Education about pain and experience with cognitive-based interventions do not reduce healthcare professionals’ chronic pain

Introduction

Pain is the most common reason that leads people to seek medical advice (Cohen, Vase & Hooten, 2021). Moreover, persistent (chronic) pain is a growing global health problem that poses significant personal, societal, and economic burdens (Cohen, Vase & Hooten, 2021; Mills, Nicolson & Smith, 2019). Although understanding the neurobiology of chronic pain states has advanced considerably, there has been little progress in their treatment (Schug & Goddard, 2014).

Pain is prevalent among healthcare professionals (HCPs), affecting individuals across a range of specialties (Ali et al., 2024; Shaygan et al., 2022; Weisman et al., 2021; Yona et al., 2022). Chronic pain is a significant occupational health concern for these workers, with prevalence estimates ranging from 30% to over 89% across various specialties and regions, and low back pain is the most commonly reported issue (Ali et al., 2024; Shaygan et al., 2022; Yamada et al., 2016). Moreover, higher prevalence rates are observed among women, younger professionals, and rotating shift workers (Ali et al., 2024; Shaygan et al., 2022; Yamada et al., 2016). However, most epidemiological data have been derived from a limited number of medical professions, highlighting a need for further research on HCPs.

In the search for novel and effective interventions for persistent pain, some HCPs have looked towards non-pharmaceutical interventions, such as pain neuroscience education (PNE), cognitive behavioral therapy (CBT), acceptance commitment therapy (ACT), and mindfulness meditation which have become increasingly popular (Ehde, Dillworth & Turner, 2014; Weisman et al., 2022). PNE is a group of educational programs with the premise that education based on current concepts and opinions from pain neuroscience can contribute to positive outcomes for participants, such as an enhanced ability to function and lessening fear and anxiety (Moseley et al., 2024; Weisman et al., 2022). CBT principles suggest that psychological problems arise from flawed thinking and maladaptive behavior patterns and can be overcome through learning and adopting more effective coping strategies, leading to symptom relief and improved functioning (Fenn & Byrne, 2013). ACT is another behavioral and cognitive intervention that employs acceptance, mindfulness meditation, commitment, and behavior change processes to foster psychological flexibility, enabling individuals to engage more consciously and flexibly with their psychological experiences and enhance values-based action (Hayes et al., 2013).

The rationale for these interventions can be traced to attempts to apply the “biopsychosocial model of pain” (Nicholas, 2022). According to this model, the experience of pain is causally composed of biological, psychological, and sociological factors. Therefore, in theory, an informed clinician should be able to identify the likely cause(s) (Nicholas, 2022). This reasoning is often used to explain the use of psychological, educational, and cognitive interventions. Another rationale for using these interventions derives from constructivist and active inference models that view the experience of pain results in some unexplained way from the brain’s “prediction about bodily harm, shaped by sensory input and context-based predictions” (Ashar et al., 2022). Accordingly, the mere fear of tissue damage may lead some individuals to experience innocuous somatosensory input as painful (Ashar et al., 2022). It logically follows that interventions that change a patient’s context-based predictions can favorably change their experience of pain.

A specific context that appeals to the proponents of these interventions is chronic pain, where no identifiable tissue damage or disease processes can be identified. Such pain states are coded in the ICD-11 as chronic primary pain (Nicholas et al., 2019). Those promoting these interventions for primary chronic pain assert that in the absence of identifiable tissue damage or disease process, the pain is likely to be of “psychological origin” and should, therefore, be more responsive to educational and cognitive-based interventions than would secondary chronic pain (Ashar et al., 2022; Donnino et al., 2021).

The guiding principle here is that psychological interventions can be central to pain reduction, which has led us to posit that the most suitable chronic pain population to assess whether or not those methods might be valuable is informed HCPs experiencing chronic pain, constituting a unique population (Weisman et al., 2022). In our view, some HCP groups, like physiotherapists, can be considered to be the most educated clinicians in pain theory and practice. In North America, it has been reported that medical students receive an average of 5 h of pain education. In contrast, American physiotherapists receive 31 h and Canadians 24.9 (Hoeger Bement & Sluka, 2015; Watt-Watson et al., 2009).

