A critical review of the role of manual therapy in the treatment of individuals with low back pain

The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.

A Prospective Qualitative Inquiry of Patient Experiences of Cognitive Functional Therapy for Chronic Low Back Pain During the RESTORE Trial

Cognitive functional therapy (CFT) is a person-centered biopsychosocial physiotherapy intervention that has recently demonstrated large, durable effects in reducing pain and disability in people with chronic low back pain (CLBP). However, exploration of the treatment process from the patients' perspectives, including the process of gaining control and agency over CLBP, is relatively understudied in this patient population. This qualitative study explored the experiences of eight participants from the RESTORE trial through longitudinally following their experiences, including interviews during baseline, mid-treatment, end-treatment, and 12-month follow-up. Data were analyzed according to a narrative approach. Findings described the overarching narrative themes of "The Journey to Self-Management." Within this overarching narrative, four distinct narratives were identified, beginning with "Left High and Dry," capturing the experience of isolation and abandonment with CLBP before commencing CFT, and concluding with three narratives of the experience of CFT from the start of treatment through to the 12-month follow-up. These included "Plain, Smooth Sailing," describing a journey of relative ease and lack of obstacles; "Learning the Ropes and Gaining Sea Legs," capturing an iterative process of learning and negotiating setbacks; and "Sailing Through Headwinds," describing the experience of struggle to gain agency and control over CLBP through CFT. Clinicians treating individuals with CLBP can use these insights to more effectively facilitate self-management, and people living with CLBP may find resonance from the narrative themes to support their journeys.

"I wish I knew then what I know now" - pain science education concepts important for female persistent pelvic pain: a reflexive thematic analysis

ABSTRACT

Pain science education (PSE) provides people with an understanding of "how pain works" grounded in the biopsychosocial model of pain; it has been demonstrated to improve outcomes in musculoskeletal pain conditions. Preliminary evidence suggests PSE may be effective for female individuals with persistent pelvic pain, but how the content of PSE needs to be modified for this group remains to be determined. A reflexive thematic analysis of qualitative data was performed to identify PSE concepts that female individuals with persistent pelvic pain consider important and why. Twenty individual, semistructured interviews were conducted with adult females who had engaged with PSE and had self-identified as having "improved" pelvic pain. Most participants had been diagnosed with endometriosis (n = 16). Four themes were generated capturing PSE concepts considered important by female individuals with "improved" pelvic pain: (1) "A sensitised nervous system leads to overprotective pain" validated their pelvic pain as being real; (2) "Pain does not have to mean the body is damaged (although sometimes it does)" provided reassurance that pelvic pain does not mean their condition is worsening; (3) "How I think, feel, and 'see' my pain can make it worse" enabled participants to find optimal ways to manage their pain; and (4) "I can change my pain… slowly" provided hope that pelvic pain can improve and empowered them to pursue pain improvement as a viable goal. This study generated 4 PSE learning concepts that were important to female individuals with improved pelvic pain and may be incorporated into PSE curricula for female individuals with pelvic pain.

Designing a primary care pharmacist-led review for people treated with opioids for persistent pain: a multi-method qualitative study

BACKGROUND

Opioids are frequently prescribed for persistent non-cancer pain despite limited evidence of long-term effectiveness and risk of harm. Evidence-based interventions to address inappropriate opioid prescribing are lacking.

AIM

To explore perspectives of people living with persistent pain to understand barriers and facilitators in reducing opioids in the context of a pharmacist-led primary care review, and identify review components and features for optimal delivery.

DESIGN & SETTING

A multi-method qualitative study undertaken in the primary care setting in the UK.

METHOD

Adults with experience of persistent pain and taking opioids participated in semi-structured interviews (n = 15, 73% female) and an online discussion forum (n = 31). The Theoretical Domains Framework (TDF) provided a framework for data collection and thematic analysis, involving deductive analysis to TDF domains, inductive analysis within domains to generate sub-themes, and sub-theme comparison to form across-domain overarching themes. The behaviour change technique taxonomy (v1) and motivational behaviour change technique classification system were used to systematically map themes to behaviour change techniques to identify potential review components and delivery features.

RESULTS

Thirty-two facilitator and barrier sub-themes for patients reducing opioids were identified across 13 TDF domains. These combined into the following six overarching themes: learning to live with pain; opioid reduction expectations; assuming a medical model; pharmacist-delivered reviews; pharmacist-patient relationship; and patient engagement. Sub-themes mapped to 21 unique behaviour change techniques, yielding 17 components and five delivery features for the proposed PROMPPT review.

CONCLUSION

This study generated theoretically informed evidence for design of a practice pharmacist-led PROMPPT review. Future research will test the feasibility and acceptability of the PROMPPT review and pharmacist training.

Healthcare professionals' knowledge, understanding and confidence to manage chronic pain after cancer treatment: A UK survey

INTRODUCTION

Healthcare professionals are vital in preparing people living with and beyond cancer about the risks of chronic pain after cancer treatment. To do so, healthcare professionals need to be knowledgeable and confident about chronic pain after cancer treatment, yet little is known about their understanding or confidence of this common long-term and late side effect of cancer treatment.

AIM

To identify healthcare professionals' knowledge and understanding of chronic pain after cancer treatment and consider how confident they are to inform, listen and signpost people living with and beyond cancer to appropriate information and support.

METHOD

A cross sectional online survey was distributed to healthcare professionals in the UK via cancer and primary care networks, cancer alliances and social media. The survey consisted of four domains: 1) knowledge and understanding, 2) information and support, 3) confidence and 4) barriers. Quantitative data were analysed with descriptive statistics and free text comments were analysed using qualitative content analysis.

RESULTS

Healthcare professionals reported limited knowledge and understanding of chronic pain after cancer treatment. Healthcare professionals lacked confidence to talk to people about chronic pain after cancer treatment and viewed their lack of knowledge as a barrier. Additional barriers included 'Limited service provision', 'Conflict between services', 'Not my role' and 'Challenges in diagnosing chronic pain in cancer survivors'.

CONCLUSION

Chronic pain after cancer can be a significant issue for those living with and beyond cancer, yet healthcare professionals report limited knowledge of it or understanding of the impact. More education is needed to increase healthcare professionals' knowledge and confidence in chronic pain after cancer treatment.

An ecosystem of accepting life with chronic pain: A meta-ethnography

Background

Chronic pain is a highly prevalent long-term condition, experienced unequally, impacting both the individual living with pain, and wider society. 'Acceptance' of chronic pain is relevant to improved consultations in pain care, and navigating an approach towards evidence-based, long-term management and associated improvements in health. However, the concept proves difficult to measure, and primary qualitative studies of lived experiences show complexity related to our socio-cultural-political worlds, healthcare experiences, and difficulties with language and meaning. We framed acceptance of chronic pain as socially constructed and aimed to conceptualise the lived experiences of acceptance of chronic pain in adults.

Methods

We conducted a systematic search and screening process, followed by qualitative, interpretive, literature synthesis using Meta-ethnography. We included qualitative studies using chronic pain as the primary condition, where the study included an aim to research the acceptance concept. We conducted each stage of the synthesis with co-researchers of differing disciplinary backgrounds, and with lived experiences of chronic pain.

