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Abstract

Introduction

This focused review examines the use and effectiveness of self-management strategies in preventing or managing pain, which is among the most common secondary conditions faced by individuals with a mobility disability.

Methods

This focused review was part of a two-phase comprehensive scoping review. Phase I was a comprehensive scoping review of the literature targeting multiple outcomes of self-management interventions for those with mobility impairment, and Phase II was a focused review of the literature on self-management interventions that target pain as a primary or secondary outcome. Two authors searched CINAHL, PubMed, and PsyclNFO for papers published from January 1988 through August 2014 using specified search terms. Following the scoping review, the authors independently screened and selected the studies and reviewed the eligible studies, and the first author extracted data from the included studies.

Results

The scoping review yielded 40 studies that addressed pain self-management interventions for those living with mobility impairment. These 40 accumulated papers revealed a heterogeneous evidence base in terms of setting (clinic, community, and online), target populations, intervention duration (3 weeks to 24 months), and mode (health-care providers and lay leaders). Most of the reviewed studies reported that the self-management intervention led to significant reduction of pain over time, suggesting that self-management may be a promising approach for addressing pain experienced by people who live with mobility limitations.

Discussion

This review also reveals moderate-to-high bias across studies, and findings indicate that future research should enhance the methodological quality to provide stronger evidence about the effectiveness of self-management strategies for reducing pain among those with mobility impairments.

Keywords

impairment acquired conditions health self-care focused review

Introduction

In the midst of the shifting paradigm in disability that has allowed us to conceptualize people with disabilities as able to achieve health,^1,2 substantial attention has focused on secondary conditions. This notion, first coined by Marge,³ recognized that people living with primary disabilities (eg, paralysis due to spinal cord injury) often experienced health problems secondary to their disability (eg, pressure sores), but that most were preventable. Yet, 25 years later, people with disabilities continue to experience high rates of secondary conditions.^4,5 In addition, there is growing evidence that prevalence of chronic conditions (eg, heart disease, cancer, diabetes, and hypertension) is significantly higher among individuals with a disability than individuals without.^6,7 Due to the increasing evidence that having a disability increases an individual's risk of experiencing poor health, there is a growing recognition of the need for health promotion efforts.^2,8,9

In the general population, rates of chronic conditions such as arthritis, diabetes, and asthma have steadily risen,^10–12 which has led to efforts targeting patient self-management of disease. Dr. Katie Lorig at Stanford was among the first to develop a layled self-management program for people living with arthritis, which yielded successful outcomes related to increasing patient knowledge, health behaviors, and health status.¹³ While a consistent definition of self-management has not been established, Barlow's definition encapsulates the complexity of the approach,

“Self-management refers to the individual's ability to manage the symptoms, treatment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition. Efficacious self-management encompasses ability to monitor one's condition and to effect the cognitive, behavioral and emotional responses necessary to maintain a satisfactory quality of life. Thus, a dynamic and continuous process of self-regulation is established.”¹⁴ (p. 178)

With an evolving health-care system and the growing number of individuals living with a disability, implementing evidence-based self-management approaches for individuals with complex medical conditions, including those with a disability, is becoming increasingly important. This is especially pertinent as individuals spend limited time (on average 12.8-18.3 minutes) with their health-care provider and yet need to have the knowledge and skills to manage their symptoms, make healthy lifestyle changes, and take medication.^15–18

Substantial heterogeneity exists within disability, including age and manner of onset (eg, congenital, disease, traumatic injury, and age-related), body system(s) affected (eg, sensory, physical, cognitive, and emotional), severity, and impairment status (eg, stable, episodic, and progressive). Yet, US disability estimates consistently show that limitations involving walking/climbing are the most common.^19–21 Notably, while having a disability increases one's risk for secondary health problems, recent evidence about the prevalence and incidence of these health issues indicate that they are highest among individuals living with mobility limitations.⁴ People living with mobility impairments are at increased risk for an array of secondary health problems,⁴ yet six commonly experienced secondary conditions among people with mobility limitations include chronic pain, chronic fatigue, depression/mental health, urinary tract infection, bladder/bowel problems, and pressure ulcer/sore.^22–24 The purpose of this paper is to provide a focused review of the literature examining self-management programs designed to prevent or manage pain, one of the leading secondary conditions experienced by individuals with mobility impairment.

Methods

Definitions

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)²⁵ guided the process for conducting this focused review of the literature. We defined the population of interest and identified search terms before searching online databases for relevant papers. Populations of interest for this search included those who experience a health condition (from birth, disease, or injury) that impairs mobility. This focused review on pain self-management was part of a comprehensive scoping review of the literature that consisted of two phases. Phase I was a scoping review of the literature that targeted multiple outcomes of self-management programs for those with mobility impairments, and Phase II specifically targeted reviewing literature focused on self-management programs that target chronic pain as either a primary or a secondary outcome. Thus, Phase I of the scoping review targeted locating published literature examining the effect of using self-management strategies to reduce or manage secondary conditions commonly experienced by individuals with disabilities. This scoping review of the literature included publications that addressed any one of the six most commonly experienced secondary conditions among people with mobility limitations, which included chronic pain, chronic fatigue, depression/mental health, urinary tract infection, bladder/ bowel problems, and pressure ulcer/sore.^22–24 Interventions included in the scoping review covered programs that taught self-management or self-control skills to prevent or manage at least one of the six identified secondary conditions.

The authors established inclusion and exclusion criteria for retaining or eliminating publications for the focused review. The inclusion criteria were (1) the publication included results of intervention outcomes on at least one of the six identified secondary conditions; (2) >50% of the sample experienced a mobility impairment, or an impairment such as arthritis or back pain that can impair mobility, even if the authors did not comment on the participants’ mobility status; (3) enrolled participants who experienced mobility impairment ≥6 months, or the mean time with disability was ≥6 months for the full sample; (4) included the targeted age range, as long as the study did not predominantly focus on age-related disability, and the sample mean age was < 65 years old; (5) explicitly included one of the identified secondary conditions, even if it was a secondary outcome; (6) conducted an intervention to assess the effects of a self-management intervention; and (7) the paper presented the main effects of the self-management intervention on outcomes of primary interest (eg, numeric or text results of clinical or statistical significance, which includes P-value or effect size). The intent of this review was to examine the effectiveness of using self-management approaches to reduce chronic pain for adults living with permanent mobility impairment, and exclusion criteria were developed to assure that the subset of papers reviewed would target these groups. Thus, criteria were developed to assure that the studies represented adult samples without explicit aging-related mobility impairment, with diagnoses likely to result in permanent mobility problems. As self-management programs may either be structured differently or have different effects for people with cognitive impairments, we developed criteria to eliminate studies with samples whose diagnoses were likely to yield cognitive problems (eg, brain injury). Criteria set for excluding papers from review were as follows: (1) sample targeted < 18 or >65 years old; (2) sample had cognitive or psychiatric impairment (eg, traumatic brain injury, bipolar, and intellectual disability); (3) sample experienced neck pain, or arthritis predominantly in the hand; (4) sample experienced a time-limited event that causes disability (eg, pregnancy); or (5) study was cross-sectional (correlational study) or a case study.

Literature search

The literature search was completed in September 2014 using the search engines CINAHL, PubMed, and PsycINFO for papers published from January 1988 through August 2014. The authors used the following terms and included the truncation algorithm to search indexed databases: disability (disability^*), physical disability (disability^*), mobility impairment, self-management, self-care, self-regulation, lifestyle, self-control, secondary conditions, urinary tract infection, bladder/bowel problems, pain, chronic pain, fatigue, depression, and mental health. In addition, we supplemented the search of indexed databases by manually examining the reference lists of literature identified through the electronic search.

