The use of pain neuroscience education (PNE) has been shown to be effective in reducing pain, improving function and lowering fear and catastrophisation. Pain neuroscience education utilises various stories and metaphors to help patients reconceptualise their pain experience. To date no individualised study has looked at which stories and metaphors may be the most effective in achieving the positive outcomes found with the use of PNE.
This study examined patient responses to the usefulness of the various stories and metaphors used during PNE for patients who underwent surgery for lumbar radiculopathy.
Twenty-seven participants who received preoperative PNE from a previous randomised control trial (RCT) were surveyed 1-year post-education utilising a 5-point Likert scale (0 – ‘do not remember’, 4 – ‘very helpful’) on the usefulness of the various stories and metaphors used during the PNE session. Participant demographics and outcomes data (pain intensity, function and pain knowledge) were utilised from the previous RCT for analysis and correlations.
Nineteen surveys were returned for a response rate of 70%. No story or metaphor mean was below 2 – ‘neutral’, lowest mean at 2.53; 6 of the 11 stories or metaphors scored a mean above 3 – ‘helpful’.
No individual story or metaphor stood out as being predominately important in being helpful in the recovery process through the use of PNE.
The overall messages of reconceptualising pain during PNE may be more important than any individual story or metaphor.
Traditional biomedical education for pain-related musculoskeletal conditions focuses on a structural pathological model as a means of explaining why someone is going through a pain experience. There is evidence to show that biomedical education, which often produces potential negative expectations through verbal suggestions, may influence pain perception in a negative way (Blasini et al.
Pain neuroscience education has shown promise as an effective educational strategy adjunct to a comprehensive multimodal rehabilitation programme (Louw et al.
While the effectiveness of the PNE approach has shown promise based on the overall concept of reconceptualising pain, the effectiveness of individual metaphors and analogies to accomplish this within a PNE session is less well known.
Even with the understanding that pain neurobiology and neurophysiology explained to patients via stories, metaphors and pictures are helpful, there is currently no evidence to determine if the total overall educational exposure (all of the stories) or single stories are most helpful in causing a conceptual shift in a person struggling with pain. Because of increasing demands on healthcare providers in regard to time management, resources distribution and healthcare costs (Orszag & Ellis
Our study was a non-experimental cross-sectional descriptive survey of participants after PNE. It is one of the follow-up studies resulting from a multi-centre randomised controlled trial (RCT) of preoperative PNE before LS for radiculopathy, which has been published elsewhere (Louw et al.
A total of 27 participants who completed the 1-year follow-up from the original RCT treatment group that received PNE were eligible for our study. Original inclusion criteria were the following: (1) scheduled for LS for radiculopathy; (2) willingness to comply with the predetermined follow-ups and (3) willingness to complete postoperative questionnaires at designated time intervals. Exclusion criteria were the following: (1) age younger than 18 years or older than 65 years; (2) not being proficient in reading or comprehending the English language; (3) scheduled for LS involving instrumentation (e.g. spinal fusion, arthroplasty); (4) participation in a formal back school or multidisciplinary pain management programme; (5) undergoing LS for a condition other than lumbar radiculopathy; (6) the presence of chronic-pain-related conditions (e.g. fibromyalgia, chronic fatigue syndrome) or (7) symptoms of cord compression.
The development and content of the preoperative PNE session has been published elsewhere (Louw et al.
Example of picture to explain ‘extra-sensitive alarm’.
Example of picture to explain ‘hospital experiences’.
Description of the metaphors and target topics used in the preoperative pain neuroscience education.
