spine were normal (2014) and a 2015 MRI showed normal sacral iliac joint and lumbar spine without sclerosis, erosions, or lesions. Diagnosis RationaleExam Components RationaleBecause Ms. Camp has had physical therapy and other conservative evaluations and treatments without success, a purely musculoskeletal evaluation is not helpful or appropriate. Chronic pain patients are fear avoidant and guarded, making extensive palpation and hands-on tests difficulty. Results of typical tests will not likely have true positives or negatives. Because pain is no longer purely biomechanical in nature, nociplastic pain patterns need to be assessed. Specifically, neurodynamic testing, sensitivity to touch, and functional movements identify nerve sensitivity. Diagnosis:Camp’s examination was mostly inconclusive from a purely musculoskeletal system perspective. Her subjective reports of pain with inconsistent aggravating and easing factors as well as a largely non-irritating exam did not indicate a specific tissue pathology. This is consistent with central sensitization or nociplastic pain. Her outcome measures indicated fear and movement avoidance, diffuse area of pain with spontaneous causes, and significant disability associated with symptoms (See table 5). She verbalized that pain was associated with an emotional disturbance, and she has a history of failed treatments. Combined with pain that does not follow a dermatomic or myotomic pattern and comorbid conditions of depression and anxiety, her pain is likely to be the result of nerve sensitivity rather than tissue damage. Pain is a complex neurophysiological process marked by hyper-excitable central nervous system to input. (Butler, Woolf 2007)Case Description: InterventionIntervention RationaleDue to clinical diagnosis of nociplastic pain, pain neuroscience protocol is the most appropriate initial treatment for Ms. Camp. Pain neuroscience education is the intervention cornerstone as it has been shown to have a positive effect on pain, disability, catastrophization, and physical performance. ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/09593985.2016.1194646","First":false,"Last":false,"PMID":"27351541","abstract":"OBJECTIVE: Systematic review of randomized control trials (RCTs) for the effectiveness of pain neuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and healthcare utilization in individuals with chronic musculoskeletal (MSK) pain. DATA SOURCES: Systematic searches were conducted on 11 databases. 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 RCTs evaluating the effect of PNE on chronic MSK pain were considered for inclusion. Additional Limitations: Studies published in English, published within the last 20 years, and patients older than 18 years. No limitations were set on specific outcome measures. DATA EXTRACTION: Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach. DATA SYNTHESIS: Study quality of the 13 RCTs used in this review was assessed by 2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation to outcomes measurements and effectiveness. CONCLUSIONS: Current evidence supports the use of PNE for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Zimney","given":"Kory"},{"family":"Puentedura","given":"Emilio J"},{"family":"Diener","given":"Ina"}],"authorYearDisplayFormat":false,"citation-label":"2261235","container-title":"Physiotherapy Theory and Practice","container-title-short":"Physiother. Theory Pract.","id":"2261235","invisible":false,"issue":"5","issued":{"date-parts":[["2016","7"]]},"journalAbbreviation":"Physiother. Theory Pract.","page":"332-355","suppress-author":false,"title":"The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature.","type":"article-journal","volume":"32"}]8 Further benefits of education for the chronic pain patient include reduction of psychosocial factors and improvement of movement.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/09593985.2016.1194646","First":false,"Last":false,"PMID":"27351541","abstract":"OBJECTIVE: Systematic review of randomized control trials (RCTs) for the effectiveness of pain neuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and healthcare utilization in individuals with chronic musculoskeletal (MSK) pain. DATA SOURCES: Systematic searches were conducted on 11 databases. 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 RCTs evaluating the effect of PNE on chronic MSK pain were considered for inclusion. Additional Limitations: Studies published in English, published within the last 20 years, and patients older than 18 years. No limitations were set on specific outcome measures. DATA EXTRACTION: Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach. DATA SYNTHESIS: Study quality of the 13 RCTs used in this review was assessed by 2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation to outcomes measurements and effectiveness. CONCLUSIONS: Current evidence supports the use of PNE for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Zimney","given":"Kory"},{"family":"Puentedura","given":"Emilio J"},{"family":"Diener","given":"Ina"}],"authorYearDisplayFormat":false,"citation-label":"2261235","container-title":"Physiotherapy Theory and Practice","container-title-short":"Physiother. Theory Pract.","id":"2261235","invisible":false,"issue":"5","issued":{"date-parts":[["2016","7"]]},"journalAbbreviation":"Physiother. Theory Pract.","page":"332-355","suppress-author":false,"title":"The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature.","type":"article-journal","volume":"32"}]8 Because Camp has a history of failed treatment, solely focusing on orthopedic specific treatments would be nonproductive. She had tried and not improved with manual therapy and modalitites. Instead, interventions were centered on de-sensitizing the nervous system from the top-down, by addressing beliefs and central processing of threats and calming nerves. Using PNE in combination with other therapies provides superior results. Louw et al suggests 22 interventions that address deficits common with nociplastic pain. Every intervention is implemented from the lens of nerve sensitivity initiating pain rather than tissue pathology. Each intervention chosen was specific to Ms. Camp’s needs and identified areas of continued nerve sensitivity. Exam and Treatment rationale: Step 1. 