Abstract
Objectives
Physical activity is essential for long-term chronic pain management, yet individuals struggle to participate. Exercise professionals, including fitness instructors, and personal trainers, are preferred delivery agents for education and instruction on chronic pain, physical activity, and strategies to use adherence-promoting behavioral skills. However, exercise professionals receive no relevant training during certification or continuing education opportunities to effectively support their participants living with chronic pain. Based on the ORBIT model for early pre-efficacy phases of development and testing of new behavioral treatments, the present Phase IIa proof-of-concept study was conducted. The purpose was to examine the impacts of a newly developed chronic pain and physical activity training workshop on psychosocial outcomes among exercise professionals. Outcomes included knowledge and attitudes regarding chronic pain, attitudes and beliefs about the relationship between pain and impairment, and self-efficacy to educate and instruct participants with chronic pain.
Methods
Forty-eight exercise professionals (Mage=44.4±11.0 years) participated in a three-hour, in-person workshop that was offered at one of four different locations. Participants completed pre- and post-workshop outcome assessment surveys.
Results
Mixed MANOVA results comparing time (pre- versus post-workshop) by workshop location (sites 1 to 4) illustrated a significant within-subjects time effect (p<0.001). All outcomes significantly improved from pre- to post-workshop (p′s<0.001), demonstrating large effect sizes (partial eta-squared values ranging from 0.45 to 0.59).
Conclusions
Findings offer early phase preliminary support for the effectiveness of the chronic pain and physical activity training workshop for exercise professionals. Based on ORBIT model recommendations, findings warrant future phased testing via a pilot randomized clinical trial as well as testing for impacts that trained professionals have on activity adherence among their clients living with chronic pain. Eventual workshop adoption by exercise professional certification organizations would ensure widespread and sustainable access to qualified exercise professionals to help individuals engage in physical activity. By increasing the capacity of available exercise professionals to deliver effective support, active individuals could better manage their chronic pain and live well.
Introduction
Chronic pain is a global public health issue impacting 20% of adults [1], [2], [3]. Chronic pain is a disease in its own right involving unpleasant sensory and emotional experiences unique to each individual and can be disabling without appropriate management [4], [5], [6], Individuals living with chronic pain experience limitations to their physical and mental health, such as reductions in physical functioning and increases in depression and anxiety [5], [7], Individuals frequently seek medical care, with direct and indirect costs from chronic pain being an estimated $56–60 billion per year in Canada, where the present research was conducted [8], [9]
Physical activity is an essential non-pharmacological strategy for long-term chronic pain management [5], [10], [11], Yet most adults living with chronic pain struggle to be physically active [12], [13], [14], Key supports for individuals to participate in physical activity are primary health care professionals (e.g., physicians, nurses, physiotherapists) and allied health care professionals, including exercise professionals who are comprised of fitness class instructors and personal trainers. To serve as supports, primary and allied health care professionals should focus on educating individuals about their chronic pain with an accompanying emphasis on appropriate physical activity participation as a first-line chronic pain management strategy [5], [15], [16], [17], [18], [19], [20]
Unfortunately, exercise professionals in Canada, who were the allied health care professionals of focus in the present research, receive no formal training on chronic pain and physical activity during their certification or continuing education opportunities by professional bodies (e.g., Canadian Society for Exercise Physiology) [15], [19], Given this lack of training, exercise professionals are limited in their knowledge, attitudes, and beliefs about chronic pain as well as in their confidence to educate and instruct their participants living with chronic pain [21], To date, improvements in these psychosocial outcomes as well as in related behavioral outcomes have been found among primary health care professionals who participated in chronic pain and physical activity training interventions. Findings have illustrated that primary health care professionals who participated in trainings were more likely to intend to and/or provide evidence-based pain management to patients (e.g., communicate accurate pain information; recommend appropriate management strategies including physical activity). Further, trained professionals reported increases in their chronic pain knowledge, more accurate attitudes and beliefs about chronic pain as well as increases in self-efficacy for educating their patients [22], [23], [24], [25], [26], [27], [28], [29], Encouraging evidence about the impact of training interventions on psychosocial and behavioral outcomes among primary health care professionals provided a rationale for attempting similar research among exercise professionals.
Thus, the focus of the present study was on developing and testing the impact of a newly developed chronic pain and physical activity training workshop intervention on psychosocial outcomes among exercise professionals. We examined the impact on exercise professionals’ knowledge and attitudes regarding chronic pain, their attitudes and beliefs about the relationship between chronic pain and impairment, as well as their self-efficacy to educate and instruct their participants living with chronic pain. Although research with primary health care professionals is encouraging, it cannot be assumed that the impact of training interventions will be directly transferable to exercise professionals who provide a different and more specific form of care to their participants. The development of a new intervention with a different population requires a series of steps. Our study aligned with recommendations of the ORBIT model for early and progressive evidence-based phased development of new behavioral treatments targeting chronic disease management (e.g., chronic pain) [30], A key early phase of the ORBIT model is the testing of a newly developed intervention in a new population via a proof-of-concept study, as done in the present research.
