Introduction: Between 20% and 33% of people across the globe live with a painful
musculoskeletal (MSK) condition. Costs correspond to almost 2% of the gross domestic
products of European countries, posing a challenge for health care systems across the
world. Patients with chronic musculoskeletal pain have a high use of healthcare, reduced
work ability, loss of productivity, and loss of quality of life. Current care guidelines
underline that pain science education (PSE) is a vital part of the care delivered to
people suffering from chronic pain. PSE is thought in part to attenuate central
sensitization and improve self-efficacy potentially mediated through decreased pain
catastrophizing and modulating nocebo-related effects. On a patient level, PSE has been
shown to reduce pain catastrophizing, pain intensity, and fear-avoidance in addition to
improved physical functioning, self-efficacy, and pain knowledge. Combining exercise and
PSE shows greater short-term improvements in pain, disability, kinesiophobia, and pain
catastrophizing compared to exercise alone and the RESTORE-trial showed the benefit of
adding cognitive components. On a societal level, PSE has further shown to minimize
health expenses. However, some of the proposed barriers include training of the therapist
delivering the education, access to training material, time during consultation, and
patients' health literacy levels. Even in Denmark, a country with a highly educated
population, the prevalence of people with inadequate health literacy is high, with nearly
4 out of 10 people facing difficulties accessing, understanding, appraising, and applying
health information. This underlines the need to consider novel ways of delivering PSE
across all levels of health literacy.
Due to the lack of tools to facilitate PSE programs, the investigators adapted an
existing pain science education program that was developed by Pas et al. (2018)
(PNE4Kids) to teach children with chronic pain about the underlying biopsychosocial
mechanisms contributing to pain. The adapted version, named PNE4Adults, consists of a
manual for the therapist and a board game to enhance engagement and participant
involvement. It provides the therapist with a clear "how-to" manual and an accessible way
for patients to understand the complex concept of pain. This new PSE program may also
hold promise for adult patients with low levels of health literacy and enhance learning
due to its practical tools and build-in teach-back. The focus on integrating PSE into
rehabilitation may enhance the therapeutic alliance needed to facilitate the patients'
ability to manage their own symptoms. The investigators feasibility study in adult
patients with chronic MSK pain in community-based rehabilitation (Eiger, Rathleff et al.
2024 - under review) showed that PNE4Adults was well accepted (100%) and understandable
by all (100%) patients, including those with low levels of health literacy. Qualitive
interviews revealed that patients (irrespective of their health literacy) acquired a
deeper understanding of their own situation and their pain. This novel approach may
reduce the inequality in delivering of pain education.
Purpose of Sub-project 1 The primary aim of the KISS-project is to evaluate the added
effect of PSE ('PNE4Adults') to "usual care" compared to "usual care" alone in
community-based rehabilitation.
The investigators hypothesis is PSE plus "usual care" will result in a larger improvement
of musculoskeletal health (MSK-HQ) after 3 months (primary endpoint) compared to patients
undergoing "usual care" in the municipality.
Purpose of Sub-project 2 The secondary aim is to use a process evaluation to understand
how it works, and for whom the program works.
The purpose of the process evaluation is to understand how it worked and for whom, and
not if it worked. The investigators will combine in-house registrations from the
municipality, clinician observations, individual interviews, and focus-group interviews
to answer what works for whom and under which circumstances. This will give the
investigators additional insights into the novel PSE intervention, shedding light on how
it induces change and uncovering any potential unintended consequences. This will support
future implementation pending results.