09/05/2018At the conclusion of Camp’s evaluation, she was introduced to the definition of pain, the concept of nociplastic pain, and treatment rationale. Based on her evaluation, the writer believed that she would benefit from treatments of PNE, goal setting, physical activity, graded imagery to reduce fear and avoidance, sleep hygiene because of reported difficulties, and manual therapy and modalities to reduce pain within a session.The writer used eight stories, proposed by pain science researchers, to guide the patient through neurophysiology. A script and outline of each education point is found in the appendix. (Table 6) The first, introduction session incorporated “pain as an alarm,” the role of the CNS in facilitating and inhibiting messages from the periphery, and the prevalence of prolonged sensitivity as well as ways to ways to “calm nerves” through education, habituation, and physical activity. At the end of the session, Camp was given a workbook that reinforced taught material and introduced concepts to be reviewed at the next session. The writer also instructed Camp to perform physical activity for at least ten minutes per day to improve blood flow and oxygen to tissues, thus making them “happier and healthier” because aerobic activity flushes out chemicals such as adrenaline and cortisol which lend to nerve sensitivity.The patient was receptive to the treatment rationale and hopeful because PT in the past has only temporarily impacted her pain experience. She verbalized that she would be compliant with the treatment regimen and home program. Of note, the therapist emphasized patient-therapist interaction throughout the exam and neuro re-education. Listening, encouraging, and motivational interviewing techniques were used to build a therapeutic relationship. Goals for Ms. Camp were created as outlined previously (table 3). A second session was scheduled for the following week.Session two: Protocol Step 2 09/26/2018Due to a tropical storm, the original session two was rescheduled to a later date. Though the writer attempted to schedule earlier, Ms. Camp did not respond to calls or emails for a week. The earliest possible appointment was made for September 26, over three weeks after first session. This session focused on review of previously taught education and introduction of new concepts. Therapeutic exercise and heart rate monitoring occurred to delineate MET necessary for aerobic exercise benefits. Sleep hygiene was discussed and stress reduction techniques outlined. Outcome measures were not retaken as the writer will perform measures four to six weeks sequentially.Ms. Camp reported noncompliance with treatment. She did not review the material given nor was she consistent with aerobic exercise. Of note, she fell down several stairs because her foot “just went wrong.” On further exam, no musculoskeletal or neuromuscular issues were identified. Since the last session she returned to work and described it as “okay.” She described her sleeping routine and noted unhelpful behaviors such as watching TV to go to sleep. She reported using appropriate stress coping methods such as removing stressors, coping with gentle yoga, walking, and sometimes eating. Her pain intensity and frequency had not changed since evaluation. The interventions focused on neuro re-education through PNE topics with 30 minutes spent on education, ten discussing sleep hygiene, ten using heat to calm nerves, and ten minutes of therapeutic exercise for a total of 60-minute session. The writer used further stories to introduce topics of ion channel adaption, nerve sensor types and adaption, spreading pain, and calming nerves. The therapist reinforced the message that Ms. Camp’s symptoms arose from tissue sensitivity rather than continued damage. The writer and patient discussed contributors to pain such as stress and sleep deprivation and gave Ms. Camp a sleep hygiene checklist. She was able to teach back concepts correctly and was acceptable to information heard. To show the patient appropriate intensity for eliciting endogenous opioid and analgesic effects of exercise, the writer and Ms. Camp walked in the hallways for ten minutes with a target heart rate of 100-110 bpm which was measured through the radial pulse. This time and intensity are proposed to be sufficient for benefits of aerobic activity and stress reduction.ADDIN F1000_CSL_CITATION<~#@#~>[{"First":false,"Last":false,"author":[{"family":"Louw","given":"Adriaan"},{"family":"Puenteduera","given":"Emilio"}],"authorYearDisplayFormat":false,"citation-label":"5563251","collection-editor":[{"given":"OPTP"}],"id":"5563251","invisible":false,"issued":{"date-parts":[["2013"]]},"publisher":"International Spine and Pain Institute","suppress-author":false,"title":"Therapeutic Neuroscience Education: teaching patients about pain","type":"book"}]1 A home exercise program (HEP) was given and included further reading in the workbook, 20 minutes of daily physical activity with ten at an intensity of 100-110 bpm, and incorporation of one sleep hygiene suggestion per night. Ms Camp verbalized that she would think of specific goals for treatment to be discussed at next session which was scheduled for the following week (10/05). Session 3: Protocol Step 410/10/2018Ms. Camp was a no-show at her scheduled appointment and rescheduled for October 10. This session was spent delineating goals, discussion of graded activity, reviewing PNE, introducing brain mapping concept with corresponding graded imagery treatment, assessment of discrimination and localization, and progression of her HEP. Ms. Camp reported compliance with the HEP given at the last session. However, she continued to experience impaired sleep despite using sleep hygiene concepts. Of note, she tied in pain neuroscience concepts with her discomfort felt, verbalizing that these symptoms, according to the educational material, are more about sensitivity than damage of her tissues. She reported improvement in pain (average intensity 3/10 on NRS scale improving from average of 6/10). She verbalizes that she “doesn’t feel limited by her pain now that she understands it doesn’t mean she’s injuring herself.” She expressed her goals revolved around returning to previously held activities. She would like to go on a road trip with her children and participate in a Breast Cancer Awareness 5K with her mother. The concept of graded activity was introduced and instructions in breaking goals into parts with a gradual increase to promote habituation of nerve sensitivity. The writer and Ms Camp made the goals specific with time frames and steps to reach each goal and broke the goals into manageable components. She wanted to drive to Atlanta, October 27th, stopping every hour to stretch and move in order to calm sensitivity. She would like to walk the 5K with her mother in December, with intermediary goals of initially walking a half mile with increased distance per week. She would like to rearrange her furniture for a family get together November 5th with intermediary goal of moving furniture over several days in five minute increments (time she believes she can do without over doing it). Upon reviewing the nerve physiology questionnaire, Ms. Camp was able to answer every question correctly, indicating improved knowledge. Further PNE was given using the stories of brain map, lion in the room, healing tissues, and emotions influence on pain experience. Topics were chosen due to patient verbalization that stress increased her pain (lion in the room), that her symptoms have spread from low back to all over, and feeling like her feet are not “hers.” Due to patient complaints, the writer incorporated graded imagery techniques into session to improve brain mapping. It is well established that chronic pain leads to deficits in neural mapping and ‘smudging’ of homunculus.ADDIN F1000_CSL_CITATION<~#@#~>[{"First":false,"Last":false,"PMCID":"PMC164382","PMID":"12937572","abstract":"OBJECTIVE: To examine if