Development of an individualised primary care program for acute low back pain using a hybrid co-design framework.

BACKGROUND: Low back pain is the leading worldwide cause of years lost to disability and the problem is worsening. This paper describes and demonstrates the scholarly development and contextual refinement of a primary care program for acute low back pain in Sydney, Australia. METHODS: Hybrid theoretical frameworks were applied, and co-design was used to contextualise the program to the local healthcare setting. RESULTS: The program was developed in four stages. In stage 1, the scientific evidence about management of acute low back pain in primary care was examined. In stage 2, stakeholders (patients and clinicians) were consulted in nationwide surveys. Data from stages 1 and 2 were used to design an initial version of the program, called My Back My Plan. Stage 3 involved the contextual refinement of the program to the local setting, MQ Health Primary Care. This was achieved by co-design with primary care clinicians and patients who had sought care for low back pain at MQ Health Primary Care clinics. In stage 4, a panel of Australian experts on clinical care for low back pain reviewed the contextualised version of My Back My Plan and final amendments were made. CONCLUSION: My Back My Plan has been developed using an innovative scholarly approach to intervention development.

My Back My Plan is a feasible and acceptable individualised program for acute low back pain in primary care.

BACKGROUND: Low back pain is the largest cause of years lived with a disability in Australia, and there is an urgent need for innovations to address global gaps between evidence and practice. METHODS: This study was a phase 1, single-group, pre-post pilot trial of My Back My Plan, a primary care program for acute low back pain. The trial was conducted at MQ Health Primary Care at Macquarie University in Sydney, Australia. The primary outcomes were feasibility and acceptability. RESULTS: Fourteen participants were recruited to the study, with 79% and 93% followed up at 1 and 3months respectively. Ten general practitioners and four physiotherapists at MQ Health Primary Care delivered the intervention. Although the rate of patient recruitment to the trial was low, other aspects of feasibility (such as intervention adherence and safety) were high. Participating clinicians reported that the program was useful for patients, and the majority stated that the program facilitated person-centred care. Patients rated My Back My Plan as highly acceptable, indicating that they had a better understanding of their low back pain, they were given personalised care and were more confident in self-managing their low back pain. At the 3month follow-up, 85% of participants stated they were very likely to recommend the program to others. CONCLUSIONS: This study suggests that the co-designed, contextually refined MBMP program for MQ Health Primary Care is acceptable to people with acute onset low back pain and warrants further evaluation.

Development of a national pain management competency profile to guide entry-level physiotherapy education in Canada.

BACKGROUND: National strategies from North America call for substantive improvements in entry-level pain management education to help reduce the burden of chronic pain. Past work has generated a valuable set of interprofessional pain management competencies to guide the education of future health professionals. However, there has been very limited work that has explored the development of such competencies for individual professions in different regions. Developing profession-specific competencies tailored to the local context is a necessary first step to integrate them within local regulatory systems. Our group is working toward this goal within the context of entry-level physiotherapy (PT) programs across Canada. AIMS: This study aimed to create a consensus-based competency profile for pain management, specific to the Canadian PT context. METHODS: A modified Delphi design was used to achieve consensus across Canadian university-based and clinical pain educators. RESULTS: Representatives from 14 entry-level PT programs (93% of Canadian programs) and six clinical educators were recruited. After two rounds, a total of 15 competencies reached the predetermined endorsement threshold (75%). Most participants (85%) reported being "very satisfied" with the process. CONCLUSIONS: This process achieved consensus on a novel pain management competency profile specific to the Canadian PT context. The resulting profile delineates the necessary abilities required by physiotherapists to manage pain upon entry to practice. Participants were very satisfied with the process. This study also contributes to the emerging literature on integrated research in pain management by profiling research methodology that can be used to inform related work in other health professions and regions.

