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Exploring Effect of Pain Education On Chronic Pain Patients' Expectation of Recovery and Pain Intensity
Exploring Effect of Pain Education On Chronic Pain Patients' Expectation of Recovery and Pain Intensity
Manasi M. Mittinty*, Simon Vanlint, Nigel Stocks, Murthy N. Mittinty and G. Lorimer Moseley
© 2018 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.
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2 Mittinty et al.: Exploring effect of pain education on chronic pain patients’ expectation of recovery
education which emerged about 15 years ago [7] is now rec- participants’ daily pain management strategies, their
ognized as part of best practice [8]. Pain education aims expectation of recovery and their perspectives on the
to give patients an overview of the underlying physiologi- value of pain education, if they had received it. All partici-
cal mechanisms and adaptive processes which support pants provided digital consent prior to prior to participat-
persistent pain, such that pain becomes ‘over-protective’ ing in the survey. The study was approved by the Human
[9, 10]. Reconceptualization of pain in this fashion shows Research Ethics Committees of the University of Adelaide
clinically important improvements [11] with increased par- and the University of South Australia.
ticipation from patients in active biopsychosocial based All participants were individuals who could read and
rehabilitation [12]. Explaining pain seems to have similar understand English, were aged 18 years and above, and at
positive effects across painful conditions, for example the time of participation, had experienced pain on most
fibromyalgia [13, 14], neck pain [15], chronic fatigue syn- days for more than three consecutive months. There was
drome [16], and chronic low back pain [17, 18]. no limitation on gender, ethnicity or country of residence.
However, one issue that remains to be investigated is
the patients’ perspective on the impact of pain education.
Although empirical data shows that learning about pain 2.2 Measures
biology improves pain and enhances the likelihood of
recovery from persistent pain [12], whether or not patients 2.2.1 Dependent variables
see value in pain education, and whether or not perceiv-
ing that value is associated with pain and expectations of The primary outcomes used in this study were; patient-
recovery, remains unknown. It is an important question perceived pain intensity and patient-perceived time to
because it is the patient’s perspective that will best inform recovery. Information on pain intensity was collected from
their future responses to painful events and the advice the participants using the question, “what is the average
they give to others – an important method of knowledge severity of your pain in the last 2 days?” Participants
transfer [19]. were asked to complete a numerical rating scale (NRS),
The current study investigated these issues using an anchored at left with “0 – no pain” and at right with “10
online cross-sectional design. We aimed to determine if – worst pain”. Participants were also asked, “how long do
participants believed that pain education had changed you think it will take for you to recover from your current
their views on their pain (hereafter referred to as pain cog- pain problem?” where recovery was outlined as reduction
nition) and had changed the way they managed their pain in pain severity and improved daily functioning. The pos-
(hereafter referred to as self-management of pain), and sible responses were “3–6 months”, “up to 1 year”, “more
whether or not these perceptions were associated with than 1 year” and “never”. In order to fulfill the require-
their expectations of recovery and their current usual pain ments of logistic regression, and because we were primar-
intensity. ily interested in whether perspectives on the impact of
pain education would be associated with expecting recov-
ery rather than not expecting recovery, we analyzed recov-
Pain education was defined as, information patients likelihood ratio test was used to find the best predictors
had received from their health care providers explaining of these relations. To compare the regression models and
their pain and potential triggers such as lack of sleep, maintain uniformity of sample size, “not applicable”
inactivity, stress which may aggravate their pain and cases from all the covariates were removed. If change in
symptoms. Participants were asked if they had received pain cognition and change in self-management demon-
pain education. If the response to this question was “yes”, strated collinearity, then separate regressions were under-
they were directed to these questions – “Did this educa- taken, as per protocol.
tion change the way you think about your pain?” and “Did Basic univariate descriptive statistics was used to
this education change the way you manage your pain?” characterize the sample for the proportion of the entire
Responses to both these questions were collected using cohort who had received pain education, those who had
simple “yes”, “no” dichotomization. observed change in pain cognition and change in self-
management of pain as a result of pain education, pain
intensity and expected recovery. Cross-tabulation was
2.3 D
ata collection and analysis used to describe pain intensity and expected recovery
in groups that were defined by age, gender, education
Univariate and multiple logistic regression was computed level, employment status, marital status, pain edu-
to estimate the odds of expected recovery among patients cation, change in pain cognition and change in self-
who had reported observed change in pain cognition and management of pain. All analysis was performed in
self-management of pain following pain education. The STATA.14.1.
Sexa
Table 2a: Unadjusted and adjusted odds ratios for patient reported recovery among individuals who observed changes to pain cognition
following pain education.
