Adriaan Louw

• PT, PhD
• International Spine and Pain Institute

Chronic pain is an ever-increasing global challenge, and few strategies have been shown to significantly alter this trajectory, and a pure pharmaceutical approach, especially opioids, is not the answer. To truly impact a person with chronic pain's life, current best-evidence supports changing their cognitions (how they think about their pain), movi...

In musculoskeletal and sports medicine, pain has traditionally been linked to tissue injury, often assuming a linear correlation between tissue damage and pain intensity. However, modern pain science has illuminated the complexity of the human pain experience, incorporating psychosocial elements, nervous system sensitization, immune responses, and...

Background: Previous qualitative research has listed trust as a component of the therapeutic alliance in physical therapy. Objective: Quantitatively correlate trust and therapeutic alliance in physical therapy care for patients with chronic low back pain. The secondary aim was to investigate the relation of trust and therapeutic alliance with ou...

The potential to classify low back pain as being characterised by dominant nociceptive, neuropathic, or nociplastic mechanisms is a clinically relevant issue. Preliminary evidence suggests that these low back pain phenotypes might respond differently to treatments; however, more research must be done before making specific recommendations. Accordin...

Background: Various factors have been shown to influence attendance to physical therapy (PT), including various psychosocial factors. Anecdotally, it is believed that higher copays are associated with fewer PT visits and shorter duration, but limited research is available to support this. Objective: To determine if higher copays for patients attend...

OBJECTIVE: To create a consensus-based framework of manual therapy treatment approaches for the major mechanisms-based pain classifications established by the International Association for the Study of Pain (IASP) nociceptive, nociplastic, and neuropathic pain. DESIGN: The hybridized consensus survey included experts who participated in working gro...

Background: One in five patients experience persistent pain and disability after total knee arthroplasty (TKA), often driven by increased sensitization of the nervous system and pain. Pain and a sensitized nervous system are major barriers to postoperative rehabilitation impeding improved movement, and function. Objective: To determine if mirror th...

Pain is an individualized experience for the person suffering from chronic pain. Significant strides have been made in the last few decades in understanding various biological changes that coincide with chronic pain. This state-of-the-art overview looks at the current evidence related to the biology of chronic pain and the implications these findin...

Background: Pain neuroscience education (PNE) has been shown to increase knowledge of pain and improve cognitions and beliefs regarding

Background: Perioperative education should be improved to decrease unfavourable outcomes after lumbar surgery. This trial aimed to compare effectiveness in terms of pain, quality of life, pain cognition, surgical experience, healthcare use, work resumption, and cost-effectiveness of perioperative pain neuroscience education (PPNE) vs traditional b...

Purpose: The purpose of this study was to deliver pain neuroscience education (PNE) to participants in grades 3 to 8 to determine whether participants in these grades had positive shifts in pain knowledge and beliefs. Methods: Three hundred twenty participants, grades 3 to 8, received a 1-time, 30-minute PNE lecture. The Neurophysiology of Pain...

Post-traumatic stress disorder (PTSD) and chronic low back pain (CLBP) are frequently co-morbid. Some research suggests that PTSD and CLBP may share common neurobiological mechanisms related to stress. Traditional biomedical education may be ineffective for PTSD and CLBP, especially when co-morbid. The purpose of this study is to determine if pain...

Background: Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion (ROM). The aim of this study was to evaluate the effect of adding a central nervous system-focused (CNS) approach to a manual therapy and a home stretching pr...

Background: Emerging evidence shows that altered cortical brain maps play a key role in the initiation and maintenance of a human pain experience and therapeutic treatments may positively influence these maps and reduce pain and disability. Objective: To determine if dry needling for spinal pain can positively alter body pain diagrams and if those...

Background Musculoskeletal pain is a common reason to seek outpatient physical therapy care. Generational differences regarding attitudes and beliefs have been found in many areas, but it has not been explored regarding pain. Objectives This study aimed to examine generational differences in attitudes and beliefs regarding pain and the potential d...

Introduction: Enhancing the therapeutic alliance has been associated with improved outcomes for patients with chronic low back pain (CLBP). Qualitatively trust has been described to be part of the therapeutic alliance, but it has not been measured quantitatively within the physical therapy literature. Objective: Examine the relationship between...

Introduction: Current evidence supports the inclusion of directional preference exercises for a subgroup of patients with low back (LBP) and leg pain. Recent pain neuroscience strategies have suggested that cortical restructuring associated with movement activating the body map representation in the brain might account for the observed improvement...