According to the mentioned theories, we hypothesized that chronic pain intensity would negatively correlate with varying levels of pain education among HCPs experiencing chronic pain. We also assumed that well-informed HCPs with chronic pain would be more likely to seek solutions for their pain. It seems plausible that these HCPs, frequently treating individuals experiencing chronic pain and utilizing cognitive-based interventions, would recognize personal psychological traits that may impede progress in pain rehabilitation. Given that HCP proponents of these theories endorse these interventions as tools for chronic pain management, it seems reasonable to expect that their own pain levels and quality of life might reflect adherence to the strategies they advocate for their patients, providing a practical, real-world “proof of concept” of the interventions’ efficacy.

We used the following formal logical argument to justify our rationale for performing the study as well as our choice of HCPs living with chronic pain (Box 1):

• Premise 1, “Cognitive” definition is: “of, relating to, or being conscious mental activities (as thinking, reasoning, remembering, imagining, learning words, and using language)” (merriam-webster dictionary). This definition also pertains to “learning,” where to “learn” is “to gain knowledge or understanding of or skill in by study, instruction, or experience”, and “study” is “application of the mental faculties to the acquisition of knowledge” (Merriam-Webster dictionary).

• Premise 2: Cognitive-based interventions (those that utilize “cognition”) reduce pain intensity and improve quality of life.

• Premise 3: Many HCPs are highly educated about pain and possess above average knowledge in this area, with many also being well-versed in cognitive-based interventions (as outlined in premise 1).

• Conclusion: Therefore, HCPs with chronic pain (HCPs+CP) who are knowledgeable about cognitive-based interventions should experience less pain (P) and improved quality of life (Q) compared to HCPs+CP who are less familiar with these interventions.

Objectives: The primary objective of this exploratory study is to assess the relationship between healthcare professionals’ familiarity with cognitive-based interventions and their chronic pain outcomes. Specifically, we aim to determine whether increased knowledge and experience with interventions such as pain neuroscience education (PNE), cognitive behavioral therapy (CBT), and related approaches are associated with lower pain intensity and improved quality of life among healthcare providers. To address this objective, we designed the study to examine the following hypotheses:

• (1)

  HCPs experiencing “chronic primary pain” (PrimaryPG according to ICD-11) and are familiar with PNE and experienced with cognitive-based interventions will demonstrate significant negative correlations between pain intensity, familiarity, and experience compared to HCPs with “chronic secondary pain” (SecondaryPG according to ICD-11). Additionally, HCPs from the PrimaryPG will have significantly lower pain intensity and better quality of life compared to HCPs from the SecondaryPG (Treede et al., 2019) with the same level of familiarity and experience with these interventions (one-tailed hypothesis).

• (2)

  HCPs+CP who experience chronic pain (and are familiar with the educational content of PNE (education/familiarity variable) and use cognitive-based interventions regularly (experience variable) will report lower pain intensities (dependent variable) compared to HCPs+CP who are less familiar with and less experienced in these interventions (one-tailed hypothesis). We expected to observe negative correlations between pain intensity, familiarity, and experience variables (i.e., the more educated/familiar and experienced HCPs are with these interventions, the lesser their reported pain intensity should be).

• (3)

  The quality of life of HCPs+CP, who are familiar with PNE and are experienced with cognitive-based interventions, should be comparable in these parameters to healthy HCPs (H-HCPs) (one-tailed hypothesis).

• (4)

  H-HCPs whose pain has resolved will perceive this resolution as attributable to educational and/or cognitive-based interventions.

Methods

Study flow, funneling, and grouping

The following sections depict the study flow and grouping we employed to achieve our aims. The study flow is also available in Fig. 1.

Results

Discussion

This exploratory study investigated whether HCPs experiencing chronic pain who were knowledgeable about PNE and cognitive-based interventions for pain derived benefit therefrom by achieving reduced pain intensity and better quality of life. The results did not support those premises and led us to reject hypotheses 1, 2, and 4. In contrast, hypothesis 3 was supported as the HCPs+CP group who were educated in, familiar with, and experienced in using cognitive-based interventions reported quality of life scores equal to healthy HCPs. This finding aligns with other observations suggesting those interventions are associated with lessening disability and improved quality of life in people experiencing chronic pain (Hajihasani et al., 2019; Hilton et al., 2017; Siddall et al., 2022). The findings also indicate that very few HCPs (n = 16) believe pain education and cognitive-based interventions aided their recovery (hypothesis 4).

