Interdisciplinary approach to chronic pain management

Identifying competencies for an advanced practice physiotherapy role within an interprofessional chronic pain clinic

BACKGROUND

Advanced practice physiotherapy (APP) models of care have shown success in access, safety, satisfaction, and care quality for musculoskeletal pain conditions in various settings. Yet, there is a gap in defining competencies for physiotherapists to be the initial point of contact for people with chronic pain. This study aims to identify and agree upon the competencies necessary for a physiotherapist to fulfill the role of an APP in an interprofessional chronic pain clinic.

METHODS

Three focus groups were conducted using a Nominal Group Technique and a modified Delphi process. Consensus on the competency, defined as agreement by ≥ 75% of participants, was sought.

RESULTS

Twenty-three experts (17 healthcare providers and six individuals with chronic pain) participated in the focus group discussions. Twenty completed the follow-up Delphi surveys. Ten essential competencies for an APP role in interprofessional chronic pain clinics were identified and achieved consensus: 1) use an evidence-based approach to practice; 2) communicate effectively with the patient; 3) perform a comprehensive assessment; 4) determine pain-related diagnoses; 5) develop therapeutic relationships; 6) provide appropriate care; 7) support patients through transitions in care; 8) collaborate with members of the interprofessional team; 9) advocate for the needs of the patients; and 10) use a reflective approach to practice.

CONCLUSION

This study identified ten competencies essential for physiotherapists to fulfill an APP role within interprofessional chronic pain clinics. These competencies serve as a foundation for informing a training program and future research evaluating the effectiveness of the APP model in this setting.

Lessons learned from the experiences of patients with chronic pelvic pain syndrome (CPP syndrome) with a multidisciplinary consultation: a qualitative study

INTRODUCTION

Chronic pelvic pain syndrome is a complex multifactorial condition with an increasing prevalence probably due to a rising awareness. Chronic pelvic pain syndrome is pain in the pelvic area and often accompanied with complaints in other organ systems of the lesser pelvis. Patients with chronic pelvic pain syndrome who present at our center are evaluated in a standardized care pathway with an integrated multidisciplinary consultation. The team works in a single center and consists of gynecologists, pain specialists, urologists, a pelvic floor physiotherapist and a psychologist. The aim of this interview study is to evaluate the value of the multidisciplinary consultation from the patient's perspectives.

METHODS

In a qualitative study, we evaluated the experiences and perspectives of patients with chronic pelvic pain syndrome concerning the multidisciplinary consultation at the Radboud University Medical Center. Semistructured interviews were conducted with patients with chronic pelvic pain syndrome who attended a multidisciplinary consultation between 2019 and 2022. All interviews were transcribed verbatim, coded and analyzed via ATLAS.ti with the conventional content analysis.

RESULTS

Data saturation was reached after seven interviews, followed by three confirmative interviews. In total, 10 patients (22-76 years) participated in the study. Three relevant themes were identified in the interviews: the deleterious effects of pain on overall health, the importance of the design of the multidisciplinary consultation, and the performance of healthcare professionals (knowledge, skills and interaction with patients and colleagues). Participants suggested that although the consultation did not improve their pain experience, there was value in having a comprehensive assessment of their disease. Patients preferred the consultation to occur at the beginning of the care. Additionally, they acknowledged the performance of healthcare providers and having their complaints recognized. However, some participants suggested the need for additional attention to mental health issues during the multidisciplinary consultation.

DISCUSSION

Even though patients did not perceive the multidisciplinary consultation to improve their pain experience, they appreciated the sense of recognition by this team.

CONCLUSION

A multidisciplinary consultation is of value from the patients' perspective. A suggestion for improvement emerged where the multidisciplinary consultation should occur at the beginning of the patient journey.

Validity and reliability study in undergraduate healthcare students towards the solution of a neglected problem in working life: Attitude scale towards patients with chronic pain

BACKGROUND

Chronic pain is the type of pain that healthcare professionals frequently encounter. Health care students' attitudes towards pain management are not sufficient and this negatively affects their chronic pain management. When students cannot manage the chronic pain they will experience professional burnout, depersonalization, and a decrease in compassion and empathy in patient care. Therefore, the first step in improving health care students' attitudes towards patients with chronic pain is to determine their attitudes.

OBJECTIVE

This study aims to test the validity and reliability of the Scale for Healthcare Professionals' Attitudes towards Patients with Chronic Pain (HCPAPCP Scale) in healthcare students.

