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Abstract

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 biopsychosocial nature of the chronicity of their pain experience. The goal of PNE is to optimize patients' pain beliefs/perceptions to facilitate the acquisition of adaptive pain coping strategies. MI, on the other hand, is a patient-centered communication style for eliciting and enhancing motivation for behavior change by shifting the patient away from a state of indecision or uncertainty. Conceptually, PNE and MI appear to be complementary interventions, with complementary rather than overlapping effects; MI primarily improves cognitive and behavioral awareness and, potentially, adherence to treatment principles, whereas PNE potentially increases pain knowledge/beliefs, awareness, and willingness to explore psychological factors that are potentially associated with pain. Therefore, combining PNE with MI might lead to improved outcomes with larger and longer-lasting effect sizes. The combined use of PNE and MI in patients having chronic pain is introduced here, along with a description of how clinicians might be able to integrate PNE and MI in the treatment of patients experiencing chronic pain. Clinical trials are needed to examine whether combining PNE with MI is superior to PNE or MI alone for improving pain and quality of life in patients having chronic pain.
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1 J. Nijs, PT, MT, MSc, PhD, Department of Physiotherapy,
Faculty of Physical Education and Physiotherapy, Pain in
Motion International Research Group, Vrije Universiteit
Brussel, Building F-KIMA, Laarbeeklaan 103, BE-1090
Brussels, Belgium; and Department of Physical Medicine and
Physiotherapy, Chronic Pain Rehabilitation, University
Hospital Brussels, Brussels, Belgium. Address all
correspondence to Dr Nijs at: jo.nijs@vub.be.
2 A.J. Wijma, PT, MSc, Department of Physiotherapy, Faculty
of Physical Education and Physiotherapy, Pain in Motion
International Research Group, Vrije Universiteit Brussel;
Department of Physical Medicine and Physiotherapy, Chronic
Pain Rehabilitation, University Hospital Brussels; and
Transcare Pain, Transdisciplinary Treatment Center,
Groningen, the Netherlands.
3 W. Willaert, PT, MSc, Department of Physiotherapy, Faculty
of Physical Education and Physiotherapy, Pain in Motion
International Research Group, Vrije Universiteit Brussel;
Department of Physical Medicine and Physiotherapy, Chronic
Pain Rehabilitation, University Hospital Brussels; and
Research Foundation–Flanders (FWO), Brussels, Belgium.
4 E. Huysmans, PT, MSc, Department of Physiotherapy,
Faculty of Physical Education and Physiotherapy, Pain in
Motion International Research Group, Vrije Universiteit
Brussel; Department of Physical Medicine and Physiotherapy,
Chronic Pain Rehabilitation, University Hospital Brussels;
Research Foundation–Flanders (FWO); and Department of
Public Health (GEWE), Faculty of Medicine and Pharmacy,
Vrije Universiteit Brussel.
5P. Mintken, PT, DPT, PhD, Department of Physical Therapy,
School of Medicine, University of Colorado, Aurora,
Colorado, and Wardenburg Health Center, University of
Colorado, Boulder, Colorado.
6 R. Smeets, PhD, Research School CAPHRI, Maastricht
University, Maastricht, the Netherlands, and CIR Revalidatie
Eindhoven/Zwolle, Eindhoven/Zwolle, the Netherlands.
7 M. Goossens, PhD, Research School CAPHRI, Maastricht
University, and CIR Revalidatie Eindhoven/Zwolle.
8C.P. van Wilgen, PT, PhD, Department of Physiotherapy,
Faculty of Physical Education and Physiotherapy, Pain in
Motion International Research Group, Vrije Universiteit
Brussel; and Transcare Pain, Transdisciplinary Treatment
Center.
9 W. Van Bogaert, PT, MSc, Department of Physiotherapy,
Faculty of Physical Education and Physiotherapy, Pain in
Motion International Research Group, Vrije Universiteit
Brussel.
10 A. Louw, PT, PhD, Department of Physical Therapy,
International Spine and Pain Institute, Louisville, Kentucky.
11 J. Cleland, PT, PhD, FAPTA, Department of Physical Therapy,
Franklin Pierce University, Manchester, New Hampshire.
12 M. Donaldson, PT, PhD, Physical Therapy Program, School
of Medicine, Tus University, Boston, Massachusetts.
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This work was partially funded by the Berekuyl Academy
Chair, funded by the European College for Lymphatic
Therapy, Harderwijk, the Netherlands, and awarded to J. Nijs,
VrijeUniversiteit Brussel, Brussels, Belgium. W. Willaert is a
PhD fellow appointed to project no. G007217 funded by the
ResearchFoundation Flanders (FWO), Brussels, Belgium. E.
Huysmans is a PhD fellow funded by FWO
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J. Nijs, PT, MT, MSc, PhD, Department
of Physiotherapy, Faculty of Physical
Education and Physiotherapy, Pain in
Motion International Research Group,
Vrije Universiteit Brussel, Building
F-KIMA, Laarbeeklaan 103, BE-1090
Brussels, Belgium; and Department of
Physical Medicine and Physiotherapy,
Chronic Pain Rehabilitation, University
Hospital Brussels, Brussels, Belgium.
Address all correspondence to Dr Nijs
at: jo.nijs@vub.be.
A.J. Wijma, PT, MSc, Department of
Physiotherapy, Faculty of Physical
Education and Physiotherapy, Pain in
Motion International Research Group,
Vrije Universiteit Brussel; Department
of Physical Medicine and
Physiotherapy, Chronic Pain
Rehabilitation, University Hospital
Brussels; and Transcare Pain,
Transdisciplinary Treatment Center,
Groningen, the Netherlands.
W. Willaert, PT, MSc, Department of
Physiotherapy, Faculty of Physical
Education and Physiotherapy, Pain in
Motion International Research Group,
Vrije Universiteit Brussel; Department
of Physical Medicine and
Physiotherapy, Chronic Pain
Rehabilitation, University Hospital
Brussels; and Research
FoundationFlanders (FWO), Brussels,
Belgium.
E. Huysmans, PT, MSc, Department of
Physiotherapy, Faculty of Physical
Education and Physiotherapy, Pain in
Motion International Research Group,
Vrije Universiteit Brussel; Department
of Physical Medicine and
Physiotherapy, Chronic Pain
Rehabilitation, University Hospital
Brussels; Research
FoundationFlanders (FWO); and
Department of Public Health (GEWE),
Faculty of Medicine and Pharmacy,
Vrije Universiteit Brussel.
P. Mintken, PT, DPT, PhD, Department
of Physical Therapy, School of
Medicine, University of Colorado,
Aurora, Colorado, and Wardenburg
Health Center, University of Colorado,
Boulder, Colorado.
M. Donaldson, PT, PhD, Physical
Therapy Program, School of Medicine,
Tufts University, Boston,
Massachusetts.
Post a comment for this
article at:
https://academic.oup.com/ptj
Perspective
Integrating Motivational Interviewing
in Pain Neuroscience Education for
People With Chronic Pain: A Practical
Guide for Clinicians
Jo Nijs,AmarinsJ.Wijma,WardWillaert,EvaHuysmans,PaulMintken,
Rob Smeets, Mariëlle Goossens,C.Paulvan Wilgen, Wouter Van Bogaert,
Adriaan Louw,JoshCleland,MeganDonaldson
Pain neuroscience education (PNE) and motivational interviewing (MI) have been widely
implemented and tested in the eld 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
biopsychosocial nature of the chronicity of their pain experience. The goal of PNE is
to optimize patients’ pain beliefs/perceptions to facilitate the acquisition of adaptive pain–
coping strategies. MI, on the other hand, is a patient-centered communication style for
eliciting and enhancing motivation for behavior change by shifting the patient away from
a state of indecision or uncertainty. Conceptually, PNE and MI appear to be complementary
interventions, with complementary rather than overlapping effects; MI primarily improves
cognitive and behavioral awareness and, potentially, adherence to treatment principles,
whereas PNE potentially increases pain knowledge/beliefs, awareness, and willingness
to explore psychological factors that are potentially associated with pain. Therefore,
combining PNE with MI might lead to improved outcomes with larger and longer-lasting
effect sizes. The combined use of PNE and MI in patients having chronic pain is introduced
here, along with a description of how clinicians might be able to integrate PNE and MI in
the treatment of patients experiencing chronic pain. Clinical trials are needed to examine
whether combining PNE with MI is superior to PNE or MI alone for improving pain and
quality of life in patients having chronic pain.
