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Pain neuroscience education (PNE) is increasingly used as part of a physical therapy treatment in patients with chronic pain. A thorough clinical biopsychosocial assessment is recommended prior to PNE to allow proper explanation of the neurophysiology of pain and the biopsychosocial interactions in an interactive and patient-centered manner. However, without clear guidelines, clinicians are left wondering how a biopsychosocial assessment should be administered. Therefore, we provided a practical guide, based on scientific research and clinical experience, for the biopsychosocial assessment of patients with chronic pain in physiotherapy practice. The purpose of this article is to describe the use of the Pain – Somatic factors – Cognitive factors – Emotional factors – Behavioral factors – Social factors – Motivation – model (PSCEBSM-model) during the intake, as well as a pain analysis sheet. This model attempts to clearly establish what the dominant pain mechanism is (predominant nociceptive, neuropathic, or non-neuropathic central sensitization pain), as well as to assess the provoking and perpetuating biopsychosocial factors in patients with chronic pain. Using this approach allows the clinician to specifically classify patients and tailor the plan of care, including PNE, to individual patients.
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Physiotherapy Theory and Practice
An International Journal of Physical Therapy
ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage:
Clinical biopsychosocial physiotherapy assessment
of patients with chronic pain: The first step in pain
neuroscience education
Amarins J. Wijma PT, PhD, C. Paul van Wilgen PT, PhD, Mira Meeus PT, PhD &
Jo Nijs PT, PhD
To cite this article: Amarins J. Wijma PT, PhD, C. Paul van Wilgen PT, PhD, Mira Meeus PT, PhD
& Jo Nijs PT, PhD (2016): Clinical biopsychosocial physiotherapy assessment of patients with
chronic pain: The first step in pain neuroscience education, Physiotherapy Theory and Practice,
DOI: 10.1080/09593985.2016.1194651
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Published online: 28 Jun 2016.
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Clinical biopsychosocial physiotherapy assessment of patients with chronic pain:
The first step in pain neuroscience education
Amarins J. Wijma, PT, PhD
, C. Paul van Wilgen, PT, PhD
, Mira Meeus, PT, PhD
, and Jo Nijs, PT, PhD
Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel,
Brussels, Belgium;
Transcare, Transdisciplinary Outpatient Treatment Centre, Groningen, The Netherlands;
Pain in Motion International
Research Group, Brussels, Belgium;
Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences,
Antwerp University, Antwerp, Belgium;
Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences,
Ghent University, Ghent, Belgium
Pain neuroscience education (PNE) is increasingly used as part of a physical therapy treatment in
patients with chronic pain. A thorough clinical biopsychosocial assessment is recommended prior
to PNE to allow proper explanation of the neurophysiology of pain and the biopsychosocial
interactions in an interactive and patient-centered manner. However, without clear guidelines,
clinicians are left wondering how a biopsychosocial assessment should be administered.
Therefore, we provided a practical guide, based on scientific research and clinical experience,
for the biopsychosocial assessment of patients with chronic pain in physiotherapy practice. The
purpose of this article is to describe the use of the Pain Somatic factors Cognitive factors
Emotional factors Behavioral factors Social factors Motivation model (PSCEBSM-model)
during the intake, as well as a pain analysis sheet. This model attempts to clearly establish what
the dominant pain mechanism is (predominant nociceptive, neuropathic, or non-neuropathic
central sensitization pain), as well as to assess the provoking and perpetuating biopsychosocial
factors in patients with chronic pain. Using this approach allows the clinician to specifically classify
patients and tailor the plan of care, including PNE, to individual patients.
Received 12 November 2015
Revised 10 January 2016
Accepted 10 May 2016
biopsychosocial; education;
neuroscience; pain
Chronic pain, also described as pain that persists
beyond normal time of healing and/or pain persist-
ing for 36 months or longer(Merskey, 1994), is a
huge global issue and major healthcare problem
(European Pain Federation, 2010), with a prevalence
of 1727% in populations all over the world (Blyth
et al, 2001; Breivik et al, 2006; Leadley et al, 2012;
Reid et al, 2011). In the US, chronic pain is more
prevalent than diabetes, heart disease, and cancer
combined (American Cancer Society, 2014;
American Diabetes Association, 2012;American
Heart Association, 2011). Chronic pain is associated
with increased medical costs, decreased income, and
huge economic burdens (Bekkering et al, 2011;van
Tulder, Koes, and Bouter, 1995), and has a large
negative impact on the patientsquality of life
(Bekkering et al, 2011; Breivik et al, 2006).
In the last few decades, evidence has shown that a
more or less irreversible state of hyperexcitability
within the central nervous system, known as non-
neuropathic central sensitization pain (CS), is pre-
sent in patients with chronic pain (Koltzenburg,
Torebjork, and Wahren, 1994; Latremoliere and
Woolf, 2009; Torebjork, Lundberg, and LaMotte,
1992). According to Woolf and Salter (2000)CSis
operationally defined as an amplification of neural
signaling within the central nervous system that
elicits pain hypersensitivity. CS is characterized by
generalized hypersensitivity of the somatosensory
system (Coombes, Bisset, and Vicenzino, 2012;
Fernandez-Carnero et al, 2009; Moloney, Hall, and
Doody, 2013; van Wilgen et al, 2013), resulting in
amplification of signaling and eventually even pain
without nociceptive input.
It is known that in patients with pain syndromes such as:
fibromyalgia (Meeus and Nijs, 2007;Staud,2011; Vierck,
2006); persisting traumatic neck pain (Herren-Gerber et al,
2004; Jull, Sterling, Kenardy, and Beller, 2007;Sterling,
2008; Sterling, Jull, Vicenzino, and Kenardy, 2003;
Sterling, Treleaven, Edwards, and Jull, 2002); tension-type
headache (Buchgreitz et al, 2008); migraine (de Tommaso
et al, 2012); subacromial impingement syndrome (Paul,
CONTACT Amarins J. Wijma, PT, PhD VUB Jette, Department Kine, Building F, Laarbeeklaan 103, B 1090 Jette, Brussels, Belgium.
Color versions of one or more of the figures in this article can be found online at
© 2016 Taylor & Francis
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Soo Hoo, Chae, and Wilson, 2012); tennis elbow
(Coombes, Bisset, and Vicenzino, 2012; Fernandez-
Carnero et al, 2009); nonspecific arm pain (Moloney,
Hall, and Doody, 2013); low back pain (Giesecke et al,
2004; Roussel et al, 2013;Staud,2011); pelvic pain
(Farmer et al, 2011; Yang et al, 2003); chronic fatigue
syndrome (Meeus et al, 2008); osteoarthritis (Mease,
Hanna, Frakes, and Altman, 2011;Staud,2011;Suokas
et al, 2012); rheumatoid arthritis (Meeus et al, 2012); and
tendinopathy (van Wilgen et al, 2013), the pain often can-
not be explained (solely) by an obvious anatomic defect or
tissue damage. In fibromyalgia, chronic whiplash, chronic
fatigue syndrome, and irritable bowel syndrome CS is
merely the predominant underlying pain mechanism
(Nijs et al, 2012; Nijs, Van Houdenhove, and Oostendorp,
2010;Staud,2011). In other chronic pain populations, such
as low back pain and osteoarthritis, a subgroup may be
present with predominant CS pain (Buchgreitz et al, 2008;
de Tommaso et al, 2012;Mease,Hanna,Frakes,and
Altman, 2011; Meeus et al, 2012;Nijs,VanHoudenhove,
and Oostendorp, 2010; Paul, Soo Hoo, Chae, and Wilson,
The neurophysiological changes in CS are related to
changes in the pain neuromatrix, modulating pain pro-
cesses by behavioral, emotional, social, and cognitive
factors (Turk and Okifuji, 2002). It is known that pain
catastrophizing (Gracely et al, 2004), pain-related anxi-
ety (Gracely et al, 2004; Hirsh, George, Bialosky, and
Robinson, 2008; Leeuw et al, 2007; Vlaeyen and Linton,
2000), trait anxiety (Hirsh, George, Bialosky, and
Robinson, 2008; Sullivan, Thorn, Rodgers, and Ward,
2004) (trait anxiety is the personal level of anxiety),
trait neuroticism (personal level of negative affectivity)
(Evers, Kraaimaat, van Riel, and Bijlsma, 2001), depres-
sive feelings and stress (Kuehl et al, 2010;McEwen and
Kalia, 2010; Rivat et al, 2010), diminished self-efficacy
(Turk and Okifuji, 2002), adverse life events (Generaal
et al, 2015), and posttraumatic stress disorders (Cohen
et al, 2002; Daenen et al, 2014; Sherman, Turk, and
Okifuji, 2000; Sterling and Chadwick, 2010; Sterling,
Hendrikz, and Kenardy, 2010) are present to varying
degrees in patients with chronic pain. These can be a
consequence of pain and/or can contribute to the tran-
sition and persistence of chronic pain. Emotions,
thoughts, attention, and stress can influence the pain-
facilitating pathways (Zusman, 2002), thereby leading
to cognitive emotional sensitization (Brosschot, 2002).
