ABSTRACT
BACKGROUND AND OBJECTIVES:
Pain education is a tool that helps health professionals in the biopsychosocial approach and in pain management in patients with musculoskeletal pain. The objectives of the study were to verify the effects of a pain education program in patients with chronic musculoskeletal pain. The evaluated outcomes were pain, kinesiophobia, catastrophizing, quality of life, central sensitization and perception of the disease.
METHODS:
Observational, retrospective study. Data from 24 participants with chronic pain, mean age 57 years, were analyzed, 83% of whom were female. Patients participated in a pain education program, which addressed topics such as acceptance, pain alarm, sleep, relaxation, negative thoughts, return to activities, relationships, and exercises.
RESULTS:
Participants showed significant changes in the cognitive representation of the disease measured by the Illness Perception Questionnaire (Brief-IPQ) (p<0.01), central sensitization by the CSI (p=0.05), catastrophism (p<0.05), pain (p<0.01), physical aspects by the Short-Form Health Survey (SF-36) (p<0.05) and in the total score of the same Instrument (p<0.05).
CONCLUSION:
The group applied pain education associated with usual physical therapy had significant effects in relation to the cognitive representation of the disease, central sensitization, catastrophizing and quality of life in patients with chronic musculoskeletal pain.
Keywords:
Chronic pain; Health education; Physical therapy specialty.
RESUMO
JUSTIFICATIVA E OBJETIVOS:
A educação em dor é uma ferramenta que auxilia os profissionais de saúde na abordagem biopsicossocial e no manejo da dor em pacientes com dor musculoesquelética. Os objetivos do estudo foram verificar os efeitos de um programa de educação em dor em pacientes com dor crônica musculoesquelética. Os desfechos avaliados foram dor, cinesiofobia, catastrofização, qualidade de vida, sensibilização central e percepção da doença.
MÉTODOS:
Estudo observacional, retrospectivo. Foram analisados os dados de 24 participantes com dor crônica, idade média de 57 anos, sendo 83% do sexo feminino. Os pacientes participaram de um programa de educação em dor, que abordou temas como aceitação, alarme da dor, sono, relaxamento, pensamentos negativos, retorno às atividades, relacionamentos e exercícios.
RESULTADOS:
Os participantes apresentaram mudanças significativas na representação cognitiva da doença mensurada pelo Illness Perception Questionnaire (Brief-IPQ) p<0,01), sensibilização central pelo CSI (p=0,05), catastrofismo (p<0,05), Dor (p<0,01), aspectos físicos pelo Questionário Short-Form Health Survey (SF-36) (p<0,05) e no escore total do mesmo instrumento (p<0,05).
CONCLUSÃO:
A educação em dor aplicada em grupo associada à fisioterapia usual apresentou efeitos significativos em relação à representação cognitiva da doença, sensibilização central, catastrofização e qualidade de vida nos pacientes com dor crônica musculoesquelética.
Descritores:
Dor crônica; Educação em saúde; Fisioterapia.
INTRODUCTION
Currently, pain is described as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage''11 DeSantana JM, Perissinoti DM, Oliveira Júnior JO, Correia LM, Oliveira CM, Fonseca PR. Definição de dor revisada após quatro décadas. BrJP. 2020;3(3):197-8.. Chronic pain (CP) is related to persistent symptoms for more than 12 weeks22 Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open. 2016;6(6):e010364., which can lead to a decrease in mobility, alteration in flexibility, muscle strength, need for gait and posture adaptation, reduction in general functionality and often difficulties in the activities of daily living22 Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open. 2016;6(6):e010364..
CP is one of the major causes of disability in the world, affecting about 14.2% of the global population22 Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open. 2016;6(6):e010364.. A recent study showed that CP affects about 39% of the adult population in Brazil33 de Souza JB, Grossmann E, Perissinotti DMN, de Oliveira Junior JO, da Fonseca PRB, Posso IP. Prevalence of chronic pain, treatments, perception, and interference on life activities: Brazilian population-based survey. Pain Res Manag. 2017:2017:4643830., generating important physical and emotional loss, in addition to socioeconomic impact, and is considered a public health problem22 Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open. 2016;6(6):e010364.,33 de Souza JB, Grossmann E, Perissinotti DMN, de Oliveira Junior JO, da Fonseca PRB, Posso IP. Prevalence of chronic pain, treatments, perception, and interference on life activities: Brazilian population-based survey. Pain Res Manag. 2017:2017:4643830..
Studies indicate that CP is frequently associated with other clinical symptoms, including fatigue, insomnia, cognitive deficits, headache, depression, and anxiety22 Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open. 2016;6(6):e010364., related to central sensitization (CS), in which there is a modification in the functional state of neurons due to intense or repetitive stimuli that provoke alterations in the pain threshold and cause hypersensitivity even in situations where there is no peripheral disease or nociceptive stimuli44 Malta DC, Oliveira MM, Andrade SSCA, Caiaffa WT, Souza MFM, Bernal RTI. Factors associated with chronic back pain in adults in Brazil. Rev Saude Publica. 2017;51(Suppl 1):9s., requiring, therefore, a multiprofessional approach33 de Souza JB, Grossmann E, Perissinotti DMN, de Oliveira Junior JO, da Fonseca PRB, Posso IP. Prevalence of chronic pain, treatments, perception, and interference on life activities: Brazilian population-based survey. Pain Res Manag. 2017:2017:4643830..