Contexte: Contexte: Les stratégies nationales nord-américaines préconisent des améliorations sensibles à la formation de base en matiére de prise en charge de la douleur afin de contribuer à la réduction du fardeau de la douleur chronique. Des travaux antérieurs ont généré un ensemble de compétences interprofessionnelles utile en matiére de prise en charge de la douleur afin de guider la formation des futurs professionnels de la santé. Cependant, trés peu de travaux ont porté sur l'acquisition de telles compétences pour des professions individuelles dans différentes régions. L'uisition de compétences spécifiques à une profession adaptées au contexte local est une première étape nécessaire pour leur intégration dans les systèmes réglementaires locaux. Notre groupe travaille à cet objectif dans le cadre de programmes de formation de base en physiothèrapie partout au Canada.Objectifs: Cette étude visait à créer un profil de compétences consensuel pour la prise en charge de la douleur, propre au contexte canadien de la physiothérapie.Méthodes: Un devis Delphi modifié a étè utilisé pour parvenir à un consensus parmi des formateurs en milieu universitaire et clinique en matière de douleur en milieu universitaire et clinique.Résultats: Des représentants de 14 programmes de formation de base en physiothérapie (93 % des programmes canadiens) et de six formateurs en milieu clinique ont été recrutés. Après deux tours, 15 compétences ont atteint le seuil d'approbation prédéterminé (75 %). La plupart des participants (85 %) ont déclaré être « très satisfaits ¼du processus.Conclusions: Ce processus a permis de dégager un consensus sur un nouveau profil de compétences en matiére de prise en charge de la douleur propre au contexte canadien de la physiothérapie. Ce profil délimite les habiletés requises des physiothérapeutes pour prendre en charge la douleur en début de pratique. Les participants ont été très satisfaits du processus. Cette étude contribue également à la littérature émergente sur la recherche intégrée en matière de prise en charge de la douleur en définissant une méthodologie de recherche qui peut être utilisée pour éclairer des travaux similaires dans d'autres professions de la santé et dans d'autres régions.

Limited evidence of moderation of the association between gastrointestinal symptoms and prospective healthcare utilisation by quality of life.

BACKGROUND: An individual's drive to seek medical help remains a complex behavioural process, incorporating psychological, social and symptom-specific factors. Within irritable bowel syndrome (IBS), gastrointestinal symptoms only predict a small portion of the high healthcare-seeking experienced. AIM: To examine the moderating role of quality of life (QoL) domains on this relationship to help explain the variance observed. METHODS: This is an analysis of a Swedish population-based prospective study of healthcare use over a 12-year period. At baseline, gastrointestinal symptoms were measured with the valid Gastrointestinal Symptom Rating Scale, and QoL via the SF-36. 1159 subjects (57% female; mean age 48.6 years) had their health records matched with the initial survey. 164 were classified as IBS by Rome II criteria. Negative binomial or logistic models were fit to evaluate the moderating effect of particular QoL domains on the relationship between gastrointestinal symptoms and prospective healthcare utilisation. RESULTS: Gastrointestinal symptoms were associated with prospective healthcare use, but moderation in this relationship by particular QoL domains was not supported; most models did not reach statistical significance. Furthermore, the impact of IBS status did not alter the moderation hypotheses. CONCLUSIONS: Particular QoL domains did not impact the relationship between gastrointestinal symptoms on prospective healthcare seeking. Future research should continue to examine other psychological, social and symptom variables to identify predictors of high healthcare consumers in IBS.

The Concept of Pain Inventory for Adults (COPI-Adult): Assessing Knowledge and Beliefs Regarding Pain Science Education.

