ASSOCIATE PROFESSOR BRONA FULLEN
UCD School of Public Health, Physiotherapy and Sports Science
"I've Actually Changed How I Live” - Rehabilitation For People With Chronic Pain
Chronic pain is defined as 'pain on a daily basis for more than 12 weeks' and affects 1 in 5 adults worldwide.
Pain can be caused by injury to nerves (neuropathic) or to musculoskeletal and organ tissue (nociceptive). It impacts a person not only from a physical perspective but from psychological and social perspectives also.
Pain prevalence rates differ from country to country (11-20%) and from one condition to another. International best practice recommendations include cognitive behavioural therapy pain management programs to reduce the impact of pain on a person’s life.
Dr Brona Fullen and her research team design and test the efficacy of this approach in specific conditions (e.g. pain after spinal cord injury and low back pain) in different healthcare settings (primary, secondary and tertiary care) and delivery modes (face-to-face and internet).
Results show this approach improves a person’s quality of life through improved function, reduced depression and pain interference and improved sleep. It also reduces healthcare service usage.
Dr Brona Fullen and her research team at the Centre for Translational Pain Research at UCD have established the prevalence of chronic pain in the Irish population, the impact that pain has from a physical, psychological and social perspective as well as the efficacy of best practice rehabilitation on changes in quality of life, function, mood and sleep-for a range of chronic conditions.
Associate Professor Fullen speaks about her research around chronic pain in the video below.
Establishing prevalence rates for chronic pain and comparing with international rates allows clinicians to determine the scale of the problem as well as informing clinical and rehabilitation needs within the Irish healthcare setting.
Determining the impact of pain from a physical, psychological and social perspective allows physiotherapists and clinicians to stratify patients based on need and to target rehabilitation more precisely.
This aims to maximise treatment outcomes and reduce use of health service resources. The aim of behavioural therapy pain management programmes are to reduce the impact of pain on a patient’s life, by improving function, mood and ability to socially engage.
This approach requires multidisciplinary input from pain management specialists from areas such as physiotherapy, psychology, occupational therapy and pain medicine. Patients are taught strategies to manage their pain long-term that include cognitive restructuring, relaxation, problem-solving skills, graded exercise exposure, occupational rehabilitation, and pain physiology education.
Dr Fullen's research is undertaken in collaboration with clinicians in primary, secondary and tertiary care centres nationally.
In primary care these programmes were designed and tested to establish how stratifying patients with low back pain based on their psychosocial factors (mood, ability to work etc.) rather than on their physical symptoms impact on long-term outcomes of pain, function and healthcare resources.
Results showed that when compared with physiotherapists usual care for back pain, this novel approach (time-limited stratified group care based on need) led to better patient outcomes in terms of pain and function as well as less healthcare use.
A behavioural therapy pain management programme aims to give patients life-long skills to manage their chronic pain. In a secondary care setting Dr Fullen has established the impact that chronic pain has on physical and psychological function as well as on the ability to work.
Her team have also demonstrated the long-term positive changes following participation in a behavioural therapy pain management programme for patients up to 14 years after they attended the service-in terms of improved mood and physical function.
Developing chronic pain after a spinal cord injury has been described as the insult added to injury. Dr Fullen and colleague Dr Olive Lennon established that 71% of people with a spinal cord injury experience pain below the level of injury despite loss of motor control and sensation.
They went on to develop an internet-delivered behavioural therapy pain management programme in collaboration with the National Rehabilitation Hospital, again to teach patients how to manage their chronic pain long-term.
Three months after completing the programme patients reported significant reductions in pain and in pain interference in their daily lives. Along with family members patients report finding the programme life changing, not only from a personal reduction in pain for themselves but the effect on the whole household by the improved mood and quality of life of the patient.
Chronic pain is frequently an invisible, misunderstood and under-estimated condition, the appropriate management is imperative for patients to begin to regain control of their lives and of their pain. Behavioural therapy pain management programme provides patients and their families with an understanding of their condition and the tools they need to allow them to make changes in their lives and learn to control their pain.
Hearing the patients voice through qualitative research shows us how this intervention can change a person’s life for the better.
“The Cost of Pain”
Dr Fullen and her researchers have shown that group based behavioural therapy pain management and online programmes have as significant improvements in pain reduction as individual sessions. Group based and online programmes reduce economic costs to the health service and allow for the allocation of resources to other areas of the system that are lacking.
Considering the cost of chronic pain in Ireland is estimated to be €5665 per person per year, or €4.76 billion per year, these findings are hugely significant for health care professionals and the health service for planning and managing resources.
The aim of behavioural therapy pain management programmes are for the patient to able to manage their own condition by the end of the programme, this too has economic benefits as patients require less health care professional input.
To facilitate access to evidence-based care for patients who face challenges with transport, an internet-delivered behavioural therapy pain management programme for people who develop pain after a spinal cord injury was developed and trialled for the first time using the rigours of a randomised controlled trial.
