http://informahealthcare.

com/dre
ISSN 0963-8288 print/ISSN 1464-5165 online

Disabil Rehabil, 2014; 36(22): 1903–1910

! 2014 Informa UK Ltd. DOI: 10.3109/09638288.2014.881566

RESEARCH PAPER

Success or failure of chronic pain rehabilitation: the importance of good

interaction – a qualitative study under patients and professionals
B. Oosterhof1, J. H. M. Dekker2, M. Sloots3, E. A. C. Bartels4, and J. Dekker5
1
Department of Occupational Therapy and 2Department of Rehabilitation Medicine, Rehabilitation Center Heliomare, Wijk aan Zee, The
Netherlands, 3Department of Occupational Therapy, Amsterdam Rehabilitation Research Center Reade, Amsterdam, The Netherlands, 4Department
Disabil Rehabil Downloaded from informahealthcare.com by University of Pittsburgh on 03/12/15

of Social and Cultural Anthropology, Faculty of Social Sciences, VU University Amsterdam, Amsterdam, UK, and 5Department of Rehabilitation
Medicine, VU University Medical Centre, EMGO Institute, Amsterdam, The Netherlands

Abstract Keywords
Aim: The aim of this study was to explore which factors are associated with a successful Communication, interaction, learning process,
treatment outcome in chronic pain patients and professionals participating in a multidiscip- pain
linary rehabilitation program, with a specific focus on the patient–professional interaction.
Methods: Patients (n ¼ 16) and professionals (n ¼ 10) were interviewed and/or observed. History
The transcribed interviews and observations were analyzed and themes were described. Results:
Patients with a positive treatment outcome came to a shared understanding of their pain with Received 21 May 2013
their professional, demonstrated new learned behavior and were able to continue their Revised 22 December 2013
For personal use only.

learning process at home. Patients with a negative treatment outcome did not reach a shared Accepted 6 January 2014
understanding of their pain with their professional, were not able to change their behavior and Published online 27 January 2014
wanted more help to achieve this. Both patient groups experienced organizational barriers
within the treatment process. Factors associated with a high quality of patient–professional
interaction included the patient experience of being taken seriously, the involvement of the
professional with the patient, a clear explanation of the pain, and an open interaction between
patient and professional. Conclusion: This study provides insight into factors which were related
to a positively or negatively experienced outcome of pain rehabilitation. A good match within
the patient–professional interaction seems essential.

ä Implications of Rehabilitation
 Within chronic pain rehabilitation good didactic skills and a client-centered attitude of the
professional may be helpful in order to make the patient feel being taken seriously.
 An assessment of the patient’s learning style might lead to a better fit of the patient
education and training according to an individual’s learning style.
 Relapse might be prevented by paying special attention to the integration of new behavior
within important life areas as work and sports.

Introduction
Chronic pain is a complex problem with physical, psychological
and social components which can lead to reduced social activities,
decreased independence, anxiety and depression [1]. Recent
studies show that 1 out of 5 people in Europe have chronic pain
[2]. Pain rehabilitation in the Netherlands is often based on a
cognitive-behavioral model. The starting point of this model is
that the pain is maintained by certain emotions, thoughts and
behavior instead of (mainly) a physical problem. Explanation
models are used within the interaction with the patient to provide
explanation about various factors that may have led to his1 current
health situation. The purpose of pain rehabilitation is to enable the
patient to think differently about his pain in order to be able to
deal with it better. The expectation is that this will lead
to decreased disability and increased quality of life [3]. Pain
rehabilitation is delivered by a variety of healthcare professionals
such as Physiotherapists, Occupational Therapists, Psychologists,
Social Workers and Sports Professionals. They work together
in an interdisciplinary team which is led by a rehabilitation
physician.
Research and clinical practice show that chronic pain
patients are not always satisfied with pain rehabilitation [4,5].

