Scand J Pain 2018; aop
Clinical pain research
Manasi M. Mittinty*, Simon Vanlint, Nigel Stocks, Murthy N. Mittinty and G. Lorimer Moseley
Exploring effect of pain education on chronic
pain patients’ expectation of recovery and pain
intensity
https://doi.org/10.1515/sjpain-2018-0023
Received January 24, 2018; revised February 18, 2018; accepted
­February 24, 2018
Abstract
Background and aims: Chronic pain affects an estimated
1 in 10 adults globally regardless of age, gender, ethnic-
ity, income or geography. Chronic pain, a multifactorial
problem requires multiple interventions. One intervention
which demonstrates promising results to patient reported
outcomes is pain education. However, patient perspective
on pain education and its impact remains fairly unknown.
A cross-sectional study involving individuals with chronic
pain examined their perspectives on pain education; did
it change their understanding about their pain and self-
management and did it have any impact on their perceived
pain intensity and recovery.
Methods: The study complied with CHERRIES guide-
lines and the protocol was locked prior to data collection.
Primary outcomes were pain intensity and participants’
expectation of recovery. Univariate and multiple logistic
regressions were used to analyze the data.
Results: Five hundred and seventy three people partici-
pated; full data sets were available for 465. Participants
who observed changes in their pain cognition and self-
management following pain education reported lower
pain intensity and greater expectation of recovery than
participants who did not observe changes to cognition
and management.
*Corresponding author: Manasi M. Mittinty, Indigenous Oral Health
Unit, The University of Adelaide, Level 4, AHMS Building, 57 North
Terrace, Adelaide, SA 5006, Australia, Phone: +61 08 8313 1360,
E-mail: manasi.mittinty@adelaide.edu.au
Simon Vanlint and Nigel Stocks: Discipline of General Practice, The
University of Adelaide, Adelaide, SA, Australia
Murthy N. Mittinty: School of Public Health, University of Adelaide,
Adelaide, SA, Australia
G. Lorimer Moseley: Sansom Institute for Health Research,
University of South Australia, Adelaide, SA, Australia
© 2018 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.
Conclusions: The results suggest that individuals who
observed changes to pain cognition and self-management
on receiving pain education reported lower pain intensity
and higher expectations of recovery than their counter-
parts who did not perceive any changes to pain cognition
and self-management.
Implications: Pain intensity and expectations about
recovery are primary considerations for people in pain.
What influences these factors is not fully understood, but
education about pain is potentially important. The results
suggest that individuals who observed changes to pain
cognition and self-management on receiving pain educa-
tion reported lower pain intensity and higher expectations
of recovery than their counterparts who did not perceive
any changes to pain cognition and self-management. The
results from this study highlight the importance of effec-
tive pain education focused on reconceptualization of
pain and its management.
Keywords: chronic pain; pain education; pain cogni-
tion; self-management of pain; pain intensity; perceived
recovery.
1 Introduction
Persistent pain is a major global health problem [1], ranked
as one of the leading causes for medical visits [2–4].
Defined as pain on most days for more than 3 months [5],
persistent pain affects people regardless of age, gender,
ethnicity, income or geography. Present understanding of
pain stipulates that it is a complex, multi-factorial condi-
tion usually triggered by tissue injury. However, nocicep-
tion – the detection and transmission of a rapid change in
tissue state – is neither sufficient nor necessary for pain
[6]. Contemporary concepts emphasize biopsychosocial
principles [6] for better understanding, assessment, pre-
vention and management of persistent pain.
Progress in our understanding of pain has led to a fun-
damental shift in management approaches. Pain biology
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2      Mittinty et al.: Exploring effect of pain education on chronic pain patients’ expectation of recovery
education which emerged about 15 years ago [7] is now rec-
ognized as part of best practice [8]. Pain education aims
to give patients an overview of the underlying physiologi-
cal mechanisms and adaptive processes which support
persistent pain, such that pain becomes ‘over-protective’
[9, 10]. Reconceptualization of pain in this fashion shows
clinically important improvements [11] with increased par-
ticipation from patients in active biopsychosocial based
rehabilitation [12]. Explaining pain seems to have similar
positive effects across painful conditions, for example
fibromyalgia [13, 14], neck pain [15], chronic fatigue syn-
drome [16], and chronic low back pain [17, 18].
However, one issue that remains to be investigated is
the patients’ perspective on the impact of pain education.
Although empirical data shows that learning about pain
biology improves pain and enhances the likelihood of
recovery from persistent pain [12], whether or not patients
see value in pain education, and whether or not perceiv-
ing that value is associated with pain and expectations of
recovery, remains unknown. It is an important question
because it is the patient’s perspective that will best inform
their future responses to painful events and the advice
they give to others – an important method of knowledge
transfer [19].
The current study investigated these issues using an
online cross-sectional design. We aimed to determine if
participants believed that pain education had changed
their views on their pain (hereafter referred to as pain cog-
nition) and had changed the way they managed their pain
(hereafter referred to as self-management of pain), and
whether or not these perceptions were associated with
their expectations of recovery and their current usual pain
intensity.
2 Methods
2.1 D
 esign and participants
A cross sectional online survey design was used to collect
data on two critical aspects of chronic pain, use of supple-
ment intake [20] and pain education. The survey question-
naire was developed according to a review of the literature
and was built in accordance with the Checklist for Report-
ing Results of Internet E-Surveys (CHERRIES) [21]. The
study protocol and questionnaire was published in The
Journal of Pain Research [22], prior to data collection. Con-
sistent with guidelines for transparency in research [23],
any deviations from the published protocol are noted. In
addition to demographic data, the survey investigated
participants’ daily pain management strategies, their
expectation of recovery and their perspectives on the
value of pain education, if they had received it. All partici-
pants provided digital consent prior to prior to participat-
ing in the survey. The study was approved by the Human
Research Ethics Committees of the University of Adelaide
and the University of South Australia.
All participants were individuals who could read and
understand English, were aged 18 years and above, and at
the time of participation, had experienced pain on most
days for more than three consecutive months. There was
no limitation on gender, ethnicity or country of residence.
2.2 Measures
2.2.1 Dependent variables
The primary outcomes used in this study were; patient-
perceived pain intensity and patient-perceived time to
recovery. Information on pain intensity was collected from
the participants using the question, “what is the average
severity of your pain in the last 2  days?” Participants
were asked to complete a numerical rating scale (NRS),
anchored at left with “0 – no pain” and at right with “10
– worst pain”. Participants were also asked, “how long do
you think it will take for you to recover from your current
pain problem?” where recovery was outlined as reduction
in pain severity and improved daily functioning. The pos-
sible responses were “3–6 months”, “up to 1 year”, “more
than 1 year” and “never”. In order to fulfill the require-
ments of logistic regression, and because we were primar-
ily interested in whether perspectives on the impact of
pain education would be associated with expecting recov-
ery rather than not expecting recovery, we analyzed recov-
ery as a dichotomous variable: those who responded with
“never” and those who chose one of the other responses.
Similarly, we dichotomized pain intensity over the last
2 days either side of the predicted median: ≤5 and ≥6. The
survey only allowed selection of whole numbers.
2.2.2 Independent variables
The independent/explanatory variables were: observed
change in views on their pain (referred to as pain cog-
nition) following pain education, observed change in
self-management of pain following pain education, and
demographic characteristics determined a priori to be
likely confounders: age, gender, education level, employ-
ment status, and marital status.
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 Mittinty et al.: Exploring effect of pain education on chronic pain patients’ expectation of recovery      3