2020 Volume 100 Number 5 Physical Therapy 1
OUP UNCORRECTED PROOF FIRST PROOF, 14/2/2020, SPi
R. Smeets, PhD, Research School
CAPHRI, Maastricht University,
Maastricht, the Netherlands, and CIR
Revalidatie Eindhoven/Zwolle,
Eindhoven/Zwolle, the Netherlands.
M. Goossens, PhD, Research School
CAPHRI, Maastricht University, and
CIR Revalidatie Eindhoven/Zwolle.
C.P. van Wilgen, PT, PhD, Department
of Physiotherapy, Faculty of Physical
Education and Physiotherapy, Pain in
Motion International Research Group,
Vrije Universiteit Brussel; and Transcare
Pain, Transdisciplinary Treatment
Center.
W. Van Bogaert, PT, MSc, Department
of Physiotherapy, Faculty of Physical
Education and Physiotherapy, Pain in
Motion International Research Group,
Vrije Universiteit Brussel.
A. Louw, PT, PhD, Department of
Physical Therapy, International Spine
and Pain Institute, Louisville, Kentucky.
J. Cleland, PT, PhD, FAPTA,
Department of Physical Therapy,
Franklin Pierce University, Manchester,
New Hampshire.
[Nijs J, Wijma AJ, Willaert W, et al.
Integrating motivational interviewing
in pain neuroscience education for
people with chronic pain: a practical
guide for clinicians. Phys Ther.
2020;100:114.]
© 2020 American Physical Therapy
Association
Published Ahead of Print:
January 29, 2020
Accepted: October 6, 2019
Submitted: January 21, 2019
Motivational Interviewing Plus Explaining Pain
Chronic pain (pain that persists beyond normal expected healing times or
for >3 months) affects around 20% of the population.1The prevalence of chronic
pain is higher than any other chronic disease,2,3including cancer, heart disease,
and diabetes. Chronic pain has a tremendous personal and socioeconomic impact; it
causes the highest number of years lived with disability4and is the most expensive
cause of work-related disability.5,6Chronic pain also decreases life expectancy,
independent of sociodemographic factors.7,8
Over the past decades, the scientic understanding of chronic pain has revealed that
biopsychosocial factors contribute to the intensity and persistence of pain.913 Factors
such as comorbidities, physical tness, behavior, psychosocial characteristics, and
environmental aspects can all inuence the pain a person experiences.913 This improved
understanding of chronic pain has shifted management strategies away from purely
biomedical treatments, such as lumbar fusion surgery,14 injections, or pharmacotherapy,
to multimodal approaches acknowledging the complex biopsychosocial nature of
chronic pain. Such multimodal approaches often include patient self-management.
The successful incorporation of self-management strategies typically requires a
behavioral change from the patient. To facilitate a behavioral change, patient education
and communication strategies such as pain neuroscience education (PNE) and
motivational interviewing (MI) have been developed and tested for the management of
chronic disabling pain.15,16 PNE entails the explanation of the
neurophysiological-endocrine-immune changes in the central nervous system in
patients with chronic pain. This approach incorporates contemporary pain
(neuro)science to educate a patient about the nature of her or his pain experience and
associated contributing factors in order for the patient to reconceptualize the meaning
of the pain experience.17 PNE facilitates the patient to gain a broader biopsychosocial
understanding of her or his pain experience, including the role of neurophysiological
(eg, central and peripheral nervous system sensitization), psychological, social, and
environmental factors in addition to biomedical factors.17,18 The typical aim of PNE is to
decrease the threat value of pain, diminish catastrophic thinking, and facilitate a more
active coping strategy (Figure).19 MI, on the other hand, is a directive, collaborative,
patient-centered communication approach for eliciting and enhancing motivation for
behavior change by helping clients to resolve ambivalence and uncertainty.20,21 MI is a
communication process in which the health care professional is supportive, empathetic,
positive, and hopeful. MI relies strongly on the therapeutic alliance to assist in changing
certain health behaviors based on the patients’ internal thoughts, decisions, and
motivation. MI also aims to strengthen personal commitment by respecting the
individual’s autonomy and assists them to reach a specic goal by exploring personal
intentions or reasons for change.20,21 MI includes 2 essential components: the
therapeutic relationship, or MI spirit, which is based on empathy, open-ended questions,
eliciting the patient’s thoughts, respecting the patient’s autonomy, and appreciating the
patient’s reections; and increasing cognitive dissonance for the current state and
“change talk,” which implies the use of each of the abovementioned aspects as well as
reective listening to delineate the patient’s ambivalence or underlying reasons for
behavior change and therefore instigating internal motivated change.2022
2Physical Therapy Volume 100 Number 5 2020
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Motivational Interviewing Plus Explaining Pain
Figure 1.
Pain neuroscience education and motivational interviewing are conceptually complementary interventions.
Both PNE19 and MI15 have been widely tested and
implemented for the management of chronic pain, and
both strategies appear to be useful components for the
treatment of patients having chronic pain.15,19 Both
strategies appear to elicit short-term effects in individuals
experiencing chronic pain.15,19 PNE and MI also appear to
have complementary results (Figure); MI appears to
primarily improve treatment adherence,15 whereas PNE
results in clinically meaningful improvements in
kinesiophobia and pain catastrophizing in the short and
medium terms, respectively.16 However, data from 12
randomized controlled trials (755 participants)
demonstrated that improvements in pain and disability
following PNE are not clinically important.16 Combining
PNE and MI might lead to improved outcomes, as PNE
and MI appear to be conceptually complementary
interventions in terms of outcomes as concerning clinical
application possibilities. Although the concepts of PNE
AQ5
and MI clinically are frequently used together, to the best
of our knowledge, no attempts have been made to
describe the combined use of PNE and MI in patients
experiencing chronic pain. This article describes how
clinicians symbiotically integrate PNE and MI into the
management of chronic pain.
Evidence Supporting the Use of PNE in
People With Chronic Pain
In populations with noncancer pain, including patients
with chronic low back pain, chronic neck pain,
bromyalgia, chronic fatigue syndrome, osteoarthritis, and
postsurgical pain, PNE appears to result in favorable
outcomes18,23 and has proven to be effective in changing
pain beliefs as well as leading to pain-coping strategies
and improving health status (level A evidence).18,23 30 Still,
only the improvements in kinesiophobia and pain
catastrophizing are considered clinically meaningful,16 and
adding 2 hours of PNE to recommended rst-line care for
patients with acute low back pain did not improve pain
outcomes.31 The learning objectives of PNE include
decreasing the threat value of pain, increasing the
patients’ knowledge about pain, and reconceptualizing of
pain into a broader biopsychosocial perspective. To
achieve this, the patient needs to understand that all pain
is produced, constructed, and modulated by the brain (eg,
pain triggered or worsened by pain anticipation) and that
their pain symptoms often relate to hypersensitivity of the
nervous system rather than (ongoing) tissue damage.
Current evidence19 suggest patients learn PNE best via
metaphors, examples, and images.
Although effective in the short term,19 the effect sizes of
PNE are typically small.32 However, PNE appears to pave
the way for more active interventions, such as
cognition-targeted exercise therapy, and combining the 2
treatment strategies generates a synergistic effect, with
medium to large effect sizes that have been shown to be
sustained at a 1-year follow-up in patients having chronic
spinal pain.33 Studies exploring the long-term effects of
PNE as an isolated intervention are scarce and limited to a
single study comparing presurgical PNE vs no
intervention for individuals undergoing surgery for
lumbar radiculopathy.34 No effects on pain-related
outcomes were observed, but large (approximately 40%)
reductions in health care utilization and related costs were
found and maintained at 3-year follow-up.34,35 Given the
potential for success, PNE programs for other populations
within the chronic pain population have been developed
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Motivational Interviewing Plus Explaining Pain
yet still require experimental testing in randomized
controlled trials. This includes PNE for pediatric chronic
pain,36 pain in athletes,37 and postcancer pain.37
In health care, contextual factors, previously known as
nonspecic factors, have a larger inuence on the
treatment outcome in patients experiencing chronic
pain38,39 than initially thought. The interpersonal and
communication skills of the health care professional
signicantly inuence the therapeutic relationship.4042
Whether it is labeled patient-centered care, the therapeutic
alliance, or shared decision-making, all theoretical
concepts surrounding the patient-therapist interaction
include active listening to be sure the patient feels heard
and validated as well as shared decision-making to ensure
the patient feels in control of the ultimate treatment
decisions. The therapist should be empathic, friendly, and
understanding, have excellent communication skills, and
establish a bond with the patient that leads to agreement
on the goals and plan of care, implying that the treatment
should be individualized. These characteristics are also
important features of MI but are less explored in current
PNE programs.