Figure 1 depicts results from the process of identifying and selecting papers for this review. Our scoping review yielded 5,068 citations, which after removing duplicates (2,624) and those that fell outside our criteria (1,244 irrelevant) left 1,200 citations for review. The review process began with establishing interrater agreement among the three study authors in identifying citations to retain for full review. The authors independently reviewed the titles/abstracts of a randomly selected 20% of the 1,200 citations, and then discussed issues for those citations with initially discordant ratings until consensus was reached. The remaining 940 citations were equally divided in a random fashion among the three authors to select citations for full review, and this consensus process was used for every citation that did not clearly fall within the established criteria. This led to selecting 109 citations for a full-text review and identifying 50 studies that met our inclusion/exclusion criteria.

These 50 papers were organized according to the secondary conditions measured across the self-management interventions. Organizing in this manner revealed that the published literature addressed only three of the six identified secondary conditions, namely, pain, depression, and/or fatigue. Yet, 22 studies targeted multiple outcomes (eg, pain and depression). Due to the large number and heterogeneity of included studies, this focused review is limited to 40 studies that targeted pain as an outcome. Then, the first author completed a standardized abstraction form for all 40 retained papers to report elements of study design, sample size, population characteristics, intervention strategies, duration, and between-group and within-group outcomes. Separate focused reviews will be published for papers that addressed outcomes of depression/mental health and fatigue.

Figure 1

PRISMA flow diagram.

Review of study bias

We assessed risk of bias using the Cochrane Risk of Bias Tool.²⁶ Risk of bias was completed for each study by considering the following five factors: sequence generation, allocation concealment, blinding, incomplete outcome data assessed, and free of selective outcome reporting. If all criteria were met, the study was considered to have low risk of bias. Where one or more criteria were partially met, the study was deemed to have a moderate risk of bias, and studies with two or more were classified as high risk.

Results

Study bias

Based on the Cochrane grading criteria, 72.5% of the studies were considered to have moderate-to-high bias (Table 1). The two most common areas of concern related to bias were the absence of blinding and concealing allocation. Yet, many studies lacked sufficient detail to ascertain one or more features in determining quality.

Participants

Forty studies included in the review represent participants with various diagnoses for which pain is a common secondary condition. Table 2 provides a snapshot related to the diagnostic groups studied, research designs used, participants enrolled, and data regarding their age, gender, and race. Over half (n = 22, 55%) of the included studies targeted individuals with chronic low back pain or musculoskeletal pain, yet more participants with arthritis or other connective tissue disorders were enrolled across the 15 studies. The type of pain participants experienced is best characterized as musculoskeletal pain. About two-thirds of the studies were randomized controlled trials (RCTs), and the total sample across the studies included 8,831 participants. The studies tended to enroll middle-aged (average 51.31 ± 5.51 years old) women (69.4%). Although women experience higher arthritis prevalence at all ages than men,¹¹ the discrepancy in arthritis prevalence between men and women is not that large. However, US estimates indicate that two-thirds of those who report experiencing activity limitations due to arthritis are women.²⁷ Younger males were better represented in studies that enrolled individuals with mobility impairments due to diagnoses such as spinal cord injury and chronic low back pain. Race was reported in less than half (48%) of the studies. Among the studies that did report race, whites comprised the vast majority (83%) of the samples. Yet, three studies included in this review were designed to target minority groups.^28–30

Table 1

Methodological quality (n = 40).

STUDY	SEQUENCE GENERATION	ALLOCATION CONCEALMENT	BLINDING	INCOMPLETE OUTCOME DATA ADDRESSED	FREE OF SELECTIVE OUTCOME REPORTING	RISK OF BIAS
Baranoff (2013)	No	No	No	No	Yes	High
Basler (1997)	Yes	No	No	Yes	Yes	Moderate
Carpenter (2012)	Yes	No	No	Yes	Yes	Low
Dysvik (2010)	No	No	No	Yes	Yes	High
Friedrich (1998)	Unclear	No	No	Yes	Yes	High
Frost (1995)	Yes	Unclear	Yes	Partial	Yes	Moderate
Gatchel (2002)	No	No	No	No	No	High
Goeppinger (2007)	Yes	Unclear	No	No	Yes	High
Jensen (2001)	No	No	No	Yes	Yes	High
Kendall (2000)	Yes	Unclear	No	Unclear	Yes	High
Kroenke (2009)	Yes	Yes	Yes	Yes	Yes	Low
Kuukkanen (1996)	No	No	No	No	Yes	High
Lamb (2010)	Yes	No	No	Yes	Yes	Moderate
LeFort (1998)	Yes	Yes	Yes	Yes	Yes	Low
Lindroth (1989)	No	No	No	Yes	Yes	High
Lindroth (1997)	Unclear	No	No	Yes	Yes	Moderate
Lorig (1989)	Unclear	Unclear	Unclear	Yes	Yes	Moderate
Lorig (2004)	Yes	No	Partial	Yes	Yes	Low
Lorig (2008)	Yes	Unclear	No	No	Yes	High
Lorig (1999)	Yes	Unclear	Unclear	Yes	Yes	Moderate
Mazzuca (1997)	No	No	Partial	Yes	Yes	Low
Mazzuca (2004)	No	No	No	Yes	Yes	High
McCracken (2007)	No	No	No	No	Yes	High
McKnight (2010)	Yes	Unclear	No	Yes	Yes	Moderate
Nawoczenski (2006)	No	No	No	Yes	Yes	High
Nicholas (2012)	No	No	No	Yes	Yes	High
Nicholas (2013)	Yes	Yes	Yes	Yes	Yes	Low
Nielson & Jensen (2004)	NO	No	NO	Yes	Yes	High
Niemisto (2003)	Yes	Yes	Yes	Yes	Yes	LOW
Perry (2010)	NO	No	NO	Yes	Yes	Moderate
Peters (1990)	Yes	No	NO	Yes	Yes	Moderate
Poole (2014)	NO	No	NO	Yes	Yes	High
Riva (2014)	Yes	No	No	Yes	Yes	LOW
Ronen (1996)	No	No	No	Yes	Yes	High
Ruehlman (2012)	Yes	Unclear	Unclear	Yes	Yes	Moderate
Rydeard (2006)	Yes	Yes	Partial	Yes	Yes	LOW
Shigaki (2013)	Unclear	Unclear	Unclear	Yes	Yes	Moderate
Shirado (2010)	Yes	Unclear	Yes	Yes	Yes	LOW
Slater (1997)	No	No	No	Yes	Yes	Moderate
Snook (1998)	Yes	No	No	Yes	Yes	Low

Settings

The review includes studies predominantly conducted in North America (n = 21, includes the US and Canada), many studies conducted in Europe (n = 7, counting Israel as in Europe) or Nordic countries (n = 5), several studies conducted in Australia or New Zealand (n = 6), and one study conducted in Asia. Interventions were delivered in an inpatient rehabilitation center,³¹ 15 were provided in clinical settings, including hospital-based outpatient clinics,^32–44 one combined delivering the intervention in a clinical setting with a transition to home,^30,45,46 several were in the community (mail or small group)^{28,29,47–51} including the home,^52,53 and six were offered via the Internet.^54–59 Notably, many clinic-based studies had a multidisciplinary team of physicians, nurses, physical therapists, and psychologists delivering the intervention. Approaches included promoting exercise in group-based settings with two studies that compared exercise approaches⁶⁰ and one combined education with exercise.⁶¹