Pain education was defined as, information patients
had received from their health care providers explaining
their pain and potential triggers such as lack of sleep,
inactivity, stress which may aggravate their pain and
symptoms. Participants were asked if they had received
pain education. If the response to this question was “yes”,
they were directed to these questions – “Did this educa-
tion change the way you think about your pain?” and “Did
this education change the way you manage your pain?”
Responses to both these questions were collected using
simple “yes”, “no” dichotomization.
2.3 D
 ata collection and analysis
Univariate and multiple logistic regression was computed
to estimate the odds of expected recovery among patients
who had reported observed change in pain cognition and
self-management of pain following pain education. The
likelihood ratio test was used to find the best predictors
of these relations. To compare the regression models and
maintain uniformity of sample size, “not applicable”
cases from all the covariates were removed. If change in
pain cognition and change in self-management demon-
strated collinearity, then separate regressions were under-
taken, as per protocol.
Basic univariate descriptive statistics was used to
characterize the sample for the proportion of the entire
cohort who had received pain education, those who had
observed change in pain cognition and change in self-
management of pain as a result of pain education, pain
intensity and expected recovery. Cross-tabulation was
used to describe pain intensity and expected recovery
in groups that were defined by age, gender, education
level, employment status, marital status, pain edu-
cation, change in pain cognition and change in self-
management of pain. All analysis was performed in
STATA.14.1.