Physical activity for adults with chronic pain: importance of exercise professionals
Engaging in physical activity is feasible given that chronic pain does not severely limit most individuals’ performance of daily activities [1], Unfortunately, the majority of adults with chronic pain are inactive or engage in less physical activity compared to their pain-free counterparts [12], [13], [14], Adults have reported difficulty with participation due to challenges, such as pain and related barriers (e.g., fatigue), common activity barriers (e.g., no motivation), and fears that being active will increase pain levels [31], [32], Also, individuals often lack the adherence-promoting self-regulatory behavioral skills and confidence to combat challenges to their activity [31], [33], [34], The impact of these factors may be reduced, and physical activity increased, if individuals receive guided chronic pain and physical activity education and instruction by appropriately trained health care professionals. Ideally, trained professionals would integrate the application of chronic pain education with instruction and education on appropriately tailored physical activity and strategies for using self-regulatory behavior skills [5], [15], [16], [17], [18], [19], [20]
A referral pathway from primary health care professionals to certified exercise professionals is recommended [15], [19], [35], This is because primary health care professionals report significant barriers to delivering added education, advice, and/or instruction to their patients, such as competing treatment priorities and a lack of time [26], [36], [37], Unfortunately, a dearth of training opportunities exists for exercise professionals as part of their certification or continuing education opportunities. At present, these professionals are ill-prepared to work with their participants who want to better manage their chronic pain through physical activity.
Development and testing of a new intervention for exercise professionals
An immediate research need is the progressive development and testing of an intervention for exercise professionals that includes training on essential chronic pain and physical activity educational and instructional components. To address this need, the ORBIT intervention development model outlines a flexible and progressive refinement process of different research phases [30], The primary focus of the model is on early pre-efficacy phases of intervention development and testing, involving a small number of selective participants. The model also highlights the importance of a return to refinement and optimization if needed and an eventual progression to randomized clinical trials, given evidence from earlier phases.
The ORBIT model begins with the identification of a significant clinical question or problem that could be addressed through an intervention. Once the problem has been identified, Phase I work is conducted, which includes identifying essential components of an intervention. In the context of the present study, the identified problem was that exercise professionals are ill-prepared to educate and instruct their participants living with chronic pain to be physically active. Training in order to solve this problem was warranted. The procedures employed from our Phase I work to identify essential components of a training workshop are summarized in the methods section.
Subsequently, Phase IIa research is conducted that includes testing via a proof-of-concept design with a small convenience sample in a real-world setting. The present study was such a Phase IIa investigation. According to the ORBIT model, this type of study design is ideal for determining the impact of a newly developed intervention on intended outcomes among a small, select sample in a cost-effective manner. Findings can then be used to inform future studies along the intervention development continuum, such as a pilot study with randomized intervention and control groups.
Purpose and hypothesis
The purpose of the present Phase IIa proof-of-concept study was to examine the impact of a preliminary, newly developed three-hour in-person chronic pain and physical activity training workshop intervention for exercise professionals. Psychosocial outcomes included exercise professionals’ knowledge and attitudes regarding chronic pain, attitudes and beliefs about the relationship between chronic pain and impairment, and self-efficacy to educate and instruct their participants living with chronic pain. Significant pre- to post-training workshop improvements in the outcome variables were expected.
Methods
Design and procedures
The study design was a proof-of-concept, treatment-only, within-subjects design with a convenience sample of exercise professional participants acting as their own controls (Phase IIa study, ORBIT model) [30], The University’s Behavioral Research Ethics Board approved the study procedures prior to conduct. Recruitment occurred via announcements distributed through a provincial exercise professional certification organization and fitness and leisure centers. Interested exercise professionals contacted a research assistant through an email address or telephone number that were contained in the study announcements. The research assistant screened interested individuals for participant inclusion criteria, including: (a) being an adult, 18+ years, (b) current exercise professional, (c) English-speaking, and (d) could attend one of four available in-person training workshops scheduled at pre-determined times and locations (i.e., private rooms at leisure centers). The training workshop was delivered in three different municipalities in a Canadian province during 2018–19 in which exercise professionals delivered physical activity instruction. A minimum sample size of 30 participants was needed to conduct the primary study analysis involving three outcome variables [38]
All interested individuals met inclusion criteria and attended a 3-h in-person training workshop (site 1 n=19; site 2 n=12; site 3 n=9; site 4 n=8). Participants provided informed consent upon arrival and completed pre- and immediately post-training workshop paper surveys to assess study outcomes and demographics (post-survey only). Each survey took approximately 15–20 min to complete. The training was offered in a structured, interactive workshop format, led by trained interventionists, similar to procedures in previous studies targeting primary health care professionals [23], [26], Participants received take-home summary print material of the training workshop content. The overall aims of the training workshop were to help the exercise professional participants learn strategies to deliver education on chronic pain as well as on the positive relationship between chronic pain and physical activity, strategies to provide guided, appropriately tailored physical activity instruction, and strategies to teach their participants to use adherence-promoting self-regulatory behavioral skills.
More specifically, the training workshop included essential components identified by the researchers, which was characteristic of Phase I preliminary work as described in the ORBIT model [30], The essential components included the provision of education to exercise professional study participants on: (1) basic pain neuroanatomy and neurophysiology as well as the biopsychosocial model of pain, (2) physical activity as an effective chronic pain self-management strategy, (3) strategies to encourage chronic pain self-management during physical activity, (4) providing appropriate physical activity counselling and instruction, and (5) strategies to teach their participants the use of evidence-based self-regulatory behavioral skills to foster their physical activity adherence [33], [34], Specific skills included self-monitoring physical activity and pain, identifying realistic and motivating short-term physical activity outcome expectations, physical activity goal setting, coping with pain and related barriers (e.g., fatigue) and common barriers (e.g., lack of time), and preventing activity relapses (i.e., lack of physical activity participation over many weeks).
