About 30 years ago, rapid advance in the scientific understanding of “how pain works”, facilitated by the seminal discovery of central sensitisation (6) and including pain's protective function, multifactorial nature, dynamic nature over time, and the most effective ways of treating it (7), had created a vast disconnect between scientific and common understanding of the problem of chronic pain. The common understanding remained rooted in a simplistic structural pathology model in which chronic pain was taken to reflect chronic tissue pathology. Evidence-based cognitive-behavioural interventions seemed in contrast to this common understanding. In response to the disconnect, a new educational approach called “intensive neurophysiology education” emerged in 2002 (1–4). The intervention became widely known as “explaining pain” (8), after the primary resource Explain Pain (9), and subsequently, “pain neuroscience education” (PNE) (5). This approach is still being widely taught and delivered under that name and in this article we use “PNE” to refer to the original intervention and to differentiate it from more modern approaches to patient pain education.

The impact of this disconnect between common and scientific understanding of pain, could be seen in patient perspectives on pain management programs that focussed not on pain reduction but on living well despite pain (10). The discovery in 1983 of central sensitisation lent weight to the idea that pain reduction was no longer a reasonable expectation. Central sensitisation was demonstrated after peripheral nerve constriction, whereby second order neurones in the spinal cord became upregulated and responsive to non-nociceptive stimuli (6). That discovery led to some seeing chronic pain as an immutable disorder of the spinal cord (11). The original biopsychosocial model (12) also lent weight to this idea—it posited that the impact of pain involves biological, psychological and social influences. Loeser's 1983 adaptation of the biopsychosocial model to the “onion skin” metaphor (13) brought a more pain-specific framework; psychologists were able to re-purpose cognitive behavioural therapies (CBTs) that were established for other diagnoses such as depression, to help patients decrease the impact of pain on their quality of life (14). Guidelines began to include cognitive and behavioural strategies and education about how to use them in the early 2000's (15).

Our consumer-focussed research identified a significant challenge with this shift towards CBT-based pain management. Many people with chronic pain and many health professionals who treated them, found it difficult to reconcile a CBT and self-management based approach with their understanding of “how pain works”—they found the suggestion confusing and invalidating (1, 2, 4). It was an understandable response: if one understands the presence and degree of pain intensity to accurately signal the presence and degree of tissue damage, then interventions that do not directly target those tissues will of course appear to be nonsense. There was a clear need for a new intervention that could provide patients with an understanding of why CBTs and self-management were biologically sensible. PNE therefore, aimed to enable and empower consumers to engage in CBTs and self-management through first explaining why, not just how, to do it. One can readily see the connection between this early mission and the taglines of public-facing modern day public pain education initiatives such as Pain Revolution (https://www.painrevolution.org)—“rethink, re-engage, recover” and Flippin' Pain (https://www.flippinpain.co.uk)—“engage, educate, empower”.

The earliest randomised controlled trials (RCTs) of PNE compared it to conventional pain education matched for dose, setting and resources, or to an active care comparator, a usual care comparator, or to a waiting list comparator. Those RCTs, in individuals with chronic pain, demonstrated medium to large effects on pain-related neurophysiology knowledge, and small effects on movement-evoked pain, pain-related worry, pain-related self-efficacy, usual pain intensity and pain-related disability (1–4). Since those trials, other trials have been undertaken in various countries, in various settings, and with various diagnostic groups, with the content and format of PNE remaining very consistent. Over 35 RCTs and several meta-analyses on PNE as a stand-alone intervention, and over 50 RCTs of more complex interventions that integrate PNE content, have been undertaken (5, 16–20) (see https://www.petalcollaboration.org/clinical-trials-of-pain-education.html for a list of RCTs). Some studies conclude that PNE as a stand-alone intervention imparts small to medium benefits across a range of outcomes, in a range of chronic pain conditions, in a range of settings and languages e.g., (5), but others report benefit in variables such as knowledge change, catastrphising and fear of pain and (re)injury, but not in pain or disability (19, 21). Opinion pieces advocate for PNE (22–25), but recent commentaries have identified significant challenges and limitations (26–28).

