ArticleLiterature Review

15 Years of Explaining Pain - The Past, Present and Future

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Abstract

Unlabelled: The pain field has been advocating for some time for the importance of teaching people how to live well with pain. Perhaps some, and maybe even for many, we might again consider the possibility that we can help people live well without pain. Explaining Pain (EP) refers to a range of educational interventions that aim to change one's understanding of the biological processes that are thought to underpin pain as a mechanism to reduce pain itself. It draws on educational psychology, in particular conceptual change strategies, to help patients understand current thought in pain biology. The core objective of the EP approach to treatment is to shift one's conceptualization of pain from that of a marker of tissue damage or disease to that of a marker of the perceived need to protect body tissue. Here, we describe the historical context and beginnings of EP, suggesting that it is a pragmatic application of the biopsychosocial model of pain, but differentiating it from cognitive behavioral therapy and educational components of early multidisciplinary pain management programs. We attempt to address common misconceptions of EP that have emerged over the last 15 years, highlighting that EP is not behavioral or cognitive advice, nor does it deny the potential contribution of peripheral nociceptive signals to pain. We contend that EP is grounded in strong theoretical frameworks, that its targeted effects are biologically plausible, and that available behavioral evidence is supportive. We update available meta-analyses with results of a systematic review of recent contributions to the field and propose future directions by which we might enhance the effects of EP as part of multimodal pain rehabilitation. Perspective: EP is a range of educational interventions. EP is grounded in conceptual change and instructional design theory. It increases knowledge of pain-related biology, decreases catastrophizing, and imparts short-term reductions in pain and disability. It presents the biological information that justifies a biopsychosocial approach to rehabilitation.

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... 3,6 Pain is likely to occur when the brain decides there is more credible evidence of threat/danger than safety. 6,7 In this paradigm, misconceptions and maladaptive thoughts and beliefs about pain are likely to overestimate the threat value of a noxious input and heighten pain and disability. 8,9 Hence, treatments that alter the threat value of noxious input by changing its meaning can modulate pain, 10 and hence provide clinicians with opportunities to reduce pain. ...
... 3,11,12 The clinical application of educating people about pain science goes by various names including pain science education (PSE), explain pain, pain biology education, pain neuroscience education, and therapeutic neuroscience education (hereafter referred to as PSE). Indeed, the underlying concepts in all these education paradigms detail the neurobiology and neurophysiology of pain and pain processing, 7 with a key aim of reconceptualizing pain as less threatening. Although PSE as a standalone treatment results in clinically significant improvements in pain catastrophizing and kinesiophobia, 13 it does not have a significant effect on pain and physical function. ...
... 25-2.15). Other studies have found improvements in pain neurophysiology knowledge and treatment outcomes after PSE, 7,10,22,25 although the authors did not analyze whether improvements in pain neurophysiology knowledge led to improvements in treatment outcomes. Therefore, it remains unclear to what extent improvements in pain knowledge after PSE are associated with improved treatment outcomes. ...
Article
Objective: This systematic review and meta-analysis aimed to determine the association between changes in patients' pain knowledge after pain science education (PSE) with treatment outcomes in people with chronic pain. Methods: Six electronic databases and 2 clinical trial registries were searched from inception to September 15, 2021 for studies where participants received PSE and had their pain knowledge and clinical outcomes assessed before and after PSE. Meta-analyses were performed for pain intensity, kinesiophobia, and pain catastrophizing. Physical function and quality of life outcomes were synthesized narratively. Risk of bias was assessed using the Cochrane tool for nonrandomized studies and the quality of evidence was assessed using GRADE. Results: Fourteen studies (n=1500 participants) were included. Meta-analyses revealed no significant associations between short-term (<12 wk) changes in pain neurophysiology knowledge with changes in pain intensity (n=1075, r=-0.01, 95% CI =-0.14 to 0.13, very low certainty), kinesiophobia (n=152, r=0.02, 95% CI =-0.27 to 0.24, very low certainty) and pain catastrophizing (n=976, r=-0.03, 95% CI=-0.18 to 0.11, low certainty). No significant associations were found between short-term changes in pain neurophysiology knowledge and physical function or quality of life either. Discussion: These findings do not support a short-term association between improvements in pain neurophysiology knowledge and better treatment outcomes in people with chronic pain. Increased understanding of how PSE works, as well as better ways to measure it, may help clinicians deliver more targeted education to help patients reconceptualize pain and promote engagement in active treatment strategies (eg, exercise).
... Pain science education has shown positive moderate effects on pain and disability in people with CLBP (Louw et al., 2011(Louw et al., , 2016. Pain science education aims to shift an individual's knowledge and beliefs about pain: namely, from pain as a marker of tissue damage to pain as a marker of the perceived need to protect (Butler & Moseley, 2013;Louw et al., 2016;Moseley & Butler, 2015a, 2015b. Increasing pain knowledge, underpinned by the willingness and capacity to take on new information, appears key to the success of pain education (Lee et al., 2016). ...
... Both groups received pain science education. The education content followed the key manual (Moseley & Butler, 2015a) using established principles of conceptual change theory (Moseley & Butler, 2015b;Vosniadou et al., 2008). Participant-specific conceptual barriers were identified by standardized targeted questioning. ...
... Participant-specific conceptual barriers were identified by standardized targeted questioning. "Target concepts" were used to convey specific details about pain neurophysiology, with the aim of reconceptualizing participants' beliefs and understanding about pain (Moseley & Butler, 2015a, 2015b. The content was communicated through story and metaphor, tied to the participant's personal experience. ...
Article
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.
... The concept of pain focuses on the understanding of "what pain really is, what function it serves, and what biological processes support it." The concept of pain, in other words, can be defined as the way a person perceives pain (Moseley & Butler, 2015). To explain the pain and its associated concepts, first, the bio-psychosocial components of pain, which are determinants, should be defined (Fisher et al., 2018;Harrison et al., 2019;Moseley & Butler, 2015). ...
... The concept of pain, in other words, can be defined as the way a person perceives pain (Moseley & Butler, 2015). To explain the pain and its associated concepts, first, the bio-psychosocial components of pain, which are determinants, should be defined (Fisher et al., 2018;Harrison et al., 2019;Moseley & Butler, 2015). These components are listed by Wijma et al. (2016) as the type of pain, motivation, somatic, cognitive, emotional, behavioral, and social factors. ...
... To evaluate the concept of pain, many components should be considered together (Pate et al., 2020). Determining biopsychosocial influences on pain can provide an understanding of the concept of pain (Fisher et al., 2018;Harrison et al., 2019;Moseley & Butler, 2015). These ideas are in a complex concept network relationship with each other, and conceptual change due to Pain Science Education occurs as a result of a slow process in line with the knowledge and beliefs gained and/or changed (Vosniadou, 2012). ...
Article
Background and purpose Pain experiences in childhood are very likely to be reflected in adulthood. The early evaluation of the concept of pain in children may eventually lead to. better patient outcomes in the future. Therefore, we aimed to culturally and developmentally adapt the Concept of Pain Inventory for Children (COPI) for Turkish children. Methods This descriptive, correlational study was conducted with 239 post-operative children aged 8–12 years between June and December 2021. The research adhered to COSMIN guidelines. The data were collected using a descriptive information form and the COPI. Factor analysis, Cronbach's alpha, and item–total score analysis were used for the data analysis. Results The resulting unidimensional scale consists of 12 items in Turkish. The scale explained 65% of the total variance. The exploratory factor analysis showed that the factor loadings of items ranged from 0.64 to 0.91. The confirmatory factor analysis showed that the factor loadings of items ranged from 0.66 to 0.92. Goodness of fit indexes were found to be as follows: Normed Fit Index >0.90; Incremental Fit Index >0.90; Comparative Fit Index >0.90; and the Root Mean Square Error of Approximation <0.08. The total Cronbach's alpha coefficient of the scale was 0.78 (reliable). Conclusions The 12-item Turkish translation of the COPI was deemed valid and reliable in 8–12-year-old children in a post-operative setting. Practice implications Evaluation of children's pain concepts during childhood may contribute to the identification of conceptual gaps for pain science education.
... Pain science education aims to promote a contemporary understanding of "how pain works." The most important learning objectives, as identified by consumers [13,14], seem to center on the protective function offered by pain, the dynamic nature of this protective function, which varies over time frames from moments to years and the influence of biopsychosocial factors on pain [15]. Through these learnings, pain science education can modify negative and maladaptive beliefs and attitudes towards pain that otherwise hamper healthy behavior, an outcome that is increasingly recognized as an important contributor to quality-of-life after cancer [16][17][18]. ...
... Second, initial educational content for the eHealth program, including key pain science education target concepts, was identified and developed during in-depth workshops attended by the multidisciplinary team described above. Books, websites, and study protocols were used as resources [15,22,[44][45][46][47][48]. This first English version of the eHealth intervention consisted of 22 sessions. ...
Article
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Purpose Here, we describe the development and pilot study of a personalized eHealth intervention containing a pain science education program and self-management support strategies regarding pain and pain-related functioning in female survivors of breast cancer. First, we aimed to evaluate the eHealth intervention’s acceptability, comprehensibility, and satisfaction; second, we aimed to assess its preliminary efficacy. Methods A mixed-method study design was used. Breast cancer survivors with persistent pain were recruited. After 6 weeks of engagement with the eHealth intervention, acceptability, comprehensibility, and satisfaction were measured quantitatively with a self-constructed questionnaire and described qualitatively using focus groups. A joint display was used to present the meta-interferences between data. Efficacy was assessed via mixed effects models with repeated measures (outcomes assessed at baseline, 6 weeks, and 12 weeks). Results Twenty-nine women with persistent pain after breast cancer surgery participated. Overall, the eHealth program was well received and experienced as easy to use and helpful. The eHealth intervention seems useful as an adjunct to comprehensive cancer aftercare. Efficacy estimates suggested a significant improvement in pain-related functioning, physical functioning, and quality of life. Conclusion A personalized eHealth intervention appears valuable for persistent pain management after breast cancer surgery. A large controlled clinical trial to determine effectiveness, and a full process evaluation, seems warranted.
... Pain science has taught us that pain is not a signal that originates from bodily tissues, nor a marker of tissue damage or pathology. In contrast, pain is a compelling perceptual experience generated by the brain based upon its evaluation of danger to bodily tissues and its need to protect these tissues [4]. ...
... Shifting people's view on pain from being an apparent threat towards being a brain output that will only arise whenever the conceivable proof of danger to the body is greater than the conceivable proof of safety to the body, is essentially the core objective of pain education. Pain education, also referred to as "pain (neuro) science education" [5,6], "therapeutic neuroscience education" [7,8], or "explaining pain" [4], gently guides people through this process of changing their conceptual understanding of pain [9]. ...
Article
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Pain affects everyone hence one can argue that it is in each individual’s interest to understand pain in order to hold correct and adaptive beliefs and attitudes about pain. In addition, chronic pain is reaching pandemic proportions and it is now well known that people living with chronic pain have a reduced life expectancy. To address and to prevent the growth of this public health disaster, we must start looking beyond adulthood. How children view pain has an impact on their behavioral coping responses which in turn predict persistent pain early in the lifespan. In addition, children who suffer from chronic pain and who are not (properly) treated for it before adolescence have an increased risk of having chronic pain during their adult life. Explaining pain to children and youth may have a tremendous impact not only on the individual child suffering from chronic pain but also on society, since the key to stop the pain pandemic may well lie in the first two decades of life. In order to facilitate the acquisition of adaptive behavioral coping responses, pain education aims to shift people’s view on pain from being an apparent threat towards being a compelling perceptual experience generated by the brain that will only arise whenever the conceivable proof of danger to the body is greater than the conceivable proof of safety to the body. Nowadays a lot of pain education material is available for adults, but it is not adapted to children’s developmental stage and therefore little or not suitable for them. An overview of the state-of-the-art pain education material for children and youth is provided here, along with its current and future areas of application as well as challenges to its development and delivery. Research on pediatric pain education is still in its infancy and many questions remain to be answered within this emerging field of investigation.
... Non-pharmacological strategies include interventions such as pain education, cognitive behavioral therapy (CBT), mindfulness, therapeutic physical exercise, among others, which aim primarily at alleviating symptoms and improving patients' quality of life (Macfarlane et al., 2017). More specifically, Pain Neuroscience Education (PNE) (Van Oosterwijck et al., 2013;Nijs et al., 2014;Amer-Cuenca et al., 2020) is aimed at changing patients' pain beliefs, emphasizing how overprotective behaviors can accentuate pain experience (Moseley and Butler, 2015). PNE has been found to be effective for reducing pain disability, catastrophizing, avoidance behaviors and physical inactivity in patients with FM (Malfliet et al., 2017). ...