Consistent with ORBIT model Phase I recommendations for identifying essential components,[30], the researchers reviewed research studies, literature reviews, and clinical recommendations for non-pharmacological treatment of chronic pain, including chronic pain education. Given the of the training workshop to target exercise professionals, the research studies and literature reviews involved mainly primary health care professional samples who were targeted for chronic pain and/or physical activity trainings, as well as literature reviews on behavioral skills important for physical activity adherence [11], [23], [26], [28], [33], [34], [39]
Measures
Knowledge and attitudes regarding chronic pain
Participants completed a modified version of the reliable and valid City of Boston’s Rehabilitation Professionals’ Knowledge and Attitudes Survey Regarding Pain (COBS) [40], The COBS was originally developed to assess knowledge and attitudes regarding chronic pain among rehabilitation professionals. The COBS was modified in the present study so that items were salient for exercise professionals. The original measure contained 26 true/false items, five multiple choice items, and four case studies, covering various aspects of pain (e.g., pain assessment, malingering). Modifications included removal of non-salient items, including three true/false items on pediatric pain as well as one true/false item and one multiple choice item on pain medications. Slight wording changes were made to four additional items (e.g., changed “therapists” to “exercise professionals” in the stems). The case studies in the original COBS were not relevant to exercise professionals and were removed, as done in past research with other samples [41], The final measure included 23 true/false items and four multiple choice items. An example true/false item was “Acute and chronic pain require similar interventions.” An example multiple choice question was “The most accurate judge of the intensity of the person’s pain is”, followed by response options that included the “treating physician; person’s primary nurse; person experiencing pain; physical therapist; occupational therapist.” Each item had a correct answer and a percentage of correct scores was calculated, which ranged from 0 to 100%. Higher scores represented higher knowledge and more informed, appropriate attitudes about chronic pain [42]
Attitudes and beliefs about the relationship between chronic pain and impairment
The 15-item Health Care Providers’ Pain and Impairment Relationship Scale (HC-PAIRS) assessed participants’ attitudes and beliefs about the relationship between chronic pain and impairment [43], The original items, which focused on attitudes and beliefs about the relationship between chronic low back pain and impairment, were modified slightly. “Back” was removed from the items to focus participant responses on beliefs about chronic pain generally. An example item was “Chronic pain patients cannot go about normal life activities when they are in pain.” Participants responded to each item on a 0 (completely disagree) to 6 (completely agree) scale. After reverse scoring three items, responses were summed. The possible response range was 0 to 90. Higher scores reflected stronger attitudes and beliefs, which do not align with current evidence, that chronic pain and impairment are invariably linked. Strong agreement has been associated with primary health care professionals’ recommendations to limit physical activity [44], Cronbach’s alpha values were 0.77 at pre-training workshop and 0.75 at post-training workshop.
Self-efficacy to educate and instruct participants with chronic pain
A 16-item measure to assess self-efficacy to educate and instruct participants with chronic pain across three domains was developed. Measurement development followed recommendations for creating self-efficacy scales and was based on a similar measure used in past research for primary health care professionals [45], [46], [47], The domains included: (a) providing education on the positive relationship between physical activity and chronic pain (6 items), (b) instructing participants with chronic pain (4 items), and (c) providing education about the use of self-regulatory behavioral skills (6 items). All items began with “At present, rate your confidence in your skills and abilities to … ” followed by the items. An example education item was “…educate participants that chronic pain is not always related to injury severity.” An example instruction item was “…adapt exercises for participants with chronic pain.” An example self-regulatory behavioral skills item was “… teach participants with chronic pain to set appropriate exercise goals.” Study participants responded to each item on a 0 (not all confident) to 10 (completely confident) scale. A mean score was calculated, with higher scores representing greater confidence. Cronbach’s alpha values were 0.97 at pre- and post-training workshop.
Analytical plan
A mixed MANOVA was conducted using SPSS 26.0 to examine the within-subjects time differences (pre- vs post-training workshop) as well as any potential differences between training workshop location sites (1 – 4) and their interaction. Dependent outcome variables included knowledge and attitudes regarding chronic pain, attitudes and beliefs about the relationship between pain and impairment, and self-efficacy to educate and instruct participants with chronic pain. If multivariate findings were significant, post-hoc univariate analyses were planned. Significance for all tests was set at p<0.05. No missing data or outliers were found, and all assumptions for the mixed MANOVA were checked and met. Of note, MANOVA offered the advantage, over individual mixed ANOVAs, of identifying patterns between the combination of multiple dependent variables, which we were interested in given encouraging evidence about the impact of training interventions on these variables among health care professionals [38]
Results
Participants
Participants included 48 exercise professionals who ranged in age from 24 – 68 years (M=44.4±11.0). Participants were mainly women (n=41; 85.4%), White (n=40; 83.3%), and employed full-time (n=23; 47.9%) or part-time (n=18; 37.5%). Most participants held a Bachelor’s degree or higher (n=34; 70.8%). All participants were certified exercise professionals working with adults in community-based fitness and leisure centers in a province in Canada.
