Why we educate patients about health and chronic pain
by Dr Nathan Johns *
The latin derivation of doctor means ‘to teach’ and teaching and educating patients formed a large part of my clinical training. However, it can be difficult to find the time and energy to educate patients as there are often so many competing clinical interests during a consultation. But on review of the evidence base of health and chronic pain research, there is strong support for health education being the key to unlocking better health outcomes.
Unfortunately, in Australia, 60% of adults do not have adequate levels of health literacy (1). Health literacy is defined by the Australian Bureau of Statistics as “the knowledge and skills needed to understand and use information relating to health issues…” such as taking medication, understanding health and illness conditions and being involved in illness prevention. Australia’s low levels of health literacy are similar to those of Canada and the United States.
Low health literacy has been associated with the reduced use of preventive services, delayed diagnoses, reduced adherence to medical instructions, reduced self-management skills, reduced physical and psychological health, increased mortality risk and higher health care costs (2).
With chronic pain affecting 20% of adult Australians and being the leading cause of disability worldwide (3), good health literacy in the treatment of this chronic condition is critical. Chronic pain is a complex condition involving interactions between the neurological, immune and musculoskeletal systems and is often poorly understood by health professionals, the public and people with pain. Chronic pain is also associated with poor physical and psychological health and management often involves the prescription of multiple medications, multiple investigations, multiple treatments and variable advice.
To recover from chronic pain, a person with pain needs education to develop a good understanding of their condition, a knowledge of the limitations of investigations and a knowledge of available successful treatments and how they work. With this knowledge, a person with pain can be taught how they can actively change to free themselves from pain and any associated disability through learned movement and cognitive strategies.
What should pain education look like?
In 2004, Moseley and Nicholas published results of a new type of education for chronic back pain, changing the way all clinicians should approach teaching(4). It differed from the traditional approach of describing the biomedical spinal changes that occur with age and injury to education on the neurophysiology of pain. Specifically, the education discussed the pain pathway including involvement of nociceptors, peripheral nerves, the spinal cord, the brain and the role of neurotransmitters. It helps a person with pain develop an understanding that the body tissues have nociceptors that, in response to damage or the threat of damage, send a danger signal along peripheral nerves to the spinal cord, which then transmits this danger signal to the brain. The brain perceives this signal and ultimately makes a decision about whether this signal should be called pain. The brain has the ability to increase this danger signal at the level of the spinal cord (raise the threat level and make pain worse) if it thinks this is pain or block this signal at the spinal cord if there is no perceived threat, that is, there is no pain.
At the conclusion of their randomised controlled trial, people with low back pain, after being given this pain neurophysiology education, had changed beliefs regarding tissue damage and pain, had improved self-efficacy that they could manage their own condition, had improved lumbar flexion, and an improved straight leg raise with reduced levels of catastrophizing thoughts when compared to a group receiving the traditional biomedical education. There was no reduction in pain level immediately after this intervention.
In a double blinded randomised controlled trial in patients with fibromyalgia, pain neurophysiology education was provided to one group and activity self-management techniques were given to the other group (5). After 3 months, pain scores were lower in the pain neurophysiology group and people in this group also had improved physical functioning, improved general health and improved mental health.
So how does education in pain work?
Through a better understanding of the pain pathway, people with pain can learn how to change the way they think and feel about their pain. This has been termed reconceptualising pain. By changing their thoughts and feelings about pain, movements can improve, activity can improve and the pain can reduce.
In a prospective study in Australia, more active pain management strategies (both exercise and cognitive based strategies) were associated with reduced disability and health care costs when compared with passive strategies (6). And following participation in a chronic pain management program, patients with an improved sense of self-management of their pain also reported a reduction in pain, disability and depression (7).
Not everyone with pain will have poor health literacy but providing education about pain neurophysiology can lead to reduced pain, improved activity and improved mood. At the Rehabilitation Medicine Group, education is the first stage of successful treatment of not only people with chronic pain, but with any other conditions leading to reduced activity and a poorer quality of life.
1. Australian Bureau of Statistics. Health Literacy. 2009.
2. Wolf MS, Davis TC, Parker RM. Editorial: the emerging field of health literacy research. Am J Health Behav. 2007;31 Suppl 1:S3-5.
3. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163-96.
4. Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004;20(5):324-30.
5. Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal A, Lambrecht L, et al. Pain physiology education improves health status and endogenous pain inhibition in fibromyalgia: a double-blind randomized controlled trial. Clin J Pain. 2013;29(10):873-82.
6. Blyth FM, March LM, Nicholas MK, Cousins MJ. Self-management of chronic pain: a population-based study. Pain. 2005;113(3):285-92.
7. Nicholas MK, Asghari A, Corbett M, Smeets RJ, Wood BM, Overton S, et al. Is adherence to pain self-management strategies associated with improved pain, depression and disability in those with disabling chronic pain? European journal of pain. 2012;16(1):93-104.
- Dr Nathan Johns is a Rehabilitation Medicine Physician providing chronic pain and rehabilitation management at The Rehabilitation Medicine Group in Moorabbin, Victoria, Australia. These thoughts are his own and there are no conflicts of interest to report.