Intervention

Intervention programs generally focused on educating participants about using cognitive-behavioral strategies to manage pain. The programs typically combined cognitive (eg, desensitization, cognitive restructuring, pain management, and problem solving), behavioral (eg, goal setting, relapse prevention, stress management, relaxation, increasing self-efficacy, and social support),^32,33 and physical components (eg, strengthening specific muscles, encouraging exercise to reduce pain, and teaching body mechanics)⁶² to address self-management. Investigators implemented various modes of delivery, including individualized,⁶² small group, or online/telephonically. Many interventions were relatively brief, ranging in duration from 3 to 4 weeks,^{30,31,34–36,38,39,61,63,64} 6 to 10 weeks,^{29,40–42,46–48,53,55–57,65–67} and one was 18 weeks.³⁸ Several studies delivered longer interventions, including two studies that recommended participants to engage in behavior change for 6 months,^53,68 and three studies that provided ongoing intervention for 12 months,^37,49,52 and one study lasted for 24 months.⁴³

In terms of the theoretical underpinnings used in these studies, several studies explicitly stated using cognitive-behavioral approaches to address behavior change,^{35,38–40,47,50,56,63} and two studies^37,66 formally addressed incorporating two primary theoretical frameworks, including social cognitive theory^{29,37,48,49,57,67} and social learning theory.⁵⁹ In addition, one research group has hypothesized that the transtheoretical model plays a role in program adherence and outcomes in pain management.⁴⁴

Outcome measures

There was substantial variability regarding the aspects of pain assessed and the specific measures used. Pain intensity was often measured, but other aspects of pain included pain interference, pain symptoms, pain severity, pain catastrophizing, pain acceptance, pain self-efficacy, pain stages of change, and pain locus of control. A visual analog scale was commonly used to assess pain intensity. Other pain instruments included the Brief Pain Inventory, Multidimensional Pain Inventory, Arthritis Impact Measurement Scales, McGill Pain Questionnaire, SF-36 pain subscale, Western Ontario and McMaster Universities Osteoarthritic Index (WOMAC), and the Wheelchair User's Shoulder Pain Index.

Table 2

Summary of 40 studies regarding the diagnoses, research design, number of participants studied, and their mean ages.

DIAGNOSES	NUMBER OF STUDIES	RESEARCH	DESISGN	TOTAL PARTICIPANTS	PARTICIPANT AGES MEAN (SD) RANGE	MALE GENDER	RACE REPORTED	WHITE RACE	TARGETS MINORITY
Spinal cord injury/ spina bifida/severe mobility impairment		RCT	0
		Quasi	2		44.4 (1.81) yrs
	3	Pre-post	1	130	38-47 yrs	57.1%	1	98.5%	0
Chronic pain/chronic low back pain		RCT	16
		Quasi	2		44.4 (5.28) yrs
	22	Pre-post	4	3764	34-55 yrs	42.9%	9	75.4%	0
Arthritis/fibromyalgia/ other connective tissue disorder		RCT	10
		Quasi	2		56.26 (6.24) yrs
	15	Pre-post	3	4937	46-65 yrs	21.0%	9	88.0%	3
Totals^a	40	RCT	n = 26,65%	8831	51.31 (5.51) yrs	30.6%	n = 19, 48%	83.1%	3

Note:

Averages and proportions weighted by sample sizes of the studies.

Results

The reviewed studies can be grouped into five broad categories, based on the type of intervention delivered. Self-management intervention approaches represent those that were delivered (1) as in-person classes in clinical settings, (2) as in-person classes in the community, (3) as mixed in-person sessions in the clinic with a transition to home, (4) in combination with exercise programming, and (5) online. This section presents results separately for these broad categories. Detailed information for all 40 reviewed studies is located in Table 3.

Self-management programs delivered in clinical settings

Of the 15 studies delivered in clinical settings, 13 (85%) reported that the self-management program resulted in significantly reduced pain. Among the nine RCTs or quasi-experimental designs, groups receiving self-management training had significantly greater reductions in pain than the groups receiving usual care^37,50 or compared with a control group.^42,65 Several studies also compared effects of the self-management program with other active intervention arms. Lamb et al⁵¹ reported that the use of cognitive-behavioral therapy (CBT) was more effective in reducing pain than active management alone and that combining active management with CBT had greater benefits than CBT only. Peters and Large⁴⁰ demonstrated that teaching self-management strategies was more effective than usual care within both inpatient and outpatient settings. However, Nicholas et al³⁹ reported that combining CBT with teaching participants’ techniques either to distract themselves from pain or to expose themselves to pain both yielded significantly less pain. Furthermore, all six studies that used a single-group, pretest-posttest design reported that the self-management program led to significantly reduced pain over time. Notably, these intensive interventions were delivered by a multidisciplinary team^35,44,69,70 during intensive 90-minute or five to eight hours/day sessions over three weeks,^{32,35,38,44,69,70} with one delivered over 12 weeks.

Program adherence was only reported in two (13%) studies,^38,39 which were conducted by the same research group and measured participants adherence using the five to seven self-management strategies taught (activity pacing, using a flare-up plan, stretch exercises, desensitizing, thought challenging, fitness exercises, goal setting). Both also examined outcomes based upon adherence to using these strategies and, as hypothesized, use of more strategies was associated with greater improvements in pain. Notably, the investigators directly observed patients use of these strategies as these studies were conducted within inpatient and all-day outpatient settings. Attrition was reported in 13 studies (87%) with an average retention rate of 81%, and four conducted intent-to-treat analyses.^37,41,47,51

Table 3

Study summary.