Catastrophizing, for instance, is related to activation of
the pain neuromatrix, increased pain, affective distress,
pain-related disability, and poorer treatment outcomes
(Edwards, Bingham, Bathon, and Haythornthwaite,
2006; Gracely et al, 2004). Therefore, the initial
examination should take into account both somatic
(bottom-up, pathoanatomical, peripheral signals) and
psychosocial (top-down, dis-inhibition, or pain facilita-
tion) factors.
Therefore a thorough clinical biopsychosocial assess-
ment is required to understand the process of CS and
allow an individualized, patient-centered explanation
including biopsychosocial interactions, also known as
pain neuroscience education (PNE) (Gallagher,
McAuley, and Moseley, 2013; Louw, Diener, Butler,
and Puentedura, 2011; Meeus et al, 2010; Moseley,
2002; Moseley, 2004; Moseley and Butler, 2013;
Moseley, Nicholas, and Hodges, 2004; Nijs et al,
2011a; Van Oosterwijck et al, 2011; Van Oosterwijck
et al, 2013). However, without clear guidelines, clini-
cians are left wondering how such biopsychosocial
assessment should be carried out and how it allows
for an interactive and patient-centered PNE.
Therefore, the purpose of this paper is to provide a
practical guide, based on scientific research and clinical
experience, for the biopsychosocial assessment of
patients with chronic pain in physiotherapy practice.
To facilitate the biopsychosocial intake of patients with
chronic pain, we suggest the use of the PSCEBSM model
(based on the SCEBS model (Speckens, 2004) plus pain
and motivation): Pain Somatic and medical factors
Cognitive factors Emotional factors Behavioral fac-
tors Social factors Motivation. This model starts with
examining and determining the type of pain, continues
with identifying the different factors associated with
chronic pain, and ends with determining the stage of
motivation of the patient. A flowchart of the model for
use in clinical practice is offered in Figure 1.Thepain
analysis sheet (Figure 2) can be used to provide a clear
overview of the PSCEBSM model, and guide the content
of PNE and treatment. The use of this model takes time,
modifications in clinical care, and needs adequate biop-
sychosocial communication skills.
Ptype of pain
In order to allow tailoring PNE to the underlying pain
mechanisms, it is important to differentiate between
the three major pain types (nociceptive, neuropathic,
and CS pain) (Figure 2). An algorithm with a set of
classification criteria for differentiating predominant
neuropathic, nociceptive and CS pain in patients with
musculoskeletal pain has been proposed by 18 pain
experts from seven countries (Nijs et al, 2014). To
identify the predominant pain type, two steps need to
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be taken. The first step entails recognizing neuropathic
pain as the predominant pain type. Neuropathic pain is
defined as pain arising as a direct consequence of a
lesion or disease affecting the somatosensory system
(Treede et al, 2008). Table 1, adapted from (Nijs et al,
2014), which shows the clinical differentiation between
predominant nociceptive, non-neuropathic CS pain
and neuropathic pain. In line with the diagnostic cri-
teria for neuropathic pain (Treede et al, 2008), central
neuropathic pain can be distinguished from CS pain by
the lack of damage to the nervous system in the latter
The second step is to differentiate between predominant
nociceptive and CS pain. The pain is more likely to be
originated from CS if the perceived pain and disability are
disproportionate to the nature of the injury or pathology
(Nijs et al, 2014) AND one of the following two criteria: 1)
The presence of a diffuse or neuro-anatomically illogical
pain distribution (Nijs et al, 2014) that is not in accordance
with dermatomes and myotomes. A widespread pain index
(also known as body diagram) can be used to assess the
pain distribution by mapping the pain locations (Margolis,
Chibnall, and Tait, 1988;Margolis,Tait,andKrause,1986).
The widespread pain index, which includes 19 body
range of scores from 0 to 19 points), can be used to aid in
this process (Wolfe et al, 2010). A score of 7 or greater
suggests widespread pain. 2) Hypersensitivity of senses
unrelated to the musculoskeletal system (Nijs et al, 2014),
which can be assessed using the Central Sensitization
Inventory (CSI) (Table 2). This includes hypersensitivity
CSI appears to be a valid, reliable, usable, and diagnostically
relevant questionnaire assessing common symptoms and
facilitating factors to CS in 25 items (Kregel et al, 2015;
Mayer et al, 2012). Based on a validation study, a cutoff
score of 40 points indicates the possibility that the symp-
toms are due to predominant CS pain (Neblett et al, 2014;
Neblettetal,2015). However, the score of the CSI should
be interpreted with caution and in accordance with the
clinical symptoms of the patient. More detailed informa-
tion regarding differentiating between predominant noci-
ceptive and CS pain and how to apply this information in
clinical practice can be found in the original paper (Nijs
et al, 2014), or adopted for low back pain patients in a more
recent paper (Nijs et al, 2015).
The outcome of the mechanism-based classification
of pain types can be either predominant nociceptive,
neuropathic, CS, or a mixed type of pain. The next
step is to identify which factors play a role in the
continuation of the patients pain. These factors can
be divided according to the other domains of the
PSCEBSM model.
Ssomatic and medical factors
In patients with CS, somatic and medical factors that
may be present include: other (past and present) ill-
nesses that might influence CS; nonuse or disuse of
body parts; changed movement patterns; exercise capa-
city; and strength and muscle tension/tonus during
movements. Medication can have (positive/negative)
side effects. Therefore other medical issues and drug
use should ideally be examined by a medical physician;
however, a physiotherapists basic understanding of
pathophysiology and medications interacting with the
central nervous system is important when providing
PNE. Physiotherapists are indeed capable of gathering
this type of information. However, the prescription,
administration, and modification of medications
should be performed by a physician.
Following the intake, a thorough physical examina-
tion should take place. It is important to recognize that
in the presence of CS, findings on clinical tests such as
the Straight Leg Raise, Upper Limb Neurodynamic
Tests (ULNTs) and assessments of movement or
Table 1. Criteria for the differential classification between pre-
dominant neuropathic (Haanpää and Treede, 2010; Haanpää
et al, 2011; Treede et al, 2008) and central sensitization pain.
Adapted from Nijs et al. (2014).
Nociceptive pain Neuropathic pain
Non-neuropathic CS
History of damage to
body tissue in the
previous 68 weeks.
History of a lesion or
disease of the nervous
system, or
postsurgical damage to
the nervous system.
No history of a lesion,
damage, or disease of
the nervous system.
Pain diminishes
according to the
natural healing
Indications from
examinations to reveal
an anomaly of the
nervous system.
No indications from
Related to tissue
damage or
potential damage.
An ankle sprain or
almost burning a
Related to a medical or
systemic cause such as
stroke, herpes,
diabetes, or some form
of neurodegenerative
No medical cause for
the pain established.
Local pain, most often
with diagnostic
signs such as
hematomas, skin
colorations, etc.
Pain and sensory
dysfunction are
Pain is
illogical and
segmentally unrelated
to the primary source
of nociception.
Several regions of
hyperalgesia at sites
outside and remote to
the symptomatic area
(still at segmentally
unrelated sites).
Pain is described as
sharp, aching, or
Pain is frequently
described as burning,
shooting, or pricking
Pain is most
frequently described
as vague and dull.
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Table 2. Cutoff scores and implications for the questionnaires used during the biopsychosocial intake.