Evidence Supporting the Use of MI in People With
Chronic Pain
MI is a strategy that originates from the eld of alcohol
and other substance abuse20 to facilitate behavioral
change toward a more healthy lifestyle.22,43,44 Since its
development, MI has been tested and applied to a variety
of patient populations, including obesity,43 arthritis,45 and
cancer.44 MI has become a popular approach for
increasing treatment adherence.15 A systematic review
identied 7 randomized clinical trials with 962
participants with chronic pain and concluded that there
was a small to moderate overall effect of MI on increased
adherence to treatment in the short term but not in the
long term.15 There were insufcient study data available to
make robust conclusions regarding the effects of MI on
pain severity or physical functioning, but the available
data suggest improvements in pain intensity but no effects
on physical functioning in patients experiencing chronic
pain.15
In addition, there is strong evidence supporting the
efcacy of MI to address lifestyle behaviors as well as the
psychosocial needs of cancer patients and survivors, but
more effort is needed to examine whether MI is also
useful for self-management of cancer-related symptoms
such as pain.44 The positive effects of MI on lifestyle
behaviors and psychosocial needs in the cancer (survivor)
population are highly relevant in the context of chronic
pain management. Indeed, chronic (post)cancer pain is
increasingly recognized as an underestimated yet
debilitating symptom in cancer (survivorship)46 and one
that requires addressing lifestyle factors as well as
psychosocial factors.47
Even though the use of MI in patients with chronic pain is
promising, there are several points to address. First, in the
bromyalgia population, both the use of opioids48 and
obesity49 are associated with diminished effects of MI,
indicating that these impeding factors need to be
considered. Second, a recent review on MI focusing on
which individuals will benet from MI reported that more
high-quality research is needed to be condent about the
effectiveness of MI.50 It is clear, however, that the
consistency of the provided MI intervention across
sessions and clinicians is critical.51 A study where nurses
were trained to deliver an MI-based pretreatment in pain
rehabilitation for patients with bromyalgia or chronic
musculoskeletal pain revealed the need for the rigorous
selection of MI counselors before training and the
important role of continuous supervision and feedback for
MI practitioners to reach proper MI delity.52 It is
important to emphasize that MI is not a separate treatment
component or treatment module; on the contrary, MI is a
communication style that should be integrated throughout
the treatment, including the (preparatory) educational
phase. Within a multidisciplinary setting, all therapists
should master MI skills to optimize its effects.
MI can be based on the transtheoretical model of the
stage of behavior change (this script is an adaptation of
the MI script developed by the UCLA Center for Human
Nutrition for weight reduction in people with obesity,
available at http://www.cellinteractive.com/ucla/
physcian_ed/scripts_for_change.html). Hence, it is
essential to know where the patient is regarding readiness
to change her or his beliefs about and/or way of dealing
with pain. Further, it is essential to stipulate on what
aspect of the pain experience the patient is ready (or not)
for change. A person can be ready to change their beliefs
about pain but not to change pain-related behavior.
Why Combining PNE and MI Is Indicated
How could MI help the delivery of PNE? Providing
valuable information in the form of PNE is an important
role of the health care professional. A common behavior
and strategy that many health care providers use is often
rooted from a paternalistic approach, thus using
presumptuous patient education rather than tailoring the
education to the needs to change behavior, thoughts, and
linguistic/intelligence level.53 This approach compromises
the therapeutic alliance and patient-centered care and
creates the risk of evoking resistance in the patient.
“Ruptures” in the therapeutic alliance are hard to
overcome and can negatively inuence the outcomes of
the treatment.54 Using MI strategies such as
elicit-provide-elicit can help increase patient receptiveness,
acceptance, and engagement. For example, the therapist
could ask the patient to share what they knows about
back pain (elicit). The therapist could then ask permission
to comment on the patient’s thoughts and beliefs based on
current best evidence (provide). Following the provision
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Motivational Interviewing Plus Explaining Pain
of new information, the therapist could then ask the
patient how the new information reconciles with their
thoughts about back pain (elicit). This approach is in line
with the nding that allowing patients to tell their own
story is a key component for enhancing the patient
experience of PNE.16 Exchanging information in MI builds
on patients’ personal knowledge and experience, assesses
their understanding of the new information, and allows
for feedback in a nonconfrontational
manner.
Individuals who can successfully combine PNE and MI
include psychotherapists, physical therapists, nurses,
doctors, or any other health care professional, as long as
they comply with certain prerequisites. First, the provider
must possess an in-depth understanding of pain
mechanisms55 and the dysfunctional central nociceptive
processing associated with chronic pain.56,57 This includes
a thorough understanding of biopsychosocial factors in
the development and sustainment of chronic pain.58
Second, health care providers need adequate skills to
provide evidence-based explanations to their patients
regarding pain mechanisms, central sensitization, and
neuropathic pain in the presence of chronic pain. Third,
specic communication skills are required. For instance, a
Socratic-style dialogue of education59 is preferred over
“lecturing” to the patient. This is where MI can be
benecial and why we advocate integrating PNE and MI.
Indeed, neither PNE and MI are standard interventions or
stand-alone treatments but rather treatment concepts that
should be individually tailored to the specic features,
needs, and perceptions of patients having pain. Indeed,
PNE typically establishes the path for more active
approaches to current evidence-based biopsychosocially
driven pain management strategies, including graded
activity,60 exposure in vivo,61 stress management, and
acceptance-based interventions (eg, acceptance and
commitment therapy).62,63 Fourth, theoretical knowledge
on behavioral learning and change is necessary to put
PNE and MI in the context of goal-directed behavioral
change.
Also, the aims of PNE and MI appear to be
complementary for optimizing a comprehensive pain
management program. The learning objectives of PNE
focus on decreasing the threat value of the pain
experience, and increasing the patients’ knowledge of
pain, whereas MI is more focused on inviting a person to
engage in a behavioral change. Such a behavioral change
in patients with chronic pain can potentially be facilitated
and accelerated through PNE supplemented with MI.
Maladaptive pain knowledge/beliefs can delay or prevent
targeted behavioral change and therefore should be
addressed through PNE. MI may be effective in eliciting
the desired change. Finally, as explained in the
introduction, the different scope of MI and PNE manifests
itself in different yet complementary
results.
How to Integrate PNE and MI in Clinical
Practice
Using MI to Prepare People for PNE
A thorough biopsychosocial intake should always precede
PNE. A clinical guide for such a biopsychosocial intake
before PNE is presented elsewhere.13 Next, it is important
to acknowledge the pain, not by telling patients, “We take
your pain seriously,” but by telling them that we
understand how it works.
Many providers use PNE without obtaining explicit
consent from the patient. This can lead to a rupture in the
therapeutic alliance when the patient accuses the provider
of thinking that the patient’s pain is “all in their head.” MI
principles suggest that the provider should ask the patient
for permission to talk about pain neuroscience. Having
the patient express consent to receive PNE maintains the
therapeutic alliance and may result in the patient being
more receptive to the message. PNE can be proposed to
patients together with other options (eg, initiating exercise
therapy straight away without prior explanation about
their pain) in a shared decision-making format. MI is a
communication style to facilitate the shared
decision-making process, especially in patients having
treatment expectations that are not in line with
evidence-based treatment guidelines. A similar approach
(elicit-provide-elicit) can be used to ask for patients’
permission to integrate stress management (and/or the
management of fear, anxiety, and behavioral factors) into
the treatment program: rst ask patients about their
thoughts on the role of stress in their daily pain
experience (elicit); ask permission to explain why stress
inuences pain (using examples given in Appendix 1) and
how coping skills may be used to address those stressors
(provide); and ask patients about their thoughts on this
new information (elicit). Integrating education about
stress physiology into PNE allows patients to understand
that stress is not purely a psychological factor but instead
represents a complex biopsychosocial issue with an
important and measurable biological component (ie,
cortisol, adrenaline, and heart rate). This approach may
allow the provider to move to the next phase of
behavioral change, including asking permission to discuss
patient-specic stressors and how to cope with them.