Pain education based on neuroscience55 Mittinty MM, Vanlint S, Stocks N, Mittinty MN, Moseley GL. Exploring effect of pain education on chronic pain patients' expectation of recovery and pain intensity. Scand J Pain. 2018;18(2):211-9. is a tool that helps health professionals in the biopsychosocial approach and management of these patients55 Mittinty MM, Vanlint S, Stocks N, Mittinty MN, Moseley GL. Exploring effect of pain education on chronic pain patients' expectation of recovery and pain intensity. Scand J Pain. 2018;18(2):211-9.,66 Mukoka G, Olivier B, Ravat S. Level of knowledge, attitudes and beliefs towards patients with chronic low back pain among final year School of Therapeutic Sciences students at the University of the Witwatersrand - A cross-sectional study. S Afr J Physiother. 2019;75(1):683. and is capable of interfering in the perception of pain with coping strategies with the objective of altering beliefs, fears, and myths of the patient about pain77 Grande-Alonso M, Suso-Martí L, Cuenca-Martínez F, Pardo-Montero J, Gil-Martínez A, La Touche R. Physiotherapy based on a biobehavioral approach with or without orthopedic manual physical therapy in the treatment of nonspecific chronic low back pain: a randomized controlled trial. Pain Med. 2019;20(12):2571-87.,88 Nijs J, Roussel N, Paul van Wilgen C, Köke A, Smeets R. Thinking beyond muscles and joints: therapists' and patients' attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther 2013;18(2):96-102..
The intervention through Explain Pain99 Moseley OG, Butler L. Explain Pain Supercharged - The clinician´s manual. Noigroup Publications, 2017. Disponível em https://www.noigroup.com/wp-content/uploads/2019/04/explain-pain-supercharged-chapter-preview.pdf
https://www.noigroup.com/wp-content/uplo...
proposes the biopsychosocial model for CP treatment, with the objective of educating patients about the biology and physiology of pain and change the limited understanding of pain as tissue injury or disease into a marker that functions as a protective alarm.
Many actions that use pain education address information on the etiology and pathophysiology of pain, a knowledge that allows individuals to have a greater understanding of the causal and aggravating factors, interfering in social and economic issues that favor the patient's recovery. Therefore, teaching patients that pain does not always mean tissue injury allows them to control its intensity and brings benefits, such as improvement in function and quality of sleep, return to activities and practice of physical exercises1010 Nijs J, Girbés EL, Lundberg M, Malfliet A, Sterling M. Exercise therapy for chronic musculoskeletal pain: innovation by altering pain memories. Manual Ther. 2015;20(1):216-2.
Pain education is a low-cost treatment modality that has been widely used66 Mukoka G, Olivier B, Ravat S. Level of knowledge, attitudes and beliefs towards patients with chronic low back pain among final year School of Therapeutic Sciences students at the University of the Witwatersrand - A cross-sectional study. S Afr J Physiother. 2019;75(1):683.
7 Grande-Alonso M, Suso-Martí L, Cuenca-Martínez F, Pardo-Montero J, Gil-Martínez A, La Touche R. Physiotherapy based on a biobehavioral approach with or without orthopedic manual physical therapy in the treatment of nonspecific chronic low back pain: a randomized controlled trial. Pain Med. 2019;20(12):2571-87.-88 Nijs J, Roussel N, Paul van Wilgen C, Köke A, Smeets R. Thinking beyond muscles and joints: therapists' and patients' attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther 2013;18(2):96-102., but there is still a lack of studies investigating the effectiveness of this modality in patients with CP.
The objective of this study was to verify the positive effects of a Pain Education Program (PEP) in patients with recurrent CP of different etiologies.
METHODS
Observational and retrospective study, conducted at the Therapy Center of Associação de Assistência à Criança Deficiente (AACD - Disabled Children Assistance Association) in São Paulo, from September 2018 to September 2019. Data was collected from the Tasy® electronic medical records of individuals who participated in the PEP, and the pain, kinesiophobia, catastrophizing, quality of life (QoL), CS, and disease perception outcomes were analyzed.
Adults of both sexes with medical diagnoses of low back pain, neck pain, scoliosis, hip and knee osteoarthritis, and rotator cuff tendinopathy were included in the study. Participants eligible for the program had CP for more than 3 months and reports of scattered and migratory pain that exceeded the 6-month time frame provided in the institutional rehabilitation protocols. Participants who did not have 100% attendance in the program were excluded from the study.
Pain education program
The PEP was applied through face-to-face sessions using Microsoft PowerPoint® and explanatory videos on neuroscience available on YouTube Google®. Sessions were composed of groups of 2 to 5 people, once a week, lasting 1h, before or after the physical therapy session.