Age
18–40 years 1 1
+41 years 0.66 (0.47–1.04) 0.08 0.65 (0.42–1.03) 0.06
Gender
Female 1 1
Male 2.04 (1.21–3.66) 0.00 2.04 (1.15–3.62) 0.01
Marital status
Single/unmarried 0.74 (0.47–1.16) 0.20 0.72 (0.44–1.16) 0.18
Partnered 0.92 (0.54–1.56) 0.76 0.85 (0.48–1.51) 0.59
Education level
Primary 1 1
Others 1.22 (0.73–2.03) 0.43 1.21 (0.71–2.05) 0.47
Employment status
Full time employed 1 1
Unemployed/leave because of pain 0.99 (0.59–1.67) 0.99 0.99 (0.57–1.71) 0.99
Part time employed 0.98 (0.56–1.74) 0.97 0.92 (0.51–1.66) 0.79
Home duties 0.83 (0.39–1.73) 0.62 0.99 (0.45–2.17) 0.98
Student 1.27 (0.65–2.48) 0.46 1.30 (0.65–2.61) 0.45
Change in pain cognition
Yes 2.06 (1.34–3.16) 0.00 2.11 (1.35–3.29) 0.00
Table 2b: Unadjusted and adjusted odds ratios for patient reported recovery among individuals who observed changes to self-management
of pain following pain education.
Age
18–40 years 1 1
+41 years 0.70 (0.47–1.04) 0.08 0.69 (0.45–1.08) 0.10
Gender
Female 1 1
Male 2.11 (1.21–3.66) 0.00 2.24 (1.26–3.99) 0.00
Marital status
Single/unmarried 0.74 (0.47–1.16) 0.20 0.71 (0.44–1.15) 0.17
Partnered 0.92 (0.54–1.56) 0.76 0.84 (0.47–1.48) 0.56
Education level
Primary 1 1
Others 1.22 (0.73–2.03) 0.43 1.21 (0.71–2.05) 0.47
Employment status
Full time employed 1 1
Unemployed/leave because of pain 0.99 (0.59–1.67) 0.99 1.05 (0.61–1.80) 0.85
Part time employed 0.98 (0.56–1.74) 0.97 1.03 (0.57–1.84) 0.91
Home duties 0.83 (0.39–1.73) 0.62 0.94 (0.43–2.06) 0.88
Student 1.27 (0.65–2.48) 0.46 1.33 (0.66–2.67) 0.41
Change in self-management of pain
Yes 2.06 (1.34–3.16) 0.00 2.00 (1.30–3.08) 0.00
There were no deviations from the published protocol [22]. Table 2a shows the unadjusted and adjusted ORs obtained
Responses were received from 573 participants. Full data from univariate and multinomial logistic regression anal-
sets were available from 465, of which 412 participants ysis stratified into two age groups, including the best
(91%) had participated in pain education (Table 1), which predictors of expected recovery. Those who observed a
meant statistical comparison based on this variable was change in pain cognition as a result of pain education were
not possible. The mean (SD) pain intensity for the entire more likely to expect to recover than those who reported
cohort was 5.8 (2). Two hundred and eighty-seven of partic- no change in pain cognitions as a result (unadjusted
ipants reported that pain education had led to a change in OR = 2.06; 95% CI = 1.34–3.16). Males were more likely than
the way they think about their pain. Two hundred and sev- females to expect to recover (unadjusted OR = 2.04; 95%
enty-nine reported that pain education had led to a change CI = 1.21–3.66). Adjusted ORs were similar (Table 2a).
in the way they manage their pain. In the logistic/simple Ninety-seven percent (97%) of those who had partici-
linear regression, the effect estimates of the outcome con- pated in pain education reported observing a change in
founder relation were adjusted for age, gender, education their self-management strategies as a result. Those who
level, employment status and marital status. observed a change in self-management strategies were
Table 3: Patient-reported recovery according to age among participants with chronic pain aged 18 years and above.
