Pain Physiology Education Improves Pain Beliefs in Patients With Chronic Fatigue Syndrome Compared With Pacing and Self-Management Education: A Double-Blind Randomized Controlled Trial

Physical treatment of functional neurologic disorders

Physical interventions are widely considered an important part of treatment of functional neurologic disorders (FNDs). The evidence base for physical interventions has been limited to a collection of case series, but the recent publication of several large cohort studies and a randomized controlled trial have provided stronger evidence to support its use. While the evidence for efficacy appears to be promising, details on how this should be delivered remain limited, perhaps due to the dominance of psychologically focused etiologic models. A move towards understanding how the symptoms of FND are generated on a neurobiologic level has resulted in an expansion of pathophysiologic models providing a clearer rationale for physical treatment. In this context, the motor symptoms of FND can be considered as learnt patterns of movement, driven by attention and belief. Physical treatment aims to retrain movement by redirecting attention and addressing unhelpful illness beliefs and behaviors. The patient's problems should be considered in a broad biopsychosocial framework where symptom-predisposing, precipitating, and perpetuating factors can be addressed within a multidisciplinary environment as a gold standard. Further research is required to refine interventions and create evidence-based treatment guidelines.

Comparison of pain neurophysiology knowledge among health sciences students: a cross-sectional study

Background

A key tool for use in approaching chronic pain treatment is educating patients to reconceptualize pain. Thus, health professionals are fundamental to the transmission of pain information to patients. Because their understanding of pain is acquired during the educational process, the aim of this study was to compare the knowledge about pain neurophysiology in first and final-year students from three different health science programs at a single University to determine their gain in knowledge using a well-known questionnaire designed to evaluate the understanding of pain.

Methods

The Neurophysiology of Pain Questionnaire (19 closed-ended questions) was administered to students in their first and final years of study in Medicine, Physiotherapy, or Nutrition. The percentage of correct responses was determined and comparisons of the results were analyzed between the programs as well as between the first and final years of study within each program. For all tests, p-values were two-sided, and results with p-values below 0.05 were considered statistically significant.

Results

The participation rate was greater than 51 % (n = 285). The mean percentage of correct responses, reported as mean (SD), among the first year students was 42.14 (12.23), without significant statistical differences detected between the programs. The mean percentages of correct responses for students in their final year were as follows: Medicine, 54.38 (13.87); Physiotherapy, 68.92 (16.22); Nutrition, 42.34 (10.11). We found statistically significant differences among all three programs and between the first and final years in Medicine and Physiotherapy. A question-by-question analysis showed that the percentage of correct responses for questions related to the biopsychosocial aspects of pain was higher for students in Physiotherapy than those in Medicine.

Conclusions

Students in their final years of Medicine and Physiotherapy programs know more about the neurophysiology of pain than students in their first years of these programs, however there are some questions where first years students have better results. Physiotherapy students have greater knowledge of neurophysiology of pain than Medicine students, especially the biopsychosocial aspects. Even so, their understanding may not be sufficient and does not guarantee an approach to chronic pain that will help patients reconceptualize their pain.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1585-y) contains supplementary material, which is available to authorized users.

Chronic pain self-management support with pain science education and exercise (COMMENCE): study protocol for a randomized controlled trial

Background

Previous research suggests that self-management programs for people with chronic pain improve knowledge and self-efficacy but result in negligible effects on function. This study will investigate the effectiveness self-management support with pain science education and exercise on improving function for people with chronic pain in comparison to a wait-list control. A secondary objective is to determine which variables help to predict response to the intervention.

