Welcome back to the Healing Pain Podcast with Edwin de Raaij, PT, PhD
Illness perception is defined as the cognitive representations or beliefs that patients have about their illness. It basically means that how you perceive your illness has an influence on the way you think, what you believe is possible, and perhaps most importantly, what you do moving forward. Physiotherapist Edwin de Raaij recently completed a systematic review called the Association of Illness Perception and Prognosis for Pain and Physical Function in Patients with Non-Cancer Musculoskeletal Pain. This is an important topic because illness perceptions have been associated with pain intensity as well as physical function in individuals with all types of musculoskeletal pain. Illness perception is a large part of Edwin’s current doctoral work. He dives into this important topic and shares a tool that he uses with his patients to help them understand pain.
We’ll be speaking with Edwin de Raaij who is a physiotherapist who hails all the way from the Netherlands. A few months ago while I was reading through the Journal of Orthopedic in Sports Physical Therapy, I came across a very interesting systematic review that Edwin completed and that review is called The Association of Illness Perception and Prognosis for Pain and Physical Function in Patients with Non-Cancer Musculoskeletal Pain. If you’re not familiar with the term illness perception, it is defined as the cognitive representations or beliefs that patients have about their illness. If that definition sounds too technical and you’d like to hear things chunk down into a simpler version like I do. It means that how you perceive your illness has an influence on the way you think, what you believe is possible and perhaps most importantly, what you do moving forward. This is an important topic because illness perceptions have been associated with pain intensity as well as physical function in individuals with all types of musculoskeletal pain. To share more about our expert speaker.
Edwin has spent over 32 years honing both the art and the science of being a physiotherapist. He is a professor at the University of Applied Sciences in Utrecht which is in the Netherlands. Illness perception is a large part of his current doctoral work which blends nicely into the biopsychosocial model of pain which is why I was so excited that he accepted my invitation to join us on the show. In this episode, he mentions a tool that he uses with his patients to help explain the full spectrum of the pain experience and all its contributing factors. This one-page downloadable tool is called the Pain Palette. This is a great tool to help you understand pain or to explain pain if you are a practitioner. He was generous enough to products provide us with a free copy. To download the pain palette, all you have to do is go to the URL, www.DrJoeTatta.com/116Download or if you on your smartphone you can text the word 116Download to the number 44222. On this episode, Edwin provides some great tips, training and frameworks. Let’s begin with Edwin and learn about illness perceptions and how they influence recovery from pain.
Illness Perception and Musculoskeletal Pain with Edwin de Raaij, PT, PhD
Edwin, welcome to the show. It’s great to have you here.
Joe, thank you for having me. It’s nice to be on this show.
I reached out to you because you published the paper in the Journal of Orthopedic and Sports Physical Therapy. The paper is called The Association of Illness Perception and Prognosis for Pain and Physical Function in Patients with Non-Cancer Musculoskeletal Pain: A Systematic Literature Review. It’s a big mouthful but it’s an interesting paper and I haven’t seen a systematic review done on this topic before. Maybe there wasn’t one done by a physical therapist, looking at it through the lens of pain and function. I wanted to have you on and maybe a good place to start is just to tell everyone who you are and how you got interested in this particular topic.
It’s nice that this review got your attention. That’s the whole idea of it. I did my bachelor education in the Netherlands in the ‘80s. I got acquainted with a certain model by a teacher of ours at the time. That model was called The Common-Sense Model of Self-Regulation of Health and Illness. At the same time, we began in the bachelor education program our journey on pain. What is pain and how does it evaluate in each person? Each person feels it different at the time and what’s the message? I clearly remember the teacher was saying, “You have to pay attention because this is difficult. This is complex and pain is complex. I thought, “I’m going to listen very carefully and then after, I’ll know what the problem is and then I’ll be a good therapist.” It turned out to be different if you know yourself.
Do these two things, a specific teacher in my time in the ‘80s, who addressed this model of illness beliefs in combination with pain. I find it a rather fascinating topic. It has been over the last 32 years for me as a practitioner. It’s always been something I was digging into and trying to figure out what does it mean, where does it come from? Finally, the last few years I’ve been doing my PhD research on this topic that’s called the percept study. This systematic literature review, the first one done by physical therapists but also done on musculoskeletal pain. There are several other reviews from this model and a common-sense model of self-regulation but it’s always done outside the musculoskeletal pain disorders.
