Elaboration of a booklet for individuals with chronic pain

Mendez, Sandra Porciuncula; Sá, Katia Nunes; Araújo, Paula Carneiro Silva de; Oliveira, Iasmyn Adélia Victor Fernandes de; Gosling, Artur Padão; Baptista, Abrahão Fontes

doi:10.5935/1806-0013.20170103

person Sandra Porciuncula Mendez

schoolEscola Bahiana de Medicina e Saúde Pública, Curso de Fisioterapia, Salvador, BA, Brasil.schoolEscola Bahiana de Medicina e Saúde Pública, Programa de Pós-graduação em Tecnologias em Saúde, Salvador, BA, Brasil.

person Katia Nunes Sá

schoolEscola Bahiana de Medicina e Saúde Pública, Programa de Pós-graduação em Tecnologias em Saúde, Salvador, BA, Brasil.schoolEscola Bahiana de Medicina e Saúde Pública, Programa de Pós-graduação em Medicina e Saúde Humana, Salvador, BA, Brasil.

person Paula Carneiro Silva de Araújo

schoolEscola Bahiana de Medicina e Saúde Pública, Programa de Pós-graduação em Tecnologias em Saúde, Salvador, BA, Brasil.

person Iasmyn Adélia Victor Fernandes de Oliveira

schoolUniversidade Federal da Bahia, Faculdade de Medicina, Programa de Pós-graduação em Medicina e Saúde, Salvador, BA, Brasil.schoolUniversidade Federal do ABC, Centro de Matemática, Computação e Cognição, São Bernardo do Campo, SP, Brasil.

person Artur Padão Gosling

schoolAliviar – Medicina da Dor, Rio de Janeiro, RJ, Brasil.

person Abrahão Fontes Baptista

schoolEscola Bahiana de Medicina e Saúde Pública, Programa de Pós-graduação em Medicina e Saúde Humana, Salvador, BA, Brasil.schoolUniversidade Federal da Bahia, Faculdade de Medicina, Programa de Pós-graduação em Medicina e Saúde, Salvador, BA, Brasil.schoolUniversidade Federal do ABC, Centro de Matemática, Computação e Cognição, São Bernardo do Campo, SP, Brasil.

Correspondence to: UFABC - Alameda da Universidade, s/n - Anchieta 09606-045 São Bernardo do Campo, SP, Brasil. E-mail:
abrahao.baptista@gmail.com

Conflict of interests: none.

Categories	Subcategories
1. What is pain?	Meanings of painCauses of pain
2. Acute pain	Meanings of acute painProcessing of acute pain
3. Chronic pain	Meanings of chronic pain Processing of chronic pain The (co)existence with pain Associated factors Mistaken beliefs Strategies for tackling pain