Given these observations, it is worthwhile to consider how the broader literature has also reported conflicting evidence regarding the efficacy of cognitive-based interventions for chronic pain. Despite the growing popularity of cognitive-based interventions for treating chronic pain states, the scientific evidence of their therapeutic efficacy is unremarkable and contradictory (Cuenca-Martínez et al., 2023; Louw et al., 2021; Martinez-Calderon et al., 2023; O’Connell et al., 2023; Pei et al., 2021; Ram et al., 2023; Sanabria-Mazo et al., 2023; Wood & Hendrick, 2019). For example, a recent umbrella review indicated that it is impossible to make clear clinical recommendations for delivering PNE to chronic pain states based on current meta-analyses (Martinez-Calderon et al., 2023). This conclusion contrasts two recent randomized clinical trials on PNE-like interventions with mindfulness that boasted extraordinary benefits such as complete chronic back pain relief (Ashar et al., 2022; Donnino et al., 2021), whereas mindfulness delivered on its own has unclear effects on pain (Hilton et al., 2017; Sanabria-Mazo et al., 2023). On the other hand, PNE and CBT have demonstrated the ability to deliver benefits unrelated to pain intensity, like decreased disability, anxiety, depression, increased functional capacity, and improved quality of life (Hajihasani et al., 2019; Sanabria-Mazo et al., 2023; Wood & Hendrick, 2019).

Our findings directly challenge premises 1 and 2 of our formal logical argument, which, although simplified, represents the prevailing logic in pain research and clinical practice (Hilton et al., 2017; Louw et al., 2021; Sanabria-Mazo et al., 2023; Tlach & Hampel, 2011; Wetherell et al., 2011). People experiencing chronic pain face a complex interplay of biological, psychological, and social factors that influence their experience, including genetic predispositions, tissue damage, inflammatory processes, psychological states, and socioeconomic conditions (Dunn et al., 2024). Despite this complexity, the field continues to employ the simplistic logic that increased knowledge and cognitive engagement with pain concepts will directly translate to improved pain outcomes in both research and in practice (Louw et al., 2021). The main observation from this study is that HCPs, despite being reasonably educated about pain in general and, more specifically, about PNE and cognitive-based approaches, continue to experience chronic pain. This finding challenges the core assumptions and the logic underlying educational and cognitive-based interventions for pain management that we clearly and formally outlined in Box 1. Theoretically, a comprehensive understanding of pain and its relevant mechanisms is expected to diminish fear and enhance the accuracy of pain-related predictions, thereby facilitating pain relief (Pei et al., 2021). However, the persistent pain experienced by these educated HCPs raises substantial doubts about the effectiveness of these strategies. If such knowledge does not ameliorate the pain experienced by the practitioners themselves, it casts skepticism on the potential for patients to achieve better outcomes through similar educational interventions. This discrepancy prompts a reevaluation of the foundational principles of educational and cognitive approaches to pain management.

When considering the mentioned theoretical frameworks of cognitive-based interventions, this study’s findings indicate that mere education or familiarity with these approaches does not significantly impact pain intensity or alter the pain trajectory among HCPs. A recent meta-analysis supports this assertion (Ram et al., 2023). Our results and those from other studies reveal that while proficiency in PNE and other cognitive-based interventions may enhance quality of life, it does not modify pain intensity or its progression (Hajihasani et al., 2019; Sanabria-Mazo et al., 2023; Sousa et al., 2024; Wood & Hendrick, 2019). This pattern is reminiscent of the framing effect described by Tversky & Kahneman (1981), which demonstrate that the way information is presented can heavily influence outcomes without altering the underlying content (Tversky & Kahneman, 1981). In other words, the apparent efficacy of those interventions observed in clinical trials may be largely attributed to contextual influences and self-conviction–akin to positive framing-rather than the specific educational content or treatment effects. In the case of PNE, it is plausible that the benefits of any educational intervention may be similarly achieved through positive framing, regardless of the content. Recent studies on PNE support this premise (Adenis et al., 2024; Ponce-Fuentes et al., 2023). This raises critical questions about PNE’s unique value, underscoring the need for comparative studies that evaluate its effectiveness against other positively framed or sham educational interventions to validate these findings further. However, we are unaware of such studies.