Address for correspondence: Barbara Oosterhof, Department of

1
Occupational Therapy, Rehabilitation Center Heliomare, Relweg 51, Throughout this publication where he or him is used, this can be
Wijk aan Zee 1949 EC, The Netherlands. E-mail: b.oosterhof@ substituted with she or her. We chose not to use both forms in order to
heliomare.nl improve readability.
 1904 B. Oosterhof et al.
According to professionals, a positive treatment outcome within
pain rehabilitation is frequently lacking. Differing expectations
of patient and professional seems to be the reason for this [4].
There is often a discrepancy between the explanation model of
the professional and the patient’s beliefs, which often focus
on an underlying organic cause of the pain and a solution for
this. Patients expect a clear diagnosis regarding the cause of the
pain, information in order to better understand their pain and
the acknowledgment that their pain is real [4,6–8]. Another reason
for a negative treatment outcome seems to be the presence of
a poor interaction between patient and professional [4]. Parsons
et al. [8], in a systematic review of qualitative studies, concluded
that patients and physicians experienced conflicts in their
interaction, even though they strived for clear interaction and
mutual respect.
Current research on chronic pain mainly focuses on determin-
ing the right interventions for the right patient [9,10]. Research
also shows that the interaction between patient and professional
Disabil Rehabil Downloaded from informahealthcare.com by University of Pittsburgh on 03/12/15
seems to play an important role for the treatment outcome [4].
Figure 1 shows the result of the interaction between patient and
professional. The expectation is that the interaction between
patient and professional influences: (1) the creation of a shared
understanding of the pain; and (2) the initiation of the patient’s
learning process required for behavior change. This study
contributes to the existing knowledge by exploring the connection
between the factors mentioned in Figure 1 and their relation to the
treatment outcome.
The aim of this study was to explore which factors are
associated with a successful treatment outcome in chronic pain
patients and professionals participating in a multidisciplinary
For personal use only.
rehabilitation program, with a specific focus on the patient–
professional interaction.
The questions for this study were:
– What are the experiences of chronic pain patients and their
professionals regarding treatment outcome? What are the
facilitators and barriers in the learning process of the patient?
– What are the experiences of chronic pain patients and their
professionals concerning their interaction within the treat-
ment process? How is this related to the experienced
treatment outcome?
Methodology
Design
A qualitative research method was used to explore: (1) the experi-
ences of patients with chronic pain and professionals concerning
the rehabilitation program; and (2) the patient–professional
Figure 1. The result of the interaction between patient and professional.
Disabil Rehabil, 2014; 36(22): 1903–1910
interaction during treatment. Interviews with patients and profes-
sionals were held and observations of therapy sessions were
performed.
Participants
Participants consisted of 16 patients with chronic pain and
10 healthcare professionals. All participants were native Dutch
speakers. All professionals had several years of working experi-
ence with chronic pain patients and received additional education
in the field of pain rehabilitation.
Inclusion criteria:
 The patient was diagnosed as having chronic pain, which
meant that he/she had pain for more than 3 months. The pain
could be either specific or non-specific in nature. In both
cases, a behavioral treatment program was indicated because
of the absence of possible medical solutions.
 The professional had one of the following occupations:
rehabilitation physician, social worker, psychologist, physio-
therapist or occupational therapist. These professions have
a major role within chronic pain rehabilitation.
Exclusion criteria:
 The patient followed a group program for the treatment
of chronic pain. Group dynamics lead to substantially
different patient experiences in group programs than indi-
vidual programs.
 The patient was diagnosed with a hyperextension injury of
the neck. These patients have different impairments than
patients with other types of chronic pain.
A group of participants was selected consisting of patients with
positive experiences and patients with negative experiences. First
purposeful sampling with the multidisciplinary team was done
in order to be able to identify patients from both groups. Patients
were informed about the study by an information letter and a
phone call in which they were asked to participate. Professionals
were selected after data was gathered from an individual interview
with their patient or an observation of their therapy session.
Professionals with different occupations were interviewed in order
to create a representative group. All participants gave their verbal
and written consent.
The patient’s characteristics and their experiences with the
treatment outcome and interaction are presented in Table 1.
The patient population consisted of four men and 12 women with
an average age of 48. The patient population was representative
for the population of people with chronic pain [2,11].
The professional’s characteristics and their experiences with the
treatment outcome and interaction are presented in Table 2.
Data collection
Interviews with patients (N ¼ 16) and professionals (N ¼ 10) were
held and observations of therapy sessions were performed.
Observations of four different therapy sessions were under-
taken. Within these observations, seven professionals were
involved.
Patients and professionals were interviewed individually:
 Seven patients were interviewed at home, after discharge.
 Four patients were interviewed after the observation of a
therapy session with their professional.
 Five professionals were interviewed, three after discharge
of the patient and two after the observation of a therapy
session with their patient.
One group interview with five patients and an independent
moderator was also held.
An interview guide with open-ended questions about the
following topics was used for the individual interviews and the
group interview: expectations about the treatment program,
 DOI: 10.3109/09638288.2014.881566 Success or failure of chronic pain rehabilitation 1905
Table 1. Participants: patients.