Significant barriers to the implementation of PNE exist. To date, the only major implementation trial in which physiotherapists were trained in PNE (16 h, 8 h online and 8 h face-to-face) or not (29), was a cluster-randomised implementation study that revealed improved pain-related self-efficacy but not better pain or disability outcomes for patients of the PNE-trained physiotherapists. Health professionals have reported significant challenges in delivering PNE such as: limited appointment time; patient-related factors including a lack of perception of education as an intervention in its own right; clinician-specific issues, such as limited confidence in the implementation process (30). Anecdotally, health professionals have told us that (i) some patients do incredibly well but others do not, (ii) they “try the pain talk” or “do explain pain”, but most patients “don’t buy it” or “don’t want it”. Such anecdotes are also borne out in qualitative analysis of primary care practitioner perspectives, which also suggest health professionals attribute difficulties with PNE to too complex content or patient/learner attitude or capacity, but not to a lack of educational expertise or training (31).

Some health professionals consider that the learning objectives of PNE contradict early pioneers of sensory neurophysiology or certain philosophical and semantic principles (32) [see (33) for a pragmatic commentary on the latter]. Others perceive that educating patients about how pain works undermines their own clinical framework or authority, but the largest group understand and accept the merit and intent of pain education and feel they lack the skills and confidence to deliver it effectively (30). Less experienced clinicians have expressed heightened apprehension about using PNE, concerned that unsuccessful implementation could harm therapeutic relationships (30). Although some services, for example many Canadian pediatric pain programs, stipulate education as mandatory before other care commences, health professionals in other jurisdictions (particularly in adult care) have reported that they stopped pain education altogether “because it is too hard and most patients don’t want it” (31). These results are consistent with the apparent ineffectiveness of PNE training for health professionals, at least as it was delivered in one implementation trial (21). Taken together, the available evidence suggests improvements are needed in the content and method of PNE and the training and support of health professionals to implement it.

People living with chronic pain have identified that good pain education is a high care priority, but that they seldom receive it (34). Our real-world data suggest that even “good” education may not be as helpful as we would like. We have investigated this by looking at PNE-related outcomes in clinical practice, outside of research studies. We collected data on knowledge, worry, pain and disability outcomes in a rolling outcome evaluation of over 1,500 consecutive patients, all of whom participated in PNE, with 93% follow-up rate. We used the only assessment for pain knowledge available—the neurophysiology of pain questionnaire (NPQ) (7) and its 12-item revised version (rNPQ) (35). We have previously presented data from 799 of the consumer cohort, all of whom used the original PNQ, and full details of the cohort and the range of diagnoses included, are presented there (36). Two patterns in the outcome evaluation data cast light on the implementation trial outcomes, the qualitative analyses and health professional anecdotes mentioned above.

The findings from the above outcome evaluation mirror the results of a series of qualitative studies exploring patients’ experience of PNE (one 90 min group session) within clinical settings. The extent of pain reconceptualisation with PNE appears highly variable, for example a positive experience:

In contrast, some found the PNE content irrelevant to themselves, their pain and their situation-

That the content of PNE can lack relevancy, a problem potentially exacerbated by the brief and didactic nature of PNE delivery within a group setting, was a consistent theme across studies (38–40) and points to the need for a stronger consumer voice in guiding the content of pain education. Moreover, even when the content is relevant, and clinical benefits ensue, we have often observed what we call “partial and patchy” reconceptualization: patients describe their pain with some language inconsistent with contemporary pain science:

and other language inconsistent with contemporary pain science:

These patterns from real world evaluation data and qualitative research studies show that there is significant room for improvement for PNE in both content and strategy. Participant reflections on a PNE-based complex chronic back pain intervention are corroborative: of all components of the treatment, the educational component was the most difficult; some didn't expect nor want “a pain talk”; some felt invalidated by it; some “couldn’t understand what the health professional was going on about” (41). Although outcome evaluation data do not allow for causal conclusions, they provide a clear hypothesis for testing: when education is successful, the likelihood of reducing pain and disability is high; when it is not, that likelihood is low and may be accompanied by negative therapeutic experiences. It is not unreasonable to propose that reconceptualization of “how pain works” might be a critical determinant of response to care.

It is difficult in science to conclude things to be definitively wrong or right. However, Tables 2–4 present the most common criticisms of the “Essential Pain Facts”, derived through the research outlined below under “Potential solutions”.