Using MI During PNE
Change talk is an essential component of MI20,21 and can
be an important addition to PNE, which traditionally has
been a more passive, paternalistic communication strategy.
The provider typically lectures about pain mechanisms
and explains the importance of changing the way in
which the patient interprets and manages the pain
experience. Using MI principles, change talk elicits
important reasons for change from the patient by having
them give voice to the need for change that is personally
important. Examples of such change talk that can be used
when providing PNE to patients with chronic pain are
presented in Appendix 1.
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Motivational Interviewing Plus Explaining Pain
Also, integrating MI during PNE can be based on the
transtheoretical model of the stage of behavior change,
implying the need to assess where the patient is about
readiness and willingness to change their beliefs about
and/or way of dealing with pain. Trying to elicit “change”
in a patient who is not ready will not be successful and
may be disruptive to the therapeutic relationship.
Appendix 2 provides a series of examples of how MI can
be used when providing PNE to patients who are in the
precontemplation stage of behavior change (ie, when the
patient is not considering change regarding any aspect of
pain-related behavior), the contemplation stage (ie, when
the patient is ambivalent about change), and the
preparation stage (ie, when the patient is preparing to
change and begins making small changes to prepare for a
larger life change). In addition to the examples, Appendix
2 also provides suggested goals and strategies to use in
each stage of behavior change. Hence, the appendix can
be used as a practical guide for clinicians willing to
integrate MI during PNE and vice versa.
Combining MI and PNE may motivate patients to invest
time and energy into changing their thoughts/beliefs by
reading PNE materials at home (this can be either a PNE
information leaet55,64 or online PNE material65 ; Appendix
2, part II, contemplation stage, item 5). The patient may
also be motivated to share this information with a
signicant other, which may facilitate social support
(Appendix 2, part III, preparation stage, item 5). The
combined approach (MI plus PNE) also may allow
clinicians to set the stage for a multimodal approach, that
is, preparing patients for a comprehensive treatment plan
to include a behavioral change to address various lifestyle
factors, including stress, sleep, and physical activity
(Appendix 2, part III, preparation stage, item 5).
Research Agenda
Although the aims of PNE and MI appear to be
complementary for optimizing a comprehensive pain
management program, it is unclear whether combining
the 2 approaches is superior to PNE or MI alone.
Therefore, clinical trials are needed to examine whether
combining PNE with MI is superior to PNE or MI alone for
improving pain and quality of life in patients with chronic
pain. We want to reiterate that combining PNE and MI
does not constitute a comprehensive pain management
program. Chronic pain management requires a
multimodal and individually tailored best practice
approach, including patient education, exercise therapy,
activity modication (including graded activity), stress
management, acceptance and commitment therapy,
cognitive therapy, sleep hygiene, and dietary
interventions. We belief that a combined approach using
PNE and MI has the potential to optimize patient
outcomes from a multimodal plan of care for patients
having chronic pain. Future research should explore the
possible additive value of combining PNE with MI within
a multimodal plan of care for patients with chronic pain.
Conclusion
Both PNE19 and MI15 have been widely investigated and
implemented in chronic pain management, and both have
been shown to be effective to some extent in the short
term for the management of chronic pain.15,19 PNE uses
contemporary pain science to educate patients about the
biopsychosocial nature of their pain experience. PNE aims
to optimize a patient’s pain beliefs/perceptions with the
goal of improving adaptive pain-coping strategies (in line
with the common-sense model).66 MI, on the other hand,
is a patient-centered communication style for eliciting and
strengthening motivation for behavior change by
facilitating patients to resolve ambivalence/uncertainty.20,21
MI and PNE appear to be complementary interventions. In
addition, they may yield complementary rather than
overlapping effects; MI primarily improves treatment
adherence,15 whereas PNE has been shown to improve
pain knowledge/beliefs and psychological factors, such as
kinesiophobia and pain catastrophizing associated with
pain.16,19 Combining MI and PNE may lead to improved
outcomes. Clinical trials are needed to examine whether
combining PNE with MI is superior to PNE or MI alone for
improving pain and quality of life in patients experiencing
chronic pain.
A patient-centered communication style such as MI may
interact with PNE to increase the effect of the treatment.
However, as many patients with chronic pain present with
specic functional impairments linked to fear avoidance
beliefs, the addition of MI to a PNE treatment may not be
enough to change patients’ behaviors regarding functional
tasks limited by the pain or fear. Therefore, it is
recommended adding not only MI but also
cognition-targeted exercises for treating musculoskeletal
chronic pain.33,67 Information and motivational strategies
do not necessarily lead to behavioral change. Combining
MI plus PNE should establish the path for more active
approaches to current evidence-based biopsychosocially
driven pain management strategies, including graded
activity,60 exposure in vivo,61 stress management, and
acceptance-based interventions.62,63 When providing such
a comprehensive multimodal pain management approach,
the desired behavioral change can be expected.
Author Contributions and Acknowledgments
Concept/idea/research design: J. Nijs, A.J. Wijma, E. Huysmans,
P. Mintken, C.P. van Wilgen, W. Van Bogaert, M. Donaldson
Writing: J. Nijs, A.J. Wijma, W. Willaert, E. Huysmans, P. Mintken,
R. Smeets, M. Goossens, C.P. van Wilgen, W. Van Bogaert,
A. Louw, J. Cleland, M. Donaldson
Data collection: J. Nijs
Dataanalysis:J.Nijs,A.Louw
Project management: J. Nijs
Consultation (including review of manuscript before submitting):
A.J. Wijma, W. Willaert, E. Huysmans, R. Smeets, M. Goossens,
C.P. van Wilgen, W. Van Bogaert, M. Donaldson
6Physical Therapy Volume 100 Number 5 2020
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Motivational Interviewing Plus Explaining Pain
Funding
This work was partially funded by the Berekuyl Academy Chair,
funded by the European College for Lymphatic Therapy,
Harderwijk, the Netherlands, and awarded to J. Nijs, Vrije
Universiteit Brussel, Brussels, Belgium. W. Willaert is a PhD fellow
appointed to project no. G007217 funded by the Research
Foundation Flanders (FWO), Brussels, Belgium. E. Huysmans is a
PhD fellow funded by FWO.
Disclosures
The authors completed the ICMJE Form for Disclosure of Potential
Conicts of Interest. J. Nijs authored a Dutch book on PNE, but the
royalties are collected by the Vrije Universiteit Brussel and not him
personally. C.P. van Wilgen authored a Dutch book on PNE. A.
Louw authored a book on PNE.
DOI: 10.1093/ptj/pzaa021
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Appendix 1.
Motivational Interviewing Strategies and Techniques
Integrated in Pain Neuroscience Education: Rationales and
Examples for Asking Permission and Eliciting Change
Talka
ASKING PERMISSION.
Rationale: Communicates respect for patients. Also,
patients are more willing to discuss changing behaviors,
thoughts, or habits when asked than when being lectured
or being told to change.
Integrating pain neuroscience education implies that the
therapist asks the patient permission to talk about an
understanding of pain neuroscience. For example, before
patients are being asked permission to discuss coping
skills, they rst ask permission to discuss why stresses
inuence pain. As soon as patients understand that stress
is not a pure psychological factor but rather represents a
complex biopsychosocial factor with an important and
measurable biological component (ie, cortisol, adrenaline,
and heart rate variability), the therapist can move to the
next stage, often including asking permission to discuss
identifying stresses and how to cope with them.
Examples of Asking Permission
“Do you allow me to explain your pain experience the
way I look at it?”
“Several physicians/health care practitioners have said
that they could not nd a specic tissue damage
causing your pain. Are you willing to look at it from a
different perspective?”
“You previously informed me that stress impacts your
pain and how you feel. Do you mind if we take a few
minutes and talk about how stress can increase a pain
experience?”
“Before we start some of the physical treatments, do
you mind if we take a few minutes and talk about
(insert pain issues, eg, spreading pain and sensitivity?)”
This sentence often reassures the patient that there will
be physical treatment and not (only) psychological
treatment.
“Do you mind if we talk about [insert what is
appropriate] (eg, changing the way you deal with your
pain, the nature of your pain, what is causing your
pain, why you are still feeling pain even though several
physicians have told you that they cannot nd anything
wrong in your spine or affected body region)?”