patients with chronic ankle instability or a history of ankle sprains without chronic instability have worse proprioception or less invertor and evertor muscle strength. DESIGN AND SETTING: We assessed proprioception and muscle strength on the Biodex isokinetic dynamometer in the laboratory of the Department of Sports Medicine, University Hospital Ghent. SUBJECTS: Subjects included 87 physical education students (44 men, 43 women, age = 18.33 +/- 1.25 years, mass = 66.09 +/- 8.11 kg, height = 174.11 +/- 8.57 cm) at the University of Ghent in Belgium. Their ankles were divided into 4 groups: a symptom-free control group, subjects with chronic ankle instability, subjects who had sustained an ankle sprain in the last 2 years without instability, and subjects who sustained an ankle sprain 3 to 5 years earlier without instability. MEASUREMENTS: Active and passive joint-position sense was assessed at the ankle, and isokinetic peak torque was determined for concentric and eccentric eversion and inversion movements at the ankle. RESULTS: Statistical analysis indicated significantly less accurate active position sense for the instability group compared with the control group at a position close to maximal inversion. The instability group also showed a significantly lower relative eversion muscle strength (% body weight). No significant differences were observed between the control group and the groups with past sprains without instability. CONCLUSIONS: We suggest that the possible cause of chronic ankle instability is a combination of diminished proprioception and evertor muscle weakness. Therefore, we emphasize proprioception and strength training in the rehabilitation program for ankle instability.","author":[{"family":"Willems","given":"Tine"},{"family":"Witvrouw","given":"Erik"},{"family":"Verstuyft","given":"Jan"},{"family":"Vaes","given":"Peter"},{"family":"De Clercq","given":"Dirk"}],"authorYearDisplayFormat":false,"citation-label":"2594833","container-title":"Journal of Athletic Training","container-title-short":"J. Athl. Train.","id":"2594833","invisible":false,"issue":"4","issued":{"date-parts":[["2002","12"]]},"journalAbbreviation":"J. Athl. Train.","page":"487-493","suppress-author":false,"title":"Proprioception and Muscle Strength in Subjects With a History of Ankle Sprains and Chronic Instability.","type":"article-journal","volume":"37"},{"DOI":"10.1097/AJP.0000000000000066","First":false,"Last":false,"PMID":"24535054","abstract":"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.","author":[{"family":"Bowering","given":"K Jane"},{"family":"Butler","given":"David S"},{"family":"Fulton","given":"Ian J"},{"family":"Moseley","given":"G Lorimer"}],"authorYearDisplayFormat":false,"citation-label":"3517535","container-title":"The Clinical Journal of Pain","container-title-short":"Clin. J. Pain","id":"3517535","invisible":false,"issue":"12","issued":{"date-parts":[["2014","12"]]},"journalAbbreviation":"Clin. J. Pain","page":"1070-1075","suppress-author":false,"title":"Motor imagery in people with a history of back pain, current back pain, both, or neither.","type":"article-journal","volume":"30"},{"First":false,"ISBN":"9780987246752","Last":false,"abstract":"Finally! A handbook arising from the last 15 years of neuroscience, clinical trials and clinical reasoning science is here for both clinicians and pain sufferers. Graded Motor Imagery (GMI) offers a novel three stage synaptic exercise process for neuropathic pain involving left/right discrimination, imagined movements and mirror therapy. With patience, persistence and often lots of hard work, GMI gives new hope for treatment outcomes. David Butler shows how curiosity and learning are critical allies in the search for why you or your patients hurt and he encourages a deep knowledge of the therapy and science behind GMI for the best outcomes. Lorimer Moseley shares his researcher's inquisitiveness about the science behind GMI and the neuromatrix: the representation of body parts in our brains and how and why these representations may be affected by injury. GMI aims to alter pain `neurotags' or sensitive networks in the brain. Graded motor imagery is a treatment in its infancy. How do we know if it is appropriate to use? How do we know what's normal? Tim Beames invites us on a clinical reasoning exploration through patient-therapist narratives, providing invaluable insights into the progression from left/right discrimination, imagined movements to use of mirrors. The online RecogniseTM programme was developed to assess and restore the Lefts and Rights in your brain. Tom Giles, the go-to guy for RecogniseTM, provides the `nuts and bolts' of how to get the best out of the online programme, smart phone app and other practical GMI tools.","author":[{"family":"Moseley","given":"G. Lorimer"},{"family":"Butler","given":"David Sheridan"},{"family":"Beames","given":"Timothy B."},{"family":"Giles","given":"Thomas J."}],"authorYearDisplayFormat":false,"citation-label":"5861054","edition":"illustrated","id":"5861054","invisible":false,"issued":{"date-parts":[["2012"]]},"publisher":"Noigroup Publications","suppress-author":false,"title":"The Graded Motor Imagery Handbook","type":"book"}]18–20 This difficulty in discrimination and localization of input can lead to prolonged pain. Those with chronic pain will have difficulty knowing where sensory input is coming from and patients will have often have globally impaired localization and two-point discrimination. To address the blurred brain map specifically, graded motor imagery has been shown to reduce pain and restore localization and discrimination abilities in comparison to typical physiotherapy.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1212/01.wnl.0000249112.56935.32","First":false,"Last":false,"PMID":"17082465","abstract":"BACKGROUND: Phantom limb and complex regional pain syndrome type 1 (CRPS1) are characterized by changes in cortical processing and organization, perceptual disturbances, and poor response to conventional treatments. Graded motor imagery is effective for a small subset of patients with CRPS1. OBJECTIVE: To investigate whether graded motor imagery would reduce pain and disability for a more general CRPS1 population and for people with phantom limb pain. METHODS: Fifty-one patients with phantom limb pain or CRPS1 were randomly allocated to motor imagery, consisting of 2 weeks each of limb laterality recognition, imagined movements, and mirror movements, or to physical therapy and ongoing medical care. RESULTS: There was a main statistical effect of treatment group, but not diagnostic group, on pain and function. The mean (95% CI) decrease in pain between pre- and post-treatment (100 mm visual analogue scale) was 23.4 mm (16.2 to 30.4 mm) for the motor imagery group and 10.5 mm (1.9 to 19.2 mm) for the control group. Improvement in function was similar and gains were maintained at 6-month follow-up. CONCLUSION: Motor imagery reduced pain and disability in these patients with complex regional pain syndrome type I or phantom limb pain, but the mechanism, or mechanisms, of the effect are not clear.","author":[{"family":"Moseley","given":"G