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The interview of a patient attending physical therapy is the cornerstone of the physical examination, diagnosis, plan of care, prognosis, and overall efficacy of the therapeutic experience. A thorough, skilled interview drives the objective tests and measures chosen, as well as provides context for the interpretation of those tests and measures, during the physical examination. Information from the interview powerfully influences the treatment modalities chosen by the physical therapist (PT) and thus also impacts the overall outcome and prognosis of the therapy sessions. Traditional physical therapy focuses heavily on biomedical information to educate people about their pain, and this predominant model focusing on anatomy, biomechanics, and pathoanatomy permeates the interview and physical examination. Although this model may have a significant effect on people with acute, sub-acute or postoperative pain, this type of examination may not only gather insufficient information regarding the pain experience and suffering, but negatively impact a patient’s pain experience. In recent years, physical therapy treatment for pain has increasingly focused on pain science education, with increasing evidence of pain science education positively affecting pain, disability, pain catastrophization, movement limitations, and overall healthcare cost. In line with the ever-increasing focus of pain science in physical therapy, it is time for the examination, both subjective and objective, to embrace a biopsychosocial approach beyond the realm of only a biomedical approach. A patient interview is far more than “just” collecting information. It also is a critical component to establishing an alliance with a patient and a fundamental first step in therapeutic neuroscience education (TNE) for patients in pain. This article highlights the interview process focusing on a pain science perspective as it relates to screening patients, establishing psychosocial barriers to improvement, and pain mechanism assessment.
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Physiotherapy Theory and Practice
An International Journal of Physical Therapy
ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: http://www.tandfonline.com/loi/iptp20
Listening is therapy: Patient interviewing from a
pain science perspective
Ina Diener PT, PhD, Mark Kargela PT, DPT, OCS, FAAOMPT & Adriaan Louw
PT, PhD
To cite this article: Ina Diener PT, PhD, Mark Kargela PT, DPT, OCS, FAAOMPT & Adriaan Louw
PT, PhD (2016): Listening is therapy: Patient interviewing from a pain science perspective,
Physiotherapy Theory and Practice, DOI: 10.1080/09593985.2016.1194648
To link to this article: http://dx.doi.org/10.1080/09593985.2016.1194648
Published online: 28 Jun 2016.
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PERSPECTIVE
Listening is therapy: Patient interviewing from a pain science perspective
Ina Diener, PT, PhD
a
, Mark Kargela, PT, DPT, OCS, FAAOMPT
b
, and Adriaan Louw, PT, PhD
c
a
Department of Physical Therapy, Stellenbosch University, Stellenbosch, South Africa;
b
Department of Physical Medicine and Rehabilitation,
Mayo Clinic, Phoenix, AZ, USA;
c
International Spine and Pain Institute, Story City, IA, USA
ABSTRACT
The interview of a patient attending physical therapy is the cornerstone of the physical examina-
tion, diagnosis, plan of care, prognosis, and overall efficacy of the therapeutic experience. A
thorough, skilled interview drives the objective tests and measures chosen, as well as provides
context for the interpretation of those tests and measures, during the physical examination.
Information from the interview powerfully influences the treatment modalities chosen by the
physical therapist (PT) and thus also impacts the overall outcome and prognosis of the therapy
sessions. Traditional physical therapy focuses heavily on biomedical information to educate
people about their pain, and this predominant model focusing on anatomy, biomechanics, and
pathoanatomy permeates the interview and physical examination. Although this model may have
a significant effect on people with acute, sub-acute or postoperative pain, this type of examina-
tion may not only gather insufficient information regarding the pain experience and suffering, but
negatively impact a patients pain experience. In recent years, physical therapy treatment for pain
has increasingly focused on pain science education, with increasing evidence of pain science
education positively affecting pain, disability, pain catastrophization, movement limitations, and
overall healthcare cost. In line with the ever-increasing focus of pain science in physical therapy, it
is time for the examination, both subjective and objective, to embrace a biopsychosocial
approach beyond the realm of only a biomedical approach. A patient interview is far more than
justcollecting information. It also is a critical component to establishing an alliance with a
patient and a fundamental first step in therapeutic neuroscience education (TNE) for patients in
pain. This article highlights the interview process focusing on a pain science perspective as it
relates to screening patients, establishing psychosocial barriers to improvement, and pain
mechanism assessment.
ARTICLE HISTORY
Received 12 November 2015
Revised 21 March 2016
Accepted 18 April 2016
KEYWORDS
Interview; neuroscience;
pain; pain education;
physical therapy; therapeutic
relationship
Introduction
Chronic musculoskeletal pain (MSKP) is one of the most
disabling health disorders in the world that causes personal,
social, and economic burden (Vos et al, 2012). Our biolo-
gical understanding of chronic MSKP has increased sub-
stantially (Moseley, 2007;Nijsetal,2012), but in the
majority of patients with chronic MSKP and dysfunctions,
biomedical explanations are unable to fully appreciate the
complex clinical picture of pain complaints, disability, and
distress (Sterling and Kenardy, 2008;Yunus,2007). Due to
the complexity of chronic MSKP, a comprehensive biopsy-
chosocial approach is required for assessment and treat-
ment (Gatchel et al, 2007;Kamperetal,2015). One
emerging biopsychosocial treatment increasingly used by
physical therapists (PTs) is therapeutic neuroscience edu-
cation (TNE) (Louw, Diener, Butler, and Puentedura, 2011;
Louw, Diener, Landers, and Puentedura, 2014). TNE as a
treatment, is an educational approach focused on helping a
patient understand their pain experience from a
neurobiology and neurophysiology (neuroscience) per-
spective, with the aim to produce a therapeutic effect
(Louw and Puentedura, 2013). The current best-evidence
supports the therapeutic effect of neuroscience education
with studies showing TNE providing strong evidence for
reducing pain, disability, pain catastrophization, and lim-
ited movement (Louw, Diener, Butler, and Puentedura,
2011; Moseley, 2002; Moseley, 2004; Moseley, Nicholoas,
and Hodges, 2004). In line with the emerging evidence for
TNE, studies associated with the utilization of TNE have
focused on a variety of disorders including: chronic low
back pain (Moseley, 2002; Moseley, 2004;Moseley,
Nicholas, and Hodges, 2004); lumbar surgery (Louw,
Diener, Landers, and Puentedura, 2014; Puentedura et al,
2009); whiplash associated disorders (Van Oosterwijck,
Nijs, Meeus, and Paul, 2011); and chronic fatigue syndrome
(Meeus et al, 2010). With clinical application of TNE to
various conditions, interest also shifted to a greater under-
standing of the educational delivery methods and content
CONTACT Ina Diener, PT, PhD idiener@icon.co.za Stellenbosch University, Department of Physical Therapy, 16 Formosa Street, Stellenbosch 7600,
South Africa.
PHYSIOTHERAPY THEORY AND PRACTICE
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© 2016 Taylor & Francis
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(Gallagher, McAuley, and Moseley, 2013;Louw,2014;
Louw, Diener, Butler, and Puentedura, 2011).
