What do patients value learning about pain? A mixed-methods survey on the relevance of target concepts after pain science education

Perceived factors influencing the success of pain neuroscience education in chronic musculoskeletal pain: a meta-synthesis of qualitative studies

PURPOSE

We aimed to identify the factors influencing the success of Pain Neuroscience Education (PNE) in chronic musculoskeletal (MSK) pain from the perspective of those experiencing PNE first-hand.

MATERIALS AND METHODS

We conducted a meta-synthesis of qualitative studies. Articles were found on MEDLINE via Pubmed, EMBASE, Cochrane Library, CINHAL, and PsycINFO up to April 2023. Eligible qualitative studies focussed on adults (>16 years old) with a diagnosis of chronic primary or secondary MSK pain who performed PNE. Thematic synthesis by Thomas and Harden was followed. The Critical Appraisal Skills Programme (CASP) tool ensured the quality of the studies, while the Confidence in Evidence from the Reviews of Qualitative Research (CERQual) approach facilitated data confidence assessment.

RESULTS

Nine studies were included (188 participants). Three analytical themes were developed: (i) "Efficient Communication of Information", emphasising the importance of accurate content transmission; (ii) "Emotional Support and Well-being", recognising emotional aspects as integral to treatment; and (iii) "Empowerment Promotion", focusing on information retention and personal transformation. The studies showed good quality, with moderate confidence in the evidence.

CONCLUSIONS

The perceived factors influencing the success of PNE are intricately related to the domain of communication, the emotional dimension of personal experience, and the capacity to be empowered.

"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.

Codesign and Evaluation of Pain Science Messages on Social Media With Adolescents With a History of Chronic Pain

Pain science education (PSE) is an important component of pediatric pain care; however, access to services is limited. To disseminate pain science concepts on social media, we partnered with adolescents with chronic pain to codesign content. We engaged 7 adolescent codesigners (aged 13-18 years) with lived experience of chronic pain to take part in 4 codesign workshops. Codesigners actively contributed to the social media campaign by selecting the social media platform, dictating design principles, generating metaphors and language, and recommending changes to mock designs. Codesigners suggested expanding the intended audience of the campaign to include people without a lived experience of chronic pain, such as friends, family, and teachers, alongside targeting adolescents with chronic pain. We published 30 posts and 102 stories over an 18-week period on Instagram, which reached over 40,000 individuals. We evaluated codesigners' experience, where they reported having clear communication and necessary supports and information to participate; were able to share their ideas and felt they were heard; and felt their input was making a difference. The outputs of this campaign could be useful to guide the tailoring of other PSE content delivered by clinicians as part of clinical care. Future testing of the content generated in this codesign process could evaluate if it leads to meaningful changes in the lives of people with chronic pain. PERSPECTIVE: Researchers partnered with adolescents with chronic pain to codesign content for a social media campaign on PSE. Adolescent codesigners actively shaped the campaign direction, broadening its scope to reach diverse audiences. Our Instagram initiative reached over 40,000 individuals, indicating the potential for innovative educational approaches.

Managing patients' reports of abdominal pain and irritable bowel syndrome-like symptoms during quiescent inflammatory bowel disease: a role for shared sensemaking

Background

Patients with inflammatory bowel disease (IBD) are often faced with distressing and confusing abdominal pain during remission. Some people respond adversely to healthcare professionals' (HCPs) suggestions that this pain and related symptoms are due to secondary irritable bowel syndrome (IBS). Exploring how HCPs view, manage, and explain pain during quiescent disease may provide insights into how communication can be improved to increase understanding and mitigate negative responses.

Methods

In-depth semi-structured interviews were conducted with 12 IBD-nurses (n = 4) and gastroenterologists (n = 8) working in the United Kingdom or the Netherlands. Reflexive thematic analysis was used to analyse interviews.

Results

Findings suggest that HCPs pay relatively little attention to pain when there is no underlying pathology and prefer to concentrate on objectifiable causes of symptoms and treating disease activity (Theme 1: Focus on disease activity, not pain and associated symptoms). Explanations of abdominal pain and IBS-like symptoms during remission were not standardised (Theme 2: Idiosyncratic and uncertain explanations for pain during remission). Processes of shared decision-making were outlined and shared sensemaking was reported as a strategy to enhance acceptance of IBS explanations (Theme 3: Shared decision making versus shared sensemaking).

