Patient Education in Pain Management

Welcome to PPA Pain Project. This page is being developed by participants of a project to populate the Pain section of Physiopedia.  The project is supervised and co-ordinated by the The Physiotherapy Pain Association.

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Original Editor - Sheik Abdul Khadir

Top Contributors - Mike Stewart, Sheik Abdul Khadir, Cecile HoSang, Jo Etherton, Kim Jackson, Michelle Lee, Admin, Yigit Unalan, 127.0.0.1, Claire Campbell, Simisola Ajeyalemi, Lauren Lopez and Jess Bell  

Introduction

Pain is a complex, multi-faceted perceptual experience that demands an explanation. As a sufferer, an inability to make sense of the often worrying and persisting uncertainties of pain, forces many to retreat from life’s pleasures. As a clinician, it is therefore vital to ensure a collaborative facilitation of meaning in those who live with pain. Educational skills are merely assumed in both practice & research.  In many disciplines, pain education accounts for less than 1% of undergraduate programme hours within the United Kingdom. 

Patient education has been defined as, "any set of planned activities designed to improve a patient's helath behaviours, health status of both."  These activities aim to facilitate the patient's knowledge base in order to help them make sense of their pain and guide them towards effective, ongoing self-management.

To facilitate an understanding of pain’s complexities and the importance of self-determined, sustained self-management, we must first develop facilitatory skills.  Facilitation can be defined as, “A technique by whichone person makes something easier for others.” . Helping & enabling are central to meaningful facilitation. Yet, the desire for practice-based educators to ensure efficient and effective learning “often leads to concentration on what they are doing rather than what the learner is doing.”  The following image shows a summary of different methods of pain education that are used by healthcare professionals and their advantages and disadvantages:

Delivery Method	Advantages	Disadvantages
Verbal 1:1  Moseley (2005)	Patient centred Questions answered	Expense Time consuming Limited recall
Audiovisual DVD Oliveira (2006)	Cheap Mass production	Impersonal Limited engagement
Booklets/Pamphlets  Burton et al., (2007)	Mass education  Cheap	Boring  Low compliance
	May change behaviours  Mass communication	Expensive  Generalisation
Email Lorig (2002)	Quick Personal	Tech limitations Spam issues
Internet Morr (2010)	Easy, free Interactive	Tech limitations Competing for attention
Joint Models Louw et al., (2012)	Visual  Realistic	Biomedical  Fear/threat nocebo inducing

. Even though patient education has been viewed and practised as a preventive strategy majorly, it includes all the information about the disease/disorder/condition the patient is concerned with. Education is a vital part of any physiotherapy rehabilitation; a process which requires the acquisition of new knowledge and skills. This requires the ability to concentrate, undertsand and process information. The information must also be retained, retrieved, integrated and used in a meaningful way." 

When including patient education as part of a pain management programme, there are certain topics which should be covered to address the areas patients often have concerns or misunderstandings about. These topics include: the anatomy and physiology of the affected part(s), the multi-faceted nature of chronic pain, the difference between acute and chronic pain, triggers and flare up management, fear avoidance and pacing, the role of exercise, the role of physiotherapy and other treatments/interventions, realistic expectations about a diagnosis and cure, and goal setting.  

Factors which will affect patient education include physiological, psychological, sociocultural and environmental. In Pain Management, the patient has to understand exactly what's happening to him/her in order to reconceptualise their pain experience. Pain is, "A multiple system output activitated by the brain based on perceived threat." . Therapeutic neuroscience education (TNE) therefore aims to help people make sense of their pain and reconceptualise their understanding of the outdated and unhelpful societial view of pain being lniked to harm or damage. For example, many patients believe that degeneration is a disease and needs to be cured. The primary goal of patient education should be to make the patient understand that degeneration is not a disease but a normal aging process and has to be treated with that view. 

Need

Cost containment studies show that educating patients results in significant savings. Educated patients maintain better health and have fewer complications; as a result, they require fewer hospitalizations, emergency department visits, and clinic and physician visits.  As the growth of health care continues to outpace inflation in many countries around the world, health policy makers have increasingly focused their attention on cost containment. Managed care has a major focus on reducing the supply of services. There is increasing attention to lowering health care costs through primary prevention efforts.</span>There is evidence to support patient education not just in general pain management but in specific pain conditions. A meta-analysis of patient education for migraine sufferers showed that education led to decreased disability, increased quality of life, and decreased frequency of migraine in the intermediate term.  For neck pain and whiplash disorders structured patient education has some benefit (albeit small) when combined with physiotherapy. 