However, with the increased focus on TNE as a
treatment, PTs may have shifted their focus too
much on the treatment, leaving behind very impor-
tant aspects of TNE, such as information gleaned
from the interview and physical examination. In
fact, it could be argued that a skilled interview
which embraces and incorporates a biopsychosocial
approach may be a key first step of a successful TNE
treatment. The aim of this paper is to illustrate how a
patient interview is far more than justcollecting
information, but rather a critical component to estab-
lishing an alliance with a patient and a fundamental
first step in TNE. Also, this paper does not aim to
describe a detailed, complete interview, but rather
highlights a few key interview issues from a pain
science perspective, like creating a therapeutic alli-
ance, screening patients, establishing psychosocial
barriers to improvement, and assessing pain
mechanisms.
Therapeutic alliance
The alliance between PT and the patient can have a
positive effect on treatment outcome (Ferreira et al,
2013;Halletal,2010). A biopsychosocial approach in
healthcare needs the transformation of the interview
toward patient-centered care, which holds the key to
personal, responsive, and fulfilling communication
between patients and clinicians (Roter, 2000). The
PT therefore, first needs to know how the patient is
doing, their perception of their own problem, how the
problem impacts their life, and vice versa, and how
their lifestyle impacts their problem (Jones and Rivett,
2004;Maitland,1986). If this is not established, there
could easily be a mismatch between the patient and
PT which makes forming a therapeutic relationship
very difficult (Ferreira et al, 2013). Patients have the
right to information from their clinicians and clini-
cians have the obligation to convey it in an under-
standable and useful manner (Oliveira et al, 2012). A
meaningful therapeutic relationship cannot occur
without empathy, the ability to perceive and under-
stand something of the patients experience of pain,
vulnerability, suffering, and expression of appropriate
concern. Empathy is the perceptual ability and cog-
nitive skill that establishes virtue and medical benefi-
cence, and provides the perceptual basis for clinical
reasoning (Oliveira et al, 2012). By reducing clinical
reasoning to its cognitive components, the larger con-
text of the patients situation could be ignored, and
the neurophysiological education approach could fail
to acknowledge that clinical reasoning is grounded in
human perception (Darlow et al, 2013). Furthermore,
a strong therapeutic relationship facilitates collabora-
tive decision making, as it will make PTs aware of
their patientsviews and preferred choices (Elwyn,
Edwards, and Kinnersley, 1999). Understanding the
patients unique experience is essential to discovery
of the patient-specific beliefs and risk factors that will
serve as the targetwhen educating a patient about
the biology and physiology of their pain experience in
a TNE approach (Louw, Diener, Butler, and
Puentedura, 2011; Moseley and Butler, 2015).
During the initial interview, identification of
patient expectation may also help guide the clinical
application of TNE (Louw, Puentedura, and Mintken,
2012; Moseley and Butler, 2015). Specifically, the
exact intervention may not be as important as the
individual expectation for the intervention (Bialosky,
Bishop, and Cleland, 2010;Bishop,Mintken,
Bialosky, and Cleland, 2013; Main, Foster, and
Buchbinder, 2010; Maitland, Hengeveld, Banks, and
English, 2005;Nijsetal,2012). Outcomes, therefore,
may not depend wholly on the type of treatment
provided, but are influenced by individual attitudes
or beliefs regarding the treatment. Manipulation of
expectation is common in the placebo literature and
suggests a causative effect of expectation on pain-
related outcomes that may translate to the clinical
management of musculoskeletal pain conditions
(Louw and Puentedura, 2014). Explaining pain in
neurophysiological terms has been shown to produce
such expectations (Louw, 2014). These expectations
and beliefs are seen as part of the contextual factors
involved in placebo or centrally-mediated mechan-
isms of treatment response.
Communication strategies utilized during the inter-
view should enhance patient participation, contribute
to patient engagement in problem-posing and problem-
solving, and facilitate patient confidence and compe-
tence to make autonomous decisions. With good clin-
ical communication, patients are more satisfied with
the care they receive, there is a better recall and under-
standing of information, and healthcare professionals
experience greater job satisfaction and less work stress
(Bialosky, Bishop, and Cleland, 2010). Patients experi-
encing pain and attending physical therapy may be
particularly vulnerable, and in certain circumstances
are not able, or unwilling, to carry the sole burden of
their medical decisions. Using both active and reflective
listening skills allows the PT to accommodate indivi-
dual patient preferences and help develop and further
patient capacity for autonomous decision making (Hall
et al, 2010).
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Screening patients
In line with various national and international efforts for
PTs to gain direct access (Boyles, Gorman, Pinto, and Ross,
2011;Flynn,2003), much attention has focused on training
PTs to screen for risk, and as an initial priority, to do no
harm (Andersson et al, 2010). It is therefore imperative that
PTs also recognize the need to screen individuals suffering
from chronic MSK pain for safety (i.e. red flags) (Figure 1).
Various red flags associated with MSK pain have been
described and are well understood (Downie et al, 2013;
Leerar, Boissonnault, Domholdt, and Roddey, 2007;Ross
and Boissonnault, 2010; Sizer, Brismee, and Cook, 2007).
Screening for red flags in accordance with direct access
standards has also warranted an increased use of review of
systems, to allow for a more comprehensive screen prior to
interview, let alone physical examination and treatment
(Goodman, 2010; Leerar, Boissonnault, Domholdt, and
Roddey, 2007; Ross and Boissonnault, 2010).
Apart from red flags, prior to initiating the interview, the
PT screen for is recommended psychosocial risk factors,
which are also known as yellow flags, as barriers to recovery.
In recent years, it has become apparent that these psycho-
social risk factors may actually be the dominating factor
associated with recovery (Linton and Nordin, 2006;Linton
et al, 2005). The research of Hill et al. (2010 and 2011)
indicates that, although it is important to assess psycholo-
gical distress in patients seeking physical therapy care for
pain, it may be unnecessary to complete multiple question-
naires (e.g. to specifically assess depression, stress, anxiety),
to make this assessment. A simple, straightforward
assessment, such as the short STarT Back Screening Tool
(Hill et al, 2010;Hilletal,2011) or the Short Form Orebro
Musculoskeletal Pain Screening Questionnaire (Linton,
Nicholas, and MacDonald, 2011), prior to the interview
may be all that is required. Both questionnaires may iden-
tify low, medium, or high psychosocial distress as a risk
status (Zimney, Louw, and Puentedura, 2014). This classi-
fication, associated with screening for risk, drives the pro-
posed treatment, including the need to (or not to) include
TNE, as well as the potential extent of the TNE needed. In
the low-risk group, in which pain is associated with low
levels of distress, suitable acute pain management and an
abbreviated TNE may be the only intervention needed
wherethePTmayeducatethepatienttoencourageadap-
tive beliefs and behaviors. Over-investigating and over-
treating this low-risk group may result in worse outcomes
(Graves et al, 2012; Webster, 2013). For the medium-risk
group, in which pain is associated with moderate distress
levels, best practice management is proposed as suitable
pain management, TNE, and targeted functional restora-
tion (Hill et al, 2010;Hilletal,2011). The high-risk group,
in which pain is associated with high distress levels, requires
special attention, directing management to reduce high
levels of fear, anxiety, depressed mood, catastrophizing,
and distress. TNE is well-designed to address these issues
(Louw, Diener, Butler, and Puentedura, 2011;Moseley,
2002; Moseley, Nicholas, and Hodges, 2004;Zimney,
Louw, and Puentedura, 2014), however, the patient may
benefit from additional psychosocial management strate-
gies such as referral to a mental health professional if the PT
Figure 1. Flowchart of the screening process during an interview associated with pain science.