OBJECTIVES: Assessing knowledge and beliefs regarding pain science can identify gaps and misconceptions. The Concept of Pain Inventory (COPI) was recently developed in children with the intent to guide targeted pain science education. We utilized the original COPI item pool to (1) develop a tool to assess an adult's concept of pain in a cohort who had not received pain science education, (2) evaluate its psychometric properties, (3) examine distribution of scores in a cohort of adults who had received pain science education, and (4) examine associations between scores and clinical variables. MATERIALS AND METHODS: A total cohort of 627 adults were recruited through social media for an online survey. Initial development was conducted on those who had not received prior pain science education (n=125), then the COPI-Adult tool was tested in those who had received prior pain science education (n=502). RESULTS: The resulting unidimensional 13-item COPI-Adult had acceptable internal consistency (α=0.78) and good test-retest reliability at 1 week (Intraclass Correlation Coefficient3,1=0.84 (95% confidence interval: 0.71-0.91). Higher COPI-Adult scores reflect greater alignment with contemporary pain science. COPI-Adult scores were correlated with revised Neurophysiology of Pain Questionnaire (rNPQ) scores and inversely correlated with average and current pain intensity, and pain interference. Adults who reported having received pain science education had significantly higher mean COPI-Adult scores than those who had not, and this difference exceeded the smallest detectable change. DISCUSSION: The COPI-Adult is a brief questionnaire with promising psychometric properties to identify conceptual gaps or misconceptions to inform individualized pain science education.

Exploration and Validation of Behavioral Pain Measures and Physiological Pain Measures Factor Structure Extracted From the Pain Assessment Tool Item Scores for Infants Admitted to Neonatal Intensive Care.

OBJECTIVE: The objective of the study was to explore and then validate the factor structure of the Pain Assessment Tool (PAT). MATERIALS AND METHODS: A retrospective medical record review was performed of all infants who were admitted to a neonatal intensive care unit between 2008 and 2018 and had 1 PAT assessment (n=2111). Scores on items of the PAT were collected. Infants were randomized to either the principal component analysis (n=1100) to explore the factor structure or confirmatory factor analysis (n=1011). RESULTS: Infants in the 2 samples were demographically comparable. A 2-factor model, consisting of factors Behavioral and Physiological Pain Measures, was extracted, explaining 39.8% of the total variance. There was a low interfactor correlation (r=0.12), and both Behavioral (r=0.59) and Physiological Pain (r=0.37) Measures factor scores were correlated with nurses' perception of pain scores. When the frequencies in the gestational age at birth categories were compared between upper and lower quartile score infants, there was more with pain at preterm than at term (χ2(3)=44.9, P<0.001) for the Physiological Pain Measures factor, whereas Behavioral Pain Measures frequency was higher at term than at preterm (χ2(3)=8.1, P<0.043). A similar pattern was observed for postmenstrual age at assessment categories: Behavioral Pain Measures (χ2(3)=41.8, P<0.001) Physiological Pain Measures (χ2(3)=46.1, P<0.001). The 2-factor correlated model performed better at explaining the observed variances: (χ2(13)=41.6, P<0.001) compared with rival models. DISCUSSION: The PAT assesses both Behavioral Pain and Physiological Pain Measures, and these dimensions need to be considered separately when assessing pain in infants in the neonatal intensive care unit. Behavioral item scores may be insufficient for detecting pain in premature infants if used alone.

Neonates as intrinsically worthy recipients of pain management in neonatal intensive care.

One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.

The Concept of Pain Inventory (COPI): Assessing a Child's Concept of Pain.

OBJECTIVES: Clinical guidelines recommend that health care providers assist children to understand their experience of persistent pain, with pain science education a key component of clinical management in pediatric pain clinics. Currently, no tool exists to assess a child's concept of pain. The aim of this study was to develop such a tool and to evaluate its psychometric properties. METHODS: After a rigorous process to generate items, assess content validity, evaluate readability and understandability, and pretest items, a cohort of 124 children (aged 8 to 12 y) independently completed the measure on 2 occasions, along with additional measures of pain, function, and pain-related distress. RESULTS: The resulting unidimensional 14-item Concept of Pain Inventory (COPI) had acceptable internal consistency (α= 0.78) and moderate test-retest reliability (intraclass correlation coefficient (3,1) = 0.55; 95% CI, 0.37-0.68). Higher COPI scores reflect greater alignment with contemporary pain science. COPI scores were inversely correlated with pain intensity and functional disability, but unrelated to pain catastrophizing and pain-related fear. At 1 to 2 months' follow-up, baseline COPI scores were inversely correlated with clinical variables of functional disability and pain intensity. DISCUSSION: These results support the COPI as a brief, psychometrically sound tool to assess a child's concept of pain. Clinically, this tool may facilitate individualized pain science education to target identified conceptual "gaps" or misconceptions and to evaluate the effectiveness of pain science education in children. Further research examining its efficacy and impact is warranted.