Questionnaire Range/Cutoff score Implications Psychometrics Practical issues
Used by the
authors in clinical
Central Sensitization
(Mayer et al, 2012;
Neblett et al, 2014,
0100/>40 points Symptom presentation may indicate
the presence of CS pain
Testretest reliability 0.82
Cronbachs alpha 0.88
Sensitivity 8182,8%, Specificity 54.875%
Number of items: 35
Time to administer: 10 min
Leeds Assessment of
Symptoms and
(Bennett, 2001)
024/12 points Neuropathic mechanisms are likely to
contribute to the patients pain
Cronbachs alpha of 0.74
Sensitivity 83%, Specificity 87%
Good validity and reliability
Number of items: 7
Time to administer: 23 min
If necessary
Body diagram
(Wolfe et al, 2010)
No cutoff score exists Time to administer: 5 min Yes
Brief Illness
(Brief IPQ)
(Broadbent, Petrie,
Main, and
Weinman, 2006;
Leysen et al, 2015)
Each item has to be viewed
Moderate overall testretest reliability
Good concurrent, predictive and discriminant validity
Number of items: 13
Time to administer: 510 min
Available on:
Pain Catastrophizing
(Osman et al,
1997; Sullivan,
Bishop, and Pivik,
30 points The patient is likely to catastrophize
if the score is above 30
Higher scores indicate higher
Cronbachsalpha 0.880.95
Good construct, criterion, concurrent and discriminant
validity(Osman et al, 2000)
Number of items: 13
Time to administer: 510 min
Rumination: items 8, 9, 10, 11
Magnification: items 6, 7, 13 Helplessness: items 1,
2, 3, 4, 5, 12
State-Trait Anxiety
(Spielberger, 1989)
3940 (Knight,
and Spears, 1983)
5455 for older
adults (Kvaal,
Ulstein, Nordhus,
and Engedal, 2005)
Two subscales: State and Trait, range
of scores per subtest 2080
Higher scores indicate greater anxiety
Testretest reliability 0.310.86
Cronbachs alpha 0.860.95 (Julian, 2011)
Validity S-scale limited
Number of items: 40
Time to administer: 10 min
State Anxiety: current state of anxiety
Trait Anxiety: relatively stable aspects of anxiety
If necessary
Tampa-Scale of
(Vlaeyen, Kole-
Snijders, Boeren,
and van Eek, 1995)
37 The patient most likely has fear of
Higher scores indicate greater fear of
Moderate construct, concurrent and predictive validity,
good internal consistency, and a moderate to good retest
reliability (Roelofs et al, 2004; Swinkels-Meewisse et al,
Number of items: 17
Time to administer: 510 min
The scoring on items 4, 8, 12, and 16 should be
If necessary
Injustice Experience
(Sullivan et al,
19 in WAD*
(Scott, Trost,
Milioto, and
Sullivan, 2013)
Above this score perceived injustice
is associated with high pain severity,
not returning to work, and narcotic
Higher scores indicate more
perceived injustice
Cronbachs alpha 0.92
Testretest reliability 0.900.98 (Rodero et al, 2012;
Sullivan et al, 2008)
Good construct validity
Number of items: 12
Time to administer: 510 min
Blame/Unfairness: items 3, 7, 9, 10, 11, 12
Severity/Irreparability: items 1, 2, 4, 5, 6, 8
(Continued )
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Table 2. (Continued).
Questionnaire Range/Cutoff score Implications Psychometrics Practical issues
Used by the
authors in clinical
Inflexibility in Pain
Scale (PIPS)
Sorjonen, and
Olsson, 2010)
No cutoff score exists
Higher scores indicate less
psychological flexibility
Cronbachs alpha 0.90 (avoidance), 0.75 (fusion), and 0.89
(total scale)
Intercorrelation between subscales 0.46
Acceptable model fit
Good construct and concurrent validity
Number of items: 16
Time to administer: 510 min
Avoidance of pain: items 2, 3, 7, 8, 9, 11, 13, 14,
15, 16
Fusion with pain thoughts: items 1, 4, 5, 6, 10, 12
If necessary
Center for
Studies Depression
(Eaton, 2004)
16 Indicative of significantor mild
depressive symptomatology
Higher scores indicate more
depressive feelings
Cronbachs alpha 0.880.91
Testretest reliability ICC = 0.87, individual items ICC =
Poor to excellent validity
Sensitivity 80.0%, Specificity 69.8%
(Kuptniratsaikul, Chulakadabba, and Ratanavijitrasil, 2002;
LaChapelle and Alfano, 2005)
Number of items: 20
Time to administer: 510 min
Somatic-retarded activity: items 1, 2, 3, 5, 7, 11, 20
Depressed affect: items 6, 10, 14, 17, 18
Positive affect: items 4, 8, 12, 16
Interpersonal affect: items 15, 19
If necessary
PHQ-2 and PHQ-9
(Arroll et al, 2010)
PHQ-9: >10 Indicative of a depressive disorder
Higher scores indicate more
depressive feelings
Cronbachs alpha 0.860.89
PHQ-9 cutoff score of >10: Sensitivity 88%, specificity
Good criteria validity (Arroll et al, 2010; Kroenke, Spitzer,
and Williams, 2003)
Number of items: 2
Time to administer: 1 min
Number of items: 9
Time to administer: 510 min
Patients who screen positive on the PHQ-2 should
be further evaluated with the PHQ-9 to determine
if they meet the criteria for a depressive disorder.
If necessary
Activity Diary Cutoff scores are not necessary. Time to administer: 1015 min Yes
*WAD: Patients with Whiplash Associated Disorders.
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muscle strength can be altered due to the CS sensitivity.
Due to the increased sensitivity to mechanical stimula-
tions and changed patterns in the central nervous sys-
tem in patients with CS, all physical examination tests
(e.g. range of motion, strength, muscle tone, neurody-
namic tests, and movement coordination) can evoke
pain. Therefore, the aim of the physical examination
is to support or refute the clinical picture of CS, assess
movement quality, determine body movement if the
manner in which the patient moves provokes symp-
toms consistent with CS (e.g. very guarded or with a lot
of tone), and determine whether there is fear of move-
ment. In the case of positive findings, clinical reasoning
skills are required to decide whether or not such phy-
sical factors are of clinical importance for the individual
patient and whether or not it contributes in the persis-
tence of CS pain. Positive findings could be: bracing
when bending; holding his/her breath while moving;
increased tonus prior to movement; verbal or nonver-
bal signs of fear; and inconsistent movement patterns.
The physical examination is important for both the
physiotherapist and the patient. By assessing com-
plaints thoroughly, both parties can be reassured that
anything dangerous/serious can be ruled out and con-
fidence is restored that the patients pain is taken
As discussed previously, cognitions and perceptions are
important factors that might contribute to (the main-
tenance of) CS pain. Besides influencing the hypersen-
sitivity in the brain by activating the pain neuromatrix
(Lee, Zambreanu, Menon, and Tracey, 2008), they also
influence the behavioral and emotional factors of
patients (Leventhal, Brissette, and Leventhal, 2003).
During history taking, the patients perceptions and
cognitions should be assessed thoroughly. Most impor-
tant are his/her perceptions about the physical and
mental aspects of pain as well as the consequences.
Furthermore the following factors should be assessed:
the expectations for care (anticipated outcome, as well
as the content of the treatment); expectations regarding
the prognosis of their pain; the coherence (the patients
ability to comprehend their whole situation and their
capacity to use available resources to deal with their
pain); and emotional representation of the pain.
Cognitive patterns, such as catastrophizing, perceived
injustice, or perceived harm, are important to
In the following section several diagnostic question-
naires are suggested to support the clinician. Not all
questionnaires have to be used; rather clinicians can
decide based on their perceptions and the patients
characteristics. Table 2 provides the cutoff scores, clin-
ical implications, and psychometric information for all
Pain perceptions
The Brief Illness Perception Questionnaire (Brief IPQ)
can be used to assess pain perceptions of the patient.
The Brief IPQ consists of 13 items and is based on the
Common Sense Model of Self-regulation (Leventhal,
Brissette, and Leventhal, 2003) (described in
Behavioral factors) and has a moderate overall test
retest reliability and good concurrent validity
(Broadbent, Petrie, Main, and Weinman, 2006; Leysen
et al, 2015). The questionnaire ends with a three-item
rank to list the personal causes of the illness. In addi-
tion, the Brief IPQ assesses the expectations for care
(items 2 and 4) as well as self-efficacy (item 3). Items 6
and 7 refer to worrying about and understanding pain,
respectively. With our clinical expertise patients scoring
high (6) on worrying about their painand low (4)
on understanding their paincould potentially benefit
from PNE for decreasing worrying and improving the
understanding of their condition.