Lorimer"}],"authorYearDisplayFormat":false,"citation-label":"3189593","container-title":"Neurology","container-title-short":"Neurology","id":"3189593","invisible":false,"issue":"12","issued":{"date-parts":[["2006","12","26"]]},"journalAbbreviation":"Neurology","page":"2129-2134","suppress-author":false,"title":"Graded motor imagery for pathologic pain: a randomized controlled trial.","type":"article-journal","volume":"67"}]21 Using two point discrimination on Ms Camp’s feet, the writer found that she was unable to distinguish between two pin-points that were less than an inch apart in her right foot. Her left foot discrimination was less than half an inch apart. Additionally, the writer graphed Ms. Camp’s back, showing the patient an image of a back with six segments and asking her to identify which segment was being touched without looking. She was unable to identify the correct segment 50% of the time. Therefore, the writer added to her HEP with instructions for right/left discrimination using the Orientate App, a free software that uses images of feet and hands to challenge discrimination ability, as well as stereognosis on her back. The app was to be used for five minutes daily and her children were to write various alphabet letters for identification on her back five minutes daily to improve brain mapping. Session four: Protocol Step five10/30/18Ms. Camp did not show up for appointment on 10/17. She called and rescheduled and upon arrival, reported she felt much better. She had successfully gone on a road trip with her children and rearranged furniture for her family get together. She had started going to the gym and working with a personal trainer. She had completed the pain workbook and had begun recognizing faulty thinking about pain and its causes. She reported compliance with her HEP, using the right/left discrimination app consistently as well as incorporating some sleep hygiene practices into her life. Ms. Camp admits that her sleep has not improved, and that she frequently wakes up “uncomfortable.” Heat modalities were used to warm low back followed by ten minutes of stationary bike during which she reviewed PNE concepts with the writer. She progressed with motor imagery, searching magazines for right and left lumbar lateral flexion for five minutes daily. The session ended with Grade 2 mobilizations and soft tissue mobilization of quadratus lumborum and hamstrings. The mobilizations were performed on her lumbar spine in prone, creating passive intervertebral accessory motion for pain relief and desensitization. The soft tissue stretches were given to create space for nerves, increase blood flow and habituate Ms Camp to movement. The writer advanced her HEP with instructions to continue specific movement identification by analyzing pictures of herself for right or left side bending. Because she is physically active through personal training, specific exercises were not given. Neurodynamic flossing of bilateral sciatic nerve was prescribed to improve space and desensitize area. Ms. Camp is improving, recognizing nerve sensitivity as principle issue rather than tissue damage. She has accomplished several goals and is increasing physical activity. Her average pain intensity has decreased and, as evidenced by her outcome measures, fear and avoidance and disability are decreasing. She was scheduled for a follow-up the next week. Session 5: Step 5 continued 11/29/18Ms. Camp did not show up for her original appointment, but was able to be reached and rescheduled for November 29. Because she had not been seen in a month, the session retook outcome measures and objective testing and reviewed PNE concepts previously discussed. Ms. Camp reported that she had multiple family deaths and had been driving back and forth from Illinois for several weeks. She denied aggravation of symptoms and has remained consistent with daily physical activity, movement, graded imagery, and sleep hygiene techniques. She also reports using the stress coping skills she learned in physical therapy such as breathing and journaling.The writer repeated measures of R/L discrimination, segment identification on her back, graphesthesia, SLR, and slump and Ms. Camp did not have any impairments. Lumbar and hip range of motion was typical and did not aggravate symptoms. The FABQ, RMDQ, and Global Perception of Improvement were retaken and improved significantly, with outcomes indicating she had low levels of avoidance and disability, improving the probability of full return to work and activities. Notably, she reports that her average pain, a 2/10, was significantly lower than previously and she now had periods of no pain (0/10). (see table 5)To review PNE concepts and determine Ms Camp’s current retention, the writer investigated her current beliefs regarding pain. She verbalized that the pain occurred “when I do repetitive movements when I don’t move for awhile because my muscles cramp and spasm.” She noted that some pain is fake and some is real. Because she still believed tissue damage is ‘real’ pain and contributes to her symptoms, the writer reviewed several pain stories including pain physiology, spreading pain, nerve sensors and changes to ion channels with chronic pain, stress as a lion, and the brain as a boardroom.1 (see table 6) Throughout the session, the writer used the teach-back method to encourage deep learning of reviewed concepts.1 Her home exercise program included the quadratus lumborum supine stretch, sciatic nerve flossing, and supine transverse abdominus marching. They were given with the explanation that the activities were not addressing impairments like poor ROM or strength but rather to encourage movement and desensitization. Her HEP also outlined continuation of physical activity (walking and yoga), creation of a mantra (throbs not threat), continuation of identifying side-bending in photo albums to progress graded imagery, and review of PNE concepts using the Pain Strategy Workbook. Due to the resolution of impairments and indication that Ms Camp was making positive changes in her pain experience, the writer rescheduled Ms Camp for a 30-minute follow-up with another chronic pain physical therapist who had been following her case. The follow-up would correct pain neurophysiology concepts and conclude physical therapy treatment for Ms Camp. Outcomes:Functional outcome measures were collected monthly, with Numerical Rating Scale (NRS), FABQ, global impression of change and RMDQ measures taken at initial exam, second measures taken at Session Four, and third measures at session five. From baseline to session four, her FABQ improved more than 25%, indicating a clinically meaningful change in fear and avoidance. RMDQ improved seven points from baseline to session four showing a significant reduction in disability. (see table) Objective measures for right and left discrimination were found using Orientate App. The app is designed to present flashcards of limbs in various positions and subject is to indicate whether the limb is right or left. At baseline (session 3) Ms Camp was able to identify an average of 24 right in 66 seconds indicating 2.75 seconds needed to identify the position of a limb. On second collection, discrimination ability improved to 2.1 seconds per image. This is within the normal range of identification speed (2.0 +/- 0.5 sec) as proposed by Moselely et al.