METHOD

This quantitative study was conducted with 205 health care students in January-February 2022. Data were collected online with Personal Information Form and the HCPAPCP Scale. To determine the reliability of the scale, internal consistency and test-retest, and for construct validity, exploratory factor analysis and confirmatory factor analysis were performed.

RESULTS

The results of the exploratory factor analysis showed that the two-factor scale consisting of 18 items, the factor structure, and the distribution of factors in items were the same as the findings of the original scale. The Cronbach's Alpha coefficient was 0.88 for the first factor and 0.74 for the second factor. Test-retest reliability was 0.60. In confirmatory factor analysis, the model had a good and acceptable fit.

CONCLUSION

We found that the HCPAPCP Scale was valid and reliable in healthcare students.

Assessing pain in persons with opioid use disorder: Approaches, techniques and special considerations

Pain and opioid use disorder (OUD) are inextricably linked, as the former can be a risk factor for the development of the latter, and over a third of persons with OUD suffer concomitant chronic pain. Assessing pain among people with OUD is challenging, because ongoing opioid use brings changes in pain responses and most pain assessment tools have not been validated for this population. In this narrative review, we discuss the fundamentals of pain assessment for populations with OUD. First, we describe the biological, psychological and social aspects of the pain experience among people with OUD, as well as how opioid-related phenomena may contribute to the pain experience in this population. We then review methods to assess pain, including (1) traditional self-reported methods, such visual analogue scales and structured questionnaires; (2) behavioural observations and physiological indicators; (3) and laboratory-based approaches, such as quantitative sensory testing. These methods are considered from a perspective that encompasses both pain and OUD. Finally, we discuss strategies for improving pain assessment in persons with OUD and implications for future research, including educational strategies for multidisciplinary teams. We highlight the substantial gaps that persist in this literature, particularly regarding the applicability of current pain assessment methods to persons with OUD, as well as the generalizability of the existing results from adjacent populations on chronic opioid therapy but without OUD. As research linking pain and OUD evolves, considering the needs of diverse populations with complex psychosocial backgrounds, clinicians will be better equipped to reduce these gaps.

Adults with excess weight or obesity, but not with overweight, report greater pain intensities than individuals with normal weight: a systematic review and meta-analysis

Context

Over 1.9 billion adult people have overweight or obesity. Considered as a chronic disease itself, obesity is associated with several comorbidities. Chronic pain affects approximately 60 million people and its connection with obesity has been displayed in several studies. However, controversial results showing both lower and higher pain thresholds in subjects with obesity compared to individuals with normal weight and the different parameters used to define such association (e.g., pain severity, frequency or duration) make it hard to draw straight forward conclusions in the matter. The objective of this article is to examine the relationship between overweight and obesity (classified with BMI as recommended by WHO) and self-perceived pain intensity in adults.

Methods

A literature search was conducted following PRISMA guidelines using the databases CINAHL, Cochrane Library, EMBASE, PEDro, PubMed, Scopus and Web of Science to identify original studies that provide BMI values and their associated pain intensity assessed by self-report scales. Self-report pain scores were normalized and pooled within meta-analyses. The Cochrane's Q test and I2 index were used to clarify the amount of heterogeneity; meta-regression was performed to explore the relationship between each outcome and the risk of bias.

Results

Of 2194 studies, 31 eligible studies were identified and appraised, 22 of which provided data for a quantitative analysis. The results herein suggested that adults with excess weight (BMI ≥ 25.0) or obesity (BMI ≥ 30.0) but not with overweight (pre-obesity) alone (BMI 25.0-29.9), are more likely to report greater intensities of pain than individuals of normal weight (BMI 18.5-24.9). Subgroup analyses regarding the pathology of the patients showed no statistically significant differences between groups. Also, influence of age in the effect size, evaluated by meta-regression, was only observed in one of the four analyses. Furthermore, the robustness of the findings was supported by two different sensitivity analyses.

Conclusion

Subjects with obesity and excess weight, but not overweight, reported greater pain intensities than individuals with normal weight. This finding encourages treatment of obesity as a component of pain management. More research is required to better understand the mechanisms of these differences and the clinical utility of the findings.

Systematic Review Registration

https://doi.org/10.17605/OSF.IO/RF2G3, identifier OSF.IO/RF2G3.