Pain catastrophizing
When pain catastrophizing is suspected, the Pain
Catastrophizing Scale (PCS) can be used to assess the
degree of pain catastrophizing. The PCS is a valid and
reliable 13-item questionnaire (Table 2) that examines
the rumination, magnification, and helplessness
patients have about their perceived ability to manage
their pain (Osman et al, 1997; Sullivan, Bishop, and
Pivik, 1995). In order to avoid prejudices, we propose
omitting the words pain catastrophizing scalefrom
the questionnaire when handing it over to the patient.
If the patient scores high (30) on the PCS, their feel-
ings and cognitions on catastrophizing should be
acknowledged and explored in the PNE session. The
patient should also be told that catastrophizing
increases the activity in the pain signature in the
brain and therefore increases their pain.
Eemotional factors
Emotional factors are related to cognitions and percep-
tions and include anxiety, anger, fear, depressive feel-
ings, and posttraumatic stress. Physiotherapists can
specifically ask about emotional factors related to the
onset of pain, such as fear of specific movements,
avoidance behaviors, a psychological traumatic onset
of the pain, or psychological issues including work,
family, financial, or social.
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State anxiety (related to an event) and trait anxiety
(personal level of anxiety) are important factors in
chronic pain. In addition to questioning the patient
about anxiety, we recommend using the State-Trait
Anxiety Inventory (STAI). This questionnaire has 20
items for assessing trait anxiety and 20 for state
anxiety. The STAI has a good internal consistency,
is reliable, and has considerable construct and con-
current validity (Spielberger, 1989). A cutoff score of
3940 has been suggested to detect clinically signifi-
cant symptoms and a higher cutoff score of 5455 has
been suggested for older adults (Knight, Waal-
Manning, and Spears, 1983;Kvaal,Ulstein,Nordhus,
and Engedal, 2005). If the outcome of the STAI
indicates that the patient has anxiety, either state or
trait, the effects of this anxiety should be explored
and discussed in the PNE session.
Fear of movement
Based on previous experiences, patients can become
fearful and begin to avoid potentially painful move-
ments. The Tampa-Scale of Kinesiophobia (TSK) is a
17-item scale that measures the somatic focus of
patients (beliefs about underlying and serious medical
problems), and activity avoidance (beliefs about (re)
injury or increased pain). The TSK has moderate con-
struct, concurrent and predictive validity, good internal
consistency, and a moderate to good retest reliability
(Roelofs et al, 2004; Swinkels-Meewisse et al, 2003).
Patients scoring high on the TSK, above 37 points, are
likely to have fear of movement (Vlaeyen, Kole-
Snijders, Boeren, and van Eek, 1995) and during the
PNE session the effects of fear of movement on the pain
neuromatrix in the brain (by increased activity in the
hypothalamicpituitaryadrenal axis and increased
attention) should be explained.
Perceived injustice as a form of anger can be measured
using the Injustice Experience Questionnaire (IEQ).
Perceived injustice can have negative effects on pain,
disability, and treatment. For example, patients devel-
oping chronic pain following a car accident do not
present with perceived injustice or anger in the acute
stage, but develop it throughout the transition phase
toward chronicity, with marked increased levels in the
chronic stage (and not in those recovering) (Ferrari,
2015). Therefore, we recommend the use of the IEQ on
patients who are suspected of having anger/perceived
injustice such as a patient who develops chronic pain
following a car accident. The IEQ has a high internal
consistency, a good construct validity, and reliability
(Sullivan et al, 2008). If high scores (>19) on this ques-
tionnaire are present, this can be used to focus part of
the PNE, by first acknowledging their feelings of anger
and injustice, and then explaining that such emotions
sustain the pain signature in the brain and may present
barriers to improvement.
Depressive feelings
Physiotherapists are not trained to diagnose depression
or other psychological states, but should be aware of
their existence and role in pain patients. Depressive
feelings can be assessed through self-report question-
naires. The two-item Patient Health Questionnaire-2
(PHQ-2) and nine-item PHQ-9 are commonly recom-
mended for depression screening in clinical and
research settings. The PHQ-2 is a quick and helpful
screening tool for depression, with a sensitivity of 86%
and specificity of 78 (Arroll et al, 2010). Patients who
report more than 2 points or higher on the PHQ-2
should be further evaluated with the PHQ-9. A score
of 10 or higher on the PHQ-9 detects depression. The
PHQ-2 has a high sensitivity (86%) and the PHQ-9 has
higher specificity (91%) (Arroll et al, 2010).
Additionally, the Center for Epidemiologic Studies
Depression scale (CES-D) (Eaton, 2004) can be used.
The CES-D is a 20-item self-report measure of depres-
sive symptomatology during the past week. Scores of 16
or greater indicate more severe symptoms. The CES-D
has a high internal consistency, good reliability, and
convergent and divergent validity (Van Dam and
Earleywine, 2011). Patients scoring high on this or
any other scale for measuring depressive feelings need
support, acknowledgement, comfort, and help, each of
which can be provided in part by PNE.
There is a bidirectional relationship between depres-
sion and pain (Kroenke et al, 2011); however, because
patients are often fearful of being labeled (its in your
head), we suggest explaining to patients with chronic
pain that depression may be a consequence rather than
a cause of chronic pain. Furthermore, we suggest
explaining the interplay between pain and depression
in the pain neuromatrix during PNE.
Physiotherapists are suggested to screen their patients
for posttraumatic stress disorder by asking the patient
about prior traumatic events and whether they fre-
quently relive the event, avoid situations that remind
them of the event, or have negative changes in beliefs
and feelings since the event. In addition, physiothera-
pists should also evaluate general levels of stress and/or
stress intolerance. Stress can be related to work factors,
relationships, financial stress, health-related stress, etc.
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and should be investigated during the assessment. If
relevant to the individual patient, the influence of stress
on the pain neuromatrix and top-down inhibitory
pathways should be explained during PNE.
Bbehavioral factors
For physiotherapists it is important to assess current
behavior and adaptations made as a consequence of
pain. Both conscious and nonconscious behavior can
be the product of cognitive and emotional information
when perceiving and interpreting inputs or perceived
threats to health and well-being (Leeuw et al, 2007;
Leventhal, Brissette, and Leventhal, 2003; Pavlov,
1927; Skinner, 1938).
Patients can be roughly divided into three sub-
groups: 1) patients who demonstrate healthy behavior
(pain experience results in no/low fear, confrontation,
and recovery) (Crombez et al, 2012); 2) avoidance
(described previously); and 3) persistence behavior.
Persisters are patients who continue to perform painful
activities until completion even though the activity is
perceived as too hard (Huijnen et al, 2011). In the long
run, persistence behavior can also be unhelpful and
result in an extreme activenon-active pattern (also
called yo-yoor overactivityunderactivity cycling)
of daily activity levels (Andrews, Strong, and Meredith,
2015; Harding and Williams, 1998). When assessing
patientsbehavior in clinical practice, the majority of
patients present with a mixed pattern: they avoid cer-
tain activities or movements, and simultaneously per-
sist in others. This observation underscores the need
for a thorough individual assessment and questioning
of each patient individually. Patients should be ques-
tioned about their work, home, and recreational activ-
ities to determine which are avoided or persisted. In
addition, patients need to be asked when and why they
chose to either persist or avoid the activities. An activity
diary may aid in this process. There are different mod-
els explaining the above-mentioned behavior, such as
the Common Sense Model of Self-regulation (CSMS),
classical conditioning, and operant conditioning
(Leventhal, Brissette, and Leventhal, 2003; Pavlov,
1927; Skinner, 1938).
The CSMS is a model that helps understand how the
perceptions, experience, and impact of having a disor-
der might influence a patients interpretation and
response (Leventhal, Brissette, and Leventhal, 2003).