“Can we talk about your [insert behavior or what you
think is appropriate] (eg, way of dealing with pain, life,
and how it is currently controlled by your pain?)”
“You realize that pain is controlling your life and that it
has been like this for quite some time. Do you mind if
we talk about how you are currently dealing with pain
and what we can do to regain control over your life?”
“You told me that you aim at returning to your favorite
sport, but currently even a gentle walk is triggering
pain. Do you mind if we talk about why such
low-intensity activity is currently triggering more pain
and search for a solution together?”
“You previously informed me that stress impacts upon
your pain and how you feel. Do you mind if we talk
about what stresses you and how you try to cope with
it?”
“Last time we discussed how your sleep problem
impacts upon your [insert body region] pain and how
you feel. Do you mind if we talk about how sleep
interacts with your [insert body region] pain and how
you try to cope with it?”
ELICITING/EVOKING CHANGE TALK
Rationale: Change talk tends to be associated with
successful outcomes. This strategy elicits reasons for
changing from patients by having them give voice to the
need or reasons for changing. Rather than the therapist
lecturing or telling patients the importance of and reasons
why they should change, change talk consists of
responses evoked from patients. Patients’ responses
usually contain reasons for change that are personally
important for them. Change talk, like several MI strategies,
can be used to address discrepancies between patients’
words and actions (eg, saying that they want to exercise
but continuing to be sedentary) in a manner that is
nonconfrontational.
Questions to Elicit/Evoke Change Talk
“What would you like to see different about your
current situation?”
“What makes you think you need to change?”
“What will happen if you don’t change?”
“What will be different if you complete this therapy
program?”
“What would be the good things about changing your
way of dealing with pain?”
“What would your life be like 3 years from now if you
changed your way of dealing with pain?”
“Why do you think others are concerned about your
pain experience?”
Elicit/Evoke Change Talk for Patients Having
Difculty Changing: Focus for the practitioner is on
being supportive as the patient wants to change but is
struggling.
“How can I help you get past some of the difculties
you are experiencing with dealing with your pain?”
“If you were to decide to change the way you are
dealing with your pain, what would you have to do to
make this happen?”
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Elicit/Evoke Change Talk by Provoking Extremes: For
use by the practitioner when there is little expressed
desire for change by the patient. Typically, this requires
having the patient describe a possible extreme
consequence.
“Suppose you don’t change your way of dealing with
your pain; what is the WORST thing that might
happen?”
“What is the BEST thing you could imagine that could
result from changing your way of dealing with pain?”
“We’ve explained that the variety of short-term pain
killers, including massage, acupuncture, and drugs,
have similar pain-relieving effects as alcohol or
smoking.68 We’ve also emphasized the short-term
nature of their effects. Suppose you continue relying
on such short-term pain killers; what is the WORST
thing that might happen to you in the long term?”
“What is the BEST thing you could imagine that could
result from changing from short-term pain killers to
long-term solutions for your [insert body region] pain
experience?”
“If you look back on the treatments you received in the
past, what is the WORST thing that might happen to
you in the long term?”
Elicit/Evoke Change Talk by Looking Forward: These
questions can be asked to patients to deploy discrepancies
by comparing the current situation with what it would be
like to not have the problem in the future.
“If you make changes to your way of dealing with pain,
how would your life be different from what it is today?”
“If you change from short-term pain killers to
long-term solutions for your [insert body region] pain
experience, how will your life be different from what it
is today?”
“How would you like things to turn out for you in 2
years?”
______________________________________________________.
aInspired by the guide Motivational Interviewing
Strategies and Techniques: Rationales and Examples,by
Sobell and Sobell (2018).69
Appendix 2.
Integrating Motivational Interviewing in Pain
Neuroscience Education: Rationales and Examples Based
on the Transtheoretical Model of Behavior Change
Examples of MI techniques when providing pain
neuroscience education based on the transtheoretical
model of the stage of behavior change.aHence, it is
important to know where the patient is with regard to
readiness to change her or his beliefs about and/or way of
dealing with pain.
I: When the Patient is in a Precontemplation Stage
(eg, when the patient is not considering change—“I’m not
willing to simply accept the pain and learn how to live with
it; you need to x the problem that is causing the pain.”)
Goals for This Stage:
1. Help the patient with self-developing a reason for
changing.
2. Validate the patient’s experience.
3. Encourage the patient for further self-exploration.
4. Leave the door open for future conversations.
Validate the Patient’s Experience:
“I can understand why you feel that way.”
“I can understand that you have little hope left for any
new treatment.”
“I can understand that you expect me to have a quick
solution for your pain experience.”
“It makes sense to target the cause of your pain, here
we strive the same purpose. What do you think is
causing the pain?”
“I understand that you believe that the wear in your
[insert body region] is causing the pain, especially
when you have seen the images of your [insert body
region].”
2. Acknowledge the Patient’s Control of the Decision:
“It’s up to you to decide if and when you are ready to
initiate the treatment, or if you prefer to end it.
“It’s up to you to decide if and when you are ready to
change your understanding of your pain experience,
but please know that we are here to help you.
“It’s up to you to decide if and when you are ready to
change how you are dealing with the pain, but please
know that we are available to help you.
“We’re here to aid you with providing treatment
options. Please remember it’s always your call which
treatment option to choose.”
“We’re here to help you with your [insert body region]
pain. Please remember you are in control and it’s
always you are making the decisions. You need to feel
comfortable with every part of the treatment. Please
indicate whenever you are not comfortable with
anything that happens here.”
3. Explore Potential Concerns:
“If I understand your situation correctly, your pain is
currently controlling your life. Is that correct or am I
wrong?”
“You let the pain decide whether or not you can
initiate and continue activities you love to do. Does
this prevent the pain getting worse? Is that strategy
benecial in the short term, in the long term, or both?
What does this strategy do to you in the long term?”
... [leave time for the patient to respond] ... “Is this
similar to the short- vs long-term effects of alcohol?”
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“Looking at the way your pain and your quality of life
has evolved over the time period you had pain, can
you imagine how your pain might cause problems in
the future?”
“You were told that your wear in the lower back[or
AQ9
other body area] is causing your back pain. Here is a
tablebwith the percentage of people—depending on
age—who have worn in their spine despite not having
any back or leg pain. Please pick your own age
category and read what proportion of people with
your age without back or leg pain have wear just like
you do in their lower spine. ... [patient responds] ...
“What does that tell you?” ... [patient responds] ...
“Perhaps there is more to it than just the wear? Are you
interested to learn about a more comprehensive
explanation for your back pain?”
“You previously tried [insert previous treatments
that specically addressed anatomical or physiological
dysfunctions]. If muscle tension and related joint dys-
functions (depending on the patient’s beliefs possibly
including impairments in motor control) are causing
your pain, why weren’t previous treatments that specif-
ically treated that muscle tension and joint dysfunctions
benecial to you?” “Perhaps the muscle tension
and joint dysfunctions are only part of the story?”
“Using this worksheet, can you list all benets of
continuing the way you are dealing with your pain
right now in this left column, and all drawbacks in the
right column? Are you willing to do that at home and
bring it back to me the next time? It will be very useful
so we can develop a tailored plan for you together.”
4. Repeat a Simple, Direct Statement About Your Stand on
the Medical Benets of Changing the Way of Dealing With
the Pain for This Patient:
“Your pain is currently controlling your life—your pain
is telling you what to do and what not to do. This way
you are rewarding your brain for producing pain. In
the long term, this is making your situation
worse—every time your brain gets better at producing
pain. How do you feel about regaining self-control
over your life?“c.
“Your pain is currently controlling your life—the pain
is telling you what to do and what not to do and you
rely on short-term pain killers with similar effects as
alcohol or smoking. How do you feel about switching
the focus toward long-term solutions?”d
“Your pain is currently controlling your life—the pain
is telling you what to do and what not to do. You’re
rewarding your brain for producing pain by giving it
short-term pain killers. How do you feel about
switching the focus toward long-term solutions?”
5. Acknowledge Possible Feelings of Being Pressured or
Frustration:
“It can be hard to initiate changes in your life when
you feel pressured by others. I want to thank you for
talking with me about this today/being so
open-minded about this today.”
