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Development and testing of pain education programme for low back pain in Nepal: The PEN-LBP trial



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Similar to developed countries, low back pain (LBP) is the biggest cause of disability in developing countries such as Nepal [1]. Surprisingly, most research on LBP in Nepal has focused on low value care – treatments with questionable effects but often with known risks or side effects and significant costs. As most health expenses in Nepal are out-of-pocket, this imposes high financial burden to the individuals who are already resource limited. Therefore, urgent utilization of high-value care for LBP is warranted [14].

We have been exploring the adaptation of contemporary pain education – part of high-value care for persistent pain – to the Nepalese context. We have previously noted [11] that this form of education could be particularly useful in Nepal because most Nepalese with chronic pain describe their pain using metaphors; it would make sense to use metaphors and patient stories in the education.

This journey faces significant challenges: (1) lack of knowledge of guideline-based care among health professionals, and (2) difficulty in delivering pain education (e.g. using EP) because of language and culture differences [5]. Our first step then was to develop a programme in Nepali using local patient stories and metaphors, and then evaluate the feasibility of conducting a clinical trial. Specifically, we aimed to assess if (1) Nepalese with LBP accepted pain education as a treatment for LBP, (2) patients accepted random allocation to one of two treatments, (3) assessor could be blinded, (4) contamination of the treatment could be prevented between the two groups, and (5) patients would adhere to the allocated treatment.

Development of education programme for low back pain

We first developed a curriculum for delivering a one hour single session pain education programme for Nepalese with LBP who have little or no education [6; 7]. The main aim of this pain education programme was to promote self-management. We took a patient-informed approach: encouraging questions about their pain and discussion of their current understanding of it. Additionally, we aimed to deliver four target concepts namely (1) pain is normal, (2) the brain creates pain, (3) learning about pain changes pain, and (4) the body learns pain and becomes over-protective over time. We developed a handbook with relevant pictures, going through several iterations after patient review.

Feasibility study

A feasibility study was conducted in a physiotherapy rehabilitation hospital in Kathmandu, Nepal [6; 7]. We invited 70 patients to recruited 40 patients with LBP of any duration. Experimental group received newly developed pain education programme for one hour, whereas control group received guideline-based care for the same length of time.

We found that conducting a randomized clinical trial comparing pain education and guideline-based care in patients with LBP in Nepal feasible. Recruitment rate exceeded our expectation of 4 patients per week. Patients accepted both the pain education programme and guideline-based care control treatment. We could blind the assessor effectively, there seemed to be no contamination between groups and adherence to treatment exceeded our target.

We had secondary outcome measures that suggested between group differences in pain intensity and pain catastrophizing both in favour of pain education group.

We conclude that a clinical trial to investigate pain education for LBP in Nepal is both warranted and feasible.

About Saurab Sharma

Saurab Sharma Professor at Kathmandu University Nepal Saurab is a musculoskeletal physiotherapist, researcher, and Assistant Professor at Kathmandu University School of Medical Sciences, Nepal. He is currently a PhD candidate at University of Otago, New Zealand working on developing culturally acceptable evidence around assessment and management of musculoskeletal pain in Nepal. He developed an online platform www.linkphysio.com to promote evidence-based practice in Nepal and other developing countries. Twitter: Link_physio.


[1] Global Burden of Disease Compare. Global Burden of Disease  Viz Hub. Seattle, USA: University of Washington, 2019.

[2] Malfliet A, Kregel J, Coppieters I, De Pauw R, Meeus M, Roussel N, Cagnie B, Danneels L, Nijs J. Effect of Pain Neuroscience Education Combined With Cognition-Targeted Motor Control Training on Chronic Spinal Pain: A Randomized Clinical Trial. JAMA Neurol 2018.

[3] Moseley G, Butler D. Explain pain supercharged. Adelaide, Australia: Noigroup publications 2017.

[4] Moseley GL, Butler DSB. Explain Pain Handbook: Protectometer, 2015.

[5] Sharma S, Abbott JH, Jensen MP. Why clinicians should consider the role of culture in chronic pain. Braz J Phys Ther 2018;22(5):345-346.

[6] Sharma S, Jensen MP, Moseley GL, Abbott JH. Pain education for patients with non-specific low back pain in Nepal: protocol of a feasibility randomised clinical trial (PEN-LBP Trial). BMJ Open 2018;8(8):e022423.

[7] Sharma S, Jensen MP, Moseley GL, Abbott JH. Results of a feasibility randomised clinical trial on pain education for low back pain in Nepal: the Pain Education in Nepal-Low Back Pain (PEN-LBP) feasibility trial. BMJ Open 2019;9(3):e026874.

[8] Sharma S, Jensen MP, Pathak A, Sharma S, Pokharel M, Abbott JH. State of pain research in Nepal: A scoping review. Pain Reports 2019:Under review.

[9] Sharma S, Palanchoke J, Reed D, Haxby Abbott J. Translation, cross-cultural adaptation and psychometric properties of the Nepali versions of numerical pain rating scale and global rating of change. Health Qual Life Outcomes 2017;15(1):236.

[10] Sharma S, Pathak A, Abbott JH, Jensen MP. Measurement properties of the Nepali version of the Connor Davidson resilience scales in individuals with chronic pain. Health Qual Life Outcomes 2018;16(1):56.

[11] Sharma S, Pathak A, Jensen MP. Words that describe chronic musculoskeletal pain: implications for assessing pain quality across cultures. J Pain Res 2016;9:1057-1066.

[12] Sharma S, Pathak A, Maharjan R, Abbott JH, Correia H, Jensen M. Psychometric properties of nepali versions of PROMIS short from measures of pain intensity, pain interference, pain behaviour, depressions, and sleep disturbance. The Journal of Pain 2018;19(3).

[13] Sharma S, Thibault P, Abbott JH, Jensen MP. Clinimetric properties of the Nepali version of the Pain Catastrophizing Scale in individuals with chronic pain. J Pain Res 2018;11:265-276.

[14] Sharma S, Traeger AC, Mishra SR, Sharma S, Maher CG. Delivering the right care to people with low back pain in low- and middle-income countries: the case of Nepal. J Glob Health 2019;9(1):010304.

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