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There has been increasing interest in the secondary prevention of chronic pain and pain-associated disability over the past 3 decades. In 2011, psychologically informed practice (PiP) was suggested as a framework for managing persistent and recurrent pain, and, since then, it has underpinned the development of stratified care linking risk identification (screening). Although PiP research trials have demonstrated clinical and economic advantage over usual care, pragmatic studies have been less successful, and qualitative studies have identified implementation difficulties in both system delivery and individual clinical management. Effort has been put into the development of screening tools, the development of training, and the assessment of outcomes; however, the nature of the consultation has remained relatively unexplored. In this Perspective, a review of the nature of clinical consultations and the clinician-patient relationship is followed by reflections on the nature of communication and the outcome of training courses. Consideration is given to the optimization of communication, including the use of standardized patient-reported measures and the role of the therapist in facilitating adaptive behavior change. Several challenges in implementing a PiP approach in day-to-day practice are then considered. Following brief consideration of the impact of recent developments in health care, the Perspective concludes with a brief introduction to the PiP Consultation Roadmap (the subject of a companion paper), the use of which is suggested as a way of structuring the consultation with the flexibility required for a patient-centered approach to guided self-management of chronic pain conditions., (© The Author(s) 2023. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Chronic lower back pain (CLBP) is a major health care burden and often results in workplace absenteeism. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions informed by the flags approach, which integrates cognitive and behavioral approaches via identification of biopsychosocial barriers to recovery, have resulted in reduced pain-related work absences and increased return to work for individuals with CLBP. However, research indicates that physicians' adherence to biopsychosocial guidelines is low., Objective: The current study examined the effects of a flags approach-based educational intervention on clinical judgments of medical students and general practitioner (GP) trainees regarding the risk of future disability of CLBP patients., Design: Randomized controlled trial (trial registration number: ISRCTN53670726)., Setting: University classroom., Subjects: Medical students and GP trainees., Methods: Using 40 fictional CLBP cases, differences in clinical judgment accuracy, weighting, and speed (experimental N = 32) were examined pre- and postintervention, as were flags approach knowledge, pain attitudes and beliefs, and empathy, in comparison with a no-intervention control group (control N = 31)., Results: Results revealed positive effects of the educational intervention on flags approach knowledge, pain-related attitudes and beliefs, and judgment weighting of psychologically based cues; results are discussed in light of existing theory and research., Conclusions: Short flags approach-based educational video interventions on clinical judgment-making regarding the risk of future disability of CLBP patients may provide opportunities to gain biopsychosocial knowledge, overcome associated attitude barriers, and facilitate development of clinical judgment-making more aligned with psychological cues., (© 2019 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Psychosocial risk factors associated with chronic orofacial pain are amenable to self-management. However, current management involves invasive therapies which lack an evidence base and has the potential to cause iatrogenic harm., Objectives: To determine: (a) whether self-management is more effective than usual care in improving pain intensity and psychosocial well-being and (b) optimal components of self-management interventions., Databases and Data Treatment: Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO, WHO International Clinical Trials Registry Platform and Clinical Trials.gov were searched. Meta-analysis was used to determine effectiveness, and GRADE was used to rate quality, certainty and applicability of evidence., Results: Fourteen trials were included. Meta-analyses showed self-management was effective for long-term pain intensity (standardized mean difference [SMD] -0.32, 95% confidence interval [CI] -0.47 to -0.17) and depression (SMD -0.32, 95% CI -0.50 to -0.15). GRADE analysis showed a high score for certainty of evidence for these outcomes and significant effects for additional outcomes of activity interference (-0.29 95% CI -0.47 to -0.11) and muscle palpation pain (SMD -0.58 95% CI -0.92 to -0.24). Meta-regression showed nonsignificant effects for biofeedback on long-term pain (-0.16, 95% CI -0.48 to 0.17, p-value = 0.360) and depression (-0.13, 95% CI -0.50 to 0.23, p-value = 0.475)., Conclusions: Self-management interventions are effective for patients with chronic orofacial pain. Packages of physical and psychosocial self-regulation and education appear beneficial. Early self-management of chronic orofacial pain should be a priority for future testing., Significance: This systematic review provides clear evidence for effectiveness of combined biomedical and psychological interventions (incorporating self-management approaches) on long-term outcomes in the management of chronic orofacial (principally TMD) pain. Self-management should be a priority for early intervention in primary care in preference to invasive, irreversible and costly therapies. Further research is needed firstly to clarify the relative effectiveness of specific components of self-management, both individually and in conjunction, and secondly on outcomes in other types of chronic orofacial pains., (© 2019 European Pain Federation - EFIC®.)