“It must be difcult for you to understand why
previous practitioners didn’t inform you about the
sensitive alarm system. Please don’t blame them, they
have a different specialization within the health care
system. We cannot fathom what you must be
undergoing. Everyone’s pain is different. Focus on the
good news: we have learned so much about pain in the
last 10 years and can explain many of the issues you
told us about. You are free to decide on how to
proceed from here.”
6. Validate That the Patient Is Not Ready:
“Please correct me if I’m wrong, but I hear you saying
that you are not ready to change your understanding of
your pain right now.”
“Please correct me if I’m wrong, but I hear you saying
that you are not ready to change the way you are
dealing with your pain right now.”
“Please correct me if I’m wrong, but I hear you saying
that you are not ready yet to change from relying on
short-term pain relief to more sustainable ways of
dealing with your [insert anatomical region if
appropriate] pain.”
7. Restate Your Position That It Is Up to the Patient:
“It’s totally up to you to decide if this is right for you
right now.
“It’s totally up to you to decide if and when you are
willing to change your understanding of pain.”
“It’s totally up to you to decide if and when you are
willing to change from relying on short-term pain relief
to more sustainable ways of dealing with your [insert
anatomical region of appropriate] pain.”
8. Encourage Reframing of the Current State of
Change—the Potential Beginning of a Change Rather
Than a Decision Never to Change:
“Everyone who’s ever changed the way they dealt with
pain starts right where you are now; they start by
seeing the reasons where they might want to regain
control over their own life. And that’s what I’ve been
talking to you about.”
“Everyone who’s ever changed from short-term pain
relief to long-term solutions starts right where you are
now; they start by seeing the reasons where they might
want to change toward more sustainable ways of dealing
with your [insert anatomical region if appropriate]
pain. And that’s what we’ve discussed today.”
II: When the Patient Is in a Contemplation Stage (eg,
when the patient is ambivalent about change—“Yes the
way I deal with my pain and especially the fact that the
pain is in control of my life is a concern for me, but I’m
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not willing or able to change my way of dealing with the
pain yet.”) At this stage, other factors, such as (a lack of)
condence and fear (of pain or movement and reinjury)
can also play an important role and should be taken into
account.
Goals for This Stage:
1. Validate the patient’s experience.
2. Acknowledge the patient’s control of the decision.
3. Clarify the patient’s perceptions of the pros and cons
of attempted change in the way they understand their
pain (to adopt a broader model of pain).
4. Clarify the patient’s perceptions of the pros and cons
of attempted change in the way they deal with the pain
experience.
5. Encourage the patient for further self-exploration.
6. Restate your position that it is up to the patient.
7. Leave the door open for moving to preparation.
Validate the Patient’s Experience:
“I’m hearing that you are thinking about rening and
extending your understanding of your pain but you’re
not ready to take action right now.”
“I’m hearing that you are thinking about changing the
way you deal with your pain but it feels like you are
not ready to take action right now.”
“I’m hearing that you are thinking about changing
from relying on pain killers to more sustainable
solutions, but you’re denitely not ready to take action
right now.
“It’s very important that you now have a more
comprehensive understanding of your pain experience
(after a rst session of pain neuroscience education).
Understanding is one thing, acting is another big step.
You’re not up to acting yet, but are you willing to
explore options for taking action in the next couple of
treatment sessions? For now, you can continue your
way of dealing with your pain.
“It’s very important that you understand that you spam
ltereis malfunctioning and that with our help you will
be able to (re)adjust your spam lter yourself.
Understanding is one thing, acting is another big step.
You’re not up to taking action yet, but are you willing
to explore options for taking action to x your spam
lter in the next couple of treatment sessions?”
Acknowledge the Patient’s Control of the Decision:
“It’s up to you to decide if and when you are ready to
explore options for taking action to readjust your spam
lter. Exploring options creates opportunities and will
never oblige you to act. Having more options is always
a good thing.”
“It’s up to you to decide if and when you are ready to
make lifestyle changes, but remember we are available
to support you.”
“Also, in the upcoming sessions, when we will explore
options for changing the way how to deal with your
pain, it will always be up to you to decide how to
move forward. Exploring options creates opportunities
and will never oblige you to take action. Having more
options is always a good thing.”
Clarify Patients’ Perceptions of the Pros and Cons of
Attempted Change in the Way in Which They
Understand Their Pain (to Adopt a Broader Model of
Pain):
“What is 1 benet of changing the way you understand
your pain experience? What is 1 drawback of
broadening the understanding of your pain
experience?”
“How would improving your understanding of your
pain experience impact upon your life in the short and
long terms?”
Clarify Patients’ Perceptions of the Pros and Cons of
Attempted Change in the Way in Which They Deal
with the Pain Experience:
“Using this worksheet, what is 1 benet of trying to
readjust the spam lter? What is 1 drawback of trying
to readjust the spam lter?”
“Using this worksheet, what is 1 benet of changing
the way to deal with pain? What is 1 drawback of
changing the way to treat with pain?”
“Using this worksheet, can you list all benets of
changing the way you are dealing with your pain right
now in this left column, and all drawbacks in the right
column?”
“How would changing the way you deal with your pain
impact upon your life in the short and long terms?”
Encourage Further Self-Exploration:
“Reading this information leaetf/watching this online
educational moviegis important to beginning a
successful pain management program. Would you be
willing to either read this information leaet or watch
it online at home and talk to me about it at our next
visit? Which option do you prefer: the online or printed
version, or both?”
“After having explored the information yourself, would
you be willing to share it with your
husband/wife/child/parent/friend (whatever is
appropriate for the patient)? If your
husband/wife/child/parent/friend is willing to explore
the information, it will be important for you to discuss
the content with her or him afterward. This will
stimulate her or his understanding of what you are
dealing with, and hopefully this will give you
additional support in your pain management program.”
“We have now addressed several factors that contribute
to your pain experience. Can you think of benets and
drawbacks of these contributing factors?”
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Restate Your Position That It Is Up to Them:
“It’s totally up to you to decide if this is right for you right
now. Whatever you choose, I’m here to support you.”
“It’s your pain; you own it and you make the
decisions—not the doctor, therapist, etc.”
Leave the Door Open for Moving to Preparation:
“After talking about this, if you feel you would like
to make some changes, the next step won’t be jumping
into action—we can begin with some preparation work.”
III: When the Patient is in a Preparation Stage
(eg, when the patient is preparing to change and begins
making small changes to prepare for a larger life
change—“The way pain is currently controlling my life is
a concern for me; I’m clear that the benets of attempting
changing the way I deal with pain outweigh the
drawbacks, and I’m planning to start within the next
month.”
Goals for This Stage:
1. Reinforce the patient’s decision to change behavior.
2. Prioritize behavior change opportunities.
3. Identify and assist in problem solving regarding
obstacles.
4. Encourage small initial steps.
5. Encourage identication of social supports.
Reinforce the Decision to Change Behavior:
“It’s great that you feel good about your decision to
change your understanding of pain; you are taking
important steps to regain control over your
life.”
“It’s great that you feel good about your decision to
change the way you deal with pain; you are taking
important steps to regain control over your life.”
“It’s great that you feel good about your decision to
change from short-term pain relief to more sustainable
solutions; you are taking important steps to regain
control over your life.
Prioritize Behavior Change Opportunities:
“Looking at your current situation, I think one of
the biggest benets would come from getting better at
dealing with everyday stress(ors) [replace by “improving
your sleep,” “becoming more physically active,”
or any other part of the pain management program,
depending on the patient]. What do you think?”
Identify and Assist in Problem Solving Obstacles:
“Have you ever attempted relaxation (or stress
management) [replace by “improving your sleep,”
“becoming more physically active,” or any other part of
the pain management program, depending on the
patient] before? What was helpful? What kinds of
problems would you expect in practicing stress
management [replace by “sleep management,”
“exercise therapy,” “physical activity management,” or
any other part of the pain management program,
depending on the patient] now? How do you think you
could deal with them?”
Encourage Small, Initial Steps:
“So, the initial goal is to try stop worrying about what
causes your pain, as you now have a comprehensive
understanding of the complexity of your pain.”
“So, the initial goal is to try stop relying on short-term
relief, as you now understand that short-term pain
relief reward your brain in producing pain/sensitive
alarm system.”
Assist the Patient in Identifying Social Support:
“Which family members or friends could support you
in regaining self-control over your life? Are they willing
to read the pain information leaet (or watch the
online educational movie) themselves and discuss it
together with you to get a better understanding of your
situation? Is there anything else I can do to help?”