Based on the perceptions a person has, he/she will
present with certain behaviors in an attempt to influ-
ence the threat of a potentially painful event. After any
event a person assesses whether or not the threat is
diminished. If, for instance, the patient experiences
lower back pain during forward bending (threat), the
perceptions and emotions can change the behavior and
pattern of forward bending. The latest fear-avoidance
model of Vlaeyen et al. (1995) supports the CSMS and
the role of pain catastrophizing in pain chronification.
According to the CSMS the fear-avoidance behavior of
the patient, physical inactivity, disuse, and consequent
disability result from current or previous pain percep-
tions. Therefore, the physiotherapist should assess the
impact of pain perceptions and behaviors on levels of
function (work, recreation, daily activities). For exam-
ple when a patient expresses the avoidance of playing
tennis due to potential back pain, the physiotherapist
should ask about the patients beliefs and emotions
about what happens during this activity.
Unconscious behavior and classical conditioning
(Pavlov, 1927) are also important. For instance,
working in a stressful situation at a desk for long
periods during which the patient perceives pain, the
desk may become associated with the pain. The desk
is a neutral stimulus, but can become associated with
recently proposed by Moseley and Vlaeyen (2015),
they postulate that classical conditioning can even-
tually result in pain from non-nociceptive impulses
by stimulus generalization,calledtheImprecision
Behavior and social factors may also become
related through operant conditioning (changing of
behavior by the use of reinforcement, after the
desired response). Operant conditioning, as
described by Skinner et al. (Skinner, 1938), is
directly applicable to pain behavior (Fordyce et al,
1973). Operant conditioning works with positive
and negative reinforcers. For example an uncon-
sciously positive reinforcement of the pain behavior
may occur when sympathetic attention is given to
the patient, which is likely to strengthen the beha-
vior and increase its likelihood in the future. When
behavior is followed by negative reinforcement such
as criticism, that behavior is less likely to occur in
the future and behavior to remove or avoid the
consequence is likely to increase. If neither happens
1973; Skinner, 1938). In the assessment, phy-
siotherapists should ask about avoided behaviors
and how the social surroundings impact this
response to identify potential positive and negative
Ssocial factors
Social and environmental factors that cause stress or a
disbalance in the identified-self of the patient can
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have a negative effect on pain. Social factors can be
divided into: housing or living situation; social envir-
onment; work; relationship with the partner; and
prior/other treatments. It is important to find out if
there are components of the social factors that are
helpful and supportive or stressful and unconsciously
unhelpful. Other important social factors include
prior/concurrent treatments and the attitudes and
beliefs of these healthcare professionals (for instance,
a former physiotherapist who has told the patient that
his/her disk was out of line). These prior/concur-
rent treatments, as well as advice and explanations
about the patients condition, will influence their
perceptions and current coping strategies. Therefore
prior/concurrent treatments should be explored and
communication between healthcare professionals is
Low levels of social support may present barriers to
improvement in chronic pain patients, and can be a
sustaining factor in CS and worsen the prognosis
(DeLongis and Holtzman, 2005;Nijsetal,2011b).
Unpublished results and clinical experience suggest
that PNE can improve social support, especially
when the therapist facilitates social support by asking
the patient to bring their spouse, child, or a close
friend to one of the sessions. If this is not feasible,
significant others can be motivated to read informa-
tion about CS, such as the book Explain Pain
(Moseley, 2013).
Determining motivation and readiness to change is
vital for further treatment. The perceptions about
the cause of pain and the treatment expectations
are crucial to understand in order to target and
modify them during the treatment (Turk and
Okifuji, 2002). This is especially true if the proposed
treatment (including PNE) might be different from
what they have heard before, and more biopsycho-
social focused.
The 16-item Psychology Inflexibility in Pain Scale
(PIPS) can be used to assess avoidance of pain and
cognitive fusion with pain where patients get inter-
twined with their thoughts, and thoughts are seen as
good internal consistency as well as criterion and
construct validity. Furthermore, it has been reported
that psychological flexibility has a mediator function
in the relationship between pain and kinesiophobia,
pain and disability, and acceptance and catastrophiz-
ing, meaning that these relationships are largely
influenced by psychological flexibility (Wicksell,
Lekander, Sorjonen, and Olsson, 2010). The PIPS is
used to examine the patients psychological flexibility
to change. Previous research has shown that patients
with chronic pain with a high degree of psychologi-
cal inflexibility are likely to be nonresponders in an
Acceptance and Commitment Therapy (ACT)-based
rehabilitation (Wicksell, Olsson, and Hayes, 2010).
Based on the assessment and a high score on one or
both scales of the PIPS, the physiotherapist might
decide not to initiate treatment. Alternatively, if the
PIPS score is high, one could focus intensively on
PNE to change cognitions and perceptions prior to
initiating the remaining parts of the rehabilitation
program. Once the focused PNE has been delivered,
the PIPS is scored again to see whether there is a
difference in score that might indicate that the
patient is now ready for rehabilitation. We realize
the latter is a pragmatic approach and not (yet)
supported by research findings.
The stage of change model is another manner to
assess the motivation for treatment and education of
the patient. The start of the PNE should be tailored
to the stage of change the patient is in (Prochaska
and Norcross, 2001).OneofthegoalsofPNEisto
transition patients in their stage of change when
necessary; however, the starting point should be
adjusted to the stage of change a patient is in. The
physiotherapist has to determine which phase the
patient is in, considering both the perception and
emotional state of the patient. In the pre-contempla-
tion phase, the patient has no intention to change,
and he/she is not willing to adapt another explana-
tion or another treatment or coping strategy. In the
contemplation phase the patient is aware of the
problem and starts thinking about changing; how-
ever, he/she still has doubts, but is open to listen.
The preparation phase is one step further: the
patient is intending to take action in the next
month and is more willing to listen to PNE and
other new explanations. In the action phase, the
patient modifies his/her behavior, experiences, and
environment in order to overcome the problems. In
this very important phase the physiotherapist plays
an important role in the inventory of existing or
potential barriers for maintaining this new behavior
and changed perceptions. In the maintenance phase,
the action has been successful and the patient works
to prevent relapse and to consolidate the goals for
more than six months. The last phase, termination,
is the phase in which people have changed and no
longer need to work to prevent relapse (Prochaska
and Norcross, 2001).
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This article describes the biopsychosocial assessment of
patients with non-neuropathic CS pain in physiotherapy
practice and includes a combination of clinical experience
and scientific evidence. Certain aspects of this approach
are scientifically validated, but some components and
combinations of components have not been studied
(Type of Pain + SCEBS model + Motivation). We
attempted to clearly delineate what is supported by
research and what is based on expert opinion.
Figure 1. Flowchart of the biopsychosocial assessment of patients with chronic pain.
Biopsychosocial physiotherapeutic pain analysis
Date: ………………………………………………………….
Name: ……………………………………………………...
Date of birth: …………………………………………..…..
Physiotherapist: …………………………………….....…...
Behavioral factors:
Social factors:
Emotional and psychological factors:
Somatic and medical factors:
Cognitive factors:
Description of the pain, current complaints, mechanism of onset:
Treatment plan:
Figure 2. Pain analysis sheet.
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Similar to the recommended approach outlined in
this article, Dansie and Turk (2013) have previously
presented a physician guide for the assessment of
patients with chronic pain. Their assessment is based
on three main questions: 1) What is the extent of the
patients disease or injury (physical impairment)? 2)
What is the magnitude of the illness? That is, to what
extent is the patient suffering, disabled, and unable to
enjoy usual activities? 3) Does the individuals behavior
seem appropriate to the disease or injury, or is there
any evidence of symptom amplification for a variety of
psychological or social reasons? Furthermore, they
advise a standardized pain assessment and a brief
screening interview in which the physician can screen
for psychosocial problems. However, unlike the exten-
sive description of the biopsychosocial assessment in
our article they focused primarily on the assessment of
pain and disability.
Diagnosis/clinical reasoning
For some patients with chronic pain, getting a diagnosis
that makes sense to them is the first step to self-man-
agement of their pain. By getting a diagnosis, the pain
is no longer in your mind,imagination,orhys-
teria(Skuladottir and Halldorsdottir, 2011) and has
become legaland acknowledged by healthcare profes-
sionals. Unpublished results by Thompson (2014) show
that for patients with chronic pain who thrive(who
live well with their pain), receiving the chronic pain
diagnosis by a healthcare professional, even though
shocking, was the first step in their self-management.