No. Sex Age Diagnosis Work status Treatment outcome Interaction

P1 F 64 Chronic back pain Teacher + +
P2 F 45 Chronic back pain Disablement insurance act + +
P3 M 36 Low back pain Alternative work for unit fitter  +
P4 F 51 Chronic back pain Optician +/ +/
P5 F 37 Chronic back pain Sick-leave (manager groceries) Not applicable (start treatment) +/
P6 F 46 Low back pain Self-employed (cosmetics) +/ +/
P7 M 51 Chronic back pain Sick leave (plumber)  +/
P8 F 52 Chronic neck pain syndrome Disablement insurance act +/ +/
P9 F 33 Pain syndrome Sick-leave (bathroom specialist) +/ +/
P10 F 48 Low back pain Project manager + +
P11 F 64 Chronic back and leg pain Disablement insurance act +/ +/
P12 M 43 Chronic back and knee pain Sick leave (truck driver) + +/
P13 M 57 Musculoskeletal problems Bailee + +
P14 F 50 Pain syndrome Disablement insurance act +/ +/
P15 F 31 Low back and leg pain Self employed +/ 
P16 F 54 Pain left hip & leg Sports teacher +/ +/

P ¼ patient, P12–P16 ¼ group interview.

Disabil Rehabil Downloaded from informahealthcare.com by University of Pittsburgh on 03/12/15

Table 2. Participants: rehabilitation professionals.

Professional relationship
No. Profession with patient number Sex Years of experience Treatment outcome Interaction
RP1 Occupational therapist P10 F 14 + +
RP2 Rehabilitation physician P5 M 5 NA +
RP3 Physiotherapist P4 M 20 NA +
RP4 Occupational therapist P3 F 14 +/ +
RP5 Psychologist P7 F 7 + +/
RP6 Physiotherapist P7 F 4 NA NA
For personal use only.

RP7 Psychologist P5 F 12 NA NA
RP8 Physiotherapist P5 M 26 NA NA
RP9 Occupational therapist P9 M 9 NA NA
RP10 Social worker P11 F 6 NA NA

RP ¼ Rehabilitation Professional; NA ¼ Not applicable (reasons: start treatment, professional stopped before end treatment or only an observation took
place).

interaction with the professionals, treatment outcome and learning
process. An observation scheme with questions was used for the
observations to evaluate the verbal and non-verbal interaction
between the patient and the professional.
Data analysis
Interviews and observations were recorded and literally tran-
scribed. The hermeneutic circle was used for the data analysis [8].
The purpose of this method is to gain understanding by going back
and forth between parts of the text and the whole text. The
transcribed interviews and observations were labeled by using a
coded scheme, via the software program Atlasti (Cleverbridge AG
Customer Center, http://www.atlasti.com). Categories were devel-
oped by grouping codes. Categories were compared to each other
and analyzed in relation to the whole text [9]. This led to the
creation of themes. The observations were analyzed in combination
with the interviews, which were held after the observation.
Various methods were used to enhance the credibility of the
study. Several methods of data-collection were used: observations,
individual interviews and a group interview. A member-check was
done after each interview, and after each observation the patient
was interviewed in order to check the obtained information.
Peer debriefing within the research group was used to affirm
emerging interpretations. Data saturation occurred with the
patients’ data. During the group interview, which was held in a
later stage of data collection, no new information was reported.
A saturation point in the professionals’ data was not achieved
due to time limitations.
The Medical Ethical Review Committee of the VU University
Medical Centre approved the study.
Results
Experiences concerning the treatment outcome
Patients who were satisfied with the treatment outcome are more
capable in performing their daily activities because they know
how to influence their complaints. Patients who were dissatisfied
with the treatment outcome are still not able to perform their daily
activities because they do not know how they can influence
their complaints. In some cases, the professional was more
positive about the treatment outcome than the patient.
The following themes were important for the accomplishment
of a positive or negative treatment outcome.
Shared understanding of the pain
Patients who were satisfied with the treatment outcome developed
a shared explanation with their professional of the causal and
maintaining factors regarding their pain. They realized that they
themselves have an important role in solving their disabilities.
Patient 10: ‘I did things in a different way, because I had back
pain. They taught me that I could do all the things I used to do;
it won’t worsen or damage my back. They convinced me within
a short period of time’.
Patient 6: ‘I was searching for a simple trick to solve my
pain. While talking with you (the researcher) I’m becoming
 1906 B. Oosterhof et al. Disabil Rehabil, 2014; 36(22): 1903–1910

aware of the fact that they conveyed a trick but it isn’t an were not aware of the fact that patients still had questions about
easy trick. The trick is to slow down and stand up for myself. their diagnostics.
I’m learning to do that’.
Learning new behavior
Patients who were dissatisfied with the treatment outcome had
Patients mentioned that it takes effort to unlearn old habits and
difficulties with understanding the professionals’ explanation of
thoughts, learn new habits and thoughts and regain confidence in
their pain or had a different explanation than their professional.
their own body.
Some patients agreed that psychosocial factors influenced
Patients who were satisfied with their treatment outcome
their pain but they did not expect those factors to be the cause
managed to stay motivated by experiencing improvements in their
of their pain.
functioning and by the confidence and reinforcement given by the
professionals. Patients learned new behavior by practicing it
Patient 7: ‘They say: it’s the muscles that won’t relax. I don’t
within the rehabilitation center, receiving feedback from the
know why they won’t relax, it seems that the reason is in my
professional, practicing it at home and evaluating their experi-
head’. ‘When you feel pain in your back, you don’t think about
ences with the professional.
(it being in) your brain’.
Patient 11: ‘Of course I understand that your pain can get
Patient 9: ‘You agreed to do things again despite your pain so
worse if you don’t feel comfortable or if you have a fight
then you need to stick to this agreement’. ‘At a certain moment
with someone’. ‘But I will not accept the explanation that my
you notice that moving becomes more flexible, which provides
Disabil Rehabil Downloaded from informahealthcare.com by University of Pittsburgh on 03/12/15

