The interview provides the clinician with the cues needed for a targeted examination to explore behavioural and emotional responses linked to the patient's narrative. The following are key elements of this process:

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  Use of open-ended questions such as “Tell me yourstory” facilitates a narrative approach to explore the patient's pain journey from their perspective.71

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  The clinician provides a flexible framework during the interview that allows for sensitive, non-judgmental questioning and careful prompting to explore and interpret the patient's experience. This includes exploration of:

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    How they represent their problem along the five belief dimensions that comprise the representation, and how previous experiences have led to adopting this representation (Table 3).

    Table 3.

    How to explore patients’ understanding of pain using the CSM framework.

    CSM constructs		Example questions
    	Interpretation	Tell me your story.Put me in your shoes and tell me how your pain feels?How has the pain impacted on you?How has the pain impacted your home/work/social life?
    Representation	Identity	What is your understanding of your problem?What do you think is going on in your body?Have you received a diagnosis for your pain? How do you see it?Have you had scans for this condition? What is your understanding of the scan results?When you have pain what do you think it means?
    	Cause	What is your understanding of the cause/s of your pain?
    	Consequences	How does the pain impact on your life (physical, work, social etc.)? What do you think will happen if you perform a movement or activity that you avoid?
    	Control/Curability	How much control do you feel you have over your pain?If so, how do you control your pain?How confident are you to do the things that you value?Can you prevent your pain from flaring up?Can you control your pain once it has flared up?
    	Timeline	How long do you expect your pain will last?Can you see yourself getting back to work, sport or other valued activities?How hopeful are you for the future? How do you see your future? Where do you see yourself in 3 months/1 year?Do you think your pain will get better?
    Behavioral response	Action	When you have pain, what do you do?What do you do when faced with a threatening movement or activity?Do you avoid important activities because of your pain?Do you modify how you do important activities because of your pain?Why do you think you shouldn’t bend/lift/run/social/work activities etc.?Would your life look different if you didn’t have pain?What do you think it will take to get better?
    	Appraisal	Is this action effective? Has it worked for you?Tell me about your goalsWhat do you think you need to achieve your goals?Is this action aligned with your goals?
    Emotional response	Emotion	How does the pain make you feel?How do you feel about losing the ability to do things you love?Does this pain get you down?Do you worry about your pain?Do you fear your pain or doing damage to yourself?How do others you care about see you?
    	Coherency	How much does your pain make sense to you?
  • •

    Contextual factors associated with their pain (e.g. home/social/work situation)

Understanding a patient's behavioural response to their pain provides an insight into their beliefs (pain representation) as well as direction for the physical examination. This includes exploration of the patient's:

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  Coping responses to pain

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  Engagement or avoidance of physical, social, work or valued activities.

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  Identification of postures, movements and activities that are feared, protected, avoided or that provoke the patient's pain

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  Lifestyle behaviours such as sleep patterns and activity levels, and barriers to engage in a healthier lifestyle.

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  Goals and expectations

Exploration of a person's emotional responses can be threatening to both the clinician and patient and needs to be sensitively done. Key aspects to explore include the patient's:

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  Emotional response to pain, past treatments, and loss of valued activities.

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  Fear of movement and activity (e.g. belief that movement may cause damage, or pain and functional loss)

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  Overall levels of psychological well-being (e.g. anxiety, mood, stress)

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  Social context and support

Clinicians must also screen for red flags, specific pathology, and comorbid health conditions.

At the end of the interview, the clinician summarises the patient's story, identifies gaps, discrepancies, and misconceptions in the representation, to reflect on how these impact the pain experience and how the patient makes sense of their pain experience.

A person's representation, behavioural and emotional responses about their pain problem may not be entirely revealed by the interview. People can hold explicit views about the body and pain, but implicitly hold beliefs, fears and worries that drive their behaviour. Implicit beliefs that drive certain behaviours may be only revealed through exposure to the threat (posture, movement or activity) during a targeted behavioural assessment.48

Guided behavioural experiments can be used to assess the patient's pain, behavioural and emotional response during the performance of these tasks. Exposure to the target activities may elicit protective responses within the body that the patient may not be aware of, as it often unravels people's implicit beliefs and fears linked to specific daily tasks. Key actions that guide this process include:

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  Target: The clinician identifies specific postures, movements or daily life activities identified in the interview as provocative, feared or avoided and that are linked to their goals.