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determines that the extent of psychosocial involvement is
beyond their scope of expertise. Motivational interviewing
techniques (Amrhein et al, 2003); careful explanations
regarding biopsychosocial pain mechanisms pertaining to
the individual (Gifford, 1998); exposure training for feared
movements (George and Zeppieri, 2009); and restoration of
normal movement based on the patientsfears,isthepro-
posed intervention for this group (Hill et al, 2010;Linton,
Nicholas, and MacDonald, 2011).
Traditional biomedical education has been shown
to narrowly frame a PTs examination and treatment
strictly into biomedical factors and as a result can
have negative effects on the patients beliefs and
recommended activity levels (Domenech et al, 2011).
Following a purely biomedical approach will prevent
the PT from appreciating possible psychosocial risk
factors and their contribution to the patients presen-
tation which is more reflective of a comprehensive
biopsychosocial approach (Nijs et al, 2012;van
Wilgen et al, 2014). This, coupled with research find-
ings that psychosocial factors often are better predic-
tors of pain, highlights the need for PTs to question
patients to gain a better understanding of their
unique psychosocial risk factors (Carragee, Alamin,
Miller, and Carragee, 2005;Jarviketal,2005).
Cognitive or psychological factors such as fear-avoid-
ance, stress, anxiety, beliefs, expectations, catastrophi-
zation, hypervigilance, depression, and maladaptive
coping should be considered during the interview as
they have been shown to have a moderating effect on
treatment outcomes (Linton, 2000; Main, Foster, and
Buchbinder, 2010;Pincus,Burton,Vogel,andField,
2002; Vlaeyen and Crombez, 1999; Wertli et al,
2014a;Wertlietal,2014b). It is important for the
PT to recognize that there is considerable overlap in
these constructs (Campbell et al, 2013). An example
of this overlap may be a patient demonstrating cata-
strophic thinking as a result of the stress and anxiety
they feel in regard to their condition. The stress and
anxiety may be the product of a stressful workplace, a
punitive spouse, or an employer with poor manage-
ment of workplace injuries. Therefore, lifestyle, and
social factors such as work factors, family factors,
culture, sedentary behavior, sleep disturbance, and
inactivity also are important factors to understand
the psychosocial contributions to the patient presen-
tation (Björck-van Dijken, Fjellman-Wiklund, and
Hildingsson, 2008;Edwards,Fillingim,andKeefe,
2001; Main, Foster, and Buchbinder, 2010;Mogil,
2015). The PT needs to be aware of the sensitive
nature of these topics with some patients and there-
fore needs to use sound clinical judgment on when it
is best to incorporate questioning in these areas. The
initial establishment of a therapeutic alliance with the
patient will ensure that the PT considers their per-
ceived level of rapport and trust with the patient prior
to questioning the patient on sensitive topics the
patient may initially be apprehensive or resistant to
discussing.
Health care professionals can have a strong influence
upon the attitudes and beliefs of patients (Darlow et al,
2013). PTs may influence their patientsunderstanding
of the source and meaning of symptoms, as well as their
prognostic expectations (Sloan and Walsh, 2010). Such
information and advice could continue to influence the
beliefs of patients for many years (Darlow et al, 2013).
Messages increasing the threat value of paincould
result in increased vigilance, worry, guilt when adher-
ence was inadequate, or frustration when protection
strategies failed (Louw, Diener, Landers, and
Puentedura, 2014). Alternatively, messages can provide
reassurance, increase confidence, give helpful advice,
and have an overall positive influence on the approach
to movement and activity (Ferreira et al, 2013;
Hasenbring and Pincus, 2015). Words have emotional
power, and may impact the outcomes of treatment in
medical settings. Studies have shown that orthopedic
words trigger specific emotional reactions in healthy
subjects, which are likely similar in patients with ortho-
pedic conditions (Louw, Diener, Landers, and
Puentedua, 2014; Vranceanu, Elbon, and Ring, 2011).
It is important to choose the best words that may
influence perception of the condition and its causes,
foster effective coping strategies, and ultimately impact
response to treatment. During the clinical interaction, it
is important to pick the most positive words; whether
used to name or describe a condition, provide treat-
ment recommendations, or generally communicate
with patients in order to encourage adaptive beliefs
and behaviors. In some cases, the words, descriptions,
and explanations used during a consultation may in
fact be more advantageous than the actual medical
treatment provided (Louw and Puentedura, 2014;
Melzack, 2001). The PT should be aware of other con-
textual factors in the interview and treatment which
can influence treatment effect or placebo mechanisms
such as characteristics of the treatment (theatrics, visual
complexity, and impressive theoretical explanations),
patient and PT characteristics (status and gender), and
the healthcare setting (home, clinic, hospital, room
setup, threatening anatomical models, and posters).
Traditionally, subjective interview questioning in
musculoskeletal health has focused on biomedical, bio-
mechanical, and pathoanatomical factors (Nijs et al,
2012). While this is helpful, it limits the PTs under-
standing of the patients unique pain experience and
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shows disregard for contextual, lifestyle, and cognitive
factors that contribute to an individuals pain experi-
ence. Kendall, Linton, and Main (1997) have created a
mnemonic that can assist a PT in comprehensive ques-
tioning of psychosocial risk factors in a patient
ABCDEFW: Attitudes and Beliefs; Behaviors;
Compensation Issues; Diagnosis and Treatment;
Emotions; Family; and Work.
Table 1 displays the category of questioning, possible
starter questions suggested by Gifford (2014), and the
potential information that may be obtained in each
area. These initial questions often require follow-up
questions to clarify information in each category.
Assessing pain
Pain is a normal human experience, but also a powerful
driving force to seek help (Gifford, 2014; Moseley, 2007).
Many patients attending outpatient physical therapy ser-
vices attend on the account of a painful experience.
When patients consult a PT with a primary complaint
of pain, pain needs to be assessed (Breivik et al, 2008).
Traditional models have PTs asking questions about the
location of the pain, duration of the pain, nature of the
pain, quality of the pain, behavior of pain, and even
intensity of the pain (Maitland, Hengeveld, Banks, and
English, 2005). In pain science, it is now well established
that a person experiencing pain develops widespread
brain activity associated with the experience, referred to
as the pain neuromatrix (Melzack, 2001;Moseley,2003).
What ignites the pain neuromatrix and ultimately the
patients pain experience is part of the individual nature
of each persons pain (Puentedura and Louw, 2012).