Biomedical model
	Population	Intervention/comparison	Follow-up measures	Results
Udermann et al.³²	I n d i v i d u a l s with chronic low back pain	They received a copy of an educative book, written examination of its content, and two interviews by telephone.	Intensity of pain, episodes of pain, self-care behaviors, knowledge and opinion on the book.	Improvement in pain, in the understanding of the content and opinions on the text were positive in general. In 9 months of follow-up: significant improvement in pain, number of episodes and perceived benefit. After 18 months of follow-up, these benefits were maintained or have further improved.
Garcia et al.³³	Individuals with chronic low back painnon-specific	Back school in groups / McKenzie individually. Both performed a set of daily exercises at home.	Pain intensity (visual analog scale (VAS)), disability (Roland-Morris), trunk flexion movement, quality of life (BREF)	The McKenzie method was slightly more effective than the Back school method for disability, but not for pain intensity immediately after the treatment. There was no untreated control group.
Hodselmans, Jaegers and Göeken³⁴	I n d i v i d u a l s with chronic low back pain	IG (intervention group): Back school program - somatic cognitive CG (control group): waiting list	Physical function and disability (RAND-36), ROM of the lumbar region,	The IG had a significant improvement in the functional status and perceived disability, probably attributable to appropriate perceptions of the physical symptoms.
Shirado et al³⁵	I n d i v i d u a l s with chronic low back pain	Phase 1. A program run by an interdisciplinary team performed in groups with a 3-hour duration.	Pain intensity (VAS), the flexibility of the trunk and hamstrings (finger-floor distance, leg elevation), muscle strength and trunk endurance, and patient satisfaction.	The result was considered satisfactory for the treatment of patients with chronic low back pain. Teaching the mechanics of the body and perform therapeutic exercises, through a multidisciplinary team approach is essential for the management of chronic low back pain.
Tavafian et al.³⁶	Women with chronic low back pain	Groups 1 and 2 were assessed and received treatment. Group 1 participated in the Back school program	Short Form Health Survey (SF-36)	The Back School" program was effective in the improvement of the quality of life of the patients. In the G2, the improvement was observed in three domains (pain, vitality and mental health), but these improvements were smaller than in G1.
Gaskell, Enright and Tyson³⁷	I n d i v i d u a l s with non-specific chronic low back pain	Nine group sessions of 2 hours each over 5 weeks.	Pain (VAS), disability (Roland Morris), anxiety and depression (HADS), perception of pain control, Fitness test and a 5-minute walking test	Levels of pain, disability, anxiety, and depression were significantly reduced. Fitness levels and perceived control improved significantly, suggesting that participants were more able to manage their low back pain. Limitations: There was no control group, and there was a high drop-out rate during the study.
Cecchi et al⁴¹	Women with non-specific chronic low back pain	Back school, individual physiotherapy, and manipulation. All participants received a booklet with information about the anatomy and biomechanics of the spine, posture and ergonomics guidelines.	Disability Roland Morris Disability Questionnaire) and pain (Pain Rating Scale).	Spinal manipulation was better associated with functional improvement and long-term pain relief than back school or individual physiotherapy but received more additional treatment during the follow-up. Pain recurrences and drug consumption were also reduced in comparison to back school or individual therapy.
Sahinet al.³⁸	I n d i v i d u a l s with chronic low back pain	IG: performed exercises, physical treatment modalities, and a back school program.CG: performed exercises and received physical treatment modalities.	Pain intensity (VAS) and functionality (Oswestry Low Back Pain Disability Questionnaire)	Improvement in pain and functionality in both groups, but the difference between the scores at the end of the treatment and after 3 months of treatment was not significant.
Sadeghi-Abdollahi et al.³⁹	Workers with chronic lower back pain	Back school Program	Pain intensity (VAS); quality of life (Short Form (SF-36).	Improvement, but not significant, of pain intensity. Three months after the end of the sessions, improvement became significant. No improvement in the quality of life was observed.
Andrade et al.⁴⁰	I n d i v i d u a l s with chronic low back pain	IG: Theoretical and practical program of the Escola de coluna (Spine School).CG: waiting list.	Pain intensity (VAS), functional capacity (Roland-Morris) and lumbar spine mobility (Schöber index).	Statistically significant improvement in pain intensity of pain, functional capacity and mobility of the lumbar spine in IG. A statistically significant difference was observed intragroup in the second and third assessments of the functional capacity and mobility variables of the lumbar spine.
Abourazzak et al.⁴²	Individuals withrheumatoid arthritis	Theoretical and practical education program	Knowledge of AR (self-questionnaire), disease activity (DAS 28), functional capacity (HAQ) and quality of life	Patient's knowledge 3 years after the education program has significantly improved. Disease activity was significantly lower in the education group after 3 years than at the beginning of the study.
Biopsychosocial Model
	Population	Intervention/comparison	Follow-up measures	Results
Pieber et al.⁴⁹	I n d i v i d u a l s with chronic low back pain	Program: 40 sessions including endurance training, psychological interventions, ergonomics sessions and healthy eating habits.	Painless ROM, the strength of the spinal extensor muscles, pain (VAS), disability (Roland-Morris) and quality of life (SF-36).	All measurements improved significantly in the post-rehab assessment and remained in the 18 months after the intervention.There was no control group.