While the current study did not find a reduction in pain intensity among HCPs knowledgeable about cognitive-based interventions, these individuals reported quality-of-life metrics comparable to those of their healthy peers. This indicates that, although these interventions may not decrease pain intensity, they do enhance life satisfaction by improving emotional resilience and psychological well-being. This finding aligns with previous research on cognitive-based interventions, underscoring their potential to improve quality of life (Hajihasani et al., 2019; Sanabria-Mazo et al., 2023; Wood & Hendrick, 2019). Future research should investigate which components of these interventions are most effective at enhancing the quality of life, considering that the educational content and level alone do not contribute to the treatment effect.

Unlike PNE, which primarily reframes pain through education, ACT, CBT, and mindfulness actively engage patients in coping with their predicaments. ACT is said to promote psychological flexibility by fostering acceptance of pain and commitment to value-based actions (Hayes et al., 2013) whereas CBT presumably targets and restructures maladaptive thought patterns (de C Williams et al., 2020; Fenn & Byrne, 2013; Sanabria-Mazo et al., 2023). Similarly, mindfulness practices are aimed to improve emotional regulation and resilience. The comparable quality-of-life scores observed in our study among HCPs with chronic pain might reflect the beneficial effects of these interventions, which together can enhance overall well-being even in the absence of significant reductions in pain intensity (Hajihasani et al., 2019; Siddall et al., 2022). Future research should further differentiate the unique contributions of ACT, CBT, and mindfulness from educational approaches like PNE in chronic pain management.

A strength of this study is the rigorous bias reduction strategies we employed. We were able to exclude survivorship bias in the H-HCPs group as the majority whose pain had resolved did not attribute this resolution to cognitive or educational interventions (only 11%). Their most common belief was that their pain was resolved through movement/exercise or rehabilitation, with spontaneous recovery being the next most common belief. In line with the previous point of discussion, it is important to mention that physical therapy interventions including exercise/movement, often naturally integrate psychological components such as safety messaging and motivation, making it difficult to completely separate their physical and cognitive elements.

The perception of those HCPs that their pain spontaneously resolved is vital to open a discussion on the natural history of chronic pain conditions; that is a scarcely mentioned topic and not adequately considered by researchers and the general public as the reason for success in clinical settings and clinical trials. For example, Chronic Regional Pain Syndrome type 1 (Sandroni et al., 2003) has been shown to resolve naturally, and both spontaneous remission and relapse have been documented in vulvodynia, where it is believed that persistence without remission is the exception rather than the rule (Reed et al., 2016). Another example is low back pain, which was once defined as acute, subacute, or chronic based on the duration of the present episode. However, low back pain is now understood as an episodic condition (Kongsted et al., 2016). When interventions are applied close to a natural resolution/remission point of these conditions, the natural reflexive conclusion can be that the treatment works. This phenomenon casts doubt upon the many anecdotal reports about people who report recovery from chronic pain due to various interventions and even clinical trials. Consequently, HCPs and researchers should be cautious when attributing success to interventions without considering natural resolution or remission of the conditions.