The themes addressed in the PEP were acceptance, pain as an alarm, sleep, relaxation, negative thoughts, return to pleasurable activities, relationships, and practice of physical exercises, based on the script of education in pain prepared by Grupo de Pesquisa em Dor (Pain Research Group)1111 Disponível em http://pesquisaemdor.com.br/?page_id=118
http://pesquisaemdor.com.br/?page_id=118...
. The participants received support material containing information about the subject of the day and some exercises to consolidate each theme, which allowed them to live new experiences that would be commented on in the following week's session.
Treatment associated with the pain education program
The PEP was associated with usual physiotherapy based on kinesiotherapy and stretching, strengthening, proprioception, body awareness and breathing exercises performed in 35 minutes sessions, twice a week for 7 weeks.
The participants were evaluated at the beginning and at the end of the program using the following questionnaires: Tampa Scale for Kinesiophobia (TSK), Short-Form Health Survey (SF-36), Central Awareness Questionnaire (BP-CSI), Illness Perception Questionnaire (Brief-IPQ), and the Pain Catastrophizing Scale (BP-PCS).
Assessment instruments
The TSK is one of the most widely used instruments that assess kinesiophobia1212 Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041-56.,1313 Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek EH. Fear of movement/ (re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62(3):363-72.. It's a self-administered questionnaire composed of 17 questions that address pain and intensity of symptoms. The scores range from one to four points, with the answer "strongly disagree" being equivalent to one point, "partially disagree" to two points, "partially agree" to three points, and "strongly agree" to four points. The final score ranges from 17 to 68 points, and the higher the score, the higher the degree of kinesiophobia. Its Brazilian Portuguese version had its measurement properties tested in individuals with chronic low back pain1414 Siqueira FB, Teixeira-Salmela LF, Magalhães LC. Analysis of the psychometric properties of the Brazilian version of the Tampa scale for kinesiophobia. Acta Ortop Bras. 2007;15(1):19-24.. It showed an excellent internal consistency of 0.95 and an adequate intra-examiner reproducibility of 0.80.
In order to assess QoL in relation to physical, mental, psychological, emotional, and social well-being, the Brazilian version of the SF-36 was used1515 Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80(1-2):329-39.,1616 Campolina AG, Bortoluzzo AB, Ferraz MB, Ciconelli RM. [Validation of the Brazilian version of the generic six-dimensional short form quality of life questionnaire (SF-6D Brazil)]. Cien Saude Colet. 2011;16(7):3103-10., composed of 36 items divided into eight topics: functional capacity, physical aspects, pain, general health status, vitality, social aspects, emotional aspects, mental health, and one more question comparing current health conditions to those of one year before. The score ranges from zero to 100, with zero being the worst general state of health and 100 the best. The Brazilian Portuguese version had its measurement properties tested in individuals with rheumatoid arthritis1616 Campolina AG, Bortoluzzo AB, Ferraz MB, Ciconelli RM. [Validation of the Brazilian version of the generic six-dimensional short form quality of life questionnaire (SF-6D Brazil)]. Cien Saude Colet. 2011;16(7):3103-10.. It showed moderate internal consistency between 0.30 and 0.50, satisfactory intra-examiner reproducibility between 0.44 and 0.85 and inter-examiner reproducibility between 0.55 and 0.81. Regarding the construct validity for the SF-36 components, functional capacity and pain were those that showed the highest correlation with the clinical parameters tested between 0.11 and 0.51 and 0.14 and 0.501515 Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80(1-2):329-39.,1616 Campolina AG, Bortoluzzo AB, Ferraz MB, Ciconelli RM. [Validation of the Brazilian version of the generic six-dimensional short form quality of life questionnaire (SF-6D Brazil)]. Cien Saude Colet. 2011;16(7):3103-10..
The Central Sensitization Questionnaire (BP-CSI) consists of two parts, part "A" contains 25 items about symptoms present daily or in most days in the last 3 months, which can be scored on a 5-point temporal Likert-type scale, and the higher the value, the higher the degree of CS, and can range from zero to 100 points in total. Part "A" evaluates the current health symptoms and part "B" evaluates whether the patient has been previously diagnosed with any of the diseases included in the central sensitivity syndrome, as well as the year of diagnosis1717 Mayer TG, Neblett R, Cohen H, Howard KJ, Choi YH, Willians MJ, et al. The development and phychometric validation of the central sensitization inventory. Pain Pract. 2012;12(4):276-85.. This questionnaire was translated and adapted to Brazilian Portuguese1818 Liebano RE, Da Silva NS. Tradução e adaptação transcultural do "central sensitization inventory" para o português brasileiro. 16º congresso nacional de iniciação científica - Conic Universidade Cidade de São Paulo, 2016 (http://conic-semesp.org.br/anais/files/2016/trabalho-1000022777.pdf).
http://conic-semesp.org.br/anais/files/2...
and had its measurement properties tested in individuals with CP1919 Caumo W, Antunes LC, Elkfury JL, Herbstrith EG, Busanello Sipmann R, Souza A, et al. The central sensitization inventory validated and adapted for a Brazilian population: psychometric properties and its relationship with brain-derived neurotrophic factor. J Pain Res. 2017:10:2109-22.. It showed an excellent internal consistency of 0.91, intra-examiner reproducibility of 0.84 and inter-examiner reproducibility of 0.91.