Identifying the primary mechanism contributing to
that pain experience (nociception, neuropathic, CS,
combination) is more important than classifying pain
according to duration (Figure 3). Identifying whether
or not the patient has predominantly nociceptive, neu-
ropathic, or CS pain is a diagnosis in itself that offers
potential treatment pathways (Nijs et al, 2014).
Biopsychosocial assessment: recommendations for
further treatment
To assess pain as a biopsychosocial phenomenon and
really comprehend the essence of a patients pain pro-
blem take time. Obviously, it is important to focus on
the changeable biopsychosocial factors while also being
aware of non-changeable aspects such as personality,
neuroticism, and the degree of trait anxiety, which are
known to be stable to some degree over time (Anusic
and Schimmack, 2016; Pettersson et al, 2004;
Prenoveau et al, 2011; Spinhoven et al, 2014).
Knowledge of these biopsychosocial factors is essen-
tial for steering the plan of care and identifying the
potential components of PNE to be used. The (psycho-
social) education of the physiotherapist, including the
competence, knowledge, biopsychosocial vision, inter-
personal factors, and fingerspitzengefühl(i.e. instinct,
intuitive flair, high situational awareness, and ability to
respond most appropriately and tactfully), combined
with two-way communication and a patient-centered
approach are important. Physiotherapists specialize in
the assessment of function, physical activity, move-
ments, muscle tension, etc. combined with strategies
to treat these impairments. Even though questionnaires
can help identify behavioral, cognitive, and emotional
factors (Table 2), we must be reflective of our biopsy-
chosocial view and knowledge of illness perceptions.
Research has shown that physiotherapists struggle in
this area (Daykin and Richardson, 2004; Haggman,
Maher, and Refshauge, 2004; Overmeer, Linton, and
Boersma, 2004; Singla, Jones, Edwards, and Kumar,
2015; Synnott et al, 2015; Valjakka et al; van Wilgen
et al, 2014). It is important, as healthcare providers, to
know and respect our limits, especially when working
with patients with chronic pain. Throughout the assess-
ment, physiotherapists should be aware of their limita-
tions and ask themselves: is this patient (with chronic
pain) in the right place here with me, or should he/she
Figure 3. Pain Neuroscience Education tailored to the primary pain mechanisms of the patient.
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be treated in a multidisciplinary setting or referred to
another provider?
Once indications for PNE are established, individua-
lized therapy can be initiated by explaining the biopsy-
chosocial diagnosis to the patient, reassuring them that
their pain is real, and explaining why they are in pain
(i.e. CS pain, neuropathic pain, and/or nociception).
Changeable factors and the receptiveness of the patient
to change further guide the content and the attitude of
the physiotherapist during PNE. Based on the stages of
change model (Prochaska and Norcross, 2001) patients
in the pre-contemplation phase need a more nurturing
parentrole, and can be more resistant and defensive.
Patients who are in the contemplation phase may ben-
efit from a Socratic teacherwho encourages patients
to achieve insights into their own condition. If the
patient is in the preparation stage, we recommend
that the physiotherapist adopt the role of an experi-
enced coachwho can provide a new game plan or can
review and modify the patients own plan. Patients in
the action and maintenance phases benefit from a phy-
siotherapist who becomes more of a consultantwho
is available to provide expert advice and support
(Prochaska and Norcross, 2001). Physiotherapists keen
to learn more about this topic are referred to the cited
We have outlined how physiotherapists may take the
first step in the successful treatment of patients with
chronic pain, by motivating the patient to achieve goals
and restore values and his/her identified-self (Higgins,
1987; Sutherland and Morley, 2008; Thompson, 2014).
Chronic pain is complicated, and a thorough biopsy-
chosocial intake, examination, and interdisciplinary
treatment plan are required for success.
Prior to providing PNE and further treatment, an
extensive biopsychosocial intake should be con-
ducted. To our knowledge this is the first article
describing the comprehensive biopsychosocial intake
of patients with central sensitization in physiotherapy
practice and is derived on scientific evidence as well
as expert opinion. This approach needs to be inves-
tigated further in clinical trials with chronic pain
We believe the biopsychosocial intake described
here is necessary to clarify the primary type of
chronic pain: predominant neuropathic, nociceptive,
or CS pain. This allows the physiotherapist to assess
the biopsychosocial factors that may be contributing
to the continuation of pain. Diagnosingthe patient
as having CS pain, nociceptive pain, neuropathic
pain, or a combination is the first step in tailoring
a patient-centered PNE that can aid the patient in
his/her self-management process.
Declaration of interest
Authors report no conflict of interest. The authors alone are
responsible for the content and writing of the paper.
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... 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. Emotional states such as fear, stress, and depression experienced by the individual in previous pain experiences increase the severity of pain. ...
... Obtaining personal data on the components of the concept of pain will help to plan pain science education (when? for how long?, etc.) and to guide the care plan (Robins et al., 2016;Wijma et al., 2016). ...
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.
... Catastrophizing consists of three subscales: rumination, magnification, and helplessness. The totality of the sub-scales is generally considered a cognitive process, though authors assert the sub-scales also have an affective presentation [66,[77][78][79][80]. Catastrophizing relates to distress and anxiety, which activate the pain neuromatrix and escalate pain, amplify distress, and increase reported disability [29,81]. Additionally, catastrophizing is further defined by a negative evaluation of one's own ability to cope with pain, also expressed as helplessness [66,79]. ...
... A unifying neurobiological theory is that depression and pain symptoms shared the same neural pathways and neurochemicals. The modulation of pain in the descending neuropathways are influenced by psychological mechanisms related to anxiety, depression, expectations, and attention [48,81,90]. Symptoms overlap between clinical depression and features in chronic pain conditions. ...
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Background: Chronic pain and the accompanying level of disability is a healthcare crisis that reaches epidemic proportions and is now considered a world level crisis. Chronic non-specific low back pain (CNLBP) contributes a significant proportion to the chronic pain population. CNLBP occurs with overlapping psychosocial factors. This study was design to investigate specific psychosocial factors and their influence on reported disability in a population with CNLBP. Methods: The specific psychosocial factors examined included fear, catastrophizing, depression, and pain self-efficacy. This cross-sectional correlational study investigated the mediating role between pain self-efficacy, the specific psychosocial factors, and reported disability. The study recruited 61 female and 29 male participants from physical therapy clinics. The participants were between 20-to-60 years of age and diagnosed with CNLBP. All participants completed the Fear Avoidance Belief Questionnaire, The Pain Catastrophizing Scale, The Patient Health Questionnaire-9, The Pain Self-Efficacy Questionnaire, and The Lumbar Oswestry Disability Index. The battery of questionnaires measured fear of physical activity, pain catastrophizing, depression, pain self-efficacy, and reported disability. Multivariate regression and mediation analyses was used to analyse the data. Results: The principal finding was a strong inverse relationship between pain self-efficacy and reported disability with a p-value < 0.001. Further, pain self-efficacy was considered a statistical mediator with consistent p-value < 0.001 for the specific psychosocial factors investigated within this data set. Pain self-efficacy was considered to have a mediating role between reported fear of physical activity and disability, reported pain catastrophizing and disability, and reported depression and disability. Additionally, age and reported pain levels proved to be statistically significant. Adjustments for age and pain level did not alter the role of pain self-efficacy. Conclusion: The results identified a mediating role for pain self-efficacy between the specific psychosocial factors (fear, catastrophizing, and depression) and reported disability. Pain self-efficacy plays a more significant role in the relationships between these specific psychosocial factors and reported disability with CNLBP than previously considered.
... The interventions to treat high FOC in women should intend to reduce their childbirth-related anxiety and stress and simplify the acceptance of uncertainties associated with the future delivery (Bewley et al., 2002;Wijma et al., 2016). The consequences of treating maternal anxiety and FOC can be assessed in many different ways, such as in terms of alleviation of apparent stress and better adjustment and acceptance during pregnancy, drawing out the request for cesarean delivery, having better mother-infant bonding during pregnancy and postpartum, have fewer childbirth complications, and having less postpartum problems (Hofberg & Ward, 2003). ...