... CBT and mindfulness training help patients to become aware of their own thoughts, emotions and behaviors so that, once identified, they can be regulated or managed facilitating the same situation (e.g., pain) to be experienced in a more flexible and fulfilling way, with less associated suffering. Consistent with PNE, directing attention to the present (rather than to future concerns or past losses or threats) may provide the appropriate safety setting to reduce the perception of alarm or danger associated with pain and allow for successful re-education of the pain program (Moseley G. L., 2003;Moseley et al., 2015). The framework of motivational interviewing and the cognitivebehavioral model of fear avoidance (Vlaeyen et al., 1995) are part of the theoretical background of CBT in the FIBROWALK program. ...
Article
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Introduction: The On&Out study is aimed at assessing the effectiveness, cost-utility and physiological underpinnings of the FIBROWALK multicomponent intervention conducted in two different settings: online (FIBRO-On) or outdoors (FIBRO-Out). Both interventions have proved to be efficacious in the short-term but there is no study assessing their comparative effectiveness nor their long-term effects. For the first time, this study will also evaluate the cost-utility (6-month time-horizon) and the effects on immune-inflammatory biomarkers and Brain-Derived Neurotrophic Factor (BDNF) levels of both interventions. The objectives of this 6-month, randomized, controlled trial (RCT) are 1) to examine the effectiveness and cost-utility of adding FIBRO-On or FIBRO-Out to Treatment-As-Usual (TAU) for individuals with fibromyalgia (FM); 2) to identify pre–post differences in blood biomarker levels in the three study arms and 3) to analyze the role of process variables as mediators of 6-month follow-up clinical outcomes. Methods and analysis: Participants will be 225 individuals with FM recruited at Vall d’Hebron University Hospital (Barcelona, Spain), randomly allocated to one of the three study arms: TAU vs. TAU + FIBRO-On vs. TAU + FIBRO-Out. A comprehensive assessment to collect functional impairment, pain, fatigue, depressive and anxiety symptoms, perceived stress, central sensitization, physical function, sleep quality, perceived cognitive dysfunction, kinesiophobia, pain catastrophizing, psychological inflexibility in pain and pain knowledge will be conducted pre-intervention, at 6 weeks, post-intervention (12 weeks), and at 6-month follow-up. Changes in immune-inflammatory biomarkers [i.e., IL-6, CXCL8, IL-17A, IL-4, IL-10, and high-sensitivity C-reactive protein (hs-CRP)] and Brain-Derived Neurotrophic Factor will be evaluated in 40 participants in each treatment arm (total n = 120) at pre- and post-treatment. Quality of life and direct and indirect costs will be evaluated at baseline and at 6-month follow-up. Linear mixed-effects regression models using restricted maximum likelihood, mediational models and a full economic evaluation applying bootstrapping techniques, acceptability curves and sensitivity analyses will be computed. Ethics and dissemination: This study has been approved by the Ethics Committee of the Vall d’Hebron Institute of Research. The results will be actively disseminated through peer-reviewed journals, conference presentations, social media and various community engagement activities. Trial registration number NCT05377567 ( clinicaltrials.gov ).
... Regarding pain, multiple occupational and non-occupational risk factors, such as leisure time physical activity (LTPA) [21], systemic disease, obesity or stress might be relevant. Thus, the etiology is multifactorial with interacting biological, psychological and social factors [22] and it is key to clarify the factors that might account for MSP, in what region and to what extent. So far, results vary. ...
... Items 4, 5, 7, and 8 were the positively stated items. The summarized score was categorized into low (0-13), moderate (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26) and high (27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40) stress. Chronic disease included cardiovascular disease, cancer, diabetes, depression, asthma, chronic obstructive pulmonary disease, metabolic disease. ...
Article
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Background The present study aimed to investigate the possible association between specific ergonomic and individual risk factors and musculoskeletal pain (MSP) in the back, shoulder, hip and knee region in workers aged 50-65y. Methods The study was a population based cross-sectional survey. The study population comprised citizens born between 1952–1966, living in Esbjerg municipality, Denmark, ultimo 2016 (n = 23,463). A questionnaire was sent electronically or by mail. The analysis included the working population only. A multivariate logistic regression was used for each of the following dependent variables; musculoskeletal pain for the past 3 months in the back, shoulder, hip and knee, where independent variables included ergonomic exposure, age, sex, body mass index (BMI) and leisure time physical activity (LTPA). Results The overall response rate was 58% and the data of individuals at work (n = 9,263) demonstrated several ergonomic exposures with increased odds for pain in specific regions. Exposure to back twisted or bend, squatting or lying on knees and to carrying or lifting were associated with musculoskeletal pain in the back, whereas exposure to back twisted or bend, arms above shoulder and repeated arm movement were associated with pain in the shoulder. Exposure to back twisted or bend, repeated arm movement, squatting or lying on knees and to carrying or lifting were associated with musculoskeletal pain in the hip. Important individual risk factors were also identified. Increasing age was significantly associated with increased pain in the hip but associated with less risk for pain in the back and shoulder. Males had higher odds for pain in the back and knee compared to females but lower odds for pain in the hip. BMI was particularly important for knee pain. The level of LTPA did not have an important association with MSP in any region. Conclusion There is a significant positive association between ergonomic exposures and musculoskeletal pain, which were specific for the back, shoulder, hip and knee. In addition, the data demonstrated a differential association with age, sex and BMI. This needs to be considered for the treatment and classification of musculoskeletal pain and for future preventive initiatives.
... (2020) and Yildirim et al. (2009) observed a decrease in pain in patients with fibromyalgia and cancer after the application of PNE as isolated treatment [39,40]. However, authors such as Moseley and Butler (2015) did not consider education as the only treatment effective for the reduction in pain and dysfunction [41]. ...
... (2020) and Yildirim et al. (2009) observed a decrease in pain in patients with fibromyalgia and cancer after the application of PNE as isolated treatment [39,40]. However, authors such as Moseley and Butler (2015) did not consider education as the only treatment effective for the reduction in pain and dysfunction [41]. ...
Article
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This study investigated the long-term effect (six-months) of a Pain Neuroscience Education (PNE) program on pain perception, quality of life, kinesiophobia and catastrophism in older adults with multimorbidity and chronic pain. Fifty participants (n = 50) were randomly assigned to the pain education therapy group (PET; n = 24) and control group (CG; n = 26). The PET group received six sessions (i.e., once a week, 50 min) about neurophysiology of pain while the CG carried on with their usual life. Perception of pain through the visual analogue scale (VAS), quality of life (EQ-5D questionnaire), kinesiophobia (TSK-11) and catastrophism (PCS) were assessed after six months since the last PNE session. Statistically significant differences on VAS (t(48) = 44, p = 0.01, ES = 0.42 [0.13, 0.65]) was found in favor to PET group. No other statistically significant differences were found. This study found that the application of a PNE intervention in an isolated form was able to significantly reduce pain perception with low effect size in the long-term (six months after intervention) in elderly people with chronic pain.
... In this condition, the investigators posted nearly every morning, following a pre-set schedule to disseminate several training components that were selected based on the research on social and emotional influences on pain. 5,17,22,[26][27][28]32,35 Training materials included short didactics to read, videos to watch, prompts to respond to, and activities to engage in. Our team consulted an advocate for people with chronic pain on intervention materials, including content, wording, and formatting, and modified our approach accordingly. ...
... These findings were surprising given the large body of literature supporting the efficacy of pain neuroscience education, validation, emotional disclosure, and overcoming avoidance in improving pain outcomes. 5,17,22,[26][27][28]32,35 There are a few possible explanations for these largely null differences in outcomes between conditions. Psychosocial intervention components might not add to the utility of standard Facebook groups for chronic pain; rather, peer support might be the driving factor of improvements in this format. ...
Article
Despite the popularity and affordances of social media groups for people with chronic conditions, there have been few controlled tests of the effects of these groups. This randomized controlled superiority trial examined the effects of Facebook groups on pain-related outcomes and tested whether a professional-led group leads to greater effects than a support group alone. We randomly assigned 119 adults with chronic pain to one of two Facebook group conditions: a standard condition (n = 60) in which participants were instructed to offer mutual support, or a professional-led condition (n = 59) in which the investigators disseminated empirically-supported, socially-oriented psychological interventions. Four groups were run (2 standard, 2 professional-led), each lasting 4 weeks and containing approximately 30 participants. Measures were administered at baseline, post-intervention, and 1-month follow-up. Across conditions, participants improved significantly in primary outcomes (pain severity and interference; medium-large effects) and a secondary outcome (depressive symptoms; small-medium effect), and they retained their outcomes 1 month after the groups ended. The 2 conditions did not differ on improvements. Overall, this study supports the use of social media groups as an additional tool to improve chronic pain-related outcomes. Our findings suggest that professional intervention may not have added value in these groups and that peer support alone may be driving improvements. Alternatively, the psychosocial intervention components used in the current study might have been ineffective, or more therapist direction may be warranted. Future research should examine when and how such guidance could enhance outcomes. Perspective Findings from this randomized trial support the use of both standard and professional-led Facebook groups as an accessible tool to enhance the lives of adults with chronic pain. This article provides direction for how to improve social media groups to optimize outcomes and satisfaction for more users.
... One of the significant milestones in this progress was made by Engel (2), who proposed a new conceptualization of illness that was different from existing biomedical frameworks, which viewed illness and its symptoms, such as pain, as an integration of social, psychological, and behavioral influences. Since Engle's initial model, other biopsychosocial models, variants of the initial model, have been theorized in the pain field (3)(4)(5)(6). Sharvit and Schweinhardt . /fneur. . ...
... Third, the first conceptualization of biopsychosocial models of pain was only published in 1977 by Engel (2). Consequentially, there are also fewer review articles on pain modulation that include social factors, even though a biopsychosocial conceptualization of pain is today's gold standard (5,6,12). ...
Article
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Researchers in cognitive neuroscience have investigated extensively how psychological factors shape the processing and perception of pain using behavioral, physiological, and neuroimaging methods. However, social influences of pain, an essential part of biopsychosocial pain models, have received relatively little attention. This is particularly true for the neurobiological mechanisms underlying social modulations on pain. Therefore, this review discusses the findings of recent neuroimaging studies measuring the effects of social manipulations on pain perception (e.g., verbal and non-verbal social signals, social interaction style, conformity, social support, and sociocultural mediators). Finally, a schematic summary of the different social modulatory themes is presented.
... However, some authors (Lederman, 2011;Moseley, 2015), believe that the benefits experienced from FDM were due to nonspecific factors, while another explanation was due to activation of neurophysiological modes of action caused by the sensation of intense pain induced by pressure from the therapist's thumb on the IJHS Vol. 6 No. 2, August 2022, pages: 1074-1086 injured area (Bland & Altman, 1994;Di Blasi et al., 2001;Ernst, 2009;Benedetti, 2010;Benedetti, 2011;Hall et al., 2010). The present study results following Kim & Lee (2019), results found the FDM was the most effective and rapid treatment method used compared to self-myofascial release and myofascial release after four weeks of treatment for neck range of motion and pain (Kim & Lee, 2019). ...
... On the contrary, it was reported in a systematic review focusing on the clinical proofs of concept for FDM treatment techniques in musculoskeletal medicine that FDM is based on a biomechanical/structural paradigm (Thalhamer, 2018). However, there is no evidence that all musculoskeletal conditions are amenable to biomechanics and peripheral tissue pathology laws (Lederman, 2011;Moseley, 2015). ...
Article
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Aim of the study: In athletes, groin pain-related adductor strain is a common problem in sports medicine, like groin injuries, so the study investigated the effect of Photobiomodulation (905 nm) and Trigger Band Technique (TBT) on handball athletes' groin adductor strain. Methods: Forty handball athletes with adductor groin strain were divided into an experimental group (A) that received Diode laser 905nm, TBT, and medical treatment, while control group (B) received sham laser with TBT and medical treatment for four weeks. Outcome measures investigated Copenhangen hip and groin outcome score, pressure algometry, creatine kinase, and lactate dehydrogenase levels. Results: Both groups showed a significant improvement in the post-treatment outcome measures, where experimental group showed more significant improvement than the control group with p-value >0.05. Conclusion: results imply that treatment of handball athlete's groin adductor strain by TBT and low-level laser is more effective than TBT alone.
