An adventurous learning journey. Physiotherapists' conceptions of learning and integrating cognitive functional therapy into clinical practice.

Background: Recent low back pain guidelines recommend a BPS approach to the management of disabling low back pain. However, the most effective way of teaching physiotherapists to implement these approaches remains unknown. The present qualitative study aimed to explore physiotherapists' conceptions of learning and integrating Cognitive Functional Therapy (CFT) into clinical practice in Finnish primary health care.Methods: We interviewed 22 physiotherapists, who participated in four to six days of CFT workshops. A phenomenographic approach was used to explore the variation in the physiotherapists' conceptions of this process.Results: Four themes emerged from the data: 1) membership of work community; 2) learning journey; 3) transition to new working methods; and 4) professional role as a physiotherapist. These themes varied in four categories of description: recognizing difference of the new approach, toward integrating the new approach, waking up to explore, commitment to new approach and expanding application of new approach. The critical aspects between the categories that enabled the integration of CFT into clinical practice were ability to overcome resistance and to change views, being shaken and ability to critically reflect on one's work, support from the work community and becoming convinced, creativity, multidisciplinary collaboration and continuous learning.Conclusion: The participants' responses to the training varied greatly, suggesting that for some, the training was insufficient to support adequate changes in their practice behavior; whereas for others, the training was a life changing experience.

Responding to social cues: An experimental paradigm exploring the link between context sensitivity and pain.

OBJECTIVES: The term context sensitivity refers to whether a response is in tune with the ever changing demands of the context, while insensitivity is the lack of responding to these cues. To date, we know little about how well patients with pain respond emotionally to changes in the cues provided by the social context, that is, how emotionally context (in)sensitive they are and if this is related to problem severity. The aim of this experimental study was to test a method for determining levels of context sensitivity in individuals with subacute and chronic pain and to explore the link between context (in)sensitivity and pain-related problems. We operationalized context (in)sensitivity as participants' emotional responses (observed facial expressions and self-reported affect) and pain bothersomeness in these contexts and explored the association between these context-(in)sensitive social-emotional responses and pain-related problems. METHODS: Sixty-two participants with pain were cued to talk openly about three different topics consecutively in a counterbalanced order: (1) their pain, (2) a negative non-pain topic, and (3) a positive non-pain topic. We measured the participants' emotional responses (observed facial expressions and self-reported affect) and pain bothersomeness across these contexts and explored the effect of social-emotional responding on pain-related problems. RESULTS: The results showed that, irrespective of individuals' baseline levels of pain bothersomeness, positive affect, and negative affect, those who reacted with more negative affect and pain bothersomeness when prompted to discuss a positive topic had higher levels of pain-related problems. Moreover, those who showed more negative facial expressions and pain bothersomeness when prompted to discuss a negative non-pain topic also had higher levels of pain-related problems. CONCLUSIONS: These findings highlight a link between sensitivity to the social context and the severity of a pain problem. We showed that individuals with greater problem severity were less sensitive to social cues in their emotional responses, as compared to individuals with less pain-related problems. As predicted, context-insensitive responding appears to be most strongly associated with pain-related problems when dealing with negative emotions. Although the cross-sectional nature of the study prohibits causal conclusions, our findings demonstrate a link and future research is clearly needed to unravel the role of context sensitivity in the development of pain over time. Statement of contribution What is already known on this subject? Responding to social cues seems to be important for adaptation to pain. The term context sensitivity refers to whether a response is in tune with the provided social cue. To date, we know little about how well patients with persistent pain respond emotionally to changes in the social context, that is, how context (in)sensitive they are and if this is linked to problem severity. What does this study add? A test of a method for determining levels of context sensitivity in individuals with persistent pain. Information about to what extent individuals with chronic pain respond context sensitively. Knowledge on the link between social context sensitivity and level of pain problems.

"When I feel the worst pain, I look like shit" - body image concerns in persistent pain.