Findings

We included 10 qualitative studies from Canada, Sweden, The Netherlands, Ireland, UK, Australia and New Zealand. Our 'lines of argument' include a fluid and continuous journey with fluctuating states of acceptance; language and meaning of acceptance and chronic pain, a challenge to identity in a capitalist, ableist society and the limits to individualism; a caring, supportive and coherent system. The conceptual framework of the meta-ethnography is represented by a rosebush with interconnected branches, holding both roses and thorns, such is the nature of accepting life with chronic pain.

Conclusion

Our findings broaden conceptualisation of 'acceptance of chronic pain' beyond an individual factor, to a fluid and continuous journey, interconnected with our socio-cultural-political worlds; an ecosystem.

Meaningful contributions of rehabilitation for people with persistent pain; a reflexive thematic analysis

PURPOSE

This study aims to explore the meaningful contributions of rehabilitation for participants living with persistent pain.

MATERIALS AND METHODS

A phenomenological methodology was used. Thirteen purposefully selected participants, who self-identified as substantially improved from persistent pain due to rehabilitation, were interviewed in-depth. Data were analyzed using reflexive thematic analyses.

RESULTS

Participants included three men and ten women, age ranging from 22-69 years, pain duration was 2-30 years. Seven interconnected themes were developed: 1) indication of negative pain and health care experiences, 2) supporting working alliance with healthcare professionals, 3) Pain Dialogue, 4) improved self-awareness and self-regulation, 5) different view on pain, 6) autonomy and personal growth and 7) hope and new perspective. Integration of these themes provided a framework for understanding meaningful contributions of rehabilitation from the participants' perspective.

CONCLUSIONS

The study identified seven interconnected themes enhancing meaningful contributions of rehabilitation for participants who have substantially improved from persistent pain. These findings provide a novel conceptual understanding of how rehabilitation can foster recovery. The themes strongly support person-centred care, an understanding of Pain Dialogue and personal growth through the lens of the lived experience. The quality of the therapeutic relationship is considered a central vehicle for improved health outcomes.

Relational vulnerability in motherhood-an existential perspective on pain and exhaustion among women

Introduction

Stress-related ill-health like pain and exhaustion are demanding public health problems in Europe. In Sweden, women are particularly at risk to develop stress-related ill-health during a period in life that coincides with child-rearing years. When entering motherhood, Swedish women's sick leave substantially increases. Yet, motherhood is rarely acknowledged in clinical encounters concerning pain and exhaustion although women suffer from these ailments more often than men. To incorporate motherhood as an existential dimension of health in the care of women living with pain and exhaustion might alleviate women's suffering. But knowledge on women's experiences of motherhood and health is scarce. Therefore, the aim of the study is to reach a deeper understanding of how women suffering from long-lasting pain and exhaustion experience their health in relation to motherhood.

Methods

Ricoeur's interpretation theory has been applied to analyze 27 phenomenological interviews with 14 mothers suffering from long-lasting pain and exhaustion.

Results

These women's experiences shed light on how closely motherhood is interwoven with the experience of their health and suffering: The women's suffering seems to be rooted in a relational vulnerability that has been uncovered during motherhood. Further, the women suffer from a burden of difficult life experiences and inner conflicts. Reconciliation with life is possible when women find an existential shelter, which offers ways to relate to their suffering making the own suffering more bearable.

Towards a better understanding of our patients. A qualitative study about how patients and their physiotherapists perceive the recovery of shoulder problems

OBJECTIVE

To investigate how people with shoulder problems and their physiotherapists perceive the recovery of shoulder problems.

METHOD

We performed a qualitative study using semi-structured interviews with patients and their physiotherapists. Nine pairs of patients and physiotherapists (n = 18) were recruited. The transcribed interviews were analyzed in a consecutive multistep iterative process using a conventional content analysis.

RESULTS

Analysis of the interviews resulted in three major themes: 'What do I expect from my recovery?', 'Am I recovering?' and 'When do I consider myself recovered?' The patients and physiotherapists talked similarly about the importance of and interdependency between these themes. Central to these three themes are the analysis of the cause of shoulder problems and the experience of uncertainty. Our analyses suggest that there are conceptual differences in how patients and physiotherapists formulate their expectations about recovery, observe the recovering process, and conceptualize when someone may be considered recovered. Different interpretations by the patients of the information provided by the physical therapists appeared to fuel these differences.

CONCLUSION

Our results show that the concept of recovery is defined by patients and physiotherapists in three distinct themes. Within these themes the patients and physiotherapists differ substantially in their conceptualization of the recovery.

IMPACT STATEMENT

This insight in the concept of recovery can help patients and physiotherapists better understand each other, enhance the alignment of ideas about the care process, and support making decisions together. Physiotherapists should be aware that patients might interpret their words, explanations, and expectations substantially different.

Holding space and sitting with emotions: the lived experiences of physiotherapists using psychological strategies in pain care

BACKGROUND

Persistent pain is the biggest global cause of years lived with disability. Physiotherapists working in pain care aim to take a holistic perspective helping persons to gain a multidimensional understanding of their condition and achieve meaningful goals despite their symptoms. In recent years there has been a paradigm shift in physiotherapeutic pain care toward a psychologically informed physiotherapy approach. Physiotherapists have incorporated principles of strategies such as: cognitive behavioral therapy (CBT); acceptance and commitment therapy (ACT); psychological flexibility; or mindfulness-based therapies in helping persons move forwards despite their pain.

OBJECTIVES

The purpose of this study was to explore the lived experience of physiotherapists using psychological strategies in pain care.

METHODS

Seven participants were purposefully recruited for this study and data was collected through semi-structured interviews. Interpretative phenomenological analysis (IPA) methods were used to analyze the data. Master themes were developed to help express the qualitative meanings of the lived experiences.

FINDINGS

Seven master themes were identified: 1) Trust; 2) Active listening; 3) Developing understanding; 4) Exploring the journey; 5) Making it meaningful; 6) Being held; and 7) Holding space and sitting with emotions. All themes are interwoven and profoundly connected in the essence of a safe "space."

CONCLUSION

Participants described a journey toward holding space and sitting with emotions. All themes were interwoven and profoundly connected in the essence of a safe "space," where persons can voice their emotions in a non-judgmental environment. The themes may represent a pathway for the physiotherapist to facilitate a person on their journey of healing.

The "future" pain clinician: Competencies needed to provide psychologically informed care

BACKGROUND & OBJECTIVE

Psychologically informed care has been proposed to improve treatment outcomes for chronic pain and aligns with a person-centered approach. Yet implementation lags behind, and studies suggest that a lack of competency leads to poor results. It is unclear what training clinicians require to deliver this care. We examine how we might improve psychologically informed care guided by the needs of the patient and in congruence with the scientific literature with a particular focus on how competencies might be upgraded and implementation enhanced.

METHODS

We selectively review the literature for psychologically informed care for pain. The patient's view on what is needed is contrasted with the competencies necessary to meet these needs and how treatment should be evaluated.

RESULTS

Patient needs and corresponding competencies are delineated. A number of multi-professional skills and competencies are required to provide psychologically informed care. Single-subject methodologies can determine whether the care has the desired effect for the individual patient and facilitate effectiveness. We argue that becoming a competent "pain clinician" requires a new approach to education that transcends current professional boundaries.