Comparing pre- versus post-training workshop outcomes
Nonsignificant MANOVA results were found for the between-subjects effect of training workshop location site, Pillai’s Trace=0.34, F(9, 132)=1.84, p>0.05, and the interaction effect, Pillai’s Trace=0.18, F(9, 132)=0.96, p>0.05.
The within-subjects time effect was significant, Pillai’s Trace=0.70, F(3, 42)=33.36, p<0.001. As seen in Table 1, post-hoc univariate analyses illustrated that all outcome variables significantly improved from pre- to post-training workshop. The improvements included: (a) increased knowledge and attitudes regarding chronic pain, F(1, 44)=31.24, p<0.001, (b) more disagreement with and, thus, more accurate attitudes and beliefs about the relationship between chronic pain and impairment, F(1, 44)=50.72, p<0.001, and (c) increased self-efficacy to educate and instruct participants living with chronic pain, F(1, 44)=63.94, p<0.001. Estimated pre- and post- marginal means are presented in Table 1. Pre- and post-training workshop raw means are presented in the Table note. As also seen in Table 1, partial eta-squared values ranged from 0.45 to 0.59, which were illustrative of large effect sizes for the outcome variables [48]
Comparing Pre- vs Post-Training Workshop Outcomes within Participants (n=48).
| Outcome | Pre-estimated marginal mean (SE) | Post-estimated marginal mean (SE) | 95% CI for difference [LL, UL] | p-Value | Partial eta-squared |
|---|---|---|---|---|---|
| Knowledge and attitudes regarding chronic pain | 65.93 (2.04) | 74.98 (1.83) | [5.78, 12.31] | <0.001 | 0.45 |
| Attitudes and beliefs about the relationship between chronic pain and impairment | 47.67 (1.57) | 38.49 (1.42) | [−11.78, –6.58] | <0.001 | 0.55 |
| Self-efficacy to educate and instruct | 5.96 (0.30) | 7.61 (0.19) | [1.23, 2.06] | <0.001 | 0.59 |
-
Note. Higher estimated marginal means illustrated: (a) higher knowledge and more informed, appropriate attitudes regarding chronic pain (0 – 100 response scale), (b) stronger, more inaccurate attitudes and beliefs that chronic pain justifies impairment (0 – 90 response scale), and (c) higher self-efficacy to educate and instruct participants with chronic pain (0 – 10 response scale). Pre- vs. post-training workshop raw means±SD were: knowledge and attitudes regarding chronic pain: 66.89 (14.12) vs. 75.54 (12.29) 67.82±13.30 vs. 76.44±11.95; attitudes and beliefs about the relationship between chronic pain and impairment: 47.58±10.03 vs. 37.79±9.95; and (c) self-efficacy: 6.09±2.00 vs. 7.71±1.33.
Discussion
This proof-of-concept study was a first step in addressing the need to build the capacity of exercise professionals to deliver appropriate education and instruction to their participants living with chronic pain [15], [19], As expected, exercise professionals who participated in the newly developed three-hour, in-person chronic pain and physical activity training workshop reported significant improvements in study outcomes. Large effects were found for improvements in exercise professional participants’ knowledge, attitudes, beliefs, and self-efficacy.
Study results are similar to those reported in prior research with primary health care professional samples. In general, when such professionals were trained on chronic pain and/or physical activity, their chronic pain knowledge, informed attitudes and beliefs, and self-efficacy were related to their intention to and/or actual provision of evidence-based pain management to patients, including being physically active [24], [26], [29], [49], The same psychosocial outcomes were examined in the present study based on these encouraging findings. Further, although not a focus of the present study, these psychosocial outcomes are expected to relate to exercise professionals’ motivation to engage and persist over time in delivering education and instruction on chronic pain and physical activity to their participants living with chronic pain [50], Doing so could then result in helping individuals better manage their pain through regular physical activity participation However, as a first step, testing whether our newly developed training workshop positively impacted the psychosocial outcomes among exercise professionals in a proof-of-concept study was needed [30]
In the present study, significant pre- to post-training workshop increases in exercise professional participants’ knowledge and attitudes regarding chronic pain (i.e., 66 to 75%) were found. The pre-training workshop score of 66% meant that the sample, on average, answered 17 – 18 of the 27 questions correctly on the measure. The post-training workshop score of 75% represented the correct answering of 20 – 21 questions. Although study findings were illustrative of large increases in knowledge and attitudes after a single training session, room for additional improvement existed. Building on ORBIT model recommendations allowing for refinement and optimization of new interventions,[30], future research should identify whether additional workshop content could further enhance exercise professionals’ knowledge and attitudes regarding chronic pain.
Study participants’ attitudes and beliefs about the relationship between chronic pain and impairment significantly decreased from 48 to 38.5. The post-training workshop score, which was below the response scale midpoint (0 – 90 scale), reflected participants’ disagreement that chronic pain and impairment were invariably linked. To put study findings into context, a comparison to scores of other samples is instructive. More specifically, the pre-training workshop mean was similar to values reported by untrained primary health care professionals in observational research [43], [51], [52], [53], Further, present study findings that the training workshop impacted exercise professionals to disagree that chronic pain and impairment is invariably linked is notable. This is because among primary health care professional samples more disagreement has been related to stronger intention to, and actual provision of, physical activity recommendations to patients with chronic pain [44], [47], Understanding whether disagreement among exercise professionals is also related to these same outcomes should be investigated in future research.