Advancements in Understanding and Classifying Chronic Orofacial Pain: Key Insights from Biopsychosocial Models and International Classifications (ICHD-3, ICD-11, ICOP)

In exploring chronic orofacial pain (COFP), this review highlights its global impact on life quality and critiques current diagnostic systems, including the ICD-11, ICOP, and ICHD-3, for their limitations in addressing COFP's complexity. Firstly, this study outlines the global burden of chronic pain and the importance of distinguishing between different pain types for effective treatment. It then delves into the specific challenges of diagnosing COFP, emphasizing the need for a more nuanced approach that incorporates the biopsychosocial model. This review critically examines existing classification systems, highlighting their limitations in fully capturing COFP's multifaceted nature. It advocates for the integration of these systems with the DSM-5's Somatic Symptom Disorder code, proposing a unified, multidisciplinary diagnostic approach. This recommendation aims to improve chronic pain coding standardization and acknowledge the complex interplay of biological, psychological, and social factors in COFP. In conclusion, here, we highlight the need for a comprehensive, universally applicable classification system for COFP. Such a system would enable accurate diagnosis, streamline treatment strategies, and enhance communication among healthcare professionals. This advancement holds potential for significant contributions to research and patient care in this challenging field, offering a broader perspective for scientists across disciplines.

Development of a pain self-management intervention framework for people with spinal cord injury

BACKGROUND

 Pain is the most common reason for medical visits to primary health care practitioners. Pain self-management interventions are encouraged and there is no known self-management intervention framework available that clinicians and people with spinal cord injury (PWSCI) can use to guide treatment selection.

AIM

 This study aimed to develop a pain self-management intervention framework for PWSCI.

SETTING

 Online and facilitated in Gauteng, South Africa.

METHODS

 A three-round modified e-Delphi method was used to reach an 80% consensus among a 21-expert panel. Fifty-nine interventions were distributed via REDCap and a final online audio meeting was held to either include or exclude interventions in the final framework. SPSS v27 was used to analyse descriptive data and content analysis was used for qualitative responses.

RESULTS

 The final developed pain self-management framework consists of 56 interventions and includes interventions from multiple health professions to encompass medical, psychological, therapeutic and social interventions. Interventions are also specified for nociceptive and/or neuropathic pain and grouped according to the biopsychosocial model.

CONCLUSION

 The interprofessional framework may be used as a guideline for PWSCI to alleviate pain, as well as assist health professionals in clinical decision-making, by providing them with the freedom to choose acceptable and adequate interventions that may be appropriate to treat the affected individual's pain.Contribution: Pain management is a basic need at the primary healthcare level and PWSCI need access to the broad range of interventions available to manage their pain. The framework highlights the variety of appropriate interventions to guide both health professionals and PWSCI with pain relief options.

Editorial to the Special Issue: "Recent Advances in the Management of Chronic Pain"

Chronic pain is a complex biopsychosocial phenomenon with far-reaching implications, not only in terms of clinical care but also in the realms of social and economic impact [...].

Assessing the feasibility of a clinical trial to evaluate an advanced practice physiotherapy model of care in chronic pain management: a feasibility study

BACKGROUND

Chronic pain management is challenging for health systems worldwide. Clinical practice guidelines recommend interprofessional chronic pain management, but chronic pain clinics often have lengthy wait-lists. Advanced practice physiotherapists (APP) in orthopedic clinics and emergency departments have provided effective care and reduced wait times. The purpose of this study is to determine the feasibility of a clinical trial to evaluate the effects of integrating an APP into a chronic pain clinic setting. The primary objectives are as follows: (1) determine the feasibility of implementing trial methods by evaluating participant recruitment rates, retention, and assessment completion; (2) determine the feasibility of implementing the APP model of care by monitoring care provided and treatment fidelity; and (3) assess contextual factors that may influence implementation of the APP model of care by exploring the perspectives of patient participants and healthcare providers related to the model of care.

METHODS

This will be a single-arm feasibility study with embedded qualitative interviews to assess contextual factors influencing implementation by exploring participant and provider perspectives. Approximately 40 adults with chronic musculoskeletal pain referred for care at an interprofessional chronic pain clinic will be invited to participate in the feasibility study. Approximately 10-12 patient participants and 5-10 health professionals from the interprofessional team will be interviewed using an interpretive description approach. The APP model of care will involve participants seeing a physiotherapist as the first point of contact within the interprofessional team. The APP will complete an initial assessment and make care recommendations. Outcome measures planned for the full trial will be reported descriptively, including pain severity, pain interference, health-related quality of life, psychosocial risk factors for chronic pain, treatment satisfaction, perceived change, healthcare utilization, and healthcare costs over one year.