Traditional models use injury, disease, surgery, or emo-
tional models to showcase the ignition of the pain neu-
romatrix. It should, however, be highlighted that the
pain neuromatrix can be ignited by smell, vision, and
words (Puentedura and Louw, 2012). It is believed that
threatening words may ignite the pain neuromatrix, and
the use (and repetitive use) of the actual word pain
may cause and increase the activation of the pain neu-
romatrix (Louw, Diener, Landers, and Puentedura, 2014;
Wilson, Williams, and Butler, 2009). Therefore, assessing
pain needs to be done with caution. Even though a pain
ratingmay be needed for third party payers, the astute
PT should sparingly consider using the word painin
the assessment and be cognisant that the manner in
which they askabout pain may influence a pain experi-
ence (Breivik et al, 2008). When considering pain rat-
ings, PTs should also be aware that pain ratings are only
subjective expressions of perceived pain and varies in
different cultures (Edwards, Doleys, Fillingim, and
Lowery, 2001;Fortier,Anderson,andKain,2009), and
gender (Fillingim, 2000; Fillingim et al, 2009).
When assessing a patients pain, there is however,
important otherinformation that needs to be gath-
ered, as it powerfully guides interpretation of the phy-
sical examination and decisions about treatment and
what pain mechanisms may be dominant in the
patients presentation (Nijs et al, 2011; Smart, Blake,
Staines, and Doody, 2010). In line with the emerging
research in pain science, it is now well established that
pain is not pain.The biopsychosocial model of pain
science has made scientists and PTs aware that in some
patients the pain experience is predominately driven by
nociceptive information and thus will have a more
nociceptive dominant pain mechanism. In other
patients, nociception by virtue of tissue healing,
becomes less dominant, but biological and physiologi-
cal processes in the peripheral nervous system becomes
a dominant issue in a persons pain experience resulting
in a possible peripheral neuropathic pain mechanism
(Smart et al, 2012b). In yet another patient, peripheral
nociceptive and neuropathic mechanisms are not the
key issues associated with the development and main-
tenance of the pain experience, but more powerfully
driven by the central nervous system, resulting in a
dominant central pain mechanism (Smart et al,
2012a). The importance of being able to identify
which of these three mechanisms are dominant, are
likely more important clinically than just asking a
pain rating(Smart, Blake, Staines, and Doody, 2010;
Smart et al, 2012a; Smart et al, 2012b; Smart et al,
2012c). The aforementioned classification of pain by
Smart et al. (2010 and 2012), has demonstrated an
accurate preliminary classification of nociceptive, per-
ipheral neuropathic, and central pain mechanisms
(Table 2).
Therefore, given the screening proposals in this
paper associated with red flags, psychosocial yellow
flags and pain mechanisms, Figure 1 illustrates a poten-
tial start of a flow diagram associated with a pain
science perspective. The PT who prioritizes TNE as a
treatment option needs both guidance to determine
which patients may be suitable for TNE and what the
proper dosing is of the TNE intervention. Upon screen-
ing for psychosocial risk factors (low, medium or high)
and taking into consideration the dominant pain
mechanism (nociceptive, peripheral neurogenic or cen-
tral), the PT can use that information to firstly, guide
the physical examination and secondly, plan the
treatment.
The physical examination should be based on the
information gathered in the interview (Jones and
Rivett, 2004). It is imperative that PTs, as they gain
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Table 1. Potential questions for psychosocial risk factors in a patient utilizing the ABCDEFW criteria.
Topic area Question Information gained
Attitudes and
Beliefs
What do you think is the cause of your pain? Fear/avoidance
Catastrophization
Maladaptive beliefs
Passive attitude toward rehabilitation
Expectations of effect of activity or work on pain
Behaviors What are you doing to relieve your pain? Use of extended rest
Reduced activity levels
Withdrawal from ADLs and social activities
Poor sleep
Boombust behavior
Self-medication alcohol or other substances
Compensation
Issues
Is your pain placing you in financial difficulties? Lack of incentive to return to work
Disputes over eligibility for benefits, delay in income assistance
History of previous claims
History of previous pain and time off work
Diagnosis and
Treatment
You have been seen and examined for your pain?
Are you worried that anything may have been missed?
Health professional sanctioning disability
Conflicting diagnoses
Diagnostic language leading to catastrophizing and fear
Expectation of fix
Advice to withdrawal from activity and/or job
Dramatization of back pain by health professional producing
dependency on passive treatments
Emotions Is there anything that is upsetting or worrying you about the
pain at this moment?
Fear
Depression
Irritability
Anxiety
Stress
Social anxiety
Feeling useless or not needed
Family How does your family react to your pain? Over-protective partner/spouse
Solicitous behavior from spouse
Socially punitive responses from spouse
Support from family for return to work
Lack of support person to talk to
Work How is your ability to work affected by your pain? History of manual work
Job dissatisfaction
Belief work is harmful
Unsupportive or unhappy current work environment
Low educational background
Low socio-economic status
Heavy physical demands of work
Poor workplace management of pain issues
Lack of interest from employer
Table 2. Clinical recognition of dominating pain mechanisms via signs and symptoms.
Nociceptive
Signs and symptoms easily recognized by clinicians. These symptom and examination clusters indicate individuals that have these features are 100 times
more likely to accurately predict a clinical classification nociceptive pain in patients classified with this type of pain (Smart, Blake et al. 2012)
Proportionate pain
Aggravating and easing factors
Intermittent sharp, dull ache or throb at rest
No night pain, dysesthesia, burning, shooting or electric
Peripheral neurogenic
Symptoms and sign clusters identified indicating patients are 150 times more likely to have a peripheral neurogenic pain states (Smart, Blake et al. 2012)
Pain in dermatomal or cutaneous distribution
Positive neurodynamic tests and palpation (mechanical tests)
History of nerve pathology or compromise
Central Sensitization
Symptoms and sign clusters identified indicating patients are 486 times more likely to have a central sensitization pain state (Smart, Blake et al. 2012)
Disproportionate pain
Disproportionate aggravating and easing factors
Diffuse palpation tenderness
Psychosocial issues
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clinical experience, adjust their examinations, especially
in regard to pain science (Butler, 2000). For example, in
patients with a more dominant nociceptive input
mechanism with low or even medium risk, a physical
examination can focus more on potential biomedical
and biomechanical issues (often referred to as high
tech), contributing to the pain state. In this group of
patients the movement tests may often demonstrate the
typical on-offbehavior of mechanical or inflamma-
tory-mechanical pain. In contrast, a patient with a high
score of psychosocial risk factors and a dominant cen-
tral pain mechanism should be approached using a
physical examination with less emphasis on biomedical
issues, but rather large, physiological movements, often
referred to as a low techexamination (Linton, 1998).
In this group of patients it is often difficult to find the
pain of the patients, and the pain provocation move-
ments often do not form an interpretable pattern to
identify the structure causing the pain. A PT should
also consider whether pain reproduction during the
physical examination is an appropriate goal for some-
one in this group as it could create negative associa-
tions of physical therapy examination and treatment
with pain and negatively impact a patients perception
of physical therapy care as a result.
The same information regarding psychosocial risk
factors and pain mechanisms can be used to guide the
treatment plan. For example, central sensitization has
been proposed as a key factor in determining if a
patient needs TNE (Louw, 2014; Louw, Puentedura,
and Mintken, 2012; Moseley, 2007), and has high psy-
chosocial risk factors (OSullivan, Dankaerts,
OSullivan, and OSullivan, 2015; Zimney, Louw, and
Puentedura, 2014). This understanding of the impor-
tance of psychosocial factors and pain mechanisms
should guide PTs to go beyondtypical interview
questions. While traditional interviews focus heavily
on the intensity, duration, behavior and nature of the
patients pain, questions more associated with the
patients beliefs may be needed. More in-depth ques-
tions should include: the patients current beliefs
regarding their pain; their perspective on their pain
experience including treatment effects; and perspective
on their outlook in regards to recovery. Table 3 show-
cases potential questions that may help a PT gain
increased understanding of the patients experiences
and beliefs (clinical experience of the authors).