The training workshop also resulted in a significant increase in exercise professional participants’ self-efficacy to educate and instruct their participants living with chronic pain. According to self-efficacy theory,[45], higher self-efficacy is key for individuals persisting in performing motivated behaviors. Given that educating and instructing participants is a motivated behavior for exercise professionals, identifying a training method to enhance their self-efficacy is promising.
Comparison to other professional samples is once again useful. The increases in self-efficacy finding parallels past research in which exercise professionals were trained to provide physical activity counselling to their participants in general, not specific to those living with chronic pain [54], Further, study participants’ post-training workshop self-efficacy was comparable to the level of self-efficacy to educate and instruct chronic pain patients found among physiotherapists in observational research [47], This is notable given that physiotherapists likely have more training in chronic conditions and their management, including chronic pain,[55], than exercise professionals. Yet, in the present study, a single 3-h training was sufficient to raise exercise professionals’ self-efficacy to a comparable level.
Strengths and limitations
The strength of the current study was its planning following the phased approach recommended in the ORBIT model for new intervention development [30], The model stresses the importance of early phases of research in which essential intervention components are identified in Phase I, with preliminary intervention testing occurring in Phase IIa. Limited generalizability is an understood tradeoff that comes with the use of the recommended proof-of-concept design with a small convenience sample in Phase IIa [30], However, at this early stage of intervention development, the goal was to obtain initial, low cost evidence of changes in outcomes in a real-world context [30], While valuable information about changes in psychosocial outcomes was observed due to the training workshop intervention, findings should be interpreted as being somewhat limited in that the changes occurred within a small sample of primarily White women and not a more diverse sample. Further, response bias in survey responses may have occurred due to the sample being self-selected who, more than likely, were motivated to learn about and receive training in chronic pain and physical activity
Future directions
Given ORBIT model recommendations that allow for refinement and optimization of new interventions,[30], an immediate next step would be to conduct focus groups with exercise professionals. The purpose would be to gain their feedback on additional content that could be included in the training workshop to further enhance their knowledge and attitudes regarding chronic pain. As noted earlier, despite positive post-training workshop changes after one training session, room for improvement existed. With the identification and integration of additional content into the training workshop, it would follow that another Phase IIa proof-of-concept study should be conducted. A successful proof-of-concept study would, in turn lead to subsequent steps in the Phase II aspect of the ORBIT intervention development process (e.g., a pilot randomized clinical trial with a larger more representative sample). The interested reader should refer to the paper by Czajkowski and colleagues for a complete description of further ORBIT model phases and studies in the intervention development process [30]. In the longer-term, testing the impact that trained exercise professionals have on their participants living with chronic pain should occur. This testing should include whether individuals exposed to exercise professionals trained in the workshop engage in more sustained physical activity over time and show resultant improvements in their pain intensity and related outcomes (e.g., depression) compared to individuals exposed to untrained exercise professionals.
Conclusions
If the intervention development proceeds to the eventual demonstration that trained exercise professionals positively impact the physical activity participation and, in turn, improvements in pain and related outcomes of their participants living with chronic pain, then a critical real-world application follows. Two steps should then be undertaken to ensure that widespread community capacity exists for exercise professionals to help their participants better manage their chronic pain through physical activity. First, exercise professional certification organizations would need to adopt and deliver the chronic pain and physical activity training workshop. Second, these same organizations would need to require that their exercise professionals take the training workshop during certification or are required to as a part of their education opportunities. Requiring the training workshop as part of certification or continuing education would be the ideal strategy to ensure that all exercise professionals who are certified by the organizations would be well-prepared to educate and instruct their participants to better manage their chronic pain through physical activity. In conclusion, this initial study included necessary early phased research in the intervention development process, with the long-term goal of creating an impactful chronic pain and physical activity training workshop for exercise professionals.
Funding source: Saskatchewan Health Research Foundation
Award Identifier / Grant number: SHRF 3969
Funding source: Saskatchewan Community Initiatives Fund
Award Identifier / Grant number: CIF 16:971
-
Research funding: Research was funded by the Saskatchewan Health Research Foundation (SHRF 3969) and the Saskatchewan Community Initiatives Fund (CIF 16:971).
-
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
-
Conflict of interest: Authors state no conflict of interest.
-
Informed consent: Informed consent has been obtained from all individuals included in this study.
-
Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance with the tenets of the Helsinki Declaration.