Objectives Research suggests that attendance by physical therapists at continuing education (CE) targeting the management of low back pain (LBP) and neck pain does not result in positive impacts on clinical outcomes. The aim of this study was to determine if therapists attending a self-paced 3-hour online Pain Neuroscience Education (PNE) program w...

Background: Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion (ROM). The aim of this study is to evaluate the feasibility and clinical impact of a CNS-focused treatment program for people with FS. Methods: 10 subjects...

Background Chronic low back pain (CLBP) has been associated with altered cortical mapping in the primary somatosensory cortex. Various sensory discrimination treatments have been explored to positively influence CLBP by targeting cortical maps. Objectives To determine if dry needling (DN) applied to patients with CLBP would yield changes in two-po...

Objective: To determine if a brief, one-on-one pain neuroscience education (PNE) session delivered by a physical therapist (PT) can influence depression. Methods: A convenience sample of patients with persistent low back pain (LBP) (n = 23) attending PT with moderate to severe depression (Patient Health Questionnaire-9 [PHQ-9]) participated in the...

Aims To assess if Pain Neuroscience Education (PNE) delivered to older adults can positively influence pain knowledge and pain beliefs. Methods A total of 55 older adults attended a 30-minute PNE lecture. The primary outcome measures of pain knowledge, fear avoidance, beliefs regarding pain and aging as well as self-reported pain were obtained bot...

Chronic spinal pain poses complex challenges for healthcare around the world and is in need of effective interventions. Pain Neuroscience Education (PNE) is a promising intervention hypothesized to improve pain and disability by changing individuals' beliefs, perceptions and expectations about pain. PNE has shown promise in small, controlled trials...

Background Pain education resources for children using appropriate language and illustrations remain scarce. Objectives We aimed to summarize the development process and testing for face and content validity of a structured comic book about pain education for children. Methods A first draft of a comic book was developed (Portuguese and English) b...

Synopsis: Society is mired in a serious health care crisis regarding the pain and opioid epidemics. Pain neuroscience education (PNE) has gained support in the last 20 years as an intervention to help people manage their chronic pain condition. In this Viewpoint, we argue exercise and movement must be the primary intervention for chronic pain cond...

Purpose: Pilot study assessing if pain neuroscience education (PNE) can shift treatment choices for patients with chronic pain in Physician Assistants (PA) students. Methods: A convenience sample of PA students (n = 29) attended a 2-hour PNE lecture. Prior to and immediately after the lecture, students completed a questionnaire regarding their beli...

Background: Central sensitisation, in addition to high levels of fear-avoidance and pain catastrophisation may exist in a subgroup of patients with shoulder pain. Pain neuroscience education (PNE) has been shown to positively influence sensitivity of the nervous system, as well as reduce fear and catastrophisation prior to lumbar and total knee sur...

Background: Frozen shoulder (FS) is a highly disabling pathology of poorly understood etiology, which is characterized by the presence of intense pain and progressive loss of range of motion (ROM). The aim of this study was to evaluate the feasibility and clinical impact of a CNS-focused treatment program for people with frozen shoulder (FS). Metho...

Chronic pain and the opioid epidemic need early, upstream interventions to aim at meaningful downstream behavioral changes. A recent pain neuroscience education (PNE) program was developed and tested for middle-school students to increase pain knowledge and promote healthier beliefs regarding pain. In this study, 668 seventh-grade middle-school stu...

We describe the case of a 75-year-old female with chronic low back pain (CLBP), on opioids for more than 15 years. She presented with an acute episode of nausea, vomiting, abdominal pain, and shortness of breath. After a complete work-up, it was concluded that her presenting symptoms were likely due to her high levels of CLBP and high dose opioids....

Objective: To investigate the effect of the examination process (history taking and physical examination) on pain and function. Methods: An observational cohort trial of patients presenting to outpatient physical therapy clinics for the first time with low back pain (n = 34, 57.7 ± 18.7 years, 53% female). A blinded investigator measured participan...

Background: Disrupted tactile acuity and poor laterality judgement have been shown in several chronic musculoskeletal pain conditions. Whether they are impaired in people with frozen shoulder (FS) remains unknown. Objectives: To determine whether there is impairment in tactile acuity and laterality judgement in subjects with FS. Methods: Thirt...