... In addition, if the individual with a stroke perceives that their sensation is impaired (as indicated by self-reporting), this could then contribute to a feeling of vulnerability of the body part affected, and thus be perceived as being more susceptible to damage. This could be an important factor in the perceived need of the individual to evoke a protective strategy such as pain due to a reduction of perceived body safety [57], resulting in further reductions in use and exposure to stimuli of the affected body part. Further studies combining subjective reporting and objective testing of somatosensation function (including discrimination abilities) in individuals with strokes who experience chronic pain would be beneficial to further investigate these findings and explore the potential therapeutic implications. ...
Article
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Background: Chronic pain and somatosensory impairment are common following a stroke. It is possible that an interaction exists between pain and somatosensory impairment and that a change in one may influence the other. We therefore investigated the presence of chronic pain and self-reported altered somatosensory ability in individuals with stroke, aiming to determine if chronic pain is more common in stroke survivors with somatosensory impairment than in those without. Methods: Stroke survivors were invited to complete an online survey that included demographics, details of the stroke, presence of chronic pain, and any perceived changes in body sensations post-stroke. Results: Survivors of stroke (n = 489) completed the survey with 308 indicating that they experienced chronic pain and 368 reporting perceived changes in somatosensory function. Individuals with strokes who reported altered somatosensory ability were more likely to experience chronic pain than those who did not (OR = 1.697; 95% CI 1.585, 2.446). Further, this difference was observed for all categories of sensory function that were surveyed (detection of light touch, body position, discrimination of surfaces and temperature, and haptic object recognition). Conclusions: The results point to a new characteristic of chronic pain in strokes, regardless of nature or region of the pain experienced, and raises the potential of somatosensory impairment being a rehabilitation target to improve pain-related outcomes for stroke survivors.
... These health professionals offer multifaceted, evidence-based approaches, including cognitive behavioural therapy (CBT), to enhance self-efficacy, increase literacy around the mind-body connection (e.g., psychoeducation about the pain cycle, pain catastrophising and fear avoidance), and utilise strategies like pacing, graded exposure, behavioural experiments and activity scheduling [6]. Psychological interventions underpinned by CBT are empirically supported in the context of pain management to reduce the multifaceted impacts and complexities associated with chronic pain and improve people's quality of life [7]. With established and efficacious treatments and services, issues arise in relation to access and timely response of freely available, public pain management units to meet growing demand and enable access to a range of effective support options. ...
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Introduction: Globally, chronic pain affects more than 30% of people worldwide and is the leading cause of disability and health care utilisation. Access to timely, person-centred, cost-effective programs is unattainable for most. People living in regional, rural and remote areas are disproportionately affected due to scarcity of services and qualified, multidisciplinary health and medical professionals. Caring and supporting people with chronic pain involves a range of interventions that incorporate a multifaceted bio-psychosocial approach. Tertiary and primary chronic pain services are optimally placed to deliver integrated models of care. This pilot study explored the effectiveness of an integrated Guided Self-Help (GSH) program within a multidisciplinary tertiary pain unit in a public hospital in Australia. Methods: A service delivery evaluation was undertaken and a pilot study implemented to determine feasibility and useability of an integrated GSH program for people with chronic pain. A single-group pre-post evaluation was provided to a convenience sample of 42 people referred to the Flinders Medical Centre Pain Management Unit (FMC PMU). Delivered via telehealth or in person by postgraduate students, a manualised GSH workbook was utilised to support adherence and fidelity. Content included goal setting, pain conceptualisation, psychoeducation, activity scheduling, pacing and cognitive strategies. The purpose of the integrated GSH pilot program was to support participants in gaining increased pain literacy, knowledge of effective physical and psychological strategies and enhance self-management of their chronic pain. Levels of psychological distress (PHQ-9 and GAD-7), pain catastrophising (PCS), and pain severity/interference (BPI) were assessed at the beginning and end of support. Integrating the program within a multidisciplinary pain unit intended to facilitate and provide participants with an understanding of their pain through a psychosocial lens, build self-efficacy, and recognise the benefits of other non-medical supports to manage their chronic pain in the future. Outcome data were routinely collected as part of FMC PMU usual practice for clinical and quality assurance purposes, then analysed retrospectively. Thus, under the National Health and Medical Research Council (NHMRC) Ethical Considerations in Quality Assurance and Evaluation Activities guidelines (NHMRC, 2014), and verified by the Southern Adelaide Local Health Network (SALHN) Research Committee (our institutional review board) via email (dated 10/09/2020), ethical review and approval were not required for this project as it constituted a quality improvement activity - specifically, a service delivery evaluation. This project is registered with the SALHN Quality Library (for quality assurance activities that are exempt from ethical approval) (Quality Register ID 3390). Results: Participants showed statistically significant improvements on the PHQ-9 [i.e., mean drop of 2.85 (t = 3.16)], GAD [mean drop of 2.52 (t = 2.71)], and PCS [mean drop of 7.77 (t = 3.47)] with small-to-moderate effect sizes. BPI scores did not change. Results were similar when stratifying analyses by those who completed 2-5 versus 6-12 sessions. Conclusion: Integrating a GSH program for people with chronic pain into a multidisciplinary tertiary pain clinic is an efficacious and scalable way to increase access to effective strategies that can increase self-efficacy and self-management. Novel, scalable, and effective solutions are needed to improve quality of life and address disparities for people with chronic pain. The psychological shifts and benefits observed support efficacy towards self-management strategies that can increase autonomy and quality of life.
... This result may be due to the characteristics of our sample which consisted of patients with chronic neck pain. The negative effects of trauma on tissues may be healed over time even though pain, which was expected to be more associated with the nervous system -in other words "centralized"-by the time, still persists (24). Similar to the study of Field et al., Michaelson et al. compared postural performance of patients with work-related chronic neck pain (WRCNP) with that of patients with chronic WAD (25). ...
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Background and Purpose: A variety of sensory-motor changes are reported in both the traumatic and non-traumatic neck pain. However, it is still unclear whether there is a significant difference between individuals with traumatic neck pain and those with non-traumatic in terms of postural control. The aim of this cross-sectional study was to investigate whether there was a difference between individuals with traumatic pain and non-traumatic neck pain in terms of postural control and disability. Methods: Ninety-two patients with chronic neck pain were grouped according to the onset of pain. Clinical test of sensory interaction balance (CTSIB) and limits of stability (LOS) test were used for postural control assessment. The Numeric Rating Scale and Neck Pain Disability Index (NPDI) were used to measure pain intensity and disability, respectively. Mann-Whitney U test was used to compare groups. Results: There were no significant differences between groups in terms of LOS, CTSIB and NPDI scores (p > 0.05). Conclusion: The results of this study suggest that postural control and disability do not differ between patients with traumatic and non-traumatic neck pain. Therefore, from a clinical perspective, postural control and disability should be evaluated without considering trauma history in patients with neck pain.
... Pain science education aims to bring scientifically accurate understandings of "how pain works" (centered around our "pain system" providing a critical protective function, the sensitivity of which changes with time frames from moments to years), to enable and empower consumers to make optimal decisions around prevention and treatment. 19 Meta-analyses demonstrate that pain science education improves painrelated knowledge, enables consumers to make sense of their pain, 26 reduces worry and improves pain and disability outcomes of active and psychological therapy-based management. 6,10,13,14,22,25,30,33,36 Those experienced in pain science education will be aware of both its potentially powerful effects and its substantial challenges. ...
... Buttler and Moseley developed a method called pain neuroscience education (PNE). Addressing concepts of neurophysiology, neurobiology, representation, and meaning of pain, PNE aims to desensitize the neural system, contrary to the traditional anatomical and biomedical model [10]. In association with educational strategies, Rizzo et al. showed that clinical hypnosis (CH) enhances the results of education processes in patients with CLBP in the short and medium terms [11]. ...
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Background Patients with chronic low back pain (CLBP) suffer with functional, social, and psychological aspects. There is a growing number of studies with multimodal approaches in the management of these patients, combining physical and behavioral therapies such as osteopathic manipulative treatment, associating pain education and clinical hypnosis. The aim of the present study will be to evaluate the effects of osteopathic manipulative treatment (OMT) associated with pain neuroscience education (PNE) and clinical hypnosis (CH) on pain and disability in participants with CLBP compared to PNE, CH, and sham therapy. Methods A randomized controlled clinical trial will be conducted in participants aged 20–60 years with CLBP who will be divided into two groups. Group 1 will receive PNE and CH associated with OMT, and G2 will receive PNE, CH, and sham therapy. In both groups, 4 interventions of a maximum of 50 min and with an interval of 7 days will be performed. As primary outcomes, pain (numerical pain scale), pressure pain threshold (pressure algometer), and disability (Oswestry Disability Questionnaire) will be evaluated and, as a secondary outcome, global impression of improvement (Percent of Improvement Scale), central sensitization (Central Sensitization Questionnaire), biopsychosocial aspects (Start Beck Toll Questionnaire), and behavior of the autonomic nervous system (heart rate variability) will be assessed. Participants will be evaluated in the pre-intervention moments, immediately after the end of the protocol and 4 weeks after the procedures. Randomization will be created through a simple randomized sequence and the evaluator will be blinded to the allocation of intervention groups. Discussion The guidelines have been encouraging multimodal, biopsychosocial approaches for patients with CLBP; in this sense, the results of this study can help clinicians and researchers in the implementation of a model of treatment strategy for these patients. In addition, patients may benefit from approaches with minimal risk of deleterious effects and low cost. In addition, it will enable the addition of relevant elements to the literature, with approaches that interact and do not segment the body and brain of patients with CLBP, allowing new studies in this scenario. Trials registration Date: September 4, 2021/Number: NCT05042115 .
... 3 The treatment highlighted the biopsychosocial nature of pain 48 and addressed biopsychosocial contributors to the CLBP experience, 17,22 mainly related to unhelpful pain-related cognitions, maladaptive behavioral strategies, deconditioning of the back and altered neural processing. 47 The treatment integrated pain science education, pre-movement brain-targeted approaches (ie, a series of strategies where the individual mentally prepared for movement without physically moving their body) proposed to normalize cortical processing associated with persistent pain, and graded movement training progressing towards re-engagement with meaningful functional goals. Participants attended 12 individual face-to-face sessions (once a week, 50−60 minutes each session), with self-directed online activities at home that participants were encouraged to do for 30 minutes 5 times per week. ...
Article
A new wave of treatments has emerged to target the altered nervous system and maladaptive conceptualizations about pain for chronic low back pain. The acceptability of these treatments is still uncertain. We conducted a qualitative study alongside a randomized controlled trial to identify perceptions of facilitators/barriers to participation in a non-pharmacological intervention that resulted in clinically meaningful reductions across 12 months for disability compared to a sham intervention. We conducted semi-structured interviews with participants from the trial's active arm after they completed the 12-week program. We included a purposeful sample (baseline and clinical characteristics) (n=20). We used reflexive thematic analysis informed by the Theoretical Framework of Acceptability for health care interventions. We identified positive and negative emotional/cognitive responses associated with treatment acceptability and potential efficacy, including emotional support, cognitive empowerment, readiness for self-management, and acceptance of face-to-face and online components designed to target the brain. These findings suggest the importance of psychoeducation and behaviour change techniques to create a positive attitude towards movement and increase the perception of pain control; systematic approaches to monitor and target misconceptions about the interventions during treatment; and psychoeducation and behaviour change techniques to maintain the improvements after the cessation of formal care. Perspective: This article presents the experiences of people with chronic low back pain toward a new non-pharmacological brain-targeted treatment that includes face-to-face and self-directed approaches. The facilitators and barriers of the interventions could potentially inform adaptations and optimization of treatments designed to target the brain to treat chronic low back pain.
... There are neuroscientifi c explanations why this kind of thinking results in us maintaining or even increasing pain (Moseley & Butler, 2015). On the other hand, when we can describe what might show us things improving, we seem to notice things improving. ...
... 39 This autonomic dysfunction negatively influences QOL. 14 Again, proper education regarding SFN and all of its complaints will help patients to make this distinction. 40 Some methodological issues should be considered. One strength of this study is the analysis method of qualitative research to avoid bias. ...