References
1. Dahlhamer, J, Lucas, J, Zelaya, C, Hahin, R, Mackey, S, DeBar, L, et al. Prevalence of chronic pain among adults – United States. MMWR 20162018;67:1001–6 https://doi.org/10.15585/mmwr.mm6736a2.Search in Google Scholar PubMed PubMed Central
2. Shupler, MS, Kramer, JK, Cragg, JJ, Jutzeler, CR, Whitehurst, DGT. Pan-Canadian estimates of chronic pain prevalence from 2000 to 2014: a repeated cross-sectional survey analysis. J Pain 2019;20:557–65 https://doi.org/10.1016/j.jpain.2018.10.010.Search in Google Scholar PubMed
3. Breivik, H, Collett, B, Ventafridda, V, Cohen, R, Gallacher, D. Surve of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287–333 https://doi.org/10.1016/j.ejpain.2005.06.009.Search in Google Scholar PubMed
4. Ballantyne, JC, Fishman, SM, Rathmell, JP, editors Bonica’s management of pain, 5th ed. Philadelphia: Wolters Kluwer Health; 2019.Search in Google Scholar
5. Health Canada. Chronic pain in Canada: laying a foundation for action. A report prepared by the Canadian Task Force. Canada: 2019. June 2019 (Cat.: H134-5/2019E-PDF) [internet]. Available from: https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019/canadian-pain-task-force-June-2019-report-en.pdf.Search in Google Scholar
6. Nicholas, M, Vlaeyen, JWS, Rief, W, Barke, A, Aziz, Q, Benoliel, R, et al. The IASP classification of chronic pain for ICD-11: chronic primary pain. Pain 2019;160:28–37. https://doi.org/10.1097/j.pain.0000000000001390.Search in Google Scholar PubMed
7. Institute of Medicine. Relieving pain in America. A blueprint for transforming prevention, care, education and research. Washington, DC: National Academies Press; 2011. https://doi.org/10.17226/13172.Search in Google Scholar PubMed
8. Gaskin, DJ, Richard, P. The economic costs of pain in the United States. J Pain 2012;13:715–24 https://doi.org/10.1016/j.jpain.2012.03.009.Search in Google Scholar PubMed
9. Wilson, MG, Lavis, JN, Ellen, ME. Supporting chronic pain management across provincial and territorial health systems in Canada: findings from two stakeholder dialogues. Pain Res Manag 2015;20:269–79 https://doi.org/10.1155/2015/918976.Search in Google Scholar PubMed PubMed Central
10. Busse, JW, Craigie, S, Juurlink, DN, Buckely, DW, Wang, L, Couban, R, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ 2017;8:E659–66 https://doi.org/10.1503/cmaj.170363.Search in Google Scholar PubMed PubMed Central
11. Dowell, D, Haegrich, TM, Chou, R. CDC guideline for prescribing opioids for chronic pain – United States. J American Med Assoc 2016;315:1624–45 https://doi.org/10.1001/jama.2016.1464.Search in Google Scholar PubMed PubMed Central
12. Dansie, EJ, Turk, DC, Martin, KR, Van Domelen, DR, Patel, KV. Association of chronic widespread pain with objectively measured physical activity in adults: findings from the national health and nutrition examination survey. J Pain 2014;15:507–15 https://doi.org/10.1016/j.jpain.2014.01.489.Search in Google Scholar PubMed
13. Jordan, JL, Holden, MA, Mason, EEJ, Foster, NE. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev 2010;20:CD005956 https://doi.org/10.1002/14651858.CD005956.pub2.Search in Google Scholar PubMed PubMed Central
14. Larsson, C, Hansson, EE, Sundquist, K, Jakobsson, U. Impact of pain characteristics and fear beliefs on physical activity levels among older adults with chronic pain. BMC Geriatr 2016;16:50 https://doi.org/10.1186/s12877-016-0224-3.Search in Google Scholar PubMed PubMed Central
15. Brittain, DR, Gyurcsik, NC, Tupper, SM, Downe, PJ. Moving forward with physical activity: self-management of chronic pain among women. Womens Health Issues 2018;28:113–6 https://doi.org/10.1016/j.whi.2017.12.006.Search in Google Scholar PubMed
16. Foster, NE, Anema, JR, Cherkin, D, Chou, R, Cohen, SP, Gross, DP, On behalf of the Lancet Low Back Pain Series Working Group, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018;391:2368–83 https://doi.org/10.1016/S0140-6736(18)30489-6.Search in Google Scholar PubMed
17. Galán-Martín, MA, Montero-Cuadrado, F, Lluch-Girbes, E, Coca-López, CM, Mayo-Iscar, A, Cuesta-Vargas, A. Pain neuroscience education and physical exercise for patients with chronic spinal pain in primary healthcare: a randomised trial protocol. BMC Musculoskelet Disord 2019;20:505 https://doi.org/10.1186/s12891-019-2889-1.Search in Google Scholar PubMed PubMed Central
18. Geneen, LJ, Martin, DJ, Adams, N, Clarke, C, Dunbar, M, Jones, D, et al. Effects of education to facilitate knowledge about chronic pain for adults: a systematic review with meta-analysis. Syst Rev 2015;4:1–21 https://doi.org/10.1186/s13643-015-0120-5.Search in Google Scholar PubMed PubMed Central