We are among those to argue that shifting community norms and consumer expectations around pain care and recovery has the potential to reduce common barriers to participating in guideline-based care and promote better clinical outcomes (30, 65, 66). Our patient partners have also identified that society-wide knowledge translation interventions that target misconceptions about pain and its management, are needed (67). Our recent meta-analyses showed that population beliefs about pain management can be positively shifted in line with guideline-based care (i.e., “staying active”, “avoiding rest”) using contemporary media campaigns (65). However, care must be taken to understand the audience and communicate with them appropriately, so as to avoid the messages being delivered in a poorly contextualised way, leading to misinterpretation, and feelings of invalidation or potentially iatrogenesis (33, 68). We have also demonstrated that approximately half of all public health education programs are unsuccessful for those from marginalised and minoritised communities (ie those who may most need the programs) and that co-developing education programs with the target audience is critical to address their needs (69). We have identified the need for better pain education delivery for disadvantaged groups such as those from ethnically minoritized groups, those with low health literacy, and those who receive their care through an interpreter (68, 70). Relevant here is the wider need across the pain field to better understand the social context of research participants, a need that has triggered a global push to include a minimum equity-relevant data set in all human pain research (71–76).

Building better pain education involves partnerships with consumers (e.g., members of the public, people with lived experience of pain and their carers/families, and patient reference groups) in the design, planning and delivery of public-facing pain education initiatives and resources [e.g., (77), see also painrevolution.org and flippinpain.co.uk]. Even so, this does not guarantee that all outreach will be acceptable by all people and in all contexts. For example, as part of ongoing efforts to optimise accessibility of Pain Revolution's public facing resources and professional development offerings within its Local Pain Educator, Local Pain Collective, and Rural Outreach Tour initiatives, Pain Revolution regularly consults consumers. It undertook two mini-surveys to arrive at the terms “Essential Pain Facts” and “Pain System Hypersensitivity”. Figure 1 provides a brief summary of these surveys and their results. The themes derived in response to Survey 2 (Figure 1) bear some resemblance to the documented characteristics of nociplastic pain (78).

Recently, three clinical trials of complex multimodal treatments that aimed to shift patients' understanding of the problem of back pain, have shown clinical benefit over and above that offered by their comparator (a sham intervention (79), an open label placebo or usual care (80, 81). Two of those trials were grounded in, and included, PNE (79, 80). They also included planned analyses of whether reconceptualization of the problem contributed to the clinical benefit. The first used a mediation analysis approach and showed that the vast majority of the overall treatment effect of a PNE-grounded intervention [the “Resolve” approach (82)] on pain at post-treatment (global effect of intervention = −0.96 [−1.47 to −0.28]) was mediated by the change in the participants' understanding of their back pain problem, assessed after the PNE component of the program (effect of mediator = −0.96 [−1.47 to −0.64]); the effects were very similar for disability (83). The other clinical trial (80) asked participants before and after treatment about their understanding of the cause(s) of their back pain. They showed that re-attribution of back pain, from tissue-related pathology to psychological stress and brain-related mechanisms, was highly related to clinical improvement (84). These trials of complex interventions suggest that reconceptualization of how pain works seems to be an important determinant of subsequent pain and disability improvements. We contend that these findings are also consistent with the possibility that reconceptualization of “how pain works” might be a critical determinant of response to care in the real world. Efforts to make pain education better seem warranted.

Numerous scientific studies, which involved hundreds of recovered consumers and health professionals, and dozens of pain, education and learning scientists (28, 30, 33, 38–41, 53, 83, 85–87) have led to significant changes in content and learning objectives. Full coverage of that work is beyond the scope of this review, but in brief: several cohorts of consumers who self-identified as having improved or completely recovered from a chronic pain condition, were interviewed or surveyed about what they learnt or did that lead to their recovery. These data formed the basis of the iterative development of “key learning objectives for pain education” (43, 53) (see https://www.painrevolution.org/painfacts for brief two-page “fact sheets” for each objective). These concepts were prioritised for importance by consumers and cross-checked for accuracy according to published scientific papers, by an interdisciplinary group of active pain researchers, and for acceptability by an interdisciplinary group of practising health and medical professionals. Finally, through collaboration with a health communications firm and more consumer consultation, four key concepts were derived and, through final consumer and clinician surveys, were labelled “Essential Pain Facts” (28, 82).