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Objective: Small fiber neuropathy (SFN) is characterized by chronic neuropathic pain and autonomic dysfunction. Currently, symptomatic pharmacological treatment is often insufficient and frequently causes side effects. SFN patients have a reduced quality of life. However, little is known regarding whether psycho-social variables influence the development and maintenance of SFN-related disability and complaints. Additional knowledge may have consequences for the treatment of SFN. For example, factors such as thinking, feeling, and behavior are known to play roles in other chronic pain conditions. The aim of this study was to obtain further in-depth information about the experience of living with SFN and related chronic pain. Methods: Fifteen participants with idiopathic SFN participated in a prospective, semi-structured, qualitative, focus group interview study. The focus groups were audio-recorded, transcribed, and analyzed cyclically after each interview. Results: The following main themes were identified: "pain appraisal", "coping", "social, work, and health environment", and "change in identity". Catastrophic thoughts and negative emotions were observed. Living with SFN resulted in daily limitations and reduced quality of life. Conclusions: Given the results, it can be concluded that an optimal treatment should include biological, psychological, and social components.
... They are associated with variable degrees of disability, determined mainly by impairments in mobility, mental health (anxiety and depression), and pain [4]. As MSKD has various treatments depending on personal needs and disability, it demands multidisciplinary care with significant utilization of health services that last in the long term [9,10]. ...
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The magnitude of the cost of chronic pain has been a matter of concern in many countries worldwide. The high prevalence, the cost it implies for the health system, productivity, and absenteeism need to be addressed urgently. Studies have begun describing this problem in Chile, but there is still a debt in highlighting its importance and urgency on contributing to chronic pain financial coverage. This study objective is to estimate the expected cost of chronic pain and its related musculoskeletal diseases in the Chilean adult population. We conducted a mathematical decision model exercise, Markov Model, to estimate costs and consequences. Patients were classified into severe, moderate, and mild pain groups, restricted to five diseases: knee osteoarthritis, hip osteoarthritis, lower back pain, shoulder pain, and fibromyalgia. Data analysis considered a set of transition probabilities to estimate the total cost, sick leave payment, and productivity losses. Results show that the total annual cost for chronic pain in Chile is USD 943,413,490, corresponding an 80% to the five diseases studied. The highest costs are related to therapeutic management, followed by productivity losses and sick leave days. Low back pain and fibromyalgia are both the costlier chronic pain-related musculoskeletal diseases. We can conclude that the magnitude of the cost in our country's approach to chronic pain is related to increased productivity losses and sick leave payments. Incorporating actions to ensure access and financial coverage and new care strategies that reorganize care delivery to more integrated and comprehensive care could potentially impact costs in both patients and the health system. Finally, the impact of the COVID-19 pandemic will probably deepen even more this problem.
... The negative impact of diagnostic labels has been further shown amongst patients experiencing low back pain: diagnostic labels which allude to specific pathoanatomy (e.g., 'joint degeneration' or 'disc bulge') led to more imaging and second-opinion consultations compared to those de-emphasizing anatomical structures and damage (e.g., 'episode of back pain', 'lumbar sprain', and 'non-specific low back pain') (O'Keeffe et al., 2022). Such reconceptualization is the aim of several biopsychosocial management strategies for patients with musculoskeletal pain (Leventhal et al., 2016;Carnes et al., 2017;Keefe et al., 2018;O'Sullivan et al., 2018;Ashar et al., 2021), most strikingly expressed in pain education approaches (Moseley and Butler, 2015;Traeger et al., 2018). Educating patients in an evidence-based manner is also concordant with many patients' desire for explanation and diagnosis (McRae and Hancock, 2017). ...
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Introduction While the placebo effect is increasingly recognised as a contributor to treatment effects in clinical practice, the nocebo and other undesirable effects are less well explored and likely underestimated. In the chiropractic, osteopathy and physiotherapy professions, some aspects of historical models of care may arguably increase the risk of nocebo effects. Purpose In this masterclass article, clinicians, researchers, and educators are invited to reflect on such possibilities, in an attempt to stimulate research and raise awareness for the mitigation of such undesirable effects. Implications This masterclass briefly introduces the nocebo effect and its underlying mechanisms. It then traces the historical development of chiropractic, osteopathy, and physiotherapy, arguing that there was and continues to be an excessive focus on the patient's body. Next, aspects of clinical practice, including communication, the therapeutic relationship, clinical rituals, and the wider social and economic context of practice are examined for their potential to generate nocebo and other undesirable effects. To aid reflection, a model to reflect on clinical practice and individual professions through the ‘prism’ of nocebo and other undesirable effects is introduced and illustrated. Finally, steps are proposed for how researchers, educators, and practitioners can maximise positive and minimise negative clinical context.
... Furthermore thought out the 20th century, an effort to avoid anesthetic and analgesic drug side effects, resulted in newborns being exposed to pain. Instead, anesthesiologists were administering oxygen in combination with nitric acid and muscle relaxants [3]. The management of neonatal pain was revolutionized by technical studies in the early 1980s, where the above pain reduction technique, also known as the Liverpool technique, was essentially disproved, as the research showed that the addition of an analgesic to anesthesia resulted in stress reduction due to reduced pain [4]. ...
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Neonates do experience pain and its management is necessary in order to prevent long-term, as well as, short-term effects. The most common source of pain in the neonatal intensive care unit (NICU) is caused by medically invasive procedures. NICU patients have to endure trauma, medical adhesive related skin injuries, heel lance, venipuncture and intramuscular injection as well as nasogastric catheterization besides surgery. A cornerstone in pain assessment is the use of scales such as COMFORT, PIPP-R, NIPS and N-PASS. This narrative review provides an up to date account of neonate pain management used in NICUs worldwide focusing on non-pharmacological methods. Non-steroidal anti-inflammatory drugs have well established adverse side effects and opioids are addictive thus pharmacological methods should be avoided if possible at least for mild pain management. Non-pharmacological interventions, particularly breastfeeding and non-nutritive sucking as primary strategies for pain management in neonates are useful strategies to consider. The best non-pharmacological methods are breastfeeding followed by non-nutritive sucking coupled with sucrose sucking. Regrettably most parents used only physical methods and should be trained and involved for best results. Further research in NICU is essential as the developmental knowledge changes and neonate physiology is further uncovered together with its connection to pain.
... For this purpose, Pain Neuroscience Education (PNE) uses the current understanding of neuroscience to help reconceptualise the experience of pain. 43,44 Translating this for the targeted culture is also important. In fact, PNE has become key to the successful management of chronic pain. ...
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Sergio Hernández-Sánchez, Emilio José Poveda-Pagán, Jose Vicente Toledo-Marhuenda, Carlos Lozano-Quijada Center for Translational Research in Physiotherapy, Department of Pathology and Surgery, Faculty of Medicine, Miguel Hernandez University, Alicante, SpainCorrespondence: Jose Vicente Toledo-Marhuenda, Center for Translational Research in Physiotherapy, Department of Pathology and Surgery, Faculty of Medicine, Miguel Hernandez University, Alicante, Spain, Tel +34 965919204, Email josetoledo@umh.esAbstract: Chronic pain is a significant and costly problem all over the world that negatively impacts the quality of life of sufferers. There are clear discrepancies between the prevalence of chronic pain in society and the low priority assigned to educating future physicians about the complexities of pain. This condition also occurs in other undergraduate health science students, although research in this area has not been studied as much as in medical schools. Based on the International Association for the Study of Pain (IASP) Pain Curriculum Outline, a systematic search of the available literature, and the authors’ own experiences, we highlight some relevant tips to educate health science trainees in the management of patients with chronic pain. These tips highlight current international recommendations for a comprehensive approach to this prevalent problem in society, which should be learnt during the university training of health professionals.Keywords: chronic pain, patient management, interprofessional education, medical education
... Another element is pain neuroscience education (PNE), which helps the patient to understand that CMP can be attributed to the brain instead of tissue damage. As a consequence, fear of perceived danger is reduced and the patient's self-efficacy increases [9]. A third important method is Acceptance and Commitment Therapy (ACT), which is used to reduce the impact of the pain by increasing the patient's psychological flexibility, ultimately teaching the patient to act in line with his/her personal values and goals, despite the presence of pain [10,11]. ...
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Objective: To provide a thorough and systematic description of an interdisciplinary multimodal pain treatment programme (IMPT) for patients with chronic musculoskeletal pain (CMP), using the TIDieR checklist as a guide. Results: The main goal of the 'Centre for Integral Rehabilitation (CIR) Excellent' IMPT is to improve daily functioning, participation and quality of life of patients with CMP by helping them to adapt their behaviour so as to better manage their symptoms. A combination of physical and psychosocial treatment methods is employed, including Emotional Awareness and Expression Therapy (EAET), Pain Neuroscience Education (PNE), Acceptance and Commitment Therapy (ACT), graded activity, exposure in vivo, and experiential learning through physical training. The interdisciplinary treatment team comprises physiotherapists, psychologists and a physiatrist. The programme lasts 10 weeks (61 h in total) and consists of three phases: a start (Week 1), education (Weeks 2-3), and skills learning phase (Weeks 4-10). Patients come in twice a week and participate in 2-4 sessions (3-4 h) per treatment day. The programme consists of both individual (physical and mental coaching) and group sessions (education, movement and behaviour outdoors/indoors). Individualisation through personal goal-setting is an important characteristic of the treatment, as well as frequent interdisciplinary consultation between care providers.
... This is greater than just taking the role of teacher 700 or expert. Over the past two decades there has been 701 a focus on therapists teaching people about chronic 702 pain through educational psychology principles [49]. to not only ask the therapist for advice, but also 767 to ask the therapist to share what they themselves 768 would do if they were in the same situation [54]. ...
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BACKGROUND: People with chronic pain may seek rehabilitation to reduce pain and restore productivity and valued roles. Theoretically, a biopsychosocial approach makes rehabilitation more meaningful, however, the limited research on meaningful rehabilitation predominantly describes the perspective of therapists and researchers. The client’s perspective of meaningfulness in rehabilitation is lacking. OBJECTIVE: To investigate the experience of meaningfulness in rehabilitation from the perspective of people with chronic pain. METHOD: Qualitative, semi-structured interviews were conducted with Australian adults who had chronic pain and recent experience of occupational therapy or physiotherapy. Sampling continued until thematic saturation occurred. Transcripts were coded and analyzed using theory-driven and data-driven thematic analysis. RESULTS: Ten participants (four males; six females) were interviewed. Pain histories ranged from nine months to 20+ years, with conditions such as fibromyalgia or trauma. Three themes from a prior concept analysis were upheld, and a further three data-driven themes emerged. Results indicate that people with chronic pain seek a “genuine connection”; from a therapist who is “credible”; and can become a “guiding partner”, and they find rehabilitation meaningful when it holds “personal value”; is “self-defined”; and relevant to their sense of “self-identity”. CONCLUSIONS: The genuine connection and guiding partnership with a credible therapist, that is sought by people with chronic pain, may be at odds with aspects of contemporary rehabilitation. Client-defined meaningfulness is an important construct to engage clients in treatment and improve work and other occupational outcomes for people with chronic pain.
... This type of language can elicit nocebo effects, creating feelings of brokenness, damage, weakness, and fragility. (52)(53)(54)(55) The long-term effects that health care providers' language and beliefs can have on their patients must be considered with every patient interaction; this impact is well-established in the literature. (56)(57)(58) ...
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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 codesign 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.
... Furthermore, when comparing different types of pain education, there are clear differences between classical biomedical education (i.e., contents related to pathophysiology and biomechanics) and Pain Neuroscience Education (PNE) (i.e., contents related to pain neurobiology and pain processing). PNE is based on the reconceptualization of pain-related cognitive factors, within a biopsychosocial model, emphasizing that any evidence of danger or safety can increase or decrease the patient's pain experience (Moseley & Butler, 2015). A recent systematic review has supported the efficacy of PNE in people with chronic musculoskeletal pain in terms of improvements in pain catastrophizing, pain-related disability, inactivity, and avoidance behaviours (Louw, Puentedura, Zimney, & Schmidt, 2016). ...
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Background/Objectives The aim of this study was to examine the effectiveness of two video-based multicomponent programs (FIBROWALK) and the Multicomponent Physiotherapy Program (MPP) for patients with fibromyalgia (FM) compared to treatment-as-usual (TAU) only. We posit that FIBROWALK, due to inclusion of specific psychological ingredients (cognitive restructuring and mindfulness), can produce additional clinical benefits when compared to TAU or MPP alone. Methods A total of 330 patients with FM were recruited and randomly allocated (1:1:1) to TAU only, TAU+FIBROWALK, or TAU+MPP. FIBROWALK and MPP consisted of weekly videos on pain neuroscience education, therapeutic exercise and self-management patient education, but only the FIBROWALK intervention provided cognitive restructuring and mindfulness. Both programs were structurally equivalent. Between-group differences in functional impairment, pain, kinesiophobia, anxious-depressive symptoms and physical functioning were evaluated at post-treatment following Intention-To-Treat and complete-case approaches. Results Compared to TAU only, individuals in the FIBROWALK arm showed larger improvements in all clinical outcomes; similarly, participants in the MPP program also showed greater improvements in functional impairment, perceived pain, kinesiophobia, depressive symptoms compared to TAU only. The FIBROWALK intervention showed superior effects in improving pain, anxiety and depressive symptoms and physical functioning compared to MPP. Conclusions This RCT supports the short-term effectiveness of the video-based multicomponent programs FIBROWALK and MPP for FM and provides evidence that cognitive behavioural and mindfulness-based techniques can be clinically useful in the context of physiotherapeutic multicomponent treatment programs.