Based on feedback the team are currently developing a large-scale study to continue to develop and improve the tool as well as incorporating the tool into routine care for spinal cord injury patient management in the National Rehabilitation Hospital.
The translational impact of Dr Fullen's research is evidenced by being called upon to provide expert advice to the Irish government by appearing before the joint committee for health and children in the Oireachtas, briefing members on the management of chronic pain in the Irish health service. This briefing contributed to pain medicine being designated a medical specialty by the Minister for Health.
Ireland is one of the first European countries to adapt this approach.
Dr Fullens' research on the need for a national strategy for pain management in Ireland initiated this discussion; quantifying under-resourced hospital services nationwide bench marked against international best practice recommendations as well as estimating costs of chronic pain management to the health service.
In 2015 Dr Fullen also briefed Dr Siobhan O'Halloran of the Department of Health Programme Management Office (who are responsible for implementing the Governments' health reform programme) regarding the need for the development of a National Strategy for Pain Management.
The stratification of low back pain patients by physiotherapists in primary care based on psychosocial factors informed the Health Information and Quality Authority’s Health Technology Assessment of Scheduled Procedures (2013).
The subsequent development and implementation of a novel triage approach for the management of back pain patients has been rolled out in Irish public hospitals and primary care centres.
About the researcher
Dr Fullen's expertise in pain physiotherapy saw her appointed as President of the European Pain Federation (2020-2023) – a multidisciplinary group of clinicians and researchers across Europe whose aims are to promote research, education and the clinical management of pain.
She was the first female and non-medical doctor appointed to this position.
Dr Fullen lectures to physiotherapy undergraduate and postgraduate students integrating her research findings into her teaching in UCD, RCSI and UL. Internationally she has led the development of a curriculum for pain physiotherapy for the European Pain Federation Diploma in Pain Physiotherapy.
Associated References
Breivik, H., Collett, B., Ventafridda, V., Cohen, R. and Gallacher, D., 2006. (opens in a new window)(opens in a new window)Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. European journal of pain, 10(4), pp.287-287.
Murphy, S.E., Blake, C., Power, C.K. and Fullen, B.M., 2016.(opens in a new window)(opens in a new window)Comparison of a stratified group intervention (STarT Back) with usual group care in patients with low back pain: a nonrandomized controlled trial. Spine, 41(8), pp.645-652.
Egan, A., Lennon, O., Power, C.K. and Fullen, B.M., 2016. “(opens in a new window)(opens in a new window)I've Actually Changed How I Live”—Patients' Long-Term Perceptions of a Cognitive Behavioral Pain Management Program. Pain Medicine, 18(2), pp.220-227.
Fullen, B.M., Blake, C., Horan, S., Kelley, V., Spencer, O. and Power, C.K., 2014. (opens in a new window)(opens in a new window)Ulysses: the effectiveness of a multidisciplinary cognitive behavioural pain management programme—an 8-year review. Irish journal of medical science, 183(2), pp.265-275.
Burke, D., Fullen, B.M., Stokes, D. and Lennon, O., 2017. (opens in a new window)(opens in a new window)Neuropathic pain prevalence following spinal cord injury: A systematic review and meta‐analysis. European Journal of Pain, 21(1), pp.29-44.
Burke, D., Lennon, O., Blake, C., Nolan, M., Barry, S., Smith, E., Maye, F., Lynch, J., O'Connor, L., Maume, L. and Cheyne, S., 2019. (opens in a new window)(opens in a new window)An internet delivered cognitive behavioural therapy pain management programme for spinal cord injury pain: A randomised controlled trial. European Journal of Pain.
Raftery, M.N., Sarma, K., Murphy, A.W., De la Harpe, D., Normand, C. and McGuire, B.E., 2011. (opens in a new window)(opens in a new window)Chronic pain in the Republic of Ireland—community prevalence, psychosocial profile and predictors of pain-related disability: results from the Prevalence, Impact and Cost of Chronic Pain (PRIME) study, part 1. Pain, 152(5), pp.1096-1103.
Fullen, B., Hurley, D.A., Power, C., Canavan, D. and O’Keeffe, D., 2006. (opens in a new window)(opens in a new window)The need for a national strategy for chronic pain management in Ireland. Irish journal of medical science, 175(2), p.68.
Fullen, B.M., Baxter, G.D., Doody, C., Daly, L.E. and Hurley, D.A., 2011. (opens in a new window)(opens in a new window)General practitioners' attitudes and beliefs regarding the management of chronic low back pain in Ireland: a cross-sectional national survey. The Clinical journal of pain, 27(6), pp.542-549.
Fullen, B.M., Doody, C., Baxter, G.D., Daly, L.E. and Hurley, D.A., 2008.(opens in a new window)(opens in a new window)Chronic low back pain: non-clinical factors impacting on management by Irish doctors. Irish journal of medical science, 177(3), pp.257-263.
(opens in a new window)(opens in a new window)European Pain Federation.