Background & Aims

Pain education (PE) has become a standard treatment component in multimodal interventions for chronic low back pain (CLBP). PE provides clinically meaningful improvements in pain and disability when combined with other non-pharmacological interventions[1]. However, its effectiveness may diminish after three months[1]. Improvements in pain intensity and disability through PE can be partly explained by reductions in fears and worries about CLBP[2]. Therefore, the lack of long-term effects can reflect the return or persistence of underlying fears and worries related to CLBP. This study explored why fears and worries might persist after a PE-grounded multimodal intervention.

Methods

We conducted a qualitative study using semi-structured interviews alongside a randomised controlled trial[3] that evaluated the effectiveness of a PE-grounded intervention for adults with CLBP. Purposive sampling was applied to recruit a diverse sample. Participants attended 50–60-minute individualised sessions weekly for 12 weeks in the PE-grounded multimodal intervention—the first two sessions involved solely PE, then PE was integrated and reinforced with graded sensory and movement training. Data were analysed using Reflexive Thematic Analysis with an inductive approach[2].

Results

Twenty individuals participated in the study (9 women and 11 men, with a median (range) age of 54 (35-70) years and a median (range) duration of CLBP of four (0.5-23.0) years. Thirteen participants (65%) reported at least 30% pain reduction on the 0-10 NRS at the 18-week follow-up. Interviews took place between 1.1 and 2.5 years after the participants’ first session of the program to understand persistent fear and worries about back pain after the treatment program. We identified three themes:
1) “Are you implying my pain is not real?”: concerns that the intervention questioned the validity of their pain experience.
2) “My problem is in my lower back”: fear or worries about the structural influences for the persistence of their back pain.
3) “I am unsure how to fit it into my daily life” when participants expressed fear and worries of future pain because they could not apply the alternative way of making sense of pain in their daily lives.

Conclusions

We identified possible reasons why fear and worries might persist after PE-grounded multimodal intervention. Based on these findings, we recommend that clinicians and researchers address these responses using communication strategies and educational content matching patients’ characteristics, experiential approaches integrated with PE, and societal reinforcements for the acceptability of PE-oriented interventions. We provided examples of how clinicians could monitor cognitive and emotional responses while receiving pain education for chronic back pain and communication strategies to address responses that might interfere with changes in fear and worries following PE-grounded multimodal interventions.

References

[1] Wood L, Hendrick PA. A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: Short-and long-term outcomes of pain and disability. European journal of pain 2019;23(2):234-249.

[2] Cashin AG, Lee H, Wand BM, Bagg MK, O’Hagan ET, Rizzo RRN, Stanton TR, Moseley GL, McAuley JH. Mechanisms of education and graded sensorimotor retraining in people with chronic low back pain: a mediation analysis. Pain 2023.

[3] Bagg MK, Wand BM, Cashin AG, Lee H, Hubscher M, Stanton TR, O’Connell NE, O’Hagan ET, Rizzo RRN, Wewege MA, Rabey M, Goodall S, Saing S, Lo SN, Luomajoki H, Herbert RD, Maher CG, Moseley GL, McAuley JH. Effect of Graded Sensorimotor Retraining on Pain Intensity in Patients With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA 2022;328(5):430-439.

Presenting Author

Rodrigo Rizzo

Poster Authors

Rodrigo Rizzo

PhD

University of New South Wales

Lead Author

E-mail

Benedict M. Wand

PhD

Faculty of Medicine, Nursing & Midwifery and Health Sciences, The University of Notre Dame Australia

Lead Author

E-mail

Hayley B. Leake

PhD

IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, Australia. Pain Educa

Lead Author

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Edel O'Hagan

The University of Sydney

Lead Author

E-mail

Adrian C. Traeger

PhD

School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia

Lead Author

E-mail

Sylvia Gustin

UNSW

Lead Author

E-mail

G. Lorimer Moseley

PhD

IIMPACT in Health, University of South Australia, Kaurna Country, Adelaide, Australia.

Lead Author

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Saurab Sharma

PhD

School of Health Sciences, Faculty of Medicine, University of New South Wales, Sydney, Australia

Lead Author

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Aidan Cashin

UNSW/Neuroscience Research Australia

Lead Author

E-mail

Matthew K. Bagg

PhD

Faculty of Medicine, Nursing & Midwifery and Health Sciences, The University of Notre Dame Australia

Lead Author

E-mail

James McAuley

PhD

Neuroscience Research Australia

Lead Author

E-mail

Samantha Bunzli

PhD

School of Health Sciences and Social Work, Griffith University, Nathan Campus, Queensland, Australia

Lead Author

E-mail

Topics

  • Specific Pain Conditions/Pain in Specific Populations: Low Back Pain