Sexa
Female 110 65 60 35 170 170 73 63 27 233
Male 14 54 12 46 26 18 51 17 49 35
Educationa
Primary 25 58 18 42 43 41 82 9 18 50
Others 99 65 54 35 153 147 68 70 32 217
Employment statusa
Full time employed 44 71 18 29 62 47 64 27 36 74
Unemployed/on leave because of pain 25 56 20 44 45 60 74 21 26 81
Part time employed 21 55 17 45 38 41 75 14 25 54
Home duties 6 75 2 25 8 26 68 12 32 38
Student/unemployed 25 63 15 38 40 8 62 5 38 13
Marital statusa
Married 39 60 26 40 65 100 66 51 34 151
Single/unmarried 47 63 28 37 75 65 80 16 20 81
Partnered 37 67 18 33 55 22 67 11 33 33
Pain education
No 14 74 5 26 19 22 65 12 35 34
Yes 110 62 67 38 177 167 71 68 29 235
Patient-provider relationship
Not good 48 64 27 36 75 76 71 31 29 107
Good 76 63 45 37 121 113 65 49 35 162
Duration of pain
<1 year 4 29 10 71 14 2 11 17 89 19
>1 year 120 66 62 34 182 187 75 63 25 250
Change in pain management
No 54 74 19 26 73 86 76 27 24 113
Yes 70 57 53 43 123 103 66 53 34 156
Change in pain cognition
No 58 74 20 26 78 78 78 22 22 100
Yes 66 56 52 44 118 111 66 58 34 169
more likely to expect to recover than those who did not pain and higher expectations of recovery than those who
observe a change (unadjusted OR = 2.06; 95% CI, 1.34– do not observe these shifts. Pain intensity and expected
3.16) (Table 2b). recovery are also affected by a range of demographic and
Table 3 shows a more comprehensive account of the other variables, but accounting for those variables in the
univariate logistic regression analysis stratified by age statistical model does not conceal the effect.
(18–40 years; 41 + years). Younger participants were more Expectations about recovery are often investigated in
likely to expect recovery (~37% = 72/196) than older partic- acute or subacute pain populations [24, 25], and in pre-sur-
ipants (~30% = 80/269). Being married, or having attained gical groups [26, 27], but not in chronic pain patients. Our
a higher level of formal education, were associated with findings are consistent with available literature insofar as
expecting to recover. younger participants have higher expectations of recovery
than older ones. This may be because older people are
more likely to suffer from multiple chronic conditions [28]
3.2 P
rimary outcome: current pain intensity and, arguably, may have lower self-efficacy when it comes
to exercise and movement-based rehabilitation. In addi-
Table 4a shows the unadjusted and adjusted ORs obtained tion, home duties affected changes in self-management
from univariate and multinomial logistic regression anal- of pain, which may also contribute to the male/female
ysis stratified into two age groups, including the best pre- differences.
dictors of perceived pain intensity. Subgroup analysis of It is notable that 40% of those who had participated
participants who observed change in pain cognition as in pain education reported that it did not change their
a result of pain education showed lower pain intensity pain cognition or self-management strategies. This rather
scores 5.7 (2) than those who reported no change. concerning failure rate might reflect, in part, patients
Individuals who reported observing a change in who already have a contemporary understanding of pain
self-management strategies as a result of pain education when they present for care, although the available data
(subgroup analysis) reported less pain intensity 5.6 (2) would suggest otherwise [11]. It might also be more likely
than/as those who reported no change. Adjusted OR for to reflect the lack of information on variables that can
participants who observed change in their pain cognition influence any educational intervention, for example the
as a result of pain education was 1.53 (95% CI, 1.01–2.33) message, the context and number of sessions, which were
(Table 4a). The adjusted association between pain inten- not collected.
sity and observed change in self-management of pain Of the confounding variables, we identified a priori
increased (adjusted OR, 1.69; CI, 1.12–2.56), suggesting that and entered into the statistical models, marital status,
participants who observed change in self-management of education level and employment status showed no asso-
pain following pain education were more likely to report ciation with “recovery”. This is in line with the literature,
less pain than participants who observed no change in which shows similar findings [29].
their self-management of pain. Pain intensity was also
affected by sex, age, duration of pain, employment status
especially home duties, which may be attributed to higher 4.1 Limitations
female participation. The full regression data shown in
Table 4b. This was a pragmatic study, in which data were col-
lected from individuals experiencing chronic pain in
the real-world, designed to answer specific questions;
4 Discussion we did not seek to fully characterize the subtle relation-
ships between different variables and we did not seek to
The aim of this study was to determine if participants determine the impact of other important variables – for
believed that pain education had changed their views example the number, type and context of education ses-
on their pain (pain cognition) and had changed the way sions, type of diagnosis, comorbidities and treatments
they self-managed their pain. We also wanted to deter- received. To investigate these issues would have required
mine whether or not these perceptions were associated a much larger sample and would have exerted a partici-
with their expectations of recovery and their perceived pant burden that pilot testing taught us would be unac-
pain intensity. Our main finding is that those who report a ceptable. Any online survey is associated with a lack of
shift in their pain cognition or self-management strategies control over who participates and how they participate.
after participating in pain education have lower perceived People self-select and we have no way of verifying the
Table 4a: Unadjusted and adjusted odds ratios for pain intensity among individuals who observed changes to pain cognition following pain
education.