... 10 This may reduce the fear of pain through understanding that pain does not necessarily mean harm (hurt vs harm). 11 Another aim of pain education is to begin exploring pain management strategies that may be helpful to reduce the impact of pain (e.g., pacing of activities, improving sleep). ...
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Background Chronic pain affects approximately 1 in every 5 Canadians and has a substantial impact on psychological well-being, relationships, ability to attend work or school, and overall functioning. The Ottawa Hospital Pain Clinic introduced orientation sessions, with the aim of providing new patients with pain education to help prepare patients for engagement with multimodal pain management strategies. This report summarizes the results of a formative evaluation of the orientation session at The Ottawa Hospital Pain Clinic to determine whether patients perceived the orientation session as beneficial. Methods Interviews were conducted, transcribed, and then thematically analyzed to understand patients’ perspectives on the orientation session. Coding was done by two team members using the constant comparison analyses method with key ideas, concepts, and patterns identified and compared to identify similarities. Results Between September 6th to October 18th, 2019, 18 patients attended an orientation session and 12 consented to participation and completed telephone interviews. The 6 themes identified included: 1) Feeling of community; 2) Participants feeling heard by providers; 3) Appreciation of the holistic approach; 4) Availability of community resources; 5) Barriers to access; and 6) Discordant feelings of preparedness for the physician appointment. Conclusion Results from this evaluation indicate that the orientation session offered at The Ottawa Hospital Pain Clinic improves chronic pain literacy, reduces feeling of isolation, and instills hope. As such, it appears to be a valuable component of pain clinic programs.
... The new approach also differed from cognitive therapy insofar as it was developed using an educational framework and was based on instructional design and conceptual change principles. 32 Language, lexicon, types of clinical population, delivery format and medium of persistent pain education have diversified, but learning objectives and content less so. 14,29,31,34,50 That is, educational content and delivery has been predominantly delivered in a clinician-as-expert manner, an approach that is consistent with the conventional translational research pipeline 20 but one that fails to apply contemporary education theory effectively. ...
Article
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.
... 3,4) PNE is an educational method among therapeutic approaches used by physical therapists or occupational therapists to transfer physiological knowledge about pain to patients and to change the concept of pain from a biomedical to a biopsychosocial phenomenon. 5) Questionnaires that assess knowledge, attitudes, and beliefs regarding pain are considered a possible way to assess whether a therapist is ready to perform PNE. Typical examples of assessment include the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT), 6) the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS), 7) and the Neurophysiology of Pain Questionnaire (NPQ). ...
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Objectives: Pain neuroscience education (PNE) has been shown to be effective in reducing pain in people with chronic musculoskeletal pain. Knowledge of pain physiology is necessary to undertake PNE, and a measure for such knowledge is necessary. The Knowledge and Attitudes of Pain (KNAP), a comprehensive assessment of knowledge, attitudes, and beliefs regarding pain for healthcare practitioners, was developed in 2020 through the assessment of construct validity, reliability, and responsiveness in Dutch and English. This study aimed to conduct cross-cultural adaptation of the KNAP into Japanese and to verify test-retest reliability among Japanese undergraduate physical therapy and occupational therapy students. Methods: Cross-cultural adaptation was performed using Beaton's five-step process. Subsequently, the KNAP was completed by participants with a 2-week interval. The study included second-, third-, and fourth-year undergraduate physical therapy and occupational therapy students. Results: A total of 50 students participated in the pilot test and a Japanese version of KNAP was created. Thirty-nine students completed the Japanese version of KNAP twice. Of the 30 items on the KNAP, the quadratic weighted kappa value was less than 0.4 for only one item (item 15), but reliability was interpreted as sufficient for the overall score, with an intraclass correlation coefficient (95% confidence interval) for the total score of 0.89 (0.80-0.94). Conclusions: This study has developed the Japanese KNAP, which has shown preliminary evidence of adequate test-retest reliability in Japanese undergraduate physical therapy and occupational therapy students.
... Despite the lack of representation for biopsychosocial factors, the therapeutic use of openly stating within public information that fear and catastrophizing are contributors to LBP is unknown [22]. However, it is shown that a focus on tissue pathology may promote the maladaptive attitudes, emotions and behaviors that contribute to pain and disability [23]. Encouragingly, LBP is described as a natural and common phenomenon by majority of websites, this approach has been suggested to help prevent the development of maladaptive reactions contributing to LBP [24]. ...
Article
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Background: Low back pain (LBP) is growing health concern that affects millions of people around the globe, and there are many misconceptions regarding causes, imaging, and appropriate treatment choices. Common people usually search Google seeking information regarding LBP from different websites. However, the content of these widely accessible websites have not be evaluated in the light of evidence. The present study aims to analyze the information presented by these websites, summarize the content, and evaluate it against the published literature. Methods: We conducted a systematic search of Google using search terms "low back pain, " "back pain, " "backache. NVivo software was used to capture the content from the internet. Content analysis (CA) was used to analyze online consumer information concerning LBP on the included websites. Results: A total of 53 websites were included in the study by screening the search pages. There were erroneous information present on majority of the websites. Almost all of the websites consisted of nocebic terms. The causes were more oriented towards biomedical model. Treatment options mentioned did not concur with the recent clinical practice guidelines. Conclusion: The Online information retrieved from a Google search lacks representation of the current best research. The findings of the study suggest that future development of websites must include information that is more accurate , and evidence driven. Online LBP information should be based on criteria that are more sensitive to the psychosocial factors that contribute to pain.
Article
Aim To assess the efficacy of pain neuroscience education combined with physiotherapy for the management of migraine. Background Physiotherapy can significantly reduce the frequency of migraine, but the evidence is based only on a few studies. Pain neuroscience education might pose a promising treatment, as it addresses migraine as a chronic pain disease. Methods In this non-blinded randomized controlled trial, migraine patients received physiotherapy + pain neuroscience education or physiotherapy alone, preceded by a three-month waiting period. Primary outcomes were frequency of headache (with and without migraine features), frequency of migraine and associated disability. Results Eighty-two participants were randomized and analyzed. Both groups showed a decrease of headache frequency (p = 0.02, d = 0.46) at post-treatment (physiotherapy: 0.77 days, 95%CI: −0.75 to 2.29 and physiotherapy + pain neuroscience education: 1.25 days, 95%CI: −0.05 to 2.55) and at follow-up (physiotherapy: 1.93, 95%CI: 0.07 to 3.78 and physiotherapy + pain neuroscience education: 3.48 days, 95%CI: 1.89 to 5.06), with no difference between groups (p = 0.26, d = 0.26). Migraine frequency was reduced significantly in the physiotherapy + pain neuroscience education group, and not in the physiotherapy group, at post-treatment (1.28 days, 95%CI: 0.34 to 2.22, p = 0.004) and follow-up (3.05 days, 95%CI: 1.98 to 5.06, p < 0.0001), with a difference between groups at follow-up (2.06 days, p = 0.003). Migraine-related disability decreased significantly in both groups (physiotherapy: 19.8, physiotherapy + pain neuroscience education: 24.0 points, p < 0.001, d = 1.15) at follow-up, with no difference between groups (p = 0.583). Secondary outcomes demonstrated a significant effect of time with no interaction between time and group. No harm or adverse events were observed during the study. Conclusion In comparison to physiotherapy alone, pain neuroscience education combined with physiotherapy can further reduce the frequency of migraine, but had no additional effect on general headache frequency or migraine-related disability. Trial Registration The study was pre-registered at the German Clinical Trials Register (DRKS00020804).
Article
The biopsychosocial (BPS) model of chronic pain can be illustrated in many ways. Our aim is to adapt three illustrations of the BPS approach selected from the literature to target different groups: patients, health professionals and clinical trainees. In clinician-patient consultations, we use an illustration which shows the interactions among the BPS domains in the creation of suffering and pain behaviours in a "vicious spiral". Moreover, we help our patients understand chronic pain often does not entail remaining tissue damage. In clinical practice, we communicate to other health professionals that the relative contribution of each BPS domain varies from patient to patient. This disproportional contribution may also change dynamically over the time. In teaching clinical trainees, we combine thoroughness (i.e., focus on "details") with an understanding of the "dynamics" of pain chronification/chronic pain, i.e., focus on helping the trainee identify the mutual and joint interactions between different parts of the BPS framework. CONCLUSION: The three illustrations can be used as pedagogical tools for better-informed BPS perspectives in different settings. PRACTICE IMPLICATIONS: Clinicians need to be keen observers and adapt their communication depending on whom they are talking to.
Article
Purpose The purpose of this paper was first to gain an in-depth understanding of the barriers and facilitators to implementing the BPS model and pain neuroscience education in the current Lebanese physical therapy health care approach and explore its acceptability. Method A qualitative semi-structured interview using purposive sampling was conducted with eight Lebanese physical therapists practising in different governorates. The transcribed text from the interviews was analyzed using inductive thematic analysis. Results Two topics were generated and constructed by the researchers: (1) “barriers to the implementation of pain neuroscience education, with subthemes including (a) “current health care approach,” (b) “basic curriculum and continuing education,” (c) “patients’ barriers”; (2) “facilitators to the implementation of pain neuroscience education,” with subthemes containing (a) “interest in the BPS model, (b) “therapeutic alliance,” and (c) “motivation for future training on BPS approach.” Conclusion The analysis of the results showed that Lebanese physical therapists currently hold a strong biomedical view of chronic pain, assessment, and treatment. However, despite the presence of barriers and challenges, they are aware and open to consider the implementation and future training about the BPS model and pain neuroscience education in their approach. • IMPLICATIONS FOR REHABILITATION • The exploration of potential barriers and facilitators to the bio-psychosocial model and pain neuroscience education implementation may provide an opportunity for better development and design of a culturally sensitive pain neuroscience education material for Arab-speaking and Lebanese physical therapists. • The exploration of barriers and facilitators to the implementation of pain neuroscience education will help to improve pain education and ensure better clinical pain management. • The most important barriers were the dominant characteristic of the Lebanese physical therapist’s health approach, which is focused on a biomechanically oriented model, and their lack of knowledge to approach chronic pain from a biopsychosocial perspective.
Article
Pain is one of the most common and long-lasting side effects reported by women surgically treated for breast cancer. Educational interventions may optimize the current physical therapy modalities for pain prevention or relief in this population. Pain neuroscience education (PNE) is an educational intervention that explains the pain experience not only from a biomedical perspective but also the psychological and social factors that contribute to it. Through a double-blinded randomized controlled trial (EduCan trial) it was investigated if PNE, in addition to the standard physiotherapy program immediately after breast cancer surgery, was more effective over the course of 18 months postoperatively than providing a biomedical explanation for pain. Primary outcome was the change in pain-related disability (Pain Disability Index, 0-70) over 12 months. Secondary outcomes included change in pain intensity, upper limb function, physical activity level, and emotional functioning over 4, 6, 8, 12, and 18 months postoperatively. Multivariate linear models for repeated (longitudinal) measures were used to compare changes. Preoperative and postoperative moderators of the change in pain-related disability were also explored. Of 184 participants randomized, the mean (SD) age in the PNE and biomedical education group was 55.4 (11.5) and 55.2 (11.4) years, respectively. The change in pain-related disability from baseline to 12 months postoperatively did not differ between the 2 groups (PNE 4.22 [95% confidence interval [CI]: 1.40-7.03], biomedical 5.53 [95% CI: 2.74-8.32], difference in change -1.31 [95% CI: -5.28 to 2.65], P = 0.516). Similar results were observed for all secondary outcomes. Future research should explore whether a more patient-tailored intervention would yield better results.