pain is mainly psychological’. ‘It suggests that I’m crazy.

a stimulus to continue training’.
In my opinion, the pain in my leg is neuralgia’.
Patient 6: ‘I had to stand in a different way, that was very
obvious, and that is something which I can do myself. I could
According to the professionals, some patients kept thinking
train my back by doing thousands of exercises but the problem
that their pain had a physical cause. They did not succeed
will still exist if I don’t change my standing posture. I had to
in helping the patient understand or experience their pain in a
make a connection with my daily life’.
different way.
Many patients who were not satisfied with the treatment
Professional 4: ‘We kept having a difference of opinion: we
outcome could not change their behavior because they experi-
think that your back isn’t damaged; we think the pain is caused
enced the content and/or intensity of the practical training as
by a false danger message from your brain while there is no
being insufficient. Several patients mentioned that the emphasis
tissue damage in your body. He said: I can’t understand that,
For personal use only.

of the treatment was on talking about new behavior instead of

I think it’s because I’m in a poor physical condition’.
learning new behavior. Some patients had a poor future perspec-
tive. They did not have a sufficient stimulant enabling them to
Acknowledgment for the physical part or the pain keep up the effort to change their behavior.
Some patients who developed a shared explanation with their
Patient 16: ‘You move in a certain way, I have always gone
professional thought it was important that (diagnostic) tests were
over my limits’. ‘I have only found out recently that I have to
done to substantiate the explanation model. They mentioned that
do it in a different way’. ‘The part of actually learning to move
it was important that test results were viewed and discussed
differently is far too short’.
together with the professional. For those patients, the test results
confirmed that their pain experience could not be explained (only)
Professionals also mentioned that behavior change takes a lot
by physical factors.
of effort, and requires a combination of explanation and practice.
Professionals helped their patients further within their learning
Patient 1: ‘They also did tests to confirm their explanation of
process by providing insight into their behavior and acknowl-
the cause of the pain’. ‘They ask you to feel whether a certain
edging them in their progress. They did this by asking questions
movement worsens the pain and this isn’t always the case’.
and prompting. According to some professionals, their patients
‘It makes you understand that in fact it’s in your head that it’s
managed to learn new behavior and implement it within their
painful, because the pain is always present’.
daily life because they have always been active or because of their
good body awareness or physical preference.
According to some patients, who had difficulties with the
According to one professional, her patient did not manage to
explanation model of the professionals, the pain is merely viewed
change his behavior because he could not keep up the effort due
as being psychological. In their experience, the treatment
to personal problems and poor social support.
consisted of only talking, instead of also being physical. In their
opinion, insufficient diagnostics had been done or the test results
Professional 5: ‘Not only the explanation, but this coupled with
remained rather vague. Those patients kept on questioning what
a strong positive experience will overrule the old negative
was wrong with their body.
experience (that movement is painful and means that my body
is damaged). That enables a person to change his behavior’.
Patient 15: ‘If they just would have said: we will try to see
Professional 1: ‘Sometimes you have to do a task 10 times
what happens when we trigger the pain, but their idea was
to find out that it goes better in a different way and that the
more: ‘we can’t find a physical reason so the pain must be in
whole activity goes better by doing the task in a different way.
your head’. ‘There was no ‘‘in-between’’’. ‘They have never
Normally you’re not aware of that. It’s not easy to change your
made a scan of my foot’. ‘Nobody can tell me what the cause
habits, your way of living’.
of my pain was and if it will come back’. ‘I still have nothing’.
Maintaining new behavior
Professionals considered sufficient diagnostics of importance
in order to be able to reach a shared understanding with the Patients who were satisfied with the treatment outcome men-
patient about the cause of their pain. In some cases though, they tioned that the learning process continues after rehabilitation.
 DOI: 10.3109/09638288.2014.881566
They created the necessary conditions for proceeding with their
learning process. One patient had the need for a follow-up period
to evaluate her progress. She experienced this follow-up as
valuable.
Patient 6: ‘I learned to understand the cause of my problems
and what I can do about it. The next step is to learn to live like
that, that’s a different story. I understand that I have to do that
on my own’.
Patient 6: ‘You have to give it a chance to learn to slow
down. When life starts to get busy again it’s easy to lapse into
your old pattern: this has always been your way to survive’.
Many patients who were not satisfied with the treatment
outcome still expressed the need for help in order to gain control
