#VisualAbstract: Patient Education Program May Reduce Disability and Symptoms of Chronic Pain

1. Adults with chronic low back pain (CLBP) randomized into a 6-week pain intervention education program were observed to have significantly relieved burden of pain-related disability and overall pain intensity when combined with the physiotherapeutic standard of care.

2. Measures of self-reported well being also improved significantly more in the pain education group compared to the control group. 

Evidence Rating Level: 1 (Excellent)

Chronic low back pain (CLBP) is a pervasive condition contributing significantly to pain-related disability worldwide. Several factors are thought to contribute to the burden of CLBP, and pharmacological treatments and physiotherapeutic intervention alone are not believed to be sufficient. The incorporation of psychological strategies and pain education is thought to be crucial, but a lack of standardization and ethnocultural considerations are barriers to widespread implementation. Western countries quite readily embrace pain education programs, and some Eastern countries currently lack robust testing for culturally relevant CLBP curricula. The current randomized controlled trial assessed whether a structured pain education intervention could reduce disability and pain intensity compared to the standard of care. A total of 92 patients with CLBP (mean [SD] age, 42.3 [10.8] years) were recruited from the Sher-e-Kashmir Institute of Medical Sciences (SKIMS) and blindly randomized 1:1 to either the control group or intervention group. Both received 40-minute guideline-based physical therapy sessions, but the intervention group underwent face-to-face education modules exploring definitions of chronic pain, its neurophysiology, and neurobiological aspects (central sensitization, fear avoidance, and social factors affecting CLBP). Didactic sessions occurred twice weekly for the first 3 weeks, followed by question-and-answer sessions in weeks 4 and 5, and a brief education manual was provided at the conclusion of the 6th week. Pain intensity during different activities of daily living (ADLs) was measured on a 0-to-10 scale. Pain-related disability was assessed using the Roland Morris Disability Questionnaire (RMDQ). Measures of self-efficacy and coping were reported using the General Self-Efficacy Scale (GSE), and emotional wellbeing was measured using the World Health Organization (WHO) Five Well-Being Index (WHO-5). Post-intervention results demonstrate that disability burden (RMDQ) scores significantly improved in both groups, but between-group mean difference reflected greater improvements in the experimental group (a 54.2% decrease in disability for experimental group, versus a 6.8% decrease in the control group) with a large effect size (p < .001, Cohen’s d = 0.75). Pain intensity decreased in both groups, with significant main effect and large effect size between the groups post-intervention (p < 0.001, Cohen’s d = 0.82). Measures of well-being on the WHO-5 improved in favor of the pain education group, with a moderate effect size (p < 0.001, Cohen’s d = 0.58). Scores on the GSE scale were not affected by the treatment. A regression found that higher reports of RMDQ at baseline were associated with elevated disability at 6 weeks, and higher educational attainment was protective against disability post-intervention. Higher pain scale scores increased the odds of high pain intensity at 6 weeks by 1.69-fold, and higher self-efficacy, female sex, and higher age at baseline were associated with positive outcomes for well-being and self-efficacy. Overall, results suggest that integrating a pain education program with standard physiotherapeutic care enhanced outcomes for CLBP patients in India, and multi-centre trials should be conducted to improve the external validity of results.

Click to read the study in PLOSONE