Article
Pain is one of the most prevalent and long‐term adverse effects described by people who have undergone breast cancer surgery. Non‐helpful perceptions and thoughts about pain may contribute to the transition of acute to persistent pain. Adding educational interventions to the current physical therapy program in this population may help to improve or prevent persistent pain. Pain neuroscience education (PNE) is a type of educational intervention that addresses the experience of pain in a broader sense by explaining pain not only from a biomedical perspective, but also from a psychological and social perspective. A double‐blinded randomized controlled trial (EduCan trial) investigated whether PNE, in addition to a standard physiotherapy program immediately after surgery for breast cancer, was more effective on somatosensory functioning in the short (4 months postoperatively) and long term (18 months postoperatively), than providing a biomedical explanation for pain. Somatosensory functioning was evaluated using a self‐reported questionnaire as well as a comprehensive quantitative sensory testing evaluation. The findings of this study revealed that adding six sessions of PNE to a standard physical therapy program (n = 184) did not result in a significantly different course of somatosensory functioning up to 18 months postoperatively as compared to biomedical pain education. These findings provide an interesting basis for future research into who should receive PNE after surgery for breast cancer (e.g., patient profiling or phenotyping) and how we can tailor it to the individual to increase its effectiveness.
Article
Introduction Low back pain (LBP) is the top health condition requiring rehabilitation in the United States. The financial burden of managing LBP is also amongst the highest in the United States. Clinical practice guidelines (CPGs) provide management recommendations and have the potential to lower health costs. Limited evidence exists on the impact of CPG implementation on downstream medical costs. Objective To examine the impact of CPG implementation in physical therapist (PT) practice on direct and downstream costs for patients with LBP. Methods A retrospective observational study examined billing data from 270 patients with LBP who were treated at multiple sites within one large academic medical center by PTs who participated in a multifaceted CPG implementation program. Costs were analyzed for direct PT services, downstream medical services, and PT utilization from September 2017 to March 2018 (pre-implementation group) and compared with costs from June 2018 to December 2018 (post-implementation group). Results Direct PT costs were significantly lower post-implementation than pre-implementation mean: $2,863 USD (SD: $1,968) vs. $3,459 USD (SD: $2,838), p = .05, 95% CI [11, 1182]. All downstream costs were lower post-implementation with statistically significant lower costs found in downstream imaging: p = .04, 95% CI [32, 1,905]; pharmacy: p = .03, 95% CI [70, 1,217]; surgery: p = .03, 95% CI [446, 9,152], and “other”: p = .02, 95% CI [627, 7,920]. Conclusion Implementing the LBP CPG in outpatient PT practice can have a positive impact on lowering downstream costs and the potential to increase the value of PT services.
Article
Background: Pain science education is commonly integrated into treatments for childhood-onset chronic pain. A core component of pain science education is learning about, and often reconceptualizing, the biology of chronic pain. Yet, few interventions have been developed specifically for young adults and little is known about how young adults conceptualize the biology of pain. This study used a qualitative methodology to examine how young adults with childhood-onset chronic pain understand the biology of pain, and the language they use in this meaning-making process, which may inform future interventions tailored to this age group. Methods: We identified a cohort of young adults with childhood onset chronic pain, and a subset of 17 young adults with continuing chronic pain completed individual, semi-structured interviews. Telephone interviews were audio recorded, transcribed verbatim, and analysed using reflexive thematic analysis. Results: We generated four themes to capture participants' conceptualization of the biology of pain: 1) Something is wrong with the body, 2) An injury hasn't healed, 3) Nerves fire when they shouldn't, 4) An overactive stress system. Conclusion: These conceptualisations, and the language used by young adults with childhood-onset chronic pain to describe them are discussed. Recommendations are provided for how pain science education interventions can be tailored for young adults.
Article
Resumen Introducción Los trastornos temporomandibulares son la causa más común de dolor crónico orofacial. Intervenciones pasivas como la terapia manual (TM) es de las herramientas más utilizadas. Sin embargo, este tipo de abordajes puede resultar insuficiente. La investigación de nuevas estrategias, ahora de naturaleza activa, como son el ejercicio o la educación, es necesaria para generar un cambio en la práctica clínica de los profesionales sanitarios y brindar una atención completa al paciente con dolor crónico. Objetivos Analizar el efecto de tres abordajes principales de forma combinada sobre el dolor, factores psicosociales, variables funcionales y biomecánicas. Métodos Se siguió un diseño de estudio de casos compuesto por tres sujetos divididos en tres modelos de intervención: educación para el dolor y terapia manual (PEdu + TM), ejercicio terapéutico y terapia manual (PEjerc + TM) y terapia manual cervical y orofacial (PTM). El periodo de intervención duró 3-4 semanas; las medidas fueron tomadas en tres momentos: preintervención, postintervención inmediata y 45 días postintervención. Dolor, características psicosociales y funcionalidad del paciente fueron evaluadas con diferentes herramientas validadas. Resultados Los resultados mostraron a corto plazo una mejora en todas las variables analizadas en el PEdu + TM y en el PEjerc + TM, pero no en el PTM. A medio plazo (45 días postintervención), el PEdu + TM mostró beneficios en todas las variables estudiadas mientras que el PEjerc + TM generó cambios positivos en las mismas variables excluyendo el dolor. Conclusión El tratamiento combinado podría ser una intervención más eficaz que la terapia manual a solas, siendo necesarios ensayos clínicos aleatorizados que corroboren dichos hallazgos.
Article
Objectives: An important part of providing pain science education is to first assess baseline knowledge and beliefs about pain, thereby identifying misconceptions and establishing individually-tailored learning objectives. The Concept of Pain Inventory (COPI) was developed to support this need. This study aimed to characterize concept of pain in care-seeking youth and their parents, to examine its clinical and demographic correlates, and to identify conceptual gaps. Methods: Following an initial interdisciplinary evaluation, a cohort of 127 youth aged 8-18 years, and their parents, completed a series of questionnaires. Results: Parents had slightly higher COPI scores than youth did, reflecting parents' greater alignment with contemporary pain science. The moderate positive association with older age among youth (r=.32) suggests that the COPI is sensitive to cognitive development and/or life experiences. Youth and parent COPI responses were weakly associated (r=0.24), highlighting the importance of targeting concept of pain in both groups. For both parents and youth, 'Learning about pain can help you feel less pain' was the least endorsed concept. This conceptual 'gap' is a key point of intervention, that could potentially lead to greater engagement with multidisciplinary pain treatment. Discussion: The COPI appears useful for identifying conceptual gaps or 'sticking points'; this may be an important step to pre-emptively address misconceptions about pain via pain science education. Future research should determine the utility of the COPI in assessing and treating youth seeking care for pain. The COPI may be a useful tool for tailoring pain science education to youth and their parents.
Article
Background: Good clinical outcomes in orthopaedics are largely dictated by the biomedical model, despite mounting evidence of the role of psychosocial factors. Understanding orthopaedic providers' conceptualizations of good clinical outcomes and what facilitates and hinders them may highlight critical barriers and opportunities for training providers on biopsychosocial models of care and integrating them into practice. Questions/purposes: (1) How do orthopaedic trauma healthcare providers define good clinical outcomes for their patients after an acute orthopaedic injury? (2) What do providers perceive as barriers to good outcomes? (3) What do providers perceive as facilitators of good outcomes? For each question, we explored providers' responses in a biopsychosocial framework. Methods: In this cross-sectional, qualitative study, we recruited 94 orthopaedic providers via an electronic screening survey from three Level I trauma centers in geographically diverse regions of the United States (rural southeastern, urban southwestern, and urban northeastern). This study was part of the first phase of a multisite trial testing the implementation of a behavioral intervention to prevent chronic pain after acute orthopaedic injury. Of the 94 participants who were recruited, 88 completed the screening questionnaire. Of the 88 who completed it, nine could not participate because of scheduling conflicts. Thus, the final sample included 79 participants: 48 surgeons (20 attendings, 28 residents; 6% [three of 48] were women, 94% [45 of 48] were between 25 and 55 years old, 73% [35 of 48] were White, and 2% [one of 48] were Hispanic) and 31 other orthopaedic professionals (10 nurse practitioners, registered nurses, and physician assistants; 13 medical assistants; five physical therapists and social workers; and three research fellows; 68% [21 of 31] were women, 97% [30 of 31] were between 25 and 55 years old, 71% [22 of 31] were White, and 39% [12 of 31] were Hispanic). Using a semistructured interview, our team of psychology researchers conducted focus groups, organized by provider type at each site, followed by individual exit interviews (5- to 10-minute debriefing conversations and opportunities to voice additional opinions one-on-one with a focus group facilitator). In each focus group, providers were asked to share their perceptions of what constitutes a "good outcome for your patients," what factors facilitate these outcomes, and what factors are barriers to achieving those outcomes. Focus groups were approximately 60 minutes long. A research assistant recorded field notes during the focus groups to summarize insights gained and disseminate findings to the broader research team. Using this procedure, we determined that thematic saturation was reached for all topics and no additional focus groups were necessary. Three independent coders identified the codes of good outcomes, outcome barriers, and outcome facilitators and applied this coding framework to all transcripts. Three separate data interpreters collaboratively extracted themes related to biomedical, psychological, and social factors and corresponding inductive subthemes. Results: Although orthopaedic providers' definitions of good outcomes naturally included biomedical factors (bone healing, functional independence, and pain alleviation), they were also marked by nuanced psychosocial factors, including the need for patients to recover from psychological trauma associated with injury and feel heard and understood-not just as outcome facilitators, but also as key outcomes themselves. Regarding perceived barriers to good outcomes, providers interwove psychological and biomedical factors (for example, "if they're a smoker, if they have depression, anxiety…") and discussed how psychological dysfunction (for example, maladaptive avoidance or fear of reinjury) can limit key behaviors during recovery (such as adherence to physical therapy regimens). Unprimed, providers also cited resiliency-related terms from psychological research, including (low) "self-efficacy," "catastrophic thinking," and (lack of) psychological "hardiness" as barriers. Regarding perceived facilitators of good outcomes, various social and socioeconomic factors emerged, including a biosocial connection between recovery, social support, and "privilege" (such as occupation or education). These perspectives emerged across sites and provider types. Conclusion: Although the biomedical model prevails in clinical practice, providers across all sites, in various roles, defined good outcomes and their barriers and facilitators in terms of interconnected biopsychosocial factors without direct priming to do so. Thus, similar Level I trauma centers may be more ready to adopt biopsychosocial care approaches than initially expected. Clinical relevance: Providers' perspectives in this study aligned with a growing body of research on the role of biomedical and psychosocial factors in surgical outcomes and risk of transition to chronic pain. To translate these affirming attitudes into practice, other Level I trauma centers could encourage leaders who adopt biopsychosocial approaches to share their perspectives and train other providers in biopsychosocial conceptualization and treatment.
Article
Wenn Menschen mit chronischen Schmerzen therapeutische Ratschläge ignorieren und körperlich inaktiv bleiben, kann das ganz unterschiedliche Gründe haben. Erst die Evaluation der individuellen Schmerzsituation entlarvt die tatsächlichen Hindernisse für ein Training. Eine patientenzentrierte Zielsetzung, das Berücksichtigen von Präferenzen und eine individuelle Übungsauswahl motivieren die Patient*innen und ebnen so den Weg zu einem aktiveren Lebensstil.
Article
The objective of this study was to determine the effect of enhancing conventional care for people with chronic painful temporomandibular disorders (TMD) with an individualised contemporary pain science education (PSE) intervention. In this randomized controlled trial, a consecutive sample of 148 participants (18 to 55 years of age) was randomized into two groups: PSE-enhanced conventional care or Conventional care alone. Conventional care involved a six-week, 12-session manual therapy and exercise program. The PSE enhancement involved two sessions of modern PSE, undertaken in the first two treatment sessions. Primary outcomes were pain intensity, assessed with a numeric pain rating scale, and disability, assessed with the craniofacial pain and disability inventory, post-treatment. Linear mixed model analyses were used to investigate between-group differences over time. There was a statistically and clinically meaningful effect of PSE enhancement on disability (Mean Difference = 6.1, 95% CI: 3.3 to 8.8), but not on pain intensity, post-treatment. Secondary analyses suggested clinically meaningful benefit of PSE enhancement on pain and disability ratings at 10-week and 18-week follow-ups, raising the possibility that preceding conventional care with a PSE intervention may result in long-term benefits. Perspective: The addition of modern Pain Science Education (PSE) intervention improved disability for people with chronic TMD receiving manual therapy and exercise, but not pain. A mean difference in pain and disability favoring the PSE group at the 10- and 18-week follow-ups, respectively, suggests that PSE addition resulted in longer-lasting effects. Trial registration: NCT03926767. Registered on April 29, 2019. https://clinicaltrials.gov/ct2/show/NCT03926767
Article
Objectives Multidisciplinary approaches to treating chronic pain have been proven effective. Currently, chronic pain patients face lengthy waitlists in pain medicine departments. To overcome this problem, we developed the “FastSchool” program to educate patients about pain management and treatment. In this study, we evaluated the benefit of a “FastSchool” session on pain and catastrophizing in chronic pain patients. Methods Included patients had chronic non-cancer pain, no more than 2 visits to a pain medicine department. Patients attended a single 3-hour session, conducted by an interprofessional team. Four topics were addressed: chronic pain mechanisms, pharmacological therapies, physical activity, and the management of analgesics. Patients completed questionnaires at baseline and at 3 months post-session to assess pain interference, pain intensity, and catastrophizing. Results The study population included 88 patients; 71 completed the follow-up questionnaires. Pain interference (p=0.002), average pain intensity (p=0.013), and catastrophizing (p<0.001) decreased 3 months after FastSchool. At M3, 35% of patients felt their pain had improved based on the Patient Global Impression of Change. Conclusion FastSchool, an innovative short-term educational program inspired by cognitive behavioral therapy, showed positive results in reducing pain impact. Practice implications Implementation of FastSchool in pain medicine departments would reduce waitlist times for non-pharmacological treatment.
