Patient and Provider Perspectives on Barriers and Facilitators to the Acceptance of Pain Neuroscience Education in Chronic Musculoskeletal Pain Conditions: A Qualitative Systematic Review Protocol

Abstract

Objective: To identify and map barriers and facilitators to the acceptance of pain neuroscience education for chronic musculoskeletal pain conditions. Introduction: Pain neuroscience education aims to reconceptualize the understanding of the biology of pain. This includes the acknowledgment of physiological and psychological processes relevant to pain experiences to ultimately change maladaptive beliefs and behaviors. Pain neuroscience education in chronic musculoskeletal pain conditions has been demonstrated to positively influence relevant treatment outcomes. Inclusion criteria: Only qualitative studies will be included. The population will include patients with chronic musculoskeletal pain and healthcare providers involved in pain management. The phenomenon of interest encompasses educational interventions on the biology and psychology of pain, which aim to reconceptualize patients’ understanding of pain. Methods: A comprehensive search strategy will be conducted on MEDLINE (PubMed), Web of Science, PsycInfo, and CINHAL. Two reviewers will independently conduct the study selection process, critical appraisal, data extraction, and data synthesis. Discrepancies will be resolved by a third reviewer. The assessment of methodological quality will be guided by JBI’s critical appraisal checklist for qualitative research. Qualitative data synthesis will follow the JBI SUMARI meta-aggregation approach. Considerations of the certainty in the results will be reported in accordance with a ConQual Summary of Findings.

1. Introduction

1.1. Background

In the last two decades, pain neuroscience education (PNE) has become an acknowledged intervention to reconceptualize patients’ understanding of the biology of chronic musculoskeletal pain [1]. PNE describes a variety of interventions that have a common aim of educating chronic pain patients about the origins of pain, the biopsychosocial aspects of its etiology, and its underlying biological functions [1]. Although there is no gold standard postulated to define key educational contents and delivery formats of PNE interventions, they frequently comprise aspects of pain neurophysiology, including explanations of nociception and nociceptive pathways, neurons, synapses, action potential, spinal inhibition and facilitation, peripheral sensitization, central sensitization, and plasticity of the nervous system [2]. Communication of educational content is commonly characterized by a simplistic scientific language that is supported by the use of pictures, drawings, booklets, or metaphors [1,3]. A well-known and recognized example of how to provide PNE content is the booklet “Explain Pain” written by Butler and Moseley [4].

PNE is associated with positive effects on chronic musculoskeletal pain conditions [5,6,7] including chronic low back pain [8,9,10,11,12], fibromyalgia [13,14], and chronic fatigue syndrome [13], as well as hip and knee osteoarthritis [15]. The most relevant treatment outcomes positively affected by PNE include pain perception [5,6,10,14,15], knowledge of pain biology [5], physical function [5,7,14], and disability [5,6,8,10,12,13]. Moreover, PNE has been demonstrated to positively influence aspects of pain control including kinesiophobia [16], pain catastrophizing [16], anxiety [14], and depression [14]. In this regard, an adjunct combination of PNE with other multimodal treatment approaches (i.e., exercise or manual therapy) has been shown to be the most promising [6,9,14,17] and has previously been described as PNE+ [18]. Favored delivery formats of PNE should be conducted via oral treatment sessions integrating reinforcement elements [13], and a volume of four to eight sessions over a period of seven to twelve weeks is recommended [10].

In recent years, a variety of qualitative systematic reviews addressing the barriers and facilitators of pain management have been published. In particular, qualitative meta-aggregations of barriers to nurse-led pain management in cancer [19], critical care [20], and intensive care [21] have been conducted. The key findings of these reviews suggest that a lack of knowledge and skills (i.e., pain assessment skills) [19,20,21], the absence of standardized guidelines and protocols for pain evaluation [19,20,21], time restrictions and limited staff numbers [19,20,21], and the perception that nurses play a subordinate role in pain management [19] are major barriers to nurse-led pain management. On the other hand, the ongoing education of nurses (professional pain assessment and management training), effective collaboration between physicians and nurses, and patient pain score discussions during nurse-to-nurse handovers have been identified as facilitators of pain assessment and management in critical care [20]. However, these qualitative reviews provide information on aspects of pain assessment and management in patients with critical health conditions rather than information about broader aspects of barriers and facilitators of PNE in chronic musculoskeletal pain conditions.