Objectives: To test whether change in fear-avoidance beliefs was a mediator of the effect of treatment on disability outcome, and to test an analytical approach, latent growth modeling, not often applied to mediation analysis., Methods: Secondary analysis was carried out on a randomized controlled trial designed to compare an intervention addressing fear-avoidance beliefs (n=119) with treatment as usual (n=121) for patients with low back pain, which found the intervention to be effective. Latent growth modelling was used to perform a mediation analysis on the trial data to assess the role of change in fear-avoidance beliefs on disability outcome. The product of coefficients with bias-corrected bootstrapped confidence intervals was used to calculate the mediating effect., Results: A statistically significant mediating effect of fear-avoidance beliefs on the effect of treatment on disability outcome was found (standardized indirect effect -0.35; bias-corrected 95% CI, -0.47 to -0.24). Poor fit of the model to the data suggested that other factors not accounted for in this model are likely to be part of the same mediating pathway., Discussion: Fear-avoidance beliefs were found to mediate the effect of treatment on disability outcome. Measurement of all potential mediator variables in future studies would help to more strongly identify which factors explain observed treatment effects. Latent growth modelling was found to be a useful technique to apply to studies of treatment mediation, suggesting that future studies could use this approach.

Purpose of Review: To explores the potential role of psychological treatments for older people who are affected by chronic pain., Recent Findings: It is now widely recognized that chronic pain is a highly prevalent health problem among older people, and guidelines have evolved to assist with the assessment and management of chronic pain. However, despite the fact that psychological treatments have been shown to be effective for a range of other conditions such as depression and anxiety, there is a relative paucity of studies focused on pain management. Although more evidence is needed, the trend from existing studies indicates that older people find psychological treatments for chronic pain to be relevant, acceptable in content, and beneficial in reducing distress and disability. Particular challenges arise for the delivery of psychological interventions to people with pain and cognitive impairment associated with dementia. There is a growing interest in this population and a good deal of research has focused on the assessment of pain, but with a small number of exceptions, almost no research activity as yet in developing psychological treatments for people with pain and dementia., Summary: We conclude that there is sufficient evidence that psychological interventions are efficacious for older people with chronic pain. We propose a number of areas for research focus over the next 10 years that will help to consolidate our knowledge and to explore new avenues for the psychological management of chronic pain in older people.

Study Objectives: One theoretical model suggests a pathway between pain and the development of depression through sleep problems. Here, we prospectively test the hypothesis that incident sleep problems, in those with persistent pain, increase risk of new onset probable depression, and investigate the role of "pain that interferes with daily life" (pain interference) on this pathway., Design: Prospective cohort study., Setting: Community based population study within UK., Participants: Participants with persistent pain nested within a larger longitudinal community study., Measurements: Participants were mailed health questionnaires at baseline (time 1) with follow-up at 3 years (time 2) and 6 years from baseline (time 3). Questionnaires at baseline and at follow up contained measures of sleep problems (Jenkins Sleep Questionnaire), depressive symptoms (Hospital Anxiety and Depressive Scale), and pain interference., Results: In total, 2,622 participants returned health questionnaires at all time points and indicated the presence of pain at each time point. After adjustment for age, gender, marital status, employment status, alcohol intake, smoking status, and body mass index, having a new period of sleep problems at year 3 more than trebled the risk of a new period of probable depression at year 6 (relative risk 3.47, 95% CI 1.97 to 6.03). Mediation analysis showed that pain interference played a significant but relatively minor role in the pathway., Conclusion: Clinicians treating patients with persistent pain may wish to consider options that involve addressing the prevention or treatment of sleep problems, in addition to their primary focus of pain management.