Table 1: Patient-reported pain intensity by participants aged 18 years and above.

Variable   Age 18–40 years   Total   Age 41 + years   Total

   
Pain intensity ≥6   Pain intensity ≤5 Pain intensity ≥6   Pain intensity ≤5
   
   
No   % No   % No   % No   %

Sexa

 Female   100   59   70   41   170   149   64   84   36   233

 Male   12   46   14   54   26   18   51   17   49   35
Education levela
 Primary   26   60   17   40   43   32   64   18   36   50
 Others   86   56   67   44   153   134   62   83   38   217
Employment statusa
 Full time employed   36   58   26   42   62   47   64   27   36   74
 Unemployed/on   37   82   8   18   45   58   72   23   28   81
leave because of pain
 Part time employed   15   39   23   61   38   27   49   28   51   55
 Home duties   5   63   3   38   8   22   58   16   42   38
 Student   17   43   23   58   40   7   54   6   46   13
Marital statusa
 Married   34   52   31   48   65   88   58   63   42   151
 Single/unmarried   47   63   28   37   75   56   69   25   31   81
 Partnered   31   56   24   44   55   21   64   12   36   33
Pain education
 No   9   47   10   53   19   24   71   10   29   34
 Yes   103   58   74   42   177   144   61   91   39   235
Duration of pain
 <1 year   7   50   7   50   14   8   42   11   58   19
 >1 year   105   58   77   42   182   160   64   90   36   250
Change in self-management of pain
 No   41   56   32   44   73   84   74   29   26   113
 Yes   71   58   52   42   123   84   54   72   46   156
Change in pain cognition
 No   46   59   32   41   78   72   72   28   28   100
 Yes   66   56   52   44   118   96   57   73   43   169

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Table 2a: Unadjusted and adjusted odds ratios for patient reported recovery among individuals who observed changes to pain cognition
following pain education.

  Patient-reported recovery (category “recovery”)

 
Unadjusted   Adjusted
 
 
OR (95% CI)   p-Value OR (95% CI)   p-Value

Age
 18–40 years   1     1  
 +41 years   0.66 (0.47–1.04)   0.08   0.65 (0.42–1.03)   0.06
Gender
 Female   1     1  
 Male   2.04 (1.21–3.66)   0.00   2.04 (1.15–3.62)   0.01
Marital status
 Single/unmarried   0.74 (0.47–1.16)   0.20   0.72 (0.44–1.16)   0.18
 Partnered   0.92 (0.54–1.56)   0.76   0.85 (0.48–1.51)   0.59
Education level
 Primary   1     1  
 Others   1.22 (0.73–2.03)   0.43   1.21 (0.71–2.05)   0.47
Employment status
 Full time employed   1     1  
 Unemployed/leave because of pain  0.99 (0.59–1.67)   0.99   0.99 (0.57–1.71)   0.99
 Part time employed   0.98 (0.56–1.74)   0.97   0.92 (0.51–1.66)   0.79
 Home duties   0.83 (0.39–1.73)   0.62   0.99 (0.45–2.17)   0.98
 Student   1.27 (0.65–2.48)   0.46   1.30 (0.65–2.61)   0.45
Change in pain cognition
 Yes   2.06 (1.34–3.16)   0.00   2.11 (1.35–3.29)   0.00

Table 2b: Unadjusted and adjusted odds ratios for patient reported recovery among individuals who observed changes to self-management
of pain following pain education.

  Patient-reported recovery (“recover”)

 
Unadjusted   Adjusted
 
 
OR (95% CI)   p-Value OR (95% CI)   p-Value

Age
 18–40 years   1     1  
 +41 years   0.70 (0.47–1.04)   0.08   0.69 (0.45–1.08)   0.10
Gender
 Female   1     1  
 Male   2.11 (1.21–3.66)   0.00   2.24 (1.26–3.99)   0.00
Marital status
 Single/unmarried   0.74 (0.47–1.16)   0.20   0.71 (0.44–1.15)   0.17
 Partnered   0.92 (0.54–1.56)   0.76   0.84 (0.47–1.48)   0.56
Education level
 Primary   1     1  
 Others   1.22 (0.73–2.03)   0.43   1.21 (0.71–2.05)   0.47
Employment status
 Full time employed   1     1  
 Unemployed/leave because of pain  0.99 (0.59–1.67)   0.99   1.05 (0.61–1.80)   0.85
 Part time employed   0.98 (0.56–1.74)   0.97   1.03 (0.57–1.84)   0.91
 Home duties   0.83 (0.39–1.73)   0.62   0.94 (0.43–2.06)   0.88
 Student   1.27 (0.65–2.48)   0.46   1.33 (0.66–2.67)   0.41
Change in self-management of pain
 Yes   2.06 (1.34–3.16)   0.00   2.00 (1.30–3.08)   0.00