In line with pain assessment, pain neuroscience
research has also brought attention to the potential
different role of body charts (George, Bialosky,
Wittmer, and Robinson, 2007; Wand et al, 2013).
Traditionally upon arrival at a physical therapy clinic
a patient was given a body chartand asked to indicate
where they hurt. The intent of the body chart was to
establish the location of the pain (Maitland, 1986). It is
now well established that there are functional and
structural changes in the brain of people struggling
with chronic pain, including structural changes in the
primary somatosensory cortex (S1) (Flor, 2000; Flor,
Braun, Elbert, and Birbuamer, 1997). The reorganiza-
tion of body maps is well studied and reported via brain
scan (Flor, 2000; Lotze and Moseley, 2007). One clinical
manifestation alluded to in regard to altered cortical
maps, is the inability and inaccuracy of patients in
identifying the exact location of their pain (Bray and
Moseley, 2011; Moseley, 2008). In line with this
research it is now proposed that strategies such as two
point discrimination, left/right discrimination, localiza-
tion and body chart drawing may be useful in detecting
cortical changes associated with structural changes of
the brain (Louw, Schmidt, Louw, and Puentedura,
2015; Louw et al, 2015; Luomajoki and Moseley,
2011). Clinically it may be helpful for PTs to reconsider
the use of body charts to develop a potential greater
understanding of the extent of a persons pain experi-
ence from a cortical representation perspective, poten-
tially influencing physical tests needed as well as
treatment (Catley, Tabor, Wand, and Moseley, 2013).
For example, in a patient with localized, well-defined
pain, it may infer a healthy representation of the
affected body chart, while a more widespread drawing
of a body chart may indicate a reorganization of the
body chart (Figure 2. In the case of the more wide-
spread pain a physical examination should include two-
point discrimination and treatment likely to include
Table 3. Proposed more in-depthquestions to explore a
patients cognitions, beliefs, and experiences regarding their
pain.
Proposed in-depthquestions
What do you think is going on with your [fill in area they are seeking help
for]?
What do you think should be done for your [fill in area they are seeking
help for]?
Why do you think you still hurt?
What would it take for you to get better?
Where do you see yourself in 3 years in regard to [fill in area they are
seeking help for]?
What have you found to be most helpful for your [fill in area they are
seeking help for]?
You have obviously seen many people seeking help. What are your
thoughts on this?
What gives you hope?
What is your expectation of PT?
If I could flip a switch and remove all your pain, what things that you
have given up on would you do again?
How has your pain impacted your family and friends?
Are you angry at anyone about your [fill in area they are seeking help
for]? Tell me about it.
Has anyone made you feel like youre just making it upor its in your
head?Tell me about it.
PHYSIOTHERAPYTHEORYANDPRACTICE 7
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strategies aimed at restoring the cortical maps (i.e.
sensory discrimination) (Catley, Tabor, Wand, and
Moseley, 2013; Luomajoki and Moseley, 2011).
TNE during the interview
Examination findings should be clearly explained and
conveyed to patients with the intent to reduce threat,
share the plan of care and empower the patient.
Traditional biomedical interviews have now expanded
to include well-studied contributing factors shown to
prolong recovery. Given the complexities of pain, this
interview, however, is far more than justasking
where and how much do you hurt?A skilled inter-
view implies that the interview also helps with educa-
tion, in essence alreadyteaching the patient about
their pain experience, including helping change poor
beliefs regarding pain.
Conclusion
The interview, by virtue of creating a therapeutic alli-
ance, prepares the patient for the physical examination
and treatments. An approach to treating patients with
pain and to reduce the burden on society should
include: an initial triage to screen for serious pathology;
identification of the dominant pain mechanism/s (noci-
ceptive, peripheral neurogenic or central sensitization),
and assessment of psychosocial risk factors (Linton,
1998; Linton, 2000). A thorough subjective examination
is key when it comes to the development of a working
hypothesis, which in turn becomes the cornerstone of
an effective plan of care. The subjective interview
should also aim to identify maladaptive beliefs and
behaviors that can be identified as a potential target
of treatment. Traditional biomedical interviews have
now expanded to include well-studied contributing fac-
tors shown to prolong recovery. Furthermore, the inter-
view is centered on the patient, ensuring empathy,
addressing concerns, and taking into consideration
patient expectations. Each PT can agree; listening is
therapy.
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... The findings of the study suggest that factors like self-efficacy, depression, pain catastrophising and physical activity impact on outcomes of the SM programmes. There is evidence that understanding of pain neuroscience and early identification of psychological barriers, may improve these factors (Diener, Kargela & Louw 2016;Louw et al. 2016). Utilising these in the SM support programmes may thus improve the outcomes of these programmes. ...
... Diener et al. 2016;Foster & Delitto 2011;Lin et al. 2020;Parker & Madden 2020). The role of vulnerability factors such as pain-related fear, catastrophising, and avoidance have been well-documented in the development and maintenance of chronic pain disability (Meulders 2019).Caneiro et al. (2020) encouraged clinicians to exercise selfreflection to explore their own beliefs and better understand their biases, which may influence their management of patients with MSKP. ...
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Background: Musculoskeletal pain (MSKP) is an extremely common pain disorder in almost all populations. Self-management (SM) support is a programme to prepare people to self-manage their health condition effectively, while maintaining quality of life. SM is a cost-effective and context-specific strategy to address the global public health burden. Objectives: Self-management needs a change in behaviour from seeking unnecessary medical care to safely self-managing symptoms. As changing individuals' behaviour is challenging, the objective of my literature review was to identify the characteristics, in both therapist and patient, to successfully engage in SM. Method: A narrative literature review, that could inform evidence-based support programmes for SM of MSKP. Results: Studies on successful implementation of SM of MSKP do not report strong outcomes. However, in more recent years a few positive outcomes were reported, possibly as a result of research evidence for the application of psychosocial skills and contemporary pain neuroscience in the management of persistent MSKP. Conclusion: Psychologically-informed physiotherapy, addressing psychosocial barriers to the maintenance of SM programmes, could facilitate more successful outcomes. Clinical implications: Before engaging in a SM support programme, obstacles to behaviour change must be identified and addressed in a SM support programme, to facilitate individuals towards taking safe responsibility for their healthcare. Therapists working with patients with persistent MSKP, should upskill themselves to be in line with the latest pain and psychosocial research literature. Moreover, communication skills training seems to be a priority for effective SM support programmes.
... Therefore, interactions with patients, including history taking and assessment, can be considered interventions in their own right. This aligns with the perspectives that "listening is therapy" (Diener, Kargela, and Louw, 2016) and "evaluation is treatment" (Louw et al., 2021). ...