Buchner et al.⁵⁶	Individuals with cervicalgia or chronic low back pain.	Multidisciplinary bio psychosocial therapy during 3 weeks of internment and 6 months of follow-up.	Return to the work, Quality of life (SF-36), pain intensity (VAS), functional capacity (Hannover back capacity score), and satisfaction with the therapy.	Both treatment groups had significantly improved all criteria. At the end of the follow-up period, there were no significant differences between the group with chronic neck pain and chronic back pain regarding the criteria to return to work, improvement in the quality of life, functional capacity, satisfaction with the therapy and pain reduction.
Morone et al.⁴⁶	Patients with chronic low back pain	IG: Back school: Brief education and active exercises for the spine. CG: medical care. The medication was the same in both groups.	Pain intensity (VAS) quality of life (SF36) and disability (Oswestry Disability Index).	Quality of life and disability have significantly improved over time in the IG. The result of the perception of pain showed a reduction in both groups but was significantly lower in the IG at the end of the treatment and the two follow-ups.
Sorensen et al.⁵²	I n d i v i d u a l s with chronic low back pain	Educational program/ individual physical training program based on the symptoms.	Pain (Numerical Rating Scale), disability (Roland Morris), attitudes facing pain Fear-Avoidance Beliefs Questionnaire and Back Beliefs Questionnaire, quality of life, sick leave, use of medical services.	There was an improvement in disability and also in the beliefs of fear and avoidance in the education group. All the other variables were almost equally influenced by the two treatments
Rundelle Davenport⁵⁷	70-year old woman with chronic low back pain.	Patient education based on the cognitive-behavioral theory.	Disability (Oswestry Disability Questionnaire), beliefs about pain (Fear-Avoidance Belief Questionnaire), symptoms of depression (Beck Depression Index) and self-efficacy (The Low Back Activity Confidence Scale).	Improvement in disability, fear-avoidance behaviors, depressive symptoms, and self-efficacy.
Coudeyre et al.⁵⁸	Patients with subacute or chronic low back pain	IG: Back book and frequent physiotherapy.CG: frequent physical therapy along with non-standard oral information (restricted to the questions asked by patients)	Satisfaction, functional capacity; pain intensity (VAS), beliefs of fear and avoidance (Fear-Avoidance Questionnaire) and knowledge.	Receiving the "back book" had a significant impact on disability within 3 months, and also had a significant impact on the patients' knowledge and satisfaction, but little effect on the beliefs of fear and avoidance.
Wu et al.⁵³	Individuals with knee osteoarthritis	The program provided information about osteoarthritis and coping skills.	Arthritis Self-efficacy Scale (ASE); The Survey of Pain Attitude (SOPA-35), consultations with healthcare professionals, number of days with pain and disability.	Significant differences were found in the beliefs of pain and days with pain after the intervention. After 8 weeks, there has been a significant improvement in self-efficacy, pain episodes and number of unplanned medical visits.
Coleman et al.⁴⁸	Patients with osteoarthritis	Specific self-management educational program together with written material.	Pain, physical function and mental health scales (WOMAC and SF-36)	There was an improvement in pain, function and mental health indexes.
Goeppinger et al.⁵⁰	Patients with osteoarthritis	Specific intervention for people with arthritis (Arthritis Self-Help Course - ASHC) and other generic, Chronic Disease Self-Management Program (CDSMP).	Quality of life, self-management behaviors and self-efficacy for arthritis.	The ASHC group showed significant improvement in self-efficacy, stretching and muscle strengthening and general health. The CDSMP group showed significant improvement in self-efficacy, disability, pain, and general health. The CDSMP group produced better results.
Watson, Cosioe Lin⁴⁷	Veterans with chronic idiopathic pain.	Classrooms Back School + handouts	Opinion, satisfaction and overall effectiveness of the program survey.	Participants reported learning new and useful "information", they considered the program "easy to understand", used the information learned, and recommended the program to others.
Salvetti et al.⁵¹	Individuals with chronic pain due to different diseases	A program that included physical exercises, psycho-educational group, sessions with an occupational therapist and a nutritionist.	Pain (VAS), disability (Oswestry Disability Index and Beck's Depression Inventory.	It was observed a significant reduction in pain intensity, disability, and depressive symptoms. These effects remained for a 6-month period.
Steihaug, Ahlsene Malterud⁵⁴	Women with chronic muscle pain	From education to interaction: Eight treatment groups, each with 12 weeks duration, and three groups with 10 months duration.	Qualitative data analysis from field notes, focus groups, training videos, and discussion groups.	The training program is now focused on some simple exercises and is characterized by the awareness of the relationship between breathing and muscle tension. The groups become the main pillar of the program, characterized by safety and a feeling of belonging, reflection, and development.
Man et al.⁴⁵	Patients with chronic pain	A program that includes education on pain, training in communication skills and coping strategies, physical exercises and functional activities.	Pain, catastrophism, self-efficacy, functional capacity and use of drugs.	Improvement in pain, quality of life, catastrophization, self-efficacy, functional capacity and improvement in employment rate.