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 Mittinty et al.: Exploring effect of pain education on chronic pain patients’ expectation of recovery      5

3 Results 3.1 Patient expected recovery

There were no deviations from the published protocol [22].
Responses were received from 573 participants. Full data
sets were available from 465, of which 412 participants
(91%) had participated in pain education (Table 1), which
meant statistical comparison based on this variable was
not possible. The mean (SD) pain intensity for the entire
cohort was 5.8 (2). Two hundred and eighty-seven of partic-
ipants reported that pain education had led to a change in
the way they think about their pain. Two hundred and sev-
enty-nine reported that pain education had led to a change
in the way they manage their pain. In the logistic/simple
linear regression, the effect estimates of the outcome con-
founder relation were adjusted for age, gender, education
level, employment status and marital status.
Table 2a shows the unadjusted and adjusted ORs obtained
from univariate and multinomial logistic regression anal-
ysis stratified into two age groups, including the best
predictors of expected recovery. Those who observed a
change in pain cognition as a result of pain education were
more likely to expect to recover than those who reported
no change in pain cognitions as a result (unadjusted
OR = 2.06; 95% CI = 1.34–3.16). Males were more likely than
females to expect to recover (unadjusted OR = 2.04; 95%
CI = 1.21–3.66). Adjusted ORs were similar (Table 2a).
Ninety-seven percent (97%) of those who had partici-
pated in pain education reported observing a change in
their self-management strategies as a result. Those who
observed a change in self-management strategies were

Table 3: Patient-reported recovery according to age among participants with chronic pain aged 18 years and above.

Variable   Age 18–40 years   Total   Age 41 + years   Total

   
PRR (no)   PRR (yes) PPR (no)   PRR (yes)
   
   
No   % No   % No   % No   %

Sexa
 Female   110   65   60   35   170   170   73   63   27   233
 Male   14   54   12   46   26   18   51   17   49   35
Educationa
 Primary   25   58   18   42   43   41   82   9   18   50
 Others   99   65   54   35   153   147   68   70   32   217
Employment statusa
 Full time employed   44   71   18   29   62   47   64   27   36   74
 Unemployed/on leave because of pain  25   56   20   44   45   60   74   21   26   81
 Part time employed   21   55   17   45   38   41   75   14   25   54
 Home duties   6   75   2   25   8   26   68   12   32   38
 Student/unemployed   25   63   15   38   40   8   62   5   38   13
Marital statusa
 Married   39   60   26   40   65   100   66   51   34   151
 Single/unmarried   47   63   28   37   75   65   80   16   20   81
 Partnered   37   67   18   33   55   22   67   11   33   33
Pain education
 No   14   74   5   26   19   22   65   12   35   34
 Yes   110   62   67   38   177   167   71   68   29   235
Patient-provider relationship
 Not good   48   64   27   36   75   76   71   31   29   107
 Good   76   63   45   37    121   113   65   49   35   162
Duration of pain
 <1 year   4   29   10   71   14   2   11   17   89   19
 >1 year   120   66   62   34   182   187   75   63   25   250
Change in pain management
 No   54   74   19   26   73   86   76   27   24   113
 Yes   70   57   53   43   123   103   66   53   34   156
Change in pain cognition
 No   58   74   20   26   78   78   78   22   22   100
 Yes   66   56   52   44   118   111   66   58   34   169

Unknown category totals not shown based on ≤5 cases; PRR = patient-provider relationship.