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When considering the need for patient-centred care, it is essential that we ask a fundemental question when educating people about pain: What do patients want? In a recent met-analysis, Yelland (2011) discovered that patients are seeking the following:

• Pain relief
• Functional improvement (work return)
• Acquired knowledge
• Believed/Listened to (social legitimisation)
• Accurate diagnosis (clearly & confidently explained)
• A positive shift in attitude
  

In addition, Gifford (2014) suggests that people in pain want to know five things:

1. What's wrong with me?
2. How long is it going to take to get better?
3. Is there anything I can do to help myself?
4. Is there anything that you can do to help me?
5. How much will it cost?
   

Therapeutic neuroscience education (TNE) should aim to address all of the above factors by facilitating a meaningful understanding of the contemporary evidence base related to pain neuroscience. This must be delivered with empathy and compassion for the person's lived pain experience.

However, despite our desire for patient centred care, Eccleston & Crombez (2007) argue that the delivery of contemporary helathcare all too often fails to live up to the needs of people in pain.  Rather than facilitating a helpful reframing of pain, which guides patients towards acceptance and self-efficacy, Eccleston & Crombez (2007) highlight the repeated and escalating perseverance loop of short-term, problem solving behaviours that many patients continue to experience. "Pain is an ideal habitat for worry to flourish." (Eccleston & Crombez, 2007). Unfortuantely, without an adequate and meaningful understanding of pain, many patient's worries continue to grow.      

Factors affecting Patient Education 

1. Inadequate assessment of pain. Assessment of the patient's symptoms should be person centred and should follow the biopsychosocial approach.  In order to effectively assess pain and begin managing and educating patients, it is essential for clinicians to relinquish some of their "authority" and empower the patient to become engaged and proactive.
   

1. Inadequate understanding of how patient perceives his/her pain. Understanding what a patient believes about the causes or consequences of pain will allow the clinician to better inform the patient and correct any misinformation. However clinicians must approach these conversations with respect in order to earn the patient's trust. Examples of perceptions of pain common among cancer patients include: a fear of addiction to medications, concerns about side effects, discussing pain will distract the doctor from curing the disease, pain is an indication of the progress of the disease.  
   
2. Variations/ differences in the information received. { For example, a patient with knee pain is confused whether to do or avoid activities like cycling and walking due to the differences in the information provided even among health care providers}. Education and pain management will be less successful if information varies among clinicians, and if the care pathway is disjointed with poor communication among team members. There is no clear consensus on the ideal mode, personnel, intensity, or content of delivery. Content of patient education should address aspects of the condition that the patient may have little knowledge about. Some of these aspects will include: decreased understanding of the various therapies, poor understanding of the disease and the  consequences of poor compliance, poor understanding of clinic visits, and poor understanding of medication dosage/regimens. 
3. Life style
4. Cultural barriers. The format and content of patient education material should be appropriate and culturally sensitive for the target audience; with consideration for language, beliefs, experiences and values. Factors such as literacy, age group, and socio-economic status will impact on how well patients will learn from the materials provided. If patients do not understand the information provided then they will nto be able to self-care effectively. 

Requirement 

The following are important in patient education for pain management:

1. Recognise the impact of, and evidence for, the use of therapeutic neuroscience education and self-management as a critical part of pain management.
2. Design and apply appropriate educational strategies based on educational science.
3. Identify the range of educational opportunities available across therapeutic domains (eg, injury, disease, medical and post surgical intervention) with consideration of age, culture and gender.
4. Consider the scope and evidence for/against various contemporary therapeutic educational styles (e.g. biomedical, psychological, neuroscience) and models (e.g stages of change theory) and service delivery modes including face to face, web-based, group education.
5. Identify key variables which may impact on knowledge outcomes for the patient (eg self efficacy, health literacy, co-morbidities, culture), the clinician (eg health professional's pain-related beliefs), the message (e.g. use of multimedia), and the context (e.g. insurance limitations; risk reduction; injury prevention)

Boon Or Bane

It is to be emphsized that sometimes the patient education may prove otherwise. The role of health-care providers is changing quickly, from making decisions for the patients to providing assistance to them in making informed decisions.
Patients are becoming increasingly educated about health related issues, thanks to the World Wide Web. There are patients patients who do not hesitate to argue over complex medical issues without having much knowledge about the same. 

Beware

Patients who have in-depth knowledge of their condition encounter problems when their expertise is seen as inappropriate in standard healthcare interactions, and expertise taught to patients in one branch of medicine can be considered non-compliant by those who are not specialists in that field.Although patient education can give people confidence in their own self-management skills, it cannot solve the power imbalance that remains when a generalist healthcare professional, however well meaning, blocks access to medication and supplies needed to manage chronic diseases successfully. There is a role for those involved in primary and hospital care, including those supporting and training healthcare professionals, to recognise these problems and find ways to acknowledge and respect chronic patients’ biomedical and practical expertise. 

Recent Related Research (from Pubmed)


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