Thorn et al.⁴⁴	Heterogeneous group with chronic pain.Rural area	Cognitive behavioral therapy (CBT): addressed thoughts and feelings in response to pain and stress. Education (EDU): addressed facts about the body, pain, and learning.	Pain intensity (Wisconsin Brief Pain Inventory), disability (Roland-Morris),catastrophism, depression, satisfaction, and quality of life.	Patients in both conditions reported significant improvement in all results related to pain. A non-significant trend was found for depressive mood with better improvement in CBT than EDU. Treatment gains were kept at 6 months of follow-up.
Quintneret al.⁵⁵	People with persistent pain.	Educational workshops Self-Training (STEPS): group educational program for 8 hours during two days, followed by optional medical visits initiated by the patient.	The number of patients who completed, costs per new patient, use of health care, perceived changes and pain management strategies.	The introduction of STEPS was associated with the reduction of public health services costs, increased use of pain management strategies and patient satisfaction.
Combined model - Neurophysiology
	Population	Intervention/comparison	Follow-up measures	Results
Moseley⁵⁹	Patients with chronic low back pain	Weekly, each patient had two physiotherapy sessions and one individual educational session on the neurophysiology of pain for four weeks.	Pain and disability (numeric pain scale and Roland Morris Questionnaire)	The physiotherapy program reduced pain and disability, and the effect of the treatment remained for one year.
Moseley¹⁶	Patients with chronic low back pain	An individual educational session on the lumbar spine and pain physiology.	Attitudes facing pain (SOPA), catastrophism (PCS) and physical performance.	There was a strong relationship between cognitive change and change in physical performance, mainly explained by the change in the catastrophic belief that pain means tissue damage.
Van Oosterwijcket al.⁶⁶	Patients with whiplash-associated chronic diseases.	Two educational sessions of 30 minutes each and a leaflet on the neurophysiology of pain.	Pain, kinesophobia, attitudes vis-à-vis the pain, cervical extension test, and brachial plexus test.	A significant decrease in kinesophobia and passive coping strategies.
Van Oosterwijcket al.⁶⁶	Patients with fibromyalgia	IG: Education on the physiology of pain CG: selfmanagement	Effectiveness of the inhibitory mechanism of pain, pressure pain threshold and questionnaires to assess pain cognitions, behavior, and health.	IG: improvement in the knowledge of pain neurophysiology, less concern with their short-term pain. Long-term improvements were observed in physical functioning, vitality, mental health and general health. In addition, the IG reported lower levels of pain and improvement of endogenous pain inhibition in comparison with the control group.
Ryan et al.⁶²	Individuals with chronic low back pain	Education in the biology of pain and group exercise classes (EDEX) and pain biology learning in a single group (ED)	Pain (numerical scale) and disability Roland Morris), self-efficacy, tests of physical performance and monitoring of activities in daily life.	More favorable results in the ED group. In the short term, the teaching of the biology of pain was more effective than the combination of teaching the biology of pain and group exercise classes.
Louw, Puentedura and Mintken⁶¹	Individuals with chronic low back pain	Education in neuroscience; and refresher training before and during exercises and water therapy.	Pain (VAS), beliefs and fears facing pain (Fear Avoidance); depression (Zung Depression Scale) and disability (Oswestry Disability Index)	One patient reported improvement in the four measures, mainly in the beliefs and behaviors facing pain. In a 7-month follow-up, all the measures continued to improve.
Moseley, Nicholas and Hodges⁶³	Individuals with chronic low back pain	IG: one individual session on the neurophysiology of pain. CG: a class on anatomy and physiology of the spine.At the end of the session, each participant received an exercise book with 10 sections.	Attitudes facing pain (SOUP); catastrophism (Pain Catastrophizing Scale); disability Roland Morris; physical performance tasks.	In the IG, it was observed a normalization in the attitudes and beliefs regarding pain, a reduction of the catastrophism and an improvement in the physical performance. Patients were less likely to seek care from other people, more likely to believe that they could control their own pain, that pain is influenced by emotional states, less likely to believe that pain is an indication of tissue damage, and perceived themselves as less disabled.
Moseley⁶⁴	Case Study. A 36-year-old woman with chronic back pain.	Education in the physiology of pain: The initial physiotherapy session aimed at teaching the patient how to perform a task. Daily practice	McGill Pain Questionnaire, Roland Morris Questionnaire, Fear Avoidance Questionnaire and self-efficacy pain questionnaire.	A sharp reduction in cortical activation in areas usually involved in pain. Education on pain physiology can be an effective strategy to overcome the barriers to acquire normal trunk muscle control in patients with low back pain _
Gallagher, McAuleye Moseley⁶⁵		Protocol: Two interventions, both using a booklet.Booklet 1 (IG): Metaphors and stories to help understand the biology of pain and concepts about pain management. Booklet 2 (CG): Advice on handling pain.	Questionnaire about pain biology, catastrophism, pain, and disability.	An increase of knowledge on the biology of pain in IG, but not in the CG. Higher reduction of catastrophic thoughts related to pain in IG than in the CG.Although both groups have improved over time, there was no differential effect on pain and disability.