a

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6      Mittinty et al.: Exploring effect of pain education on chronic pain patients’ expectation of recovery
more likely to expect to recover than those who did not
observe a change (unadjusted OR = 2.06; 95% CI, 1.34–
3.16) (Table 2b).
Table 3 shows a more comprehensive account of the
univariate logistic regression analysis stratified by age
(18–40 years; 41 +  years). Younger participants were more
likely to expect recovery (~37% = 72/196) than older partic-
ipants (~30% = 80/269). Being married, or having attained
a higher level of formal education, were associated with
expecting to recover.
3.2 P
 rimary outcome: current pain intensity
Table 4a shows the unadjusted and adjusted ORs obtained
from univariate and multinomial logistic regression anal-
ysis stratified into two age groups, including the best pre-
dictors of perceived pain intensity. Subgroup analysis of
participants who observed change in pain cognition as
a result of pain education showed lower pain intensity
scores 5.7 (2) than those who reported no change.
Individuals who reported observing a change in
self-management strategies as a result of pain education
(subgroup analysis) reported less pain intensity 5.6 (2)
than/as those who reported no change. Adjusted OR for
participants who observed change in their pain cognition
as a result of pain education was 1.53 (95% CI, 1.01–2.33)
(Table 4a). The adjusted association between pain inten-
sity and observed change in self-management of pain
increased (adjusted OR, 1.69; CI, 1.12–2.56), suggesting that
participants who observed change in self-management of
pain following pain education were more likely to report
less pain than participants who observed no change in
their self-management of pain. Pain intensity was also
affected by sex, age, duration of pain, employment status
especially home duties, which may be attributed to higher
female participation. The full regression data shown in
Table 4b.
4 Discussion
The aim of this study was to determine if participants
believed that pain education had changed their views
on their pain (pain cognition) and had changed the way
they self-managed their pain. We also wanted to deter-
mine whether or not these perceptions were associated
with their expectations of recovery and their perceived
pain intensity. Our main finding is that those who report a
shift in their pain cognition or self-management strategies
after participating in pain education have lower perceived
pain and higher expectations of recovery than those who
do not observe these shifts. Pain intensity and expected
recovery are also affected by a range of demographic and
other variables, but accounting for those variables in the
statistical model does not conceal the effect.
Expectations about recovery are often investigated in
acute or subacute pain populations [24, 25], and in pre-sur-
gical groups [26, 27], but not in chronic pain patients. Our
findings are consistent with available literature insofar as
younger participants have higher expectations of recovery
than older ones. This may be because older people are
more likely to suffer from multiple chronic conditions [28]
and, arguably, may have lower self-efficacy when it comes
to exercise and movement-based rehabilitation. In addi-
tion, home duties affected changes in self-management
of pain, which may also contribute to the male/female
differences.
It is notable that 40% of those who had participated
in pain education reported that it did not change their
pain cognition or self-management strategies. This rather
concerning failure rate might reflect, in part, patients
who already have a contemporary understanding of pain
when they present for care, although the available data
would suggest otherwise [11]. It might also be more likely
to reflect the lack of information on variables that can
influence any educational intervention, for example the
message, the context and number of sessions, which were
not collected.
Of the confounding variables, we identified a priori
and entered into the statistical models, marital status,
education level and employment status showed no asso-
ciation with “recovery”. This is in line with the literature,
which shows similar findings [29].
4.1 Limitations
This was a pragmatic study, in which data were col-
lected from individuals experiencing chronic pain in
the real-world, designed to answer specific questions;
we did not seek to fully characterize the subtle relation-
ships between different variables and we did not seek to
determine the impact of other important variables – for
example the number, type and context of education ses-
sions, type of diagnosis, comorbidities and treatments
received. To investigate these issues would have required
a much larger sample and would have exerted a partici-
pant burden that pilot testing taught us would be unac-
ceptable. Any online survey is associated with a lack of
control over who participates and how they participate.
People self-select and we have no way of verifying the
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 Mittinty et al.: Exploring effect of pain education on chronic pain patients’ expectation of recovery      7

Table 4a: Unadjusted and adjusted odds ratios for pain intensity among individuals who observed changes to pain cognition following pain
education.