STUDY	DESIGN SETTING	PARTS	INTERVENTION	OUTCOME MEASURES	TIME TO FOLLOW-UP	RESULTS	CONTROL/ COMPARISON CONDITION	ADHERENCE	ATTRITION	EFFECT SIZE
Baranoff et al (2013)	Single group pre/post test; Clinic-based; Australia	CP n = 186 Age = 43.5	CBT multidisciplinary program with group-based classes and diverse instructors, including a psychologist, physiotherapist, pain physician and nurse. Components included: appropriate exercises and activities, fear avoidance, cognitive restructuring, relaxation training, goal setting and education regarding chronic pain. Dose: 3 weeks, 6 hrs/day for 5 days/week	Daily pain average Pain acceptance Pain catastrophizing	BL, 3 wk, 3.75 mo	Between group N/A Within group Sig decrease in pain intensity at 3 weeks and 3 mos follow-up, with small effect Sig improvement in pain acceptance across time, with large effect	N/A	No	Yes. 10 withdrew; 95% retained 176/186 for whom data analyzed	Yes Pain Acceptance .66/73 Pain Intensity -.33/-.33
Basier et al (1997)	RCT; Clinic-based, Germany	CLBP n = 94 Age = 49.3	CBT treatment; delivered in a small group setting included: posture training, relaxation techniques, information about pain cycle, different treatments, demoralization, how to modify thoughts and feelings, scheduling pleasant activities. Dose:12 weekly sessions, 2.5 hrs each	Pain diary (intensity, control, days of pain, med use) Heidelberg Coping Scale (HCS) Dusseldorf Disability Scale (DDS) Days lost at work	BL, 12 wk, 9 mo	Between group Sig decrease in pain intensity and control over pain, not pain days or pain med use Within group N/A	Usual care	No	Yes. 11 withdrew; 87.4% retained 76/87 for whom data analyzed	No; included mean/SD to calc
Carpenter et al (2012)	RCT; Internet based, US	CLBP n = 141 Age = 42.5	CBT intervention: components include information about pain, modifying thoughts about pain, stress management, relaxation techniques, goal setting and motivation to increase physical activity. Dose: 3 weeks, 6 chapters provided 60-90 mins of online content	Survey of Pain Attitudes (SOPA-32) Pain Catastrophizing Scale Pain Self-efficacy Scale (SES) Pain level average per wk (1-10)	BL, 3 wk, 6 wk	Between group No sig improvement in Pain Severity Sig improvement in SOPA Sig improvement in Pain Catasophizing Scale Sig improvement in SES Wait list group also showed Sig improvement after intervention Within group N/A	Usual Care	Yes. Provided part self-report of online use of website, including chapters completed. 81% completed 6 chapters	Yes; 23 withdrew over 6 weeks; 83.7% retained 118/141 for whom data analyzed	Yes; Pain Control 1.01 Pain Catastrophizing -.59
Dysvik et al (2010)	Quasi-experimental; Clinic-based, Norway	CP n = 113 Age = 44.67	CBT program which included therapeutic dialogues, building skills, understanding	Brief Pain Inventory (BPI) Pain Stages of Change Questionnaire (PSOCQ)	BL, 8 wk	Between Group Significant reduction in pain intensity and inference No sig differences	Random subsample of CBT group received an additional package and Wait-list control	No	Yes, 4 withdrew; 96.6% retained for whom data	No; no mean/ SD; includeds mean diff/95% cl. Address
			the relationship between thoughts, feelings and behavior, physical activity and homework. Select members of treatment group received an “additional package” of a contract plus 2 extra counselor visits Dose: 8 weeks, 5 hrs/ week			between those participants who received or did not receive the added component Within Group N/A			were analyzed	clincal significance using RC index with 19% reliable change on Pain Interference & unclear on BP SF36
Friedrich et al (1998)	RCT; Clinic-based, Austria	CLBP n = 93 Age = 44.12	Combined exercise and motivation program; individual sessions with PT trained in motivational techniques. Exercise component included individual, submaximal, gradually increasing exercise program. Motivation component included counseling and information strategies, reinforcement techniques, oral agreement regarding treatment contract, and an exercise diary. Dose: 10 sessions, 25 mins each, 2-3 sessions/ week	Pain Intensity (numeric scale)	BL, 4 wk, 4 mo, 12 mo	Between group Significant btwn grp differences in pain ratings Within group Sig differences in pain ratings for both grps observed at all 3 follow-up assessments	Standard exercise program	Yes. Reported mean sessions attended for both groups out of 10. Exp 9.6 (96%) & Control 8.6 (86%)	Yes, 19 withdrew at first follow up, 9 at 2nd, and 24 at the 3rd; 74.2% retained for whom data were analyzed	No; included mean/SD to calc
Frost et al (1995)	RCT; Clinic-based, UK	CLBP n = 71 Age = 36.32	Backschool Intervention: tailored educational program that covered functional anatomy, body mechanics, advice regarding functional activities and exercise, relaxation techniques, ergonomic advice, plus workshops to prevent back injury. + Fitness program supervised by a physiotherapist to do: stretching, progressive exercise circuit, light aerobics, and receive encouragement. DDose: 4 weeks, 8-1 hr sessions	Sensory and affective pain–-Numeric Rating Scale Pain locus of control questionnaire	BL, 4wk, 6 mo, 2.5 yr	Between Group Sig reduction in sensory and affective pain Within Group Sig reduction in sensory and affective pain	Backschool educaction intervention only	Yes, reported attendance as 86% of sessions	Yes, 10 withdrew, 87.7% retained for whom data were analyzed	No; included mean/SD to calc
Gatchel et al (2002)	Single group pre/post test; Clinic-based, US	CP n = 65 Age = 54.9	Multisciplinary pain treatment program included medical and medication management, physical therapy (6-12 sessions), group counseling (coping, stress, social support–-10 sessions), and individual psychological management (CBT, biofeedback, stress management–-10 to 16 sessions). Dose: Individualized to receive appropriate sessions	Dallas Pain and Disability Questionnaire (DPDQ) Dallas Pain Drawing Visual Analog Sclae (VAS) Multidimensional Pain Inventory (MPI)	Pre-post program	Between Group N/A Within Group Sig improvement in pain intensity over program	N/A	No	No	No; included mean/SD to cale
Goeppinger et al (2007)	RCT; Community setting, US	Arthritis n = 416 Age = 64	Compared 2 programs: Chronic Disease Self-Management Program (CDSMP)and Arthritis Self-Help Course (ASHC): both provide efficacy- enhancing strategies such as symptom reinterpretation, problem solving; includes educational component that covers exercise, nutrition, medication management, advance directives, better breathing, and communication strategies. Dose: 6 weekly, 2-2.5 hr sessions	Pain Visual Numeric Scale	BL, 4 mo, 12 mo	Between Group Significant reduction in pain in favor of the CDSMP for the full grp and African Americans Within Group Sig reduction in pain at 4 mos for CDSMP participants, but not African American CDSMP participants	CDSMP vs ASHC	Yes, attendance at 6 sessions for total and AfAm grps. AHSC 4.3/4.3, CDSMP 4.9/4.4	Yes; 4 mo 77% all 320/416 & 78% AfAm 283/365; 12 mo 67% of all 167/248 & 66% of AfAm 145/220	No; no mean/ SD; presents mean diff.
Jensen et al (2001)	Single group pre/post test; Clinic-based, US	CP n = 141 Age = 44.7	CBT multidisciplinary program, included sessions with physiotherapist, psychologist, pain physician and nurse. Content based on CBT principles and consisted of exercises and activity; cognitive restructuring, relaxation training, goal setting and education regarding chronic pain. Dose: 3 weeks, 5.5 days/ week	Pain Intensity, numeric scale	BL, 3 wk, 6 mo, 12 mo	Between Group N/A Within Group Sig decrease in pain at 3 weeks, 6 and 12 mos (medium effect)	N/A	No	Yes; 56 withdrew; 72% retained 141/197	No; included mean/SD to cale
Kendall et al (2000)	RCT; Community setting, Sweden	Fibromyalgia n = 20 Age = 46.55	Compared 2 groups Mensendieck system (MS): discussion, analysis of patient's movement patterns, integrate sensory and cognitive	Pain at worse site: Visual Analog Scale (VAS)	BL, 3 mo, 6 mo, 18 mo	Between Group Significantly increased pain self-efficacy at 6 months in favor of MS program Within Group	Compared BS and BAT groups	No	Yes; 4 withdrew; 80% retained 16/20	No; included mean/SD to cale