Story | Metaphor | Target topic |
---|---|---|
1 | Alarm system: Your nerves working like an alarm system to protect you | Neurons, synapses, action potential and nociception |
2 | Extra-sensitive alarm: The nerves (alarm system) in your back becoming extra sensitive | Peripheral sensitisation, neuropathic pain, central sensitisation and hyperalgesia |
3 | Nerve sensors: Nerve sensors telling you about movement, stress and cold | Ion channel expression, peripheral sensitisation, neuroplasticity and hyperalgesia |
4 | Yellow flags: Issues (yellow flags) that keep your alarm system extra sensitive | Biopsychosocial risk factors, fear avoidance and pain catastrophisation |
5 | Nosy neighbours: Why nerves can become sensitive and how spreading pain might occur | Neuroplasticity, hyperalgesia, peripheral sensitisation and immune responses |
6 | Hospital experiences: Surgery and hospital experiences ramping up the alarm system | Fear avoidance, pain catastrophisation and stress biology |
7 | Calming sensitive nerves: Calming down the alarm system – knowledge and movement | Cognitive therapy, inhibition, endogenous mechanisms of pain control, aerobic exercise, desensitisation and addressing fear |
8 | Hurt does not equal harm: Understanding ‘hurt does not equal harm’ and ‘sore but safe’ sayings about extra-sensitive nerves | Peripheral and central sensitisation, fear avoidance, coping strategies, behaviour change, goal setting, pacing and graded exposure |
9 | Dry and wet brain: The brain’s pain medicine | Endogenous mechanisms of pain control, neurotransmitters, inhibition and facilitation |
10 | No freaking over flare-ups: The ups and downs of normal recovery | Pacing, graded exposure, hyperalgesia, goal setting and internal locus of control |
11 | Pain is normal: Pain after surgery is to be expected and normal | Realistic goals, pain biologically normal, sensitisation and neuroplasticity |
A survey was developed, based on the aims of the study and previous survey studies used by the research team in developing PNE programmes for low back pain and spine surgery (Louw et al.
After the 1-year follow-up for the RCT (Louw et al.
Demographic data and the outcomes of the survey data were extracted and entered into an Excel spreadsheet with conversion to SPSS version 24 (IBM Corporation) for full analysis. Descriptive statistics such as means, counts and percentages were used to describe the participants. Ranges, mode and frequency of each metaphor were calculated from survey data.
The study was approved by the Health Research Ethics Committee at Stellenbosch University (Ethics Reference #: N09/09/247).
Nineteen of the 27 participants (response rate = 70.3%) completed the PNE metaphor survey. Participants completing the survey had a mean age of 51.3 years and 11 were female (58%).
Participant demographics
Characteristics | % | |
---|---|---|
Age, mean (s.d.), year | 51.3 | 13.0 |
Female, |
11 | 58 |
Race or ethnicity, |
||
White people | 19 | 100 |
Education level, |
||
Postgraduate | 6 | 32 |
College graduate | 5 | 26 |
High school graduate | 8 | 42 |
Primary reason for surgery, |
||
Pain | 12 | 63 |
Numbness or paraesthesia | 3 | 16 |
Decreased function | 3 | 16 |
Failed treatment | 1 | 5 |
Duration of back and leg pain prior to surgery, mean (s.d.), week | 76.7 | 111.9 |
Data presented in number and percentage unless otherwise indicated.
s.d., standard deviation.
Individual metaphor information.
Metaphor | Range | Mode | Mean | s.d. |
---|---|---|---|---|
Alarm system ( |
2–4 | 3 | 3.11 | 0.58 |
Extra-sensitive alarm ( |
2–4 | 3 | 3.16 | 0.77 |
Nerve sensors ( |
2–4 | 3 | 3.00 | 0.67 |
Yellow flags ( |
0–4 | 3 | 2.78 | 1.00 |
Nosy neighbours ( |
2–4 | 2 | 2.89 | 0.83 |
Hospital experiences ( |
2–4 | 3 | 3.11 | 0.74 |
Calming sensitive nerves ( |
2–4 | 3 | 3.00 | 0.59 |
Hurt does not equal harm ( |
1–4 | 3 | 2.84 | 0.69 |
Dry and wet brain ( |
0–4 | 2 and 3 | 2.53 | 0.94 |
No freaking over flare ups ( |
2–4 | 3 | 2.79 | 0.63 |
Pain is normal ( |
2–4 | 3 | 3.21 | 0.63 |
s.d., standard deviation.