Chapter
A brief history of pain and its assessment precedes a review of the influence of psychological factors on the perception of pain and its effects in a range of musculoskeletal and neuropathic pain disorders. Research into psychological factors, and models of pain and disability are then described. An overview of psychological interventions precedes a description of secondary prevention, the role of psychological targeting based on risk identification in stratified or matched care and the development of psychologically informed practice (PiP) in clinical and occupational settings. Finally, the importance of the social context and the nature of communication are highlighted.
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The biopsychosocial model (BPS) of chronic pain aspires to be comprehensive, incorporating psychological and social factors omitted from biomedical models. Although psychosocial factors are viewed as highly influential in understanding behavioral and psychological responses to pain, these factors are usually viewed as modifiers of biological causes of the experience of pain itself, rather than as equal contributors to pain. To further advance the BPS model, we re-examine a classic 1994 paper by Wilbert "Bill" Fordyce, "Pain and suffering: what is the unit?" In this paper, Fordyce suggested that pain-related disability and suffering should be viewed as "transdermal", as having causes both inside and outside the body. We consider Fordyce's paper theoretically important because this concept allows us to more fully break free of the medical model of chronic pain than customary formulations of the BPS model. It makes it possible to place psychological and social factors on an equal footing with biological ones in explaining pain itself and to remove distinctions between pain mechanisms and pain meanings. The brain's salience network now offers a platform on which diverse influences on pain experience-from nociception to multisensory indicators of safety or danger-can be integrated, bridging the gap between impersonal nociceptive mechanisms and personal meanings. We also argue that Fordyce's article is practically important because this concept expands the BPS model beyond the bounds of the clinical encounter, opening the door to the full range of social, psychological, and biological interventions, empowering patients and non-medical providers to tackle chronic pain.
Article
Objective Persons living with HIV (PWH) experience a disproportionate level of comorbid chronic pain and depression compared to individuals who do not have a diagnosis of HIV. Many PWH report pain that impairs daily function, is severe, and requires medical management. Depression alone is associated with HIV disease progression, medication non-adherence, and increased mortality. Given that numerous studies show that PWHs have chronic pain and depression despite pharmacologic treatment, there is a clear need for additional treatment modalities to address these conditions. Design In this paper, we describe our protocol for a multisite, randomized controlled trial of the effectiveness of a collaborative behavioral intervention, called HIV-Pain and Sadness Support (HIVPASS), designed for PWH who endorse chronic pain and depressive symptoms, as compared to an attention matched Health Education (HE) condition. The HIVPASS intervention is based on Behavioral Activation and designed to target both pain and depression using an integrated model that promotes collaboration between HIV medical and psychological providers. Setting and methods We plan to (1) recruit PWH who endorse chronic pain and depression in three sites located in New England and the Midwestern United States and (2) compare our HIVPASS intervention to a full attention matched HE intervention with the primary outcome of pain interference, and secondary outcomes of depression, physical activity, HIV medication adherence, and health-related quality of life. Follow-up assessments will occur monthly for three months during the intervention phase and then during the post-intervention phase at months four, six, nine and twelve. Conclusions We provide descriptions of our protocol and interventions of our randomized controlled trial for comorbid chronic pain and depression in PWH. Trial Registration: ClinicalTrials.gov NCT02766751 https://clinicaltrials.gov/ct2/show/NCT02766751?term=stein%2C+michael&draw=2&rank=5
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Pain and dizziness are common experiences throughout the lifespan. However, nearly a quarter of those with acute pain or dizziness experience persistence, which is associated with disability, social isolation, psychological distress, decreased independence, and poorer quality of life. Thus, persistent pain or dizziness impacts peoples' lives in similarly negative ways. Conceptual models of pain and dizziness also have many similarities. Many of these models are more expansive than explaining mere symptoms; rather they describe pain or dizziness as holistic experiences that are influenced by biopsychosocial and contextual factors. These experiences also appear to be associated with multi-modal bodily responses related to evaluation of safety, threat detection and anticipation, as influenced by expectations, and predictions anticipation, not simply a reflection of tissue injury or pathology. Conceptual models also characterize the body as adaptable and therefore capable of recovery. These concepts may provide useful therapeutic narratives to facilitate understanding, dethreaten the experience, and provide hope for patients. In addition, therapeutic alliance, promoting an active movement-based approach, building self-efficacy, and condition-specific approaches can help optimize outcomes. In conclusion, there are significant overlaps in the patient experience, theoretical models and potential therapeutic narratives that guide care for people suffering with persistent pain or dizziness.
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This review summarizes the current meta-analysis literature on treatment outcomes of CBT for a wide range of psychiatric disorders. A search of the literature resulted in a total of 16 methodologically rigorous meta-analyses. Our review focuses on effect sizes that contrast outcomes for CBT with outcomes for various control groups for each disorder, which provides an overview of the effectiveness of cognitive therapy as quantified by meta-analysis. Large effect sizes were found for CBT for unipolar depression, generalized anxiety disorder, panic disorder with or without agoraphobia, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders. Effect sizes for CBT of marital distress, anger, childhood somatic disorders, and chronic pain were in the moderate range. CBT was somewhat superior to antidepressants in the treatment of adult depression. CBT was equally effective as behavior therapy in the treatment of adult depression and obsessive-compulsive disorder. Large uncontrolled effect sizes were found for bulimia nervosa and schizophrenia. The 16 meta-analyses we reviewed support the efficacy of CBT for many disorders. While limitations of the meta-analytic approach need to be considered in interpreting the results of this review, our findings are consistent with other review methodologies that also provide support for the efficacy CBT.
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IMPORTANCE Reassurance is a core aspect of daily medical practice, yet little is known on how it can be achieved. OBJECTIVE To determine whether patient education in primary care increases reassurance in patients with acute or subacute low back pain (LBP). DATA SOURCES Medline, EMBASE, Cochrane Central Register for Controlled Trials, and PsychINFO databases were searched to June 2014. DESIGN Systematic review and meta-analysis of randomized and nonrandomized clinical trials. STUDY SELECTION To be eligible, studies needed to be controlled trials of patient education for LBP that were delivered in primary care and measured reassurance after the intervention. Eligibility criteria were applied, and studies were selected by 2 independent authors. MAIN OUTCOMES AND MEASURES The primary outcomes were reassurance in the short and long term and health care utilization at 12 months. DATA EXTRACTION AND SYNTHESIS Data were extracted by 2 independent authors and entered into a standardized form. A random-effects meta-analysis tested the effects of patient education compared with usual care on measures of reassurance. To investigate the effect of study characteristics, we performed a preplanned subgroup analysis. Studies were stratified according to duration, content, and provider of patient education. RESULTS We included 14 trials (n = 4872) of patient education interventions. Trials assessed reassurance with questionnaires of fear, worry, anxiety, catastrophization, and health care utilization. There is moderate-to high-quality evidence that patient education increases reassurance more than usual care/control education in the short term (standardized mean difference [SMD], −0.21; 95% CI, −0.35 to −0.06) and long term (SMD, −0.15; 95% CI, −0.27 to −0.03). Interventions delivered by physicians were significantly more reassuring than those delivered by other primary care practitioners (eg, physiotherapist or nurse). There is moderate-quality evidence that patient education reduces LBP-related primary care visits more than usual care/control education (SMD, −0.14; 95% CI, −0.28 to −0.00 at a 12-month follow-up). The number needed to treat to prevent 1 LBP-related visit to primary care was 17. CONCLUSIONS AND RELEVANCE There is moderate-to high-quality evidence that patient education in primary care can provide long-term reassurance for patients with acute or subacute LBP.
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Introduction: Low back pain (LBP) is the leading cause of disability worldwide. Of those patients who present to primary care with acute LBP, 40% continue to report symptoms 3 months later and develop chronic LBP. Although it is possible to identify these patients early, effective interventions to improve their outcomes are not available. This double-blind (participant/outcome assessor) randomised controlled trial will investigate the efficacy of a brief educational approach to prevent chronic LBP in 'at-risk' individuals. Methods/analysis: Participants will be recruited from primary care practices in the Sydney metropolitan area. To be eligible for inclusion participants will be aged 18-75 years, with acute LBP (<4 weeks' duration) preceded by at least a 1 month pain-free period and at-risk of developing chronic LBP. Potential participants with chronic spinal pain and those with suspected serious spinal pathology will be excluded. Eligible participants who agree to take part will be randomly allocated to receive 2×1 h sessions of pain biology education or 2×1 h sessions of sham education from a specially trained study physiotherapist. The study requires 101 participants per group to detect a 1-point difference in pain intensity 3 months after pain onset. Secondary outcomes include the incidence of chronic LBP, disability, pain intensity, depression, healthcare utilisation, pain attitudes and beliefs, global recovery and recurrence and are measured at 1 week post-intervention, and at 3, 6 and 12 months post LBP onset. Ethics/dissemination: Ethical approval was obtained from the University of New South Wales Human Ethics Committee in June 2013 (ref number HC12664). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conference meetings. Trial registration number: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12612001180808.
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Study Design. Multicenter, randomized, controlled trial on preoperative pain neuroscience education (NE) for lumbar radiculopathy.Objective. To determine if the addition of NE to usual preoperative education would result in superior outcomes in regards to pain, function, surgical experience and healthcare utilization post-surgery.Summary of Background Data. One in four patients following lumbar surgery (LS) for radiculopathy experience persistent pain and disability, which is non-responsive to perioperative treatments. NE focusing on the neurophysiology of pain has been shown to decrease pain and disability in chronic low back pain (LBP) populations.Methods. Eligible patients scheduled for LS for radiculopathy were randomized to receive either usual preoperative care (UC) or a combination of UC plus one session of NE delivered by a physical therapist (verbal one-on-one) and a NE booklet. Sixty-seven patients completed the following outcomes prior to LS (baseline), and one, three, six and 12 months after LS: LBP (Numeric Rating Scale (NRS)), leg pain (NRS), function (Oswestry Disability Index), various beliefs and experiences related to LS (10 item survey with Likert responses), and post-operative utilization of healthcare (Utilization of Healthcare Questionnaire).Results. At one-year follow up, there were no statistical difference between the experimental and control groups in regards to primary outcome measure of LBP (p = 0.183), leg pain (p = 0.075) and function (p = 0.365). In a majority of the categories regarding surgical experience, the NE group scored significantly better: better prepared for LS (p = 0.001); preoperative session preparing them for LS (p < 0.001) and LS meeting their expectations (p = 0.021). Healthcare utilization post-LS also favored the NE group (p = 0.007) resulting in 45% less healthcare expenditure compared to the control group in the 1-year follow-up period.Conclusion. NE resulted in significant behavior change. Despite a similar pain and functional trajectory over the one year trial, LS patients who received NE viewed their surgical experience more favorably and utilized less healthcare in the form of medical tests and treatments.