Construct validity was moderate, ranging across the competing instruments from 0.62 to 0.68.
The Brief-IPQ is an instrument that provides an assessment regarding perceptions of diseases. It has nine items composed of a scale ranging from zero to 10 each. The items covered are related to cognitive assessment of the disease, emotional representation, and comprehension of the disease2020 Nogueira GS, Seidl EMF, Tróccoli BT. Análise fatorial exploratória do questionário de percepção de doenças versão breve (Brief-IPQ). Psic Teor e Pesqu. 2016;32(1):161-8.. The scores range from zero to 80 and the higher the score, the greater the perception of threat of the disease. Its measurement properties were tested through exploratory factor analysis, in which two factors were extracted, the first denominated with an internal consistency of 0.80 and the second cognitive with a value of 0.52, therefore, good, and moderate internal consistency, respectively2020 Nogueira GS, Seidl EMF, Tróccoli BT. Análise fatorial exploratória do questionário de percepção de doenças versão breve (Brief-IPQ). Psic Teor e Pesqu. 2016;32(1):161-8..
The PCS evaluates the level of catastrophic thinking. It consists of 13 items graded in 5 points, in which the patient must mark the option that best describes his thoughts or feeling in relation to pain, where zero refers to minimum pain, 1 mild, 2 moderate, 3 intense and 4 very intense. The total score is obtained by adding all the items and can range from zero to 52. The higher the score, the higher the degree of catastrophizing. The instrument is composed of three subscales: hopelessness, magnification, and rumination2121 Lopes RA, Dias RC, Queiroz BZ, Rosa NM, Pereira Lde S, Dias JM, et al. Psychometric properties of the Brazilian version of the Pain Catastrophizing Scale for acute low back pain. Arq Neuropsiquiatr. 2015;73(5):436-44.. It was translated and adapted into Brazilian Portuguese2121 Lopes RA, Dias RC, Queiroz BZ, Rosa NM, Pereira Lde S, Dias JM, et al. Psychometric properties of the Brazilian version of the Pain Catastrophizing Scale for acute low back pain. Arq Neuropsiquiatr. 2015;73(5):436-44. and its measurement properties were tested in individuals with acute low back pain, with good intra-examiner (0.80) and inter-examiner (0.75) reproducibility. Rash analysis showed adequate reproducibility coefficients of 0.95 for the items and 0.90 for individuals, showing that the scale is able to divide subjects into three levels of catastrophizing (mild, moderate, and high). Construct validity was weak to moderate with correlation between the competing instruments between 0.02 and 0.40.
This study was approved by the institution's Ethics Research Committee involving human beings through opinion number 4.307.641, CAAE: 30009220.2.0000.0085.
Statistical analysis
The sample characteristics were analyzed descriptively. The effects of the PEP were tested using paired Student's t-test and represented with measures of dispersion such as mean and standard deviation of the pre- and post-intervention data, the mean of the pre- and post-intervention period differences and confidence interval of the differences. Changes with p<0.05 were considered significant. All analyses were performed in the IBM SPSS Statistics Software2121 Lopes RA, Dias RC, Queiroz BZ, Rosa NM, Pereira Lde S, Dias JM, et al. Psychometric properties of the Brazilian version of the Pain Catastrophizing Scale for acute low back pain. Arq Neuropsiquiatr. 2015;73(5):436-44..
RESULTS
The data from 24 participants was analyzed, mean age 57±3 years, 83% were female, 50% had low back pain, 9% cervicalgia, 21% hip osteoarthritis, 8% rotator cuff tendinopathy, 4% scoliosis, 4% knee osteoarthritis, and 4% other diagnoses. Seven participants who did not attend the program 100% were excluded.
The individuals who underwent the PEP presented significant alterations in the cognitive representation of the disease measured by the Brief-IPQ (p<0.01), central sensitization by the CSI (p=0.05), catastrophizing (p<0.05), pain (p<0.01), physical aspects by the SF-36 (p<0.05) and in the total score of the same instrument (p<0.05) (Table 1).
Kinesiophobia, assessed by the TSK, presented the results of 36.46 in pre-intervention and 35.83 in post-intervention, showing a slight decrease in kinesiophobia, however, with no statistically significant difference. Regarding the perception of the disease, as assessed by the Brief-IPQ, the patients showed improvement, with a reduction from 39.08 to 31.54 after the intervention, a statistically significant result. Central sensitization, as assessed by the BP-CSI questionnaire, showed a reduction from 41.46 to 37.46 after the intervention. Catastrophic thinking also decreased significantly, with an initial score of 23.42 reduced to 18.71 after the intervention.
