Why might fears and worries persist after a pain education-grounded multimodal intervention for chronic back pain? A qualitative study

The effect of pain education (PE) on pain intensity and function diminishes after a few months in people with chronic low back pain (CLBP). One possible explanation is the return of underlying fears and worries related to the condition. To explore topics related to participants' beliefs and feelings that might explain why fears and worries persist after a PE-grounded intervention for CLBP. We conducted a qualitative study involving semistructured interviews with participants from the active arm of a randomised controlled trial who received an individualised PE-grounded intervention for adults with CLBP. We used reflexive thematic analysis with an inductive approach. Twenty participants were interviewed (9 women and 11 men, median age = 54 years, median pain duration = 4 years, 13 reporting at least 30% pain reduction on the trial primary outcome). Three themes were identified: 1) "Are you implying my pain is not real?": a few participants believed the validity of their pain was being questioned. 2) "You don't understand, my pain is different": most participants considered the influence of an altered nervous system but did not exclude the possibility of having structural and biomechanical influences for the persistence of their back pain. 3) "I am unsure how to fit it into my daily life": fear and worries persisted when participants could not figure out how to apply an alternative way of making sense of pain in their daily lives. Patients' perceptions about PE should be monitored and might be addressed with communication strategies, educational content that matches patients' characteristics, and reinforcements over time.