19. Gyurcsik, NC, Shields, CA, Brawley, LR, Cary, MA. Physical activity for arthritis and diabetes: psychological aspects of self-management behavior for people with chronic disease. In: Horne, TS, Smith, AL, editors Advances in sport and exercise psychology, 4th ed. Illinois: Human Kinetics; 2019. p. 425–43.Search in Google Scholar
20. Qaseem, A, Wilt, TJ, McLean, RM, Forciea, MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the american college of physicians. Ann Intern Med 2017;166:514–30 https://doi.org/10.7326/M16-2367.Search in Google Scholar PubMed
21. Cary, MA, Tupper, SM, Gyurcsik, NC, Ratcliffe-Smith, D, Brawley, LR. Examination of exercise providers’ knowledge and beliefs to offer integrated counseling to adults with chronic non-cancer pain. ISBNPA; 2017. 2017 Abstract Book. https://www.isbnpa.org/index.php?r=article/view&id=70.Search in Google Scholar
22. Anderson, DR, Zlateva, I, Coman, EN, Kahtri, K, Tain, T, Kerns, RD. Improving pain care through implementation of the stepped care model at a multisite community health center. J Pain Res 2016;9:1021–9 https://doi.org/10.2147/JPR.S117885.Search in Google Scholar PubMed PubMed Central
23. Bennell, KL, Ahamed, Y, Jull, G, Bryant, C, Hunt, MA, Forbes, AB, et al. Physical-therapist-delivered pain coping skills training and exercise for knee osteoarthritis: randomized controlled trial. Arthritis Care Res 2016;68:590–602 https://doi.org/10.1002/acr.22744.Search in Google Scholar PubMed
24. Carlin, L, Zhao, J, Dubin, R, Taenzer, P, Sidrak, H, Furlan, A. Project ECHO telementoring intervention for managing chronic pain in primary care: insights from a qualitative study. Pain Med 2018;19:1140–6 https://doi.org/10.1093/pm/pnx233.Search in Google Scholar PubMed PubMed Central
25. Courtenay, CM, Carey, NC. The impact and effectiveness of nurse-led care in the management of acute and chronic pain: a review of literature. J Clin Nurs 2008;17:2001–13 https://doi.org/10.1111/j.1365-2702.2008.02361.x.Search in Google Scholar PubMed
26. Fowles, JR, O’Brien, MW, Solmundson, K, Oh, PI, Shields, CA. Exercise is medicine canada physical activity counselling and exercise prescription training improves counselling, prescription, and referral practices among physicians across Canada. Appl Physiol Nutr Metab 2018;43:535–9 https://doi.org/10.1139/apnm-2017-0763.Search in Google Scholar PubMed
27. Jacobs, CM, Guildford, BJ, Travers, W, Davies, M, McCracken, LM. Brief psychologically informed physiotherapy training is associated with changes in physiotherapists’ attitudes and beliefs towards working with people with chronic pain. Br J Pain 2016;10:38–45 https://doi.org/10.1177/2049463715600460.Search in Google Scholar PubMed PubMed Central
28. Monaghan, J, Adams, N, Fothergill, M. An evaluation of a pain education programme for physiotherapists in clinical practice. Musculoskeletal Care 2018;16:103–11 https://doi.org/10.1002/msc.1218.Search in Google Scholar PubMed
29. Slater, H, Davies, SJ, Parsons, R, Quintner, JL, Schug, SA. A policy-into-practice intervention to increase the update of evidence-based management of low back pain in primary care: a prospective cohort study. PLoS One 2012;7:e38037.10.1371/journal.pone.0038037Search in Google Scholar PubMed PubMed Central
30. Czajkowski, SM, Powell, LH, Adler, N, Naar-King, S, Reynolds, KD, Hunter, CM, et al. From ideas to efficacy: the ORBIT model for developing behavioral treatments for chronic diseases. Health Psychol 2015;34:971–82 https://doi.org/10.1037/hea0000161.Search in Google Scholar PubMed PubMed Central
31. Ambrose, KR, Golightly, YM. Physical exercise as non-pharmacological treatment of chronic pain: why and when. Best Pract Res Clin Rheumatol 2015;29:120–30 https://doi.org/10.1016/j.berh.2015.04.022.Search in Google Scholar PubMed PubMed Central
32. Warner, LM, Wolff, JK, Spuling, SM, Wurm, S. Somatic and affective barriers for self- and physical activity. J Health Psychol 2019;24:1850–62 https://doi.org/10.1177/1359105317705979.Search in Google Scholar PubMed
33. Artinian, NT, Fletcher, GF, Mozaffarian, D, Kris-Etherton, P, Van Horn, L, Lichtenstein, AH, et al. Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults. Circ 2010;122:406–41 https://doi.org/10.1161/CIR.0b013e3181e8edf1.Search in Google Scholar PubMed PubMed Central
34. Brawley, LR, Gierc, MSH, Locke, SR. Powering adherence to physical activity by changing self-regulatory skills and beliefs: are ready to counsel?. Kines Rev 2013;2:4–16 https://doi.org/10.1123/krj.2.1.4.Search in Google Scholar
35. Warburton, ER, Charlesworth, SA, Foulds, HJA, McKenzie, DC, Shephard, RJ, Bredin, SSD. Qualified exercise professionals. Best practice for work with clinical populations. Can Fam Physician 2013;59:759–61. https://europepmc.org/article/PMC/3710048.Search in Google Scholar
