1. What We Say Matters
The Role of Pain Neuroscience Education (PNE) In Treating Chronic Pain
Sean Smitham, PhD
Clinical Psychologist
Northwest Spine and Pain Management

2. Intro: Rubber Arm Experiment
What is going on there? The experience of pain is real even when there is no actual tissue damage. Pretty cool right? But how can that be?

3. But First…. Pain is always real. Knowledge is power.
When patients are referred to pain psychology, they almost always arrive somewhat defensive. They’re suspicious that we or their referring provider believes their pain is “all in their head”.
It is this resistance and the corresponding “all in their head” neurotag that is our first target in the psychological treatment of pain. So, what’s a neurotag?

4. Pain Neuroscience Education (PNE) Therapeutic Neuroscience Education (TNE)
Today I want to 1) summarize the science that helps explain what we saw in the opening video and 2) give you a brief glimpse into why we believe psychology has an important role in treating chronic pain – not just managing pain and not just coping with pain but treating some of the causes of chronic pain.

5. 6 Big Ideas Behind the Neuroscience of Pain
Single cell insufficiency
Neurotags (Neurosignature)
Dynamically created (experience) / Dynamically activated (cooperation and competition)
Neuromatrix
Distributed Processing
Neuroplascticity
The Neuroscience of Pain – Ridiculously simplified. If you understand these 6 Big Ideas you’ll have a good overview of the power and purpose of Pain Neuroscience Education.

6. 6 Big Ideas Behind the Neuroscience of Pain
Single cell insufficiency
Neurotags (Neurosignature)
Dynamically created / Dynamically activated
Neuromatrix
Distributed Processing
Neuroplascticity

7. Three friends “Let’s meet downtown and catch a movie”
Each friend “taking the bus” (same behavior, different sequence of neurotags (i.e., neurosignature))
Each moving simultaneously
“meeting downtown to watch a movie” = neuromatrix

8. 100 billion neurons
125,000 miles of neurons
1000 to 10,000 synapses for each neuron

9. 6 Big Ideas Behind the Neuroscience of Pain
Single cell insufficiency
Neurotags (Neurosignature)
Dynamically created / Dynamically activated
Neuromatrix
Distributed Processing
Neuroplascticity

12. Neuroplasticity can by “hacked” by chronic pain
Neuroplasticity can by “hacked” by chronic pain. Processing power usually reserved for other functions may be “reassigned” to focus on pain. The pain neuromatrix expands and new pain neurotags may be created (the sticky nature of the pain neuromatrix.

13. Eye Blink “Reflex”

14. Journal of Neurophysiology
Iannetti, et al., 2014, 2015
Wallwork, et. al., 2016.
Journal of Neurophysiology
Large
Size of Eye
Blink Response
Originally thought to be a reflex mediated by the brain stem
Small

15. Journal of Neurophysiology
Iannetti, et al., 2014, 2015
Wallwork, et. al., 2016.
Journal of Neurophysiology
Size of Eye
Protection
Reflex
As perceived threat increases (neurotag), response increases.
Far
Near
Distance to Eye

16. Journal of Neurophysiology
Iannetti, et al., 2014, 2015
Wallwork, et. al., 2016.
Journal of Neurophysiology
Size of Eye
Protection
Reflex
Hand close to eye, but strong barrier. Response is less than hand far response. Have the subject close their eyes and then sneak the barrier away – same small response. But replace the strong barrier with a weak barrier and we the blink response is strong again.
You cannot fool the nervous system. Important note: notice the strong/weak barrier is based on a learning history about the properties of strong/weak materials. Cognitive historical neurotag contributing to the mind’
Strong
Weak
Barrier

17. Head Stimulator

18. Intensity
Bayer, TL, et al. Pain. 1991

19. Intensity 10
Pain
Min
Intensity
Max

20. Intensity 10
The power of authority figures
Pain
Min
Intensity
Max

21. Pain increases more than before Intensity10
Multiple neurotags increasing the experienced pain – pain neuromatrix. Dynamically activated
Pain
Min
Intensity
Max

22. Recording 10
Pain
Min
Intensity
Max

23. (Mental Research Institute, Palo Alto, CA circa 1966)
Glip Glop
(Mental Research Institute, Palo Alto, CA circa 1966)

25. Sample PNE Lesson
Sensitive Nerves and the Pain Neuromatrix

28. Patient as Partner
Shared Decision Making

29. Now to take a more detailed look into the practical ways pain psychology aims to treat patients

31. Putting It All Together
Key Domains of Pain Care

33. Take Home Point #1
The mind is always working for your survival. Always.
Pain is about the protection of the individual. It is an output of the mind and is influenced heavily by context (current, historical).
Pain does NOT accurately communicate information about the state of the tissues.
(e.g., Rubber arm, Brain stimulator, Wrist Zap)

34. Take Home Point #2
How we and our patients understand and talk about pain matters
Thoughts, Feelings, Beliefs = internal messages that can increase
(e.g., Brain Stimulator, Glip Glop)

35. Take Home Point #3 Knowledge is power
When people learn why they hurt – they hurt less.