Conclusion

Future work should focus on establishing how pain during remission may be best defined, when to diagnose IBS in the context of IBD, and how to explain both to patients. The formulation of standardised explanations is recommended as they might help HCPs to adopt practices of shared sensemaking and shared decision-making. Explanations should be adaptable to specific symptom presentations and different health literacy levels.

How do the target concepts of pain science education combined with exercise contribute to the effect on pain intensity and disability in patients with chronic spinal pain? A systematic review and meta-analysis with moderator analysis

The aim of this study was to assess the moderator effect of the target concepts covered in the Pain science education (PSE) sessions, including both the total amount of target concepts and each individual target concept, on changes in pain intensity and disability in patients with chronic spinal pain (CSP). A systematic search of PubMed, Scopus, Embase, Web of Science and CENTRAL was conducted from inception to March 10, 2024. A random effects model was used for meta-regression analysis. A total of 11 studies were included. The total amount of target concepts of PSE showed a significant correlation with changes in pain intensity (k=11; F=4.45; p=0.04; R2=26.07 %). In terms of each target content, only a significant effect on pain intensity was obtained for 'transfer knowledge about pain to an adaptive behavioural change' (z=-2.35, P =0.019, 95 %CI -3.42 to -0.31) and 'reconceptualization of pain' (z=-2.43, P =0.015, 95 %CI -3.70 to -0.39). No significant effect on disability was found. These results may be useful for optimising the effectiveness of PSE programmes.

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.

Do threats and reassurances reside in the biological, psychological or social domain? A qualitative study in adults and young people with chronic pain

Objective

Understanding biopsychosocial contributions to a sensitised pain system is a key target of many pain management programs. The 'Protectometer' is a freely available educational tool that guides people with chronic pain to explore their personal threats and reassurances, identifying them as 'DIMs' (danger in me) or 'SIMs' (safety in me), to guide personalised pain management. This study aimed to explore common types of DIMs and SIMs, and examine differences between adults and young people.

Materials and Methods

A retrospective qualitative study was conducted. Written DIMs (n = 504) and SIMs (n = 711) were collected from 96 participants with chronic pain (77 adults aged 18-85 years; 19 young people aged 9-17 years) across 15 multidisciplinary pain management groups. DIMs and SIMs were transcribed and analysed using deductive content analysis.

Results

Four overarching themes were identified: 'Engaging with the environment', 'In my body', 'My emotional health', and 'Activities and behaviours'. Similarities in SIMs were found, with the greatest proportion of SIMs in the social domain (49% adults; 47% young people). While adult DIMs were fairly evenly spread across the biological (37%), psychological (27%) and social domains (36%), young people's DIMs were predominantly in the psychological (44%) and social (43%) domains.

Discussion

These findings provide insights into common threats and reassurances people in pain perceive, and revealed age-related differences in biopsychosocial contributions to pain and pain relief. Findings also highlight the importance of social-based interventions as part of pain management therapies for both adults and young people.

Recommendations for patient education in the management of persistent pelvic pain: a systematic review of clinical practice guidelines

ABSTRACT

Patient education has a critical role in the management of pain. There is considerable heterogeneity in patient education for females with persistent pelvic pain (PPP), and it remains unclear what is considered best clinical practice. Therefore, this systematic review identified and summarised recommendations for patient education in the management of benign gynaecological and urological conditions associated with PPP, as endorsed by international guidelines. Academic and relevant guideline databases were searched from inception to May 2022. Included guidelines were those for the management of benign gynaecological and urological conditions associated with PPP in adult females published in English, of any publication date, and endorsed by a professional organisation or society. Two independent reviewers screened 3097 records; 17 guidelines were included in the review. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Recommendations were pooled using descriptive synthesis. Persistent pelvic pain guideline quality was generally poor. Three guidelines were classified as "excellent" (The NICE, RANZCOG, and ESHRE endometriosis guidelines) and therefore recommended for use. Eleven guidelines (64.7%) recommended patient education for females with PPP. Recommendations for education content were variable, however most frequently covered treatment strategies and pelvic pain diagnoses. For education delivery, the most frequent recommendations were for support groups and written/printed materials. Further research into tailored education interventions is needed for females with PPP.

Acceptability and feasibility of virtual reality to promote health literacy in primary care from the health professional's view: A qualitative study

OBJECTIVE

The development of health literacy is important in the management of chronic pain and virtual reality may be an effective medium for its development. This study aims to understand the usability and acceptability of a virtual reality-based pain education system for the facilitation of health literacy.