You said something there which I want to start to tweeze out a little bit. You said, “A common sense model of self-regulation,” can you explain what that means?
It’s probably the most simple to do it by thought experiments. I would like you to join me in this thought experiment and to imagine yourself that you are getting physically hurt. For you, this is the first time you experience this injury or whatever you imagine yourself. While you are imagining yourself such injury, I would like to ask you what kind of questions do you ask yourself about the discomfort you experience, the pain you experience, the problems you have with it? What kind of questions do you want to know? When I asked the same thought experience in students or patients, I always get the same answers. Probably you will recognize these questions I will pop up now because most people would like to know “What is wrong with me?” This is one of the first questions you will think about.
Another question is, “How can it be controlled? Can something be done about it? Is it treatable? How long would it last?” Another dimension of perceptions, because we’re talking about perceptions is “What are the consequences and what caused my discomfort and my pain?” The answers to those questions are called representations, beliefs, perceptions, thoughts or ideas. More or less it’s common sense and that’s why I love this model because it’s built on common-sense and pain is very difficult. When I see the word common sense, I think “Now, I can probably understand it.” These common sense are the answers people give themselves to those questions and these questions stand for the five core dimensions of this model.
I definitely want to jump into those five core dimensions. Should we do that now or should we start with what are illness perceptions per se?
Perhaps we can start with the latter. The illness perceptions are the core elements of this model and it works like this. If you experience a health threat, you make representations of the health threat. Cognitive, also emotional and these are called the representations and these are called the beliefs, the perceptions. More or less, based on these perceptions. You can try to cope with the health threat. You can try to behave in a certain way. Within this model, because it’s a self-regulation model, it also has a feedback loop and in this feedback loop, you appraise your coping, your behavior and the goal is to reduce the health threat. This is the way how this model works. It’s a simple self-regulation model. Sometimes simple things might be giving insight in difficult and complex systems. These representations, initial research in the year ‘70s and ‘80s of the last century pointed out that these representations consist of five core domains or dimensions as they call it.
For instance identity. Identity stands for a label or name people give to a certain condition. You may well recognize this from other resource because when people are having back pain, the first thing they want to know is what’s wrong with me and give me your label? Because most back pain or what we call a more specific back pain can be rather confusing for people. More specific or there is not a medical cause for your condition might be confusing for them. Another dimension of these illness perceptions is timeline. People ask themselves always, “How long would it last?” It is also a core element of the model. What are the consequences of a certain condition that I experience? Should I lay down? Should I move? Should I respect the pain or just ignore the pain and go through with what I’m doing? All these questions pop up into people’s head. Also beliefs about the cause, that’s the very important thing nowadays.
We live in a timeline where for me as a therapist, I have to engage my own cause or beliefs on back pain because I was educated in another time frame than the pain science gives us now in the inside of pain. This was the challenge for me. For lay people, when they experience pain, it’s a normal thing to ask themselves, “What has caused my pain?” We know that most answers are always, “I have pain so something is wrong with me. The more pain I have, the more wrong there has to be in my physical body.” We know that’s not the case right now. Also something like control beliefs that’s the fifth dimension and our beliefs about, “Can I do something about it? Can someone else do something about it?” These are the main dimensions of these illness perceptions. Later in time, these illness perceptions have been extensively researched especially in hospitals among patients with COPD or arthritis or the systemic diseases. Researches for other dimensions occurring in the research. Also coherence, “Do I understand what I have?” That’s an important dimension of the illness perceptions and emotional reactions to it. Finally, they saw nine dimensions of common-sense model arising from this research.
It’s a good framework that people can hold in their mind. As they’re working with the client or even if you are someone who struggles with chronic pain, I’m sure they repeat these five dimensions are identity, timeline, consequences, the cause of beliefs and control beliefs. I want to start to pick apart a couple of these if we can. Identity is interesting to me when you talk about giving it a label or a name. Specifically when we think about low back pain because the research is pretty clear that whether you’re a physical therapist, a chiropractor or any type of physician. No matter which licensed practitioner you are, we still don’t have a good way to diagnose exactly what’s happening in lower back pain when it comes to the tissue that might be the cause if it’s a tissue at all. It brings me to the point of should we label people who have low back pain with a herniated disc, degenerative disc disease, facet problems? Are those things beneficial or are they hurting or is it potentially somewhere in between?