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Mounting evidence supports the use of face-to-face pain neuroscience education for the treatment of chronic pain patients. This study aimed at examining whether written education about pain neuroscience improves illness perceptions, catastrophizing, and health status in patients with fibromyalgia. A double-blind, multicenter randomized controlled clinical trial with 6-month follow-up was conducted. Patients with FM (n = 114) that consented to participate were randomly allocated to receive either written pain neuroscience education or written relaxation training. Written pain neuroscience education comprised of a booklet with pain neuroscience education plus a telephone call to clarify any difficulties; the relaxation group received a booklet with relaxation education and a telephone call. The revised illness perception questionnaire, Pain Catastrophizing Scale, and fibromyalgia impact questionnaire were used as outcome measures. Both patients and assessors were blinded. Repeated-measures analyses with last observation carried forward principle were performed. Cohen's d effect sizes (ES) were calculated for all within-group changes and between-group differences. The results reveal that written pain neuroscience education does not change the impact of FM on daily life, catastrophizing, or perceived symptoms of patients with FM. Compared with written relaxation training, written pain neuroscience education improved beliefs in a chronic timeline of FM (P = 0.03; ES = 0.50), but it does not impact upon other domains of illness perceptions. Compared with written relaxation training, written pain neuroscience education slightly improved illness perceptions of patients with FM, but it did not impart clinically meaningful effects on pain, catastrophizing, or the impact of FM on daily life. Face-to-face sessions of pain neuroscience education are required to change inappropriate cognitions and perceived health in patients with FM.
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Brains, it has recently been argued, are essentially prediction machines. They are bundles of cells that support perception and action by constantly attempting to match incoming sensory inputs with top-down expectations or predictions. This is achieved using a hierarchical generative model that aims to minimize prediction error within a bidirectional cascade of cortical processing. Such accounts offer a unifying model of perception and action, illuminate the functional role of attention, and may neatly capture the special contribution of cortical processing to adaptive success. This target article critically examines this "hierarchical prediction machine" approach, concluding that it offers the best clue yet to the shape of a unified science of mind and action. Sections 1 and 2 lay out the key elements and implications of the approach. Section 3 explores a variety of pitfalls and challenges, spanning the evidential, the methodological, and the more properly conceptual. The paper ends (sections 4 and 5) by asking how such approaches might impact our more general vision of mind, experience, and agency.
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Might science need philosophy for a precise and complete understanding of pain?
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To evaluate the evidence for the effectiveness of neuroscience education (NE) for pain, disability, anxiety, and stress in chronic musculoskeletal (MSK) pain. Systematic searches were conducted on Biomed Central, BMJ.com, CINAHL, the Cochrane Library, NLM Central Gateway, OVID, ProQuest (Digital Dissertations), PsycInfo, PubMed/Medline, ScienceDirect, and Web of Science. Secondary searching (PEARLing) was undertaken, whereby reference lists of the selected articles were reviewed for additional references not identified in the primary search. All experimental studies including randomized controlled trials (RCTs), nonrandomized clinical trials, and case series evaluating the effect of NE on pain, disability, anxiety, and stress for chronic MSK pain were considered for inclusion. Additional limitations: studies published in English, published within the last 10 years, and patients older than 18 years. No limitations were set on specific outcome measures of pain, disability, anxiety, and stress. Data were extracted using the participants, interventions, comparison, and outcomes (PICO) approach. Methodological quality was assessed by 2 reviewers using the Critical Review Form-Quantitative Studies. This review includes 8 studies comprising 6 high-quality RCTs, 1 pseudo-RCT, and 1 comparative study involving 401 subjects. Most articles were of good quality, with no studies rated as poor or fair. Heterogeneity across the studies with respect to participants, interventions evaluated, and outcome measures used prevented meta-analyses. Narrative synthesis of results, based on effect size, established compelling evidence that NE may be effective in reducing pain ratings, increasing function, addressing catastrophization, and improving movement in chronic MSK pain. For chronic MSK pain disorders, there is compelling evidence that an educational strategy addressing neurophysiology and neurobiology of pain can have a positive effect on pain, disability, catastrophization, and physical performance.
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Objective: The aim of this study was to compare the effectiveness of a combination of aquatic exercise and pain neurophysiology education with aquatic exercise alone in chronic low back pain patients. Design: Single-blind randomized controlled trial. Setting: Outpatient clinic. Subjects: Sixty-two chronic low back pain patients were randomly allocated to receive aquatic exercise and pain neurophysiology education (n = 30) or aquatic exercise alone (n = 32). Interventions: Twelve sessions of a 6-week aquatic exercise programme preceded by 2 sessions of pain neurophysiology education. Controls received only 12 sessions of the 6-week aquatic exercise programme. Main measures: The primary outcomes were pain intensity (Visual Analogue Scale) and functional disability (Quebec Back Pain Disability Scale) at the baseline, 6 weeks after the beginning of the aquatic exercise programme and at the 3 months follow-up. Secondary outcome was kinesiophobia (Tampa Scale of Kinesiophobia). Results: Fifty-five participants completed the study. Analysis using mixed-model ANOVA revealed a significant treatment condition interaction on pain intensity at the 3 months follow-up, favoring the education group (mean SD change: −25.4± 26.7 vs −6.6 ± 30.7, P < 0.005). Although participants in the education group were more likely to report perceived functional benefits from treatment at 3 months follow-up (RR=1.63, 95%CI: 1.01–2.63), no significant differences were found in functional disability and kinesiophobia between groups at any time. Conclusions: This study’s findings support the provision of pain neurophysiology education as a clinically effective addition to aquatic exercise.
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Study design: Multicenter, randomized, controlled trial on preoperative pain neuroscience education (NE) for lumbar radiculopathy. Objective: To determine if the addition of NE to usual preoperative education would result in superior outcomes with regard to pain, function, surgical experience, and health care utilization postsurgery. Summary of background data: One in 4 patients after lumbar surgery (LS) for radiculopathy experience persistent pain and disability, which is nonresponsive to perioperative treatments. NE focusing on the neurophysiology of pain has been shown to decrease pain and disability in populations with chronic low back pain. Methods: Eligible patients scheduled for LS for radiculopathy were randomized to receive either preoperative usual care (UC) or a combination of UC plus 1 session of NE delivered by a physical therapist (verbal one-on-one format) and a NE booklet. Sixty-seven patients completed the following outcomes prior to LS (baseline), and 1, 3, 6, and 12 months after LS: low back pain (numeric rating scale), leg pain (numeric rating scale), function (Oswestry Disability Index), various beliefs and experiences related to LS (10-item survey with Likert scale responses), and postoperative utilization of health care (utilization of health care questionnaire). Results: At 1-year follow-up, there were no statistical differences between the experimental and control groups with regard to primary outcome measure of low back pain (P = 0.183), leg pain (P = 0.075), and function (P = 0.365). In a majority of the categories regarding surgical experience, the NE group scored significantly better: better prepared for LS (P = 0.001); preoperative session preparing them for LS (P < 0.001) and LS meeting their expectations (P = 0.021). Health care utilization post-LS also favored the NE group (P = 0.007) resulting in 45% less health care expenditure compared with the control group in the 1-year follow-up period. Conclusion: NE resulted in significant behavior change. Despite a similar pain and functional trajectory during the 1-year trial, patients with LS who received NE viewed their surgical experience more favorably and used less health care facility in the form of medical tests and treatments. Level of evidence: 2.
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Unlabelled: Multiple investigators have recently asked whether neuroimaging has shown that chronic pain is a brain disease. We review the clinical implications of seeing chronic pain as a brain disease. Abnormalities noted on imaging of peripheral structures have previously misled the clinical care of patients with chronic pain. We also cannot assume that the changes associated with chronic pain on neuroimaging are causal. When considering the significance of neuroimaging results, it is important to remember that "disease" is a concept that arises out of clinical medicine, not laboratory science. Following Canguilhem, we believe that disease is best defined as a structural or functional change that causes disvalue to the whole organism. It is important to be cautious in our assertions about chronic pain as a brain disease because these may have negative effects on 1) the therapeutic dialogue between clinicians and patients; 2) the social dialogue about reimbursement for pain treatments and disability due to pain; and 3) the chronic pain research agenda. Considered scientifically, we may be looking for the cause of chronic pain through neuroimaging, but considered clinically, we are in fact often looking to validate pain complaints. We should not yield to the temptation to validate pain with the magnetic resonance imaging scanner (structural or functional). We should not see pain as caused by the brain alone. Pain is not felt by the brain, but by the person. Perspective: Neuroimaging investigators have argued that brain imaging may demonstrate that chronic pain is a brain disease. We argue that "disease" is a clinical concept and that conceiving of chronic pain as a brain disease can have negative consequences for research and clinical care of patients with chronic pain.
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Objectives: There is evidence that education on pain physiology can have positive effects on pain, disability, and catastrophization in patients with chronic musculoskeletal pain disorders. A double-blind randomized controlled trial (RCT) was performed to examine whether intensive pain physiology education is also effective in fibromyalgia (FM) patients, and whether it is able to influence the impaired endogenous pain inhibition of these patients. Methods: Thirty FM patients were randomly allocated to either the experimental (receiving pain physiology education) or the control group (receiving pacing self-management education). The primary outcome was the efficacy of the pain inhibitory mechanisms, which was evaluated by spatially accumulating thermal nociceptive stimuli. Secondary outcome measures included pressure pain threshold measurements and questionnaires assessing pain cognitions, behavior, and health status. Assessments were performed at baseline, 2 weeks, and 3 months follow-up. Repeated measures ANOVAS were used to reveal possible therapy effects and effect sizes were calculated. Results: After the intervention the experimental group had improved knowledge of pain neurophysiology (P<0.001). Patients from this group worried less about their pain in the short term (P=0.004). Long-term improvements in physical functioning (P=0.046), vitality (P=0.047), mental health (P<0.001), and general health perceptions (P<0.001) were observed. In addition, the intervention group reported lower pain scores and showed improved endogenous pain inhibition (P=0.041) compared with the control group. Discussion: These results suggest that FM patients are able to understand and remember the complex material about pain physiology. Pain physiology education seems to be a useful component in the treatment of FM patients as it improves health status and endogenous pain inhibition in the long term.
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Objectives: Reconceptualization of pain and reduction of pain-related catastrophizing are primary objectives in chronic pain rehabilitation. Teaching people about the underlying biology of pain has been shown to facilitate these objectives. The objective of this study was to investigate whether written metaphor and story can be used to increase knowledge of the biology of pain and reduce pain-related catastrophizing. Methods: In this randomized single-blind partial cross-over controlled trial, 79 people with chronic pain received either a booklet of metaphors and stories conveying key pain biology concepts or a booklet containing advice on how to manage chronic pain according to established cognitive-behavioral principles. The primary outcome variables, pain biology knowledge and catastrophizing, were measured before randomization, at 3 weeks and at 3 months, at which time the control group was crossed over to receive the metaphors and stories booklet. Pain and disability were secondary outcome variables. Results: The Metaphors group showed larger changes in both variables (time × group interactions: P < 0.01, effect size Cohen d = 0.7 for catastrophizing and 1.7 for pain biology knowledge). Gains were maintained for at least 3 months. Changes were replicated in the Advice group when crossed over. There was no change in pain or self-reported disability in either group. Discussion: We conclude that providing educational material through metaphor and story can assist patients to reconceptualize pain and reduce catastrophizing. Metaphor and story could be used as a precurser to other interventions that target functional capacity.
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Studies exploring how students learn and understand science processes such as diffusion and natural selection typically find that students provide misconceived explanations of how the patterns of such processes arise (such as why giraffes' necks get longer over generations, or how ink dropped into water appears to "flow"). Instead of explaining the patterns of these processes as emerging from the collective interactions of all the agents (e.g., both the water and the ink molecules), students often explain the pattern as being caused by controlling agents with intentional goals, as well as express a variety of many other misconceived notions. In this article, we provide a hypothesis for what constitutes a misconceived explanation; why misconceived explanations are so prevalent, robust, and resistant to instruction; and offer one approach of how they may be overcome. In particular, we hypothesize that students misunderstand many science processes because they rely on a generalized version of narrative schemas and scripts (referred to here as a Direct-causal Schema) to interpret them. For science processes that are sequential and stage-like, such as cycles of moon, circulation of blood, stages of mitosis, and photosynthesis, a Direct-causal Schema is adequate for correct understanding. However, for science processes that are non-sequential (or emergent), such as diffusion, natural selection, osmosis, and heat flow, using a Direct Schema to understand these processes will lead to robust misconceptions. Instead, a different type of general schema may be required to interpret non-sequential processes, which we refer to as an Emergent-causal Schema. We propose that students lack this Emergent Schema and teaching it to them may help them learn and understand emergent kinds of science processes such as diffusion. Our study found that directly teaching students this Emergent Schema led to increased learning of the process of diffusion. This article presents a fine-grained characterization of each type of Schema, our instructional intervention, the successes we have achieved, and the lessons we have learned.