___________________________________________________.
aAdapted from the MI script developed by the UCLA
Center for Human Nutrition for weight reduction in people
with obesity, available at http://www.cellinteractive.com/
ucla/physcian_ed/scripts_for_change.html.
bThe table is based on the meta-analysis reported.70
cDepending on how you provide pain neuroscience
education,” brain talk” can be scary for patients and drive
the dualism model. If you notice that patients are
uncomfortable with relating their pain to changes in the
brain, keep away from brain talk until they have (further)
improved their understanding about pain. For patients
with little knowledge about pain and pain science, any
reference to the brain may fuel the idea that the pain is
“fake” or “in my head.
dThe term “short-term pain killers” may be inappropriate
for patients struggling with long-term drug use. In such
patients, alternative wording, such as “short-term pain
relief” or “short-term analgesia” is more suitable.
eFactors aggravating pain can be explained as those
pushing on a car’s accelerator, whereas factors relieving
pain are those that activate brain-orchestrated descending
nociceptive inhibition, which can be explained easily to
patients using a car’s brake or spam lter metaphor. For
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explaining the spam lter metaphor, the following
conversation can be included:
Therapist: “Do you use email?”
Patient: “Yes, I do.”
Therapist: “Do all emails sent from anywhere in the world
to your email account end up in your inbox?”
Patient: “I hope not; the spam lter should keep out
inappropriate messages, including publicity.”
fThis information can be found in the publications
Explain Pain55 and Why You Hurt64 and at http://www.
paininmotion.be/education/tools-for-clinical-practice,
https://www.optp.com/Everyone-Has-Back-Pain, and
http://www.paininmotion.be/education/tools-for-clinical-
practice.
gPain neuroscience education tools can be accessed at
https://www.retrainpain.org/,https://www.youtube.com/
channel/UCAfjSufXOnORMLMtSid6CQQ (“Brainman”
videos), or http://www.paininmotion.be/patients/
information (Dutch language video).
14 Physical Therapy Volume 100 Number 5 2020
... The sessions were designed based on current bestevidence for mental and behavioral health in rehabilitation [14,[22][23][24][25][26][27][28]. The content included three 90-minute educational sessions (Table 1) for a total of 4.5 hours. ...
... Indepth interviewing allows for screening whether PSE is indicated in a child while also ensuring that clinicians hear the child's story. 54,119 For instance, with the COPI 106 as a guiding platform, misconceptions or gaps regarding a contemporary scientific understanding of pain can be identified as a first and important step of personalized PSE interventions. ...
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Chronic musculoskeletal pain (CMP) is an urgent global public health concern. Pain neuroscience education (PNE) is an intervention used in the management of CMP aiming to reconceptualize an individual's understanding of their pain as less threatening. This mixed-methods review undertook a segregated synthesis of quantitative and qualitative studies to investigate the clinical effectiveness, and patients’ experience of, PNE for people with CMP. Electronic databases were searched for studies published between January 1, 2002, and June 14, 2018. Twelve randomized, controlled trials (n = 755 participants) that reported pain, disability, and psychosocial outcomes and 4 qualitative studies (n = 50 participants) that explored patients experience of PNE were included. The meta-analyzed pooled treatment effects for PNE versus control had low clinical relevance in the short term for pain (−5.91/100; 95% confidence interval [CI], −13.75 to 1.93) and disability (−4.09/100; 95% CI, −7.72 to −.45) and in the medium term for pain (−6.27/100; 95% CI, −18.97 to 6.44) and disability (−8.14/100; 95% CI, −15.60 to −.68). The treatment effect of PNE for kinesiophobia was clinically relevant in the short term (–13.55/100; 95% CI, –25.89 to –1.21) and for pain catastrophizing in the medium term (–5.26/52; 95% CI, –10.59 to.08). A metasynthesis of 23 qualitative findings resulted in the identification of 2 synthesized findings that identified several key components important for enhancing the patient experience of PNE, such as allowing the patient to tell their own story. These components can enhance pain reconceptualization, which seems to be an important process to facilitate patients’ ability to cope with their condition. The protocol was published on PROSPERO (CRD42017068436). Perspective: We outline the effectiveness of PNE for the management of pain, disability, and psychosocial outcomes in adults with CMP. Key components that can enhance the patient experience of PNE, such as allowing the patient to tell their own story, are also presented. These components may enhance pain reconceptualization.
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Importance Many patients with acute low back pain do not recover with basic first-line care (advice, reassurance, and simple analgesia, if necessary). It is unclear whether intensive patient education improves clinical outcomes for those patients already receiving first-line care. Objective To determine the effectiveness of intensive patient education for patients with acute low back pain. Design, Setting, and Participants This randomized, placebo-controlled clinical trial recruited patients from general practices, physiotherapy clinics, and a research center in Sydney, Australia, between September 10, 2013, and December 2, 2015. Trial follow-up was completed in December 17, 2016. Primary care practitioners invited 618 patients presenting with acute low back pain to participate. Researchers excluded 416 potential participants. All of the 202 eligible participants had low back pain of fewer than 6 weeks’ duration and a high risk of developing chronic low back pain according to Predicting the Inception of Chronic Pain (PICKUP) Tool, a validated prognostic model. Participants were randomized in a 1:1 ratio to either patient education or placebo patient education. Interventions All participants received recommended first-line care for acute low back pain from their usual practitioner. Participants received additional 2 × 1-hour sessions of patient education (information on pain and biopsychosocial contributors plus self-management techniques, such as remaining active and pacing) or placebo patient education (active listening, without information or advice). Main Outcomes and Measures The primary outcome was pain intensity (11-point numeric rating scale) at 3 months. Secondary outcomes included disability (24-point Roland Morris Disability Questionnaire) at 1 week, and at 3, 6, and 12 months. Results Of 202 participants randomized for the trial, the mean (SD) age of participants was 45 (14.5) years and 103 (51.0%) were female. Retention rates were greater than 90% at all time points. Intensive patient education was not more effective than placebo patient education at reducing pain intensity (3-month mean [SD] pain intensity: 2.1 [2.4] vs 2.4 [2.2]; mean difference at 3 months, –0.3 [95% CI, –1.0 to 0.3]). There was a small effect of intensive patient education on the secondary outcome of disability at 1 week (mean difference, –1.6 points on a 24-point scale [95% CI, –3.1 to –0.1]) and 3 months (mean difference, –1.7 points, [95% CI, –3.2 to –0.2]) but not at 6 or 12 months. Conclusions and Relevance Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature. Trial Registration Australian Clinical Trial Registration Number: 12612001180808
Article
Introduction: Patient education is a relatively new science within the field of health care. In the past it consisted mainly of the transfer of knowledge and mostly biomedically based advice. Research has shown this to not be effective and sometimes counterproductive. As health care has moved away from applying a traditional paternalistic approach of 'doctor knows best' to a patient-centred care approach, patient education must be tailored to meet persons' individual needs. Purpose: The purpose of this master paper is to increase awareness of patients' health literacy levels. Health literacy is linked to literacy and entails people's knowledge, motivation and competences to access, understand, appraise and apply health information in order to make judgements and take decisions in everyday life concerning health care, disease prevention and health promotion to maintain or improve quality of life during the life course. Many patients have low health literacy skills, and have difficulty with reading, writing, numeracy, communication, and, increasingly, the use of electronic technology, which impede access to and understanding of health care information. Implications: Multiple professional organizations recommend using universal health literacy precautions to provide understandable and accessible information to all patients, regardless of their literacy or education levels. This includes avoiding medical jargon, breaking down information or instructions into small concrete steps, limiting the focus of a visit to three key points or tasks, and assessing for comprehension by using the teach back cycle. Printed information should be written at or below sixth-grade reading level. Visual aids can enhance patient understanding.