  Pain intensity
 
Unadjusted   Adjusted
 
 
OR (95% CI)   p-Value OR (95% CI)   p-Value

Age
 18–40 years   1     1  
 +41 years   0.84 (0.57–1.23)   0.38   0.90 (0.58–1.38)   0.63
Gender
 Male   1.69 (0.98–2.92)   0.05   2.02 (1.12–3.61)   0.01
 Female   1     1  
Marital status
 Married   1     1  
 Single/unmarried   0.68 (0.44–1.05)   0.08   0.73 (0.46–1.17)   0.19
 Partnered   0.87 (0.52–1.44)   0.59   0.84 (0.48–1.46)   0.55
Education level
 Primary   1     1  
 Others   1.09 (0.67–1.76)   0.70   0.93 (0.56–1.55)   0.80
Employment status
 Full time employment   1     1  
 Unemployed/leave because of pain  0.50 (0.29–0.85)   0.01   0.47 (0.27–0.82)   0.00
 Part time employed   1.81 (1.06–3.11)   0.02   1.78 (1.02–3.10)   0.04
 Home duties   1.11 (0.56–2.21)   0.75   1.17 (0.56–2.41)   0.67
 Student   1.78 (0.93–3.40)   0.07   1.95 (0.99–3.81)   0.05
Change in pain cognition
 Yes   1.53 (1.03–2.27)   0.03   1.53 (1.01–2.33)   0.04

Table 4b: Unadjusted and adjusted odds ratios for pain intensity among individuals who observed changes to self-management of pain
following pain education.

  Pain intensity
 
Unadjusted   Adjusted
 
 
OR (95% CI)   p-Value OR (95% CI)   p-Value

Age
 18–40 years   1     1  
 +41 years   0.84 (0.57–1.23)   0.38   0.93 (0.60–1.43)   0.74
Gender
 Male   1.69 (0.98–2.92)   0.05   2.17 (1.21–3.89)   0.00
 Female   1     1  
Marital status
 Married   1     1  
 Single/unmarried   0.68 (0.44–1.05)   0.08   0.73 (0.45–1.16)   0.18
 Partnered   0.87 (0.52–1.44)   0.59   0.83 (0.48–1.45)   0.53
Education level
 Primary   1     1  
 Others   1.09 (0.67–1.76)   0.70   0.93 (0.55–1.55)   0.79
Employment status
 Full time employment   1     1  
 Unemployed/leave because of pain  0.50 (0.29–0.85)   0.01   0.48 (0.28–0.84)   0.01
 Part time employed   1.81 (1.06–3.11)   0.02   1.89 (1.09–3.28)   0.02
 Home duties   1.11 (0.56–2.21)   0.75   1.13 (0.54–2.34)   0.73
 Student   1.78 (0.93–3.40)   0.07   2.00 (1.02–3.92)   0.04
Change in self-management of pain
 Yes   1.53 (1.03–2.27)   0.03   1.69 (1.12–2.56)   0.01