As for physical aspects, one of the SF-36's domains, the patients presented statistically significant results, developing from 24.38 to 40.29 after the pain education. QoL, measured by the SF-36, presented a statistically significant improvement with an increase from 367.00 to 416.33. The other analyzed outcomes didn't show statistically significant changes.
Figure 1 shows the mean pre- and post-intervention differences and the direction of all the instruments evaluated in the study.
DISCUSSION
After the intervention, patients had significant changes in the outcomes of cognitive representation of the disease, CS, catastrophizing, pain, physical aspects, and QoL.
CP is a global issue that generates significant impact on people's lives leading to functional impairments, emotional problems, and high demand on health services with high impact on economy2222 Joypaul S, Kelly F, McMillan SS, King MA. Multi-disciplinary interventions for chronic pain involving education: a systematic review. PLoS One. 2019;24(10:e0223306.. The comprehension of this condition is very complex when it comes to identifying the etiology and adopting the appropriate management, and despite the available pharmacological resources, many patients do not achieve the expected results2323 Australia Pain. National Pain Strategy Pain Management for all Australians: National Pain Summit initiative. 2011. Available from: http://www.painaustralia.org.au/improving-policy/national-pain-strategy
http://www.painaustralia.org.au/improvin...
.
Most patients included in this study were women (83%). The data corroborates that of other studies, such as the review of studies on the prevalence of CP in the Brazilian population, which found a mean of 29.3 to 73.3%, with a predominance of female patients, mean age of 54 years old and with back pain as the most common complaint2424 Vasconcelos FH, Araújo GC. Prevalence of chronic pain in Brazil: a descriptive study. BrJP. 2018;1(2):176-9..
Low back pain affects a significant part of the global population and has very heterogeneous characteristics, and there are several studies describing the biological, psychological, and social characteristics that explain the variations in the disease presentation2525 Galan-Martin MA, Montero-Cuadrado F, Lluch-Girbes E, Coca-López MC, Mayo-Iscar A, Cuesta-Vargas A. Pain neuroscience education and physical exercise therapy for patients with chronic spinal pain in Spanish physiotherapy primary care: a pragmatic randomized controlled trial. J Clin Med. 2020;9(4):1201.,2626 Hodges PW. Hybrid approach to treatment tailoring for low back pain: a proposed model of care. J Orthop Sports PhysTher. 2019;49(6):453-63..
There is high-quality evidence supporting the use of biopsychosocial interventions, focusing on active management strategies that address psychosocial domains and physical function2626 Hodges PW. Hybrid approach to treatment tailoring for low back pain: a proposed model of care. J Orthop Sports PhysTher. 2019;49(6):453-63.
27 Foster NE, Anema JR, Cherkin D, Chou D, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-83.-2828 Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070): 736-47.. Pain Neuroscience Education (PNE) has been studied as a therapeutic resort since the late 1990s in different CP populations with the objective of modifying concepts and changing patients' knowledge about their pain condition99 Moseley OG, Butler L. Explain Pain Supercharged - The clinician´s manual. Noigroup Publications, 2017. Disponível em https://www.noigroup.com/wp-content/uploads/2019/04/explain-pain-supercharged-chapter-preview.pdf
https://www.noigroup.com/wp-content/uplo...
,2929 Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017;25(3):160-8. by addressing concepts about the neurophysiology of pain with the use of simple and didactic resources. This technique teaches people about the biology and physiology of their pain experiences, including information about CS, peripheral sensitization, allodynia, inhibition, facilitation, and neuroplasticity, among other subjects99 Moseley OG, Butler L. Explain Pain Supercharged - The clinician´s manual. Noigroup Publications, 2017. Disponível em https://www.noigroup.com/wp-content/uploads/2019/04/explain-pain-supercharged-chapter-preview.pdf
https://www.noigroup.com/wp-content/uplo...
,2929 Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017;25(3):160-8..
Literature reinforces that pain education is a treatment modality that has been growing and becoming more popular, with evidence indicating positive results for catastrophizing, anxiety, disability, and movement restriction, corroborating the present study's findings, which found more significant effects for catastrophizing reduction and improvement of physical aspects2929 Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017;25(3):160-8..
CP patients present important complaints regarding not only physical but also emotional conditions and, after pain education, they presented improvement in these outcomes, with significant change not only in the physical domains, but also in the cognitive representation of the disease, evidenced by satisfactory results in the assessment of the psychological condition and the reported level of pain.
Scientific evidence indicates CS as an aggravating factor in patients with CP99 Moseley OG, Butler L. Explain Pain Supercharged - The clinician´s manual. Noigroup Publications, 2017. Disponível em https://www.noigroup.com/wp-content/uploads/2019/04/explain-pain-supercharged-chapter-preview.pdf
https://www.noigroup.com/wp-content/uplo...
,2929 Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017;25(3):160-8. and pain education teaches the patient about CS and its role in CP2929 Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017;25(3):160-8.. The face-to-face sessions together with graphic educational material, such as booklets, are effective to change the cognitive aspects related to pain and improve the health status in patients with several types of chronic musculoskeletal pain2929 Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017;25(3):160-8.. There was a significant reduction in the participants' CS in the present study, which associated with the other evidence was an important factor in the comprehension of the CP mechanism.