Full-text available
There is increasing evidence shows that fear of childbirth (FOC) may have short- and long-term adverse effects on mothers and babies if left untreated. The childbirth process is an experience with many dimensions, multifaceted, and unique for each woman, still strongly influenced by the social-cultural context in which women belongs. To identify and explore the factors contributing to the fear of childbirth among recently delivered women of Pune city, India. The study used a qualitative study approach. A total of 15 in-depth interviews were conducted with women who have recently given birth in maternity hospitals. Interviews were conducted using an interview guide (open ended-questionnaire). Interviews were audio-recorded. The participants were called into a separate room for the interview; full privacy was given to the interviewees, thus making a safe and reliable environment. All collected interviews were transcribed and analyzed. Axial coding was used to develop codes into major themes contributing to FOC were derived. Seven major themes emerged from the analysis of the transcribed interviews. The seven major themes are fear related to the child, fear of parenthood, fear due to mode of delivery, negative pregnancy/delivery experience, psychological aspects attributed to fear of pregnancy, fear of pain, and social background. FOC occurs in most of pregnant women irrespective of parity. The determinants of FOC are influenced by women context; thus, variation in factors of FOC is observed. The FOC related factors show the complex interconnection between them, and it may vary from woman to woman and settings to settings concerning women context.
... In addition, for users, this can increase motivation by adapting exercises to the user's daily life. Not only that, but it enhances their entertainment and sports activity by adding new technologies to conventional treatments such as videogames or virtual reality [12]. ...
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Mixed reality presents itself as a potential technological tool for the management of people with musculoskeletal disorders, without having as many adverse side effects as immersive virtual reality. The objective of this study was to explore the possibilities of a mixed-reality game, performing task-oriented cervical exercises compared to conventional therapeutic exercises in sensorimotor outcome measures in asymptomatic subjects. A randomized crossover pilot study was performed with two intervention groups: a mixed-reality group (MRG) and a conventional exercise group (CEG). The cervical joint position error test (CJPET) and deep cervical flexor endurance test (DCFET) were measured as sensorimotor outcomes. Statistically significant differences were found in the pre–post comparison in the DCFET for both groups (MRG: t = −3.87, p < 0.01; CEG: t = −4.01, p < 0.01) and in the extension of the CJPET for the MRG (t = 3.50, p < 0.01). The rest of the measurements showed no significant differences comparing both groups pre- and postintervention (p > 0.05). Mixed reality has apparently the same positive effects as conventional exercises in sensorimotor outcomes in asymptomatic subjects. These results could help in future studies with mixed virtual reality in the management of people with musculoskeletal disorders.
Background Physical therapists use several evaluation measures to identify the most important factors related to disability. However, the degree to which these evaluation components explain shoulder disability is not well known and that may detract clinicians from the best clinical reasoning. Objective To determine how much evaluation components explains shoulder function. Methods Eighty-one individuals with unilateral shoulder pain for at least four weeks and meeting clinical exam criteria to exclude cervical referred pain, adhesive capsulitis, and shoulder instability, participated in this study. Several typical clinical evaluation components were assessed as potential independent variables in a regression model using the Disabilities of the Arm, Shoulder, and Hand (DASH) score as a proxy to shoulder function. Two multivariate models were built to include (1) evaluation components from physical exam plus clinical history and (2) a model considering all previous variables and magnetic resonance imaging (MRI) data. Results Pain catastrophizing was the best variable in the model explaining at least 10% of the DASH variance. Sex and lower trapezius muscle strength explained considerably less of shoulder function. The MRI data did not improve the model performance. Conclusion The complexity of shoulder function is not independently explained by pathoanatomical abnormalities. Psychological aspects may explain more of shoulder function even when combined with physical components in some patients.
Aim: Although the importance of biopsychosocial models for chronic diseases is emphasized nowadays, the lack of assessment tools to meet this need draws attention. This study was planned to assess the validity, reliability, and responsiveness of the Cognitive Exercise Therapy Approach-Biopsychosocial Questionnaire (BETY-BQ) in patients with fibromyalgia. Method: Hospital Anxiety and Depression Scale (HADS), Mindful Attention Awareness Scale, Health Assessment Questionnaire, the Fibromyalgia Impact Questionnaire, and Short-Form 36 (SF-36) were used for the validity of BETY-BQ. For the reliability study, evaluations were repeated at 1-week intervals and for the responsiveness, the same scales were applied to patients under medical treatment at 3-month intervals. Results: The correlations of BETY-BQ with the other scales were found to be moderate to high (respectively r = .591, P < .001 and r = .441, P < .001; r = -.419, P < .001; r = .617, P < .001; r = .722, P < .001; r = -.580 and -.374, P = .001 and P < .001) and with SF-36 sub-parameters were found to be weak-moderate. The test-retest method was used for reliability, and the correlation between the responses was very high (r = .901, P < .001). The intraclass correlation coefficient (ICC) was found to be high (ICC = 0.899, P < .001). Cronbach's alpha (α) value was found to be .947. In the correlation analysis of time-dependent changes, BETY-BQ correlated weakly with other scales and moderately correlated with HADS (HADS-anxiety r = .489, P = .006, HADS-depression r = .500, P = .005). Conclusions: BETY-BQ was presented in the literature as a valid, reliable, and sensitive scale that can be used both in the biopsychosocial evaluation and as an easily understood, practical scale that can be answered in a short time in the practices of healthcare professionals.
Introduction Persistent pain significantly impacts daily living. Visual arts interventions can have positive outcomes, but little is known about benefits for people with persistent pain. This study aimed to explore participant experiences of utilising visual art in expressing and managing their persistent pain experience through a visual diary. Method As part of a small exploratory study nested in a larger project, participants with a history of persistent pain were recruited from a local pain management clinic. Six participants with persistent pain attended five weekly intervention sessions involving art observation, creation and discussion, at the Art Gallery of NSW. Participants explored their ideas about their pain experience through artmaking using visual and written data from self-reported pain diaries. Thematic analysis was used. Results Analysis of five diaries was conducted. Visual and written expressions of the pain experience varied. Colour was used by participants to represent ideas and emotions. Capital letters were used to convey tone, or emphasis. Three main themes emerged from the written and visual data: ‘The lived experience of pain’, ‘The powerful drive for growth beyond change itself’ and ‘Personal values and perceptions guiding daily living and decision-making’. Conclusion This study provides insights into the potential benefits of using visual arts to help manage persistent pain experiences and improve health outcomes.
This chapter aims to address the management of chronic pain in primary care and takes as its starting point that all reasonable attempts to investigate and treat modifiable causes of pain have been made. The goal of treating chronic pain is to support the patient to live as well as possible, with the maximum quality of life, in spite of their chronic pain. Evaluating patient‐reported outcomes is an important part of a comprehensive chronic pain assessment. There is good evidence for the limited benefit of pharmaceutical interventions in many chronic pain conditions with 40–50% of patients obtaining some benefit. Self‐management tools can be effective to complement other drug and non‐drug therapies. Pain Management Programs are based on combined psychological and behavioral approachesand combine patient education and practice sessions aimed at helping people with chronic pain to manage their pain and everyday activities better.
Background Patient expectations related to physical therapy outcomes are commonly collected through surveys and close-ended questionnaires. These methods may not optimally capture patients' expectations for physical therapy, especially in the patients' own words. Louis Gifford identified four questions attempting to guide clinicians' understanding of patients’ expectations for physical therapy. However, a qualitative assessment mapping the expectations that patients have prior to starting physical therapy appears to be undocumented. Objectives The aim of this study was to determine patient expectations prior to beginning physical therapy for individuals with musculoskeletal conditions. Design Qualitative analysis with structured interviews and open-ended participant responses. Methods Twenty-five people (18 female, 7 male; mean age: 47.04 years) were interviewed prior to their initial physical therapy evaluation using a pragmatic approach rooted in phenomenology. Data were transcribed, coded, and thematized using qualitative data analysis software. Results Outcome, education, exercise, evaluation, and cause of pain were key themes expressed by participants. Participants appear to want to better understand their symptoms, how they can improve symptoms, what the clinician will do, and how long they will attend physical therapy. Many participants were not certain where physical therapy fit within their overall healthcare plan, and perceptions of manual therapy were vague. Conclusions These identified themes highlight what patients may expect from a physical therapy experience and clinicians should work to identify and satisfy each patient's individual expectations to optimize outcomes.