There has been increasing interest in the secondary prevention of chronic pain and pain-associated disability over the past 3 decades. In 2011, psychologically informed practice (PiP) was suggested as a framework for managing persistent and recurrent pain, and, since then, it has underpinned the development of stratified care linking risk identification (screening). Although PiP research trials have demonstrated clinical and economic advantage over usual care, pragmatic studies have been less successful, and qualitative studies have identified implementation difficulties in both system delivery and individual clinical management. Effort has been put into the development of screening tools, the development of training, and the assessment of outcomes; however, the nature of the consultation has remained relatively unexplored. In this Perspective, a review of the nature of clinical consultations and the clinician–patient relationship is followed by reflections on the nature of communication and the outcome of training courses. Consideration is given to the optimization of communication, including the use of standardized patient-reported measures and the role of the therapist in facilitating adaptive behavior change. Several challenges in implementing a PiP approach in day-to-day practice are then considered. Following brief consideration of the impact of recent developments in health care, the Perspective concludes with a brief introduction to the PiP Consultation Roadmap (the subject of a companion paper), the use of which is suggested as a way of structuring the consultation with the flexibility required for a patient-centered approach to guided self-management of chronic pain conditions. [ABSTRACT FROM AUTHOR]

Painful musculoskeletal disorders represent an enormous burden at the individual, organizational, and societal levels.[72] In the workplace context, disabling effects of pain are influenced by a wide range of psychosocial factors, including pain beliefs, psychological distress, social support, self-efficacy, and perceptions of organizational support.[[26], [49], [52], [66]] Moreover, a patient's ability to return to work (RTW) or maintain employment can be affected by multiple overlapping systems outside of the clinic. Work and pain: a lifespan development approach.; Oxford: Oxford University Press, 2020. p., 160-77. 9 Bhattacharya A,, Ray T. Precarious work, job stress, and health-related quality of life. In all cases, interventions may need to address workplace and individual issues[82] and prognostic factors that vary by pain duration.[[12], [40], [89]] The effective management of pain-associated limitations in the workplace therefore requires consideration of both physical and psychosocial factors as well as overall management planning.[76] 2.1. [Extracted from the article]

Originally the term "yellow flags" was used to describe psychosocial prognostic factors for the development of disability following the onset of musculoskeletal pain. The identification of yellow flags through early screening was expected to prompt the application of intervention guidelines to achieve secondary prevention. In recent conceptualizations of yellow flags, it has been suggested that their range of applicability should be confined primarily to psychological risk factors to differentiate them from other risk factors, such as social and environmental variables. This article addresses 2 specific questions that arise from this development: (1) Can yellow flags influence outcomes in people with acute or subacute low back pain? and (2) Can yellow flags be targeted in interventions to produce better outcomes? Consistent evidence has been found to support the role of various psychological factors in prognosis, although questions remain about which factors are the most important, both individually and in combination, and how they affect outcomes. Published early interventions have reported mixed results, but, overall, the evidence suggests that targeting yellow flags, particularly when they are at high levels, does seem to lead to more consistently positive results than either ignoring them or providing omnibus interventions to people regardless of psychological risk factors. Psychological risk factors for poor prognosis can be identified clinically and addressed within interventions, but questions remain in relation to issues such as timing, necessary skills, content of treatments, and context. In addition, there is still a need to elucidate mechanisms of change and better integrate this understanding into the broader context of secondary prevention of chronic pain and disability. [ABSTRACT FROM AUTHOR]

Presents a clinical review of musculoskeletal pain. Idea that musculoskeletal symptoms are a major reason for consultation in primary care; Management of acute back pain; Identification of risk factors for chronic pain; Collaborative management between physicians; Belief that the ideas of the patient concerning the problem must be a part of management.