Why might fears and worries persist after a pain education-grounded multimodal intervention

Key points

1. 01Some participants felt the pain education message implied their pain was 'not real' or 'all in their head,' which undermined trust and limited benefit
2. 02Most participants accepted that the nervous system plays a role in pain but rarely stopped believing structural or physical factors were also contributing
3. 03Participants who could not translate pain education concepts into daily routines were more likely to retain fears and worries about future pain
4. 04A trusting clinician-patient relationship and active listening were key to reducing feelings of invalidation
5. 05Social environment mattered: opposing messages from family, friends, and other health professionals made it harder to maintain a nervous-system understanding of pain

How it was conducted

Design

Qualitative study using semi-structured telephone interviews with reflexive thematic analysis (inductive approach)

Parent trial

RESOLVE RCT - graded sensorimotor retraining with individualised pain education versus sham, conducted in Sydney, Australia, 2016-2019

Participants

20 adults with nonspecific chronic low back pain (pain lasting more than 3 months) who completed the active arm of the RESOLVE trial

Intervention

12-week individualised pain-education-grounded multimodal program: sessions 1-2 pain education only; sessions 3-12 pain education integrated with sensory precision training, mental rehearsal, and graded movement

Sampling

Purposive sampling for diversity in age, sex, and pain characteristics; balanced by pain reduction outcome (at least 30% vs. less than 30% on 0-10 NRS at 18 weeks)

Interview timing

Interviews conducted 1.1 to 2.5 years after participants' first program session

What they found

• 20 participants were interviewed: 9 women (45%) and 11 men (55%), median age and pain duration not fully legible in text but median pain duration ranged from 0.5 to 23.0 years
• 13 of 20 participants (65%) reported at least 30% pain reduction on the 0-10 NRS at the 18-week follow-up
• Three themes were identified from the data: (1) perception that pain was being invalidated, (2) persistent belief in structural or biomechanical causes alongside nervous system explanations, and (3) difficulty applying pain education to daily life
• Participants who reported feelings of invalidation also tended to show limited change in pain intensity and perceived recovery
• Participants who could describe applying PE concepts to daily routines reported reduced worry about pain consequences; those who could not lacked self-efficacy and reported forgetting content after the program ended

Limitations

• Single time-point interviews conducted 1 to 2.5 years after the intervention, requiring retrospective recall which may introduce memory bias
• No people with lived experience of chronic low back pain were included in the research team or data analysis
• Sample drawn from a single-centre Australian trial; findings may not transfer to people from diverse cultural and linguistic backgrounds or primary care settings
• Pain education is constantly evolving and findings cannot be generalised to all types of pain-education-grounded interventions

Why it matters

For patients

If you have done a pain education program and still feel worried about your back, it may help to tell your clinician, since unaddressed fears about pain being 'not real' or structural concerns being dismissed are common and can be worked through with better communication.

For clinicians

Monitoring patients for feelings of invalidation, residual biomedical beliefs, and low self-efficacy in applying pain education concepts can guide targeted communication strategies and booster sessions to sustain long-term gains.

For readers

This study highlights that the fading benefits of pain education seen in trials may reflect specific, addressable patient experiences rather than a fundamental failure of the approach, pointing to refinements in delivery rather than abandonment of pain education.