Several limitations of this study warrant acknowledgment. A potential critique concerns our classification criteria for primary pain, which may have been overly inclusive and potentially incorporated cases attributable to secondary pain conditions. However, this concern is mitigated by two key factors. Firstly, the majority of reported pain sites in our sample were lower back (35.9%), neck (23.4%), shoulder (18.9%), and upper back (19.9%) (see Table 4), regions frequently associated with non-specific pain conditions in clinical practice and research literature (i.e., primary pain) (Chiarotto & Koes, 2022; Kazeminasab et al., 2022; Park et al., 2020; Risetti et al., 2023). Secondly, our study population consisted of educated HCPs who, given their professional training and knowledge, can likely distinguish between specific and non-specific pain etiologies. Their self-reported pain classifications are presumably more accurate than the general population’s. An additional limitation is our decision to collapse the primary and secondary pain groups for subsequent analyses after finding no significant differences between them. While this approach was statistically justified based on our initial comparisons, it potentially obscures meaningful clinical distinctions between these pain categories that might emerge with larger samples or more nuanced assessment methods. By combining these groups, we may have diluted potential subgroup effects specific to either primary or secondary pain mechanisms.

Another potential critique of our methodology is the absence of a formal assessment of the respondents’ educational quality, particularly regarding their understanding of pain neuroscience. While tools such as the Neurophysiology of Pain Questionnaire could have been employed to this end, we contend that such an approach would have been both unnecessary and potentially counterproductive in the context of our study. Firstly, including additional assessment tools would have significantly increased the survey’s length and complexity, potentially compromising completion rates and, by extension, the robustness of our dataset. The balance between comprehensive assessment and participant engagement is delicate, and we prioritized maintaining a high response rate to ensure a representative sample (Rolstad, Adler & Rydén, 2011).

Moreover, our study population is comprised of educated HCPs whose baseline knowledge of pain science and cognitive-based approaches can already be reasonably assumed to exceed that of the general population. Their professional credentials and ongoing clinical practice serve as a proxy for their cognitive engagement with pain concepts, validating a key premise of our research without necessitating further testing. What further supports our argument is that our study population consisted primarily of physiotherapists (44%) from anglophone countries with established pain education curricula (Canada, United States of America, United Kingdom, and Australia proportion = 50.9%) and evidence which consistently demonstrates that they receive more extensive training in pain mechanisms compared to other disciplines (Briggs, Carr & Whittaker, 2011; Hoeger Bement & Sluka, 2015; Mezei, Murinson & Team, 2011; Shipton et al., 2018; Watt-Watson et al., 2009).

Furthermore, it is worth noting that cognitive approaches to pain management, despite their theoretical complexity, often distill into relatively straightforward, accessible messages when applied clinically. The proliferation of media and educational resources, apps, and tools aimed at simplifying these concepts for laypersons further supports the notion that a detailed assessment of our respondents’ grasp of cognitive-based approaches might yield diminishing returns regarding insights gained (Choi, 2021; Devan et al., 2019; Sage et al., 2008; Weisman et al., 2022).

In light of these considerations, we believe our approach strikes an appropriate balance between methodological rigor and practical constraints, allowing us to focus on our primary research questions without unduly burdening participants or introducing potential confounders. Future studies might explicitly explore the relationship between detailed cognitive approaches, knowledge, and clinical outcomes. Still, for the purposes of our investigation, the participants’ professional status and self-reported familiarity with cognitive-based interventions provided sufficient context for our analyses.

Although online dissemination methods are valid for reaching the desired population (Weisman et al., 2021; Yona et al., 2022), selection bias cannot be wholly excluded. Finally, while the desired sample size was reached, many respondents did not complete the questionnaire, and not all health professions and countries were equally represented. An increased completion rate would have allowed for more subgroup analyses and exploration of the effects of countries (i.e., culture), which may have yielded different quality-of-life scores. Finally, other factors that could have influenced our findings were not assessed, including sociodemographic and socioeconomic profiles, sleep quality, night shift work, and the extent of direct work with chronic pain patients.

Conclusion

HCPs who live with chronic pain, are familiar with PNE, and are experienced in cognitive-based interventions such as CBT, ACT, and mindfulness do not correlate with reported lowered pain intensity. However, the quality of life of those HCPs was similar to that of healthy HCPs. Very few healthy HCPs whose chronic pain had resolved believe that education about pain or cognitive-based interventions contributed to this resolution. Most HCPs with resolved pain believed that movement/exercise and physical therapy contributed to their pain resolution or that their pain resolved spontaneously. The findings question the theoretical basis of those interventions, namely those that apply the biopsychosocial model or the reasoning of predictive processing to assess for causality of pain and their use as self-management tools.

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