The Role of Pain Neuroscience Education in Cancer Recovery

According to a European study, cancer patients felt their pain was viewed as secondary to the cancer treatment itself, and they wish more time was spent consulting on the pain they were experiencing .1 These results are important because it demonstrates the need for Pain Neuroscience Education (PNE) in treating these patients from the beginning stages of treatment and beyond. When treating cancer, it can be lost that this biological process is connected to a human being. The resulting pain can slowly strip away the interdependent, complex components that make us human.

PNE is a foundational pain management tool that helps form a greater understanding of how the biological, psychological, and sociological components of our being are important and play a role in managing and changing the pain experience.2 PNE helps accomplish this by eliminating some fear, worry, and stress through increasing knowledge, and awareness. This can lead to greater empowerment and sense of control for the patient.

PNE can be thought of as a knowledge translation process that helps patients better understand their pain experience in hopes of changing their interpretation of it.  One of the main metaphors that we use for mechanical persistent pain conditions (Pain lasting more than 3 months) is this idea of hurt vs harm. This teaches that instead of pain representing damage to the tissues, that there is something wrong with the area, and that you are broken or debilitated, it can be thought of as an area that has heightened awareness or sensitivity due to multiple biopsychosocial factors.2 A common emerging theme viewing pain as a protector (Tame the Beast Video). Our brain does not want us to do a certain task because it perceived it as dangerous before and does not want us to experience that again.

PNE has been proven to be effective in reducing pain for many chronic musculoskeletal disorders,3 but what role does it have in helping active cancer patients and survivors where these biological processes are life-threatening, or in other words where hurt can equal harm?

A possible role of PNE during active cancer treatments is to help the individual learn to distinguish between active cancer pain and pain as a result of active cancer treatments.Helping them understand that pain is a primitive protective mechanism that can be exacerbated by context and fear can provide relief.3  The context here is cancer in our society, and the fear can be loss of life, the unknown, and the billion other worries and stress that can coincide with it. So, when going through active cancer treatments it is beneficial to know that tissue injuries are going to result, and this is going to take the natural healing process that involves pain. The difference here can be knowing that this pain is a result of a life saving treatments, not the cancer itself. A mindset that changes the perspective of the experience and can change the interpretation from life-threatening to life-saving.

Survivorship can come with its own challenges as there are often side-effects that result from these life-saving procedures. This can include increased risk of future cancers, joint and muscle pain, peripheral neuropathies,5 and central sensitization. 6 This is where the hurt vs harm analogy becomes very relevant as pain remains despite the elimination of the biological threat, and beyond the normal tissue healing time. This brings up past experiences, fears, and emotions, which all without proper knowledge and interpretation behind it, can lead to behaviours such as remaining sedentary (See Flow Model7).

Some education points through this stage:

  • knowing common medications are linked to peripheral neuropathy,
  • joint pain is common in breast cancer survivors7,
  • how thoughts and emotions can alter pain response,2
  • and how there is help available to work on active management strategies such as graded motor imagery,8 neurodynamic techniques,9 and exercise.7

In my opinion, PNE’s role in cancer rehabilitation should be immediate and ongoing as the European study demonstrated its importance to patients. Pain, a biopsychosocial phenomenon can take less priority to cancer, a biological entity. Although pain is a symptom of this baffling physiological process, it is the aspect that can lead us to seek help, it takes away our ability to move, it can increase fear/worry/stress and can hurt our relationships. We need to let individuals with cancer know that we are listening, that we can help them understand the what and why surrounding their pain, and that we can help them gain some control over something that is trying to take that control from them.

  1. Breivik H, Cherny N, Collett B, de Conno F, Filbet M, Foubert AJ, Cohen R, Dow L. Cancer-related pain: a pan-European survery of prevalence, treatment, and patient attitudes. Ann Onc. 2009; 20 (8): 1420-33
  2. Moseley GL, Butler DS. Fifteen years of explaining pain: the past,present and future. Jour Pain. 2015;16(9): 807-13.
  3. Louw A, Zimney K, Puentedura EL, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: a systematic review of the literature. Physio Theor Prac. 2016. DOI: 10.1080/09593985.2016.1194646
  4. Bennett MI, Rayment C, Hjermstad M, Aass N, Caraceni A, Kaasa S. Prevalence and aetiology of neuropathic pain in cancer patients: a systematic review. Pain.2012; 153:359-65.
  5. Segal R, Zwaal C, Green E, Tomasone J, Loblaw A, Ptrella T, et al. Exercise for people with cancer. Toronto (ON): Cancer Care Ontario; 2015 Jun 30. Program in Evidence-based Care Guideline No.: 19-5
  6. Nijs J, Leysen L, Adriaenssens N, Ferrandiz MEA, Devoogdt N, Tassenoy A…Meeus M. . Pain following cancer treatment: guidelines for the clinical classification of predominant neuropathic, nociceptive and central sensitization pain. Acta Onco. 2016;55:659-63.
  7. Sangster M. Cancer rehabilitation for the physiotherapist (powerpoint). Delivered October 21st Think Healthcare.
  8. Bowering JK, O’Connell N, Tabor, A, Catley MJ, Leake HB, Moselet LG, Stanton TR. The effects of graded motor imagery and its components on chronic pain: a systematic review and meta-analysis. Jour Pain. 2013; 14: 3-13.
  9. Kumar SP, Saha S. Mechanism-based classification of pain for physical therapy management in palliative care: a clinical commentary. Ind Jour Pall Care. 2011; 17: 80-86.