Methods/Design

This study will be an unblinded, randomized controlled trial with 110 participants comparing a 6-week program that includes self-management support, pain science education and exercise to a wait-list control. The primary outcome will be function measured by the Short Musculoskeletal Function Assessment - Dysfunction Index. Secondary outcomes will include pain intensity measured by a numeric pain rating scale, pain interference measured by the eight-item PROMIS pain interference item-bank, how much patients are bothered by functional problems measured by the Short Musculoskeletal Function Assessment - Bother Index, catastrophic thinking measured by the Pain Catastrophizing Scale, fear of movement/re-injury measured by the 11-item Tampa Scale of Kinesiophobia, sense of perceived injustice measured by the Injustice Experience Questionnaire, self-efficacy measured by the Pain Self-Efficacy Questionnaire, pain sensitivity measured by pressure pain threshold and cold sensitivity testing, fatigue measured by a numeric fatigue rating scale, pain neurophysiology knowledge measured by the Neurophysiology of Pain Questionnaire, healthcare utilization measured by number of visits to a healthcare provider, and work status. Assessments will be completed at baseline, 7 and 18 weeks. After the 18-week assessment, the groups will crossover; however, we anticipate carry-over effects with the treatment. Therefore, data from after the crossover will be used to estimate within-group changes and to determine predictors of response that are not for direct between-group comparisons. Mixed effects modelling will be used to determine between-group differences for all primary and secondary outcomes. A series of multiple regression models will be used to determine predictors of treatment response.

Discussion

This study has the potential to inform future self-management programming through evaluation of a self-management program that aims to improve function as the primary outcome.

Trial registration

ClinicalTrials.gov NCT02422459, registered on 13 April 2015.

Theoretical Considerations for Chronic Pain Rehabilitation

Conventional rehabilitation of patients with chronic pain is often not successful and is frustrating for the treatment team. However, theoretical developments and substantial advances in our understanding of the neurological aspects of chronic pain are changing these experiences. Modern theoretical models of pain consider pain to be a perceptual inference that reflects a "best guess" that protective action is required. This article argues that keen observation and open and respectful clinician-patient and scientist-clinician relationships have been critical for the emergence of effective rehabilitation approaches and will be critical for further improvements. The role in modern pain rehabilitation of reconceptualizing the pain itself-by "Explaining Pain," careful and intentional observation of the person in pain, and the strategic and constant communication of safety-is emphasized. It also is suggested that better understanding of the neural mechanisms underpinning chronic pain has directly informed the development of new therapeutic approaches, which are being further refined and tested. Conventional pain treatment (where the clinician strives to find the pain-relieving medication or exercise) or pain management (where the clinician helps the patient to manage life despite unabating pain) is being replaced by pain rehabilitation, where a truly biopsychosocial approach allows clinicians to provide patients with the knowledge, understanding, and skills to reduce both their pain and disability. A brief overview is provided of the key aspects of modern pain rehabilitation and the considerations that should lead our interaction with patients with chronic pain.

The short term effects of preoperative neuroscience education for lumbar radiculopathy: A case series

BACKGROUND

Recently a preoperative pain neuroscience education (NE) program was developed for lumbar surgery (LS) for radiculopathy as a means to decrease postoperative pain and disability. This study attempts to determine the short term effects, if any, of providing NE before surgery on patient outcomes.

METHODS

A case series of 10 patients (female = 7) received preoperative one-on-one educational session by a physical therapist on the neuroscience of pain, accompanied by an evidence-based booklet, prior to LS for radiculopathy. Post-intervention data was gathered immediately after NE, as well as 1, 3 and 6 months following LS. Primary outcome measures were Pain Catastrophization Scale (PCS), forward flexion, straight leg raise (SLR) and beliefs regarding LS.

RESULTS

Immediately following NE for LS for radiculopathy, all patients had lower PCS scores, with 5 patients exceeding the MDC score of 9.1 and 8 of the patients had PCS change scores exceeding the MDC by the 1, 3 and 6 month follow ups. Physical changes showed that fingertip-to-floor test in 6 patients had changes in beyond the MDC of 4.5 cm and 6 patients had changes in SLR beyond the MDC of 5.7°. The main finding, however, indicated a positive and more realistic shift in expectations regarding pain after the impending LS by all patients.