Ng et al. [22] conducted a qualitative review that aimed to identify barriers and facilitators of a biopsychosocial approach in musculoskeletal pain practice by systematically reviewing primary qualitative studies addressing the perspectives of relevant healthcare professionals. The principal determinants of this evidence synthesis suggest that healthcare professionals’ personal factors, knowledge, and skills (including the misconception of clinical practice guidelines) and the perception of patients’ factors influence the biopsychosocial approach. Moreover, healthcare professionals perceived clinical guideline formulations, community factors, funding models, resourcing, training issues, health policy, and organizational and social factors to directly influence this approach [22]. The primary studies included in the review reflected on barriers and facilitators to the model of biopsychosocial care, including healthcare providers’ perspectives on clinical practice guidelines [23,24,25,26,27,28,29], their experiences in the diagnosis of psychosocial factors and yellow flag identification [29,30,31], their personal beliefs about a biopsychosocial model of care [32,33,34,35,36], their personal views on stratified care approaches [37,38], and their perceived barriers to behavioral medicine approaches [39]. However, a systematic analysis of qualitative studies investigating the barriers and facilitators of PNE use as a stand-alone educational intervention is currently pending.

Available qualitative studies on this topic identified, for instance, that Lebanese physiotherapists reported feeling unprepared to apply PNE confidently as they themselves were working in a system in which the biomechanical model was still the predominant model of reference [40]. Additionally, the authors of a qualitative study in Australia found that only a limited number of relevant PNE themes (prioritization of active treatment strategies; pain and tissue damage rarely relate; learning about pain can help individuals and society) are regularly communicated to patients diagnosed with osteoarthritis [41]. Conversely, under-represented PNE themes included the role of the brain in pain, reassuring that pain is real, conveying the concept of danger sensors in contrast to pain sensors, and demonstrating that pain depends on a trade-off between danger and safety [41].

Considering patients’ perspectives on barriers to and acceptance of PNE, Dannecker et al. [42] identified that chronic low back pain patients indeed value PNE content delivered in a single-session educational video format. However, patients’ reactions to PNE contents were negatively affected by a desire for unfulfilled confirmation that pain is real, and other upcoming questions remain unanswered in the video [42]. In another qualitative study, the perspectives of patients with rotator cuff-related shoulder pain on PNE were explored [43]. The authors identified that a change in patient beliefs about the biology of pain was facilitated by individualized educational sessions and strong therapeutic relationships. Patients valued when therapists were able to listen to and accept their beliefs [43].

These studies have provided valuable insights into the challenges associated with implementing PNE interventions in musculoskeletal care. However, to the best of our knowledge, a systematic analysis of primary qualitative research investigating the barriers and facilitators of PNE use in chronic musculoskeletal pain conditions is currently pending.

1.2. Objective

Following the understanding of barriers and facilitators as a prerequisite to inform implementation strategies for predefined interventions [44], the primary aim of the planned qualitative systematic review is to identify barriers and facilitators to the use and acceptance of PNE in the management of chronic musculoskeletal pain conditions. We will consider multiple perspectives of patients with chronic musculoskeletal pain and healthcare providers relevant to the medical care system of this patient group. As far as data availability allows, an in-depth comparison of determinants affecting the use and acceptance of PNE by healthcare professionals and patients will be conducted. In line with this objective, the specific research questions of this review are as follows.

(a) Which barriers and facilitators to the acceptance of PNE do healthcare providers experience in the management of chronic musculoskeletal pain conditions?

(b) Which barriers and facilitators to the acceptance of PNE are postulated by patients with chronic musculoskeletal pain?

2. Materials and Methods

2.1. Design and Registration

This qualitative systematic review protocol was registered in the Open Science Framework (https://osf.io/cf7r3 (accessed on 10 October 2023)). The protocol was reported in accordance with the reporting items of the (PRISMA) statement checklist for Systematic Review and Meta-Analysis Reporting Protocols (

Table 1. PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) 2015 checklist: recommended items to address in a systematic review protocol *.