CONCLUSIONS

Providing person-centered care guided by the needs of the patient and in line with the scientific literature shows great potential but requires multiple competencies. We propose that training the pain clinician of the future should focus on psychologically informed care and the competencies required to meet the individual's needs. Single-subject methodology allows for continual evaluation of this care.

Hidden family rules: perspective on a dysfunctional paternalistic system and the persistence of pain

This article explores how paternalistic control and power reside within the family system and how this may influence pain and its persistence. Drawing upon clinical case studies and existing literature, this exploration emphasises the role of paternal dysfunction in creating emotional memory images and delves into how this may influence the chronification and treatment resistance of pain (i.e., making pain "sticky"). We argue that a dysfunctional paternalistic family system, often characterised by authoritarian dynamics, emotional neglect, and abuse, results in adverse experiences and emotional memory images that create a fertile ground for the entrenchment and propagation of psychosomatic symptoms, including pain. Further, the paper emphasizes the potential intergenerational effects of such a scenario, where inherited "Family Rules" drive maladaptive coping mechanisms, which contribute to the persistence of psychological and physiological distress across generations. Understanding these complexities offers new perspectives on treating psychological disorders and their physiological ramifications. It also highlights the urgency of addressing dysfunctional familial dynamics in psychotherapeutic interventions for both immediate and long-term psychophysiological health outcomes.

How do people with chronic pain explain their use, or non-use, of pain-related healthcare services? A qualitative study of patient experiences

PURPOSE

This study aims to explore how people with chronic pain explain their use or non-use of pain-related healthcare services and their expectations of the healthcare provider, and explore how explanations and expectations vary between different levels of pain-related healthcare use.

MATERIALS AND METHODS

We conducted 20 individual semi-structured interviews with purposely sampled adults between 39 and 77 years of age with chronic pain. All interviews were audio-recorded, transcribed and analysed using a thematical template analysis approach.

RESULTS

Four key drivers for pain-related healthcare use were identified: (1) the healthcare system facilitates clinical pathways, (2) appraisal of pain-related healthcare initiatives influences future use, (3) autonomy, beliefs and values determine healthcare behaviour, and (4) recommendations from others impact healthcare behaviour. Comparing explanations across different pain-related healthcare user groups (high, medium and low) showed that perceived needs, beliefs and values, and appraisal of previous healthcare experiences differed between these groups.

CONCLUSIONS

Beliefs, pain characteristics, recommendations, and the search for a diagnostic label, often initiate pain-related healthcare use. Healthcare is modified by two interconnected systems: (1) perceived needs, beliefs and values and (2) previous healthcare experiences. Differences related to these systems could explain some of the variance in pain-related healthcare use.Implications for RehabilitationDifferent use of pain-related healthcare services for people with chronic pain could be related to differences in perceived needs, beliefs and values and appraisal of previous healthcare.It may be helpful to explore the perceived needs and beliefs of those seeking healthcare due to chronic pain.Previous healthcare experiences may impact and should be explored.

Understanding the lived experience of chronic pain: A systematic review and synthesis of qualitative evidence syntheses

Background

Although multiple measures of the causes and consequences of chronic non-cancer pain (CNCP) are available and can inform pain management, no quantitative summary of these measures can describe the meaning of pain for a patient. The lived experience of pain tends to be a blind spot in pain management. This study aimed to: (1) integrate qualitative research investigating the lived experience of a range of CNCP conditions; (2) establish common qualitative themes in CNCP experience; and (3) evaluate the relevance of our results through a survey questionnaire based on these themes, administered across the United Kingdom.

Methods

Four bibliographic databases were searched from inception to February 2021 to identify Qualitative Evidence Syntheses (QES) that investigated the lived experience of CNCP and its impact on everyday life and activities. Themes and trends were derived by thematic qualitative analysis in collaboration with two patient and public involvement representatives who co-created twenty survey statements. The survey was developed for testing the QES themes for validity in people living with pain.

Results

The research team identified and screened 1323 titles, and considered 86 abstracts, including 20 in the final review. Eight themes were developed from the study findings: (1) my pain gives rise to negative emotions; (2) changes to my life and to myself; (3) adapting to my new normal; (4) effects of my pain management strategies; (5) hiding and showing my pain; (6) medically explaining my pain; (7) relationships to those around me; and (8) working while in pain. Each theme gave rise to one or two survey questions. The survey was shared with members of the UK pain community over a 2-week period in November 2021, and was completed by 1219 people, largely confirming the above themes.

Conclusion/Implications

This study provides a validated summary of the lived experience of CNCP. It highlights the adverse nature, complications, and consequences of living with CNCP in the UK and the multiple shortcomings in the ways in which pain is addressed by others in the UK. Our findings are consistent with published meta-ethnographies on chronic non-malignant musculoskeletal pain and chronic low-back pain. Despite the underrepresentation of qualitative research in the pain literature compared to quantitative approaches, for understanding the complexity of the lived experience of pain, qualitative research is an essential tool.

Experiences of diagnosis and treatment for upper limb Complex Regional Pain Syndrome: a qualitative analysis

INTRODUCTION

Complex Regional Pain Syndrome (CRPS) most frequently affects the upper limb, with high associated disability. Delays to diagnosis and appropriate treatment can adversely impact prognosis and quality of life, but little is known about the healthcare experiences of people with CRPS. This study aimed to explore lived experiences of diagnosis and treatment for people with upper limb CRPS.

METHODS

Participants were recruited through online support groups and multiple public and private healthcare settings in the Greater Wellington Region, New Zealand. Semi-structured interviews were conducted with participants who had experienced upper limb CRPS for more than three months and less than three years. Interviews were transcribed verbatim and analysed using reflexive thematic analysis.

RESULTS

Thirteen participants (11 female, 2 male) aged between 43 and 68 years were interviewed. Duration of CRPS ranged from 7 months to 2.5 years. Five themes were identified. Participants initially engaged in healthcare out of a desire to return to being the person they were before having CRPS. Three interacting experiences epitomised the overall healthcare experience: (1) not knowing what is going on, (2) not being taken seriously, and (3) healthcare as adding another layer of load. Meanwhile, participants used multiple approaches in an attempt to not let CRPS stop them from continuing to live their lives.

CONCLUSIONS

Participants in this study felt that credible information, validation, and simplification from healthcare providers and systems would support their process of navigating towards a meaningful life and self-concept in the presence of CRPS.

What matters to people with chronic musculoskeletal pain consulting general practice? Comparing research priorities across different sectors

OBJECTIVES

Chronic musculoskeletal pain (CMP) is a common condition, often consulted in general practice. Our previous study identified research priorities among people with CMP using a broad recruitment strategy. It is unclear whether these research priorities reflect specific settings, including the population in general practice. Potential dissimilarities may have important implications for future research. Therefore, the study aims to explore potential differences between the previously established research priorities compared to priorities of people with CMP consulting general practice.

METHODS

Eighty-eight people living with CMP (51 females/37 males) from four regions of Denmark were recruited when they consulted their general practitioner. Participants were presented to an online survey and asked to prioritise predefined research themes (n=14) and research questions (n=38). The prioritisations were summarised into a Top-10 research priorities and compared the Top-10 from our previous study.