It all comes down to, “What do you define of the pain?” It begins with the definition of terms. The whole conceptual change of pain in this last decade is important for people with lower back pain. For a long time, we tried to explain pain. The identity label, we tried to explain it from the physical body. Then you say, “I had a concept that pain arises from the body.” That’s not a concept anymore that I can lean on as a clinician because pain as we know how it works in this era, it’s a construct that’s multidimensional. You can’t blame the tissue for being in pain. If it’s multidimensional, then this is something which has to be communicated with people in pain. You feel it in your back but that isn’t always an important factor in trying to explain the pain. You feel it in your back, but it doesn’t have to be from your back. That’s a very difficult concept for people to understand because we all are educated in our early life that that pain is something physical.
We have pain nerves and pain comes from tissues but it’s not the case right now. It’s important to start always as a physical therapist with your clinical reasoning process with the physical body. You have to rule out the reflexes and you have to know what state of the tissues because it’s one dimension of the pain palette. In this pain palette, it’s multi-dimensional and other factors also contribute to the pain experience. We have to understand and we have to accept as clinicians that the physical dimension and the state of the tissues, play a part in our pain experience. In musculoskeletal back pain experiences, it’s only a minor part. I don’t know if it answers your questions, but the label for people with low back pain and saying, “It’s because of your slipped disc or because of your core instability or whatever,” that’s not the whole picture. Instead, it’s a very small part of the whole picture.
It’s a perfect answer to a question that’s complex. It doesn’t have an exact answer but it’s more to help our audience to start to tweeze through some of this information and process it. You mentioned that pain palette which was the giveaway that everyone can download. I want to come back because it’s a brilliant thing that everyone should download. Before we do that, one more part of these five dimensions is the timeline. Which is an interesting one for us to contemplate when it comes to chronic pain. It can be very difficult for a clinician when a patient comes into your office who has let’s say chronic back pain and the patient goes, “How long will it take before this gets better?”
In some ways, the practitioner is on the spot there to give an answer. I spoke about this concept with Dr. Mark Bishop in one of the previous episodes about expectations. What we tell patients and what patients believe that expectation oftentimes informs their outcome in both positive and negative way. It makes me think, “Should we talk to people about the natural course of a timeline of their disease of when they might start to feel better? What if they never have any significant pain relief?” Time is interesting to me. It’s like Einstein, like time is relative. It’s all those things I constantly think about.
I can say several things about it. Timeline in my opinion and we see that in research is associated with control beliefs. The better people have an idea of how to control their condition, the shorter their condition might be bothering them. Expectations are important. It was Benedetti in 2007 in fundamental research about the experience of hotness on your skin. He did an experiment with getting a red cue associated with 48 degrees on your skin. That’s probably painful for people and he associated the blue visual cue with less heat on your skin. Then after conditioning the participants in this way, they trick the experiments and they did use a blue cue but applied 48 degrees Celsius on the skin. You look at brain activity in this experiments and you see the brain activity not what you normally see at 48 degrees but with much lower degrees. It’s not only expectations in the sense of beliefs or what people think. It’s also the neurobiology system which reacts to certain expectancies.
For timeline and patients asked me, “How long will this last?” In the past, it was more or less easy when you thought, “This is tissue damage,” and we know a little bit about how the healing process of tissue damage is and you talk about these process then it’s okay. Nowadays, when you see what influences there are in this multidimensional aspect of pain, I communicate with my patients, “That’s hard to tell. I first have to look at the whole picture of you. Let’s sit down and try to analyze what factors do influence your pain and are they manageable? Because if they are not manageable, then I cannot say something about a timeline. That’s probably something we have to work on.” To give a prognosis is difficult but it also has a favorable condition if you do so because people are holding onto it. The placebo effects can probably also help them. It’s a very good question but it’s hard to answer it straight.
As you are going through this five-point framework on these five dimensions, if a patient comes into the clinic or comes into your office, is there a way to test for this? Is there a way to measure this in the office?