Trajectories of post-surgical pain in infants admitted to neonatal intensive care.

BACKGROUND: The aim of this study was (a) to statistically identify distinct trajectories of pain following surgery in infants less than 6 months of age, and (b) to compare these trajectories to descriptions of chronic pain in infants in the neonatal intensive care unit (NICU). METHODS: This was a retrospective medical record review of infants admitted to a NICU between 2008 and 2018 following surgery. All infants who underwent one major procedure to the abdomen or thorax and returned to the NICU following surgery were included. Pain was assessed regularly using a validated Pain Assessment Tool. Group-based trajectory analysis was used to determine the trajectory of recovery from pain following surgery. RESULTS: A total of 726 infants were included in the study. A two-group trajectory model, defined as typical and atypical pain trajectories, was selected. The typical group (n = 467) consisted of infants who had significantly fewer days (1.5 ± 2.3 vs 5.3 ± 5.5, p < .001) and recorded instances of pain (2.0 ± 3.4 vs 9.7 ± 10.5, p < .001) compared to infants in the atypical group (n = 259). The incidence of iatrogenic neonatal abstinence syndrome was greater in the atypical than the typical group (11% vs 5%, p = .001). CONCLUSIONS: This study has revealed two distinct pain trajectories in infants after surgery. While recovery from pain occurs within days in the typical group, the atypical group demonstrates pain for a significantly longer period, often weeks and months following surgery. This latter group adheres closely to current descriptions of chronic pain in infants.

Management of acute low back pain: the practices and perspectives of primary care clinicians in Australia.

Low back pain (LBP) is the highest cause of years lived with a disability in Australia and the most frequent musculoskeletal condition for which patients seek primary care. The aims of this study were to: (1) evaluate the current practices and perspectives of Australian GPs and physiotherapists managing acute back pain; and (2) explore alignment of care with clinical guidelines. This was a prospective cross-sectional Internet survey conducted from March 2018 to May 2018 of experienced Australian GPs and physiotherapists. Descriptive statistics were used to analyse all quantitative outcomes. Two hundred primary care practitioners (72% physiotherapists and 28% GPs) from all States and Territories of Australia completed the survey. Most primary care practitioners were familiar with clinical guidelines for acute back pain management and reported delivery of many of the core components of guideline-based care, including education, advice about favourable prognosis, encouraging activity and self-management and discouraging prolonged bed rest. Deviations from guideline-based care were common, including provision of analgesic medication, passive therapies and using radiological imaging. Australian primary care clinicians in this sample were aware of back pain guidelines and typically implement care that is consistent with guideline-based recommendations. Divergences from these guidelines may indicate that primary care practitioners are delivering evidence-based and person-centred care that integrates clinicians' judgement with patients' preferences and guideline-based evidence.