METHODS

Semi-structured interviews were conducted with health professionals who had used a VR-based pain education system within their clinical practice, to explore perceptions of feasibility. Data collection and analyses were informed by the Unified Theory of Acceptance and Use of Technology and the Integrated Model of Health Literacy.

RESULTS

From 10 participants, the VR-based system was considered feasible in providing immersive experiential learning which addressed patient understanding and health-related communication.

CONCLUSION

VR appears to be perceived as an acceptable and feasible technology to support the development of health literacy in people with chronic pain. Its largest perceived benefit was its capacity to provide an immersive and entertaining alternative to conventional methods of pain education.

PRACTICE IMPLICATIONS

Virtual reality is considered as a feasible method of facilitating patient understanding and health-related communication related to chronic pain. Feasibility of such a tool relies clinically on time available, social expectations of VR, and the role of immersive and experiential learning within the management of chronic pain.

Pain neuroscience education for patients with chronic pain: A scoping review from teaching-learning strategies, educational level, and cultural perspective

OBJECTIVE

(1) To identify the characteristics of PNE programs in terms of teaching-learning strategies, session modality, content delivery format, number of sessions, total minutes and instructional support material used in patients with chronic musculoskeletal pain, (2) to describe PNE adaptations for patients with different educational levels or cultural backgrounds, and (3) to describe the influence of the patient's educational level or cultural background on the effects of PNE.

METHODS

The PRISMA guideline for scoping reviews was followed. Nine databases were systematically searched up to July 8, 2023. Articles that examined clinical or psychosocial variables in adults with chronic musculoskeletal pain who received PNE were included.

RESULTS

Seventy-one articles were included. Studies found benefits of PNE through passive/active teaching-learning strategies with group/individual sessions. However, PNE programs presented great heterogeneity and adaptations to PNE were poorly reported. Most studies did not consider educational level and culture in the effects of PNE.

CONCLUSIONS

Despite the large number of studies on PNE and increased interest in this intervention, the educational level and culture are poorly reported in the studies.

PRACTICAL IMPLICATIONS

It is recommended to use passive and/or active teaching-learning strategies provided in individual and/or group formats considering the patient's educational level and culture.

Teaching Patients About Pain: The Emergence of Pain Science Education, its Learning Frameworks and Delivery Strategies

Since it emerged in the early 2000's, intensive education about 'how pain works', widely known as pain neuroscience education or explaining pain, has evolved into a new educational approach, with new content and new strategies. The substantial differences from the original have led the PETAL collaboration to call the current iteration 'Pain Science Education'. This review presents a brief historical context for Pain Science Education, the clinical trials, consumer perspective, and real-world clinical data that have pushed the field to update both content and method. We describe the key role of educational psychology in driving this change, the central role of constructivism, and the constructivist learning frameworks around which Pain Science Education is now planned and delivered. We integrate terminology and concepts from the learning frameworks currently being used across the PETAL collaboration in both research and practice-the Interactive, Constructive, Active, Passive framework, transformative learning theory, and dynamic model of conceptual change. We then discuss strategies that are being used to enhance learning within clinical encounters, which focus on the skill, will, and thrill of learning. Finally, we provide practical examples of these strategies so as to assist the reader to drive their own patient pain education offerings towards more effective learning. PERSPECTIVE: Rapid progress in several fields and research groups has led to the emergence 'Pain Science Education'. This PETAL review describes challenges that have spurred the field forward, the learning frameworks and educational strategies that are addressing those challenges, and some easy wins to implement and mistakes to avoid.

Bridging the gap: Understanding the barriers and facilitators to performance for Black, Asian and Minority Ethnic medical students in the United Kingdom

INTRODUCTION

Differential attainment is a well-known phenomenon in medical education. Despite a strong impetus for institutions and researchers to move away from a 'student deficit model' when exploring the attainment gap, little attention has been given to understanding the experiences of Black, Asian and Minority Ethnic (BAME) medical students. Informed by the social construction of learning theory, this is the first national study to explore how multiple dimensions of the medical school environment impact academic performance of BAME undergraduate medical students across the UK.