			information into body movements Dose: 18, 40-min individual weekly sessions and 2 group sessions over 20 weeks + 3 and 6 mo post treatment group sessions Body Awareness Therapy (BAT): discussion, exercises to stimulate sensory activation, relaxation and breathing techniques, exercises to promote awareness of muscular tension and relaxation. Dose: 20 weeks, delivered 19, 90-min group weekly sessions, + 3 and 6 mos post-treatment group sessions			Sig decrease in pain at worse site at 18 mos in MS group
Kroenke et al (2009)	RCT; Clinic-based, US	CP n = 250 Age = 55.5	3 mos antidepressant therapy followed by 6 sessions of pain self-management program delivered every other week during second 3 mos; final 6 mos was a continuation phase focused on relapse prevention. Included 5 in-person contacts (at baseline, 6, 12, 16 and 20 weeks) and 8 telephone contacts (1, 3, 9, 14, 18, 22 weeks and at 8 and 10 mos). Dose: 10 mos, 5 x/week for about 1 hr/session	Brief Pain Inventory (BPI) Global Improvement in Pain (GCPS) Roland Pain Disability Scale SF-36 Bodily Pain	BL, 3 mo, 6 mo, 12 mo	Between Group Sig improvement in all pain measures Within Group N/A	Usual Care	No	Yes; 45 withdrew; 82% retained 205/250. Intent to treat analyses for full sample	Yes; Pain Severity .54 and Pain Inerference .62 at 12 months
Kuukkanen et al (1996)	RCT; Home-based, Finland	CLBP n = 90 Age = 39.9	Compared 3 Groups Intensive exercise training program which included 7 exercises targeting the trunk and extremities using pulleys, plinths and barbells. Two sessions per wk were supervised by physiotherapist.	Back pain intensity: Borg Index	BL, 3 mo, 6 mo, 12 mo	Between Group Within Group Sig decrease in back pain in all groups at 3 mo, 6 mo, and 12 mo	Usual care	No	Yes; 13 withdrew; 84.9% retatained 73/86	No; Included mean/SD to calc
			Dose: 3 mos of 5.2 sessions/week Group 2 Exercise program which Included same exercises as Group 1, but without the equipment and supervised by physiotherapist once per month. Dose: 3 mos of 3.5 sessions/week Group 3 Control group allowed to follow any treatment program, but without ergonomic guidance
Lamb et al (2010)	RCT; Clinic-based, UK	CLBP n = 699 Age = 54	Active management (AM) + Cognitive Behavioral Approach (CBA) AM: One individual session to set goals and Individualize exercise program + informational book CBA: Six 90-min group sessions to target unhelpful beliefs about pain and activity, and promote engagement n leisure, physical and occupational activity. Components Include: explore unhelpful beliefs; skill development thru homework, increase activity levels, manage over activity, address catastrophizing and fear avoidance, and improve coping skills. Dose: 6 sessions, 90 minutes	Modified Von Korff Scale (pain sub scale)	BL, 3 mo, 6 mo, 12 mo	Between group Sig decrease in pain measures at 3, 6, and 12 mos Within group N/A	Active Management (AM) program	No	Yes; 103 withdrew; 85% retained at 12 months 598/701 and Included in analyses	Yes; .37 at 12 months for MVK pain .35 pain self-efficacy
LeFort et al (1998)	RCT; Community-based, Canada	CP n = 110 Age = 39.48	Group-based psychoeducational program (Chronic Pain Self-Management Program, modified from the Arthritis Self-Management Program) led by a nurse with group problem solving, mutual support, various cognitive behavioral self-management techniques, a workbook and relaxation tape, and education	Pain quality (SF-MPQ) Pain problem severity (0-100), SF-36 Bodily Pain subscale	BL, 6 wk	Between Group Sig improvement in pain problem and severity and bodily pain Within Group N/A	Wait-list control	Yes, mean of 4.7 sessions/ person out of 6	Yes, 8 withdrew, 92.7% retained 108/110. Intent to treat analyses	No; Included mean/SD to calc
			about pain, nutrition and walking. Dose: 6 weeks, 2 hr sessions/week
Lindroth et al (1989)	Quasi-experimental: Clinic-based, Australia	RA and OA n = 195 Age = 60.08	Self-management behaviorally-based course with content delivered by multi-disciplinary team that covered medical aspects, pain management, exercise, available treatments, stress management, self-awareness, communication skills, work simplification, joint protection, nutrition and leisure, and availability of community resources. Dose: 6, 2.5 hr weekly session	Pain Visual Analog Scale (VAS)	BL, 6 wk, 3 mo, 12 mo	Between Group Within Group N/A	Usual care comparison group of patients attending a university hospital who received no education	No	Yes; 46 withdrew; post test 93.3% retained 178/195 & 79% retained 154/195 at 12 mos.	No; included mean/SD to calc
Lindroth et al (1997)	RCT; Clinic-based, Sweden	RA n = 96 Age = 54.98	Self-management course with multi-disciplinary health professionals; topics covered physical, social, and emotional problems, medical aspects, problem solving, exercise and nutrition, medication, and social support. Dose: 8 weeks, 2.5 hr weekly sessions	Pain Visual Analog Scale (VAS) Capacity to relieve pain	BL, 3 mo, 12 mo	Between Group Sig reduction in pain at 3 mos, but not 12 mos Sig difference in capacity to relieve pain at 3 and 12 mos Within Group N/A	Control group	No	Yes; 4 withdrew; 96% retained 96/100	No; included mean, no SD
Lorig & Holman (1989)	RCT; Community setting, US	RA and OA and Other n = 543 Age = 64	Examined effects of reinforcing self-management program 8 mos after its completion; participants randomized to 1 of 3 groups. Arthritis Reinforcement Course (ARC): developing and endurance exercise program, cognitive pain management, communication skills, and nutrition. Dose: 6 weeks, 2 hr sessions/week Newsletter	Pain Visual Analog Scale	BL, 4 mo, 8 mo, 20 mo	Between Group Within Group Sig reduction in pain over time	2 reinforcement groups: Arthritis Reinforcement Course, Newsletter plus 3rd Control group	Yes. 24% people attended 6 wk course. No info on reading newsletters	Yes; 46 withdrew; 91% retained 497/543. Those withdrew had worse symptoms	No; included mean/SD to calc
			mailed bi-monthly on arthritis reinforcement course. Control with no reinforcement
Lorig et al (2004)	Study 1 RCT; Home-based, US Study 2 RCT; Community-based, US	Study 1 OA and RA n = 1090 Age = 62.2 Study 2 OA and RA n = 341 Age = 65.2	Study 1 Self-Management Arthritis Relief Therapy (SMART) was a mail-delivered, tailored print intervention consisting of personal letter, summary report and suggested plan of action. Repeated every 4 weeks for 12 mos based on individualized questionnaire completed. Participants provided a handbook, tailored letter with exercise and arthritis behavior information, and relaxation tape. Study 2 Compared mailed SMART program with community-based Arthritis Self-Management Program (ASMP) ASMP used interactive small group sessions with lay leaders; topics included knowledge about arthritis, nutrition and medications, skills for improving function and reducing pain, use of cognitive restructuing tequniques, physical activity, improving communication. Dose: 6, 2 hr sessions/ week	Pain Visual Analog Scale	BL, 1 yr, 2 yr, 3 yr	Study 1 Between Group Within Group N/A Study 2 Between Group Within Group N/A	SMART compared to Usual care (Study 1) ASMP (Study 2)	Yes. ASMP mean attendance 4.6/6 sessions, SMART 12% not participate	Yes; withdrawals reported annually (33 yr 1, 46 yr 2, 73 yr 3); 90% yr 1, 83% yr 2, 73% yr 3 retained for 249/341	No; included change scores/SD
Lorig et al (2008)	RCT; Internet-based, US	RA, OA, F n = 855 Age = 52.35	Intervention based on Chronic Disease Self-Management Program (CDSMP) Web-based arthritis self-management program which includes: individualized exercise plan, use of cognitive symptom management, methods for managing negative emotions, aspects of communicating with doctors, healthy eating,	Pain Visual Numeric Scale	BL, 6 mo, 12 mo	Between Group Sig reduction in pain at 6 and 12 mos Within Group N/A	Usual care	Yes, mean login of 31.6 ± 24.5 tiems over 6 weeks	Yes; used Intent to Treat	No; included change scores/SD
			fatigue management, action planning, feedback, and methods of solving arthritis-related problems. Dose: 6 weeks, 1-2 hours of online instruction/week