RESULTS

Treatment (n=57), diagnosis (n=46), cross-sectoral management (n=39) and influence on daily life (n=39) were the most selected research themes. The most prioritised research questions regarded the effectiveness of treatments and cross-sectoral management, improving diagnostic approaches and how pain affects the individuals' mental state. Four out of ten research questions aligned with our previous Top-10.

CONCLUSIONS

Our study identified several differences in research priorities between people living with CMP from the general population and from general practice. These findings highlight the needs for investigating how different settings influence research prioritisation. This adds important knowledge for researchers and policymakers focusing on future research within the management of CMP.

Incorporating personal narratives in positive psychology interventions to manage chronic pain

In this perspective paper, we argue for incorporating personal narratives in positive psychology interventions for chronic pain. Narratives refer to the telling and retelling of events. Narratives detail accounts of events and provide rich, in-depth information on human interactions, relationships, and perspectives. As such, narratives have been used to understand people's experiences with pain and pain coping mechanisms-as well as to facilitate therapeutic outcomes. Furthermore, narrative research has shown that narration can help restore and promote relief, calm, hope, self-awareness, and self-understanding in chronic pain sufferers. Positive psychology interventions have been successful in improving the lives of people living with chronic pain, but these psychology interventions do not typically incorporate personal narratives. Still, narrative, and positive psychology scholarship foci overlap, as both aim to enhance people's quality of life, happiness, and well-being, and to promote the understanding of psychosocial strengths and resources. In this article, we provide a rationale for incorporating personal narratives as an agentic form of positive psychology intervention. To that aim, we outline areas of convergence between positive psychology and narrative research and show how combining positive psychology exercises and narration can have additive benefits for pain sufferers. We also show how integrating narration in positive psychology intervention research can have advantages for healthcare research and policy.

'I think it affects every aspect of my life, really': Cancer survivors' experience of living with chronic pain after curative cancer treatment in England, UK

AIM

To explore cancer survivors' experiences of living with chronic pain after curative cancer treatment in England, UK.

METHODS

A qualitative study using telephone interviews with adult cancer survivors experiencing chronic pain after curative cancer treatment. Interview data was analysed using a reflexive thematic approach [1-3].

FINDINGS

Nineteen participants: 14 female, 5 male, mean age 62.4 years, 1.5-48 years since cancer diagnosis, eight tumour groups represented. Six participants (31.6%) developed chronic pain more than ten years after completing cancer treatment (range 0-25 years). Five themes were generated which highlighted the experience of chronic pain after cancer treatment for cancer survivors: 1) 'Hear me… believe me…. Please'. Survivors felt that they had not been listened to when they tried to talk about their chronic pain after cancer treatment, nor at times, believed. 2) 'Expectation versus reality'. Survivors had anticipated returning to pre cancer quality of life yet living in chronic pain prevented them from doing so. 3) 'They don't understand…. We don't understand'. Cancer survivors did not feel informed or prepared for the risk or reality of chronic pain after cancer treatment and this compounded the difficulties of coping with and managing their pain. They felt health care professionals lacked knowledge and understanding of chronic pain after cancer. 4) 'Negotiating the maze'. Cancer survivors encountered unclear and limited pathways for support, often bouncing from one support team to another. Identifying and accessing services was a challenge, and the responsibility of this was often left to the survivor. 5) 'Validate my pain, validate me'. Palpable relief and benefit was felt when health care professionals diagnosed and acknowledged their chronic pain after cancer treatment.

CONCLUSIONS

Cancer survivors can feel ill prepared for the risk of chronic pain after cancer treatment and can experience challenges accessing support from healthcare professionals and clinical services.

'I Will Fight for People to Not Have the Experience I've Had': A Thematic Analysis of the Experiences and Perspectives of Chronic Pain Lived Experience Advocates

Navigating the healthcare system with chronic pain, alongside navigating the experience of the chronic pain itself, is recognised to be highly challenging. Frequently available interventions do not fully meet the needs of people with chronic pain. This study aimed to explore the perspectives of people who have been through these experiences and now support and campaign for improved approaches to chronic pain management. Semi-structured interviews of 10 participants who independently support others through some form of chronic pain advocacy or support were conducted online. Data were digitally recorded, transcribed, and analysed using reflexive thematic analysis, through a critical realist and constructivist lens. Data were interpreted to represent a journey into chronic pain advocacy, represented by three overarching themes. Advocacy as healing incorporates sub-themes of pain trauma, gaining knowledge, and using my experience for good. Unequal partnership includes respect and unmet needs from institutions. The final theme, evolution, relates to two sub-themes of pushing boundaries and personal growth. Participants talked about the dual benefit of their contribution to pain advocacy, both in terms of helping others and also their own personal benefit. Overall findings indicated that pain advocacy can take multiple and various forms. Commonly, our participants who took on the role of pain advocacy were motivated by their own early difficult experiences, both navigating their pain and healthcare systems, and by a wish for others to not have similar difficult experiences. Having taken on the role, despite its challenges, rewards can include recognition and personal growth.

Perspective on salutogenic approaches to persistent pain with a focus on mindfulness interventions

In this article, we provide a unique perspective on the use of mindfulness interventions in a whole health framework embedded within the theory of salutogenesis and the concept of painogenic environments. We argue that mindfulness is a valuable tool to bridge exploration of inner experiences of bodily pain with socio-ecological influences on thoughts and emotions. We outline research from neuroimaging studies that mindfulness techniques mediate neural processing and neuroplastic changes that alleviate pain and related symptoms. We also review evidence examining behavioural changes associated with mindfulness meditation providing evidence that it promotes self-regulatory activity, including the regulation and control of emotion and catalysation of health behaviour changes; both of which are important in chronic illness. Our viewpoint is that mindfulness could be a core element of salutogenic approaches to promote health and well-being for people living with pain because it rebuilds a fractured sense of cohesion. Mindfulness empowers people in pain to embrace their existence; shifting the focus away from pain and giving their lives meaning. We propose that integrating mindfulness into activities of daily living and individual or community-based activities will promote living well in the modern world, with or without pain; thus, promoting individual potential for fulfilment. Future research should consider the effects of mindfulness on people with pain in real-life settings, considering social, environmental, and economic factors using a broader set of outcomes, including self-efficacy, sense of coherence and quality of life.

Pediatrician Explanations of Pediatric Pain in Clinical Settings: A Delicate Craft

Explaining chronic pain to children and families can be challenging, particularly in the absence of an obvious physiologically identifiable cause for the child's pain. In addition to medical intervention, children and families may expect clinicians to provide clarity around the cause of pain. Such explanations are often provided by clinicians who have not received formal pain training. This qualitative study sought to explore the following question: What do pediatricians consider to be important when providing pain explanations to children and their parents? Using semistructured interview methods, 16 UK pediatricians were interviewed regarding their perceptions of explaining chronic pain to children and families in clinical settings. Data were analyzed using inductive reflexive thematic analysis. Analyses generated 3 themes: 1) timing of the explanation, 2) casting a wider net, and 3) tailoring of the narrative. Study findings demonstrated the need for pediatricians to skilfully interpret where children and families are in their pain journey and deliver an appropriate and adaptable explanation relating to individual needs. Analyses identified the importance of providing a pain explanation that could be repeated and understood by others outside the consultation room, to enable children and families to accept the explanation. PERSPECTIVE: Study findings identify the importance of language in addition to familial and broader factors that may influence the provision and adoption of chronic pain explanations provided by pediatricians to children and families. Improving pain explanation provision may influence treatment engagement for children and their parents, subsequently impacting pain related outcomes.