METHODS

Using a sequential explanatory mixed-methods approach, the authors conducted a survey and facilitated three focus groups across medical schools in the UK between 2020-2021. Participants self-identified as being from BAME backgrounds. Quantitative analyses included descriptive statistics and bivariate analyses. Qualitative data were analysed using thematic analysis, subsequently identifying inductive themes.

RESULTS

Three hundred sixty-two respondents completed the Phase 1 survey, and 17 participants participated in the Phase 2 focus groups. Although both survey and focus group participants identified facilitators to learning such as supportive relationships, students reported facing numerous barriers that they felt impeded their learning and performance. These barriers included limited access to educational resources, and undiversified curricula and medical school populations. Students also described both experiencing and witnessing various forms of racism throughout their educational journeys.

DISCUSSION

Students encountered various difficulties throughout their medical training that they felt impacted their learning and performance. This study offers novel insights into the experiences of BAME students and builds upon previous research. It also reveals the pervasive nature of racism within medical schools, highlighting the urgent need for institutional changes. Educators and institutions must go beyond merely recognising these barriers and facilitators; they must proactively innovate and adapt. In doing so, they pave the way for inclusive learning environments that truly foster a sense of belonging for BAME students.

We Are All in This Together-Whole of Community Pain Science Education Campaigns to Promote Better Management of Persistent Pain

Persistent pain is a major public health issue-estimated to affect a quarter of the world's population. Public understanding of persistent pain is based on outdated biomedical models, laden with misconceptions that are contrary to best evidence. This understanding is a barrier to effective pain management. Thus, there have been calls for public health-based interventions to address these misconceptions. Previous pain-focussed public education campaigns have targeted pain beliefs and behaviours that are thought to promote recovery, such as staying active. However, prevailing pain-related misconceptions render many of these approaches counter-intuitive, at best. Pain Science Education improves understanding of 'how pain works' and has been demonstrated to improve pain and disability outcomes. Extending Pain Science Education beyond the clinic to the wider community seems warranted. Learning from previous back pain-focussed and other public health educational campaigns could optimise the potential benefit of such a Pain Science Education campaign. Pain Science Education-grounded campaigns have been delivered in Australia and the UK and show promise, but robust evaluations are needed before any firm conclusions on their population impact can be made. Several challenges exist going forward. Not least is the need to ensure all stakeholders are involved in the development and implementation of Pain Science Education public messaging campaigns. Furthermore, it is crucial that campaigns are undertaken through a health equity lens, incorporating underrepresented communities to ensure that any intervention does not widen existing health inequalities associated with persistent pain. PERSPECTIVE: Public misconceptions about pain are a significant public health challenge and a viable intervention target to reduce the personal, social, and economic burden of persistent pain. Adaptation of Pain Science Education, which improves misconceptions in a clinical setting, into the public health setting seems a promising approach to explore.

'Symptom-free' when inflammatory bowel disease is in remission: Expectations raised by online resources

OBJECTIVES

Up to 60% of patients with inflammatory bowel disease (IBD) experience symptoms when in remission. Qualitative research suggests patients seldom feel they receive adequate explanations for these. This study explores how, and how often, ongoing symptoms during remission are represented on readily searchable patient websites.

METHODS

Bing, Google, and Yahoo were searched for websites providing medical information about IBD. Thematic analysis was used to inductively explore themes around symptoms during quiescent IBD, followed by deductive content analysis to quantify core themes.

RESULTS

Results indicated that remission is commonly defined as "few or no symptoms" and that there is limited information available on symptoms during remission. 55.6% of IBD websites provided a definition of remission based on symptom control only, while 44.4% also incorporated inflammatory control. The few websites that mentioned that symptoms may continue during remission (21.7%) related these to IBS.

CONCLUSIONS

Current website information is predominantly biomedical and fails to adequately explain how symptoms may persist during remission and how IBS and IBD may be linked.

PRACTICE IMPLICATIONS

Lack of explanatory models of symptoms in remission may lead to distress and increase anxiety about symptoms. Clearer explanations of these symptoms are needed.

Experiences from pre-surgery physiotherapy and thoughts about future exercise among patients with disc herniation or spinal stenosis: A qualitative study

BACKGROUND

Continuous exercising after a physiotherapy intervention for low back pain (LBP) is known to be crucial, but sustaining new habits may be challenging.

AIM

To describe patients' pre- and post-surgery experiences after a pre-surgery physiotherapy intervention, and their thoughts about future exercise and self-management.