over their complaints or improve their functioning. Some patients
mentioned that they had little guidance in their return to work and
sport.
Disabil Rehabil Downloaded from informahealthcare.com by University of Pittsburgh on 03/12/15
Patient 16: ‘Advice regarding sport came at the last moment.
It would have been nicer if they had discussed it earlier.
This would have given me the opportunity to consider how
I would continue playing sport after discharge’.
One professional thought a follow-up appointment was essen-
tial for her patient:
Professional 4: ‘He has learned the skills but I think it will take
much more time for him to implement those skills into his
daily life’. ‘I would love to see him again for a treatment period
For personal use only.
to be able to evaluate what he learned initially, what his current
ideas are and if the skills are useful for him’.
Organizational problems
Satisfied patients as well as dissatisfied patients mentioned
organizational problems, which hindered their learning process:
cancelled appointments, professionals coming late for appoint-
ments and changes within the rehabilitation program which were
not communicated or implemented. These kinds of organizational
problems were more prominent within the stories of the
dissatisfied patients.
These organizational problems were not mentioned by the
professionals.
Experiences concerning the interaction
In general, patients who were satisfied with the treatment outcome
were also satisfied with their interaction with the professionals.
However, some of the patients with a dissatisfying treatment
outcome were satisfied with the interaction, even though most of
those patients experienced problems in the interaction with one
or more professionals. In some cases, the professionals evaluated
the interaction as being more positive than the patients did.
The following themes were important concerning the inter-
action between patient and professional.
Being taken seriously
Patients who felt that they were being taken seriously experienced
that the professional showed understanding for their situation.
Patient 2 about her fear of movement: ‘they took it seriously
by saying: it isn’t strange at all that you start to panic’.
Some patients felt that the professional did not take their pain
seriously enough nor acknowledged their efforts to solve the pain.
Success or failure of chronic pain rehabilitation 1907
Patient 5: ‘he thought that I was crazy instead of having a
physical problem. I would have solved it if that had been the
case. In contrast, I’m a person who does not give up; I never
let frustrations get the upper hand. That has also never been
mentioned before. It’s already been 1.5 years that I’ve been
trying to recover’.
The professional involved with Patient 5 argued that he just
tried to formulate his psychosocial explanation in such a way that
the patient would feel being taken seriously.
Professional 2: ‘I’ve tried to only mention the behavioral
aspects of the story. In my opinion it’s important that
people think about their problems in a nuanced manner.
They shouldn’t get the hope, perhaps false hope, that we can
fix the problem easily with an injection. I try to avoid the
message, ‘it’s in your head’, because people don’t accept such
a message’.
According to this professional, this patient could have
misunderstood his message because of her former experiences
with health care, negative thoughts and different expectations
regarding rehabilitation.
Being involved
Patients who were satisfied with the interaction experienced the
professional as having a tranquil, personal manner and as being
able to listen well. Also, they perceived these professionals as
being involved in trying to find solutions, giving them a different
perspective on their situation and guiding them within their
learning process.
Patient 4: ‘Our contact was very pleasant. She addressed my
questions by asking further: ‘how would you do this, how
would you do that? She was very active by suggesting other
things. She really listened to me and came up with solutions,
well; actually, she guided me to a solution’.
Patients who were not satisfied with the interaction experi-
enced that the professional did not listen well, was not involved
with them or was not concerned with their learning process.
Patient 14: ‘I didn’t get the impression that they knew me.
The last time I mentioned that I was disappointed about the
guidance, they said: ‘you were doing fine in sports’. I said:
‘I would have appreciated it if you had told me so because
I felt differently about it or perhaps insecure’.
One professional argued that some patients did not want
to hear an honest explanation about the pain, which then makes
the professional unpopular. In his opinion, this honest explanation
is necessary in order to really help the patient.
Professional 3: ‘Recently, I received a bottle of wine from a
patient. Surely it had to do with her previous therapist who
taught her about her pain. She was angry as her previous
therapist thought that the pain was in her head. I hadn’t
provided her with an explanation as yet. To be honest,
I think the other therapist should get the bottle of wine. It’s
our task to help the patient to think in a different way about
their pain’.
Giving a clear explanation
A clear, recognizable explanation enabled some patients to be
able to understand their pain and explain it to other people.
 1908 B. Oosterhof et al.
Patient 2: ‘They make it very clear that there’s something
wrong in your body by showing you scans and by saying:
‘you are missing 6 intervertebral discs, that’s not ok’. The
continuous confirmation that something is wrong is stored in
your head. I recognized myself in the story of a person who
at first overburdens herself, and then starts to avoid things
because of the constant message that movements can do harm’.
The explanation about the role of the brain in producing pain is
difficult to understand for some patients. Patients tend to interpret
this explanation as the pain being imaginary.
Patient 3: ‘They explain that your body gives a signal which
is stronger than it actually is. My understanding of this
explanation is that the pain shouldn’t even be there and it’s me
imagining that I have pain’.
Also, the professionals mentioned that the explanation about
Disabil Rehabil Downloaded from informahealthcare.com by University of Pittsburgh on 03/12/15
the functioning of the pain system was difficult to understand for
some patients. According to them, this was due to either a limited
level of education or a practical leaning style of the patient.
They tried to clarify the explanation model by having the same
story told by several professionals, using metaphors or by
practicing instead of talking. Professionals also mentioned that
they were insufficiently skilled in pain education and in defining
and using one clear explanation model.
Professional 4: ‘Even for me it’s difficult to understand
and explain it. It’s only recently that we started to work like
this’. ‘Next to that, it was also a person with a limited level
For personal use only.
of education’.
Being open
Some patients mentioned that the treatment plan was made in
agreement with them, while for other patients the purpose of
treatment was not always clear. Some patients discussed it openly
when they disagreed with the professional or when the therapy did
not fit their expectations. This resulted in a different explanation
by the professional or a change of approach. Other patients found
it difficult to discuss their criticism because they did not want to
hurt the feelings of the professional.
Patient 9: ‘I never heard: ‘‘this is the plan’’, and, ‘‘it takes so
many weeks’’. I never recognized a direction in that respect’.
Professionals experienced having a good or bad interaction
with the patient dependent upon the patient being or being not
open about his ideas and questions. One professional reflected
that he did not check the patient’s ideas enough.
Professional 3: ‘It surprised me that she didn’t get the point.
She was very friendly and she didn’t say in a direct manner:
‘‘manipulate my back, that’s what you’re here for’’. Maybe her
‘‘yes, but’’ questions were ‘‘I don’t agree’’ questions, and
I didn’t notice this. Maybe I should have checked more often
by asking: ‘‘do you really understand it?’’’.
Discussion
This study provides insight into factors which were related to
a positively or negatively experienced treatment outcome and
patient–professional interaction.
Patients with a positive treatment outcome came to a shared
understanding of their pain with their professional, demonstrated
new learned behavior and were able to continue their learning
process at home. Patients with a negative treatment outcome did
Disabil Rehabil, 2014; 36(22): 1903–1910
not come to a shared understanding of their pain with their
professional, were not able to change their behavior and wanted
more help to achieve this. Both patient groups experienced
organizational barriers within the treatment process.
One of the factors which play an important role in achieving
a positive treatment outcome was the presence of a shared
understanding of the pain. This was also mentioned in a review by
Verbeek [4]. This study provides insight in factors that influence
the establishment of a shared understanding, in a positive or
negative way.
Patients, in our study, who shared an understanding of their
pain with their professional became aware of having an active role
in dealing with their pain. This is supported by the conclusions
of other studies [5,12]. The patients of the current study felt
that their professional took their pain seriously. They received
an explanation that coincided with their own experiences and
conceptual framework [12,13].
Patients who did not share their professional’s understanding
of pain did not feel understood in their physical pain experience.
A possible reason for this could be the professional’s emphasis on
the psychosocial factors maintaining their pain. This focus could
have suggested to the patients that they imagine their pain, which
would obviously be a very sensitive issue. The neurophysiological
explanation about the role of the brain in producing pain is
complex [14]. The explanation can easily be misunderstood and
interpreted as ‘‘the pain is in my head so therefore it is not real’’.
According to previous research, education [15] and verbal skills
[9] are not predictors of treatment outcome. According to
Siemonsma, ‘‘a rational problem-solving style is identified as a
significant predictor of the effectiveness of cognitive treatment
of illness perceptions’’ [9]. Further research is needed in order to
determine whether pain education in the current form is suitable
for every patient.
An unambiguous explanation about pain from the multidis-
ciplinary team in simple words, eventually with the use of
metaphors, is very important. It increases the chance that the
patient will better understand the explanation model [12,16].
A solid exploration of the patient’s beliefs is needed in order to be