What is known and what is still unknown within chronic musculoskeletal pain? A systematic evidence and gap map

ABSTRACT

Evidence and gap maps (EGMs) can be used to identify gaps within specific research areas and help guide future research agendas and directions. Currently, there are no EGMs within the broad domain of chronic musculoskeletal (MSK) pain in adults. The aim of this study was to create a contemporary EGM of interventions and outcomes used for research investigating chronic MSK pain. This EGM was based on systematic reviews of interventions published in scientific journals within the past 20 years. Embase, PubMed, the Cochrane Library, and PsycINFO were used to retrieve studies for inclusion. The quality of the included reviews was assessed using AMSTAR-II. Interventions were categorised as either physical, psychological, pharmacological, education/advice, interdisciplinary, or others. Outcomes were categorised using the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommendations. Of 4299 systematic reviews, 457 were included. Of these, 50% were rated critically low quality, 25% low quality, 10% moderate quality, and 15% rated high quality. Physical interventions (eg, exercise therapy) and education were the most common interventions reported in 80% and 20% of the studies, respectively. Pain (97%) and physical functioning (87%) were the most reported outcomes in the systematic reviews. Few systematic reviews used interdisciplinary interventions (3%) and economic-related outcomes (2%). This contemporary EGM revealed a low proportion of high-quality evidence within chronic MSK pain. This EGM clearly outlines the lack of high-quality research and the need for increased focus on interventions encompassing the entire biopsychosocial perspective.

Development of a booster intervention for graded sensorimotor retraining (RESOLVE) in people with persistent low back pain: A nested, randomised, feasibility trial

INTRODUCTION

Low back pain contributes to an increasing global health burden exacerbated by unsustained improvements from current treatments. There is a need to develop, and test interventions to maintain initial improvements from low back pain treatments. One option is to implement a booster intervention. This study aimed to develop and test the feasibility of implementing a booster intervention delivered remotely to supplement the benefits from a complex intervention for chronic low back pain.

METHOD

This study was nested in the RESOLVE trial. The booster intervention was developed by an expert group, including a clinical psychologist, exercise physiologist and physiotherapists, and based on a motivational interviewing framework. We developed a conversational flow chart to support the clinician to guide participants towards achieving their pre-specified personal goals and future low back pain self-management. Participants with chronic low back pain who were aged over 18 years and fluent in English were recruited. The booster intervention was delivered in one session, remotely, by telephone. The intervention was considered feasible if: participants were able to be contacted or <3 contacts were necessary to arrange the booster session; there were sufficient willing participants (<15% of sample unwilling to participate); and participants and research clinicians reported a perceived benefit of >7/10.

RESULTS

Fifty participants with chronic non-specific low back pain were recruited to test the feasibility of implementing the booster intervention. Less than three contact attempts were necessary to arrange the booster session, only one participant declined to participate. Participants perceived the session to be beneficial; on a 0 to 10 scale of perceived benefit, the average score recorded was 8.3 (SD 2.0). Clinicians also reported a moderate perceived benefit to the participant; the average score recorded by clinicians was 6.3 (SD 1.6).

CONCLUSION

We developed a step by step, simple booster intervention that was perceived to be beneficial to participants with chronic low back pain. The booster can feasibly be delivered remotely following a complex intervention.

Pain through the perspective of art and creativity: insights from the Unmasking Pain project

People struggle to tell their story of living with pain and when they do it is articulated in a way that may not be understood, heard or taken seriously. Unmasking Pain is an artist-led project that explored creative approaches to tell stories of life with pain. The project was led by a dance theatre company that specialises in storytelling and emotional experiences for players and audiences. The project involved artists and people living with ongoing pain co-creating activities and environments to curiously explore "oneself", through imagination and creative expression. This article discusses insights and perspectives emerging from the project. The project revealed the power of art to make-sense of oneself with or without pain, and how art facilitates expression of complex inner experience and personal stories. People described Unmasking Pain as "explorative joy despite pain", and "a new set of rules" that contrasts with those experienced during clinical encounters. We discuss how art has the potential to improve clinical encounters and promote health and well-being, and whether artist-led activities are an intervention, therapy, or something else. Pain rehabilitation specialists from the project described Unmasking Pain as "freeing-up thinking", allowing conceptual thought beyond the biopsychosocial model of pain. We conclude that art has the potential to shift people living with pain from "I can't do, I am not willing to do it" to "Perhaps I can, I'll give it a go, I enjoyed".

Understanding pain in modern society: insights from attitudes to pain in the Medieval Period

Historical records provide knowledge about the way people lived in the past. Our perspective is that historical analyses of the Medieval Period provide insights to inform a fuller understanding of pain in the present era. In this article, we appraise critiques of the writings of people living with pain during the mid (high) to late Medieval Period (c. 1,000-1,500 AD) to gain insights into the nature, attitudes, lived experience, and sense-making of pain. In the Medieval Period, pain was understood in terms of Galen's four humours and the Church's doctrine of pain as a "divine gift", "punishment for sin" and/or "sacrificial offering". Many treatments for pain were precursors of those used in modern time and society considered pain to be a "shared experience". We argue that sharing personal stories of life is a fundamental human attribute to foster social cohesion, and that nowadays sharing personal stories about pain is difficult during biomedically-focussed time-constrained clinical consultations. Exploring pain through a medieval lens demonstrates the importance of sharing stories of living with pain that are flexible in meaning, so that people can connect with a sense of self and their social world. We advocate a role for community-centred approaches to support people in the creation and sharing of their personal pain stories. Contributions from non-biomedical disciplines, such as history and the arts, can inform a fuller understanding of pain and its prevention and management.

Multiple-Case Study Exploration of an Occupational Perspective in a Persistent Pain Clinic

There is growing interest in an occupational perspective when working with people experiencing chronic pain. The Activity Card Sort Australia (18-64) is a client-centered and occupation-centered tool that has not been explored with this population. The aim of this study was to explore the process and experience of completing the ACS-Aus (18-64) with people experiencing chronic pain. This observational multiple-case study included video and audio-recordings of three participants (one male, one female, one nonbinary) completing the ACS-Aus (18-64) and semi-structured interviews at 1-week follow-up. Findings The findings for the process included two themes: the interaction (understanding engagement, therapeutic relationship and rapport, motivational interviewing) and the card sort (storytelling and reminiscing, identifying gaps and possibilities, categorizing and grouping cards). Occupational narratives of participants were developed from the experience. The ACS-Aus (18-64) supported participants to re-engage with their occupational selves and imagine future occupational engagement. Longitudinal studies are required to explore outcomes.

Effectiveness of psychosomatic therapy for patients with persistent somatic symptoms: Results from the CORPUS randomised controlled trial in primary care

OBJECTIVE

To evaluate the effectiveness of psychosomatic therapy versus care as usual in primary care for patients with persistent somatic symptoms (PSS).

METHODS

We conducted a pragmatic, two-armed, randomised controlled trial among primary care patients with PSS in the Netherlands that included 39 general practices and 34 psychosomatic therapists. The intervention, psychosomatic therapy, consisted of 6-12 sessions delivered by specialised exercise- and physiotherapists.