METHODS

Individual semi-structured interviews at two time-points were analysed with content analysis. Patients randomised to pre-surgery physiotherapy in an RCT evaluating the intervention, who had participated in ≥12 sessions, were invited. Eighteen patients were interviewed 0-8 months after pre-surgery physiotherapy, and sixteen of those completed a second interview 3-14 months later.

RESULTS

Three categories emerged: 1) "Personal experiences from pre-surgery participation", described how participation was perceived as challenging and sometimes stressful, but wellness improved. Cooperation with the physiotherapist was considered crucial and gave confidence. 2) "Attitudes to exercise", described exercise as an action of prevention and rehabilitation that demands motivation. Exercise was perceived to be good for you, physically but also improving mental health and other systems. 3) "Future physical activity - individual responsibility", described the return to former activities and potential challenges for the future. New knowledge was perceived to have changed the prerequisites for exercise and increased security in every-day physical activities.

CONCLUSION

Pre-surgery physiotherapy may enhance self-management through increased confidence, improved knowledge about progression, and awareness about exercise for pain relief, producing a new mindset. Challenges for continuing exercise should be addressed during the intervention. The result can inform supportive strategies for patients to continue with self-management after LBP rehabilitation.

Endorsing a Biopsychosocial Perspective of Pain in Individuals With Chronic Pain: Development and Validation of a Scale

OBJECTIVES

Patients' beliefs about pain play an important role in their readiness to engage with chronic pain self-management. The central aim of this study was to validate a self-report instrument to assess a specific set of pain beliefs, patients' endorsement of a biopsychosocial model of chronic pain Patients' Endorsement of a Biopsychosocial Model of Chronic Pain Scale (PEB).

METHODS

Interdisciplinary experts in the field of pain were involved in creating an instrument, the PEB Scale, to operationalize patients' endorsement of a biopsychosocial pain model. A sample of 199 patients with chronic pain was recruited to evaluate the factorial structure (principal axis factoring), the internal consistency (Cronbach alpha), the convergent and discriminant validity (correlational analyses), incremental validity (multiple, hierarchical regression analyses), and construct validity (differential population analysis) of the instrument.

RESULTS

The factor analysis resulted in a unidimensional, 11-item instrument that explained 51.2% of the total variance. Cronbach alpha (=0.92) indicated high internal consistency of the created set of pain-related beliefs. Regression analyses demonstrated that PEB is a strong predictor of patients' engagement with pain self-management ( P < 0.001) after controlling for demographic variables, anxiety, depression, and other pain-related beliefs.

DISCUSSION

Our results show that the PEB Scale is a highly reliable self-report instrument that has the potential to predict patients' readiness to adopt pain self-management. Future research should focus on revalidating the scale to operationalize PEB. Moreover, the PEB Scale should be implemented in longitudinal study designs to investigate its ability to predict the transition from acute to chronic pain and patients' long-term pain management.

Sexual Disability in Low Back Pain: Diagnostic and Therapeutic Framework for Physical Therapists

BACKGROUND

The literature shows a relationship between sexual activity and low back pain (LBP). The aim of this work is to provide a theoretical framework and practical proposal for the management of sexual disability in individuals with LBP.

METHODS

Based on a literature review, a team of specialized physical therapists developed a pattern for the management of LBP-related sexual disability.

RESULTS

A patient reporting LBP-related sexual disability may be included in one of four clinical decision-making pathways corresponding to one of the following: #1 standard physical therapy (PT); #2 psychologically informed physical therapy (PIPT); #3 PIPT with referral; or #4 immediate referral. Standard PT concerns the management of LBP-related sexual disability in the absence of psychosocial or pathological issues. It includes strategies for pain modulation, stiffness management, motor control, stabilization, functional training, pacing activities comprising education, and stay-active advice. PIPT refers to patients with yellow flags or concerns about their relationship with partners; this treatment is oriented towards a specific psychological approach. "PIPT with referral" and "Immediate referral" pathways concern patients needing to be referred to specialists in other fields due to relationship problems or conditions requiring medical management or pelvic floor or sexual rehabilitation.

CONCLUSIONS

The proposed framework can help clinicians properly manage patients with LBP-related sexual disability.