Pain neuroscience education (PNE) and motivational interviewing (MI) have been widely implemented and tested in the field of chronic pain management, and both strategies have been shown to be effective in the short term (small effect sizes) for the management of chronic pain. PNE uses contemporary pain science to educate patients about the biopsych...

The modern clinician faces more challenges than ever before, including a worldwide pain epidemic and skepticism among critics about the efficacy of hands-on treatment. This book, written by four renowned physical therapists and pain neuroscientists, provides techniques that combine manual therapy and pain neuroscience to help practitioners meet the...

Background: 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 a...

BACKGROUND: Frozen shoulder (FS) is a musculoskeletal condition of poorly understood etiology that results in shoulder pain and large mobility deficits. Despite some physical therapy interventions, such as joint mobilization and exercise, having shown therapeutic benefit, a definitive treatment does not currently exist. The aim of this study will b...

Objective: Because of the pain and opioid epidemic in the United States, there is a need to update clinician's knowledge, attitudes, and beliefs regarding persistent pain across healthcare disciplines. The aim of this study was to determine if healthcare professionals can positively change their knowledge, attitudes, and beliefs regarding chronic...

Around 20% of patients undergoing surgery for lumbar radiculopathy develop chronic pain after surgery, leading to high socioeconomic burden. Current perioperative interventions, including education and rehabilitation, are not always effective in preventing prolonged or chronic postoperative pain and disability. Here, a shift in educational interven...

Introduction: Individuals with co-morbid post-traumatic stress disorder (PTSD) and pain have higher disability, pain, and pain catastrophizing beliefs than patients without PTSD. Pain neuroscience education (PNE) may be an effective tool to help those with PTSD and pain reduce maladaptive beliefs about pain. The purpose of this paper is to report t...

Objective The aim of this study was to determine if a preoperative pain neuroscience education program would result in superior outcomes compared to usual preoperative education for total knee arthroplasty. Design Controlled clinical trial with alternating allocation. Setting Community-based hospital. Subjects Consecutive sample of 120 patients...

Study Design: A prospective, single-arm, pre-postintervention study. Objective: To determine the preliminary usefulness of providing pain neuroscience education (PNE) on improving pain and movement in patients presenting with non-chronic mechanical low back pain (LBP). Background: PNE has been shown to be an effective intervention for the treatment...

When dealing with chronic pain, it is often not possible for clinicians to provide adequate answers to their patients about what might be wrong, and why they continue to have their pain. This has led to greater use of diagnostic “labels” for conditions such as fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, chronic Lyme disease, a...

Background: Chronic Regional Pain Syndrome (CRPS) is a condition that physical therapists may encounter in an outpatient orthopedic setting. In physical therapy (PT) treatment of CRPS addresses pain and the changes observed in the brain through the use of graded motor imagery (GMI). Case Description: A 57-year-old female presented to an outpatient...

Purpose: Evaluate the effectiveness and efficiency of two different pain neuroscience education (PNE) lectures provided to physician assistant (PA) students. Primary outcomes explored were knowledge of pain and shift in attitudes and beliefs about chronic pain after the lecture. Methods: A PNE lecture was provided at two separate university PA p...

Background: Standard preoperative education for total knee arthroplasty (TKA) has been shown to have no effect on postoperative outcomes. This may be because such education programs fail to educate patients about pain. Pain neuroscience education (PNE) focuses on teaching people more about pain from a neurobiological and neurophysiological perspec...

Evidence shows that patients who better understand their pain, and what pain truly is, experience less pain, have less fear, move better, exercise more and can regain hope. Pain Neuroscience Education is written by clinicians for clinicians, with all information presented in a way that is relevant and readily applicable to “real-world” clinical se...

Comorbidities associated with orofacial pain There is evidence demonstrating that the presentation of chronic pain conditions such as low back pain, headache, and orofacial pain share common charac- teristics (De Leeuw & Klasser, 2013). Pain localization in these conditions often exhibits spreading pain into other areas. Orofacial pain has clear co...

Study Design Case report. Background Aggressive physical therapy in the freezing stage of frozen shoulder may prolong the course of recovery. Central sensitization may play a role in the early stages of frozen shoulder. Pain neuroscience education, tactile discrimination, and graded motor imagery have been used in a number of conditions with centr...