PRIMARY OUTCOME MEASURE

patient's level of functioning.

SECONDARY OUTCOMES

severity of physical and psychosocial symptoms, health-related quality of life, health-related anxiety, illness behaviour and number of GP contacts.

RESULTS

Compared to usual care (n = 85), the intervention group (n = 84) showed no improvement in patient's level of functioning (mean difference - 0.50 [95% CI -1.10 to 0.10]; p = .10), and improvement in health-related anxiety (mean difference - 1.93 [95% CI -3.81 to -0.04]; p = .045), over 12 months. At 5-month follow-up, we found improvement in physical functioning, somatisation, and health-related anxiety. The 12-month follow-up revealed no therapy effects. Subgroup analyses showed an overall effect in patient's level of functioning for the group with moderate PSS (mean difference - 0.91 [95% CI -1.78 to -0.03]; p = .042). In the year after the end of therapy, the number of GP contacts did not differ significantly between the two groups.

CONCLUSION

We only found effects on some secondary outcome measures, and on our primary outcome measure especially in patients with moderate PSS, the psychosomatic therapy appears promising for further study.

TRIAL REGISTRATION

the trial is registered in the Netherlands Trial Registry, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR7356 under ID NTR7356.

Chronic Struggle: An Institutional Ethnography of Chronic Pain and Marginalization

There have been several recent calls to re-think chronic pain in response to the growing awareness of social inequities that impact the prevalence of chronic pain and its management. This in turn has resulted in new explorations of suffering as it relates to pain. While laudable, many of these clinically oriented accounts are abstract and often fail to offer a critical theoretical understanding of social and structural inequities. To truly rethink pain, we must also reconsider suffering, beginning in the everyday expert knowledge of people with chronic pain who can offer insights in relation to their bodies and also the organization of the social circumstances in which they live. Our team undertook a sociological approach known as institutional ethnography (IE) to explicate the work of people in managing lives beset by chronic pain and the inequities that stem from marginalization. In keeping with our critical paradigm, we describe participant accounts as situated, rather than lived, to de-emphasize the individual in favour of the social and relational. Through our analysis, we offer a new concept of chronic struggle to capture how pain, illness, economic deprivation, and suffering constitute a knot of experience that people living with chronic pain are obliged to simplify in order to fit existing logics of medicine. Our goal is to identify the social organization of chronic pain care which underpins experience in order to situate the social as political rather than medical or individual. PERSPECTIVE: This article explicates the health work of people living with chronic pain and marginalization, drawing on their situated experience. We offer the concept of chronic struggle as a conceptualization that allows us to bring into clear view the social organization of chronic pain in which the social is visible as political and structural rather than medical or individual.

'It Makes Me Feel Old': Understanding the Experience of Recovery From Ankle Fracture at 6 Months in People Aged 50 Years and Over

Ankle fracture is a common injury, and depending on injury severity, treatment may be a support boot, cast or surgery. Older people, particularly those with severe injuries who are asked to restrict weight bearing, struggle with early recovery. To elicit older peoples' experience of recovery 6 months after injury, we drew on a phenomenological approach using interviews. Findings revealed that getting on with life was a way of accepting what it feels like to 'be vulnerable', needing to 'be safe' while determinedly working hard to 'be myself'. Being vulnerable identified endurance of inactivity, loneliness and dependency in the non-weight bearing period of recovery, followed by a struggle to weight bear while lacking confidence and being fearful of falling and causing further damage. Being safe conveyed fragility where sensations, pain and stiffness acted as bodily reminders of injury. Lack of function and awareness of danger led to carefulness where planning or curtailing of activities ensured their safety. Being myself showed a determination to push away from a disrupted self-identify of being older or disabled while being challenged by the continuous process of learning to be more mobile. A lack of readiness for old age created a drive to age well. Despite loss of ability, participants hoped to regain their pre-injury way of living. This study challenges practice that disregards the hard work required to recover from ankle fracture. As comorbidity increases with age, failure to consider this aspect may contribute to frailty in this group of older people.

The Daily Grind of Living With Chronic Pain: An Applied Hermeneutic Exploration

The purpose of this research is to explore the philosophy regarding understanding the complex experience of living with chronic pain. As well, this article addresses a person's suffering as an evolving process of learning to not only manage pain but to learn how to live well through exploring their suffering narrative. A hermeneutical interpretive approach was used to engage participants in this research and to offer a philosophical reinterpretation of living with chronic pain from a humanistic and tacit perspective. This work is offered to invite and extend our discussions about the complexity of living with chronic pain. It can also be understood as a process of rewriting oneself from a lived chaotic state of pain into a new affective historical consciousness. This transition from acute to chronic pain explored through a philosophical context can provide insight into the ways in which patients learn to live well with their condition.

From protection to non-protection: A mixed methods study investigating movement, posture and recovery from disabling low back pain

BACKGROUND

Movement and posture are commonly believed to relate to low back pain (LBP). Yet, we know little about how people make sense of the relationship between their LBP, movement and posture, particularly after recovery. We aimed to qualitatively explore this understanding, how it changes and how it relates to quantitative changes.

METHODS

A mixed method study in the context of an existing single-case design involving 12 people with disabling non-specific LBP. Interviews were conducted before and after a 12-week physiotherapy-led Cognitive Functional Therapy intervention, and qualitative findings from these were integrated with individualized, quantitative measures of movement, posture, psychological factors, pain and activity limitation.

RESULTS

Strong beliefs about movement and posture were identified during the baseline interviews. Lived experiences of tension and stiffness characterized the embodiment of 'nonconscious protection', while healthcare and societal messages prompted pain-related fear and 'conscious protection'. Through varied journeys, most participants reported improvements over time with less protective movement and postural strategies. For some, being less protective required focused attention ('conscious non-protection'), but most returned to automatic, normal and fearless patterns ('nonconscious non-protection'), forgetting about their LBP. One participant reported no meaningful shift, remaining protective. Greater spinal range, faster movement, more relaxed postures and less back muscle EMG accompanied positive changes in self-report factors.

CONCLUSION

The findings offer a framework for understanding how people make sense of movement and posture during the process of recovery from persistent, disabling non-specific LBP. This involved a re-conceptualisation of movement and posture, from threatening, to therapeutic.

SIGNIFICANCE

Findings from qualitative interviews before and after a Cognitive Functional Therapy intervention in 12 people with disabling low back pain highlighted an individualized recovery journey from conscious and nonconscious protection to conscious non-protection for some, and nonconscious non-protection for many. Pre and post-quantitative measures of movement, posture, psychological factors, pain and activity limitation integrated well with the qualitative findings. The findings suggest movement and posture may form part of a multidimensional pain schema.