Prognostic factors for pain and functional disability in children and adolescents with persisting pain: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: The aim of this study was to investigate prognostic factors for pain and functional disability in children and/or adolescents with persisting pain. DATABASES AND DATA TREATMENT: To be included, studies had to be published, peer-reviewed prospective cohort studies of children and/or adolescents with persisting pain at baseline, that reported at least one baseline prognostic factor and its relationship with pain or functional disability at least 1 month after baseline. Two reviewers independently assessed study eligibility, completed data extraction and undertook quality assessment. Meta-analyses were performed when a prognostic factor was reported in two or more studies. RESULTS: Of 10,992 studies identified from electronic database searches, 18 were included, investigating 62 potential prognostic factors. In clinical settings, insufficient data were available for meta-analysis. Some positive associations with pain and/or disability were reported by single studies for older age, baseline pain intensity and baseline functional disability across multiple combinations of follow-up times and outcomes. In community settings, meta-analyses of two studies found that prognostic factors for the ongoing presence of pain at medium-term (1-year) follow-up were older age (OR 1.25; 95% CI = 1.05-1.47), weekly day tiredness (OR 1.69; 95% CI = 1.14-2.51), weekly abdominal pain (OR 1.44; 95% CI = 1.03-2.02) and waking during the night (OR 1.49; 95% CI = 1.05-2.13). No studies in community settings reported on prognostic factors for functional disability. CONCLUSIONS: Prognostic factors having significant associations with future pain and disability were identified; however, as few were investigated in more than one comparable study, the results need to be interpreted with caution. SIGNIFICANCE: Prognostic factors from across the biopsychosocial spectrum are important to consider in paediatric pain clinical practice. However, most prognostic factors that experts have previously agreed upon have not been assessed in prospective cohort studies to date. The findings may help with prioritising data to collect during clinical assessments of children presenting with pain, in the context of pain and functional disability outcomes.

Effects of Psychology and Extragastrointestinal Symptoms on Health Care Use by Subjects With and Without Irritable Bowel Syndrome.

BACKGROUND & AIMS: There is controversy about whether psychological factors (anxiety and depression) increase health care seeking by patients with irritable bowel syndrome (IBS). We investigated whether psychological factors increase health care seeking by patients with IBS and the effects of extragastrointestinal (extra-GI) symptoms. METHODS: We performed a population-based prospective study of health care use over a 12-year period in Sweden. From 2002 through 2006, 1244 subjects were selected randomly for an examination by a gastroenterologist and to complete questionnaires, including the Rome II modular questionnaire. Psychological factors were measured with the valid Hospital Anxiety and Depression scale and extra-GI symptoms were measured with a symptom checklist. Responses from 1159 subjects (57% female; mean age, 48.65 y) were matched with health records in 2016 (164 were classified as having IBS based on Rome II criteria). RESULTS: The overall association between depression or anxiety and health care use varied in subjects with and without IBS at baseline. The presence of extra-GI symptoms strengthened the relationship between anxiety and depression and prospective psychiatric visits for subjects with IBS and without IBS (incidence rate ratio, 1.14-1.26). Extra-GI symptoms did not alter the association of anxiety or depression with use of GI or extra-GI health care. CONCLUSIONS: In a population-based study in Sweden, we found that individuals with high baseline anxiety or depression were more likely to seek psychiatric health care, but not GI or extra-GI health care, in the presence of extra-GI symptoms at baseline. Patients with IBS might benefit from more thorough assessments that examine extra-GI and psychological symptoms, to reduce health care utilization.

Exploring the concept of pain of Australian children with and without pain: qualitative study.

OBJECTIVE: A person's concept of pain can be defined as how they understand what pain actually is, what function it serves and what biological processes are thought to underpin it. This study aimed to explore the concept of pain in children with and without persistent pain. DESIGN: In-depth, face-to-face interviews with drawing tasks were conducted with 16 children (aged 8-12 years) in New South Wales, Australia. Thematic analysis was used to analyse and synthesise the data. SETTING: Children with persistent pain were identified from a pain clinic waiting list in Australia, and children without pain were identified through advertising flyers and email bulletins at a university and hospital. PARTICIPANTS: Eight children had persistent pain and eight children were pain free. RESULTS: Four themes emerged from the data: 'my pain-related knowledge', 'pain in the world around me', 'pain in me' and 'communicating my concept of pain'. A conceptual framework of the potential interactions between the themes resulting from the analysis is proposed. The concept of pain of Australian children aged 8-12 years varied depending on their knowledge, experiences and literacy levels. For example, when undertaking a drawing task, children with persistent pain tended to draw emotional elements to describe pain, whereas children who were pain free did not. CONCLUSIONS: Gaining an in-depth understanding of a child's previous pain-related experiences and knowledge is important to facilitate clear and meaningful pain science education. The use of age-appropriate language, in combination with appropriate assessment and education tasks such as drawing and discussing vignettes, allowed children to communicate their individual concept of pain.