Article
Importance Effective treatments for chronic spinal pain are essential to reduce the related high personal and socioeconomic costs. Objective To compare pain neuroscience education combined with cognition-targeted motor control training with current best-evidence physiotherapy for reducing pain and improving functionality, gray matter morphologic features, and pain cognitions in individuals with chronic spinal pain. Design, Setting, and Participants Multicenter randomized clinical trial conducted from January 1, 2014, to January 30, 2017, among 120 patients with chronic nonspecific spinal pain in 2 outpatient hospitals with follow-up at 3, 6, and 12 months. Interventions Participants were randomized into an experimental group (combined pain neuroscience education and cognition-targeted motor control training) and a control group (combining education on back and neck pain and general exercise therapy). Main Outcomes and Measures Primary outcomes were pain (pressure pain thresholds, numeric rating scale, and central sensitization inventory) and function (pain disability index and mental health and physical health). Results There were 22 men and 38 women in the experimental group (mean [SD] age, 39.9 [12.0] years) and 25 men and 35 women in the control group (mean [SD] age, 40.5 [12.9] years). Participants in the experimental group experienced reduced pain (small to medium effect sizes): higher pressure pain thresholds at primary test site at 3 months (estimated marginal [EM] mean, 0.971; 95% CI, –0.028 to 1.970) and reduced central sensitization inventory scores at 6 months (EM mean, –5.684; 95% CI, –10.589 to –0.780) and 12 months (EM mean, –6.053; 95% CI, –10.781 to –1.324). They also experienced improved function (small to medium effect sizes): significant and clinically relevant reduction of disability at 3 months (EM mean, –5.113; 95% CI, –9.994 to –0.232), 6 months (EM mean, –6.351; 95% CI, –11.153 to –1.550), and 12 months (EM mean, –5.779; 95% CI, –10.340 to –1.217); better mental health at 6 months (EM mean, 36.496; 95% CI, 7.998-64.995); and better physical health at 3 months (EM mean, 39.263; 95% CI, 9.644-66.882), 6 months (EM mean, 53.007; 95% CI, 23.805-82.209), and 12 months (EM mean, 32.208; 95% CI, 2.402-62.014). Conclusions and Relevance Pain neuroscience education combined with cognition-targeted motor control training appears to be more effective than current best-evidence physiotherapy for improving pain, symptoms of central sensitization, disability, mental and physical functioning, and pain cognitions in individuals with chronic spinal pain. Significant clinical improvements without detectable changes in brain gray matter morphologic features calls into question the relevance of brain gray matter alterations in this population. Trial Registration clinicaltrials.gov Identifier: NCT02098005
Article
Background: Current treatment for adults with chronic pain often includes Pain Neuroscience Education (PNE) to make people understand the nature underlying their pain and thus provides a clear rational for a biopsychosocial approach. Despite recommendations to use Pain Neuroscience Education as well in children with chronic pain, a specific program, tailored to children aged 6-12 years is lacking. Objectives: The aim of this study was to develop a Pain Neuroscience Education program for children with chronic pain and test its feasibility. Methods: First the internet and scientific literature was searched for sources (e.g., books, videos, etc.) that might be supportive in teaching children about the neurophysiology of pain. Based on this content, we developed a Pain Neuroscience Education program for children, 'PNE4Kids', which was tested for feasibility in three groups of healthy children (n=18; 9 girls and 9 boys) aged between 6 and 12 years old. Results and conclusions: This paper provides both scientists and clinicians with a specific program to explain the neurophysiology of pain to children with chronic pain, since it is past high time to use a modern neuroscience approach in this vulnerable population. Further research should examine the effectiveness of this developed PNE4Kids program on pain-related outcomes in children with chronic pain. Registration number: NCT02880332 (https://clinicaltrials.gov/ct2/show/NCT02880332).
Article
Background: Available evidence favors the use of pain neuroscience education (PNE) in patients with chronic pain. However, PNE trials are often limited to small sample sizes and, despite the current digital era, the effects of blended-learning PNE (ie, the combination of online digital media with traditional educational methods) have not yet been investigated. Objective: The study objective was to examine whether blended-learning PNE is able to improve disability, catastrophizing, kinesiophobia, and illness perceptions. Design: This study was a 2-center, triple-blind randomized controlled trial (participants, statistician, and outcome assessor were masked). Setting: The study took place at university hospitals in Ghent and Brussels, Belgium. Participants: Participants were 120 people with nonspecific chronic spinal pain (ie, chronic neck pain and low back pain). Intervention: The intervention was 3 sessions of PNE or biomedically focused back/neck school education (addressing spinal anatomy and physiology). Measurements: Measurements were self-report questionnaires (Pain Disability Index, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, Illness Perception Questionnaire, and Pain Vigilance and Awareness Questionnaire). Results: None of the treatment groups showed a significant change in the perceived disability (Pain Disability Index) due to pain (mean group difference posteducation: 1.84; 95% CI = -2.80 to 6.47). Significant interaction effects were seen for kinesiophobia and several subscales of the Illness Perception Questionnaire, including negative consequences, cyclical time line, and acute/chronic time line. In-depth analysis revealed that only in the PNE group were these outcomes significantly improved (9% to 17% improvement; 0.37 ≤ Cohen d ≥ 0.86). Limitations: Effect sizes are small to moderate, which might raise the concern of limited clinical utility; however, changes in kinesiophobia exceed the minimal detectable difference. PNE should not be used as the sole treatment modality but should be combined with other treatment strategies. Conclusions: Blended-learning PNE was able to improve kinesiophobia and illness perceptions in participants with chronic spinal pain. As effect sizes remained small to medium, PNE should not be used as a sole treatment but rather should be used as a key element within a comprehensive active rehabilitation program. Future studies should compare the effects of blended-learning PNE with offline PNE and should consider cost-effectiveness.
Article
Background Arthritis is a leading cause of chronic pain and functional limitations. Exercise is beneficial for improving strength and function and decreasing pain. We evaluated the effect of a motivational interviewing-based lifestyle physical activity intervention on self-reported physical function in adults with knee osteoarthritis (KOA) or rheumatoid arthritis (RA). Methods Participantswere randomized to intervention or control. Control participants received a brief physician recommendation to increase physical activity to meet national guidelines. Intervention participants received the same brief baseline physician recommendation in addition to motivational interviewing sessions at baseline, 3, 6, and 12 months. These sessions focused on facilitating individualized lifestyle physical activity goal setting. The primary outcome was change in self-reported physical function. Secondary outcomes were self-reported pain and accelerometer-measured physical activity. Self-reported KOA outcomes were evaluated by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for KOA (WOMAC scores range from 0 to 68 for function and 0 to 20 for pain) and the Health Assessment Questionnaire (HAQ) for RA. Outcomes were measured at baseline, 3, 6, 12, and 24 months. Multiple regression accounting for repeated measures was used to evaluate the overall intervention effect on outcomes controlling for baseline values. Results Participants included 155 adults with KOA (76 intervention, 79 control) and 185 adults with RA (93 intervention, 92 control). Among KOA participants, WOMAC physical function improvement was greater in the intervention group compared to the control group (difference: 2.21 (95% CI 0.01, 4.41)). WOMAC pain improvement was greater in the intervention group compared to the control group (difference: 0.70 (95% CI −0.004, 1.41)). There were no significant changes in physical activity. Among RA participants, no significant intervention effects were found. Conclusion Participants with KOA receiving the lifestyle intervention experienced modest improvement in self-reported function and a trend towards improved pain compared to controls. There was no intervention effect for RA participants. Further refinement of this intervention is needed for more robust improvement in function, pain, and physical activity.
Article
Purpose: The literature review is aimed at examining and summarizing themes related to patient-centeredness identified in qualitative research from the perspectives of patients and physiotherapists. Following the review, a secondary aim was to synthesize the themes to construct a proposed conceptual framework for utilization within physiotherapy. Methods: A systematic search of qualitative studies was conducted including all articles up to 2015 September. Methodological quality was examined with a checklist. The studies were examined for themes suggestive of the practice of patient centeredness from perspective of the therapists and/or the patients. Data were extracted using a data extraction form and analyzed following "thematic synthesis." Results: Fourteen articles were included. Methodological quality was high in five studies. Eight major descriptive themes and four subthemes (ST) were identified. The descriptive themes were: individuality (ST "Getting to know the patient" and ST "Individualized treatment"), education, communication (ST "Non-verbal communication"), goal setting, support (ST "Empowerment"), social characteristics of a patient-centered physiotherapist, a confident physiotherapist, and knowledge and skills of a patient-centered physiotherapist. Conclusions: Patient-centeredness in physiotherapy entails the characteristics of offering an individualized treatment, continuous communication (verbal and non-verbal), education during all aspects of treatment, working with patient-defined goals in a treatment in which the patient is supported and empowered with a physiotherapist having social skills, being confident and showing specific knowledge.