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Introduction: There are increasing recommendations to use the biopsychosocial model (BPSM) as a guide for musculoskeletal research and practice. However, there is a wide range of interpretations and applications of the model, many of which deviate from George Engel’s original BPSM. These deviations have led to confusion and suboptimal patient care. Objectives: 1) To review Engel’s original work; 2) outline prominent BPSM interpretations and misapplications in research and practice; and 3) present an “enactive” modernization of the BPSM. Methods: Critical narrative review in the context of musculoskeletal pain. Results: The BPSM has been biomedicalized, fragmented, and used in reductionist ways. Two useful versions of the BPSM have been running mostly in parallel, rarely converging. The first version is a “humanistic” interpretation based on person- and relationship-centredness. The second version is a “causation” interpretation focused on multifactorial contributors to illness and health. Recently, authors have argued that a modern enactive approach to the BPSM can accommodate both interpretations. Conclusion: The BPSM is often conceptualized in narrow ways and only partially implemented in clinical care. We outline how an “enactive-BPS approach” to musculoskeletal care aligns with Engel’s vision yet addresses theoretical limitations and may mitigate misapplications.
... From a biopsychosocial view, psychological factors play an essential role in the onset and progression of chronic pain. The cognitive-behavioural model of avoiding fear in cases of chronic pain suggests that pain-related fear contributes to the development and maintenance of pain-related disability (Diener et al., 2016). Therefore, addressing the beliefs, cognitions, and behaviours associated with patients' pain symptoms has become a crucial issue for consideration during treatment, particularly during the treatment of chronic pain. ...
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The socio-emotional condition during the COVID-19 pandemic subsidises the (re)modulation of interactive neural circuits underlying risk assessment behaviour at the physical, emotional, and social levels. Experiences of social isolation, exclusion, or affective loss are generally considered some of the most “painful” things that people endure. The threats of social disconnection are processed by some of the same neural structures that process basic threats to survival. The lack of social connection can be “painful” due to an overlap in the neural circuitry responsible for both physical and emotional pain related to feelings of social rejection. Indeed, many of us go to great lengths to avoid situations that may engender these experiences. Accordingly, this work focuses on pandemic times; the somatisation mentioned above seeks the interconnection and/or interdependence between neural systems related to emotional and cognitive processes such that a person involved in an aversive social environment becomes aware of himself, others, and the threatening situation experienced and takes steps to avoid daily psychological and neuropsychiatric effects. Social distancing during isolation evokes the formation of social distress, increasing the intensity of learned fear that people acquire, consequently enhancing emotional and social pain.
... In that sense, our study subjects reflected that no critical problems were found using technologies and contact was qualified as outstanding. Communication is a crucial aspect of health treatments [33,34] and many professionals believe that telerehabilitation could fail in this aspect. However, as it has been shown, this was not the case in the programme developed. ...
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The total isolation of patients with coronavirus disease 2019 (COVID-19) requires non-face-to-face medical assistance. There is evidence of the efficacy of home treatments with exercises in patients with respiratory disorders which could become the therapeutic method of choice for the treatment and supervision of patients isolated due to infection during home confinement. This study’s objective was to analyse the experience and opinions of isolated patients with COVID-19 included in a programme of telerehabilitation exercises for 14 days and it is intended to reflect, from a qualitative point of view, the viability and usefulness of telerehabilitation tools in the management of these patients. Twenty-five participants of a telerehabilitation programme were interviewed by telephone through semi-structured interviews, following a positivist and objective model. The data were categorised and analysed through NVIVO qualitative analysis software. The information obtained was classified into four main topics (telerehabilitation programme, perception of clinical benefit, psychological aspects and level of health care) and six subtopics (technical aspects, communication, improvement aspects, exercise plan, motivation and applicability to public health systems). The telerehabilitation programme established in patients confined by COVID-19 is very well received, without considerable technical difficulties and generates physical and psychological improvements. Patients highlight the importance of applying this type of programme in public health systems.
... 2 Due to their job description, nurses are also responsible for treating pain in patients, and reporting and discussing the effect of the given analgesic with doctors. 2 This scoping review therefore showed that a well-established and trusting relationship between nurses and patients is important, and affects whether and how pain is reported by the patients and assessed by the nurses. In line with the conclusions of Diener, Kargela and Louw, 27 we found that the relation between patients and nurses is important and affects the level of trust patients have with nurses and how well nurses can assess pain. A poor relationship will probably lead to the underreporting of pain, even when a patient has severe pain. ...
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Pain assessment tools are often used by patients to report their pain and by health professionals to assess patients’ reported pain. Although valid and reliable assessment of pain is essential for high-quality clinical care, there are still many patients who experience inappropriate pain management. The aim of this scoping review is to examine an overview of how hospitalized patients evaluate and report their pain in collaboration with nurses. Systematic searches were conducted, and ten research articles were included using the PRISMA guidelines for scoping reviews. Content analysis revealed four main themes: 1) the relationship between the patient and nurse is an important factor of how hospitalized patients evaluate and report their post-surgery pain, 2) the patient’s feelings of inconsistency in how pain assessments are administered by nurses, 3) the challenge of hospitalized patients reporting post-surgery pain numerically, and 4) previous experiences and attitudes affect how hospitalized patients report their pain. Pain assessment tools are suitable for nurses to observe and assess pain in patients. Nevertheless, just using pain assessment tools is not sufficient for nurses to obtain a comprehensive clinical picture of each individual patient with pain.
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Resumen El desafío diario del clínico es le cuidado del paciente como individuo. ¿Cómo integrar la mejor evidencia científica disponible con la experiencia clínica del terapeuta y con los valores y las preferencias del paciente que sufre una lumbalgia inespecífica? Una vez descartadas las posibles causas específicas, ¿cómo adaptar el tratamiento del paciente en función de sus posibilidades de recuperación y de los resultados probables del tratamiento? Este artículo presenta el razonamiento clínico detallado del fisioterapeuta, así como una argumentación exhaustiva para cara etapa del tratamiento de una paciente que presenta dolor lumbar clasificado como «lumbalgia inespecífica con ciatalgia con bajo riesgo de cronificación». Desde la evaluación subjetiva hasta el tratamiento, pasando por una exploración física detallada y estructurada, este caso clínico es el reflejo de una población de pacientes que se observa a menudo en la consulta.
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Introduction/Objectives Therapeutic alliance (TA) is an integral part of building a patient and clinician relationship. TA begins at the initial encounter; however, the specific TA behavioural practices that are most impactful and linked to pain reduction and improved function remain unclear. The primary objective of this study was to explore physical therapist behaviours and interactions during the initial physical therapy evaluation and how they related to the patient's perception of TA. A secondary objective was to explore the relationship between TA, pain intensity, and function. Methods A mixed methods study was conducted. Pain intensity, TA and self-reported function were assessed at three time points. Spearman's Rho (ρ) was used to quantify if there was an association between increased TA and function and reduced pain intensity, while a checklist of TA themes and behavioural practices was used for the qualitative analysis. Results There was a statistically significant negative correlation between patient-perceived TA and pain intensity immediately after the initial evaluation (ρ = −0.39 [p = 0.048]). Behavioural practices associated with higher TA included information gathering, pausing to listen, using humour and transitions, and use of clarifying questions. Behavioural practices associated with patient-perceived lower TA interactions were lack of touch, the absence of pain neuroscience education, and not restating what the patient said during the interview. Conclusion This study highlights a relationship between TA and reduction of pain intensity after the initial evaluation and identifies key behavioural practices that could positively and negatively impact TA during the clinical encounter.