CONCLUSIONS

The results of the case series suggest that immediately after NE, patients scheduled for LS for radiculopathy had meaningful detectable changes in pain catastrophizing, fingertip-to-floor test, passive SLR and positive shifts in their beliefs about LS.

Manual physical therapists' use of biopsychosocial history taking in the management of patients with back or neck pain in clinical practice

OBJECTIVE

To develop and evaluate process indicators relevant to biopsychosocial history taking in patients with chronic back and neck pain.

METHODS

The SCEBS method, covering the Somatic, Psychological (Cognition, Emotion, and Behavior), and Social dimensions of chronic pain, was used to evaluate biopsychosocial history taking by manual physical therapists (MPTs). In Phase I, process indicators were developed while in Phase II indicators were tested in practice.

RESULTS

Literature-based recommendations were transformed into 51 process indicators. Twenty MTPs contributed 108 patient audio recordings. History taking was excellent (98.3%) for the Somatic dimension, very inadequate for Cognition (43.1%) and Behavior (38.3%), weak (27.8%) for Emotion, and low (18.2%) for the Social dimension. MTPs estimated their coverage of the Somatic dimension as excellent (100%), as adequate for Cognition, Emotion, and Behavior (60.1%), and as very inadequate for the Social dimension (39.8%).

CONCLUSION

MTPs perform screening for musculoskeletal pain mainly through the use of somatic dimension of (chronic) pain. Psychological and social dimensions of chronic pain were inadequately covered by MPTs. Furthermore, a substantial discrepancy between actual and self-estimated use of biopsychosocial history taking was noted. We strongly recommend full implementation of the SCEBS method in educational programs in manual physical therapy.

Self-management interventions for chronic disease: a systematic scoping review

OBJECTIVE

To investigate the contributions of physiotherapy and occupational therapy to self-management interventions and the theoretical models used to support these interventions in chronic disease.

DATA SOURCES

We conducted two literature searches to identify studies that evaluated self-management interventions involving physiotherapists and occupational therapists in MEDLINE, the Cochrane Library, CINAHL, EMBASE, AMED (Allied and Complementary Medicine), SPORTdiscus, and REHABDATA databases.

STUDY SELECTION

Four investigator pairs screened article title and abstract, then full text with inclusion criteria. Selected articles (n = 57) included adults who received a chronic disease self-management intervention, developed or delivered by a physiotherapist and/or an occupational therapist compared with a control group.

DATA EXTRACTION

Four pairs of investigators performed independent reviews of each article and data extraction included: (a) participant characteristics, (b) the self-management intervention, (c) the comparison intervention, (d) outcome measures, construct measured and results.

DATA SYNTHESIS

A total of 47 articles reported the involvement of physiotherapy in self-management compared with 10 occupational therapy articles. The type of chronic condition produced different yields: arthritis n = 21 articles; chronic obstructive pulmonary disease and chronic pain n = 9 articles each. The theoretical frameworks most frequently cited were social cognitive theory and self-efficacy theory. Physical activity was the predominant focus of the self-management interventions. Physiotherapy programmes included disease-specific education, fatigue, posture, and pain management, while occupational therapists concentrated on joint protection, fatigue, and stress management.

CONCLUSIONS

Physiotherapists and occupational therapists make moderate contributions to self-management interventions. Most of these interventions are disease-specific and are most frequently based on the principles of behaviour change theories.

Aquatic exercise and pain neurophysiology education versus aquatic exercise alone for patients with chronic low back pain: a randomized controlled trial

Objective:

The aim of this study was to compare the effectiveness of a combination of aquatic exercise and pain neurophysiology education with aquatic exercise alone in chronic low back pain patients.

Design:

Single-blind randomized controlled trial.

Setting:

Outpatient clinic.

Subjects:

Sixty-two chronic low back pain patients were randomly allocated to receive aquatic exercise and pain neurophysiology education ( n = 30) or aquatic exercise alone ( n = 32).