Section and Topic	Item No	Checklist Item	Page
Administrative Information
Title:
Identification	1a	Identify the report as a protocol of a systematic review.	1
Update	1b	If the protocol is for an update of a previous systematic review, identify as such.	Not applicable
Registration	2	If registered, provide the name of the registry (such as PROSPERO) and registration number.	2
Authors:
Contact	3a	Provide name, institutional affiliation, and e-mail address of all protocol authors; provide physical mailing address of the corresponding author.	1
Contributions	3b	Describe contributions of protocol authors and identify the guarantor of the review.	6
Amendments	4	If the protocol represents an amendment of a previously completed or published protocol, identify as such and list changes; otherwise, state plan for documenting important protocol amendments.	Not applicable
Support:
Sources	5a	Indicate sources of financial or other support for the review.	6
Sponsor	5b	Provide name for the review funder and/or sponsor.	6
Role of sponsor or funder	5c	Describe roles of funder(s), sponsor(s), and/or institution(s), if any, in developing the protocol.	6
Introduction
Rationale	6	Describe the rationale for the review in the context of what is already known.	3
Objectives	7	Provide an explicit statement of the question(s) the review will address with reference to participants, interventions, comparators, and outcomes (PICO).	3
Methods
Eligibility criteria	8	Specify the study characteristics (such as PICO, study design, setting, time frame) and report characteristics (such as years considered, language, publication status) to be used as criteria for eligibility for the review.	3 to 4
Information sources	9	Describe all intended information sources (such as electronic databases, contact with study authors, trial registers, or other grey literature sources) with planned dates of coverage.	4
Search strategy	10	Present draft of search strategy to be used for at least one electronic database, including planned limits, such that it could be repeated.	4 to 5
Study records:
Data management	11a	Describe the mechanism(s) that will be used to manage records and data throughout the review.	5 to 6
Selection process	11b	State the process that will be used for selecting studies (such as two independent reviewers) throughout each phase of the review (that is, screening, eligibility, and inclusion in meta-analysis).	5
Data collection process	11c	Describe the planned method of extracting data from reports (such as piloting forms, done independently, in duplicate) and any processes for obtaining and confirming data from investigators.	5 to 6
Data items	12	List and define all variables for which data will be sought (such as PICO items, funding sources) and any pre-planned data assumptions and simplifications.	Not applicable
Outcomes and prioritization	13	List and define all outcomes for which data will be sought, including prioritization of main and additional outcomes, with rationale.	Not applicable
Risk of bias in individual studies	14	Describe anticipated methods for assessing risk of bias of individual studies, including whether this will be performed at the outcome, study level, or both; state how this information will be used in data synthesis.	5 to 6
Data synthesis	15a	Describe criteria under which study data will be quantitatively synthesized.	Not applicable
	15b	If data are appropriate for quantitative synthesis, describe planned summary measures, methods for handling data, and methods for combining data from studies, including any planned exploration of consistency (such as I2, Kendall’s τ).	Not applicable
	15c	Describe any proposed additional analyses (such as sensitivity or subgroup analyses, meta-regression).	Not applicable
	15d	If quantitative synthesis is not appropriate, describe the type of summary planned.	6
Meta-bias(es)	16	Specify any planned assessment of meta-bias(es) (such as publication bias across studies, selective reporting within studies).	6
Confidence in cumulative evidence	17	Describe how the strength of the body of evidence will be assessed (such as GRADE).	6

* It is strongly recommended that this checklist be read in conjunction with the PRISMA-P Explanation and Elaboration (cite when available) for important clarification on the items. Amendments to a review protocol should be tracked and dated. The copyright for PRISMA-P (including checklist) is held by the PRISMA-P Group and is distributed under a Creative Commons Attribution Licence 4.0 [46].

) [45].

To ensure research transparency, the final review will additionally include a checklist for reporting qualitative evidence synthesis (ENTREQ) [47]. The structure of this protocol and the subsequent qualitative review report will follow the guidelines of the Manual for Evidence Synthesis developed by the Joanna Briggs Institute (JBI) [48].