Background and aims Persistent pain is a pervasive condition that is often associated with a distorted body image. Most research into pain and body image investigated neural or physiological correlates (e.g. phantom limb pain), and much less is known about the psychological experience of body image changes in response to pain such as appearance concerns. The aim was to examine body image concerns in people with persistent pain, in particular appearance concerns and related coping behaviours and appearance-related emotions such as anger and shame. Methods Design was cross-sectional and data was collected through in-depth semi-structured interviews with people suffering from persistent musculoskeletal pain (n=7; six females; age=19-56), and analysed with inductive thematic analysis (TA). Results Two main themes were identified: "Relationship to the painful body" and "Dissatisfaction with the body", each containing three subthemes, along with the side-theme "Appearance concerns affected by pain and mood". All participants reported appearance concerns, predominantly about their weight and related coping behaviours such as avoidance of mirrors, exercising or dieting and pain-induced mood changes that were associated with a negative body image. Conclusions People with persistent pain report appearance concerns, often related to pain-induced negative mood changes, and reduced functioning. It remains unclear to what extent attitudes towards the body change over time in accordance with pain. A wider concept of body image is required, including the perception of reduced functioning, related appraisals (e.g. "I look weak and old") and appearance investment.

Do psychological factors increase the risk for back pain in the general population in both a cross-sectional and prospective analysis?

This study aimed to conduct a comprehensive evaluation of background, individual and workplace psychological risk factors to investigated their relationship with spinal pain. Because there is some doubt as to whether the results of cross-sectional findings hold in longitudinal studies, a prospective study was superimposed upon a cross-sectional design of the effects of psychological variables on back pain and function to determine, whether similar results are obtained. Participants were workers randomly selected from the general population, where 372 had not experienced pain during the past year, and 209 had experienced considerable pain problems. A cross-sectional comparison of these groups using multivariate statistics indicated that the most potent risk factors were psychological distress (odds ratio=13.2) and poor function (odds ratio=6.4). Much smaller levels of risk were found for perceived workload, gender and foreign birth. Those participants with no pain were followed for one year to determine development of a spinal pain problem. Although few participants developed a significant pain problem, the prospective analyses showed that psychological distress (odds ratio=2.2), catastrophizing (odds ratio=3.0), and workload (odds ratio=2.3) produced the highest odds ratios. Taken together these results underscore the need for a multidimensional view of the development of pain disability. Moreover, individual psychological factors such as distress and catastrophizing as well as work place factors like work load were found to be highly related to the development of back pain in a sample of workers from the general population. The cross-sectional and prospective results were similar in character and demonstrate that cross-sectional studies may provide valuable information. Because psychological variables were relevant very early on, these factors may be important targets for pain prevention programs.

A prospective study of the effects of sexual or physical abuse on back pain.

A prospective investigation of the effects of abuse on future pain and disability was conducted in order to understand better the possible causal role of abuse. Participants were 422 females from a previous population study (Pain 73 (1997) 47-53) who either reported no spinal pain (n=194) or some spinal pain (n=228) at the baseline. A standardized questionnaire was used to assess self-reported physical and sexual abuse during childhood and as an adult. One year later, a follow-up questionnaire was used to evaluate pain and physical function outcomes. Results for the No Pain Group showed that only self-reported physical abuse at baseline was associated with an increased occurrence of new episodes of back pain (odds RATIO=2.65). Both sexual and physical abuse were linked to as much as four-fold increase in the occurrence of a new episode of functional problems at follow-up. However, for the Pain Group, no significant differences were found between those reporting and not reporting abuse at baseline and either pain or disability at follow-up. This unique prospective study with individuals from the general population underscores the probable importance of abuse in the etiology of a pain or disability problem. Nevertheless, since no clear relationship between abuse and pain was shown for those already reporting pain at baseline, the role of abuse in the development of persistent pain is still not comprehensible. There is a need for investigations with prospective designs employing patients as well as nonpatients as subject.

Early identification and intervention in the prevention of musculoskeletal pain.

BACKGROUND: A large number of people suffer from upper extremity disorders, but a few apparently consume the majority of the resources. Early interventions are badly needed to prevent the development of persistent disability. Since psychological factors are central in the development of a chronic problem these might be utilized in this endeavor. METHODS: A series of studies are described where a screening procedure based on psychological risk factors was employed to help identify people at risk for developing long-term work disability. The utility of a cognitive-behavioral group intervention that focuses on coping strategies as prevention was assessed in three randomized-controlled studies where participants had low, medium, and high risk, respectively. RESULTS: The study with low risk showed no significant difference between the groups, while the studies with medium- and high-risk populations demonstrated significantly lower work disability than control groups receiving treatment as usual. CONCLUSIONS: It appears to be feasible to identify patients with high levels of risk and to subsequently lower the risk for work disability by administering a cognitive-behavioral intervention focusing on psychological aspects of the pain problem.