Models	Themes	Guidance/Strategies	Main Results
Biomedical	Anatomy and biomechanics³²^-⁴⁰; Epidemiology and physiopathology of pain³³^,³⁷^,³⁸^,⁴⁰^,⁴¹.	Correct posture and movements in daily activities³³^,³⁵^-³⁹^,⁴¹; Physical Exercise³³^,³⁴^,³⁷^,⁴¹; Stay active³⁵^,³⁷^,⁴¹;	Reduction of pain³²^,³³^,³⁵^,³⁷^-⁴⁰; Reduction of incapacity³⁴^,³⁷^,³⁸^,⁴⁰; Improvement to quality of life³⁶; Awareness of the problem⁴²; Satisfaction⁴²; Improved spinal mobility⁴⁰; Reduction of anxiety and depression³⁷; Perceived Control³⁷; Improved physical ability³⁷.
	Management of pain⁴³^,⁴⁷; Pharmaceuticals⁴⁷^,⁴⁸; Nutrition⁴⁷^,⁴⁹^-⁵¹; Sleep⁴⁴^,⁴⁷; Anatomy and pathology⁴⁷^,⁴⁹^,⁵³^,⁵³; Basic physiology of pain⁴⁴^,⁵¹^,⁵⁴^,⁵⁵; Ergonomics⁴⁶^,⁴⁹^,⁵¹^,⁵⁴^,⁵⁶; Response to pain, management of stress and mental health, dysfunctional beliefs, poorly adaptive behaviours, and capacity to tackle pain⁴³^,⁴⁵^,⁵¹^,⁵³^,⁵⁶.	Physical exercise⁴⁶^,⁵¹^,⁵³^,⁵⁵; Encouragement of spontaneous movements⁵²; Acceptance of pain and use of relaxation during routine daily activities⁵⁶; Stopping smoking⁴⁷; Weight control⁴⁷^,⁴⁸; Mapping of the problem⁵²; Counselling sessions⁵³; Principles of behavioral cognitive therapy⁴⁸^,⁵⁰^,⁵¹^,⁵⁵^-⁵⁷; Explanatory leaflets⁴⁸; Activity sheets⁵⁵; Techniques for motivation and self-regulation⁴³.	Reduction of intensity of pain⁴⁴^,⁴⁶^,⁴⁸^-⁵¹^,⁵⁶; Reduction of physical incapacity⁴⁴^,⁴⁶^,⁴⁷^,⁴⁹^-⁵¹^,⁵³^,⁵⁶^-⁵⁸; Improvement in general health and quality of life (QoL)⁴⁴^,⁴⁶^,⁴⁷^,⁴⁹^,⁵⁰; Improvement to self-efficiency and strategies for management and tackling of pain⁴³^,⁵⁰^,⁵³; Reduction of catastrophism and poorly adaptive beliefs⁴⁴^,⁵²; Reduction of symptoms showing depression and anxiety⁴⁴^,⁵¹;Improved awareness⁴³^,⁵⁸; Satisfaction⁵⁵^,⁵⁶^,⁵⁸; Reduction of health expenses⁵³^,⁵⁵; Increased rate of return to work⁵⁶.
Neurophysiology of pain	Characteristics, purpose, and processing of acute pain, and processing and sustenance factors for chronic pain, including emotions, stress, cognition, and behaviour¹⁶^,⁵⁹^,⁶⁰^-⁶⁶.	Use of illustrations, examples and metaphors⁶¹^,⁶⁴^,⁶⁶; Exercise booklets for home⁵⁹^,⁶³; Pain log book⁶⁴; Informative leaflet⁶⁰^,⁶⁶; Questionnaire on the neurophysiology of pain⁶⁵^,⁶⁶; Practice of exercises⁵⁹^,⁶¹.	Pain education⁵⁹^-⁶²; Greater tolerance to pain⁶²^,⁶⁶; Reduction of incapacity⁵⁹^,⁶¹^,⁶¹; Normalization of attitudes and beliefs with regard to pain¹⁶^,⁶¹^-⁶³; Improvement in vitality and mental health⁶⁰; Reduction of catastrophism¹⁶^,⁶¹^-⁶³^,⁶⁵; Improvement to physical performance⁶⁰^,⁶¹^,⁶⁵^,⁶⁶; Increased awareness about the biology of pain⁶⁵; Reduction of concern about pain in the short term⁶⁰; Improved endogenous inhibition⁶⁰; Changes to brain activities⁶⁴.