Although the benefits of exercise are well-established, many patients with CP present increased pain in response to this activity, which can predispose these individuals to physical inactivity and, in the long term, to disability3030 Nijs J, Paul C, Wilgen V, Oosterwijck JV, Ittersum MV, Meeus M. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: Practice guidelines. Man Ther. 2011;16(5)413-8.. When approaching these patients, it's important to have a broader view that enlightens them about the benefits of physical activity in order to reduce the feeling of threat they feel from practicing exercises.
A randomized clinical trial3131 Malfliet A, Kregel J, Coppieters I, De Pauw R, Meeus M, Roussel N, et al. Effect of pain neuroscience education combined with cognition-targeted motor control training on chronic spinal pain: a randomized clinical trial. JAMA Neurol. 2018;75(7):808-17. concluded that pain education alone in the short term was more effective for pain and self-efficacy than the combination of pain education and group exercises for patients with chronic low back pain. A systematic review3232 Rice D, Nijs J, Kosek E, Wideman T, Hasenbring MI, Koltyn K, et al. Exercise-induced hypoalgesia in pain-free and chronic pain populations: State of Art and Future Directions. J Pain. 2019;20(11):1249-66. pointed out that pain education techniques associated with the usual therapeutic interventions provide improvement of pain and disability in patients with CP. In the present study, the combinations of techniques showed satisfactory effects.
It's important that the therapists introduce the management of stress and exercise therapy in their biopsychosocial rehabilitation program, explaining these components of the treatment during the educational sessions and how they will contribute to reduce the central nervous system hypersensitivity2929 Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017;25(3):160-8.,3030 Nijs J, Paul C, Wilgen V, Oosterwijck JV, Ittersum MV, Meeus M. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: Practice guidelines. Man Ther. 2011;16(5)413-8.. Comprehending the neurophysiological and psychobiological bases of CP is crucial for the development of adequate and efficient strategies for the multidisciplinary assessment and treatment of pain, because it's been already showed that patients with CP present abnormal cerebral processing of body information and that negative emotional states can significantly alter the brain's behavior and amplify the suffering related to pain3333 Ryan CG, Gray HG, Newton M, Granat MH. Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial. Man Ther. 2010;15(4):382-7..
CP remains a global health problem, but there is still a lack of studies on pain education, as well as a lack of protocols and training for health care professionals to raise awareness of the multifactorial aspects involved3434 Marris D, Theophanous K, Cabezon P, Dunlap Z, Donaldson M. The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: a systematic review and meta-analysis of randomized controlled trials. Physiother Theory Pract. 2019;28:1-12.. Although interest in pain education and clinical training in developing countries has increased, restrictions from governments and health administrations represent a significant obstacle for practicing change3434 Marris D, Theophanous K, Cabezon P, Dunlap Z, Donaldson M. The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: a systematic review and meta-analysis of randomized controlled trials. Physiother Theory Pract. 2019;28:1-12.. For more than a decade, the International Association for the Study of Pain (IASP) has worked to reduce the negative impact of lack of pain education through funding and training programs in developing countries. The treatment of pain as a human right is an important moral goal underlying all IASP activities related to individuals who suffer from pain11 DeSantana JM, Perissinoti DM, Oliveira Júnior JO, Correia LM, Oliveira CM, Fonseca PR. Definição de dor revisada após quatro décadas. BrJP. 2020;3(3):197-8..
Many actions that use pain education address information on the etiology and pathophysiology of pain, a knowledge that allows individuals to have a greater understanding of the causal and aggravating factors, interfering in social and economic issues that favor the patient's recovery1010 Nijs J, Girbés EL, Lundberg M, Malfliet A, Sterling M. Exercise therapy for chronic musculoskeletal pain: innovation by altering pain memories. Manual Ther. 2015;20(1):216-2,3535 Vieira AS, Castro KV, Canatti JR, Oliveira IA, Benevides SD, Sá KN. Validação de uma cartilha educativa para pessoas com dor crônica: EducaDor. BrJP. 2019;2(1):39-43.. Thus, teaching patients that pain does not always mean tissue damage enables better control of pain intensity, improved function and sleep, return to activities and encouragement to practice physical exercises3535 Vieira AS, Castro KV, Canatti JR, Oliveira IA, Benevides SD, Sá KN. Validação de uma cartilha educativa para pessoas com dor crônica: EducaDor. BrJP. 2019;2(1):39-43..
There are different methods of employing educational actions in the field of pain, involving booklets, explanatory videos, films, individualized meetings, group activities and lectures. Printed instruments are more used because they increase communication among the interested parties, promote standardization of the subjects approached and can be consulted whenever necessary3636 Louw A, Zimney K, O'Hotto C, Hilton S. The clinical application of teaching people about pain. Physiother Theory Pract. 2016;32(5):385-95.,3737 Mendez SP, Sá KN, Araújo PC, Oliveira IA, Gosling AP, Baptista AF. Desenvolvimento de uma cartilha educativa para pessoas com dor crônica. Rev Dor. 2017;18(3):199-211..