Adding Brief Pain Science or Ergonomics Messages to Guideline Advice Did Not Increase Feelings of Reassurance in People With Acute Low Back Pain: A Randomized Experiment

OBJECTIVE: To investigate the effects of adding pain science or ergonomics messages to guideline advice on feelings of reassurance and management intentions among people with acute low back pain (LBP). DESIGN: Three-arm parallel-group randomized experiment. METHODS: We recruited people with acute LBP (pain for ≤6 weeks) to participate in an online experiment. Participants were randomized at a 1:1:1 ratio to one of three groups: guideline advice alone or guideline advice with the addition of brief pain science or ergonomics messages. The intervention was delivered via prerecorded videos in all 3 groups. Coprimary outcomes were reassurance that (1) no serious condition is causing LBP and (2) continuing with daily activities is safe. Secondary outcomes were perceived risk of developing chronic pain, management intentions (bed rest, see a health professional, see a specialist, and imaging), credibility, and relevance of the advice in addressing the participant's concerns. RESULTS: Two thousand two hundred ninety-seven responses (99.3% of 2,313 randomized) were analyzed. Adding brief pain science or ergonomics messages to guideline advice did not change reassurance that LBP was not caused by serious disease. The addition of ergonomics advice provided worse reassurance that it is safe to continue with daily activities compared to guideline advice (mean difference [MD], -0.33; 95% CI: 0.13, 0.53). There was no difference between groups on management intentions. CONCLUSION: Adding pain science or ergonomics messages to guideline advice did not increase reassurance or change management intentions in people with acute LBP. Ergonomics messages may lead to reduced feelings of reassurance. J Orthop Sports Phys Ther 2023;53(12)1-11. Epub 26 September 2023. doi:10.2519/jospt.2023.12090.

Treating persistent pain after breast cancer: practice gaps and future directions

This paper discusses the growing problem of persisting pain after successful treatment of breast cancer and presents recommendations for improving pain-related outcomes for this group. We discuss the dominant treatment approach for persisting pain post-breast cancer treatment and draw contrasts with contemporary treatment approaches to persistent pain in non-cancer-related populations. We discuss modern application of the biopsychosocial model of pain and the notion of variable sensitivity within the pain system, moment by moment and over time. We present the implications of increasing sensitivity over time for treatment selection and implementation. By drawing on transformative changes in treatment approaches to persistent non-cancer-related pain, we describe the potentially powerful role that an intervention called pain science education, which is now recommended in clinical guidelines for musculoskeletal pain, may play in improving pain and disability outcomes after successful breast cancer treatment. Finally, we present several research recommendations that centre around adaptation of the content and delivery models of contemporary pain science education, to the post-breast cancer context.

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.

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.

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.

Suggestions in Hypnosis to Aid Pain Education (SHAPE) in People with Chronic Low-Back Pain: A Pilot Feasibility Randomized, Controlled Trial

Chronic low back pain (CLBP) is a debilitating and burdensome condition, and new treatment strategies are needed. This study aimed to evaluate (1) the feasibility of undertaking a controlled clinical trial investigating a novel intervention for people with CLBP: hypnotically reinforced pain science education, and (2) the acceptability of the intervention as rated by participants. A priori feasibility and intervention acceptability criteria were set. Twenty participants with CLBP were recruited and randomized to receive: (1) hypnotically delivered pain science education that utilizes hypnotic suggestions to enhance uptake of pain science concepts; or (2) pain science education with progressive muscle relaxation as an attention control. Twenty participants were recruited, however, not solely from the hospital waitlist as intended; community sampling was required (13 hospital, 7 community). Most criteria were met in the community sample but not the hospital sample. Protocol modifications are needed before progressing to a full scale randomized controlled trial for hypnotically reinforced pain science education. Improvements in relevant secondary outcomes paired with moderate-high treatment acceptability ratings are promising.

Learning the neurobiology of pain: A scoping review of pain education from an instructional design perspective

OBJECTIVES

Learning modern pain biology concepts can improve important clinical outcomes for people with chronic pain. The primary purpose of this scoping review is to examine and report characteristics of chronic musculoskeletal pain education programs from an instructional design perspective.

METHODS

Following PRISMA-ScR guidelines, PubMed, Medline, and CINAHL databases were systematically searched. Articles included expert recommendations and those reporting pain education programs used in clinical trials enrolling adults with chronic neuromusculoskeletal pain and published in English between 1990 and 2021. Three authors independently evaluated articles for eligibility through title, abstract, and full text review. Instructional design characteristics such as learning outcomes, support materials, learning assessment methods, and key concepts communicated were summarized.