Script A - Theme: What is pain?

Do you think that the size of the body injury determines how much the person will feel pain?The association between the size of the injury size and the pain presence was reported by 5 of the 12 interviewees, as can be observed in the speech of R12, which related the size of the injury to the greatest pain: "I think the intense injury will generate a greater pain.... and in fibromyalgia you have to learn how to live with it, otherwise you get desperate ... sometimes I am feeling well, but at other times I cannot even get up. So, this is not compared to a small injury, it's compared to a big one". As for four individuals, this association does not exist, as exemplified by the report of R10 on its experience after a surgical procedure: "When I did my heart surgery I felt a lot of pain, I got to take morphine. There were patients there who did the same surgery I did, and the pain was not such intense. So, no matter the size of the hurt, or injury, it has nothing to do".

Do you think there is a possibility of a non-painful injury on the body?
Most of the interviewees (8) stated that there is no possibility of an injury not to cause pain; some of them were emphatic, while others were not so sure. Two patients interviewed mentioned herniated disc as an example of an injury where pain relieves but does not cease with the use of medication. R12, however, referred to the herniated disc to justify her understanding that there may be an injury that does not cause pain, which is visible in her statement: "It's possible once I've heard reports from several people saying they have three, four hernias and feel nothing". Another respondent, R2, mentioned leprosy, to exemplify the existence of a painless injury.

Do you think pain can work as a warning system so that you stop doing what you're doing?
Only one interviewee does not believe that pain can work as a warning system for the individual to stop what he is doing. The other interviewees, despite the chronic pain, stated that pain can act as a warning. One of them, R11, was emphatic in reporting: "For sure, that's why I say it's a warning sign for us" .

Do you think that the amount of money or study of a person has influences in how much pain he/she feels? The question that investigated whether there is a relationship between the amount of money or study and the amount of pain that the person feels divided opinions. The interviewees related the financial condition to the possibility of seeking resources for their relief and even to discover the cure, but also related to increased stress and concerns. These data can be observed by the reports of two of them: R7 stated that "no money can stop the pain ... not the chronic pain, as the chronic pain is even horrible" and R11, when reflecting on his own history complained: "I spent so many hours sitting, working, and then I harmed my own health. So today I look back and see the evil I've done to myself".

Do you use the same treatment method when you feel a momentary pain or when this pain lasts for several months?
When asked if they would use the same treatment method when experiencing both momentary pain and pain lasting for months, most of the answers were negative. Momentary pain, as has been made clear, has a short duration. The R12 speech exemplifies well this representation since she points that it is a pain that "comes and goes" . Regarding the handling of momentary pain, the responses indicated two strategies: the use of medications and the visit to the emergency. In turn, the pain that lasts has been considered to be the one that merely gets better, but it does not cease. Several methods were used for its handling, namely acupuncture, physical therapy, blockade, RPG, water aerobics, physical conditioning, chiropractic, swimming and also the ambulatory treatment of pain.

Is there a discomfort difference between the pain that comes and goes and the one that lasts?
Only one person said there is no difference between pain that comes and goes and another one that lasts, but she did not explain the reason. The lasting pain was mentioned as the pain that is not forgotten, that decreases its intensity, but it remains forever. It was also related to desperation, sleep disturbance, and drug dependence. For R12, the difference consists of the following: "the pain that comes and goes, a headache that you take an analgesic and it ceases instantly. The pain that comes sneaky makes you nervous, stressed, you have to learn how to live with it, so to live well I have to get used to the pain" .

