Changing beliefs in the face of adversity: preoperative pain education tested

Here at BiM it’s no secret that we are very interested in pain education – so called Explaining Pain or EP. Using examples from current thinking in pain science, EP posits that the more one knows about their pain, and the less threatening one perceives their circumstances to be, the better the (actual) pain should be [1-3].  There is now strong evidence that EP can indeed improve pain and disability outcomes, at least in the short term, for people with chronic pain conditions [4, 5]. However, like most other treatments for chronic pain, using education like EP to make long term, robust changes to pain, disability and the use of healthcare that goes along with it, remains a harder nut to crack [6].

The latest candidates to be brave enough to pick up the cracker have been a group from Las Vegas, USA. Adriaan Louw, extensively trained in EP via the NOIgroup system, recently published the results of his RCT testing a 30-min version of EP in 67 patients with lumbar radiculopathy. Patients who were in line to receive lumbar surgery were randomised into two groups: EP for 30-min or usual care (a short chat with the spinal surgeon). Adriaan kindly previewed his results here on BiM in February. The manuscript for the study has just been published ahead of print in the journal Spine[7]. As I am part of a group running an RCT on EP for acute low back pain, naturally I was keen to have a peek at the details.

So what did they find? No effects on pain (sigh) or function (grumble). However there did appear to be some impressive reductions in healthcare utilization – 45% at 12 months (EP: $2678 vs control: $4833). The authors didn’t report confidence intervals but by my calculation we can be confident that the mean spendings were somewhere between 11% and 78% lower in those who got EP. Not super precise but nothing to sneeze at for a very brief and inexpensive intervention, right? If a 30-min educative consultation has potential to massively reduce healthcare costs then that is what we would call, in clinical research terms, a Bobby-Dazzler.  There were however a couple of reservations I had when appraising the results of this trial.

The first is the drop-outs. Those pesky drop-outs. We know that when patients drop out of trials, it might be because they are doing worse (although this is not always the case – in a pilot study on EP undertaken by our research group, the drop-outs at 12 months were doing significantly better at 6 months than the non-drop-outs). Worsening outcomes in the intervention group (for whatever reason) might render an effective treatment, well, ineffective. In this study, 4 participants dropped out: 3 from the treatment group and 1 from the control group. It is not clear whether the analysis of healthcare use accounted for these participants i.e by intention to treat. This is not a big number (6%), but in a smaller study like this one, any drop-outs will have the potential to bias results. If the drop-outs did use much more healthcare (alas, we will never know) this might have made an important difference to the apparent results and to the conclusion of the study.

A second issue is in the outcome measures. The researchers appear to have used validated questionnaires that measure thoughts (catastrophising – PCS) and beliefs (fear – FABQ) at baseline, but these were not measured again at follow-up. We can only guess that due to the nature of clinical research, the researchers opted instead for a simpler follow-up consisting of a few single-item questions e.g. “The pre-operative education prepared me well for the surgery”. That the longer questionnaires, like PCS and FABQ, are only given once to check that groups are sufficiently similar at baseline is often the case in clinical trials. Researchers must make decisions on which questionnaires to include, as more onerous follow-ups carry the risk of more people dropping out.  We call this ‘participant burden’.

Certainly the short statements used by the authors to assess satisfaction with the surgery reflect an important outcome in itself. The surgeons in particular would be very pleased. Satisfaction scores, however, provide less insight into whether the patient’s thoughts and beliefs about the pain, a fundamental target of EP, have indeed changed. An increase in satisfaction could be related to the extra time with a friendly and enthusiastic physio, contributing to the (much dreaded by researchers) non-specific effects of any treatment. My personal feeling is that of all places to change beliefs, a waiting list for surgery may be one of the more challenging arenas. Maybe one outcome that might truly reflect a reconceptualization of pain in a trial like this one is the number of patients who opt out of surgery after receiving EP.

Nonetheless, Louw et al have done the noble and very difficult task of investigating a promising and inexpensive intervention using the highest methodological standard. They are working on delivering good education in the face of significant adversity: a medical fraternity who most likely have an opposing set of beliefs and messages that they too deliver to patients. This research encourages more thought on how, in such a sea of influence, we can change pain-related beliefs for the better, reduce excessive suffering and stem the mass delivery of ineffective healthcare.

Adrian Traeger

Adrian Traeger Body In MindAdrian is doing his PhD through Neuroscience Research Australia in Sydney looking at a new treatment for low back pain. His background is in musculoskeletal physiotherapy, where he found himself  coming back to the same (currently) unanswerable questions: “Why do some treatments work brilliantly for one person and not for the next?”; “What are our treatments for spinal pain actually doing?”. He has a sneaking suspicion that the more we find out about the nervous system, the closer we will come to some answers.

Outside of back pain research, Adrian loves fried chicken, good country songs and animals with flat faces. He doesn’t like highway driving, Nickelback or confrontation.

References

1. Moseley GL, & Arntz A (2007). The context of a noxious stimulus affects the pain it evokes. Pain, 133 (1-3), 64-71 PMID: 17449180

2. Moseley GL (2004). Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur J Pain, 8 (1), 39-45 PMID: 14690673

3. Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, & Nijs J (2013). Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin J Pain, 29 (10), 873-82 PMID: 23370076

4. Louw A, Diener I, Butler DS, & Puentedura EJ (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil, 92 (12), 2041-56 PMID: 22133255

5. Clarke CL, Ryan CG, & Martin DJ (2011). Pain neurophysiology education for the management of individuals with chronic low back pain: systematic review and meta-analysis. Manual Ther, 16 (6), 544-9 PMID: 21705261

6. Engers A, Jellema P, Wensing M, et al. Individual patient education for low back pain. Cochrane Database Syst Rev 2008(1):CD004057 doi:10.1002/14651858.CD004057.pub3

7. Louw A, Diener I, Landers MR, & Puentedura EJ (2014). Preoperative Pain Neuroscience Education for Lumbar Radiculopathy: A Multi-Center Randomized Controlled Trial With One-Year Follow-Up. Spine PMID: 24875964