Twitter was buzzing a few days ago with the posting of a new paper that came out on November 5th in JAMA Neurology. Adrian Traeger and his fellow collaborators published an excellent study looking into the effects of pain education for patients with acute low back pain. It was interesting to read the replies and repost of the article on Twitter with comments such as: “game changer”, “challenging my biases”, “Explain Pain hits a snag”, “education not helpful”, and others.
I thought I would offer a few thoughts on what I took home from the study but could not do it in 280 characters, so here it is in blog format.
One thing I think we all need to keep in mind is that pain is multidimensional and thus leads to being very heterogeneous. The idiom, “If you have seen one, you have seen them all” does not work for a person in pain. When you have seen one person in pain, you have seen one person in pain. We need to move past the thinking that any ONE intervention (pain science education included) is going to be the panacea for all pain related problems. Pain is too complex and multidimensional for that ever to work.
Can ONE intervention be the ONE thing, ONE patient needs, sure. However, ONE intervention cannot be the ONE thing, ALL patients need.
First, the authors should be commended on such an excellent well-controlled research study. There was a significant amount of effort put into controlling the two different interventions. I encourage everyone to not only download the study but also get the comprehensive Supplementary Online Content provided. They detailed out all of their education that was provided. My only caution would be that this study was done in Sydney, Australia and I think we need to be careful and realize that education should be delivered in culturally competent manner and individualized to the person in front of us because of the multidimensionality of pain. Therefore, education in one region of the world may not sound the same in another. It may actually sound different to two different people in the same part of the world.
So what did the study find? My interpretation was that two one-hour sessions of intensive pain education alone was not superior or inferior to the outcomes of just providing listening, showing interest, and attention of the clinician for those with acute low back that were at risk for chronic pain. Both groups showed some good improvements in pain and function within a few weeks and long term over one year.
Here are my biases that were confirmed with the study results:
- Most acute problems get better through natural progression. Make sure we are providing some reassurance to our patients about this very important fact and do not over treat them.
- Therapist-patient interaction of listening, showing interest, and attention (aka. Therapeutic alliance) maybe plays an important role in outcomes. Both groups got better with listening, showing interest and providing attention. We cannot fully deduce this from this study if that is the case, as it was not designed for that question. We do have other studies that do back up the importance of the therapeutic alliance. What this study did show that by providing pain science education you are able to maybe develop some of the elements of therapeutic alliance to help with outcomes. More research would be needed, but this study leads to some evidence that providing pain science education maybe one method that can develop therapeutic alliance and produce just as a good of result as the “placebo patient education” method. (We can argue if it should be called placebo education, but I won’t go there at this time)
- Our systematic review back in 2016 we found that education alone (which from my understanding of the methods of this study is what they provided) does not seem like the best approach. If anything education needs to be paired with active treatment and other helpful interventions, something we have referred to as PNE+.
- Potentially too much education (intensive 2 hours) may not be needed. In my case report published back in 2013, I provided 20 minutes of pain education to a similar type of patient that might have been in this study. The “fire hydrant approach” of giving intensive education might be better switched to a lighter version of sprinkling in some shorter less intense pain education with PNE+ interventions. Others might argue that we need more than 2 hours to make the changes that are needed through pain education. Only more research can answer that question.
Areas of interest and future study as we continue to unpack pain education’s role in the care for people in pain.
- My first area of interest is to see the other secondary measures (eMethods 5) the authors collected and looks like will be publishing separately in a planned mediation analysis.
- Another is perhaps the idea that pain neuroscience education might be a way of developing a therapeutic alliance? Something that we are currently in the works of investigating.
- The last would be the idea about dosing of pain neuroscience education. How much pain neuroscience education is needed and how much pain knowledge does the patient really need? Do we need 2 hours, maybe only 20 minutes, maybe 2 minutes, maybe none?
For me this was a great study that continues to add to the understanding of how to best utilize pain science education and creates many more avenues for study as we work to understand things further. For me no one study is ever a “game changer”, hopefully I’m always challenging my biases, I don’t think this study shows all education is not helpful, and every study should put a snag into things by creating more questions to explore.
Curious to hear what others are thinking and how their views have been changed or confirmed based on this study. In addition, if you have interest in future study of how to best use pain neuroscience please contact us at ISPI and our Pain Neuroscience Research Group, we are always looking for research and clinic collaborators.