"Listen to me, learn from me": a priority setting partnership for shaping interdisciplinary pain training to strengthen chronic pain care

ABSTRACT

What are the care-seeking priorities of people living with chronic pain and carers and how can these shape interdisciplinary workforce training to improve high-value pain care? Phase 1: Australian people living with chronic pain (n = 206; 90% female) and carers (n = 10; 40% female) described their pain care priorities (eDelphi, round 1). A coding framework was inductively derived from 842 pain care priorities (9 categories, 52 priorities), including validation; communication; multidisciplinary approaches; holistic care; partnerships; practitioner knowledge; self-management; medicines; and diagnosis. Phase 2: In eDelphi round 2, panellists (n = 170; valid responses) rated the importance (1 = less important; 9 = more important) of the represented framework. In parallel, cross-discipline health professionals (n = 267; 75% female) rated the importance of these same priorities. Applying the RAND-UCLA method (panel medians: 1-3: "not important," 4-6: "equivocal," or 7-9: "important"), "important" items were retained where the panel median score was >7 with panel agreement ≥70%, with 44 items (84.6%) retained. Specific workforce training targets included the following: empathic validation; effective, respectful, safe communication; and ensuring genuine partnerships in coplanning personalised care. Panellists and health professionals agreed or strongly agreed (95.7% and 95.2%, respectively) that this framework meaningfully reflected the importance in care seeking for pain. More than 74% of health professionals were fairly or extremely confident in their ability to support care priorities for 6 of 9 categories (66.7%). Phase 3: An interdisciplinary panel (n = 5) mapped an existing foundation-level workforce training program against the framework, identifying gaps and training targets. Recommendations were determined for framework adoption to genuinely shape, from a partnership perspective, Australian interdisciplinary pain training.

Clinical encounters may not be responding to patients' search for meaning and control over non-specific chronic low back pain - an interpretative phenomenological analysis

PURPOSE

Considering the need to study the experiences of individuals with musculoskeletal problems in contexts that have not yet been investigated as well as the relevance of fostering a research agenda towards person-centred care, this study aimed to explore the experiences of non-specific chronic low back pain from the perspective of Portuguese individuals living with it.

MATERIAL AND METHODS

An interpretative phenomenological analysis was employed to explore the experiences of eight participants, who were recruited purposefully from two primary care centres and one clinic. Semi-structured one-to-one interviews were carried out, audio-recorded and transcribed verbatim.

RESULTS

Three themes were generated as interrelated parts of an extended account that explored the participants' meaning making of their experience: "Non-specific chronic low back pain as a disruptive experience"; "Searching for the meaning of non-specific chronic low back pain"; and, "Clinical encounters that perpetuate the lack of understanding about non-specific chronic low back pain."

CONCLUSIONS

This study offers insight into the Portuguese individuals' experiences of non-specific chronic low back pain. Particularly, it suggests that clinical encounters may not be aligned with patients' needs and expectations. These findings may help clinicians in transferring this knowledge to therapeutic approaches to individuals with similar experiences/contexts.IMPLICATIONS FOR REHABILITATIONPatients with NSCLBP need to understand their pain and to retain a sense of control over their lives.Encounters with health professionals may perpetuate the lack of understanding about pain and strategies to control it, as patients consider themselves unable to have an active role in the decision-making and are disempowered to deal with their pain.Health professionals should involve patients and promote the co-construction of an explanation that integrates both health professionals' knowledge and patients' narratives.There is a need to align both the patients' and health professionals' perspectives regarding health care in order to implement patient-centred and individually tailored treatment.

Portraying improvement in the management of chronic pain: A multi-modal longitudinal interpretative phenomenological analysis study

Chronic pain is a common, profoundly disabling and complex condition whose effects on identity may explain the distress experienced by those affected by it. This paper concerns a study exploring how the relationship with pain and sense of self evolved following participation in a pain management program (PMP). Participants were interviewed at three timepoints: before attending a PMP, 1 month after the PMP and 6 months after the PMP. To facilitate a deep experiential description of pain and its effects, interviews were guided by participant-generated drawings of pain and Self. Interviews and drawings were analyzed longitudinally using interpretative phenomenological analysis. The evolving experience of participants was outlined through different trajectory types. Here we describe the upward and positive trajectory of three female participants who were able to regain control over their lives. From a state of psychological stress where pain was represented as an aggressive and oppressive presence, participants' drawings, their narratives and indeed their lives, changed for the best. Pain stopped being the main feature, they were able to integrate it into their lives, make important changes and find a new balance. The results demonstrate the idiosyncratic nature of chronic pain and offer a nuanced account of its links to the lifeworld of those living with it.

Massage Therapy: A Person-Centred Approach to Chronic Pain

Person-centred care is an emergent movement within evidence-based medicine that has the potential to transform the health care system. Person-centred care is a collaborative approach in which health care professionals partner with patients to co-design and deliver personalized care with a focus on physical comfort, emotional well-being, and patient empowerment. By embracing person-centred care through two-way communication, patient engagement, and self-management strategies, massage therapists have the potential to further reduce suffering associated with chronic pain in our society.

Key Learning Statements for persistent pain education: an iterative analysis of consumer, clinician and researcher perspectives and development of public messaging

Over the last decade, the content, delivery and media of pain education have been adjusted in line with scientific discovery in pain and educational sciences, and in line with consumer perspectives. This paper describes a decade-long process of exploring consumer perspectives on pain science education concepts to inform clinician-derived educational updates (undertaken by the authors). Data were collected as part of a quality audit via a series of online surveys in which consent (non-specific) was obtained from consumers for their data to be used in published research. Consumers who presented for care for a persistent pain condition and were treated with a pain science education informed approach were invited to provide anonymous feedback about their current health status and pain journey experience 6, 12 or 18 months after initial assessment. Two-hundred eighteen consumers reported improvement in health status at follow-up. Results of the surveys from three cohorts of consumers that reported improvement were used to generate iterative versions of 'Key Learning Statements'. Early iteration of these Key Learning Statements was used to inform the development of Target Concepts and associated community-targeted pain education resources for use in public health and health professional workforce capacity building initiatives. Perspective This paper reflects an explicit interest in the insights of people who have been challenged by persistent pain and then recovered, to improve pain care. Identifying pain science concepts that consumers valued learning provided valuable information to inform resources for clinical interactions and community-targeted pain education campaigns.

Experiences of general practitioners explaining central sensitisation to patients with persistent physical symptoms: a focus group study

OBJECTIVE

Patients with persistent physical symptoms (PPS) require an explanation that is acceptable and comprehensible to them. Central sensitisation (CS) is an explanatory model for PPS and chronic pain that has been broadly applied in the context of pain medicine, but, until recently, not by general practitioners (GPs). We explored how GPs used the CS model in their consultations with patients with PPS.

DESIGN AND SETTING

A qualitative focus group study among GPs in the Netherlands.

METHODS

We instructed 33 GPs on how to explain CS to patients with PPS. After 0.5-1.5 years of using the CS model, 26 GPs participated in focus groups and interviews to report and discuss their experiences with CS as an explanatory model. Audio recordings were transcribed and two researchers independently analysed the data. The text was coded, codes were organised into themes and discussed until consensus was reached.

RESULTS

We identified eleven themes and grouped these into four categories.The GPs regarded the CS model as evidence-based, credible and giving recognition to the patient. On the other hand, they found explaining the CS model difficult and time-consuming. They tailored the CS model to their patients' needs and used multiple consultations to explain the model. The GPs reported that the use of the CS model seemed to improve the understanding and acceptance of the symptoms by the patients and seemed to reduce their need for more diagnostic tests. Furthermore, patients seemed to become more motivated to accept appropriate therapy.