DISCUSSION

This study will inform plans to implement a full-scale study to evaluate the impact of an APP model of care in an interprofessional chronic pain management program. The results of the full study are intended to inform stakeholders considering this model to improve patient-centered and health system outcomes in interprofessional pain management program settings.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05336903 (Registered April 5, 2022).

Impact of a 12-week olfactory training programme in women with migraine with aura: protocol for a double-blind, randomised, placebo-controlled trial

INTRODUCTION

Migraine is a leading cause of disability and suffering worldwide. However, conventional pharmacological migraine preventive therapies are often challenging and accompanied by adverse effects. Recently, structured odour exposure has shown to successfully increase pain thresholds in patients with chronic back pain. Despite the importance of the olfactory system in migraine, there are no studies investigating the impact of structured odour exposure in patients with migraine.

METHODS AND ANALYSIS

This double-blind randomised placebo-controlled trial will be conducted at the Headache Clinic of the University Pain Center at TU Dresden, Germany and aims at investigating the impact of a 12-week structured exposure to odours in women with migraine. Fifty-four women between 18 and 55 years with migraine with aura will be recruited and randomised to training with odours and odourless training. The primary outcomes are mechanical and electrical pain thresholds. Secondary outcomes comprise olfactory threshold and the number of headache days. Other exploratory measurements are headache associated pain intensity, acute analgesic intake, symptoms of anxiety and depression, and quality of life. Additionally, this protocol assesses neuroanatomical and neurofunctional changes associated with the 12-week olfactory training. Data analysis will be executed on the basis of the general linear model considering repeated measurements.

ETHICS AND DISSEMINATION

Ethical approvals were obtained from the Ethics Board of the TU Dresden (Protocol No. BO-EK-353082020). Participation will only be possible after written informed consent is provided. Findings will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

DRKS00027399.

How Does Meditation-Based Lifestyle Modification Affect Pain Intensity, Pain Self-Efficacy, and Quality of Life in Chronic Pain Patients? An Experimental Single-Case Study

INTRODUCTION

Chronic pain is a growing worldwide health problem and complementary and integrative therapy options are becoming increasingly important. Multi-component yoga interventions represent such an integrative therapy approach with a promising body of evidence.

METHODS

The present study employed an experimental single-case multiple-baseline design. It investigated the effects of an 8-week yoga-based mind-body intervention, Meditation-Based Lifestyle Modification (MBLM), in the treatment of chronic pain. The main outcomes were pain intensity (BPI-sf), quality of life (WHO-5), and pain self-efficacy (PSEQ).

RESULTS

Twenty-two patients with chronic pain (back pain, fibromyalgia, or migraines) participated in the study and 17 women completed the intervention. MBLM proved to be an effective intervention for a large proportion of the participants. The largest effects were found for pain self-efficacy (TAU-U = 0.35), followed by average pain intensity (TAU-U = 0.21), quality of life (TAU-U = 0.23), and most severe pain (TAU-U = 0.14). However, the participants varied in their responses to the treatment.

CONCLUSION

The present results point to relevant clinical effects of MBLM for the multifactorial conditions of chronic pain. Future controlled clinical studies should investigate its usefulness and safety with larger samples. The ethical and philosophical aspects of yoga should be further explored to verify their therapeutic utility.

Dealing with Chronic Pain: Tips to Teach Undergraduate Health Sciences Students

Chronic pain is a significant and costly problem all over the world that negatively impacts the quality of life of sufferers. There are clear discrepancies between the prevalence of chronic pain in society and the low priority assigned to educating future physicians about the complexities of pain. This condition also occurs in other undergraduate health science students, although research in this area has not been studied as much as in medical schools. Based on the International Association for the Study of Pain (IASP) Pain Curriculum Outline, a systematic search of the available literature, and the authors' own experiences, we highlight some relevant tips to educate health science trainees in the management of patients with chronic pain. These tips highlight current international recommendations for a comprehensive approach to this prevalent problem in society, which should be learnt during the university training of health professionals.