Interventions:

Twelve sessions of a 6-week aquatic exercise programme preceded by 2 sessions of pain neurophysiology education. Controls received only 12 sessions of the 6-week aquatic exercise programme.

Main measures:

The primary outcomes were pain intensity (Visual Analogue Scale) and functional disability (Quebec Back Pain Disability Scale) at the baseline, 6 weeks after the beginning of the aquatic exercise programme and at the 3 months follow-up. Secondary outcome was kinesiophobia (Tampa Scale of Kinesiophobia).

Results:

Fifty-five participants completed the study. Analysis using mixed-model ANOVA revealed a significant treatment condition interaction on pain intensity at the 3 months follow-up, favoring the education group (mean SD change: −25.4± 26.7 vs −6.6 ± 30.7, P < 0.005). Although participants in the education group were more likely to report perceived functional benefits from treatment at 3 months follow-up (RR=1.63, 95%CI: 1.01–2.63), no significant differences were found in functional disability and kinesiophobia between groups at any time.

Conclusions:

This study’s findings support the provision of pain neurophysiology education as a clinically effective addition to aquatic exercise.

Pain education to prevent chronic low back pain: a study protocol for a randomised controlled trial

INTRODUCTION

Low back pain (LBP) is the leading cause of disability worldwide. Of those patients who present to primary care with acute LBP, 40% continue to report symptoms 3 months later and develop chronic LBP. Although it is possible to identify these patients early, effective interventions to improve their outcomes are not available. This double-blind (participant/outcome assessor) randomised controlled trial will investigate the efficacy of a brief educational approach to prevent chronic LBP in 'at-risk' individuals.

METHODS/ANALYSIS

Participants will be recruited from primary care practices in the Sydney metropolitan area. To be eligible for inclusion participants will be aged 18-75 years, with acute LBP (<4 weeks' duration) preceded by at least a 1 month pain-free period and at-risk of developing chronic LBP. Potential participants with chronic spinal pain and those with suspected serious spinal pathology will be excluded. Eligible participants who agree to take part will be randomly allocated to receive 2×1 h sessions of pain biology education or 2×1 h sessions of sham education from a specially trained study physiotherapist. The study requires 101 participants per group to detect a 1-point difference in pain intensity 3 months after pain onset. Secondary outcomes include the incidence of chronic LBP, disability, pain intensity, depression, healthcare utilisation, pain attitudes and beliefs, global recovery and recurrence and are measured at 1 week post-intervention, and at 3, 6 and 12 months post LBP onset.

ETHICS/DISSEMINATION

Ethical approval was obtained from the University of New South Wales Human Ethics Committee in June 2013 (ref number HC12664). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conference meetings.

TRIAL REGISTRATION NUMBER

https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12612001180808.

Reducing catastrophic thinking associated with pain

SUMMARY Over the past two decades increasingly compelling research has identified pain catastrophizing as an important psychological risk factor for a wide range of pain-related outcomes. In response to this literature, there have been calls for the clinical use of catastrophizing as a prognostic indicator of problematic recovery, and for the development of clinical interventions that target catastrophizing and its correlates. This article provides a review of the evidence-based assessment and management tools that are available for the clinical management of patients with elevated levels of catastrophic thinking. Recent research and clinical implementation strategies are discussed for the following interventions: cognitive behavioral techniques, emotional disclosure, reassurance and activity encouragement, neurophysiological education, and graded activity and exposure.