36. Clark, RE, McArthur, C, Papaioannou, A, Cheung, AM, Laprade, J, Lee, L, et al. “I do not have time. Is there a hand-out I can use?”: combining physicians’ needs and behavior change theory to put physical activity evidence into practice. Osteoporosis Int 2017;28:1953–63 https://doi.org/10.1007/s00198-017-3975-6.Search in Google Scholar PubMed
37. Hébert, ET, Caughy, MO, Shuval, K. Primary care providers’ perceptions of physical activity counselling in a clinical setting: a systematic review. Br J Sports Med 2012;46:625–31 https://doi.org/10.1136/bjsports-2011-090734.Search in Google Scholar PubMed
38. Tabachnick, BG, Fidell, LS. Using multivariate statistics., 7th ed. New York: Pearson; 2019.Search in Google Scholar
39. Stevenson, K, Jackson, S, Shufflebotham, J, Roddy, E, Foster, NE. Development and delivery of a physiotherapist-led exercise intervention in a randomised controlled trial for subacromial impingement syndrome (the SUPPORT trial). Physiotherapy 2017;103:379–86 https://doi.org/10.1016/j.physio.2017.03.005.Search in Google Scholar PubMed
40. Rochman, D, Herbert, P. Occupational and physical therapists’ knowledge and attitudes regarding pain: a survey, American Pain Society Bulletin 2000;4–5:7. Available from https://prc.coh.org/html/rehab_professionals.htm.Search in Google Scholar
41. Reyes, AN, Brown, CA. Occupational therapists’ pain knowledge: a national survey. Disabil Rehabil 2016;38:1309–17 https://doi.org/10.3109/09638288.2015.1090486.Search in Google Scholar PubMed
42. Rochman, DL, Sheehan, MJ, Kulich, RJ. Evaluation of a pain curriculum for occupational therapists: experiences from a master’s-level graduate program over six years. Disabil Rehabil 2013;35:1933–40 https://doi.org/10.3109/09638288.2013.766273.Search in Google Scholar PubMed
43. Rainville, J, Bagnall, D, Phalen, L. Health care providers’ attitudes and beliefs about functional impairments and chronic back pain. Clin J Pain 1995;11:287–95 https://doi.org/10.1097/00002508-199512000-00006.Search in Google Scholar PubMed
44. Darlow, B, Fullen, BM, Dean, S, Hurley, DA, Baxter, GD, Dowell, A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a review. Eur J Pain 2012;16:3–17 https://doi.org/10.1016/j.ejpain.2011.06.006.Search in Google Scholar PubMed
45. Bandura, A. Self-efficacy theory: the exercise of control. New York: Freeman; 1997.Search in Google Scholar
46. Bandura, A. Guide for constructing self-efficacy scales. In: Pajares, F, Urdan, T, editors Self-efficacy beliefs of adolescents. North Carolina: Information Age Publishing; 2006. p. 307–38.Search in Google Scholar
47. Blouin, JE, Cary, MA, Marchant, MG, Gyurcsik, NC, Brittain, DR, Zapski, J. Physiotherapists’ intention to counsel clients with chronic pain on exercise: a focus on psychosocial factors. Physiother Can 2019;71:319–26 https://doi.org/10.3138/ptc-2018-38.Search in Google Scholar PubMed PubMed Central
48. Richardson, JTE. Eta squared and partial eta squared as measures of effect size in educational research. Educ Res Rev 2011;6:135–47 https://doi.org/10.1016/j.edurev.2010.12.001.Search in Google Scholar
49. Anderson, D, Zlateva, I, Davis, B, Bifulco, L, Giannotti, T, Coman, E, et al. Improving pain care with project ECHO in community health centers. Pain Med 2017;18:1882–9 https://doi.org/10.1093/pm/pnx187.Search in Google Scholar PubMed PubMed Central
50. Bandura, A. Social foundations of thought and action. New York: Prentice-Hall; 1986.Search in Google Scholar
51. Houben, RMA, Vlaeyen, JWS, Peters, M, Ostelo, RW, Stomp-van den Berg, SG. Health care providers’ attitudes and beliefs toward chronic low back pain: factor structure and psychometric properties of the HC-PAIRS. Clin J Pain 2004;20:37–44 https://doi.org/10.1097/00002508-200401000-00008.Search in Google Scholar PubMed
52. Rainville, J, Carlson, N, Polatin, P, Gatchel, RJ, Indahl, A. Exploration of physicians’ recommendations for activities in chronic low back pain. Spine 2000;25:2210–20 https://doi.org/10.1097/00007632-200009010-00012.Search in Google Scholar PubMed
53. Sieben, JM, Vlaeyen, JWS, Portegijs, PJM, Warmenhoven, FC, Sint, AG, Dautzenberg, N, et al. General practitioners’ treatment orientations towards low back pain: influence on treatment behaviour and patient outcome. Eur J Pain 2009;13:412–8 https://doi.org/10.1016/j.ejpain.2008.05.002.Search in Google Scholar PubMed
54. O’Brien, MW, Shields, CA, Oh, PI, Fowles, JR. Health care provider confidence and exercise prescription practices of Exercise is Medicine Canada workshop attendees. Appl Physiol Nutr Metab 2017;42:384–90 https://doi.org/10.1139/apnm-2016-0413.Search in Google Scholar PubMed
55. Watt-Watson, J, McGillion, M, Hunter, J, Choiniere, M, Clark, AJ, Dewar, A, et al. A survey of prelicensure pain curricula in health science faculties in Canadian universities. Pain Res Manag 2009;14:439–44 https://doi.org/10.1155/2009/307932.Search in Google Scholar PubMed PubMed Central
© 2020 Walter de Gruyter GmbH, Berlin/Boston