The study is a reflection for the professionals who assist patients with CP to improve their understanding of pain, neuroscience, and CS. It's important that there be more attention to the development of pain education projects that help patients understand, accept and deal with pain through breathing, meditation, practices that improve sleep quality, return to pleasurable activities and activities of daily living, ensuring the well-being, as well as improvement of functionality and QoL.
Among the limitations of the study is the fact that it's not a clinical trial that analyzes the effectiveness of the pain education program, but it demonstrates that the combination with usual therapy can be safe and promote changes in individuals with CP, and studies using the usual therapy as a control group in order to analyze the effectiveness of this combination are necessary. Pain education is an easily applicable tool, with good acceptance by the patients when they become aware of the multiple aspects that influence the sensation of pain3838 Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, Nijs J. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin J Pain. 2013;29(10):873-82.,3939 Watson JA, Ryan CG, Cooper L, Ellington D, Whittle R, Lavender M, et al. Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis. J Pain. 2019;20(10):1140.e1-1140.. This study reinforces the need for an approach focused on the biopsychosocial approach for the treatment of CP, which involves not only biomechanical or musculoskeletal alterations, but a wide set of dysfunctions that cause and maintain pain.
CONCLUSION
Pain education applied in patients with musculoskeletal CP associated with usual physical therapy presented positives effects in relation to the cognitive representation of the disease, CS, catastrophizing, physical aspects and QoL.
REFERÊNCIAS
-
1DeSantana JM, Perissinoti DM, Oliveira Júnior JO, Correia LM, Oliveira CM, Fonseca PR. Definição de dor revisada após quatro décadas. BrJP. 2020;3(3):197-8.
-
2Fayaz A, Croft P, Langford RM, Donaldson LJ, Jones GT. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open. 2016;6(6):e010364.
-
3de Souza JB, Grossmann E, Perissinotti DMN, de Oliveira Junior JO, da Fonseca PRB, Posso IP. Prevalence of chronic pain, treatments, perception, and interference on life activities: Brazilian population-based survey. Pain Res Manag. 2017:2017:4643830.
-
4Malta DC, Oliveira MM, Andrade SSCA, Caiaffa WT, Souza MFM, Bernal RTI. Factors associated with chronic back pain in adults in Brazil. Rev Saude Publica. 2017;51(Suppl 1):9s.
-
5Mittinty MM, Vanlint S, Stocks N, Mittinty MN, Moseley GL. Exploring effect of pain education on chronic pain patients' expectation of recovery and pain intensity. Scand J Pain. 2018;18(2):211-9.
-
6Mukoka G, Olivier B, Ravat S. Level of knowledge, attitudes and beliefs towards patients with chronic low back pain among final year School of Therapeutic Sciences students at the University of the Witwatersrand - A cross-sectional study. S Afr J Physiother. 2019;75(1):683.
-
7Grande-Alonso M, Suso-Martí L, Cuenca-Martínez F, Pardo-Montero J, Gil-Martínez A, La Touche R. Physiotherapy based on a biobehavioral approach with or without orthopedic manual physical therapy in the treatment of nonspecific chronic low back pain: a randomized controlled trial. Pain Med. 2019;20(12):2571-87.
-
8Nijs J, Roussel N, Paul van Wilgen C, Köke A, Smeets R. Thinking beyond muscles and joints: therapists' and patients' attitudes and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther 2013;18(2):96-102.
-
9Moseley OG, Butler L. Explain Pain Supercharged - The clinician´s manual. Noigroup Publications, 2017. Disponível em https://www.noigroup.com/wp-content/uploads/2019/04/explain-pain-supercharged-chapter-preview.pdf
» https://www.noigroup.com/wp-content/uploads/2019/04/explain-pain-supercharged-chapter-preview.pdf -
10Nijs J, Girbés EL, Lundberg M, Malfliet A, Sterling M. Exercise therapy for chronic musculoskeletal pain: innovation by altering pain memories. Manual Ther. 2015;20(1):216-2
-
11Disponível em http://pesquisaemdor.com.br/?page_id=118
» http://pesquisaemdor.com.br/?page_id=118 -
12Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92(12):2041-56.
-
13Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek EH. Fear of movement/ (re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62(3):363-72.
-
14Siqueira FB, Teixeira-Salmela LF, Magalhães LC. Analysis of the psychometric properties of the Brazilian version of the Tampa scale for kinesiophobia. Acta Ortop Bras. 2007;15(1):19-24.
-
15Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80(1-2):329-39.
-
16Campolina AG, Bortoluzzo AB, Ferraz MB, Ciconelli RM. [Validation of the Brazilian version of the generic six-dimensional short form quality of life questionnaire (SF-6D Brazil)]. Cien Saude Colet. 2011;16(7):3103-10.
-
17Mayer TG, Neblett R, Cohen H, Howard KJ, Choi YH, Willians MJ, et al. The development and phychometric validation of the central sensitization inventory. Pain Pract. 2012;12(4):276-85.