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  Question: Before exposure, the clinician asks the patient about their beliefs, fears and anticipated outcome (e.g. pain escalation) in relation to the task they are about to perform.

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  Expose: The clinician performs non-judgemental observation of the behaviours adopted by the patient such as autonomic responses (e.g. respiratory pattern, body tension), pain behaviours (e.g. grimacing) and safety-seeking behaviours (e.g. bracing, avoidance of limb loading) during the performance of the nominated tasks.

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  Reflect: The clinician asks the patient if they are aware of their behaviour during the performance of the task and guides the patient to reflect on the reason why they adopted such behaviour. For instance, a patient with knee pain may shift their weight to the opposite leg while getting up from a chair. Their reason for such behaviour may be that they believe that putting weight through the joint may cause more wear and tear. A patient with back pain may not be aware that they brace their abdominal muscles and breath-hold while picking an object off the floor. When asked about it, they may say that it is ‘common knowledge’ that people protect their back and brace their core when they bend.

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  Expose with control: First the clinician coaches the patient to relax their body posture and breathing pattern to ensure the patient feels safe and calm. During exposure, the clinician provides strategies to control unhelpful behavioural (e.g. avoidance of leg loading on sit to stand) and emotional (e.g. worry about pain) responses, providing an opportunity for the person to perform the task in a different way (new mindset and behaviour) that often yields a different outcome. For a person with knee pain the strategy may be engaging leg muscles and loading both legs equally on sit to stand. For a person with back pain, the strategy may be breathing, relaxing the back and core while bending or lifting.

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  Appraise: After exposure, the clinician asks the patient to reflect on their experience and if the predicted outcome occurred or not.

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  Repeat exposure in new way: The clinician repeats exposure of the task to build confidence, and gradually progresses the task towards the patient's needs and goals. Clinicians must consider and be sensitive to the patient's levels of distress, tissue sensitivity and levels of conditioning, as an aversive experience may negatively reinforce their beliefs and emotional responses (i.e. “bending is scary, it makes my pain worse and should beavoided”). This guides how quickly exposure is progressed to more threatening and demanding tasks.

This process tests the validity of patients’ belief systems; where discrepancies between anticipated and actual pain experience may challenge and disconfirm the person's beliefs that movement is threatening and should be avoided.77 In addition, it can reinforce that valued activities can be safely confronted when performed with effective strategies and a more positive mindset. This process provides the clinician with clear directions for targeted management.66,78

This is an interactive learning process where the clinician uses the patient's own narrative and experience during the examination to help them make sense of their pain condition through a biopsychosocial lens, with the aim to facilitate mindset and behavioural change, and reduce emotional distress. In this process, the clinician:

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  Uses a person-centred communication style that empowers the patient's narrative and that enables effective shared decision-making in the rehabilitation process.

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  Explains in the patient's own words how unhelpful beliefs, behaviours and emotional responses to pain can set up a vicious cycle of pain and disability.

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  Delivers education in simple language combined with their experiences during the guided behavioural experiments to dispel myths about pain.

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  Identifies new ways of thinking as well as positive behavioural and emotional ways to respond to pain.

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  Promotes learning not only via explanation, but also via demonstration, behavioural experimentation (doing, and reflecting), visual feedback (mirror, recording), and self-experimentation (out of the clinic).

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  Uses educational resources78,79 (e.g.www.lowbackpaincommunication.com), educational websites, and patient stories to augment this learning process (e.g. www.painhealth.csse.uwa.edu.au;www.myjointpain.org.au;www.pain-ed.com).

• •

  Identifies goals and sets realistic time frames.

Behavioural change may only occur if the patient feels confident to independently test the new strategies in their daily life. In order to reinforce behaviour change clinicians need to:

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  Encourage patients to integrate the new learned functional strategies immediately into daily activities to build self-efficacy and to strengthen the new representation.

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  Engage family and friends to support the process.

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  Encourage healthy lifestyle changes such as physical activity, weight loss and good sleep habits. Changes that are in line with patient's context, preferences, and goals are likely to be sustainable.

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  Coach patients to progress gradually according to their goals, level of conditioning and perceived control over their pain.

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  Encourage patients to respond differently to pain (in a more positive way) and perform valued activities with confidence, and without pain vigilance.

This enables a process of self-learning and self-discovery during the rehabilitation that helps patients build confidence, reinforce the new mindset and feel in charge of their rehabilitation to achieve their goals.