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1212/01.wnl.0000249112.56935.32","First":false,"Last":false,"PMID":"17082465","abstract":"BACKGROUND: Phantom limb and complex regional pain syndrome type 1 (CRPS1) are characterized by changes in cortical processing and organization, perceptual disturbances, and poor response to conventional treatments. Graded motor imagery is effective for a small subset of patients with CRPS1. OBJECTIVE: To investigate whether graded motor imagery would reduce pain and disability for a more general CRPS1 population and for people with phantom limb pain. METHODS: Fifty-one patients with phantom limb pain or CRPS1 were randomly allocated to motor imagery, consisting of 2 weeks each of limb laterality recognition, imagined movements, and mirror movements, or to physical therapy and ongoing medical care. RESULTS: There was a main statistical effect of treatment group, but not diagnostic group, on pain and function. The mean (95% CI) decrease in pain between pre- and post-treatment (100 mm visual analogue scale) was 23.4 mm (16.2 to 30.4 mm) for the motor imagery group and 10.5 mm (1.9 to 19.2 mm) for the control group. Improvement in function was similar and gains were maintained at 6-month follow-up. CONCLUSION: Motor imagery reduced pain and disability in these patients with complex regional pain syndrome type I or phantom limb pain, but the mechanism, or mechanisms, of the effect are not clear.","author":[{"family":"Moseley","given":"G Lorimer"}],"authorYearDisplayFormat":false,"citation-label":"3189593","container-title":"Neurology","container-title-short":"Neurology","id":"3189593","invisible":false,"issue":"12","issued":{"date-parts":[["2006","12","26"]]},"journalAbbreviation":"Neurology","page":"2129-2134","suppress-author":false,"title":"Graded motor imagery for pathologic pain: a randomized controlled trial.","type":"article-journal","volume":"67"}]21Ms. Camp also reached all goals she made in therapy. The first was to complete a long-distance car trip with her children. She incorporated graded activity strategies, breaking the drive into one-hour increments but reported that she did not have functionally limiting pain afterward. The second goal was to rearrange furniture which Ms Camp was able to do by breaking the activity into smaller amounts. As for the goals set forth by the writer, Ms. Camp met all though not in the proposed time frames. (see table) DiscussionImpact on patientThroughout her treatment, Ms Camp gradually returned to activities she had been avoiding for years. While she did not have complete elimination of pain, she verbalized that her pain “didn’t mean as much” because she recognized that it was due to a hypersensitive nervous system. In the time frame she was being seen, Ms Camp did not miss a day of work due to pain, nor did she take prescription pain relievers as was her habit. As evidenced by changes in her outcome measures, she improved in function and ability. Of note, the writer suspects a large portion of improvement was related to the patient’s positive outlook. Consistent with the literature, her ability to reframe negative experiences and belief that she could change likely contributed considerably to her progress.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.3109/09593985.2011.562602","First":false,"Last":false,"PMID":"21721995","abstract":"Chronic low back pain (CLBP) remains prevalent in society, and conservative treatment strategies appear to have little effect. It is proposed that patients with CLBP may have altered cognition and increased fear, which impacts their ability to move, perform exercise, and partake in activities of daily living. Neuroscience education (NE) aims to change a patient's cognition regarding their pain state, which may result in decreased fear, ultimately resulting in confrontation of pain barriers and a resumption of normal activities. A 64-year-old female with history of CLBP was the patient for this case report. A physical examination, the Numeric Pain Rating Scale (NPRS), Oswestry Disability Index (ODI), Fear-Avoidance Beliefs Questionnaire (FABQ), and Zung Depression Scale were assessed during her initial physical therapy visit, immediately after her first physical therapy session, and at 7-month follow-up. Treatment consisted of an abbreviated NE approach, exercises (range of motion, stretches, and cardiovascular), and aquatic therapy. She attended twice a week for 4 weeks, or 8 visits total. Pre-NE, the patient reported NPRS?=?9/10; ODI?=?54%; FABQ-W?=?25/42,; FABQ-PA?=?20/24, and Zung?=?58. Immediately following the 75-minute evaluation and NE session, the patient reported improvement in all four outcome measures, most notably a reduction in the FABQ-W score to 2/42 and the FABQ-PA to 1/24. At a 7-month follow-up, all outcome measures continued to be improved. NE aimed at decreasing fear associated with movement may be a valuable adjunct to movement-based therapy, such as exercise, for patients with CLBP.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Puentedura","given":"Emilio Louie"},{"family":"Mintken","given":"Paul"}],"authorYearDisplayFormat":false,"citation-label":"3516653","container-title":"Physiotherapy Theory and Practice","container-title-short":"Physiother. Theory Pract.","id":"3516653","invisible":false,"issue":"1","issued":{"date-parts":[["2012","1"]]},"journalAbbreviation":"Physiother. Theory Pract.","page":"50-62","suppress-author":false,"title":"Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: a case report.","type":"article-journal","volume":"28"},{"DOI":"10.1016/j.math.2012.11.001","First":false,"Last":false,"PMID":"23273516","abstract":"It is well established that the biomedical model falls short in explaining chronic musculoskeletal pain. Although many musculoskeletal therapists have moved on in their thinking and apply a broad biopsychosocial view with regard to chronic pain disorders, the majority of clinicians have received a biomedical-focused training/education. Such a biomedical training is likely to influence the therapists' attitudes and core beliefs toward chronic musculoskeletal pain. Therapists should be aware of the impact of their own attitudes and beliefs on the patient's attitudes and beliefs. As patient's attitudes and beliefs influence treatment adherence, musculoskeletal therapists should be aware that focusing on the biomedical model for chronic musculoskeletal pain is likely to result in poor compliance with evidence based treatment guidelines, less treatment adherence and a poorer treatment outcome. Here, we provide clinicians with a 5-step approach toward effective and evidence-based care for patients with chronic musculoskeletal pain. The starting point entails self-reflection: musculoskeletal therapists can easily self-assess their attitudes and beliefs regarding chronic musculoskeletal pain. Once the therapist holds evidence-based attitudes and beliefs regarding chronic musculoskeletal pain, assessing patients' attitudes and beliefs will be the natural next step. Such information can be integrated in the clinical reasoning process, which in turn results in individually-tailored treatment programs that specifically address the patients' attitudes and beliefs in order to improve treatment adherence and outcome. Crown Copyright ? 