Lorig et al (1999)	RCT; Community setting, US	RA, OA, undiagnosed arthritis n = 219 Age = 62.50	Intervention based on the Arthritis Self-Management Program (ASMP) for Spanish-speaking people. Intervention delivered by lay-leaders & included education on how to access care, importance of exercise, self-management techniques, relaxation techniques, problem solving, healthy behaviors, and goal setting. Sessions included participation in group exercise. Dose: 6 week, 2 hr session/week	Pain Visual Numeric Scale	BL, 4 mo, 12 mo	Between Group Sign improvement in pain at 4 mos Within Group Sig improvement in pain at 12 mos Small effect size for change in pain	Wait-list control	No	Yes; 46 withdrew 86% retained at 4 months 285/331	Yes, .37 pain
Mazzuca et al (1997)	Quasi-experimental; Mixed clinic/community settings, US	OA n = 211 Age = 62.40	Self-care education intervention, included an individualized session with nurse educator that emphasized non-pharmacologic management of join pain, preservation of function by problem solving and practice of joint protection principles plus 5–-10 min phone calls at 1 week and 1 month. Dose: 1 month, initial 30-60 min individual session, plus phone calls at 1 week and 1 month	Global pain: Health Assessment Questionnaire Pain at rest, Visual Analogue Scale Pain when walking, Visual Analogue Scale	BL, 4 mo, 8 mo, 12 mo	Between Group Significantly lower pain at rest by 12 mos Within Group N/A	Attention control group received 20-minute audiovisual presentaiton on arthritis	No	Yes, 52 withdrew; 72% retained 134/186 and analyses conducted on these	No, included means/SD to calc
Mazzuca et al (2004)	RCT; Mixed clinic/community settings, US	OA n = 186 Age = 61.80	Self-management program, included an exercise prescription, application of heat or cold, behavioral principles of joint protection including weight loss,	Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain and function of knee	BL, 3 mo, 6 mo, 12 mo	Between Group Within Group N/A	Wait-list control	No	withdrew; 78% retained 165/211 at 12 mos w/analyses conducted on	No; included means/SC to calc
			and acetaminophen. Control = usual care. Dose: 18 weeks, inital 30-60 min individualized meeting plus biweekly calls for 16 weeks
McCracken et al (2007)	Single group pretest/post test; Clinic-based, UK	Mobility Impairment related CP n = 53 Age = 46.30	CBT pain management course designed to Increase psychological flexibility; included daily exercise education, skills training, and psychological sessions. Incorporated exposure, acceptance, cognitive defusion, mindfulness, values-based methods. Dose: 3 weeks, ~80-hr	Usual pain in past wk Avg daily uptime Rest due to pain	BL, 3 wk, 3 mo	Between group NA Within group Severely dx grp showed SIG pre/post Improvement for pain distress, pain anxiety, and rest due to pain, but not usual pain rating	N/A	No	Yes for 3 month follow up; 55% of program completers	Yes, 1.30 for pain acceptance & 7 pain distress
McKnight et al (2010)	RCT; Community setting, US	OA n = 273 Age = 52.59	Strength Training Group. Phase 1, 9 mos of 3x/week 60 mins supervised training. Phase 2,15 mos of reduced contact by phone. Self-management Group. Phase 1, 9 mos of 12 weekly, 90 mins sessions and weekly phone calls; taught behavioral skills of goal setting, problem solving, coping skills, and self-motivation. Phase 2 over 15 mos reduced phonee calls. Combined group: concurrently completed strength training and self-management programs. Dose: 24 mos	Pain Visual Analog Scale Pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Body pain: Short Form 36 (SF-36)	BL, 3 mo, 9 mo, 18 mo, 24 mo	Between Group Within Group Sig less pain (VAS, SF36, WOMAC) for all 3 groups	Compared 3 groups (strength, Self-Management, and combined)	Yes, compliance 67.5% Phase I & 50.3% Phase 2	Yes, 72 withdrew over 2 years; 74% retained 201/273 and analyses conducted on them	Yes, -.70 Combined, -.59 SM, -.24 ST
Nawoczenski et al (2006)	Quasi-experimental; Home-based, US	SCI & SB-related pain n = 41 Age = 42.71	Scapula-focused home-exercise intervention. Information on stretching and strengthening exercises. Handouts with pictures of exercises. Completed daily adherence log, weekly telephone calls. Augment exercises at week 4. Dose: 8 weeks	Wheelchair Users Shoulder Pain Index (WUSPI)	BL, 8 wk	Between group Sig improvement In WUSPI scores Within group Sig reduction in WUSPI scores	Control group asymptomatic SCI participants	Yes. reported rates of adherence	Yes, 2 withdrew; 95% retained 39/41. Intent-to-treat	No; no means/SD presented
Nicholas et al (2012)	Single group with pre/post test;	CP n = 567 Age = 44.0	CBT interactive group sessions included teaching sel-management	Pain-related disability: Roland and Morris Disability	BL, 3 wk	Between Group N/A Within Group Sig improvement on all pain measures	N/A	Yes, reported adherence to proportion strategies	No	Yes, .42 pain, 30% reliable pain Improvement
	Clinic-based, Australia		strategies, activity pacing, thought challenging, desensitization, goal setting, and stretch exercises. Dose: 3 weeks, 8 hrs/ day, 5 days/week	Questionnaire Pain Intensity, Multidimensional Pain Inventory (MPI) Catastrophizing: Pain Response SelfStatements Scale (PRSS)		Those performing more self-management strategies experienced greater effects on pain intensity and pain-related disability
Nicholas et al (2013)	RCT; Clinic-based, Australia	CP n = 140 Age = 42.67	Two CBT groups. CBT + interoceptive exposure or CBT + distraction. CBT + intraoperative exposure (deliberately experiencing pain to reduce fear): multidisciplinary team teaching education, self-monitoring of sensations, repeated deliberate exposure to the pain, engaging in activities expected to aggravate pain. CBT + distraction Dose: 3 weeks, 8 hrs/day, 5 days/week	Multidimensional Pain Inventory (MPI)	BL, 3 wk, 1 mo, 6 mo, 12 mo	Between Group Within Group Sig improvement in pain intensity for both groups (medium effect)	2 CBT groups, one targeting exposuree and the other targeting distraction	Yes. adherece related to effects	Yes, reported for each assessment; 58% retained 82/140 at 1 year	Yes; -.54 & -.50 for exposure & distraction
Nielsen & Jensen (2004)	Single group with pre/post test; Clinic-based, US	Fibromyalgia = 198 Age = 46.4	Program aimed at improving pain management skills and physical and psychological functioning. Includes physical and occupational therapy, group CBT, reduction of pain behavior, assertiveness and relaxation training, and tapering of medications when indicated. Dose: 4 weeks, 5 days/week	Pain Severity: West Haven Yale Multidimensional Pain Inventory (WHYMPI)	BL, 4wk, 4 mo, 6 mo	Between Group N/A Within Group Sig improvement in pain severity	N/A	No	Reported at each assessment; 48 withdrew; retained 81% by 6 mos 205/253	Yes; .47 pain control, not pain severity (included mean/SD)
Niemisto et al (2003)	RCT; Clinic-based, Finland	CP n = 196 Age = 37.09	Intervention included evaluation, treatment and exercise sessions with a focus on manipulation with a muscle-energy techniques and stabilizing exercises aiming to correct lumbopelvic rhythm, included an educational booklet.	Pain intensity, Visual Analogue Scale Oswestry Low Back Pain Disability Questionnaire (0DL-0-100)	BL, 5 mo, 12 mo	Between Group Sig improvement in pain intensity and pain-related disability Within Group Sig differences for pain intensity and pain-related disability	Physician consultation group	No	Yes; 8 withdrew; retained for 196/204 included in analyses	No; included means/SC to calc
			Dose: 4 weeks, 1 hr sessions/week
Perry et al (2010)	Comparative parallel, cohort design; Clinic-based, Australia	SCI-related CP n = 36 Age = 44.13	CBT pain management program (PMP) included: relaxation; desensitization skills; goal setting; pacing and upgrading activities; cognitive restructuring; rationalization of medications, exercise, stretch, communication; and relapse prevention Dose: 10 group sessions; 45 hrs contact time	Usual pain intensity Pain Response Self-statement scale (PRSS): Catastrophizing subscale Pain Inference, Multidimensional Pain Inventory-SCI Version; Pain-related Self-efficacy Statement Questionairre (PSEQ)	BL, 6 mo, 7 mo, 9 mo	Baseline PMP group had significantly higher than usual pain intensity. Between group Significant impact for pain interference, but not pain intensity or catastrophizing Within group Significant improvements for pain Interference, pain catastrophizing, and pain self-efficacy	Usual care (meds, PT, clinical intervention)	No	Yes; 1 withdrew; 35/36 retained at 6 mos & 30 at 9 mos	Yes; presented ~1.0 usual Pain Intensity, ~.3 selfefficacy, ~.55 life Interference