able to fit the explanation model to those beliefs. A Socratic-style
dialogue is a useful conversation method which stimulates the
patient to think actively about his own situation [9].
It could be of importance to substantiate the explanation model
with (diagnostic) tests. The dissatisfaction of some patients with
respect to diagnostics was confirmed by Verbeek [4]. Laerum and
Rhodes [17,18] advise the professionals to go through test results
together with patients. This enables them to conclude for
themselves what is the cause of the pain and which potential
solutions are available. According to different researchers, the
focus should be on a good patient–professional interaction
regarding the cause of pain [4,12]. The female patients in
Steihaug’s [19] study were less focused on receiving a diagnosis
when their pain was acknowledged, and when they realized that
their pain was logical. Therefore, it is of importance that the
patients receive the confirmation that their pain is real [4,6–8].
Patients want understanding regarding attempts to solve the pain,
even if those attempts are not effective.
This study has found that learning and maintaining new
behavior is an intensive process. Patients with a positive treatment
outcome became more and more aware of the relationship
between their pain and their behavior, which is in accordance with
the findings of Liddle’s and Steihaug’s study [5,12]. Due to
changes in their perception, the participants of Liddle’s and
Steihaug’s study became more confident about their possibilities
to prevent or stabilize their symptoms. The patients from
this study managed to change their behavior by practicing
and reflecting upon the new behavior. Kolb [20] argues that
 DOI: 10.3109/09638288.2014.881566
‘‘learning behavior is the result of an integration of the four
learning stages of concrete experience, reflective observation,
abstract concept formation and active experimentation’’.
Some patients of this study were not able to experience the
connection between their behavior and their pain. A cause of this
could be the lack of an underlying acceptable, understandable
explanation model. Siemonsma [9] argues that next to mental
experimentation, physical experimentation can contribute to a
change in perceptions about pain. In her opinion, mental
experimentation is the most important part of treatment. This
current study suggests that it was more likely the learning style
of the patient that determines whether mental experimentation
or physical experimentation is most important.
One finding of this study is that patients were dissatisfied
about the planning and organization of treatment. Possibly, this
affected the learning process negatively. A research report
from Revalidatie Nederland (the Dutch branch organization for
rehabilitation) [21] shows that patient satisfaction scores con-
Disabil Rehabil Downloaded from informahealthcare.com by University of Pittsburgh on 03/12/15
cerning the planning of rehabilitation treatment are low, and that
this phenomenon is widespread. Rehabilitation centers should pay
attention to this if they want to show their patients that they are
being taken seriously. This current study found that some patients
expressed the need for follow-up support while others did not
express this need. Turk and Burkwinkle [22] argue that follow-up
interventions are essential in order to enable patients to change
their behavior after living with chronic pain for several years.
The question is, which follow-up interventions are effective and
for whom. It is realistic to expect that follow-up interventions are
only useful when the patient is aware of having an active role in
dealing with his pain, and is learning new behavior. Follow-up
For personal use only.
interventions can be stimulating in terms of taking responsibility
for one’s own learning process. Patients with a negative treatment
outcome experienced being poorly guided in returning to work
and playing sport. Relapse might be prevented by paying special
attention to the integration of new behavior within these important
life areas.
This study indicates that the quality of the interaction between
patient and professional is important regarding treatment
outcome.
Patients and professionals experienced the interaction with
each other either positively or negatively. Factors associated with
a high quality of patient–professional interaction included the
patient experience of being taken seriously, the involvement of
the professional with the patient, a clear explanation of the pain,
and an open interaction between patient and professional.
This study suggests that improvements can be made by the
education of professionals in didactic skills and through the
development of a more client-centered attitude. A client-centered
attitude is needed [3,17], with skills in listening, acknowledging
personal experiences and empowering the patient’s possibilities
and efforts, in order to make the patient feel that he is being taken
seriously. This study found that there was not always an open
patient–professional interaction which made it difficult to fit the
education and training to the patient’s beliefs, knowledge,
skills and learning style. Open communication can be created
by regularly checking if the patient has understood the given
information and what his ideas are about it. It enhances the chance
on congruency between patient and professional [4] and success-
ful behavior change.
Currently, positive treatment outcome of pain rehabilitation
is mainly pursued by choosing the right treatment intervention