Script B - Theme: How does the body perceive and process pain?

How do you think an aggressive stimulus turns into a pain in our body?
The great majority of the individuals interviewed stated that they did not know how the transformation of an aggressive stimulus into pain happens, as can be seen in the R23 speech: "It's a questioning in our mind".

Are you able to differentiate a nerve, the marrow, and the brain? How could each be related to pain?
Few interviewees knew differences between nerve, marrow, and brain. There have been some attempts, observed in speeches such as: "each one hurts in one place", "our body is a whole"; "everything is connected to the nervous system"; "may be linked to the emotional system that triggers pain throughout the body". Three of the interviewees highlighted the brain. One of them, R15, said: "when we work our brain we can improve; when we put in our mind that we can, that we are capable of, we strive and we can improve".One of the interviewees attributed the pain he feels to the nerve: "I think it hurts because of the nerve".

Do you think that in the body there is some form or substance to decrease the pain felt by a person?
Most interviewees believe that in the body there is some form or substance that can decrease the pain felt by a person. Some strategies for pain reduction were mentioned, such as: do exercises, stretches, rest, being joyful and being calm. One interviewee conditioned the improvement to the presence of a professional: "if there is a professional who can guide us and say what we have, and what we can improve, and how we can collaborate".One person attributed the role of decreasing pain to antibodies, while another one mentioned the hormones. R26 was more specific: "Endorphin, right? That stimulates us... when we are more joyful the pain decreases".

How long have you been in pain? Do you think the painful information could be recorded in the body?
The interviewees reported a varied time of pain coexistence. Most of them said they felt pain between 2 and 12 years. As for the questioning about the possibility of recording the painful information, opinions were divided. Among those who believe that the pain is recorded, R19, who has been living with chronic pain for 10 years, mentioned suffering as a cause: "because we suffer so much that it gets marked". R16, who also has been suffering for 10 years, related the pain presence to the belief: "And everything comes from the mind, right? If I say that the hand is aching and put it in my mind, it will hurt". R17 agreed about the pain record and explained as follows: "because we see that place and looks like we're already in pain".

Do you believe that your emotional state influences your pain? Why?
Only one interviewee said he did not believe that his emotional state influenced his pain: "I do not think so, I think everything is the same". Other interviewees expressed the influence of the emotional state in many ways, as can be observed in the following speech: "When I get nervous, I feel my whole body aching". Two interviewees commented that thinking influences the pain they feel. One of them was emphatic: "Sure ... the more you think about pain, the more it hurts".

Script C - Theme: How do I influence my pain?

Do you think a person's intellectual level influences how they feel the pain?
The questioning about the intellectual level's influence on the way the pain is felt has divided opinions. Some aspects have been mentioned as favorable to those with a higher intellectual level, such as: having other means of dealing with their problem, knowing how to act, knowing how to care themselves, asking for help and being distracted. R33 believes that most important is how to deal with pain: "If you're weak, you just think about your pain, that has no solution, and then it ends up getting worse. If you do not take it too seriously, think it will end up soon".

Do you think culture affects pain?
The great majority of interviewees (13) stated they do not believe that pain was influenced by culture. The way of treating pain, access to natural resources and receiving guidelines were mentioned as aspects influenced by culture. R37 highlighted the importance of how a person deals with the problem: "I think pain is pain, it depends on how you look. I live like this for 20 years. Either you learn to live with this difficulty, or you die. And I rather live, because I've been almost dead. And my positive attitude influences other close people who do not know how to face the pain. We have to fight to live. There are people who give up living. The poorest people are more likely to deal with this situation".

Have you ever missed school or work because of the pain? Most people interviewed (9) reported difficulty in reconciling work with pain. Difficulties relating to the working environment, the necessity of returning home, stress and visits to the emergency were the mentioned aspects. R38 attributed his absence from work to the pain: "Today I do not work because of the pain, I'm away from work. It was very bad, I could not do my job properly, any movement would increase the pain, and that would steal my joy". Four people reported they never missed a day of work because of the pain. One of them, R30, despite saying that "it was horrible", considered,"it's the way I face my life". One interviewee reported she had stopped studying because she could not stand still. Another one, however, noted that during the classes she was distracted and forgot the pain.