Peters & Large, (1990)	RCT; Clinic-based, New Zealand	CP n = 68 Age = 43.9	Three groups: Inpatient, Outpatient, and Control group. Inpatient treatment: education about pain, behavior management strategies (relaxation, biofeedback), adaptive cognitions via cognitive restructuring, visualization and imagery techniques, exercise, vocational counseling, and medication management. Dose: 4 weeks Outpatient treatment: education, practical advice on exercising and achieving goals, medication and stress management. Dose: 9 weeks, 2 hr session/week	McGill Pain Questionnaire (MPQ) Pain Behavior Checklist (PBC) Pain Drawings (by patient & by physiotherapist) Pain intensity: Visual Analogue Scale (VAS)	BL, 1 wk, 4 wk, 12 mo	Between Group Sig improvement for pain (VAS), pain behavior checklist in both patient groups Within Group Sig improvements for pain and health measures for all groups over time	Inpatient, Outpatient, and Control groups	No	Yes; 20 withdrew; 77% retained 66/86 Included in analyses	No
Poole et al (2014)	Single group with pre/post test; Internet-based, US	Systemic Sclerosis n = 16 Age = 52.2	Internet-based program with specialized web site that translated self-management workbook content online, with feedback form to evaluate the program. Included: 10 modules, videos, worksheets, and resources. Dose: 10 week program	Pain Visual Analog Scale	BL, 10 wk	Between Group N/A Within Group	N/A	No	Yes, 5 withdrew; 76% retained 16/21. Data only reported	Yes; -.31
Riva et al (2014)	RCT; Internet-based, Switzerland	CLBP n = 51 Age = 47.29	Two groups: Interactive or Static website. Interactive website features designed to	Pain Burden (select questions from chronic pain grading scale)	BL, 4wk, 8 wk	Between group Within group Sig decreased in pain burden over	Interactive versus static website	No	Yes, none	Yes, .49
			empower patients, promote physical activity, prevent medication misuse and manage pain burden through static and interactive features. Static website features included a library, first aid section, and FAQ section. Interactive features included: weekly action plan, quiz game, virtual gym, testimonials and commentaries. Dose: 8 weeks of website access			time, with a moderate effect
Ronen et al (1996)	Single group with pre/post test; Mixed clinic/community settings, Israel	Arthritis n = 60 Age = 54	8 week rehabilitation course including therapy and patient education, followed by a 12-month home-based program. Dose: 8 weekly, 2.5 hr sessions	Pain symptoms: Arthritis Impact Measurement scales	BL, 8 wk, 12 mo	Between Group N/A Within Group Sig reduction in pain at 8 weeks and 12 weeks	N/A	Yes, percent of participants continuing exercise afgter the course	Only analyzed data from 60 people who have completed the course	Yes, different time points -1.19, .50, -44
Ruehlman et al (2012)	RCT; Internet based, US	Chronic Pain (60% back) n = 330 Age = 44.93	The Chronic Pain Management Program (CPMP) is an online interactive program to teach pain self-management. Derived from cognitive behavior therapy, interpersonal, & self-management approaches to address the adaptive burdens of chronic pain in adults. Custom learning plan created after completing Profile Chronic Pain and targets both online/offline activities.	Profile of Chronic Pain (PCP-S scale)–-pain magnitude measured interference, severeity. emotional burden Pain Attitudes and Beliefs (PCP-EA)–-perceived disability; perceived control, belief in a medical cure, pain-induced fear pain interference in 10 areas of daily functioning catastrophizing pain knowledge	BL, 7 & 14 weeks	Between Group Sig difference between groups in rate of change for pain intensity, interference, pain burdent, and catastrophizing Within Group Both groups showed reductions in pain outcomes over time	Wait-list control	No	Yes; 25 withdrew; 92% retained; ITT applied	Yes; .20 severity, .30 for interference, .18 catastrophizing
Rydeard et al (2006)	RCT; Community setting, Canada	CBP n = 39 Age = 35.62	Specific exercise training group received Pilates exercise program that trained activation of specific muscles to stabilize the lumbar pelvic region. Dose: 4 weeks, 3-1 hr sessions/wk with trainer 15 min home sessions, 6x per week	Pain Intensity, Numerical Rating Scale (NRS-101)	BL, 3 mo, 6 mo, 12 mo	Between Group Sig greater improvements in pain intensity for pilates group at 3 mos, plus 6 & 12 mos Within Group	Usual care (physician consultation)	Compliance 100% clinic appts, no measure of home protocol	Yes, retained all for Part I and Part II lost up to 18; retained 42% 13/31 by one year follow up 39/39	No; included mean/SD to calc
Shigaki et al (2013)	RCT; Internet-based, US	RA n = 106 Age = 50.13	Internet-based program with weekly educational modules for Improving self-efficacy of RA Self-Management, plus tools for group Interaction and weekly phone contact to encourage program tool use. Dose: 10 weeks	Pain symptoms: Arthritis Impact Measurement scale Pain today: Rapid Assessment of Disease Activity In Rheumatology (RADAR)	BL, 10 wk, 9 mo	Between Group Within Group N/A	Wait-list control	No	Yes; post-test 86% retained 93/108; 9 months 81% retained 88/108, analyses included these	Yes; at post-test .37 & .57, at 9 months .19 & .31
Shirado et al (2010)	RCT; Home-based, Japan	CLBP n = 200 Age = 42.2	Brochure on therapeutic exercise and body mechanics and a 15-30 min session with health care professional to learn the proper exercise form to strengthen trunk muscles and stretching, followed by individual sessions with clinic staff to ensure proper form and provide encouragement to home exercises. Participants provided a home exercise diary. Dose: 8 weeks. 1 session per week	Pain Visual Analogue Scale, back pain Japan Low back pain Evaluation Questionnaire (JLEQ)	2 wk prior, BL, 8 wk, 12 wk, 6 mo, 12 mo	Between Group Sig improvement in JLEQ scores at 8 weeks and at 12 mos Within Group Sig improvement In both groups on JLEQ and VAS scores	Control received nonsteroidal antiinflammatory drugs	No	Yes; 8 withdrew; 96% retained 193/201	No; Included change & Confidence Intervals
Slater et al (1997)	Quasi-experimental; Clinic-based, US	CLBP n = 34 Age = 44.70	Education about back pain and function, systematic increases in exercise, activity planning and contracting, contingent reinforcement for improving function and activity and non-reinforcement of pain behaviors, self-management and problem-solving training. Individualized components: medication and palliative tapering, family support, vocational problem-solving. Dose: 6 months, 8, 1 hr Individualized treatment sessions	McGill Pain Questionnaire	BL, 6 mo	Between Group Sig decrease in pain Within Group N/A	Usual care (meds, non-Invasive procedures, activity recommendations, PT, clinical Intervention)	No	No	No; applied model for clinically significant change; 41% reliable Improvement 1/3 outcomes; only 1 person on pain
Snook et al (1998)	RCT; Home-based, US	CLBP n = 85 Age = 45.48	Instruction in the control of early morning lumbar flexion: no bending, squatting or sitting in the first 2 hours	Diary for daily pain Intensity Number of pain days	BL, 6 mo, 12 mo	Between Group Within Group	Sham treatment of common exercises that are ineffective In reducing back pain	Yes. reported compliance In average	Phase I 15 withdrew,	No
			f after waking; after 2 hours modified activity allowed, but no bending; after 4 hours slight bending allowed; usual activities allowed after 6 hours. Dose: 45 mins of instruction			Sig decrease in pain intensity and mean pain days for at 6 and 12 mos		minutes of not bending back	82% retained 70/85; Phase 2 25 withdrew, 71% 60/85