Extensive research has also been directed towards improving how PNE could be implemented more effectively [e.g., (19, 30)]. This has meant drawing on more contemporary approaches to curriculum development and lesson plans [e.g., (43)] and using more contemporary educational frameworks and strategies [see (28)]. Modern pain education takes a constructivist approach to learning, integrates active, constructive, interactive and inventive learning tasks (88), includes a range of teaching “tactics” during educational encounters, and uses novel clinical tools such as sequential art, storytelling, active tasks and virtual-reality mediated embodied experiences. The theoretical frameworks and some strategies have been drawn from education research, where they have been shown to improve learning in over 300 meta-analyses of data from several million participants (89). Other strategies are based on the principles that govern the neurophysiology of learning (43); others are grounded in social cognitive theory (90). It is important to acknowledge that many clinicians have already begun to use contemporary teaching methods to enhance their educational offerings, although up to 40% of health professionals who regularly deliver pain education are unable to name an educational strategy (30).

In 2023, the Pain Education Team to Advance Learning (PETAL) Collaboration was formed. This international, interdisciplinary collaboration of researchers, clinicians and consumers engaged in pain education research and seeking to synergise international efforts, elected to use “Pain Science Education” to describe modern pain education. There were two reasons for this move: (i) to differentiate, from PNE [which is still taught and delivered in its original form (28)], modern patient education that incorporates these developments in content and method, and (ii) to reflect that wider range of scientific knowledge (rather than just “neuroscience”) that is now included.

The intent of making pain education better is clear: maximise learning about how pain works in order to optimise endorsement and adoption of a graded reactivation and self-management approach to recovery. The logic is simple: if the didactic “old school” PNE approach is one of the most effective treatments we currently have for chronic pain (91), then much more effective education (i.e., a “stronger dose”) is likely to be more beneficial, and thus deliver better clinical outcomes. Robust clinical trials will support or refute this logic.

Co-designed education involves authentic and meaningful engagement with learners (consumers, clinicians and the public) and health professionals throughout the design and development stages, ensuring that tools and resources resonate with their needs, thereby improving acceptability and uptake (92). Pain Science Education draws heavily on co-design methods as well as progress in educational and conceptual change sciences (28). Tools and resources are designed to enrich the learning environment, provide learning opportunities for learners with a wider range of skills and previous educational attainment, and make learning more enjoyable and meaningful—promoting what Hattie and O'Donoghue call the “will” and “thrill” of learning (89). The strategies embedded in these tools are not unique to patient pain education, but have only recently been integrated into it. One such strategy is sequential art, known colloquially as “comics” or “cartoons”, which can be presented in isolation—conveying a specific point— and also as a coherent whole in which certain characters assist to build a longer, cohesive narrative (93). For example, character development of Snoopy and Charlie Brown in Peanuts allows their personality and context to infer complex meanings and inferences (94). Randomised controlled experiments demonstrate that the use of sequential art enhances learning outcomes across several domains (95).

Recent patient-targeted pain education resources for the general public use sequential art (e.g., https://www.tamethebeast.org and flippinpain.co.uk/formula/), for children and youth (96, 97) and for adults with chronic pain (82, 98). The development of these resources involved individual stories to target a specific concept, linking concepts and inferring more complex, nuanced concepts through the development of characters across multiple stories. Extensive consumer involvement during development promotes the relevance, readability and acceptability of the resources, but the international use of the resources means that colloquial language and cultural references, which can offer powerful learning opportunities, are necessarily limited.

We also co-designed a series of brief animated videos in partnership with people living with osteoarthritis to challenge common misconceptions (e.g., osteoarthritis is caused by “wear and tear” of joint cartilage) that reduce participation in guideline-based care. Using Pain Science Education concepts to provide compelling alternative narratives (e.g., “bioplasticity of cartilage”), our pilot data (n = 291) showed that a single view trial of these animations led to medium to large reductions in misconceptions in both lay people (with and without OA) and health professionals (99). People with OA also reported reduced fear of movement and an increased intention to exercise, and feedback on the videos was highly positive, with many citing the clear and patient-friendly explanations. The positive reception was unlikely to reflect resonance with pre-held beliefs. To the contrary, the content probably challenged pre-held beliefs: over 70% of consumers reported that it was different from information previously provided to them by health professionals. We do not know whether this reflects poor knowledge or poor education strategy of their previous providers.