Systematic review and meta-analysis suggest that varying prevalence of non-acute pain in critically ill infants may be due to different definitions.

AIM: Our aim was to quantify the prevalence of non-acute pain in critically ill infants and to identify how non-acute pain was described, defined and assessed. METHODS: This systematic review and meta-analysis used multiple electronic databases to search for papers published in any language to March 2018: 2029 papers were identified, and 68 full texts were screened. Studies reporting the prevalence of non-acute pain in infants younger than 2 years and admitted to critical care units were included. The extracted data included the use of non-acute pain descriptions, definitions and pain assessment tools. RESULTS: We included 11 studies published between 2002 and 2018 that comprised 1204 infants from Europe, the USA, Canada and India. They were prospective observational (n = 7) and retrospective observational (n = 1) studies and randomised controlled trials (n = 3). The prevalence of non-acute pain was 0%-76% (median 11%). Various pain assessment tools were used, and only two could be pooled. This gave a pooled prevalence of 3.7%-39.8%. A number of different descriptors were used for non-acute pain, and all of these were poorly defined. CONCLUSION: The prevalence of non-acute pain in infants admitted to critical care units varied considerably. This could have been because all the studies used different definitions of non-acute pain.

Whether chronic pain is medically explained or not does not moderate the response to cognitive-behavioural therapy.

OBJECTIVES: To determine whether pain-related treatment outcomes, following an online Cognitive Behavioural Therapy (CBT) intervention for chronic pain, were moderated by the pain etiology of a medically explained or unexplained origin. METHODS: Data were available from 471 participants who completed the online pain management program between March 2013 and August 2014. Participants' pain symptoms were classified as being medically explained symptoms (MES: n = 292) or medically unexplained symptoms (MUS: n = 222) via analysis of clinical data. Outcome variables were pain-related disability, average pain intensity, depression and anxiety. RESULTS: Moderation analyses were non-significant for all dependent variables. Between group differences (CBT and control) were larger for depression in those classified with MES, compared with MUS (MUS: mean change = -3.50 [95% CI = -4.98 to -2.22]; MES: mean change = -5.72 [95% CI = -7.49 to -4.09]). However, between group differences were small for pain intensity (MUS: mean change = -0.03 [95% CI = -0.83 to 0.81]; MES: mean difference = -1.12 [95% CI = -1.84 to 0.40]). CONCLUSION: The therapeutic outcomes examined in this study associated with an online CBT program do not appear to be altered by whether the participants' pain symptoms are medically explained or unexplained.

Conditioned Pain Modulation (CPM) is Reduced in Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis of CPM and the Role of Psychological Factors.

This systematic review summarises evidence assessing endogenous pain inhibition in people with irritable bowel syndrome (IBS) compared with healthy controls using conditioned pain modulation (CPM) and offset analgesia (OA). Evidence regarding the role of psychological variables is also examined. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Four electronic databases were searched to retrieve studies assessing CPM or OA in adults diagnosed with IBS according to the ROME II/III criteria. Standardized mean differences were calculated for each study and a random effects model was used for meta-analysis. Eleven studies were included, 5 of which reported results on the relationship between CPM and psychological variables. None of the studies assessed OA. The risk of bias assessment found a lack of assessor blinding in all studies. The pooled effect estimate was 0.90 (95% CI, 0.40-1.40) indicating a significantly lower CPM effect in people with IBS compared with controls. This effect was reduced to 0.51 when 1 outlier was excluded from the analysis. In addition, reduced CPM responses were significantly correlated with higher anxiety (r=0.17 to 0.64), stress (r=0.63), and pain catastrophizing (r=0.38) in people with IBS; however, the evidence available was limited and the strength of these associations variable. Depression was not found to be associated with CPM in these IBS cohorts. The results of this review suggest that people with IBS, as a group, demonstrate reduced pain inhibition measured by CPM. The preliminary evidence about the association between psychological factors and CPM warrants further investigations.