2012. Published by Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Roussel","given":"Nathalie"},{"family":"Paul van Wilgen","given":"C"},{"family":"K?ke","given":"Albère"},{"family":"Smeets","given":"Rob"}],"authorYearDisplayFormat":false,"citation-label":"3515844","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"3515844","invisible":false,"issue":"2","issued":{"date-parts":[["2013","4"]]},"journalAbbreviation":"Man. Ther.","page":"96-102","suppress-author":false,"title":"Thinking beyond muscles and joints: therapists' and patients' attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment.","type":"article-journal","volume":"18"}]12,17 By the end of her time in therapy, Ms Camp had met her goals and had no limitations due to her previous pain.The patient had difficulty keeping appointments and there were lengthy intervals between sessions and had corresponding difficulty with retaining concepts. Suggested frequency of PT sessions for low back pain is weekly.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1016/j.math.2011.04.005","First":false,"Last":false,"PMID":"21632273","abstract":"Central sensitization provides an evidence-based explanation for many cases of 'unexplained' chronic musculoskeletal pain. Prior to commencing rehabilitation in such cases, it is crucial to change maladaptive illness perceptions, to alter maladaptive pain cognitions and to reconceptualise pain. This can be accomplished by patient education about central sensitization and its role in chronic pain, a strategy known as pain physiology education. Pain physiology education is indicated when: 1) the clinical picture is characterized and dominated by central sensitization; and 2) maladaptive illness perceptions are present. Both are prerequisites for commencing pain physiology education. Face-to-face sessions of pain physiology education, in conjunction with written educational material, are effective for changing pain cognitions and improving health status in patients with various chronic musculoskeletal pain disorders. These include patients with chronic low back pain, chronic whiplash, fibromyalgia and chronic fatigue syndrome. After biopsychosocial assessment pain physiology education comprises of a first face-to-face session explaining basic pain physiology and contrasting acute nociception versus chronic pain (Session 1). Written information about pain physiology should be provided as homework in between session 1 and 2. The second session can be used to correct misunderstandings, and to facilitate the transition from knowledge to adaptive pain coping during daily life. Pain physiology education is a continuous process initiated during the educational sessions and continued within both the active treatment and during the longer term rehabilitation program. Copyright ? 2011 Elsevier Ltd. All rights reserved.","author":[{"family":"Nijs","given":"Jo"},{"family":"Paul van Wilgen","given":"C"},{"family":"Van Oosterwijck","given":"Jessica"},{"family":"van Ittersum","given":"Miriam"},{"family":"Meeus","given":"Mira"}],"authorYearDisplayFormat":false,"citation-label":"1947295","container-title":"Manual Therapy","container-title-short":"Man. Ther.","id":"1947295","invisible":false,"issue":"5","issued":{"date-parts":[["2011","10"]]},"journalAbbreviation":"Man. Ther.","page":"413-418","suppress-author":false,"title":"How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: practice guidelines.","type":"article-journal","volume":"16"},{"DOI":"10.3109/09593985.2011.562602","First":false,"Last":false,"PMID":"21721995","abstract":"Chronic low back pain (CLBP) remains prevalent in society, and conservative treatment strategies appear to have little effect. It is proposed that patients with CLBP may have altered cognition and increased fear, which impacts their ability to move, perform exercise, and partake in activities of daily living. Neuroscience education (NE) aims to change a patient's cognition regarding their pain state, which may result in decreased fear, ultimately resulting in confrontation of pain barriers and a resumption of normal activities. A 64-year-old female with history of CLBP was the patient for this case report. A physical examination, the Numeric Pain Rating Scale (NPRS), Oswestry Disability Index (ODI), Fear-Avoidance Beliefs Questionnaire (FABQ), and Zung Depression Scale were assessed during her initial physical therapy visit, immediately after her first physical therapy session, and at 7-month follow-up. Treatment consisted of an abbreviated NE approach, exercises (range of motion, stretches, and cardiovascular), and aquatic therapy. She attended twice a week for 4 weeks, or 8 visits total. Pre-NE, the patient reported NPRS?=?9/10; ODI?=?54%; FABQ-W?=?25/42,; FABQ-PA?=?20/24, and Zung?=?58. Immediately following the 75-minute evaluation and NE session, the patient reported improvement in all four outcome measures, most notably a reduction in the FABQ-W score to 2/42 and the FABQ-PA to 1/24. At a 7-month follow-up, all outcome measures continued to be improved. NE aimed at decreasing fear associated with movement may be a valuable adjunct to movement-based therapy, such as exercise, for patients with CLBP.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Puentedura","given":"Emilio Louie"},{"family":"Mintken","given":"Paul"}],"authorYearDisplayFormat":false,"citation-label":"3516653","container-title":"Physiotherapy Theory and Practice","container-title-short":"Physiother. Theory Pract.","id":"3516653","invisible":false,"issue":"1","issued":{"date-parts":[["2012","1"]]},"journalAbbreviation":"Physiother. Theory Pract.","page":"50-62","suppress-author":false,"title":"Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: a case report.","type":"article-journal","volume":"28"}]6,12 As time stretches out, patients are less likely to retain information, maintain a credible relationship with the therapist, and are less likely to return to the clinic.12 It is unknown how much inconsistency of sessions impacted her outcomes or the length of therapy course. The protocol had strengths and limitations. It was easily adaptable to the patient’s needs. It guided the writer in implanting PNE concepts with appropriate review, reconceptualization, and transition into treatment. It provided a broad framework for applying therapeutic education into an orthopedic setting and was easily implemented into the clinical setting. However, there was a large deviation from the suggested two, thirty-minute sessions. Partially because of the time between sessions and the inexperience of the writer, PNE sessions lasted far longer than the proposed time in order to communicate concepts and correct beliefs. Furthermore, though the protocol called for