Toward a theory-driven classification of rehabilitation treatments

Rehabilitation is in need of an organized system or taxonomy for classifying treatments to aid in research, practice, training, and interdisciplinary communication. In this article, we describe a work-in-progress effort to create a rehabilitation treatment taxonomy (RTT) for classifying rehabilitation interventions by the underlying treatment theories that explain their effects. In the RTT, treatments are grouped together according to their targets, or measurable aspects of functioning they are intended to change; ingredients, or measurable clinician decisions and behaviors responsible for effecting changes; and the hypothesized mechanisms of action by which ingredients are transformed into changes in the target. Four treatment groupings are proposed: structural tissue properties, organ functions, skilled performances, and cognitive/affective representations, which are similar in the types of targets addressed, ingredients used, and mechanisms of action that account for change. The typical ingredients and examples of clinical treatments associated with each of these groupings are explored, and the challenges of further subdivision are discussed. Although a Linnaean hierarchical tree structure was envisioned at the outset of work on the RTT, further development may necessitate a model with less rigid boundaries between classification groups, and/or a matrix-like structure for organizing active ingredients along selected continua, to allow for both qualitative and quantitative variations of importance to treatment effects.

Chronic pain in patients with the hypermobility type of Ehlers-Danlos syndrome: evidence for generalized hyperalgesia

Chronic widespread pain is highly present in patients with the Ehlers-Danlos syndrome hypermobility type (EDS-HT), but up to now, evidence for generalized hyperalgesia is lacking. The aim of this study is to investigate whether pressure pain thresholds (PPTs) at both symptomatic and asymptomatic body areas differ in EDS-HT patients compared to healthy subjects. Twenty-three women with EDS-HT and 23 gender- and age-matched healthy controls participated. All subjects marked on Margolis Pain Diagram where they felt pain lasting longer than 24 h in the past 4 weeks. Then, they completed several questionnaires assessing pain cognitions, fatigue, disability, and general health status, in order to take the possible influence of these factors on PPTs into account. Patients also completed a form concerning the type of pain they experienced. Thereupon, a blinded researcher assessed PPTs at 14 body locations on the trunk and extremities. PPTs were compared for the two complete groups. In addition, PPTs of patients and controls who did not report pain in a respective zone were compared. PPTs of the patients were significantly lower compared to those of the control group, also when pain-free samples per zone were compared. The mean (SD) PPT was 2.9 (1.62) kg/cm(2) in the EDS-HT patients and 5.2 (1.88) kg/cm(2) in the controls (P < 0.001). No confounding factors responsible for the observed differences could be revealed. In half of the patient group, a predominantly neuropathic pain component was likely present. This study provides evidence for the existence of hyperalgesia even in asymptomatic areas (generalized secondary hyperalgesia). The generalized hyperalgesia may represent the involvement of a sensitized central nervous system, which inquires an adapted pain management for this patient group.

Complementary and alternative treatments in sports medicine

Many patients suffering from pain and dysfunction attributable to musculoskeletal conditions will use some form of complementary and alternative medicine (CAM). Unfortunately, there is a paucity of both the quantity and quality of CAM treatments for specific musculoskeletal conditions. Many CAM treatments are used for a variety of musculoskeletal conditions, but may be more commonly used for specific conditions. This article addresses the use of CAM for specific musculoskeletal conditions, followed by a review of other CAM treatments and their potential indications for a multitude of conditions, based on the current medical literature and traditional use.

Pacing: a concept analysis of the chronic pain intervention

BACKGROUND

The intervention of pacing is regularly recommended for chronic pain patients. However, pacing is poorly defined and appears to be interpreted in varying, potentially contradictory manners within the field of chronic pain. This conceptual lack of clarity has implications for effective service delivery and for researchers' ability to conduct rigorous study. An examination of the background literature demonstrates that while pacing is often one part of a multidisciplinary pain management program, outcome research is hindered by a lack of a clear and shared definition of this currently ill-defined construct.

OBJECTIVES

To conduct a formal concept analysis of the term 'pacing'.

METHODS

A standardized concept analysis process (including literature scoping to identify all uses of the concept, analysis to determine defining attributes of the concept and identification of model, borderline and contrary cases) was used to determine what the concept of pacing does and does not represent within the current evidence base.