Pain intensity
Unadjusted Adjusted
OR (95% CI) p-Value OR (95% CI) p-Value
Age
18–40 years 1 1
+41 years 0.84 (0.57–1.23) 0.38 0.90 (0.58–1.38) 0.63
Gender
Male 1.69 (0.98–2.92) 0.05 2.02 (1.12–3.61) 0.01
Female 1 1
Marital status
Married 1 1
Single/unmarried 0.68 (0.44–1.05) 0.08 0.73 (0.46–1.17) 0.19
Partnered 0.87 (0.52–1.44) 0.59 0.84 (0.48–1.46) 0.55
Education level
Primary 1 1
Others 1.09 (0.67–1.76) 0.70 0.93 (0.56–1.55) 0.80
Employment status
Full time employment 1 1
Unemployed/leave because of pain 0.50 (0.29–0.85) 0.01 0.47 (0.27–0.82) 0.00
Part time employed 1.81 (1.06–3.11) 0.02 1.78 (1.02–3.10) 0.04
Home duties 1.11 (0.56–2.21) 0.75 1.17 (0.56–2.41) 0.67
Student 1.78 (0.93–3.40) 0.07 1.95 (0.99–3.81) 0.05
Change in pain cognition
Yes 1.53 (1.03–2.27) 0.03 1.53 (1.01–2.33) 0.04
Table 4b: Unadjusted and adjusted odds ratios for pain intensity among individuals who observed changes to self-management of pain
following pain education.
Pain intensity
Unadjusted Adjusted
OR (95% CI) p-Value OR (95% CI) p-Value
Age
18–40 years 1 1
+41 years 0.84 (0.57–1.23) 0.38 0.93 (0.60–1.43) 0.74
Gender
Male 1.69 (0.98–2.92) 0.05 2.17 (1.21–3.89) 0.00
Female 1 1
Marital status
Married 1 1
Single/unmarried 0.68 (0.44–1.05) 0.08 0.73 (0.45–1.16) 0.18
Partnered 0.87 (0.52–1.44) 0.59 0.83 (0.48–1.45) 0.53
Education level
Primary 1 1
Others 1.09 (0.67–1.76) 0.70 0.93 (0.55–1.55) 0.79
Employment status
Full time employment 1 1
Unemployed/leave because of pain 0.50 (0.29–0.85) 0.01 0.48 (0.28–0.84) 0.01
Part time employed 1.81 (1.06–3.11) 0.02 1.89 (1.09–3.28) 0.02
Home duties 1.11 (0.56–2.21) 0.75 1.13 (0.54–2.34) 0.73
Student 1.78 (0.93–3.40) 0.07 2.00 (1.02–3.92) 0.04
Change in self-management of pain
Yes 1.53 (1.03–2.27) 0.03 1.69 (1.12–2.56) 0.01
authenticity of responses, clarifying their responses, or taken into consideration for the analysis, it is for this
preventing individuals completing the survey twice on reason the results must be interpreted cautiously.
different devices. Our approach will also have excluded
potential participants who have no internet access. Our Acknowledgements: The authors would like to thank all
recruitment strategy depended on circulation of the the individuals who participated in our study and the
survey link via consumer organizations and clinician fol- organizations and societies who promoted our survey on
lowers of professional development websites. This means their websites.
that we would not have recruited those patients not Authors’ statements
involved with such organizations or with clinicians who Research funding: M. N. Mittinty is funded by John
are engaged with the professional development websites Lynch’s NHMRC Australian Fellow funding (ID 478115).
we used. Considering that many people with persistent G. L. Moseley has received support from Pfizer, Kaiser
pain do not fully engage with the community, the reader Permanente, USA; Workers’ Compensation Boards in
must consider the limited extent to which our sample Australia, North America, and Europe; Agile Physi-
was representative of the persistent pain population. Our otherapy, USA; Results Physiotherapy, USA; the Interna-
design does not allow causal conclusions about effects of tional Olympic Committee and the Port Adelaide Football
one variable on another, nor the time course of effects. Club, Australia. G. L. Moseley is supported by a Princi-
The current study also had strengths. For example, our pal Research Fellowship from the National Health and
survey design was consistent with recommended proto- Medical Research Council of Australia.
cols; we published the full survey protocol prior to data Conflict of interest: G. L. Moseley receives royalties for
collection; we identified important potential confounders books on pain and rehabilitation, including two books
a priori and controlled for them in our analysis; we calcu- that are cited in this article. He receives speaker fees for
lated required sample size prior to commencement and lectures on pain and rehabilitation. All the authors declare
our sample exceeded the required sample size; the distri- that they have no conflict of interest.
bution of our independent and confounder variables was Informed consent: Informed consent was required and
broadly reflective of the wider population, reducing the collected digitally from all participants.
risk of selection bias on these variables. Ethical approval: The study was approved by the Human
Research Ethics Committee, The University of Adelaide,
and University of South Australia, Australia.
5 Conclusions
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