That simplest way is to ask them about it or ask their thoughts and their ideas about, “How long do you think this will last? What are your own thoughts about what you’re experiencing right now?” Most of the time people will tell them in their narratives this information to you. You can extract it from their narratives. One time a patient said to me just before I wanted to start my physical examinations. She told me, “Will you be very careful with my pelvis?” I said, “Yes, but may I ask why?” “It’s very vulnerable,” she told me. “Why is it vulnerable?” “I’ve got holes in it,” she told me. That’s strange for me as a practitioner to hear there are holes in it. I said, “What do you mean about that?” “I was in the hospital and the doctor showed me an X-ray and it shows some holes.” I asked her, “If I show you an X-ray of this area, could you probably point me where they were?” “Let’s try it.” I took just a photo on the screen and she pointed out the foramen obturator of the pelvic. It was the cause of her pain in her idea. Listening to the story is very important and try to ask questions. It’s motivational interviewing for a part. Go on the topic they present to you.
They call it open-ended questions.
Do something with the information they give you. Don’t go on the list of questions you ask. Listen to them and try to incorporate their information in your next question. That’s my favorite thing to do. Listen to the narrative and try to hear these beliefs and these perceptions. You can also use questionnaires to assess them. Researches, I like to use them in that way if you want to do quantitative research. There are three questionnaires but the first one was done in the ‘90s. It’s a 71-item questionnaire. For clinicians, it’s very long and it gives some patient burden. They did a revised version at the beginning of this century. In 2006, there was a nine-item list published in the English version. In 2007, I did my paper on the cross-cultural consolidation and adaptation of questionnaire in my Dutch language. It’s simple to use but when I talk about this questionnaire, I always say, “You can ask your patients to fill it out, but the real story is behind the question.” You have always tried to get the context within the answer of the question because you’ll answer the question with number zero to ten. You don’t know what a seven means unless you know the story behind it.
Some of those questionnaires, if you don’t use it in practice, you can look through them. Sometimes just pull one or two questions and use them as part of your interview with the patient, which gives you a lot of good information. The next place we should go to is as you went through this paper and this meta-analysis. I was reading 1,400 studies and you wound it down to probably somewhere around 26. Is there an association between pain and someone’s illness perception?
The main finding is that, yes, there is but the association is small. That’s very logical because pain is a multidimensional experience. I would have been very surprised to get an association of 0.7 or 0.8 It’s a very small association. Most of the research is done outside the physical therapy practices. That’s also something we work on right now in the future papers. I found only two papers, which researched the physical therapy practice but they didn’t asses pain. They didn’t assess the physical functioning in patients. There is little known about these associations. That thing we know right now is yes, they are and they are all pointing in the right direction, which means it didn’t matter which kind of illness or disease you have, musculoskeletal disease or illness. If you score high on a certain dimension, it’s associated with the highest score on pain and that is throughout all these different diseases. That I find rather reassuring because it’s logical from the common sense model point of view. The limitation in physical functioning, there’s the same findings in cross-sectional studies.
We’re talking about associations here. Association doesn’t say something about causation. It’s which way does it go? Does the perception influence the pain or the limitation in physical functioning or is it the other way around? It’s an interesting question. Based on cross-sectional studies, we can’t tell there. We also find some longitudinal studies but far less than in literature and just two on pain. It’s not something we can say about how it does work in the prognosis. There’s an area for research, they are still open. Adrian Traeger, about his RCT, published on the effect of patient education in acute low back pain and he also measured some beliefs. They did see a shift of beliefs but they didn’t see an association of this shifts on the shift from pain. These beliefs, they see change but it doesn’t have the effect on pain or physical activity. It’s in contrast with what I said before here. It’s very nice to look into further. How does it work? How is the causation? How are the prognostic pathways organized? We are still not sure about that.
Are you referring to the paper that came out about pain education use in acute low back pain and it showed not so favorable results for pain education, that it might not be necessary?
Yes, that’s the one I’m talking about.
It’s going to make a lot of waves because the research was pointing in the other direction. I was the first one to say potentially with acute pain, it might not be necessary. You mentioned longitudinal, you started to look at some of the research long-term. Are these IPs, are they not prognostic in some way? Can they help the practitioner say, “I gave them this nine-item tool and these are showing up?” From the intake, “I’m hearing all these problems.” Is it prognostic to say, “This patient may have a poor outcome. This patient may need more therapy. This patient may need multidisciplinary therapy?” These are challenges that have to be addressed for them to improve.