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ABSTRACT Background and Objective: Education seems to play a key role in the treatment of chronic musculoskeletal pain. In this thesis, the impact of Pain Neuroscience Education (PNE), a modern, biopsychosocial form of education, on pain-associated cognitions of patients is investigated. Methodology: The structure of this bachelor thesis is based on that of an Overview of Systematic Reviews (SRs). The database search yielded 469 results, of which six SRs were included. For the assessment of the methodological quality of the included publications , the Jadad Decision Algorithm was applied in addition to two validated assessment tools (AMSTAR 2 and ROBIS) and the evaluation of the adequacy of the review conclusions. Results: Implementation of PNE in subjects with chronic musculoskeletal pain (CMP) appears to positively influence kinesiophobia in the short term and pain catastrophizing in the medium term to a small degree. Long-term results are currently not available. Conclusion: To enable the development of a clear PNE guideline and to achieve an associated treatment optimization, future research efforts should focus on the identification of the ideal application duration and therapy combination, as well as the investigation of the long-term effects of PNE. ABSTRACT Hintergrund und Ziel: Edukation scheint in der Behandlung chronischer muskuloskelettaler Schmerzpatient*innen eine Schlüsselrolle zu spielen. In der vorliegenden Arbeit wird die Auswirkung von Pain Neuroscience Education (PNE), einer modernen, biopsychosozialen Schulungsform, auf schmerzassoziierte Kognitionen Betroffener untersucht. Methodik: Der Aufbau dieser Bachelorarbeit ist an jenen eines Overviews of Systematic Reviews (SRs) angelehnt. Die Datenbanksuche ergab 469 Ergebnisse, von denen sechs SRs inkludiert wur-den. Für die Beurteilung der methodischen Qualität der eingeschlossenen Publikationen fand nebst zweier validierter Assessment Tools (AMSTAR 2 und ROBIS) und der Beurteilung der Adäquanz der Review-Konklusionen auch der Jadad Decision Algorithm Anwendung. Ergebnisse: Die Umsetzung von PNE bei Proband*innen mit chronischen muskuloskeletta-len Schmerzen (CMP) scheint Kinesiophobie kurzfristig und Schmerz-Katastrophisieren mittelfristig geringgradig positiv beeinflussen zu können. Langfristige Resultate stehen ak-tuell noch nicht zur Verfügung. Conclusio: Um die Entwicklung eines klaren PNE-Leitfa-dens zu ermöglichen und eine damit einhergehende Behandlungsoptimierung zu erreichen, sollten sich künftige Forschungsbemühungen auf die Identifikation der idealen Applikati-onsdauer und Therapie-Kombination, sowie die Untersuchung der Langzeiteffekte von PNE fokussieren.
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Pain education within physical therapist educational programs needs to continually evolve to meet current best practice guidelines. This model presentation describes the successful implementation of a pain curriculum using various active learning approaches including VoiceThread assignments in an entry-level physical therapist educational program. An 8-week curriculum was developed to assist students in meeting the synthesis and evaluation learning objectives of the International Association for the Study of Pain (IASP) curricular guidelines. Active learning homework assignments allowed students to practice communicating difficult pain principles while receiving constructive feedback. Course outcomes were measured through changes in a modified version of the Pain Attitude and Beliefs Scale (PABS), the Pain Care Confidence Scale (PCCS), qualitative student feedback, and performance on both practical and written examinations. All students passed the practical examination where they successfully demonstrated pain principle communication skills. The students showed less biomedical beliefs in 5 of the 7 PABS biomedical subscale questions and greater biopsychosocial beliefs in 2 of the 7 biopsychosocial subsections (P < .05). Student scores on the PCCS also improved significantly (P < .05) from 5.0 to 8.1 on the combined confidence level for treating patients in pain. Implementation of the IASP curriculum within an entry-level physical therapist education program resulting in positive results in student learning and changing beliefs using a combined lecture and active learning approach.
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The APTA’s Vision Statement for the profession is guided by principles of innovation, access, equity, and advocacy, which calls on physical therapists to stretch their influence beyond the walls of the clinic and the individuals they treat. Access and equity are problems that span multiple health care professions and entities; yet, addressing social determinants of health (SDOH) is a paradigm shift that clinicians’ need continued support to achieve. This paper has two objectives: (1) to define the Fundamental Cause Theory (FCT) and the Socioecological Model (SEM) within the context of physical therapy in order to promote best clinical practice and (2) to apply the concept of “fundamental interventions” in clinical practice to mitigate the negative impact of downstream effects of social determinants of health across levels of the SEM–individual, interpersonal, institutional, community, and societal. This theoretical lens provides the conceptual framework necessary for physical therapists to think creatively about ways to change their practice in their own contexts to impact the life of individual patients and transform the movement health of society. Impact As health care providers, physical therapists have a responsibility to make every effort to meet the needs of their patients and optimize movement health in society; yet significant structural and systemic barriers often prevent patients from reaching their fullest potential. Clinicians can no longer subscribe to a narrow scope of practice focused on individual attainment of therapy goals. This Perspective discusses FCT and SEM theoretical frameworks that can help physical therapists develop, test, and implement functional interventions to address the needs of society as a whole.
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Representational body maps are dynamically maintained in the brain and negatively influenced by neglect, decreased movement and pain. Graded motor imagery (GMI) utilizing various tactile and cognitive processes have shown efficacy in decreasing pain, disability and movement restrictions in musculoskeletal pain. Limited information is known about these cortical changes patient undergoing lumbar surgery (LS), let alone the therapeutic effect of GMI for LS. A 56-year old patient underwent LS for low back pain, leg pain and progressive neurological deficit. Twenty-four hours prior to and 48h after LS various psychometric, physical movement and tactile acuity measurements were recorded. Apart from predictable postoperative increases in pain, fear-avoidance, disability and movement-restrictions, pressure pain thresholds (PPT), two-point discrimination (TPD) and tactile acuity was greatly reduced. The patient underwent 6 physiotherapy (PT) treatments receiving a GMI program aimed at restoring the PPT, TPD and tactile acuity. The results revealed that GMI techniques applied to a patient immediately after LS, caused marked improvements in movements (flexion average improvement/session 3.3 cm; straight leg raise average 8.3°/session) and an immediate hypoalgesic effect. GMI may provide PT with a non-threatening therapeutic treatment for the acute LS patient and establish a new role for PT in acute LS patients.
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Can a brief tactile intervention associated with brain remapping improve pain and spinal movement in patients with chronic low back pain? A convenience sample of patients with chronic low back pain completed various pre-intervention measurements including low back pain (Numeric Pain Rating Scale), fear-avoidance (Fear Avoidance Beliefs Questionnaire), disability (Oswestry Disability Index) and spinal flexion (fingertip-to-floor). A 5-minute localization of tactile stimuli treatment was administered to the low back, followed by immediate post-intervention measurement of pain and spinal flexion. Sixteen patients (female = 12; mean age 48.2 years) with chronic low back pain (median duration 10 years) presented with a mean low back pain of 5.56 out of 10, moderate disability (mean Oswestry Disability Index 34.38%) and high fear-avoidance associated with physical activity (average 17.25). Immediately following treatment, the group’s mean pain rating for low back pain decreased by 1.91, while forward flexion improved by 4.82 cm. The results from the case series indicate that following a brief tactile discrimination intervention, patients with chronic low back pain exceeded minimal detectible change for forward flexion. Being able to improve movement, without using physical movement, may provide an added benefit for patients with chronic low back pain afraid to move.