Background Patients’ beliefs about their condition have been shown to play a significant role in their pain experience and response to treatment, especially when a patient sees their tissue health as vulnerable or aged. Educational can alter these beliefs. Prior to new information, patients often have to be de-educated regarding common misbeliefs t...

Pain neuroscience education (PNE) has gained considerable attention in research. Three systematic reviews have shown increasing efficacy of PNE decreasing pain, disability, pain catastrophization, movement restrictions, and healthcare utilization. In the development of any new therapeutic approach, it is proposed that there are three stages: develo...

Objectives To determine the beliefs and describe the health care experiences of patients with complex regional pain syndrome. Methods A survey tool for patients with complex regional pain syndrome was designed for this study. The survey tool collected self-reported measures associated with pain, disability, health care experiences, education, beli...

Objective: To determine the effects of a brief single component of the graded motor imagery (GMI) sequence (mirror therapy) on active range of motion (AROM), pain, fear-avoidance and pain catastrophization in patients with shoulder pain. Design: Single-blind case series SETTING: Three outpatient physical therapy clinics PARTICIPANTS: Patients wi...

Pain neuroscience education (PNE) is an educational strategy aimed at teaching people more about pain from a neurobiological and neurophysiological perspective. Current best-evidence provides strong support for PNE to positively influence pain ratings, dysfunctions, fear-avoidance and pain catastrophization, limitations in movement, pain knowledge,...

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 th...

Objectives: Purpose was to assess physiotherapists' value of using postural assessment of individuals with fibromyalgia. Secondary analysis on correlation of posture assessment by physiotherapists. Design: A non-experimental, retrospective, observational survey analysis of relationship of posture with individuals having fibromyalgia and healthy con...

Background: Results from a previous multicenter randomized controlled trial (RCT) on preoperative pain neuroscience education (PNE) for lumbar radiculopathy found no significant difference in patient reported outcomes between groups. However, patients who received PNE viewed their surgical experience more favorably and utilized significantly less h...

Purpose: To determine the referral patterns, utilization and indications for postoperative physical therapy (PT) for lumbar radiculopathy. At least 50 % of patients following lumbar surgery (LS) for radiculopathy are referred for PT to address postoperative pain and disability. Very little is known regarding factors following LS that predict refer...

Objective: To determine if a neuroplasticity educational explanation for a manual therapy technique will produce a different outcome compared to a traditional mechanical explanation. Methods: Sixty-two patients with chronic low back pain (CLBP) were recruited for the study. Following consent, demographic data were obtained as well as pain rating...

Pain Neuroscience Education (PNE) has been shown to increase patient and healthcare provider knowledge of pain. To date, however, no study has examined if that knowledge is maintained over time. Patients suffering from chronic pain were invited to attend a free PNE lecture. Patients were required to complete intake demographics followed by two self...

Objective To evaluate the evidence for the effectiveness of sham surgery in orthopedics by conducting a systematic review of literature. Methods Systematic searches were conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect and Web of...

Teaching people about the neurobiology and neurophysiology of their pain experience has a therapeutic effect and has been referred to as pain neuroscience education (PNE). Various high-quality randomized controlled trials and systematic reviews have shown increasing efficacy of PNE decreasing pain, disability, pain catastrophization, movement restr...

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, du...

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 s...

Introduction: Despite scientific progress with regard to pain neuroscience, perioperative education tends to stick to the biomedical model. This may involve, for example, explaining the surgical procedure or ‘back school’ (education that focuses on biomechanics of the lumbar spine and ergonomics). Current perioperative education strategies that are...

Chronic pain is incredibly complex, and so are decisions as to its treatment. During physical therapy care, pain neuroscience education (PNE) aims to help patients understand more about their pain from a biological and physiological perspective. Accompanying the growing evidence for the ability of PNE to reduce pain and disability in patients with...

Aims To examine how the choice of words explaining ultrasound (US) may influence the outcome of physiotherapy treatment for low back pain (LBP). Methods Sixty-seven patients with LBP < 3 months were randomly allocated to one of three groups – traditional education about US (control group [CG]), inflated education about US (experimental group [EG])...

Objective: To determine if a 3-hour therapeutic neuroscience education session alters physical therapy student's knowledge of pain and effects their attitudes and beliefs regarding treating chronic pain. Methods: Seventy-seven entry-level doctoral physical therapy students participated in the study. Following consent, demographic data were obtai...