RESULTS

A conceptual model including the core attributes of action, time, balance, learning and self-management emerged. From these attributes, an evidence-based definition for pacing was composed and distributed to stakeholders for review. After consideration of stakeholder feedback, the emergent definition of pacing was finalized as follows: "Pacing is an active self-management strategy whereby individuals learn to balance time spent on activity and rest for the purpose of achieving increased function and participation in meaningful activities".

CONCLUSION

The findings of the present concept analysis will help to standardize the use and definition of the term pacing across disciplines for the purposes of both pain management and research.

"What is killing me most": chronic pain and the need for palliative care in the Eastern Cape, South Africa

Palliative care and the provision of pain relief medicine are essential components of health care, yet little research has been conducted on access to pain medicine in rural areas of sub-Saharan Africa. The objective of this study was to examine patient experiences and health care provider attitudes towards chronic pain and palliative care in Eastern Cape Province, South Africa. The study used a mixed-methods approach to evaluate experience of chronic pain in a district hospital and associated clinics. Questionnaires and in-depth interviews were conducted with 45 current and former patients receiving care and 26 health care providers. Forty-six percent (n = 19) of patients rated their pain in the last month as severe. Thirty-nine percent (n = 17) of individuals stated that they had never been provided with an explanation for the cause of their pain. Multiple regression analysis found that being female, not having received a social welfare grant, and not having received an explanation for the cause of pain were associated with higher ratings of pain (P < .10 for each variable). Factors inhibiting the provision of palliative care included insufficient access and availability of pain medication and providers' association of palliative care with end-of-life care. Adequate pain relief is often deprioritized in a busy health care setting. Ensuring patients receive sufficient relief for their pain requires interventions at clinical and policy levels, including the provision of needed pain medication and training in palliative care for all providers.

How good is the neurophysiology of pain questionnaire? A Rasch analysis of psychometric properties

The Neurophysiology of Pain Questionnaire (NPQ) was devised to assess how an individual conceptualizes the biological mechanisms that underpin his or her pain. Despite its widespread use, its psychometric properties have not been comprehensively interrogated. Rasch analysis was undertaken on NPQ data from a convenience sample of 300 spinal pain patients, and test-retest reliability was assessed in a sample of 45 low back pain patients. The NPQ effectively targeted the ability of the sample and had acceptable internal consistency and test-retest reliability. However, some items functioned erratically for persons of differing abilities or were psychometrically redundant. The NPQ was reanalyzed with 7 questionable items excluded, and superior psychometric properties were observed. These findings suggest that the NPQ could be improved, but future prospective studies including qualitative measures are needed. In summary, the NPQ is a useful tool for assessing a patient's conceptualization of the biological mechanisms that underpin his or her pain and for evaluating the effects of cognitive interventions in clinical practice and research. These findings suggest that it has adequate psychometric properties for use with chronic spinal pain patients.

PERSPECTIVE

Rasch analysis was used to analyze the NPQ. Despite several limitations, these results suggest that it is a useful tool with which to assess a patient's conceptualization of the biological mechanisms that underpin his or her pain and to evaluate the effects of cognitive interventions in clinical practice and research.

Primary care physical therapy in people with fibromyalgia: opportunities and boundaries within a monodisciplinary setting

Despite the fact that people with fibromyalgia syndrome (FMS) frequently are seen by primary care physical therapists, guidelines for the management of FMS are based primarily on outcomes from multidisciplinary and tertiary care treatment studies. Few data addressing the treatment of patients with FMS in primary care currently are available. The evidence-based guidelines on the management of FMS are based, in part, on evidence from studies examining physical therapy treatment components alone (eg, aerobic exercise, education). Thus, the recommendations can be applied to primary care physical therapy. Primary care physical therapy for patients with FMS should include education, aerobic exercise, and strengthening exercise. For other treatment components such as passive treatments, activity management, and relaxation, less evidence currently is available to advocate their use in primary care physical therapy. Superior results are to be expected when various treatment components are combined.