From the research we did in the system that we do, I can’t give a clear answer to that question. There is still a need for more research in that area to get answers to that question. If we look at it from let’s say the evidence-based medicine perspective, we don’t only have the research evidence, we also have your clinical circumstances and your patient’s preferences and your clinical experience as a clinician which is important enough to base medicine. If I may talk about that side of evidence-based medicine and I’m talking about my own experience in this. When you asked a question about concern because that’s also an illness perception dimension. “How concerned are you about your illness?” If people are concerned and they stay concerned, you might want to say one day these could be a negative prognostic factor for pain or physical functioning.
Also the coherence dimension, sometimes people score high on that dimension in a way, but yet, “I know what I’ve got. I understand what I have. It’s a problem.” “Tell me what do you make of your own low back pain?” It always pops out and I have to go to my manual therapist. He might tell it this way, then it popped out and I go to my clinician. He adjusts the vertebra and it’s okay. He thinks he has a good coherence but it’s not what we think nowadays of how it should work. It’s also probably a negative prognostic factor for self-regulation. It is dependent on another person which may adjust his vertebra. In my work, it’s ridiculous nowadays. From research, we can’t tell that’s the way how it works but from a common-sense idea, it’s sometimes logical when you work one-on-one with patients and you find some negative thoughts, some high perceptions that you think, “That’s not good progression in returning to work or you’re returning to sports in helping him with his lower back pain.
Sometimes common sense is an uncommon practice.
I wrote something about the patient’s journey is very dependent on the therapist’s journey. The common sense of the therapists sometimes also is the common sense of patients. What we know from Ben Darlow’s research and from Stanley, from New Zealand, that the ideas patients themselves have in qualitative research papers about their low back pain is it’s tolerable. It’s complex. They feel dependent. They don’t know what they could do about it. It’s negative and Stanley also questions these people, “How do you how do you get these ideas? Where do you get it from?” 89% answered, “I get it from the healthcare system. I get it from my practitioner, from my physician.” The common sense sometimes is working with us but sometimes also working against us. An important thing is what is your own common sense as a therapist? Are these belief you have okay? Do you back them off with research? Do you back them up with results you have?
As we talk about this topic, we’re talking about cognitive factors and whenever people hear cognitive factors or psychology or emotions, the antenna that goes up first is this is something that’s in the realm of psychology. If anyone who’s followed my podcast knows that there’s a tremendous place for psychology in the area of pain medicine. However, many of these things that we’re talking about can be worked on with the patient in physical therapy as you do in treatment from day one to day two to day ten.
Yes, you can. If I can quote a tweet from Derek Griffin. It’s my favorite tweet for October month this year. He says, “Many physios argue I’m not a psychologist. That’s very true but you’re also not a biomechanics or an exercise physiologist. Deal with humans, deal with psychology.” The way you can deal as a physical therapist with psychology as not only cognitive because that’s true what you said this is about cognition and it’s called cognitive strategy that I talked about so far. What I’m excited about is exposure with movement and in that way try to change these unhelpful beliefs people might have about their illness. It’s the core business of us as a physical therapist to do something with the body and to do something with movement. The exposure with movement has shown some possibilities for trying to cope with long-lasting persistent pain. I refer to the great work of the group of O’Sullivan and his cognitive functional therapy reasoning process. That’s what I’m very enthusiastic about. Exposure as long now has a great value when it comes to containing fear and trying to help people to overcome their fears and also overcome their movement-related fear behavior. It’s a very important thing you can do in your practice.
Let’s switch hats. Let’s take our clinician hat off and put on our artistic hat. You and your wife create something called the Pain Palette. Can you talk about it and tell me about its evolution and its application?
It started for me two and a half years ago now. I was already 30 years working as a clinician but I attended the CFT workshop in London, Peter O’Sullivan’s Cognitive Function Therapy Workshop. The experience where some kind of puzzle pieces that all came together for me. I saw all kinds of things merging and I thought, “I have to try to get this across to patients in a way that not only I can do some patient education or try to do cognitive strategies to explain pain to them. I also want to have something in which they can identify themselves in the multi-dimensionality of pain without me using all these difficult words and try to explain in the neurophysiology, the neuroanatomy of our pain system.” My PhD project, I have a great team, my Professors Raymond Ostelo, Harriet Wittink and Francois Maissan are helping me in trying to order my ideas and trying to make it in a practical way so I can use with the patients.
