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Every year, Americans spend at least $50 billion on treating and caring for low back pain, which is the primary cause of job-related disability and missed work hours, according to the National Institute of Health. While back treatments, such as surgery, medicine, exercise, chiropractic care, and alternative health care, are often used, a recent study published in Spine may reveal a much more cost-effective way to reduce medical tests and costs among back surgery patients: pain education.
The study, led by Adriaan Louw, Ph.D., from the International Spine Pain Institute in Story City, Iowa, investigated if neuroscience and pain education can help patients experience better outcomes and recovery after undergoing lumbar radiculopathy surgery, which is the irritation of nerves in the lower spine region that can cause pain. Patients who were eligible for the study and who are about to undergo lumbar surgery for radiculopathy were randomly assigned to the experimental group (combining usual preoperative education from a surgeon and neuroscience and pain education from a physical therapist) or the control group (receiving only preoperative education from a surgeon). All patients filled out a series of surveys that measured their perceived satisfaction, outcomes and beliefs of their surgical experience before the surgery, and one, three, six and 12 months after the surgery.
Among 67 patients who completed the study, the one-year follow-up revealed no significant difference in low back pain and function between those who had received pain education and those who did not. However, patients who had pain education not only had a more positive experience but also used 45 less medical tests and treatments during the one year following surgery.
The study analyzed the average cost of treatment in the experimental group to be almost $2,700, while the control group spent an average of over $4,800. Since this clearly shows that neuroscience and pain education can reduce medical costs among back surgery patients, Dr. Louw was asked regarding why the patients seem to fare better with pain education than those without it, even though both experience similar levels of pain and disability.
“We believe the holy grail of healthcare education is behavior change,” Louw said in an online interview with Guardian Liberty Voice. “Typically most measurements we conduct, especially over time, consist of self-report surveys. Pain has ‘good days’ and ‘bad days’ depending on the day, emotions, local football team, work and so forth. Also, we cannot control what people put down on paper; however, we assume some level of honesty.”
Louw mentioned that many surgical patients expect to be “pain-free” after surgery, but that notion is unrealistic. Some degree of pain will exist after a surgery and is normal. Thus, this is the “cornerstone” of pain education. “Unrealistic expectations are strongly linked to the success of a surgery,” Louw said. “By teaching people before surgery that they will have pain, what the pain means and that over time it will ease off, we set realistic expectations.”
“Now here’s the neat part: Our study showed that our patients had similar pain and function than people who did not get pain education, but despite this, they statistically rated their surgical experience as more successful and felt less compelled to seek medical care (treatment and tests) for their pain. This is evident in the fact that they spent 45 percent less on healthcare compared to the group that did not get any additional pain education. We thus saw a behavioral change.
“An easy analogy is smoking. How do we know a patient has heard us and is making a meaningful change after a doctor tells him or her to stop smoking? They change their behavior – they quit smoking. Our patients made the ultimate change: despite having similar pain and disability, they saw pain as a normal post-surgical experience and thus changed their behavior by seeking less medical care and tests for the ‘normal’ pain.”
Pain education on patient outcomes is not new. Louw and his colleagues had conducted several such experiments in the past few years. “Our team completed a systematic review in 2011 on the efficacy of neuroscience education for chronic pain. To date, there are 12 randomized controlled trials and two systematic reviews showing that if we teach people in pain more about their pain from a biological and physiological perspective (how pain works), they experience less pain, move better, function better and have better thoughts about pain.
“The neat part is that it has primarily been conducted on chronic pain patients who are clinically challenging to treat and suffer a lot. Furthermore, apart from the randomized controlled trials and systematic reviews, there are several case studies and case series. There are approximately 10 to 12 scientists in the world working on this and between us we have a dozen or so studies going on about neuroscience education. The evidence is quite impressive for an approach which officially came about in 2002. However, some pioneers likely did it before then.”
The old and outdated explanation of pain states that if tissue damage exists, such as a cut or fracture, then the nerves send a message to the brain about the problem. The pain intensity is directly proportionate to the severity of the injury. This idea stemmed from the 17th century French philosopher René Descartes who described pain as a one-way pathway that always lead to the brain. However, modern neuroscience reveals that pain is much more complex than that.
Science writer Paul Ingraham of Save Yourself wrote that the brain is not a passive organ that gullibly believes every message that the peripheral nerves send. “The brain critically evaluates all danger messages it receives — considering them in context, sizing them up before deciding whether or not to take one seriously,” he stated. Depending on how the brain interprets message, the brain sends its own messages to the nerve endings that affect their sensitivity. Thus, pain is a two-way pathway that is stimulated by not only the tissues but also the environment and psychology. This is the main difference between the old pain theory and the current version.
As more strong evidence suggests that pain education can improve back surgery patient satisfaction and reduce medical costs, more clinicians and other healthcare professionals may need to adopt this system to improve patient care. “To date, all of the neuroscience education has been done on chronic pain,” Louw added. “Our group wanted to see if we can do it preemptively and believe we made some headway. We believe the best way to treat chronic pain is prevention. By teaching people preemptively about pain, we can decrease the associated fear and anxiety and from a biological perspective, which has been corroborated by functional MRI studies we have conducted, calm the nervous system, thus decreasing the potential of chronic pain development.
“This alone is huge for clinicians. We believe pain education should become a clinical language to help people understand more about their pain early on. We have a series of studies ongoing, in progress and submitted for publication where we are trialing this approach to various pain states. It is likely that the more ‘feared’ and complex pain states will benefit more from this educational calming of the nervous system.”
By Nick Ng