-
18Liebano RE, Da Silva NS. Tradução e adaptação transcultural do "central sensitization inventory" para o português brasileiro. 16º congresso nacional de iniciação científica - Conic Universidade Cidade de São Paulo, 2016 (http://conic-semesp.org.br/anais/files/2016/trabalho-1000022777.pdf).
» http://conic-semesp.org.br/anais/files/2016/trabalho-1000022777.pdf -
19Caumo W, Antunes LC, Elkfury JL, Herbstrith EG, Busanello Sipmann R, Souza A, et al. The central sensitization inventory validated and adapted for a Brazilian population: psychometric properties and its relationship with brain-derived neurotrophic factor. J Pain Res. 2017:10:2109-22.
-
20Nogueira GS, Seidl EMF, Tróccoli BT. Análise fatorial exploratória do questionário de percepção de doenças versão breve (Brief-IPQ). Psic Teor e Pesqu. 2016;32(1):161-8.
-
21Lopes RA, Dias RC, Queiroz BZ, Rosa NM, Pereira Lde S, Dias JM, et al. Psychometric properties of the Brazilian version of the Pain Catastrophizing Scale for acute low back pain. Arq Neuropsiquiatr. 2015;73(5):436-44.
-
22Joypaul S, Kelly F, McMillan SS, King MA. Multi-disciplinary interventions for chronic pain involving education: a systematic review. PLoS One. 2019;24(10:e0223306.
-
23Australia Pain. National Pain Strategy Pain Management for all Australians: National Pain Summit initiative. 2011. Available from: http://www.painaustralia.org.au/improving-policy/national-pain-strategy
» http://www.painaustralia.org.au/improving-policy/national-pain-strategy -
24Vasconcelos FH, Araújo GC. Prevalence of chronic pain in Brazil: a descriptive study. BrJP. 2018;1(2):176-9.
-
25Galan-Martin MA, Montero-Cuadrado F, Lluch-Girbes E, Coca-López MC, Mayo-Iscar A, Cuesta-Vargas A. Pain neuroscience education and physical exercise therapy for patients with chronic spinal pain in Spanish physiotherapy primary care: a pragmatic randomized controlled trial. J Clin Med. 2020;9(4):1201.
-
26Hodges PW. Hybrid approach to treatment tailoring for low back pain: a proposed model of care. J Orthop Sports PhysTher. 2019;49(6):453-63.
-
27Foster NE, Anema JR, Cherkin D, Chou D, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-83.
-
28Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070): 736-47.
-
29Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther. 2017;25(3):160-8.
-
30Nijs J, Paul C, Wilgen V, Oosterwijck JV, Ittersum MV, Meeus M. How to explain central sensitization to patients with 'unexplained' chronic musculoskeletal pain: Practice guidelines. Man Ther. 2011;16(5)413-8.
-
31Malfliet A, Kregel J, Coppieters I, De Pauw R, Meeus M, Roussel N, et al. Effect of pain neuroscience education combined with cognition-targeted motor control training on chronic spinal pain: a randomized clinical trial. JAMA Neurol. 2018;75(7):808-17.
-
32Rice D, Nijs J, Kosek E, Wideman T, Hasenbring MI, Koltyn K, et al. Exercise-induced hypoalgesia in pain-free and chronic pain populations: State of Art and Future Directions. J Pain. 2019;20(11):1249-66.
-
33Ryan CG, Gray HG, Newton M, Granat MH. Pain biology education and exercise classes compared to pain biology education alone for individuals with chronic low back pain: a pilot randomised controlled trial. Man Ther. 2010;15(4):382-7.
-
34Marris D, Theophanous K, Cabezon P, Dunlap Z, Donaldson M. The impact of combining pain education strategies with physical therapy interventions for patients with chronic pain: a systematic review and meta-analysis of randomized controlled trials. Physiother Theory Pract. 2019;28:1-12.
-
35Vieira AS, Castro KV, Canatti JR, Oliveira IA, Benevides SD, Sá KN. Validação de uma cartilha educativa para pessoas com dor crônica: EducaDor. BrJP. 2019;2(1):39-43.
-
36Louw A, Zimney K, O'Hotto C, Hilton S. The clinical application of teaching people about pain. Physiother Theory Pract. 2016;32(5):385-95.
-
37Mendez SP, Sá KN, Araújo PC, Oliveira IA, Gosling AP, Baptista AF. Desenvolvimento de uma cartilha educativa para pessoas com dor crônica. Rev Dor. 2017;18(3):199-211.
-
38Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, Nijs J. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin J Pain. 2013;29(10):873-82.
-
39Watson JA, Ryan CG, Cooper L, Ellington D, Whittle R, Lavender M, et al. Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis. J Pain. 2019;20(10):1140.e1-1140.
Publication Dates
-
Publication in this collection
11 June 2021 -
Date of issue
Apr-Jun 2021
History
-
Received
29 Sept 2020 -
Accepted
05 Apr 2021