one session to correct misbeliefs, the writer incorporated review and correction into every session because the patient had difficulty grasping concepts. Using a home exercise program to provide educational material is not ideal. Because it was not possible to see the patient with sufficient frequency for education dissemination, her homework became a necessary evil. Because compliance is often an issue in the chronic pain population, education would preferably be performed one-on-one. From the writer’s experience, PNE sessions should take place every session, introducing small amounts of information which allows for processing and deep learning. Many patients describe long education sessions as a ‘fire-hydrant’ approach and they become overwhelmed. Splitting topics into small portions and spreading it over multiple weeks seems to be a more reasonable and effective approach to PNE.Retrospectively, the writer would have used a weekly email reminder to confirm appointments with the patient as well as provide accountability and potentially send review of PNE concepts. Additionally, the patient specific goals should have been created at the first session to improve her motivation. To assess how Ms Camp believed she was improving, the Global Impression of Change measure could have been regularly used to track changes between sessions. Reflection:I have been fascinated with chronic pain since my first year of physical therapy school. Neurophysiology and the process of nociception versus nociplastic pain captured my attention. In many of my clinical rotations, therapists would complain about getting a chronic pain patient, trying to hand them off to other PTs and frequently recounting interactions as “war” stories. The health care system has failed these patients. However, one clinical instructor mentored me and introduced me to current pain neuroscience. She also exemplified compassion and care, creating incredible therapeutic relationships with her patients. Given an opportunity to incorporate the latest pain neuroscience research into treating this population, I was able to practice what had been demonstrated and present an effective means of modifying the pain experience. Because many people with prolonged pain are without hope for recovery, it was a privilege to use an independent study to learn and apply effective treatment methods. Several things went better than expected. I found it natural to develop relationships with my patients. Attempting to form a therapeutic alliance like my mentor’s, I worked on communication skills and incorporated motivational interviewing techniques into patient interactions. It seemed natural to see them as people first, rather than merely as patients. Rather than setting goals and home exercise programs myself, I discussed options with the patient, sharing power and responsibility. For example, “Steve” was noncompliant after weeks of treatment though we had adjusted his HEP many times and I’d reduced it to the bare-minimum. After brainstorming together, we created a schedule and alternated days of activity because he previously felt overwhelmed and therefore did nothing. We also wrote his goals on a big sheet of paper which he taped to his bathroom wall as a reminder. This type of cooperative relationship is shown to improve outcomes in reducing pain intensity and hypersensitivity.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.2522/ptj.20130118","First":false,"Last":false,"PMID":"24309616","abstract":"BACKGROUND: Physical therapy influences chronic pain by means of the specific ingredient of an intervention as well as contextual factors including the setting and therapeutic alliance (TA) between provider and patient. OBJECTIVE: The purpose of this study was to compare the effect of enhanced versus limited TA on pain intensity and muscle pain sensitivity in patients with chronic low back pain (CLBP) receiving either active or sham interferential current therapy (IFC). DESIGN: An experimental controlled study with repeated measures was conducted. Participants were randomly divided into 4 groups: (1) AL (n=30), which included the application of active IFC combined with a limited TA; (2) SL (n=29), which received sham IFC combined with a limited TA; (3) AE (n=29), which received active IFC combined with an enhanced TA; and (4) SE (n=29), which received sham IFC combined with an enhanced TA. METHODS: One hundred seventeen individuals with CLBP received a single session of active or sham IFC. Measurements included pain intensity as assessed with a numerical rating scale (PI-NRS) and muscle pain sensitivity as assessed via pressure pain threshold (PPT). RESULTS: Mean differences on the PI-NRS were 1.83 cm (95% CI=14.3-20.3), 1.03 cm (95% CI=6.6-12.7), 3.13 cm (95% CI=27.2-33.3), and 2.22 cm (95% CI=18.9-25.0) for the AL, SL, AE, and SE groups, respectively. Mean differences on PPTs were 1.2 kg (95% CI=0.7-1.6), 0.3 kg (95% CI=0.2-0.8), 2.0 kg (95% CI=1.6-2.5), and 1.7 kg (95% CI=1.3-2.1), for the AL, SL, AE, and SE groups, respectively. LIMITATIONS: The study protocol aimed to test the immediate effect of the TA within a clinical laboratory setting. CONCLUSIONS: The context in which physical therapy interventions are offered has the potential to dramatically improve therapeutic effects. Enhanced TA combined with active IFC appears to lead to clinically meaningful improvements in outcomes when treating patients with CLBP.","author":[{"family":"Fuentes","given":"Jorge"},{"family":"Armijo-Olivo","given":"Susan"},{"family":"Funabashi","given":"Martha"},{"family":"Miciak","given":"Maxi"},{"family":"Dick","given":"Bruce"},{"family":"Warren","given":"Sharon"},{"family":"Rashiq","given":"Saifee"},{"family":"Magee","given":"David J"},{"family":"Gross","given":"Douglas P"}],"authorYearDisplayFormat":false,"citation-label":"6047676","container-title":"Physical Therapy","container-title-short":"Phys. Ther.","id":"6047676","invisible":false,"issue":"4","issued":{"date-parts":[["2014","4"]]},"journalAbbreviation":"Phys. Ther.","page":"477-489","suppress-author":false,"title":"Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study.","type":"article-journal","volume":"94"}]22I also found that I was able to communicate difficult concepts of pain neuroscience to patients. Due to the abundant resources and an excellent mentorship, I learned how to present the information as well as use clinical judgement to determine if a patient was understanding, engaging, or disagreeing. In retrospect, I wish I had been better organized. Because every session felt rushed and was filled with treatment, I frequently forgot components of the protocol. There were many times a patient left and I remembered I had not asked their goals, done a specific neurodynamic test, given an outcome measure, or provided a particular educational topic. In the future, I will create a template for the evaluation and treatment sessions to encourage orderliness.I didn’t expect patient retention and compliance to be as difficult as it was. After two to three sessions, patients would not return to clinic nor respond to calls or emails. Initially, I began with a ten-patient case-load. Over the course of five months, all but two were lost to follow up. Of note, during my last weeks, several called wishing to continue with treatment but I was unable to see them because the semester ended. These characteristics are common to chronic pain patients in general and the VA in particular.ADDIN F1000_CSL_CITATION<~#@#~>[{"DOI":"10.1080/09593985.2016.1194646","First":false,"Last":false,"PMID":"27351541","abstract":"OBJECTIVE: Systematic review of randomized control trials (RCTs) for the effectiveness of pain neuroscience education (PNE) on pain, function, disability, psychosocial factors, movement, and healthcare utilization in individuals with chronic musculoskeletal (MSK) pain. DATA SOURCES: Systematic searches were conducted on 11 databases. 