Pre-Clinical Student Application of Pain Neuroscience Education in a Student-Run Free Clinic
Background and Purpose:
Following the call for further research at the American Physical Therapy Association’s 2019 Combined Section Meeting session titled, “Pain Talks: Conversations With Pain Science Leaders on the Future of the Field”, a group of pre-clinical Doctor of Physical Therapy students were inspired to incorporate pain neuroscience education (PNE) at their student-run free clinic. Current literature indicates that PNE is a useful tool in the treatment of patients with non-nociceptive pain (1) and that pre-clinical students can correctly distinguish between pain mechanisms (2). However, the extent to which pre-clinical students can apply PNE to the treatment of a patient with persistent pain is not established. The purpose of this study is to describe a model for the application of PNE by pre-clinical, doctor of physical therapy students in the evaluation and treatment of a patient with persistent pain at a student-run free clinic.
Case Description:
The patient was referred to a student-run free clinic with a primary diagnosis of fibromyalgia, history of hypertension and persistent, global pain. The patient had complicating psychosocial factors including high levels of stress, depression, and self-reported Post-Traumatic Stress Disorder. Five students shared treatment responsibilities in a team-based approach, and met weekly to devise the treatment plan, incorporate relevant literature, and receive mentorship from the supervising physical therapist. The students hypothesized that the patient presented with signs and symptoms consistent with the mechanism-based classification of nociplastic pain (3,4,5). The students used a multifaceted approach to reduce pain, improve overall fitness, and equip the patient with healthy coping techniques. Two students conducted weekly treatment sessions in a biweekly alternating schedule to ensure continuity of care. Treatments included aerobic and strength training, manual therapy, relaxation exercises, lateralization training, and PNE, using various explanations and metaphors for nociplastic pain each treatment session (5,6,7,8,9,10). Metaphors included “the brain is in a pain meeting” to address patient’s concerns about memory and emotional changes due to her pain and the “living alarm system” metaphor to explain the allodynia and hyperalgesia she experienced.
Outcomes (chart has been removed):
At initial visit, the patient stated on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain she has felt, that her worst pain was 10/10 and best was 5/10. At discharge, her pain was 8/10 and 2/10, respectively, a clinically meaningful reduction in pain. A body chart was administered beginning at the fifth visit; the patient marked 32 painful sites. The patient marked only 15 sites at discharge. The PCS and FABQ were introduced at the sixth visit; the PCS improved from 42 to 40, and the FABQ increased from 43 to 73 at discharge. After 10 sessions, the patient indicated on a Global Rating of Change scale that she believed herself to be “moderately better.”
Discussion:
This case study demonstrates that pre-clinical students can correctly identify a neurophysiological mechanism for pain and apply PNE in the treatment of a patient with persistent pain. While the patient reported overall improvement, the FABQ score indicated an increase in fear avoidance beliefs and outcome measures failed to demonstrate a clinically meaningful change. This is not uncommon for patients that are newly exposed to PNE. It is possible the patient’s maladaptive psychosocial factors may play a role in the increased score. This approach nevertheless offers a model for preclinical students to apply PNE in a pro bono therapy clinic.