PAIN NEUROSCIENCE EDUCATION IN UNDER-SERVED AND UNDERSTUDIED POPULATIONS
E" Puentedura1, AG Silva2, S Sharma3, M Pokharel4
1Baylor University, Doctor of Physical Therapy, Waco, Texas, United States, 2University of Aveiro, School of Health Sciences, Aveiro, Portugal, 3Department of Physiotherapy, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal, 4Annapurna Neurological Institute and Allied Sciences, Physiotherapy, Kathmandu, Nepal
Learning objectives: Understand the factors that can impact the effectiveness of Pain Neuroscience Education. Learn from the researchers and clinicians on the adaptation of Pain Neuroscience Education to a diverse population including older adults, and individuals with lower socioeconomic status (low income and education). Personalize Pain Neuroscience Education to the individual and cultural characteristics of patients with chronic pain
Description: Chronic pain is a highly prevalent condition disproportionately affecting some populations such as older adults and individuals from low socioeconomic status, which are also populations under-served and understudied. Although chronic pain can affect up to 83% of older adults1 and is one of the main determinants of disability;2 pain in older adults is often ignored.1 Older adults pose additional challenges including cognitive and sensory impairments, presence of multiple comorbidities as well as inappropriate beliefs about pain and its treatment. Similarly, chronic pain prevalence and its impact is substantially high in low-income populations, where patients have low socioeconomic status and little or no safety net. For example, the prevalence of chronic pain in rural Nepal is 50% with significant out of pocket costs associated with the treatment.3 Biopsychosocial assessment and management of pain, although a current gold standard, is not adopted in Nepal despite chronic pain due to the musculoskeletal cause being the number one cause of disability.3 The current focus of research and perhaps clinical practice is largely biomedical.3
Pain neuroscience education (PNE) has been shown to have positive effects in reducing pain, disability, and psychosocial problems, improving patient's knowledge of pain mechanisms, facilitating movement and decreasing healthcare consumption.4 But studies on older adults, low educated and low-income samples from developing countries are scarce,4 providing limited examples and strategies for clinicians to adapt PNE to these populations. Nevertheless, factors such as culture, education level, pain cognition, coping strategies, the underlying pain mechanism, and age (e.g. kids or older adults) will influence how therapists deliver PNE, therefore it requires an individualized patient-centered approach for it to be effective.
Physiotherapists require an in-depth understanding of pain mechanisms, the communication skills to listen to patient stories and educate them about their own pain and how they can manage it. Also, various important requirements for effective PNE in clinical practice are described such as the explanation must be intelligible, plausible and beneficial to the patient and the new explanation should be shared and confirmed by the direct environment of the patient. Furthermore, a recent systematic review and meta-analysis identified several aspects important for enhancing the patient experience of PNE, such as allowing the patient to tell their own story.5 Nevertheless, PNE is not delivered as a standalone approach, it is usually combined with manual therapy and exercise. PNE helps re-conceptualize patients' views towards exercise and facilitates patients' adherence to all forms of exercise, including time-contingent exercise. The positive impact of combined PNE and exercise on both pain and disability is higher than for exercise alone.6
In order to adopt PNE intervention in an Eastern culture, Sharma and colleagues recently developed a PNE program by using local patient stories, proverbs and metaphors, and the intervention was accepted as a credible intervention for the management of low back pain by individuals with low socioeconomic status (education and income).7 The feasibility study suggested that PNE was more effective than guideline-based care for low back pain. A recent viewpoint also highlighted that the health system strengthening approaches are necessary to tackle the burden of pain in low- and middle-income countries (LMICs), and educating the general population about pain is one useful way not just for the pain management but also for achieving healthy aging.8 PNE can be an useful intervention if it is adapted to suit local cultural contexts to LMICs. Similarly, adaptations of PNE are necessary for institutionalized older adults with adjustments to match their cognitive and poor hearing abilities by strategies such as shortening sessions, increasing repetitions, and combining dance.9 Community-dwelling older adults praise aspects such as the therapist-patient relationship or his ability to choose examples they can relate to, and PNE, when combined with exercise positively impacts self-management and self-efficacy, perceived functioning and general well-being.