The overall ranking (mean of the means) of the pain metaphors was 2.94 on the 0–4-point Likert scale. The highest ranking (mean score) metaphors in order of importance were (1) the general concept of pain being normal after surgery (3.21), (2) extra-sensitive alarm system (3.16), (3) the body’s living alarm system (3.11), (4) surgery experience influencing nerve sensitivity (3.11) and (5) nosy neighbours (2.89) (
Rating of the pain neuroscience education metaphors (0 = cannot remember; 4 = very helpful).
One participant scored ‘dry and wet brain’ and ‘yellow flags’ as 0 – do not remember. Another participant scored ‘hurt does not equal harm’ as 1 – not very helpful. All of the other metaphor stories scored between 2 – neutral and 4 – very helpful on the Likert scale. The median score for all the metaphors was 3 – helpful. The mode for each metaphor ranked 3 – helpful, except for ‘nosy neighbours’ where the mode was 2 – neutral and ‘dry and wet brain’ which tied between 2 – neutral and 3 – helpful with the participants. The overall combined themes centred around two main issues: ‘easy to understand’ and ‘knew what to expect after surgery’.
This is the first study to investigate, from a patient’s perspective, if specific metaphors associated with PNE are more helpful than others. The results from this study indicate no one metaphor seems to be superior to other metaphors for people undergoing PNE prior to LS for radiculopathy at the 1-year recovery follow-up period. Patients are interested in learning more about pain (Louw, Louw & Crous
The layout of the material in our study was similar to the study by Gallagher et al., who had patients read a book of metaphors associated with pain science, covering 11 different sections, and not one specific story (Gallagher, Mcauley & Moseley
The PNE programme tested in this trial was a culmination of more than a half-dozen studies to develop the PNE programme, with the intent to address all (or most) of the pertinent information patients may need to know after undergoing lumbar radiculopathy surgery (Louw et al.
From the patients’ perspective, the overall theme of ‘pain after surgery is expected and normal’ carried some weight, both in being ranked highest and in the summary of the general themes. This may be specific to this patient population as it has been shown that patients have a mismatch in regard to their expectations and experiences when it comes to LS (Toyone et al.
Pain is a normal human experience (Moseley
All of the stories contained in the preoperative PNE programme centred around this theme of sensitisation and normality of pain, which further strengthens the argument why the sum of all the metaphors was seen as beneficial (Louw
While this is an initial exploratory survey investigating which PNE metaphors may be most effective and significant and follow-up research is needed, it may provide some clinical insights in the delivery of PNE. Our study showed that no one metaphor was more important than another. Therefore, clinicians do not have to feel tied into using a specific set protocol to deliver PNE. Considering the multidimensionality of pain and the heterogeneous nature of each individual in pain, this makes sense that the delivery of PNE in a clinical setting is probably best delivered in a heterogeneous fashion based on the patient in front of the clinician.
The most effective dosage (time spent) on NPE has not been established, and may vary hugely between acute and persistent pain situations, and between low and high sensitisation. The systematic review by Louw et al. (
Therefore, which individual metaphors the clinician utilises may not be as important as long as they all tie into a central understanding of why the patient still hurts. As the patient triangulates information from the various stories and metaphors as part of the PNE process, it may be important that there are no contradictory messages from the healthcare provider and there is congruency in the message.
This study contains various limitations. The sample size is a small sample of convenience with no
No single metaphor or story was superior to other metaphors in the PNE process to help individuals in their recovery after lumbar radiculopathy surgery. Multiple pain metaphors, combined into one single story, may be important from a patient’s perspective, in helping them understand their pain experience.
The authors acknowledge the participants for their time and insight for completing the surveys.
Adriaan Louw, Emilio J. Puentedura, Ina Diener, and Kory J. Zimney have published books on pain neuroscience education and receive royalties from them.
A.L. was the project leader; I.D. and E.J.P. assisted in project design; K.J.Z. provided statistical analysis and T.C. was involved in data analysis and IRB submission through Southwest Baptist University. A.L., I.D., E.J.P., K.J.Z. and T.C. were all involved in manuscript writing and preparation.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
The data that support the findings of this study are available from the corresponding author, upon reasonable request.
The views expressed in this article are their own and not an official position of the institution or funder.