Factors Associated with Increased Analgesic Use in German Women with Endometriosis during the COVID-19 Pandemic

(1) Background: Endometriosis is a frequent chronic pain condition in women of fertile age. Pain management with analgesics is frequently used by women with endometriosis. During the COVID-19 pandemic, access to health services was temporarily restricted in various countries for persons without serious conditions, resulting in increased physical and mental health issues. The present study was conducted in order to assess the risk factors predicting increased analgesic intake by women with endometriosis during the COVID-19 pandemic. (2) Methods: The increased intake of over-the-counter (OTC) and prescription-only (PO) analgesics was assessed with an anonymous online questionnaire, along with demographic, pandemic-specific, disease-specific, and mental health characteristics. Anxiety and depression were assessed with the Generalized Anxiety Disorder Scale (GAD-2) and the Patient Health Questionnaire for Depression (PHQ-2), respectively. Pain-induced disability was assessed with the pain-induced disability index (PDI). (3) Results: A high educational level (OR 2.719; 95% CI 1.137–6.501; p = 0.025) and being at higher risk for depressive disorders, as measured by PHQ-2 ≥ 3 (OR 2.398; 95% CI 1.055–5.450; p = 0.037), were independent risk factors for an increased intake of OTC analgesics. Current global pain-induced disability (OR 1.030; 95% CI 1.007–1.054; p = 0.010) was identified as a risk factor for an increased intake of PO pain medication. The degree of reduction in social support and in social networks were independent predictors of an increased intake of PO analgesics in a univariate logistic regression analysis, but lost significance when adjusted for additional possible influencing factors. (4) Conclusions: In this population, an increased intake of OTC analgesics was related to a higher educational level and having a depressive disorder, while a higher pain-induced disability was an independent risk factor for an increased intake of PO analgesics. Pandemic-specific factors did not significantly and independently influence an increased intake of analgesics in women with endometriosis during the first wave of the COVID-19 pandemic in Germany. Healthcare providers should be aware of the possible factors related to increased analgesic use in women with endometriosis in order to identify persons at risk for the misuse of pain medication and to prevent potential adverse effects.

Development and psychometric testing of the intention to engage in children's healthy weight (iCHeW) guideline scale for dental staff

STATEMENT OF PROBLEM

In the evaluation of interdisciplinary interventions for childhood overweight and obesity, behavioural determinants can provide valuable insight into the reasons behind lack of adherence, or ineffectiveness of the intervention. Therefore, it is vital to assess the behavioural determinants of staff when evaluating the implementation of such interdisciplinary interventions. This study aimed to develop and psychometrically evaluate the intention to engage in Children's Healthy Weight guideline (iCHeW) scale, which assesses the behavioural determinants influencing dental staff's intention to conduct children's growth assessments.

METHODS

Initial items were generated based on review of the literature and the dimensions of the integrative model of behavioural prediction (IM). To test this scale, a cross-sectional survey design was undertaken consisting of three phases: (i) face validity; (ii) content validity; and (iii) psychometric evaluation of the iCHeW scale with a national sample of 125 dental staff.

RESULTS

The 35 items generated for the iCHeW scale were revised following feedback from a reference group. These 35 items were then appraised by an expert panel, yielding 27 items for psychometric testing. Using exploratory factor analysis, a five-factor solution was extracted, which corresponded to the IM domains, with the deletion of two items. Overall, Cronbach's alpha of the iCHeW scale was 0.95, with the following values for each subscale: (i) attitudes, 0.93; (ii) behavioural constraints, 0.83; (iii) perceived norms, 0.93; (iv) self-efficacy, 0.94; and (v) behavioural intention, 0.95.

CONCLUSIONS

The iCHeW scale is valid and reliable for assessing dental staff's intention to provide routine growth assessments to children and demonstrates potential for use with non-dental staff.

Pain and suicide: what should we tell our trainees?

Chronic pain is a debilitating medical condition affecting a significant percentage of the population worldwide. Considerable evidence suggests that pain is an independent risk factor for suicide and inadequately managing pain has been identified as a risk for suicidal behaviour. Additionally, medications used to treat pain may also contribute to suicidal behaviour. Extensive research on pain highlights deficiencies in the clinical management on pain with more gaps in care when patients have pain in combination with mental illness and suicidal behaviour. Providing trainees additional knowledge and equipping them with relevant tools to screen and manage chronic pain efficiently is a potential strategy to mitigate suicide risk. Also, trainees need to be educated on how to screen for suicidality in individuals with pain and apply suicide prevention interventions. This paper will emphasise the necessity to improve education about pain, its close relationship with suicide and effective suicide screening as well as management strategies for medical providers. With additional research, it is the hope that novel treatment modalities will be developed to treat pain to improve the quality of life of individuals suffering from this condition and to decrease suicide risk in this patient population.

