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.


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


  1. stuart miller says:

    Hi, I think, as was said, the time to educate is not necessarily in the pre-op class – not as much time to reflect and internalize the information – understanding the alpha band insight effect and how to get under the radar is difficult. I love the quote ‘culture eats strategy for breakfast.’ Find the opportunity for ownership vs buy-in and maybe you have a chance. Nibble away at the cultural bias (confirmation bias). Stress lies in the lack of control and uncertainty in the presence of conflict (and lack of emotional support) -it’s hard to talk about pain when someone says they can cut it out. Finally, Ste5e, I think (if your analogy relates to consciousness), you have to understand how the swamp is there and why the alligators are emerging before you drain it. I welcome insight – back to Brazil.

  2. stuart miller says:

    Hey, there was a recent post by Jessica Van Oosterwijck – ‘can pain neuroscience education improve endogenous pain inhibition?’ – I guess it takes time to reflect on the knowledge and lower health care costs (11 % +).
    The highlights: oral education has been shown to be more effective [Nijs] – It was felt that providing written information is especially important for those patients with memory or concentration problems, as they get the chance to read the information which was provided during the oral session -might be good to do a MOCA. The best effects of pain neuroscience education are achieved during an individual session [Nijs]. I know Lorimer does brilliantly with groups but not everyone is as gifted a storyteller. Recent studies increasingly use one or two sessions with a duration between 30 and 45 minutes [4 above and Nijs]. More is not better..cheers !

  3. Swamps and aligators.
    Picking off people one group at a time, going against the cultural and contextual head wind – very tricky, yes.
    When are we going to tackle the cultural issue head on. That of the 25ish% of us in pain right here, right now most of us have pain that is a product of a nervous sytem evolved to keep us safe but a bit overeager in that duty. That of the people that have pain only a relatively small minority axctually have acute pain that means what it says – the rest is an unhelpful opinion of a ‘jobsworth’ nervous system exhibiting the dark side of the wonder of neuroplasticity.
    This message has to be carried to the mainstream media, the sunday supplements, the daily news programmes, the schools, the prime time evening telly slots. The emporer has no effing clothes on!
    Then we can work. Without the cultural drag. So when we educate people they say – oh I heard of that – is that what I have – OK.
    My problem is that time after time the big reveal about the nervous system is too much of a right turn. It’s true, it makes sense, it offers a less travelled road to recovery. And the will o’ the wisps of mainstream medicine that will take so many of our patients off the hard to travel path of self awareness and self-managment in a culture that foolishly has bought into an easy lie that everything can be fixed -with a scalpel, a tablet or some ninja move by a guru therapist. And that medical establishment will take some steering too – away from the way it has learned to successfully pay its mortgage but unsuccessfully help 25% of the patients it farms.
    Oh well. One patient at a time – that’s the job at my level.
    If I am fighting the aligators – who will drain the swamp? Does that have to me too?
    We need more stuff like Loz did with Spratty making the supplement in The Australian. I hoped that was going to be a break through. What is the story that will break the tyranny of ‘all pain is damage’.
    Kind thoughts,

  4. Adrian Traeger says:

    Dear Zara, Marcel and Ina,

    Thank you all for your thoughtful comments.

    Zara, you are right to point out that many of these people probably have a lot invested in an alternative explanation of their pain. It certainly would have been interesting if the intervention group had poorer outcomes than the control group due to a nocebo effect. The data doesn’t suggest this but we were a little surprised that there didn’t seem to even a (possible) placebo effect from having 30min with a friendly physio vs. nothing. Perhaps the intervention did place seeds of doubt in some participants – but the satisfaction scores indicate otherwise.
    I also think 30min is too short for this kind of intervention. A mere trickle as you say. If however, the findings on health care use can be replicated, the potential for such a brief intervention to have massive public health impact is very enticing!

    Marcel, I agree that 30min is unlikely to induce “deep learning” . Deep learning is definitely the Holy Grail of Explaining Pain. We are still trying to think about how to best help patients think about pain differently. It might be that certain individuals require more intensive educational intervention. However as our friend Neil O’Connell has discussed extensively on this blog, when it comes to physiotherapy treatment, more is not always better. This could be the case for education as well. Is more pain education always better?

    Ina, the reduction in healthcare usage despite any change in pain or disability is definitely the most exciting finding of this study. My concern was the wide confidence interval around the estimate of cost savings, which was not reported in the manuscript. We can’t be sure that the intervention resulted in a meaningful change in costs after surgery nor in health behavior. It might be as little as 11%. I definitely think that if the result can be replicated in a larger sample then we as practitioners can start getting really excited. Until then, I’m sure both patients and practitioners alike would argue that the hunt must go on for brief interventions that can make robust changes to pain and disability. When such interventions pop up in journals like Spine perhaps some more minds will start changing out there?


  5. Ina Diener says:

    The most exciting about the results was, that DESPITE the fact that there was not a significant difference in report on pain or perceived disability, the ‘healthcare usage’ was less – that may mean that the neuroscience education really changed their behavior?! And is that not what we want from an intervention for pain patients?
    Furthermore – the only way to work with this mighty group of healthcare providers, is to show them that neuroscience education is favorable to their outcome – therefore publication in SPINE is sooo good!

  6. Thanks Adrian,

    It would be interesting to have more information on “the harder nut to crack” group as you put it. Would they have more benefit when explain pain education is given for a long period and has emphasis on “deeper” learning?

    Marcel Korper

  7. Zara Hansen says:

    Really nicely written commentary. I can’t say I’m too surprised at the results. I certainly wouldn’t be first in line to offer pain education to a bunch of people who have taken the difficult, perhaps desperate, decision to allow someone to operate on them. At this point they have a lot invested in believing/trusting that there is something mechanical/physical that can be significantly helped by their surgeon. In fact, I wonder if placing doubt into their minds could have the effect of minimising any surgical placebo effect.
    Also, in this bunch of patients I would want a few hours spread over several weeks rather than 30 mins. As you say Adrian, we are up against a sea of influence, a trickle of information probably won’t be enough.
    Ooh, I love extending metaphors!