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8      Mittinty et al.: Exploring effect of pain education on chronic pain patients’ expectation of recovery
authenticity of responses, clarifying their responses, or
preventing individuals completing the survey twice on
different devices. Our approach will also have excluded
potential participants who have no internet access. Our
recruitment strategy depended on circulation of the
survey link via consumer organizations and clinician fol-
lowers of professional development websites. This means
that we would not have recruited those patients not
involved with such organizations or with clinicians who
are engaged with the professional development websites
we used. Considering that many people with persistent
pain do not fully engage with the community, the reader
must consider the limited extent to which our sample
was representative of the persistent pain population. Our
design does not allow causal conclusions about effects of
one variable on another, nor the time course of effects.
The current study also had strengths. For example, our
survey design was consistent with recommended proto-
cols; we published the full survey protocol prior to data
collection; we identified important potential confounders
a priori and controlled for them in our analysis; we calcu-
lated required sample size prior to commencement and
our sample exceeded the required sample size; the distri-
bution of our independent and confounder variables was
broadly reflective of the wider population, reducing the
risk of selection bias on these variables.
5 Conclusions
Findings, from this patient-reported, internet survey
suggest that pain education induced change in pain cog-
nition and self-management of pain can influence pain
intensity and recovery in chronic pain patients. These
findings are important as several studies [30–32] have
documented that although pain education helps to alter
patients’ knowledge about pain this effect can be lost over
time, producing no long-term benefits [33] and repetition
of pain education session [34] may allow consolidation
of the information. Our study findings show that patients
reporting change in both their pain cognition and self-
management of pain on receiving pain education were
more likely to report not only lower pain intensity scores
but were also more likely to have an optimistic view about
recovery. These findings are pertinent for future practice
and research, as they give a new direction for employ-
ing pain education. Future strategies should be directed
towards enhancing cognizance and management of pain
at an individual level. One limitation of this study is the
responses are patient-perceived hence could be affected
by measurement/misclassification error which is not
taken into consideration for the analysis, it is for this
reason the results must be interpreted cautiously.
Acknowledgements: The authors would like to thank all
the individuals who participated in our study and the
organizations and societies who promoted our survey on
their websites.
Authors’ statements
Research funding: M. N. Mittinty is funded by John
Lynch’s NHMRC Australian Fellow funding (ID 478115).
G.  L. Moseley has received support from Pfizer, Kaiser
Permanente, USA; Workers’ Compensation Boards in
Australia, North America, and Europe; Agile Physi-
otherapy, USA; Results Physiotherapy, USA; the Interna-
tional Olympic Committee and the Port Adelaide Football
Club, Australia. G. L. Moseley is supported by a Princi-
pal Research Fellowship from the National Health and
Medical Research Council of Australia.
Conflict of interest: G. L. Moseley receives royalties for
books on pain and rehabilitation, including two books
that are cited in this article. He receives speaker fees for
lectures on pain and rehabilitation. All the authors declare
that they have no conflict of interest.
Informed consent: Informed consent was required and
collected digitally from all participants.
Ethical approval: The study was approved by the Human
Research Ethics Committee, The University of Adelaide,
and University of South Australia, Australia.
References
[1] Goldberg DS, McGee SJ. Pain as a global public health priority.
BMC Public Health 2011;11:770.
[2] Sauver JL, Warner DO, Yawn BP, Jacobson DJ, McGree ME, Pank-
ratz JJ, Melton LJ, Roger VL, Ebbert JO, Rocca WA. Why patients
visit their doctors: assessing the most prevalent conditions in a
defined American population. Mayo Clin Proc 2013;88:56–67.
[3] Deyo RA, Mirza SK, Turner JA, Martin BI. Overtreating
chronic back pain: time to back off? J Am Board Fam Pract
2009;22:62–8.
[4] Mäntyselkä P, Kumpusalo E, Ahonen R, Kumpusalo A, Kau-
hanen J, Viinamäki H, Halonen P, Takala J. Pain as a reason to
visit the doctor: a study in Finnish primary health care. Pain
2001;89:175–80.
[5] Treede RD, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R,
Cohen M, Evers S, Finnerup NB, First MB, Giamberardino MA.
A classification of chronic pain for ICD-11. Pain 2015;156:1003.
[6] Engel GL. The need for a new medical model: a challenge for
biomedicine. Science 1977;196:129–36.
[7] Moseley GL, Butler DS. Fifteen years of explaining pain: the
past, present, and future. J Pain 2015;16:807–13.
[8] Maher C, Underwood M, Buchbinder R. Non-specific low back
pain. Lancet 2017;389:736–47.
Brought to you by | provisional account
Unauthenticated
Download Date | 3/19/18 1:03 AM