2.2. Inclusion Criteria

2.2.1. Population

This review will include all qualitative studies conducted on healthcare providers involved in the management of chronic musculoskeletal pain. This will include all relevant physician specialty groups (i.e., family physicians, orthopedic specialists, and neurologists), psychology, nursing, physiotherapy, sports therapy, occupational therapy, osteopathy, and chiropractic care. The included studies need to include providers’ experiences, perspectives, and attitudes toward PNE use in the management of chronic musculoskeletal pain conditions. In this way, provider-centric barriers and facilitators of PNE incorporation into standard care can be identified. Studies conducted on in-training medical and health science students will be excluded.

In addition, studies focusing on patients with chronic musculoskeletal pain and their perspectives on the acceptance of PNE as an adjunctive therapeutic intervention will be included.

2.2.2. Phenomenon of Interest

We will include all qualitative studies focusing on the perspectives of educational interventions targeting an improved understanding of the biology and physiology of pain. These interventions must focus on patients’ understanding of the origins of pain, biopsychosocial aspects of its etiology, and underlying biological functions. In that regard, educational interventions need to shift patients’ perspectives on pain as an indication of tissue damage toward pain as an indication of one’s perceived need to protect the body. Following this understanding of PNE, we will exclude studies on educational interventions that exclusively promote treatment strategies (exercise approaches, manual therapy, psychological interventions, and pharmacological interventions) or how to cope with and manage pain (i.e., relaxation, imagery, and self-management skills).

2.2.3. Context

We will include studies investigating provider perspectives in musculoskeletal care settings of primary, secondary, or tertiary care. We will exclude provider perspectives from palliative care settings, intensive care units, and emergency departments. Additionally, perspectives on educational pain interventions in patients with chronic cancer pain, chronic postsurgical pain, chronic pain in pediatric or adolescent populations, and chronic pregnancy-related pain will be excluded.

2.2.4. Types of Studies

In this review, we aim to identify the barriers and facilitators relevant to PNE acceptance. In this regard, we want to explore opinions, motives, and attitudes to understand how patients and providers evaluate the use of PNE in their individual contexts, conditions, and social reality norms. Thus, we will only consider original qualitative research, including interviews, focus group studies, observational ethnographic studies, and distinctly reported qualitative results of mixed-methods studies.

2.3. Search Strategy

A three-phase search strategy will be conducted using MEDLINE (PubMed), Web of Science, PsycInfo, and CINHAL. In phase one, an initial search will be conducted on MEDLINE (PubMed), in which the applied keywords, MESH terms, and search strings will be based on the research team’s knowledge of the field.

Table 2. Preliminary search strategy.

Search	Query	Results
#1	Search: “Health Personnel” [Mesh] OR “Nurses” [Mesh] OR “Physicians” [Mesh] OR “Physical Therapists” [Mesh] OR “Psychotherapists” [Mesh] OR “Occupational Therapists” [Mesh] OR “health care provider*” [tw] OR “care provider*” [tw] OR stakeholder* [tw] OR “physician*” [tw] OR “general practitioner*” [tw] OR “orthopaedic specialist*” [tw] OR neurologist* [tw] OR physiotherapist* [tw] OR ostepath* [tw] OR chiropractor* [tw] OR nurse* [tw] OR psychologist* [tw] OR psychiatrist* [tw] OR kinesiologist* [tw] OR physiologist* [tw] OR “sports therapist*” [tw] OR surgeon* [tw] OR patient* [tw] OR client* [tw] OR people [tw]	9,812,130
#2	Search: “pain education” [tw] OR “pain neuroscience education” [tw] OR “pain science education” [tw] OR “explain* pain” [tw] OR “therapeutic neuroscience education” [tw] OR “pain neurophysiology education” [tw] OR “pain biology” [tw]	1068
#3	Search: “Qualitative Research” [Mesh] OR qualitative [tw] OR narrative [tw] OR “focus group*” [tw] OR observation* [tw] OR interview* [tw] OR “mixed method*” [tw] OR “action research” [tw] OR “content analysis” [tw] OR hermeneutic [tw] OR questionnaire [tw] OR “grounded theory” [tw] OR phenomenolog* [tw] OR explor* [tw] OR “group discussion” [tw] OR ethnographic* [tw] OR “praxis research” [tw] OR “formative evaluation” [tw] OR “process evaluation” [tw] OR participatory [tw] OR “real-world” [tw] OR “life world” [tw]	3,442,055
#4	Search: experience* [tw] OR view* [tw] OR perspective* [tw] OR attitude* [tw] OR behaviour* [tw] OR barrier* [tw] OR facilitator* [tw] OR enabler* [tw] OR determinant* [tw] OR “support* factor*” [tw] OR “inhibiting factor*” [tw] OR impact [tw]	4,497,711
#5	#1 AND #2 AND #3 AND #4	275