Do you believe that fat influences the pain a person feels?
Only two people interviewed said they do not believe there is a relationship between obesity and pain. One of them, R29, justified her opinion with her own example: "I guess it does not influence, because I was fat and now I'm not, and I still feel pain".However, most interviewees (15) believe that there is an association between obesity and pain. The justifications were related to the difficulty of walking, moving and carrying out daily activities. R33 considered: "It's already difficult to bear the pain, let alone the weight".

Who feels pain the most, man or woman? As for the questioning about the relationship between gender and pain, the great majority believes that women feel more pain than men. One of them, R34 justified the fact by the multiple activities developed by women: "Because the woman works at home, in the field, she has sons. The woman's work exposes her more to the pain, because she falls, cuts the finger on the ax". Men were identified as having the lowest threshold and also a lower pain tolerance, as can be observed in the speech of R36: "Because men feeling a little pain spend all day in bed. Most men are like that. I'm ‘dying' of pain, and I'm always doing things". R37, who shares the same opinion, adds: "When a man has pain he goes on saying he is ‘dying'".

Can physical activity influence pain? Almost all interviewees (15) stated that they believe that the practice of physical activity contributes to the pain improvement. R28, however, made a reservation: "If physical activity is done properly, it improves pain". Interviewee R37 stated her doctor advised her to do physical activity, but realizes that she has no condition: "I have arthrosis, I cannot walk". One interviewee (R40) presented a point of view different from the others: "There are people who do physical activity and report a pain worsening right after".

Do you think that alcohol consumption influences the pain people feel?
Alcohol consumption is associated with increased pain, in the opinion of the majority of interviewees to this question. Three people reported that they drink to temporary relieve pain, stating that it "softens" (R30), "dozes off" (R37), "anaesthetize" the pain (R38). Some interviewees stated drinking is pointed out by others as associated with pain relief, as noted in R32's speech: "I've seen a lot of people say that they drink to get better". It was observed a position opposite to the consumption of alcohol by some interviewees: "Alcohol affects everything! It affects the judgment, the heart". (R35) "I do not drink anymore, and I am against who drinks because I think it affects everything, morals, the body" (R39).

Do you think that smoking influences the pain people feel?Smoking is associated with increased pain, in the opinion of most of the interviewees. Many of them even made observations on other ravages caused by cigarettes. As with alcohol consumption, one interviewee considered that use of the cigarette "anaesthetize" the pain (R30). There was a strong rejection of cigarette use by some interviewees: "Cigarette causes disease, worsens pain" (R33); "Smoking is not good. You get that itch in your throat, throat clearing, harming your lungs" (R35); "Smoking is bad for health, it causes several problems" (R40).

Do you think that spiritual practices influence the pain people feel?
The relationship between spiritual practices and pain divided opinions. Interviewees who believe that spiritual practices contribute positively were more detailed in their observations, as noted in R39: "I think it improves, we feel safer, we have to believe in something; otherwise things get worse". Prayers and beliefs were mentioned as pain relief factors. R42 believes that spiritual practices do not influence the pain's improvement or worsening, but they promote comfort, and he concludes: "It gives us support, a peace of mind for us to be calm".

Script D - Theme: How to control pain?

What do you do when you are in pain?
When asked about pain control, the main reference was the medication, mentioned by all interviewees. Some, like R42, have mentioned venous blockade as a form of pain control. "It's a palliative that is great for me! If I could, I would take it every day, so I did not have to feel ‘it' (the pain)". Because when we leave, we come out renewed, sleep is calmer". In addition to medication, other practices have been mentioned for pain relief, such as prayer, rest, relaxation, physical activities, embroidery, massage, acupuncture, and physiotherapy.

Do you think there is a relationship between movement and pain?
Most interviewees related the pain they feel to the movements they perform, as can be seen in the speech of R46: "when I start to move, I start to feel pain". Some note that despite this, they need to move: "I think when I stop it worsens, that's where I have to move myself" (R50). The same understanding was reported by R52: "you have to keep doing things, I do, I've done all my life, I do not mind, I do them even when I feel pain, it ceases, then it comes back, it happens again, I live my life like this".

Do you believe you can re-educate yourself so that you can move in spite of the pain?
The great majority of interviewees stated they believe they can re-educate themselves to keep on moving in spite of the pain. Only R44 did not believe this possibility:"no, only if I take medicine, for me it's the medicine because I have not seen anything else to make it better, I do not see anything". R54 said he believed in re-education, although he did not have this experience: "I know that for some people it works, I've never tried to do it myself".