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Multiple dimensions across the biopsychosocial spectrum are relevant in the management of non-specific chronic low back pain (NSCLBP). Cognitive functional therapy is a behaviourally targeted intervention which combines normalisation of movement and abolition of pain behaviours with cognitive reconceptualisation of the NSCLBP problem, while also targeting psychosocial and lifestyle barriers to recovery. To examine the effectiveness of cognitive functional therapy for people with disabling NSCLBP who are awaiting an appointment with a specialist medical consultant. A multiple case (n=26) cohort study consisting of 3 phases (A1-B-A2). Measurement phase A1 was a baseline phase during which pain and functional disability were collected on three occasions over three months for all participants. During phase B, participants entered a cognitive functional therapy intervention program, involving approximately eight treatments over an average of 12 weeks. Finally, phase A2 was a 12 month no-treatment follow-up period. Outcomes were analysed using repeated measures ANOVA or Friedman's test (with post-hoc Bonferroni) across seven time intervals, depending on normality of data distribution. Statistically significant improvements in both functional disability (p<0.001) and pain (p<0.001) were observed immediately post-intervention, and maintained over the 12 months follow-up period. These reductions reached clinical significance for both disability and pain. Secondary psychosocial outcomes were significantly (p<0.01) improved after the intervention, including depression, anxiety, back beliefs, fear of physical activity, catastrophising and self-efficacy. Not a randomised controlled trial. While primary outcome data was self-reported, the assessor was not blinded. These promising results suggest that cognitive functional therapy should be compared to other conservative interventions for the management of disabling NSCLBP in secondary care settings in large randomised clinical trials. © 2015 American Physical Therapy Association.
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To assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain. Systematic review and random effects meta-analysis of randomised controlled trials. Electronic searches of Cochrane Back Review Group Trials Register, CENTRAL, Medline, Embase, PsycINFO, and CINAHL databases up to February 2014, supplemented by hand searching of reference lists and forward citation tracking of included trials. Trials published in full; participants with low back pain for more than three months; multidisciplinary rehabilitation involved a physical component and one or both of a psychological component or a social or work targeted component; multidisciplinary rehabilitation was delivered by healthcare professionals from at least two different professional backgrounds; multidisciplinary rehabilitation was compared with a non- multidisciplinary intervention. Forty one trials included a total of 6858 participants with a mean duration of pain of more than one year who often had failed previous treatment. Sixteen trials provided moderate quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.21, 95% confidence interval 0.04 to 0.37; equivalent to 0.5 points in a 10 point pain scale) and disability (0.23, 0.06 to 0.40; equivalent to 1.5 points in a 24 point Roland-Morris index) compared with usual care. Nineteen trials provided low quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.51, -0.01 to 1.04) and disability (0.68, 0.16 to 1.19) compared with physical treatments, but significant statistical heterogeneity across trials was present. Eight trials provided moderate quality evidence that multidisciplinary rehabilitation improves the odds of being at work one year after intervention (odds ratio 1.87, 95% confidence interval 1.39 to 2.53) compared with physical treatments. Seven trials provided moderate quality evidence that multidisciplinary rehabilitation does not improve the odds of being at work (odds ratio 1.04, 0.73 to 1.47) compared with usual care. Two trials that compared multidisciplinary rehabilitation with surgery found little difference in outcomes and an increased risk of adverse events with surgery. Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care. © Kamper et al 2015.
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Background and Purpose: Chronic pain is often associated with faulty cognitions and beliefs. One approach to alter cognitions and beliefs is to teach patients about the neurophysiology and neurobiology of their pain experience through therapeutic neuroscience education [TNE]. Mounting evidence has shown the benefit of TNE for patients with chronic pain by easing pain, decreasing disability and pain catastrophization, increasing physical movements and increasing adherence to therapeutic treatments such as exercise. Whether TNE is able to help a patient with chronic pain reconceptualize the role of a specific profession in relation to their pain is yet to be determined. The purpose of this study was to examine if an educational session, specifically aimed at increasing a patient's knowledge of how pain works physiologically and biologically, could alter a patient's view of physiotherapy. Methods: A questionnaire was developed, validated and used to measure patient attitudes and beliefs regarding physiotherapy. A 3-hour educational session on TNE was delivered to 10 patients with fibromyalgia [FM] in a lecture format allowing for questions, answers and interactive discussion. Questionnaires were administered before and after the TNE session. Results: Ten female patients with FM with 14.2 years of pain underwent TNE. Patients underwent a positive shift in all categories associated with physiotherapy. Two shifts reached statistical significance (p < 0.05) associated with physiotherapy's ability to explain the pain (p = 0.011) and helping patients understand their pain better (p=.018). Discussion: The current study provides preliminary results showing that an educational session teaching patients with chronic pain about the neurophysiology and neurobiology of pain may in fact help them reconceptualize the role of physiotherapy. This enhanced view of physiotherapy may be yet another important benefit of TNE and the overall recovery of the patient.
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Purpose: To compare the usage of 'provocative' terms in two patient education booklets for lumbar surgery. Background: The recently completed FASTER trial failed to support the use of an evidence-based educational booklet to significantly improve postsurgical outcomes over rehabilitation and usual care. The use of a different booklet in another recently completed trial resulted in a significant saving in healthcare utilization; earlier return to work; and greater patient satisfaction with surgery. We propose that the terminology used in these booklets may account for the differing results. Methods: An expert review panel was identified and tasked with identifying and highlight 'provocative' words within two patient educational booklets – Booklet A 'Your Back Operation' and Booklet B'Your Nerves are Having Back Surgery'. Reviewers were blinded to title and authorship of the booklets. Data Analysis: Descriptive statistics including means, total scores. Results: Seventeenreviewers from 7 different countries participated and found that Booklet A had almost 3 times as many provocative terms as Booklet B. Booklet A had an average of 67.2 provocative terms per reviewer compared to only 22.6 terms for Booklet B. Conclusions: The findings of this study suggest that use of an educational booklet that minimizes the use of provocative terminology may have the potential to decrease fear, anxiety and patient pain experiences following lumbar surgery. Further research is warranted.
Article
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.
Article
The social domain of the biopsychosocial model of pain has been greatly understudied compared with the biological and psychological domains but holds great promise for furthering our understanding, and better treatment, of pain. Recent years have seen an explosion of interest in social neuroscience and have revealed the ability of pain stimuli to alter social interactions. These experiments suggest that rodents are capable of producing simplified versions of any number of social phenomena involving empathy, previously thought to be the sole province of human beings. This review describes the state of science in both humans and nonhuman animals, and notes intriguing parallels in observations from both species. Indeed, my laboratory is starting to demonstrate perfectly translatable findings regarding social modulation of pain in rodents and humans.