CONCLUSION

GPs reported that they were able to provide explanations with the CS model to their patients with PPS. They regarded the model as evidence-based, credible and giving recognition to the patient, but explaining it difficult and time-consuming.

"I don't want to be a burden" A qualitative study of the beliefs of women with chronic low back pain in relation to their painful experience

BACKGROUND

Women's pain is still poorly understood. Moreover, maladaptive pain beliefs contribute to the disability associated with low back pain and play a key role in the transition from acute to chronic symptoms.

OBJECTIVES

To explore the beliefs of women with non-specific chronic low back pain in terms of nature of symptoms, fears associated with pain, expectations for recovery, family, social and work-related limitations, and perceived self-efficacy.

DESIGN AND METHODS

A qualitative study with an interpretative approach was undertaken. Face-to-face, semi-structured individual interviews were performed. Study participants were 10 women with non-specific chronic low back pain living in the Metropolitan Region of Chile. Thematic analysis was used to analyze the data. A deductive process was used to code the text and categorize the data.

RESULTS

Participants described maladaptive beliefs about pain, leading to fearful attitudes and low expectations for recovery. These beliefs seemed to perpetuate pain and limit engagement in daily tasks and meaningful activities. Some of these beliefs were associated with information provided by healthcare professions. Despite having maladaptive beliefs, women perceived themselves as self-effective.

CONCLUSION

Women with chronic low back pain described a range of different pain beliefs across a complex categorial structure. The contents of such structure may interfere with their decisions about therapeutic options. Their beliefs were often ungrounded in scientific principles, even if the information may have been provided by healthcare providers. Physical therapists would benefit from these findings to improve communication with their patients and assess the role of beliefs in decision-making.

A qualitative evidence synthesis using meta-ethnography to understand the experience of living with osteoarthritis pain

ABSTRACT

Osteoarthritis pain affects the lives of a large number of people around the world. Understanding other people's experience is integral to effective care and qualitative research can have an important part to pay in education and good clinical practice. We aimed to systematically search for, identify, and synthesise qualitative research exploring the experience of living with osteoarthritis in order to incorporate this knowledge into an educational resource. We comprehensively searched four bibliographic databases and used the methods of meta-ethnography to synthesise qualitative research findings. We screened 10123 titles, 548 abstracts and 139 full texts. We included findings from 118 reports (105 unique samples) of at least 2534 adults living with osteoarthritis around the world. We developed 7 themes from more than 600 findings: it is part of my life's tapestry; (yet) it is consuming me; it constrains my body and my occupations; I am becoming separated yet dependent; I accept, but I will not let it define me; (yet) this makes me feel less than the person I was. Our findings highlight the profound impact that osteoarthritis can have on people's lives and the struggle to hold onto a sense of self. They indicate that recognising these losses, and taking osteoarthritis seriously, is an integral part of effective healthcare. This finding may be transferable beyond this condition.

Perceived working mechanisms of psychosomatic therapy in patients with persistent somatic symptoms in primary care: a qualitative study

OBJECTIVES

To explore the perceived working mechanisms of psychosomatic therapy according to patients with persistent somatic symptoms (PSS) and their psychosomatic therapists.

DESIGN

Qualitative study using semistructured face-to-face interviews and focus groups. All interviews were audiorecorded, transcribed verbatim and analysed, by two researchers independently, based on the thematic analysis.

SETTING

Alongside a randomised controlled trial to establish the (cost-)effectiveness of psychosomatic therapy in patients with PSS in primary care, we conducted a process evaluation with a qualitative study. Patients were recruited in general practice in three regions in the Netherlands.

PARTICIPANTS

Interviews were conducted with twenty patients with PSS who received psychosomatic therapy and 25 psychosomatic therapists. In addition, two focus groups were conducted with six and seven psychosomatic therapists, respectively.

INTERVENTION

Psychosomatic therapy, delivered by specialised exercise and physical therapists, is a multimodal and tailored treatment based on the biopsychosocial model.

OUTCOME MEASURES

Experiences, opinions and views from patients' and therapists' perspective on psychosomatic therapy were identified.

RESULTS

A total of 37 interviews with patients, 25 interviews and two focus groups with therapists were analysed. Three main themes emerged from the data of the patients: (1) continuous alternation of psychosocial conversations and body-oriented exercises; (2) awareness of body-mind connection and (3) good relationship with therapist. Four main themes emerged from the data of the therapists (1) building rapport; (2) continuously searching for common ground; (3) making patients aware of the interaction between body and mind; and (4) continuous alternation between exploration and treatment.

CONCLUSION

According to patients as well as therapists, the continuous alternation of psychosocial conversations and body-oriented exercises to provide awareness of the interaction between body and mind are the perceived working mechanism of psychosomatic therapy. Therapeutic alliance and finding common ground between patient and therapist are prerequisites for the success of psychosomatic therapy.

TRIAL REGISTRATION NUMBER

NL7157 (NTR7356).

The Therapeutic Alliance May Yet Prove Effective

Letter to the Editor-in-Chief in response to JOSPT article "Education With Therapeutic Alliance Did Not Improve Symptoms in Patients With Chronic Low Back Pain and Low Risk of Poor Prognosis Compared to Education Without Therapeutic Alliance: A Randomized Controlled Trial" by Miyamoto et al.J Orthop Sports Phys Ther 2021;51(10):526-527. doi:10.2519/jospt.2021.0203.

Author Response to "The Therapeutic Alliance May Yet Prove Effective"

Author response to the JOSPT Letter to the Editor-in-Chief "The Therapeutic Alliance May Yet Prove Effective" J Orthop Sports Phys Ther 2021;51(10):527-528. doi:10.2519/jospt.2021.0203-R.

Exploring how people with chronic pain understand their pain: a qualitative study

OBJECTIVES

A fundamental principle of pain management is educating patients on their pain using current neuroscience. However, current pain neurophysiology education (PNE) interventions show variable success in improving pain outcomes, and may be difficult to integrate with existing understanding of pain. This study aimed to investigate how people with chronic pain understand their pain, using qualitative exploration of their conceptualisations of pain, and how this understanding accommodated, or resisted, the messages of PNE.

METHODS

Twelve UK adults with chronic pain were recruited through advertisements on online pain networks. Semi-structured interviews were conducted remotely, with responses elicited using the Grid Elaboration Method (GEM) and then a PNE article. Participants' grid elaborations and responses to PNE were analysed using thematic analysis (TA).

RESULTS

Three main themes were extracted from participants' grid elaborations: communicating pain, explaining pain and living with pain. These themes incorporated varied, inconsistent sub-themes: of pain as simultaneously experiential and conceptual; in the body and in the mind; diagnosable and inexplicable; manageable and insuperable. Generalised, meta-level agreement was identified in participants' PNE responses, but with doubts about its practical value.

CONCLUSIONS

This study shows that people understand pain through inconsistent experiential models that may resist attempts at conceptual integration. Participants' elaborations showed diverse and dissonant conceptualisations, with experiential themes of restricted living; assault on the self; pursuit of understanding pain and abandonment of that pursuit. Responses, although unexpectedly compatible with PNE, suggested that PNE was perceived as intellectually engaging but practically inadequate. Experiential disconfirmation may be required for behavioural change inhibited by embedded fears and aversive experiences.

ETHICAL COMMITTEE NUMBER

UCL REC# 17833/003.