 Mittinty et al.: Exploring effect of pain education on chronic pain patients’ expectation of recovery      9
[9] Moseley GL, Vlaeyen JW. Beyond nociception: the imprecision
hypothesis of chronic pain. Pain 2015;156:35–8.
[10] Lee H, Hübscher M, Moseley GL, Kamper SJ, Traeger AC,
Mansell G, McAuley JH. How does pain lead to disability? A
systematic review and meta-analysis of mediation studies in
people with back and neck pain. Pain 2015;156:988–97.
[11] Louw A, Zimney K, Puentedura EJ, Diener I. The efficacy of pain
neuroscience education on musculoskeletal pain: a systematic
review of the literature. Physiother Theory Pract 2016;32:332–
55.
[12] Pires D, Costa D, Martins I, Cruz E. A pain neuroscience educa-
tion program for fibromyalgia patients with cognitive deficits: a
case series. Man Ther 2016;25:e110–1.
[13] Van Oosterwijck J, Meeus M, Paul L, De Schryver M, Pascal
A, Lambrecht L, Nijs J. Pain physiology education improves
health status and endogenous pain inhibition in fibromyal-
gia: a double-blind randomized controlled trial. Clin J Pain
2013;29:873–82.
[14] Yu L, Norton S, Almarzooqi S, McCracken LM. Preliminary
investigation of self-as-context in people with fibromyalgia. Br
J Pain 2017;11:134–43.
[15] Van Oosterwijck J, Nijs J, Meeus M, Truijen S, Craps J, Van den
Keybus N, Paul L. Pain neurophysiology education improves
cognitions, pain thresholds, and movement performance in
people with chronic whiplash: a pilot study. J Rehabil Res Dev
2011;48:43–58.
[16] Meeus M, Nijs J, Van Oosterwijck J, Van Alsenoy V, Truijen S.
Pain physiology education improves pain beliefs in patients
with chronic fatigue syndrome compared with pacing and self-
management education: a double-blind randomized controlled
trial. Arch Phys Med Rehabil 2010;91:1153–9.
[17] Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW,
Guzman J, van Tulder MW. Multidisciplinary biopsychosocial
rehabilitation for chronic low back pain: Cochrane systematic
review and meta-analysis. Br Med J 2015;350:h444.
[18] Ryan CG, Gray HG, Newton M, Granat MH. Pain biology educa-
tion and exercise classes compared to pain biology educa-
tion alone for individuals with chronic low back pain: a pilot
randomised controlled trial. Man Ther 2010;15:382–7.
[19] Moseley GL. Evidence for a direct relationship between cogni-
tive and physical change during an education intervention in
people with chronic low back pain. Eur J Pain 2004;8:39–45.
[20] Gaikwad M, Vanlint S, Moseley GL, Mittinty MN, Stocks N.
Factors associated with vitamin d testing, deficiency, intake,
and supplementation in patients with chronic pain. J Diet Suppl
2017:1–3.
[21] Eysenbach G. Improving the quality of Web surveys: the Check-
list for Reporting Results of Internet E-Surveys (CHERRIES). J
Med Internet Res 2004;6:e34.
[22] Gaikwad M, Vanlint S, Moseley GL, Mittinty MN, Stocks N.
Understanding patient perspectives on management of their
chronic pain–online survey protocol. J Pain Res 2017;10:31.
[23] Ohtake PJ, Childs JD. Why publish study protocols? Phys Ther
2014;94:1208–9.
[24] Perrot S, Allaert FA, Concas V, Laroche F. “When will I recover?”
A national survey on patients’ and physicians’ expectations
concerning the recovery time for acute back pain. Eur Spine J
2009;18:419.
[25] Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming
RG, Bleasel J, York J, Das A, McAuley JH. Prognosis in patients
with recent onset low back pain in Australian primary care:
inception cohort study. Br Med J 2008;337:a171.
[26] Auer CJ, Glombiewski JA, Doering BK, Winkler A, Laferton JA,
Broadbent E, Rief W. Patients’ expectations predict
surgery outcomes: a meta-analysis. Int J Behav Med
2016;23:49–62.
[27] Rief W, Shedden-Mora MC, Laferton JA, Auer C, Petrie KJ, Salz-
mann S, Schedlowski M, Moosdorf R. Preoperative optimiza-
tion of patient expectations improves long-term outcome in
heart surgery patients: results of the randomized controlled
PSY-HEART trial. BMC Med 2017;15:4.
[28] Morone NE, Greco CM. Mind–body interventions for
chronic pain in older adults: a structured review. Pain Med
2007;8:359–75.
[29] Jones CA, Suarez-Almazor ME. Patient expectations and total
knee arthroplasty. JCOM 2017;24.
[30] Holliday SM, Hayes C, Dunlop AJ, Morgan S, Tapley A, Hender-
son KM, van Driel ML, Holliday EG, Ball JI, Davey A, Spike NA.
Does brief chronic pain management education change opioid
prescribing rates? A pragmatic trial in Australian early-career
general practitioners. Pain 2017;158:278–88.
[31] Demoulin C, Brasseur P, Roussel N, Grosdent S, Wolfs S,
Osinski T, Bornheim S, Crielaard J, Vanderthommen M, Bruyère
O. Does improvement of knowledge about neurophysiology of
pain occur and persist in patients with chronic low back pain
after a single group session of pain physiology education?
Musculoskelet Sci Pract 2016;25:e40–1.
[32] Clarke CL, Ryan CG, Martin DJ. Pain neurophysiology education
for the management of individuals with chronic low back
pain: a systematic review and meta-analysis. Man Ther
2011;16:544–9.
[33] Niedermann K, Fransen J, Knols R, Uebelhart D. Gap between
short-and long-term effects of patient education in rheuma-
toid arthritis patients: a systematic review. Arthritis Care Res
2004;51:388–98.
[34] Iversen MD, Hammond A, Betteridge N. Self-management of
rheumatic diseases: state of the art and future perspectives.
Ann Rheum Dis 2010;69:955–63.
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