Musculoskeletal pain conditions share risk factors with other chronic health conditions such as cardiovascular disease, type 2 diabetes, and mental health disorders.80 The pattern of health and disease in our population is changing. As such, the proportion of patients who experience pain (in one or more body regions) and that have comorbid health conditions continues to increase.81

Clinicians should refer patients for co-care in the presence of comorbid mental (e.g. emotional distress, depression, eating disorders) and physical health conditions (e.g. type 2 diabetes, heart disease, morbid obesity). We contend that multi-disciplinary care including psychologist, pain physician, medical doctor and physiotherapist needs to be integrated, so the team shares a common framework and delivers consistent messages that prevents care fragmentation and patient distress.82,83

There are a number of barriers to implement behavioural change. These include:

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  Patients’ own beliefs about pain (e.g. caused by structural damage) and expectations towards management (e.g. treatments targeting a faulty structure will ‘fix’ their pain).

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  Patients may be confronted by mixed or erroneous messages across many levels of society including family, work, and media. For instance, a patient may receive evidence-based information from their physiotherapist that it is safe to exercise with knee osteoarthritis; however, when sharing this message with their partner the information is confronted by ‘popular belief’ that exercise is harmful as it causes joint wear and tear. For patients with low self-efficacy, this situation may reduce the patient's confidence in engaging with an exercise programme.

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  Patients can also receive mixed messages when engaging with the healthcare system. For example, one clinician tells the patient that it is safe to return to work, while another says that returning to work may hinder recovery. These mixed messages often leave the patient confused and distressed.

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  Clinician's tendency to lecture patients, rather than adopting a patient-centred reflective approach to care.

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  Clinicians’ beliefs about pain, implicit biases, perceived competence to address psychosocial factors and other comorbid heath conditions, time constraints of appointments, financial pressures are some of the barriers for clinicians to implement person-centred approaches.

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  Lack of adequate funding for evidence-based care.

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  Social circumstances may also be a barrier for implementation of sound advice. Consider a patient with knee osteoarthritis who has been advised to exercise regularly. Although the advice is sound, this patient is a single mother of two, who works part-time and cares for her own ill mother. This context may not be conducive of implementing the suggested management plan.

Both patients and clinicians need to understand pain from a biopsychosocial perspective in which multiple factors can influence the onset and persistence of pain, and that ultimately the development of self-management skills is paramount. Patients’ beliefs and treatment expectations may benefit from mass media campaigns that aim to promote evidence-based information and subsequently improve health behaviours in musculoskeletal pain, as it has in other fields such as heart disease.84 Here are strategies that may benefit clinicians in the delivery of a person-centred approach to managing musculoskeletal pain:

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  Be interested, curious and non-judgemental.

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  Observe experienced clinicians in action.

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  Seek peer review feedback and mentoring.

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  Self-reflect upon clinical sessions that yielded both positive and negative outcomes.

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  Watch videos of yourself interacting with a patient to identify potential areas for change in terms of clinical skills, verbal and non-verbal communication style, habits and biases.

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  Develop communication skills that allow for sensitive exploration of the person's experience across multiple domains to identify targets for behavioural change.

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  Take time to listen, reflect and act accordingly.

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  Develop good diagnostic, observational, analytical and interpretive skills to confidently address unhelpful behaviours and provide adequate clinical advice to patients.

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  Develop skills to better manage coexisting physical and mental health problems.

The process of change is unique for each person.77 For some this process can be fast (4–12 weeks), while for others it may take longer (3–6 months). Booster sessions may be necessary for when pain again becomes uncontrollable, distressing and/or disabling. During pain flares, the old representation can resurge strongly, often re-activating unhelpful behavioural and emotional responses. Clinicians must use pain flares as an opportunity for reinforcing the new representation and new ways to respond to pain without emotional distress, protective behaviours and avoidance of movement, physical, work or social engagement.66,85

The critical role that beliefs can have on the outcome of musculoskeletal pain is illustrated in Table 4 (Jamie's story - a journey to recovery; and an interview with Jamie). These beliefs include those of the clinician and the patient. It highlights how person-centred care can be used to facilitate helpful beliefs, as well as positive behavioural and emotional responses to musculoskeletal pain (Fig. 2). This approach in the acute phase can prevent ongoing pain and disability in the long term,86 and in the chronic phase reduce the disability burden of musculoskeletal pain.87,88 There are huge obstacles to deliver this model of care that need to be overcome.

Figure 2.

The process of changing beliefs and behaviour.

Note: See Appendices 1 and 2 for further details on Jamie's story.

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