The preliminary search strategy was conducted on Medline (PubMed) on 17 July 2023.

lists the initial search strategy. Subsequently, the retrieved articles will be screened for titles, abstracts, and index terms to build a comprehensive search strategy for the target population and the phenomenon of interest. In phase two, tailored searches for each of the listed databases will be carried out. In the final phase, the reference lists of the retrieved articles will be screened for additional studies. For this review, only English-language publications will be considered, and the search strategy will not be limited by date.

2.4. Study Selection

Two authors (LK and NR) will independently screen titles and abstracts of the retrieved articles and will exclude any studies not fulfilling the inclusion criteria. The remaining articles will be full-text screened for inclusion (LK; NR). Discrepancies will be resolved using a process of consensus and discussion between the two authors. In cases of hardship, decisions on article inclusion will be made by third-party reconciliation (AC or EW). No studies will be excluded because of their insufficient quality. The study selection process will be supported by the JBI’s online application software SUMARI (Adelaide, Australia).

2.5. Assessment of Methodological Quality

Two reviewers (LK and EW) will independently assess eligible articles for methodological quality using the JBI critical appraisal instrument for qualitative research [48]. Missing information relevant to the critical appraisal process will be requested by directly contacting the corresponding authors of the respective studies. Disagreements will be resolved by discussion or third-party arbitration (AC). The results of the methodological quality assessment will be reported in a narrative table format.

In accordance with the critical appraisal process, studies will be excluded from the analysis if the voices of participants are not adequately represented (Q8: “Are participants, and their voices, adequately represented?”) or if the applied methods and conclusions drawn from the study reports do not reflect the analysis and interpretation of data (Q2: “Is there congruity between research methodology and research questions or objectives?”, Q4: “Is there congruity between research methodology and the representation and analysis of data?” Q10: “Do the conclusions drawn in the research report flow from the analysis or interpretation of the data?”).

2.6. Data Extraction

Data extraction will be conducted independently by two reviewers (LK and EW) using the standardized JBI SUMARI data extraction tool. The extracted data will include specific details about the populations, context, culture, geographical location, study methods, and phenomenon of interest relevant to the review question and specific objectives. Findings and illustrations will be extracted and assigned a level of credibility. Emerging disagreements between the two reviewers during the data extraction process will be resolved by discussion or third-party conciliation (AC). If necessary, the authors of the included studies will be contacted to provide any missing information relevant to the data extraction process. The preliminarily developed data extraction form will be piloted and amended if needed.

2.7. Data Synthesis

Where possible, qualitative research findings will be pooled using the JBI SUMARI meta-aggregation approach [48]. This involves the aggregation or synthesis of findings to generate a set of statements that represent aggregation by assembling the findings and categorizing these findings based on similarity in meaning. These categories are then subjected to synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Only unequivocal and credible findings will be included in this aggregation. Non-supported findings will be presented separately. Where textual pooling is not possible, the findings will be presented in narrative form.

2.8. Appraisal of Certainty in the Review Findings

To establish confidence in the output of the qualitative synthesis, the review findings will be graded according to the ConQual approach [49]. The results of the ConQual grading will be displayed in a Summary of Findings table. The title, population, phenomenon of interest, and context of the review will be displayed in a table. The table will further include the key findings of the review and the type of research informing it. Moreover, it will highlight how the ConQual score was calculated for each finding by providing information on the dependability and credibility scores and how they were calculated.

3. Conclusions

The results of the planned review will help to inform patients, care providers, and other stakeholders about specific barriers and facilitators in pain neuroscience education for chronic musculoskeletal pain conditions. To achieve a sustainable change in daily practice, supported implementation projects could be considered as an effective tool.