Which Patients With Chronic Pain Are More Likely to Improve Pain Biology Knowledge Following Education?

BACKGROUND: Pain education is an important part of multidisciplinary management of chronic pain. The characteristics of people likely to have more improvement in pain biology knowledge following pain education are unknown. OBJECTIVE: To identify the baseline factors predicting changes in pain biology knowledge in adults with chronic pain following a 2-hour multidisciplinary pain education session. METHODS: Fifty-five adults with chronic pain attended a 2-hour pain education session prior to a multidisciplinary assessment at a pain clinic. Patients completed the 12-item revised Neurophysiology of Pain Questionnaire (rNPQ, score/12) before and after the pain education session. The primary outcome was change in pain biology knowledge, evaluated with the change in rNPQ score. Ten preselected predictors were investigated using univariate models followed by multivariable models with a manual forwards-building process. RESULTS: Education level and age were significantly associated with change in rNPQ score in the univariate models. Participants with higher levels of education had, on average, 1.96 (0.68 to 3.23) points more improvement in rNPQ score than those with lower levels of education. For every 10 years older a participant was, his or her rNPQ score changed on average by 0.5 (0.1 to 0.8) points less. In the multivariable model, only the education level remained significant, explaining 17% of the variance (R2  = 0.17). The clinical variables that were assessed (pain severity, pain interference, pain self-efficacy, depression, anxiety, and pain catastrophizing) did not predict any knowledge change. CONCLUSION: This study suggests that, of those patients with chronic pain who choose to attend pain education, more educated patients are more likely to improve their pain biology knowledge after a pain education session.

Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain: A Randomized Clinical Trial.

Importance: Many patients with acute low back pain do not recover with basic first-line care (advice, reassurance, and simple analgesia, if necessary). It is unclear whether intensive patient education improves clinical outcomes for those patients already receiving first-line care. Objective: To determine the effectiveness of intensive patient education for patients with acute low back pain. Design, Setting, and Participants: This randomized, placebo-controlled clinical trial recruited patients from general practices, physiotherapy clinics, and a research center in Sydney, Australia, between September 10, 2013, and December 2, 2015. Trial follow-up was completed in December 17, 2016. Primary care practitioners invited 618 patients presenting with acute low back pain to participate. Researchers excluded 416 potential participants. All of the 202 eligible participants had low back pain of fewer than 6 weeks' duration and a high risk of developing chronic low back pain according to Predicting the Inception of Chronic Pain (PICKUP) Tool, a validated prognostic model. Participants were randomized in a 1:1 ratio to either patient education or placebo patient education. Interventions: All participants received recommended first-line care for acute low back pain from their usual practitioner. Participants received additional 2 × 1-hour sessions of patient education (information on pain and biopsychosocial contributors plus self-management techniques, such as remaining active and pacing) or placebo patient education (active listening, without information or advice). Main Outcomes and Measures: The primary outcome was pain intensity (11-point numeric rating scale) at 3 months. Secondary outcomes included disability (24-point Roland Morris Disability Questionnaire) at 1 week, and at 3, 6, and 12 months. Results: Of 202 participants randomized for the trial, the mean (SD) age of participants was 45 (14.5) years and 103 (51.0%) were female. Retention rates were greater than 90% at all time points. Intensive patient education was not more effective than placebo patient education at reducing pain intensity (3-month mean [SD] pain intensity: 2.1 [2.4] vs 2.4 [2.2]; mean difference at 3 months, -0.3 [95% CI, -1.0 to 0.3]). There was a small effect of intensive patient education on the secondary outcome of disability at 1 week (mean difference, -1.6 points on a 24-point scale [95% CI, -3.1 to -0.1]) and 3 months (mean difference, -1.7 points, [95% CI, -3.2 to -0.2]) but not at 6 or 12 months. Conclusions and Relevance: Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature. Trial Registration: Australian Clinical Trial Registration Number: 12612001180808.