Implications/conclusions: Although chronic pain is a major problem, significant groups of individuals with pain do not receive appropriate (non-pharmacological) pain management. Physiotherapists have the responsibility to try and reach these individuals using best-evidence personalized approaches such as PNE and exercise. This symposium will bring together physiotherapists with both clinical and research experience to show how PNE can be personalized to different individuals, cultures and clinical contexts to improve its utility and efficacy.
References:
1. Pickering G, Zwakhalen S, Kaasalainen S, eds. Pain Management in Older Adults. Cham: Springer International Publishing, 2018.
2. Silva AG, Queirós A, Sa-Couto P, Rocha NP. Self-reported disability: Association with lower extremity performance and other determinants in older adults attending primary care. Phys Ther 2015, 95(12): 1628-37.
3. Sharma S, Jensen MP, Pathak A, Sharma S, Pokharel M, Abbott JH: State of clinical pain research in Nepal: a systematic scoping review. PAIN Reports 2019, 4(6):e788.
4. Louw A, Zimney K, Puentedura EJ, Diener I The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice 2016, 32: 1–24.
5. Watson JA, Ryan CG, Cooper L, Ellington D, Whittle R, Lavender M, Dixon J, Atkinson G, Cooper K, Martin DJ: Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and metaanalysis. J Pain 2019, 20(10):1140.e1141-1140.e1122.
6. Bodes PG, Lluch Girbés E, Roussel NA, Gallego Izquierdo T, Jiménez Penick V, Pecos Martín D. Pain neurophysiology education and therapeutic exercise for patients with chronic low back pain: a single-blind randomized controlled trial. Arch Phys Med Rehabil. 2018;99(2):338-347.
7. Sharma S, Jensen MP, Moseley GL, Abbott JH: Results of a feasibility randomised clinical trial on pain education for low back pain in Nepal: the Pain Education in Nepal-Low Back Pain (PEN-LBP) feasibility trial. BMJ Open 2019, 9(3):e026874.
8. Sharma S, Blyth FM, Mishra SR, Briggs AM: Health system strengthening is needed to respond to the burden of pain in low and middle-income countries and to support healthy ageing. Journal of Global Health 2019, 9(2).
2. Silva AG, Queirós A, Sa-Couto P, Rocha NP. Self-reported disability: Association with lower extremity performance and other determinants in older adults attending primary care. Phys Ther 2015, 95(12): 1628-37.
3. Sharma S, Jensen MP, Pathak A, Sharma S, Pokharel M, Abbott JH: State of clinical pain research in Nepal: a systematic scoping review. PAIN Reports 2019, 4(6):e788.
4. Louw A, Zimney K, Puentedura EJ, Diener I The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice 2016, 32: 1–24.
5. Watson JA, Ryan CG, Cooper L, Ellington D, Whittle R, Lavender M, Dixon J, Atkinson G, Cooper K, Martin DJ: Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and metaanalysis. J Pain 2019, 20(10):1140.e1141-1140.e1122.
6. Bodes PG, Lluch Girbés E, Roussel NA, Gallego Izquierdo T, Jiménez Penick V, Pecos Martín D. Pain neurophysiology education and therapeutic exercise for patients with chronic low back pain: a single-blind randomized controlled trial. Arch Phys Med Rehabil. 2018;99(2):338-347.
7. Sharma S, Jensen MP, Moseley GL, Abbott JH: Results of a feasibility randomised clinical trial on pain education for low back pain in Nepal: the Pain Education in Nepal-Low Back Pain (PEN-LBP) feasibility trial. BMJ Open 2019, 9(3):e026874.
8. Sharma S, Blyth FM, Mishra SR, Briggs AM: Health system strengthening is needed to respond to the burden of pain in low and middle-income countries and to support healthy ageing. Journal of Global Health 2019, 9(2).
Key-words: 1. Pain Neuroscience Education 2. Older adults 3. Health status disparities
Funding acknowledgements: No
All authors, affiliations and abstracts have been published as submitted.
