Therapeutic Neuroscience Education: Teaching Patients About Pain; A Guide for Clinicians by A. Louw and E. Puentedura. International Spine and Pain Institute. OPTP, Minneapolis, MN, 2013, 292 pages, soft cover, $59.
This text fills a growing need to educate physical therapists on patient instruction in Therapeutic Neuroscience Education (TNE). Both authors are physical therapists and experts in the field of orthopedic manual therapy and the treatment of chronic pain. Adriana has worked closely with Neuro Orthopedic Institute and the leaders in pain science in Australia and around the world. Each chapter contains recent research and the background principles are clearly evidence based. This biopsychosocial approach is appropriate for any patient with chronic pain including patients with pelvic pain.
Chapter 1 describes the biopsychosocial approach in more detail with red and yellow flags and questionnaires. Chapter 2 reviews the research on TNE. A systematic review of 8 well-done RCTs is summarized showing the TNE effect on decreasing pain experience, improving function and physical movements, and decreasing catastrophization. It also shows how biomedical education (traditional back school) may possibly make pain worse. Different types of education styles are summarized and one conclusion is that one-on-one education is the most effective method of TNE. This chapter also lists the essential items to be covered in TNE: neurophysiology of pain, nociceptive pathways, neurons, synapses, action potential, spinal inhibition and facilitation, plasticity of the nervous system, and central and peripheral sensitization. No reference to anatomical models or discussion of the emotional aspects of pain is included in TNE.
The pain neuroscience questionnaire is introduced in chapter 3. This "test" can be given to patients to assess their understanding of pain physiology. The authors explain the answers to each question using the most current evidence. The chapter ends with a discussion of the placebo effect and one conclusion is that the placebo becomes an effective treatment. One example of this is a systematic review showing sham surgery to be as effective as real surgery.
In chapter 4, specific topics in TNE are introduced in patient-friendly language. Each topic includes a brief description of the goal of the topic for the PT and then follows with a detailed example of how to explain it to patients by using pictures, stories, and metaphors. It is recommended that the therapist individualize the education to the patient's condition and cognitive capacity. Each topic also includes a suggestion of images the therapist should have on hand to explain the topic. It is suggested that the PT "gather such images to develop a clinical tool for educating patients." In other words, you could print images from the Internet, draw them yourself, or take pictures. Topics include a nail in foot, waking up the alarm system, why did nerves get so sensitive, speeding bus hurts more than an ankle sprain, noisy neighbors, driving the same road over and over, inflammatory soup, when lions attach, and more.
Chapter 5 addresses the application of TNE in the clinic with information about time, cost, billing, training of staff, and more. It is explained that not all clinics will use all strategies and that there are many ways to individualize the application. In the outpatient setting, most women's health practices allow for one-on-one time with the patients and are easily able to integrate this technique.
The effects of prolonged stress on all systems of the body are reviewed in detail in chapter 6. This helps therapists explain the patient's symptoms, thus decreasing fear and ultimately decreasing pain. The second part of this chapter outlines adjunctive treatments and their effect on the patient, including aerobic exercise, strengthening and stabilizing exercises, posture, relaxation and meditation, diet, sleep, coping skills, humor, manual therapy, modalities, goal setting, pacing, and graded exposure.
A case presentation is given in chapter 7. The case includes history, questionnaires, and examination. The intervention is described in a complete manner. More than 30 pages are devoted to detailed description of what is done and why it is done. Subsequent treatments, outcomes, progression, and assessment of change are all included. Pain scientists agree that asking patients with chronic pain to report pain intensity does not provide any value and may increase fear and intensity of pain. Instead functional scales are used to measure progress. Several examples of full-text questionnaires are given in the text.
The final chapter briefly explores group education, education of the general public, and preemptive education (given in the acute stage of injury or before surgery). This text is a must have for every PT treating chronic pain. It is the perfect combination of easy-to-read topics and explanations of neurophysiology. The information can be applied to the clinic today.
Why You Hurt: Therapeutic Neuroscience Educational System by A. Louw. International Spine and Pain Institute. OPTP, Minneapolis, MN, 2014, 120+ cards, $199.95.
This system is designed to complement the text Therapeutic Neuroscience Education: Teaching Patients About Pain; A Guide for Clinicians. The TNE text suggests that clinicians should create a tool box of images to be used in the education of patients. Another option is to purchase the cards already made. The system includes a 5-page booklet that gives a very brief explanation of TNE. A teaching index is also included, which explains how each card is organized.
Each topic includes between 6 and 30 cards, including image cards and homework cards. Each card is 81/2" by 61/2" glossy, cardboard stock that appears to be study enough to withstand use in a busy clinic for years. Image cards have a full-color picture on one side to enhance learning and help the patient remember the lesson. The back side of the image card has teaching cues to be used initially by the PT to convey the message. Therapists are encouraged to individualize the information to the specific patient condition and learning capacity. Each card also includes 2 research papers for further reading, as well as the correlating pages in Therapeutic Neuroscience Education: Teaching Patients About Pain; A Guide for Clinicians, and other texts that Adriana has written. While the image cards cannot be copied, the homework cards can be. There is also a digital version of the homework cards on the OPTP Web site. Homework cards incorporate 2 elements: deep learning and empowering the patient. By following a structure of self-study and homework, the patient is held to a higher level of responsibility for her own recovery.
Topics included in this text include the pain neurophysiology questionnaire, sensitive nerves, nerve sensors, nosy neighbors, calming nerves, pain and the brain, brain's pain map, body, Inc's CEO, loins and stress, tissue issues, neurogenic inflammation, the brain's body maps, immune system and pain, and emotions and pain. This system brings the process full circle with evidence, therapists' instruction, and patient education points. It should be used in conjunction with the full text Therapeutic Neuroscience Education: Teaching Patients About Pain: A Guide for Clinicians. The cards are well done and professional and cover the topic fully. Whether you make your own cards or use the educational system, the TNE technique is a must learn for therapists working with patients who have chronic pain, including chronic pelvic pain.
Beth Shelly, PT, DPT, WCS, BCB-PMD
Moline, Illinois
[email protected]