In those conversations and those interactions, I created the Pain Palette in my head because pain is multidimensional and it can be painted from different colors. Why don’t we make the pain palette which has different dimensions of pain almost on this palette? I have not researched this yet but when I see myself as a clinician using this in daily practice, sometimes it’s helping me but helping patients also. When I establish with a patient, “You normally think pain is due to tissue damage and more pain is more damage. I recognize something in you that you try to see it from a different perspective.” If they say, “Yes, I try to do that.” Sometimes I try to explain that they are just diagnosis and still they’re looking at it and they are going to tell their story. It was an eye-opener for me. I have to listen and to be still. I see emotions are part of this. They come with a story.
Before I go on and I give it praise which I want to do, what’s on the palette itself? What does it say? On a paint palette, it’s a flat piece of wood or plastic. We’d have all these little dots of ink and each ink or paint represents some part of the paint experience so what’s on your palette?
The cognitive dimension is on the palette, also emotional aspects are on the palette as a color. That social dimension can be a very important factor in pain. The stage of life and all that goes with it. The physical part is very important for us as a physical therapist and it means life. Is someone resilient for exercises? How does he treat his body? Is he healthy in that way? Another very important dimension is the body structure and function. That’s always the part that people try to explain the pain from. We have to know as a physical therapist what role has that dimension in the pain experience. That’s very important but sometimes it’s very small. Another dimension is comorbidity. It’s also a very important one. Genetics could play a role, although I’m not the expert in this. I know that this might play a role. We have also color which only has dots because this is probably what attributes to pain, but they can be something in the future. It can be something specifically for that patient very important and we can use that dot to express a dimension.
It’s beautiful because people can start to paint their own picture of their own experience. It also tells people, “How am I painting a picture of this experience? Am I painting a picture of this experience in a way that helps me cope or am I painting a picture of this experience in a way that is keeping me stuck?” What I love about it is it’s so simple but it says so much.
If you merge all these colors, what do you get? You get a dark brown color. The trick is in critical reasoning, just try to pull them out and look at them separately and try to establish with the patient “Which is so important for you? What dimension attributes most to pain at this moment?”
Also in my mind, I can see like if I gave this pink palette each patient, one patient may use more of the cognitive ink and another patient might use more of the structure or where they are in life. It starts to help someone say, “I’d use this paint more because I feel like the stage of life where I’m in is affecting my pain,” versus someone else might say, “It’s my emotions or it’s my lack of movements. It may also have a comorbidity of being obese which is not helping my pain.” It’s great. It’s creative and the paper is great, but when I saw the pain palette I was like, “This is something that’s useful.” It starts to bring together a whole lot of different concepts in a way that people can use. Edwin, it’s been great chatting with you. If people want to learn more about you and your work and your research, can you tell them how they can reach out to you?
You can find me on Twitter under my normal name, Edwin de Raaij. Through social media, I’m easy to find. If there are any questions or people would like to know more or there are some things they want to discuss with me, I’m happy to do so.
I’m going to encourage everyone to tweet Edwin. Share this podcast out on social media. You can tweet to him and thank him for this great work on his podcast and the research he is doing. Make sure to share this podcast out with all your friends and family and colleagues whether it’s Twitter, Facebook or LinkedIn. I want to thank you all for being here. Make sure you hop on over to DrJoeTatta.com/podcasts. There’s a little box there on the right-hand side the page where you can sign up for the mailing list and when you do that, I’ll send you a brand new podcast to your inbox each and every week. Many blessings to you all.
- Edwin de Raaij – Twitter
- The Association of Illness Perception and Prognosis for Pain and Physical Function in Patients with Non-Cancer Musculoskeletal Pain: A Systematic Literature Review
- Dr. Mark Bishop – Previous episode
About Edwin de Raaij, PT, PhD
Education – Born 1964 in the Netherlands – Bachelor physiotherapy 1982-1986 – Manual therapy 2001-2004 – Master physiotherapy University Utrecht 2004-2007 – PhD candidate 2015-2020 University VU Amsterdam.
Work experience – 32 years’ work experience private practice – 2006-today teacher University of applied sciences Utrecht – 2007-today co-founder and teacher at Fysiometrics – Lectures and presentations at symposia in the Netherlands.
Special interest – Pain, ‘how hard can it be…..’ – Unhelpful movement related fear cognitions – Illness Perceptions (IPs) and their role in physiotherapy – Understanding working mechanisms in physiotherapy – Helping people to be, get or stay in control regarding: o Pain o Next step in education – How to match physiotherapy in EBM – Pain Palette
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