RESULTS

The search revealed 5260 articles of which 40 were included: 27 clinical studies, 7 expert recommendations, and 6 articles reporting on pain education from participant perspectives. Detailed reporting of instructional design characteristics informing replication in subsequent studies is sparse. Most included trials used only lecture and did not assess participant learning.

CONCLUSIONS

More comprehensive reporting of pain education programs is needed to facilitate replicability.

PRACTICAL IMPLICATIONS

This article proposes detailed and standardized reporting of trials using pain education programs employing a modified version of the TIDieR checklist.

Making exercise count: Considerations for the role of exercise in back pain treatment

INTRODUCTION

Chronic low back pain (CLBP) is pain that has persisted for greater than three months. It is common and burdensome and represents a significant proportion of primary health presentations. For the majority of people with CLBP, a specific nociceptive contributor cannot be reliably identified, and the pain is categorised as 'non-specific'. Exercise therapy is recommended by international clinical guidelines as a first-line treatment for non-specific CLBP.

AIM

This comprehensive review aims to synthesise and appraise the current research to provide practical, evidence-based guidance concerning exercise prescription for non-specific CLBP. We discuss detailed initial assessment and being informed by patient preferences, values, expectations, competencies and goals.

METHODS

We searched the Cochrane Database of Systematic Reviews, PubMed and the Physiotherapy Evidence Database (PEDro) using broad search terms from January 2000 to March 2021, to identify the most recent clinical practice guidelines, systematic reviews and randomised controlled trials on exercise for CLBP.

RESULTS/DISCUSSION

Systematic reviews show exercise is effective for small, short-term reductions in pain and disability, when compared with placebo, usual care, or waiting list control, and serious adverse events are rare. A range of individualised or group-based exercise modalities have been demonstrated as effective in reducing pain and disability. Despite this consensus, controversies and significant challenges remain.

CONCLUSION

To promote recovery, sustainable outcomes and self-management, exercise can be coupled with education strategies, as well as interventions that enhance adherence, motivation and patient self-efficacy. Clinicians might benefit from intentionally considering their own knowledge and competencies, potential harms of exercise and costs to the patient. This comprehensive review provides evidence-based practical guidance to health professionals who prescribe exercise for people with non-specific CLBP.

Graded motor imagery modifies movement pain, cortical excitability and sensorimotor function in complex regional pain syndrome

Patients with complex regional pain syndrome suffer from chronic neuropathic pain and also show a decrease in sensorimotor performance associated with characteristic central and peripheral neural system parameters. In the brain imaging domain, these comprise altered functional sensorimotor representation for the affected hand side. With regard to neurophysiology, a decrease in intracortical inhibition for the sensorimotor cortex contralateral to the affected hand has been repetitively verified, which might be related to increased primary somatosensory cortex functional activation for the affected limb. Rare longitudinal intervention studies in randomized controlled trials have demonstrated that a decrease in primary somatosensory cortex functional MRI activation coincided with pain relief and recovery in sensorimotor performance. By applying a randomized wait-list control crossover study design, we tested possible associations of clinical, imaging and neurophysiology parameters in 21 patients with complex regional pain syndrome in the chronic stage (>6 months). In more detail, we applied graded motor imagery over 6 weeks to relieve movement pain of the affected upper limb. First, baseline parameters were tested between the affected and the non-affected upper limb side and age-matched healthy controls. Second, longitudinal changes in clinical and testing parameters were associated with neurophysiological and imaging parameters. During baseline short intracortical inhibition, as assessed with transcranial magnetic stimulation, was decreased only for hand muscles of the affected hand side. During movement of the affected limb, primary somatosensory cortex functional MRI activation was increased. Hand representation area size for somatosensory stimulation in functional MRI was smaller on the affected side with longer disease duration. Graded motor imagery intervention but not waiting, resulted in a decrease of movement pain. An increase of somatosensory hand representation size over graded motor imagery intervention was related to movement pain relief. Over graded motor imagery intervention, pathological parameters like the increased primary somatosensory cortex activation during fist movement or decreased short intracortical inhibition were modified in the same way as movement pain and hand performance improved. No such changes were observed during the waiting period. Overall, we demonstrated characteristic changes in clinical, behaviour and neuropathology parameters applying graded motor imagery in patients with upper limb complex regional pain syndrome, which casts light on the effects of graded motor imagery intervention on biomarkers for chronic neuropathic pain.

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.