for the right patient. This study stresses the importance of creating
the right interaction with the patient and points out factors
that play an important role within this process.
Strength of this study is that several data collection methods
were used and that data from both patients and professionals were
Success or failure of chronic pain rehabilitation 1909
gathered. A weak point of this study is that data saturation did not
occur for the professional’s data collection. The diversity of the
professional’s group could be a reason for this. A group interview
with professionals could have provided a more representative
view of their ideas and experiences. Due to organizational
reasons, however, this was not possible.
This study provides insight into the factors which were related
to a positively or negatively experienced outcome of pain
rehabilitation. This study provides professionals with insight
into some do’s and don’ts within the rehabilitation of chronic pain
patients. A good match within the patient–professional interaction
seems to be essential.
Acknowledgements
The authors would like to thank the patients and professionals
who were willing to share their experiences with the first-named
author.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper. This study
was financed by Rehabilitation center Heliomare.
References
1. Fisher GS, Emerson L, Firpo C, et al. Chronic pain and occupation:
an exploration of the lived experience. Am J Occup Ther 2007;61:
290–302.
2. Breivik H, Collett B, Ventafridda V, et al. Survey of chronic pain
in Europe: prevalence, impact on daily live, and treatment. Eur J
Pain 2006;10:287–333.
3. Consensus report Pain Rehabilitation The Netherlands [Concensus
rapport pijnrevalidatie Nederland]. Pain Expertise Center Maastricht
[Pijn Kennis Centrum Maastricht]; 2005:23.
4. Verbeek J, Sengers MJ, Riemens L, Haafkens J. Patient expectations
of treatment for back pain: a systematic review of qualitative and
quantitative studies. Spine 2004;29:2309–18.
5. Liddle SD, Baxter GD, Gracey JH. Chronic low back pain: patients
experiences, opinions and expectations for clinical management.
Disabil Rehabil 2007;29:1899–909.
6. Petrie KJ, Frampton T, Large RG, et al. What do patients expect
from their visit to a pain clinic? Clin J of Pain 2005;4:297–301.
7. Slade SC, Molley E, Keating JL. Listen to me, tell me: a qualitative
study of partnership in care for people with non-specific chronic low
back pain. Clin Rehabil 2009;23:270–80.
8. Parsons S, Harding G, Breen A, et al. The influence of patients and
primary care practitioners beliefs and expectations about chronic
musculoskeletal pain on the process of care. Clin J Pain 2007;23:
91–8.
9. Siemonsma PC, Stuive I, Roorda, LD, et al. Best candidates for
cognitive treatment of illness perceptions in chronic low back pain:
results of a theory-driven predictor study. J Rehabil Med 2011;43:
454–60.
10. George SZ, Wittmer VT, Fillingim RB, Robinson ME. Comparison
of graded exercise and graded exposure clinical outcomes for
patients with chronic low back pain. J Orthop Sports Phys Ther
2010;40:694–704.
11. Picavet HSJ, Gils van HWV, Schouten JSAG. Complaints of the
musculoskeletal system within the Dutch population: prevalence,
consequences and groups of risk. RIVM and CBS 2000:73–4.
12. Steihaug S. Women’s strategies for handling chronic muscle pain:
a qualitative study. Scand J Prim Health Care 2007;25:44–8.
13. Daykin AR, Richardson B. Physiotherapists pain beliefs and their
influence on the management of patients with chronic low back pain.
Spine 2004;29:783–95.
14. Butler DS, Moseley GL. Explain pain. Adelaide: Noigroup
Publications; 2012.
15. Hulst van der M, Vollenbroek-Hutten MMR, Ijzerman MJ.
A systematic review of sociodemographic, physical and psycho-
logical predictors of multidisciplinary rehabilitation- or, back school
 1910 B. Oosterhof et al.
treatment outcome in patients with chronic low back pain. Spine
2005;30:813–25.
16. Mabeck C, Olesen F. Metaphorically transmitted disease. How
do patients embody medical explanations. Fam Pract 1997;14:
271–8.
17. Laerum E, Indahl A, Sture Skouen J. What is ‘‘the good back-
consultation’’? A combined qualitative and quantitative study of
the chronic low back patients’ interaction with and perceptions of
consultations with specialists. J Rehabil Med 2006;38:255–62.
18. Rhodes LA, McPhillips-Tangum CA, Markham C, Klenk R. The
power of the visible: the meaning of diagnostic tests in chronic back
pain. Soc Sci Med 1999;48:1189–203.
19. Steihaug S, Ahlsen B, Malterud K. From exercise and education to
movement and interaction, treatment groups in primary care for
Disabil Rehabil Downloaded from informahealthcare.com by University of Pittsburgh on 03/12/15
For personal use only.
Disabil Rehabil, 2014; 36(22): 1903–1910
women with chronic neuromuscular pain. Scand J Prim Health Care
2001;19:249–54.
20. Kolb DA, Fry R. Towards an applied theory of experiential learning.
In: Cooper CL, ed. Theories of group process. London: Wiley;
1975:33–58.
21. Research of the Quality of the Rehabilitation [Kwaliteit van
de revalidatiezorg onderzocht] [internet]. Rehabilitation the
Netherlands Utrecht [Revalidatie Nederland]; 2007 [cited 2012
August 27]. Available from: http://www.revalidatienederland.nl/
uploads/Y9qvlROM6GnSG-0qF2M3Ow/Zd5hjJYaEt9SNVJmEBYJ
2g/Rapport_Revalidatie_Patientenraadpleging_2006.pdf [last
accessed 15 Jan 2014].
22. Turk DC, Burwinkle TM. Cognitive-behavioural perspective on
chronic pain patients. Crit Rev Phys Rehabil Med 2006;18:1–38.