Sociodemographic trends in a UK temporomandibular joint disorder clinic

Introduction Temporomandibular disorders (TMD) are a common source of facial pain, resulting from an interaction of biopsychosocial factors. However, social risk factors related to TMD have been researched very little, particularly in patients attending a tertiary care service.Aims To review sociodemographic trends among patients referred to a UK tertiary TMD clinic for specialist management. To provide an insight into the sociodemographic risk factors associated with TMD in patients referred for specialist input and to discuss the surrounding literature.Methods Retrospective review of notes of patients referred to a UK tertiary TMD clinic. Trends in areas of deprivation from which patients came from were quantified into deciles using the English Multiple Indices of Deprivation.Results The mean age of patients was 41.1 years, with women being overrepresented compared to men. Most patients were referred by their general dental practitioner, although a variety of secondary care specialties also referred to this service. A disproportionate number of patients came from the highest decile of deprivation, a trend seen throughout the entire sample and in patients seen by dental professionals specifically. There was no apparent association between this and longer symptom duration.Conclusion Women and those from areas with the highest levels of deprivation were overrepresented in this tertiary clinic setting. Dentists should maintain an awareness of the risk factors for TMD development as well as those which may complicate its management in cases requiring specialist input.

International Association for the Study of Pain Presidential Task Force on Cannabis and Cannabinoid Analgesia: research agenda on the use of cannabinoids, cannabis, and cannabis-based medicines for pain management

ABSTRACT

The President of the International Association for the Study of Pain established a task force on cannabis and cannabinoid analgesia to systematically examine the evidence on (1) analgesic pharmacology of cannabinoids and preclinical evidence on their efficacy in animal models of injury-related or pathological persistent pain; (2) the clinical efficacy of cannabis, cannabinoids, and cannabis-based medicines for pain; (3) harms related to long-term use of cannabinoids; as well as (4) societal issues and policy implications related to the use of these compounds for pain management. Here, we summarize key knowledge gaps identified in the task force outputs and propose a research agenda for generating high-quality evidence on the topic. The systematic assessment of preclinical and clinical literature identified gaps in rigor of study design and reporting across the translational spectrum. We provide recommendations to improve the quality, rigor, transparency, and reproducibility of preclinical and clinical research on cannabis and cannabinoids for pain, as well as for the conduct of systematic reviews on the topic. Gaps related to comprehensive understanding of the endocannabinoid system and cannabinoid pharmacology, including pharmacokinetics and drug formulation aspects, are discussed. We outline key areas where high-quality clinical trials with cannabinoids are needed. Remaining important questions about long-term and short-term safety of cannabis and cannabinoids are emphasized. Finally, regulatory, societal, and policy challenges associated with medicinal and nonmedicinal use of cannabis are highlighted, with recommendations for improving patient safety and reducing societal harms in the context of pain management.

Participants' unspoken thoughts and feelings negatively influence the therapeutic alliance; a qualitative study in a multidisciplinary pain rehabilitation setting

PURPOSE

This study aimed to explore factors that influence participants' perceptions of the therapeutic alliance with healthcare professionals; their participation in the alliance; and their commitment to treatment in a multidisciplinary pain rehabilitation setting.

MATERIALS AND METHODS

A qualitative research-design was used and 26 participants in a multidisciplinary pain rehabilitation program were interviewed in-depth.

RESULTS

Initially, participants reported to be satisfied with their healthcare professionals. After deeper reflection on the therapeutic alliance, several unspoken thoughts and feelings and relational ruptures emerged. Almost all participants mentioned a history of disappointing and fragmented healthcare, and they reported on how this affected their cognitions, perceptions, and beliefs about the current program. Participants felt insufficiently empowered to voice their concerns and regularly chose to avoid confrontation by not discussing their feelings. They felt a lack of ownership of their problems and did not experience the program as person-centered.

CONCLUSIONS

Several factors were found that negatively influence the quality of therapeutic alliance (agreement on bond) and efficacy of the treatment plan (agreement on goals and tasks). To improve outcomes of pain rehabilitation, healthcare professionals should systematically take into account the perceptions and needs of participants, and focus more on personalized collaboration throughout the program offered.Implications for rehabilitationDifferences in perceptions and experiences of pain, together with differences in beliefs about the causes of pain, negatively influence the therapeutic alliance.When participants and healthcare professionals operate from different paradigms, it is important that they negotiate these differences.From the perspective of participants, a clear-cut organization of healthcare that encourages collaboration is required.It is important to focus on personalized collaboration from the start and during treatment, and to recognize and discuss disagreement on diagnosis and treatment plans.During this collaboration, healthcare professionals should systematically take into account the perceptions and needs of the participants.