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Low back pain (LBP) is a heterogeneous disorder including patients with dominant nociceptive (e.g., myofascial low back pain), neuropathic (e.g., lumbar radiculopathy), and central sensitization pain. In order to select an effective and preferably also efficient treatment in daily clinical practice, LBP patients should be classified clinically as either predominantly nociceptive, neuropathic, or central sensitization pain. To explain how clinicians can differentiate between nociceptive, neuropathic, and central sensitization pain in patients with LBP. Narrative review and expert opinion SETTING: Universities, university hospitals and private practices METHODS: Recently, a clinical method for the classification of central sensitization pain versus neuropathic and nociceptive pain was developed. It is based on a body of evidence of original research papers and expert opinion of 18 pain experts from 7 different countries. Here we apply this classification algorithm to the LBP population. The first step implies examining the presence of neuropathic low back pain. Next, the differential diagnosis between predominant nociceptive and central sensitization pain is done using a clinical algorithm. The classification criteria are substantiated by several original research findings including a Delphi survey, a study of a large group of LBP patients, and validation studies of the Central Sensitization Inventory. Nevertheless, these criteria require validation in clinical settings. The pain classification system for LBP should be an addition to available classification systems and diagnostic procedures for LBP, as it is focussed on pain mechanisms solely. Chronic pain, neuroscience, diagnosis, clinical reasoning, examination, assessment.
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What are physiotherapists' perceptions about identifying and managing the cognitive, psychological and social factors that may act as barriers to recovery for people with low back pain (LBP)? Systematic review and qualitative metasynthesis of qualitative studies in which physiotherapists were questioned, using focus groups or semi-structured interviews, about identifying and managing cognitive, psychological and social factors in people with LBP. Qualified physiotherapists with experience in treating patients with LBP. Studies were synthesised in narrative format and thematic analysis was used to provide a collective insight into the physiotherapists' perceptions. Three main themes emerged: physiotherapists only partially recognised cognitive, psychological and social factors in LBP, with most discussion around factors such as family, work and unhelpful patient expectations; some physiotherapists stigmatised patients with LBP as demanding, attention-seeking and poorly motivated when they presented with behaviours suggestive of these factors; and physiotherapists questioned the relevance of screening for these factors because they were perceived to extend beyond their scope of practice, with many feeling under-skilled in addressing them. Physiotherapists partially recognised cognitive, psychological and social factors in people with LBP. Physiotherapists expressed a preference for dealing with the more mechanical aspects of LBP, and some stigmatised the behaviours suggestive of cognitive, psychological and social contributions to LBP. Physiotherapists perceived that neither their initial training, nor currently available professional development training, instilled them with the requisite skills and confidence to successfully address and treat the multidimensional pain presentations seen in LBP. Registration: CRD 42014009964. [Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, O'Sullivan K (2015) Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review.Journal of PhysiotherapyXX: XX-XX]. Copyright © 2015. Published by Elsevier B.V.
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Chronic pain is a public health problem that is likely to increase as the population ages, and has few effective treatments. Although viewed by many as profoundly distressing and disabling, there are a surprising number of people (approximately 30%) who cope well with their chronic pain and do not continue to seek treatment. There is little theory to explain how and why these individuals manage their pain well. This means there is limited knowledge about the approaches used by people who cope well and whether these strategies could help those who have more difficulty. This thesis presents a substantive grounded theory of living well with chronic pain, the theory of re-occupying self. Seventeen individual interviews were recorded, with data collection, analysis and theory generation following classical grounded theory methodological approach. Constant comparison, theoretical sampling, theoretical coding, and theoretical sensitivity were used to identify the main concern of people who cope well with pain. This concern is achieving self-coherence, and is resolved by re-occupying self. Resolution involves making sense to develop an idiographic model of their pain; deciding to turn from patient to person, facilitated or hindered by interactions with clinicians and occupational drive; and flexibly persisting where occupational engaging and coping allow individuals to develop future plans. By completing this process, individuals form a coherent self-concept in which they re-occupy the important or valued aspects of themselves. This study supports using Acceptance and Commitment Therapy because of its functional contextual view of people and their actions. This study illustrates that coping strategies are used in different ways depending on the primary goal within that context. Occupations, or active; purposeful; meaningful; contextualised and human activities, are used by people to make sense of their situation, and as a key motivation for developing coping strategies. These findings lead to new research questions about values-aligned activity, coping with identity change, and acceptance.
The stability of individual differences is a fundamental issue in personality psychology. Although accumulating evidence suggests that many psychological attributes are both stable and change over time, existing research rarely takes advantage of theoretical models that capture both stability and change. In this article, we present the Meta-Analytic Stability and Change model (MASC), a novel meta-analytic model for synthesizing data from longitudinal studies. MASC is based on trait-state models that can separate influences of stable and changing factors from unreliable variance (Kenny & Zautra, 1995). We used MASC to evaluate the extent to which personality traits, life satisfaction, affect, and self-esteem are influenced by these different factors. The results showed that the majority of reliable variance in personality traits is attributable to stable influences (83%). Changing factors had a greater influence on reliable variance in life satisfaction, self-esteem, and affect than in personality (42%-56% vs. 17%). In addition, changing influences on well-being were more stable than changing influences on personality traits, suggesting that different changing factors contribute to personality and well-being. Measures of affect were less reliable than measures of the other 3 constructs, reflecting influences of transient factors, such as mood on affective judgments. After accounting for differences in reliability, stability of affect did not differ from other well-being variables. Consistent with previous research, we found that stability of individual differences increases with age. (PsycINFO Database Record
Overactivity is a frequently used term in chronic pain literature. It refers to the phenomenon whereby individuals engage in activity in a way that significantly exacerbates pain, resulting in periods of incapacity. Overactivity, as a construct, has been derived solely from patients' self-reports, raising concerns about the legitimacy of the construct. Self-reported overactivity reflects an individual's belief, collected retrospectively, that their earlier activity levels have resulted in increased levels of pain. This may be different to an individual actually engaging in activity in a way that significantly exacerbates pain. In the present study, a five-day observational study design was employed to investigate the validity of overactivity as a construct by examining the relationship between a self-report measure of overactivity, patterns of pain, and objectively measured physical activity over time. A sample of 68 adults with chronic pain completed a questionnaire investigating self-reported habitual engagement in overactivity and activity avoidance behaviour, before commencing five days of data collection. Over the five-day period participants wore an activity monitor, and recorded their pain intensity six times a day using a handheld computer. Associations were found between: 1) high levels of pain and both high overactivity and high avoidance, 2) high levels of overactivity and more variation in pain and objective activity across days, and 3) high levels of overactivity and the reoccurrence of prolonged activity engagement followed by significant pain increases observed in data sets. These results offer some preliminary support for the validity of overactivity as a legitimate construct in chronic pain.
Objectives: Dysregulated biological stress systems and adverse life events, independently and in interaction, have been hypothesised to initiate chronic pain. We examine whether (1) function of biological stress systems, (2) adverse life events, and (3) their combination predict the onset of chronic multisite musculoskeletal pain. Methods: Subjects (n=2039) of the Netherlands Study of Depression and Anxiety, free from chronic multisite musculoskeletal pain at baseline, were identified using the Chronic Pain Grade Questionnaire and followed up for the onset of chronic multisite musculoskeletal pain over 6 years. Baseline assessment of biological stress systems comprised function of the hypothalamic-pituitary-adrenal axis (1-h cortisol awakening response, evening levels, postdexamethasone levels), the immune system (basal and lipopolysaccharide-stimulated inflammation) and the autonomic nervous system (heart rate, pre-ejection period, SD of the normal-to-normal interval, respiratory sinus arrhythmia). The number of recent adverse life events was assessed at baseline using the List of Threatening Events Questionnaire. Results: Hypothalamic-pituitary-adrenal axis, immune system and autonomic nervous system functioning was not associated with onset of chronic multisite musculoskeletal pain, either by itself or in interaction with adverse life events. Adverse life events did predict onset of chronic multisite musculoskeletal pain (HR per event=1.14, 95% CI 1.04 to 1.24, p=0.005). Conclusions: This longitudinal study could not confirm that dysregulated biological stress systems increase the risk of developing chronic multisite musculoskeletal pain. Adverse life events were a risk factor for the onset of chronic multisite musculoskeletal pain, suggesting that psychosocial factors play a role in triggering the development of this condition.