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A Randomized-controlled Trial of Using a Book of Metaphors to Reconceptualize Pain and Decrease Catastrophizing in People With Chronic Pain

Gallagher, Laura BSc (OT)*; McAuley, James PhD; Moseley, G. Lorimer PhD*,†

doi: 10.1097/AJP.0b013e3182465cf7
Original Articles

Objectives: Reconceptualization of pain and reduction of pain-related catastrophizing are primary objectives in chronic pain rehabilitation. Teaching people about the underlying biology of pain has been shown to facilitate these objectives. The objective of this study was to investigate whether written metaphor and story can be used to increase knowledge of the biology of pain and reduce pain-related catastrophizing.

Methods: In this randomized single-blind partial cross-over controlled trial, 79 people with chronic pain received either a booklet of metaphors and stories conveying key pain biology concepts or a booklet containing advice on how to manage chronic pain according to established cognitive-behavioral principles. The primary outcome variables, pain biology knowledge and catastrophizing, were measured before randomization, at 3 weeks and at 3 months, at which time the control group was crossed over to receive the metaphors and stories booklet. Pain and disability were secondary outcome variables.

Results: The Metaphors group showed larger changes in both variables (time×group interactions: P<0.01, effect size Cohen d=0.7 for catastrophizing and 1.7 for pain biology knowledge). Gains were maintained for at least 3 months. Changes were replicated in the Advice group when crossed over. There was no change in pain or self-reported disability in either group.

Discussion: We conclude that providing educational material through metaphor and story can assist patients to reconceptualize pain and reduce catastrophizing. Metaphor and story could be used as a precurser to other interventions that target functional capacity.

Supplemental Digital Content is available in the text.

*Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia

Neuroscience Research Australia and The University of New South Wales, Sydney, NSW, Australia

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

G.L.M. is supported by NHMRC Senior Research Fellowship ID 571090. Financial interests: After the completion of data collection, the booklet of metaphors was published. Royalties from its sale help fund research projects in GLM’s group. The authors declare no conflict of interest.

Reprints: G. Lorimer Moseley, PhD, University of South Australia, PO Box 2471 Adelaide, SA 5001, Australia (e-mail:

Received April 12, 2011

Accepted December 12, 2011

© 2013 Lippincott Williams & Wilkins, Inc.