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 RCTs evaluating the effect of PNE on chronic MSK pain were considered for inclusion. Additional Limitations: Studies published in English, published within the last 20 years, and patients older than 18 years. No limitations were set on specific outcome measures. DATA EXTRACTION: Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach. DATA SYNTHESIS: Study quality of the 13 RCTs used in this review was assessed by 2 reviewers using the PEDro scale. Narrative summary of results is provided for each study in relation to outcomes measurements and effectiveness. CONCLUSIONS: Current evidence supports the use of PNE for chronic MSK disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.","author":[{"family":"Louw","given":"Adriaan"},{"family":"Zimney","given":"Kory"},{"family":"Puentedura","given":"Emilio J"},{"family":"Diener","given":"Ina"}],"authorYearDisplayFormat":false,"citation-label":"2261235","container-title":"Physiotherapy Theory and Practice","container-title-short":"Physiother. Theory Pract.","id":"2261235","invisible":false,"issue":"5","issued":{"date-parts":[["2016","7"]]},"journalAbbreviation":"Physiother. Theory Pract.","page":"332-355","suppress-author":false,"title":"The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature.","type":"article-journal","volume":"32"}]8 Patients drive long distances to go to the Durham VA, and the orthopedic PT clinic maintains a trend of patients lost to follow up. Typically, therapist refer patients to clinics closer to their homes. However, there are not many PTs specializing in chronic pain and referral was not preferred for my patients. Overall, applying a protocol for PNE in the chronic pain population was a richly rewarding experience. I learned the necessity of establishing relationships yet letting the patient take responsibility for their own treatment. I learned the need for grey thinking, maintaining flexibility with the protocol, adjusting the steps and interventions per the patient’s needs. I vastly grew in my knowledge of chronic pain, central sensitization, nociplastic pain, and the current literature in treatment. Rather than becoming bored or burned out from hours upon hours of research and writing and treating, I am more determined to seek out the most effective and helpful treatment for chronic pain patients and will continue this passion into my professional career. ReferencesADDIN F1000_CSL_BIBLIOGRAPHY1. Louw A, Puenteduera E. Therapeutic neuroscience education: teaching patients about pain. International Spine and Pain Institute; 2013.2. Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther 2017;25(3):160-168. doi:10.1080/10669817.2017.1323699.3. Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an internet-based survey. J. Pain 2010;11(11):1230-1239. doi:10.1016/j.jpain.2010.07.002.4. Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man. Ther. 2003;8(3):130-140. doi:10.1016/S1356-689X(03)00051-1.5. Louw A, Puentedura EJ. Therapeutic neuroscience education, pain, physiotherapy and the pain neuromatrix. IJHS 2014;2(3). doi:10.15640/ijhs.v2n3a4.6. Nijs J, Paul van Wilgen C, Van Oosterwijck J, van Ittersum M, Meeus M. How to explain central sensitization to patients with “unexplained” chronic musculoskeletal pain: practice guidelines. Man. Ther. 2011;16(5):413-418. doi:10.1016/j.math.2011.04.005.7. Culvenor AG, ?iestad BE, Hart HF, Stefanik JJ, Guermazi A, Crossley KM. Prevalence of knee osteoarthritis features on magnetic resonance imaging in asymptomatic uninjured adults: a systematic review and meta-analysis. Br. J. Sports Med. 2018. doi:10.1136/bjsports-2018-099257.8. Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract 2016;32(5):332-355. doi:10.1080/09593985.2016.1194646.9. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain 2011;152(3 Suppl):S2-15. doi:10.1016/j.pain.2010.09.030.10. Campbell JN, Meyer RA. Mechanisms of neuropathic pain. Neuron 2006;52(1):77-92. doi:10.1016/j.neuron.2006.09.021.11. Chung EJ, Hur Y-G, Lee B-H. A study of the relationship among fear-avoidance beliefs, pain and disability index in patients with low back pain. J Exerc Rehabil 2013;9(6):532-535. doi:10.12965/jer.130079.12. Louw A, Puentedura EL, Mintken P. Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: a case report. Physiother Theory Pract 2012;28(1):50-62. doi:10.3109/09593985.2011.562602.13. Vaughan B, Mulcahy J, Fitzgerald K, Austin P. Evaluating patient’s understanding of pain neurophysiology: rasch analysis of the neurophysiology of pain questionnaire. Clin. J. Pain 2018. doi:10.1097/AJP.0000000000000658.14. Nijs J, Van Houdenhove B, Oostendorp RAB. Recognition of central sensitization in patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice. Man. Ther. 2010;15(2):135-141. doi:10.1016/j.math.2009.12.001.15. Diener I, Kargela M, Louw A. Listening is therapy: Patient interviewing from a pain science perspective. Physiother Theory Pract 2016;32(5):356-367. doi:10.1080/09593985.2016.1194648.16. Courtney CA, Fernández-de-Las-Pe?as C, Bond S. Mechanisms of chronic pain - key considerations for appropriate physical therapy management. J Man Manip Ther 2017;25(3):118-127. doi:10.1080/10669817.2017.1300397.17. Nijs J, Roussel N, Paul van Wilgen C, K?ke A, Smeets R. Thinking beyond muscles and joints: therapists’ and patients’ attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man. Ther. 2013;18(2):96-102. doi:10.1016/j.math.2012.11.001.18. Willems T, Witvrouw E, Verstuyft J, Vaes P, De Clercq D. Proprioception and muscle strength in subjects with a history of ankle sprains and chronic instability. J. Athl. Train. 2002;37(4):487-493.19. Bowering KJ, Butler DS, Fulton IJ, Moseley GL. Motor imagery in people with a history of back pain, current back pain, both, or neither. Clin. J. Pain 2014;30(12):1070-1075. doi:10.1097/AJP.0000000000000066.20. Moseley GL, Butler DS, Beames TB, Giles TJ. The graded motor imagery handbook. Noigroup Publications; 2012.21. Moseley GL. Graded motor imagery for pathologic pain: a randomized controlled trial. Neurology 2006;67(12):2129-2134. doi:10.1212/01.wnl.0000249112.56935.32.22. Fuentes J, Armijo-Olivo S, Funabashi M, et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys. Ther. 2014;94(4):477-489. doi:10.2522/ptj.20130118. ................
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