Patients with low back pain (LBP) often display faulty beliefs and cognitions regarding their pain experience. Pain neuroscience education (PNE) aims to alter the pain experience by targeting these faulty beliefs and cognitions. One PNE strategy aims specifically to reframe commonly held beliefs about tissues by patients with LBP as the single sour...

Representational body maps are dynamically maintained in the brain and negatively influenced by neglect, decreased movement and pain. Graded motor imagery (GMI) utilizing various tactile and cognitive processes have shown efficacy in decreasing pain, disability and movement restrictions in musculoskeletal pain. Limited information is known about th...

Can a brief tactile intervention associated with brain remapping improve pain and spinal movement in patients with chronic low back pain? A convenience sample of patients with chronic low back pain completed various pre-intervention measurements including low back pain (Numeric Pain Rating Scale), fear-avoidance (Fear Avoidance Beliefs Questionnair...

In recent years there has been an increased interest in pain neuroscience in physical therapy. Emerging pain neuroscience research has challenged prevailing models used to understand and treat pain, including the Cartesian model of pain and the pain gate. Focus has shifted to the brain’s processing of a pain experience, the pain neuromatrix and mor...

Recently a preoperative pain neuroscience education (NE) program was developed for lumbar surgery (LS) for radiculopathy as a means to decrease postoperative pain and disability. This study attempts to determine the short term effects, if any, of providing NE before surgery on patient outcomes. A case series of 10 patients (female = 7) received pre...

Therapeutic neuroscience education (TNE) has been shown to be effective in the treatment of mainly chronic musculoskeletal pain conditions. This case study aims to describe the changes in brain activation on functional magnetic resonance imaging (fMRI) scanning, before and after the application of a newly-designed preoperative TNE program. A 30-yea...

Patients with low back pain (LBP) often display faulty beliefs and cognitions regarding their pain experience. Pain neuroscience education (NE) aims to alter the pain experience by targeting these faulty beliefs and cognitions. One NE strategy aims specifically to reframe commonly held beliefs about tissues by patients with LBP as the single source...

Purpose: To compare the usage of 'provocative' terms in two patient education booklets for lumbar surgery. Background: The recently completed FASTER trial failed to support the use of an evidence-based educational booklet to significantly improve postsurgical outcomes over rehabilitation and usual care. The use of a different booklet in another rec...

Background and Purpose: Chronic pain is often associated with faulty cognitions and beliefs. One approach to alter cognitions and beliefs is to teach patients about the neurophysiology and neurobiology of their pain experience through therapeutic neuroscience education [TNE]. Mounting evidence has shown the benefit of TNE for patients with chronic...

Use of Therapeutic Neuroscience Education to address Psychosocial Factors Associated with Acute Low Back Pain: A Case Report.

Study design: Multicenter, randomized, controlled trial on preoperative pain neuroscience education (NE) for lumbar radiculopathy. Objective: To determine if the addition of NE to usual preoperative education would result in superior outcomes with regard to pain, function, surgical experience, and health care utilization postsurgery. Summary of...

Study Design. Multicenter, randomized, controlled trial on preoperative pain neuroscience education (NE) for lumbar radiculopathy.Objective. To determine if the addition of NE to usual preoperative education would result in superior outcomes in regards to pain, function, surgical experience and healthcare utilization post-surgery.Summary of Backgro...

Abstract Therapeutic neuroscience education (TNE) aims to alter a patient's thoughts and beliefs about pain and has shown efficacy in treating chronic pain. To date, TNE sessions mainly consist of one-on-one verbal communication. This approach limits availability of TNE to pain patients in remote areas. A 32-year-old patient with chronic low back p...

Pain neuroscience education for patients with CRPS or RSD

Abstract Acute low back pain (LBP) from injuries is prevalent in the work place. It has been shown that patients with psychosocial factors often progress with persistent pain and lead to significant workers compensation costs. Therapeutic Neuroscience Education (TNE) has been shown to be beneficial in changing a patient's cognition regarding their...

Objective: Evaluate content and educational delivery methods of preoperative education in total joint arthroplasties of the hip and knee (THA and TKA) addressing postoperative pain. Data sources: Systematic searches conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), Ps...

Introduction: Studies have shown that lumbar surgery (LS) outcomes may be influenced by perception. However, the perceptions of the general population regarding LS are not known. Therefore, the purpose of this study was to investigate the general population's perceptions regarding LS. Subjects: This study included 262 participants (mean age: 46....