Measuring knowledge change in Explain Pain interventions

Explaining pain is a big part of how we treat patients with chronic pain. Through education, we try to change those inaccurate pain beliefs that contribute to the maintenance of pain. However, explaining pain clearly is not always easy, and for patients, learning new concepts that contradict with strong existing beliefs can be challenging too. Therefore it makes sense to regularly assess our patients to ensure our message is getting through.

The patient-version of the Neurophysiology of Pain Questionnaire (NPQ) [3] has been used extensively to assess pain biology knowledge in patients. Prior to education, it can help identify inaccurate beliefs, such as ‘chronic pain means that an injury hasn’t healed properly’. After education, it can be used to assess knowledge change and identify gaps in knowledge. Yet, despite its widespread use, the English version of the NPQ had never been formally assessed.

To test the NPQ, we analysed the responses of a random sample of 345 chronic spinal pain patients [2]. We used Rasch analysis, a fancy statistical process, to help answer the following questions:

  • Are the NPQ questions too easy or too hard?
  • Does the difficulty of the questions target the ability of patients?
  • Can the NPQ questions be summed to provide an overall score of ‘pain biology knowledge’?
  • Do any of the questions duplicate the content of others?

We also assessed whether the NPQ was reliable by reassessing as group of patients a week later.

We found the NPQ effectively targets the ability of chronic spinal pain patients and is sensitive enough to distinguish between high and low performers. The NPQ had acceptable test-retest reliability and could be validly summed to provide a score of pain biology knowledge. However, some questions functioned erratically or duplicated others and preliminary analysis suggested the tool could be improved with the removal of some questions.

Our teaching can result in the knowledge uptake which can facilitate a reconceptualisation of pain and in turn reduce pain [1]. Despite some limitations, the patient-version of the NPQ is a useful tool for briefly assessing a patient’s beliefs regarding pain prior to education and for ensuring our Explain Pain message is understood.

Mark Catley

Mark Catley Body In MindMark Catley is a PhD candidate in the Body in Mind Research Group (at University of South Australia) in Adelaide. When he is not busy researching, Mark works as a physiotherapist in a rehabilitation hospital. He is interested in the brain’s involvement in the transition from acute pain to chronic pain, and is currently investigating the relationship between cognitive variables,  mood and sensory function in people with back pain.

He also has a very particular approach to cooking rice.  For perfectly cooked rice: 2/3 cup rice, double that in COLD water, and then 8mins in microwave uncovered. Actually, he has a particular approach to many things – including windows.  He is the only BiM team member you should ever get to clean a window.


[1] Butler DS, Moseley GL. Explain pain. Adelaide, S. Aust: Noigroup Publications, 2003.

[2] Catley MJ, O’Connell NE, & Moseley GL (2013). How Good Is the Neurophysiology of Pain Questionnaire? A Rasch Analysis of Psychometric Properties. Journal of Pain PMID: 23651882 PDF here PDF here

[3] Moseley L (2003). Unraveling the barriers to reconceptualization of the problem in chronic pain: the actual and perceived ability of patients and health professionals to understand the neurophysiology. Journal of pain, 4 (4), 184-9 PMID: 14622702



  1. Thanks BiM researchers for your work. Relating to another recent post ‘can the internet help?’, it would be interesting to see an NPQ turned into an online survey which could be posted onto social media websites. For every person with a pain story, there is a number of pain free people part of that person’s world reinforcing ‘old’ (but hardy) pain beliefs…encouraging further investigations into finding the exact structure causing the pain, suggesting they take a sickie or greeting that person with ‘how’s your back?’ rather than ‘how are you’? After all, ‘it takes around 75 years for a medical myth to be erased from public thinking’ (not sure where this fact comes from, but I think it holds some truth). I’d gladly post a link to a NPQ survey on my Facebook if there was one (perhaps there is?).

  2. The medical profession tries to impose their flawed beliefs about pain onto the public. Medicine cant make up their mind about a theory of pain- whether its the gate control theory or the energy crises hypothesis and research on pain is stuck in 18th century physics. Placebo responses in pain treatments are poorly explained, as well as medically unexplained symptoms. Medicine is lost when it comes to pain care and continues in a path of misdirection, which has lead to misunderstandings and mistreatment of pain and people in pain.

  3. Perhaps educational research can add to Mark’s comment “learning new concepts that contradict with strong existing beliefs can be challenging.” Several convincing studies in the areas of science and maths have shown that erroneous early beliefs, or intuitions, are not supplanted by scientific information, but the two beliefs co-exist. Under stress, even scientists are more likely to revert to the naïve belief. My experience is that young dancers automatically revert to their intuitive pain concepts when confronted with stressful situations, regardless of their scientific understanding. When a particular type of movement has been a pain trigger, I have been tying new imagery to the name of the trigger movement. Although I have had good results so far, I don’t know whether this is sound neurologically. I’m hoping someone can give me advice.

    Some of the studies I mentioned are:

    Barton K, Fugelsang J, Smilek D. Inhibiting beliefs demands attention. Thinking & Reasoning 15, no. 3 (2009): 250-267.

    Kelemen D, Rottman J, Seston R. Professional Physical Scientists Display Tenacious Teleological Tendencies: Purpose-Based Reasoning as a Cognitive Default. Journal of Experimental Psychology: General (2012, October 15). Advance online publication. doi:10.1037/a0030399.

    Shtulman A, Valcarcel J. Scientific knowledge suppresses but does not supplant earlier intuitions. Cognition, Volume 124, Issue 2, August 2012, Pages 209–215.

    Stavy R, Goel V, Critchley H, Dolan R. Intuitive interference in quantitative reasoning. Brain research 1073 (2006): 383-388.

  4. Any way we can get this across to the primitive systems/assessment guides: WorkSafe, Safe Work Australia, AMA Guidelines and Accident Compensation Act? It would really help injured workers, like myself, who are being left without compensation and acknowledgment from these Government orgs’ out of date and uneducated impairment assessments. I have Pudendal Neuralgia/Pelvic chronic pain and I am seen as having a 0% impairment (that Independent Medical Examiners stated as being ‘permanent’), with $0 medical help, $0 weekly entitlements, $0 compensation…

    Questionnaires such as these desperately need to be implemented. The Act 1985 is simply unacceptable.. Thank you so much for your research.