Culture-sensitive Pain Neuroscience Education: Implementation in non-Western populations

September 24, 2021

Culture-sensitive Pain Neuroscience Education: Implementation in non-Western populations


  Pain Neuroscience Education (PNE) is an educational intervention that aims to teach patients about pain using the biological and psychological perspectives. Besides the neurophysiological mechanism of pain, this education also focuses on the improvement of maladaptive pain beliefs such as the perception of pain as a threatening situation or relating pain intensity with the severity of tissue damage. In the scope of this education, we aim to change patients’ understanding from the threatening nature of pain to a protective signal for the body (1, 2). In addition, the important content of PNE is the focus on disproportional relationship between pain and tissue damage (pain ¹ tissue damage).

Although the evidence on the use of PNE to reduce pain intensity and disability and to improve function and pain related perceptions is increasing (3), the implementation of PNE appears to be mainly limited to Western populations.

  There is growing evidence on the meaning and interpretation of pain are influenced by the culture. In fact, this is an expected finding. Because the term culture may imply the unity of ideas, values, and perceptions of a certain group of people who have the same national boundaries, there is no generally accepted definition. Starting from here, we planned a review to make an evidence-based synthesis on cultural differences in pain beliefs, cognitions, and behaviors in patients with chronic pain. Our study is novel as it is the first systematic review investigating culture-related differences in pain cognitions (4). We found differences in coping strategies, illness perceptions, self-efficacy, fear avoidance beliefs, locus of control, and pain attitudes between various cultures (4).

Taking into account the cultural variations in the meaning of pain, pain beliefs and cognitions, and sociodemographic and environmental differences, merely translated PNE teaching and home education materials may not be sufficiently effective for the populations from non-Western countries.

  For these reasons, we culturally adapted PNE materials (teaching presentation and home education leaflet) for Turkish migrants living in Belgium by a Delphi study based on the suggestions of an expert committee (5). Five groups of experts were included with varying experience: 1) those having expertise in applying PNE, 2) those with expertise in assessing and treating Turkish patients with chronic pain, 3) those with expertise in adapting PNE for specific groups, 4) therapists who are familiar Turkish cultures, and 5) first-generation Turkish patients with chronic musculoskeletal pain.

  The novel aspect of our study is the development of separate teaching materials for Turkish women and men suffering with chronic pain. Inspired by an interactive PNE program for Brazilian chronic pain patients (6), different female and male characters were created, matching the patients’ stories of acute and chronic pain. Generally, culture- and gender-specific adaptations were performed in pictures and visual information. We selected pictures that look like the appearance of Turkish patients for example we included a woman with scarf. Based on the low-education and health literacy level of Turkish patients, detailed information on the mechanism of pain neurophysiology was avoided. For the explanation of pain modulation, the spam-filter metaphor could not be used, as the majority of older Turkish patients is not familiar with using e-mail. Therefore, appropriate metaphors for Turkish patients were selected by the expert committee and researchers. In Turkey, men tend to avoid expressing pain-related symptoms because male gender is considered as a symbol of power, whereas women are using more coping and palliative strategies to manage chronic pain. However, they are using passive coping strategies thermal agents, massage, and herbal remedies. In addition, men are more prone to have kinesiophobia than women. On the other hand, we can see an overdoing activity pattern (especially non-helpful activities such as house-work or handcraft activities) in Turkish women. Implications and treatment strategies were adapted in accordance with these culture- and gender-specific pain cognitions of patients.

  In addition, as an insufficient ability of patients to use online home education materials and their low education level, we developed a printed home education leaflet including a lot of visual displays and simplified information. For easy reading, this leaflet was limited with 10 pages keeping the core information. In a recent study adapting PNE materials for African patients with chronic pain, a home education material was developed in an audio-form because of the very low education level of patients (7).

  Then, the adapted PNE materials were piloted to compare the effectiveness of the culture-sensitive and standard PNE programs (8). We found that both the culture-sensitive and standard PNE programs resulted in improvements in knowledge of pain, pain intensity and disability, and pain cognitions in Turkish migrants with chronic low back pain. Full randomized controlled trials are needed to investigate the effects of the culture-sensitive PNE in native non-Western populations with chronic pain.



Ceren Gursen, PhD

Hacettepe University,
Faculty of Physical Therapy and Rehabilitation
Ankara, Turkey




1.               Nijs J, Clark J, Malfliet A, Ickmans K, Voogt L, Don S, et al. In the spine or in the brain? Recent advances in pain neuroscience applied in the intervention for low back pain. Clin Exp Rheumatol. 2017;35 Suppl 107(5):108-15.

2.               Moseley GL, Butler DS. Fifteen Years of Explaining Pain: The Past, Present, and Future. J Pain. 2015;16(9):807-13.

3.               Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016;32(5):332-55.

4.               Orhan C, Van Looveren E, Cagnie B, Mukhtar NB, Lenoir D, Meeus M. Are Pain Beliefs, Cognitions, and Behaviors Influenced by Race, Ethnicity, and Culture in Patients with Chronic Musculoskeletal Pain: A Systematic Review. Pain Physician. 2018;21(6):541-58.

5.               Orhan C, Cagnie B, Favoreel A, Van Looveren E, Akel U, Mukhtar NB, et al. Development of culturally sensitive Pain Neuroscience Education for first-generation Turkish patients with chronic pain: A modified Delphi study. Musculoskelet Sci Pract. 2019;39:1-9.

6.               Reis FJJ, Bengaly AGC, Valentim JCP, Santos LC, Martins EF, O'Keeffe M, et al. An E-Pain intervention to spread modern pain education in Brazil. Braz J Phys Ther. 2017;21(5):305-6.

7.               Mukhtar NB, Meeus M, Gursen C, Mohammed J, Dewitte V, Cagnie B. Development of culturally sensitive pain neuroscience education materials for Hausa-speaking patients with chronic spinal pain: A modified Delphi study. PLoS One. 2021;16(7):e0253757.

8.               Orhan C, Lenoir D, Favoreel A, Van Looveren E, Yildiz Kabak V, Mukhtar NB, et al. Culture-sensitive and standard pain neuroscience education improves pain, disability, and pain cognitions in first-generation Turkish migrants with chronic low back pain: a pilot randomized controlled trial. Physiother Theory Pract. 2021;37(5):633-45.