PNE Review II: Mentally "Buffing" Chronic Pain Patients
POSTED ON 9/11/2017 IN Research BY Christopher Centeno
I've blogged before about a new and disturbing trend in physical therapy called pain neuroscience education, or PNE. While I've tried to just ignore the daily and copious bovine excrement blowing up my Twitter feed regarding PNE, it's hard to ignore where all of this came from and is headed. You see, if you have chronic pain, PNE is coming to a PT's office near you and even invading the local universities like Viking marauders hijacking common sense in favor of demagoguery. Meaning, even though there's a valid reason why you hurt and a way to diagnose and treat it, you're about to be told it's all in your head or at least all in your nerves. Let me explain.
Chronic Pain Exists Because Physicians Are Largely Awful at Diagnosing What's Wrong with the Musculoskeletal System
PNE (aka therapeutic neuroscience education, or TNE) is a reboot of chronic pain programs from the '80s and '90s. This is pretty funny because most younger PTs believe this to be some sort of new ancient wisdom handed down from on high; whereas, it's really a recycled failed idea. Where it differs is that PNE recognizes that pain signals are real. Where it's identical is that the solution to chronic pain is to convince patients to ignore their pain. Also where it's the same is this idea that chronic pain is some enigma wrapped in a riddle, hence the need to talk patients out of disability.
So is chronic pain real? Absolutely. Why can't it be effectively diagnosed and treated by most physicians? Because they have absolutely no training that would allow that to happen. How did we get to a place where the average physician, regardless of whether in private practice or in a university medical school, is not expert in the area of chronic pain diagnosis? First, many medical subspecialties originate in internal medicine. The basic concept here is that medications should be used to treat everything. Understanding how the muscles, nerves, and joints work doesn't fit well into that mind-set; in fact, it's often diametrically opposed to it. Second, we have subspecialists tied to surgery. While there is more biomechanical understanding in that group, the focus isn't on the diagnosis of complex chronic pain conditions or dysfunction of the normal biomechanics, but on how surgery X might help problem Y. Since most chronic pain patients get worse and not better with surgery, groups like orthopedic surgeons view these patients as one big puzzle. Is any specialty more inclined to understand chronic pain? Interventional spine is about as close as you can get, but the basic tenet of that group causes more problems for these patients. Let me explain.
The single unifying theory behind interventional spine is the "pain generator." This means that some single injection into the spine to numb a specific part will provide robust relief. However, while a few patients with chronic spinal pain will be able to be diagnosed this way, most will not. Why? They have multiple areas that hurt, and blocking the pain from any one of them will give them less than robust relief. Hence, these patients often fall into the "I don't have a diagnosis" category in interventional spine.
How do I know this is a real problem? Just talk to any chronic pain patient and listen to their story about being shuffled from one medical specialist to another and getting a ubiquitous blank stare. Many of these patients who have responded to nothing, we and other physicians are often able to help by realizing how the biomechanics work and by understanding that the multiple areas that hurt all need to be treated at once.
So what happens when a chronic pain patient without a diagnosis meets a physical therapist trained in PNE? Since the physicians who have much more training than the physical therapist can't diagnose what's wrong, the likelihood that the average physical therapist will is even smaller. In addition, the physical therapists that might be able to diagnose and treat these patients are all super specialists who are few and far between and less likely to buy into the ideas behind PNE. Hence, the likelihood of finding a therapist who can help is infinitesimal.
Therefore, we have the setting for a perfect storm that supports PNE—patients who are hard to diagnose meeting armies of medical specialists and physical therapists who aren't trained to diagnose them. Throw in that many of these patients don't have a common imaging study with a "smoking gun" finding and it's not hard to see why they get marginalized. It's not hard to see why physical therapists who practice PNE are so convinced that the patient's pain is based on the idea of being injured or having a spine that's deteriorating rather than a real physical problem that needs a physical treatment.
Buff 'Em Up!
If you really want to see how we physicians are trained to think, read Samuel Shem's House of God. It was the first time the public was introduced to the inner mind and slang of physicians in a big city training hospital.
Some quotes will tell you all you need to know: “Law XIII. THE DELIVERY OF MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE”
“But GOMERS are not just dear old people,” said Fats.
“Gomers are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We're cruel to the GOMERS, by saving them, and they're cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.”
GOMER stands for "Get Out of My ER." These are older people with incurable diseases who end up in the ER because they're indigent or because their families are concerned about their declining health. They can either be "Turfed" or "Buffed." Turfing means to send them to another specialty, not because you think they can really be helped by that specialist but because in a game of "hot potato," your job is to get rid of the GOMER. Another option if he or she can't be turfed is "Buffing." Here, you get labs, which always look awful, and then give patients what they need to make the labs look better, and then get the patients out the door. The patient will feel a bit better, but you know it won't last.
At the end of the day, PNE is just a form of "buffing." The physical therapist doesn't understand the disease state that's causing the chronic pain. However, you can mentally buff chronic pain patients by trying to make them believe that their pain is not as bad as they think it is and that they really don't have a disease, but rather just hyperactive nerves. While it's all a big fiction, much like buffing in the House of God, patients will report feeling better. It's this last part that's the most disturbing about PNE.
You see, PNE has been tried before. Back in the '80s and '90s, it was called a comprehensive, multidisciplinary chronic pain program. Back then, the concepts were the same, save for the recognition that chronic pain patients had abnormal nerve activity (central sensitization). Patients would enter these obnoxiously expensive and resource-intensive 2–3 week programs where they would be mentally "buffed." Most would figure out, pretty quick, that this personal hell would all be over once they reported that their perception of their pain wasn't real and that the coping strategies they learned were helping their pain and improving their function. Hence, the chronic pain programs all reported amazing results. However, they became a bit of a joke in the medical community because after spending tens of thousands of dollars on these programs, these patients all still had pain, and all were still disabled. They maybe had a few more strategies on how to cope with their pain, but that was all they got out of the program.
Fast-forward a few decades, and physical therapists in their 20s, 30s, and 40s don't remember these programs as they were gone or in decline by the time they began their careers. Hence, PNE looks like a new and fresh idea in how to approach these patients. In addition, the little research done so far on PNE looks amazing as the buffing effect in medicine is quite real. However, all of these same patients who see a PNE therapist who will report amazing effects will be right back in somebody's ER or office once their pain flares, no closer to a successful diagnosis and treatment.
The upshot? I'll leave you with a paper I wrote many years ago. My dog had a limp that would go away when I gave her a treat. I reviewed the pain inhibition pathways from the brain to the spinal cord that allowed my dog to suppress the pain from her hip arthritis to meet a biologic imperative: food. Hence, PNE patients are no different. They, too, can activate pain-suppression pathways to reduce their pain, but after being mentally "buffed" in this way, don't expect any real long-term progress! PNE is simply a medical magic trick that was discredited long ago and has its roots in the ERs of the 1960s and '70s and the chronic pain programs of the '80s and '90s. Just remember, after her treat, my dog's limp would always return!
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