The ancient (100) tactic of storytelling can foster deeper engagement with the studied material and has long been thought to improve the extent of learning and retention (101). Storytelling interventions, by altering health-related societal norms, have been shown to impact major public health issues, including sexual health, substance use, hypertension control, and vaccination, across diverse international contexts including culturally diverse communities (102). Storytelling can stimulate and maintain interest in the topic, provide a structure for delivery and remembering the material, and improve the connection between the educator and the learner (103, 104). Examples in the pain field include the children's comic book “Medikidz Explain Chronic Pain: What's Up with Moira's Grandad” (105) and “Painful Yarns. Metaphors and stories to help understand the biology of chronic pain” (106). The former addresses the challenges that older people with chronic pain experience when trying to explain to their grandchildren why they are sometimes unable to play with them because of their condition. The latter consists of short stories used as metaphors for pain science concepts; a small clinical trial suggested it improved understanding of pain biology (107). Our patient partners have also highlighted the potential of patient testimonial storytelling: “Storytelling is powerful. There is nothing like someone else's experience with a good outcome—it shows that it can work.” Supplementary material 1 [(67), p. 6].

One tool that has enhanced educational outcomes in mainstream education is virtual reality (VR)-mediated embodied learning experiences. A meta-analysis of 43 trials, undertaken in several education settings, reported medium to large effect sizes on a range of learning outcomes, including cognitive, intellectual, motor and behavioural outcomes (108). VR-enhanced education creates experiences within a virtual environment, usually via head-mounted goggles, that target specific learning objectives. Using VR to enhance health education has been explored in women undergoing breast cancer (109) or cardiac (110) surgery. VR is not new to the chronic pain space (111), and others have delivered the didactic “presentation-based’ PNE using VR goggles (112, 113), reporting positive results. Using VR to deliver content in a similar way to how it might be delivered face-to-face or online seems a missed opportunity—the learning potential created by VR is likely to come from generating compelling and memorable experiences and active learning activities.

We have assisted one VR-based platform in its objective to generate experiences and activities, to achieve deep learning of PSE's learning objectives. Three independent research groups have undertaken preliminary investigation: Skidmore et al. (114) found that the Reality Health VR-enhanced pain education platform (Reality Health, Sydney, Australia) is easy for health professionals to use; provides credibility for using education as an intervention; provides users with safe experiences that reinforce and rapidly consolidate PSE's learning objectives. Mardon et al. (115) found it to be feasible, acceptable and safe for use with war Veterans with and without post-traumatic stress, and health professionals who treat them: key themes were novelty, compelling learning experiences, enjoyable, easy to use, and made complex concepts easy to understand. Kennedy et al. (116) evaluated the platform with patients on a waiting list for specialist pain services in Australia: 28 participants, 11% identifying as Australian Aboriginal origin and 9 as being born overseas, rated highly its ease of use (4.6/5), enjoyment (4.7/5), and their desire to use it again (4.3/5); 23 reported improvement with physical activities and mood, and 19 reported improvement in pain levels after the VR-based program. Clinical audit data appear promising: 315 long-term injured workers completed a VR-enhanced pain education program, showing substantial pre-post reductions in pain, pain interference and self-efficacy (full outcome evaluation data are presented with permission at https://www.petalcollaboration.org). Whether or not VR-enhanced PSE improves clinical outcomes more effectively than PSE without VR is yet to be investigated in a clinical trial.

With or without access to VR-enhanced pain education, a range of tactics can be employed by pain educators to enhance deep learning of PSE's learning objectives (82, 98). Using a modified ICAP conceptual change framework (88, 117), tasks that foster deep learning, from “active”, to “constructive” and “interactive/inventive” tasks, should improve pain education outcomes, just as they have been shown to do in conventional educational contexts. The RECLAIMA acronym (Table 5) can guide clinicians towards simple tactics that they can use “in the moment” to push learners towards deeper learning, and the SALAD task (28) can be used to integrate constructive and inventive strategies into reading, video-based or audio-based “homework”.