Notes: Results column with missing detail indicate no significant differences were reported.

Abbreviations: CP, chronic pain; SCI, spinal cord injury; SB, spina bifida; CLBP, chronic low back pain; CP, chronic pain; OA, osteoarthritis arthritis.

Seven (47%) clinic-based studies reported effect sizes, with data indicating that changes in participants’ pain ratings were generally small to medium (-0.33 to -0.54), while effect sizes for accepting or coping with pain were medium to large (0.62-1.3). However, a 10-session, group-based CBT program that included 45 contact hours reported a large effect size (1.0) for usual pain ratings by those with spinal cord injury.³³ In this comparative parallel design study, Perry et al enrolled 36 participants all of whom were receiving care at a pain clinic, including 92% who experienced neuropathic pain. The study did not randomly allocate participants to groups, and significant differences in usual pain intensity existed at baseline between the self-management and usual-care groups, with the self-management group experiencing significantly greater pain. Notably, effect sizes are based on the final sample size of 13 people retained in the study at the final assessment by nine months. Thus, while the effect size on usual pain intensity was large, the small sample size may be biased as it includes both those with higher pain and who, for whatever reason, valued the intervention.

Self-management programs delivered in community settings

This section describes the results of five studies conducted in community-based settings. All the community-based studies compared the self-management approach with another arm using RCT designs, and most (n = 4, 80%) reported significant effects of the self-management program on pain outcomes. Three (60%) studies with a comparison arm reported a significant between-group effect,^28,29,47 while two studies did not report significant between-group effects for reduced pain.^48,49 A mailed self-management program was not significantly better than sessions delivered in person or usual care.⁴⁹ Delivering reinforcement strategies using newsletters or in-person sessions eight months after the self-management intervention was no more effective in reducing pain than doing nothing.⁴⁸ Notably, while Goeppinger et al²⁸ reported significant between-group effects for pain outcomes, the study compared two self-management programs, namely, the Arthritis Self-Help Course (ASHC) and Chronic Disease Self-Management Program (CDSMP). The authors examined the effectiveness of incorporating cultural adaptations to the ASHC and the CDSMP for a predominantly (82%) African-American sample and reported 4- and 12-month outcomes for the entire group and separately for African-Americans. By four months, for both the entire sample and African-Americans, CDSMP participants reported significantly less pain than ASHC participants, yet these changes were not sustained at one year. These results suggest that only one of these two culturally adapted self-management programs resulted in significant reductions for pain. However, it is worth noting that both self-management programs yielded significant four-month changes on other measured outcomes.

Four (80%) of the community-based studies reported on program adherence. Goeppinger et al²⁸ and LeFort⁷¹ reported participants attending between 72% (M = 4.3/6) and 82% (M = 4.9/6) of sessions of a six-week program. Yet, Lorig and Holman⁴⁸ reported that only 24% of people randomized to attend a six-week course designed to reinforce self-management strategies eight months after the initial intervention attended the sessions. In a separate study conducted by Lorig et al⁴⁹ that compared a mail-delivered, tailored print self-management (SMART) program to usual care and a six-session group-based arthritis self-management program, the average number of mailings participants completed was three out of a possible four, which includes 11% of SMART participants who never participated. This 75% participation rate is similar to that of the studies by Goeppinger et al²⁸ and LeFort.⁴⁷ The average retention rate reported across all five community-based studies was 85%, which is notable given that four were conducted over a year or longer and only one conducted intent-to-treat analyses.⁴⁷ Yet, none of the classes delivered in community-based settings reported effect sizes.

Self-management delivered in a mixed clinical/community settings

Three studies provided initial training in the clinical setting and transitioned ongoing program delivery to the home, with significant effects only reported by one. In two separate studies, Mazzuca et al^30,45 initially offered individualized training by a nurse educator in the clinic who provided telephone follow-up to reinforce self-care activities twice (at one and four weeks) in one study³⁰ and up to nine times (biweekly for 18 weeks) in the other.⁴⁵ The programs yielded no significant between-group effects on pain at posttest or six-month follow-up, but one study observed significant differences in pain by 12 months. Ronen et al⁴⁶ combined clinical and community settings so that participants received eight weeks of rehabilitation in a multidisciplinary setting before transitioning to continue using self-management strategies at home. While there was no control group, participants reported significantly reduced pain at eight weeks and one year. The study by Ronen et al was the only one to report on participants’ adherence during the home-based phase of principles taught (range 32%-82%) and continued exercise (60%). It is important to note that the authors do not address attrition and only present data for the 60 participants who fully completed the program at one year. However, the average retention reported by two other studies was 75%.^30,45 As the only study to report on effect sizes, Ronen et al reported that the intervention yielded large effects (-1.19) on pain at the eight-week posttest and moderate effects (-0.50) one year later.

Self-management programs combined with exercise

All the 11 studies that examined self-management programs that formally incorporated exercise reported a significant improvement in pain over time. Yet, as described below, two studies that compared the effects of multiple strategies found that all the strategies resulted in significantly reduced pain over time with no difference between groups. For example, Kuukkanen and Malkia⁶⁰ found no difference between participants in an exercise program, an intensive exercise training (eg, supervised sessions, special equipment), or a control group that received usual care. In addition, McKnight et al⁴³ found no differences in pain between those given a strength program, a self-management program, and a combined strength and self-management program. However, effect size data indicate that while all groups reported improved pain, the combined self-management with strength training group experienced larger effects (-0.70) than either the self-management (–-0.59) or strength training (0.24) group. Notably, this was the only study to report on effect sizes.

The six studies (55%) that reported in some manner on participants’ compliance with the intervention components reveal compliance rates of 67.5%-100%. Compliance was high for attending in-person exercise sessions (86%-91%);^34,61 self-management classes (75%), supervised strength training (75%), or the combined classes (72%);⁴³ completing clinic visits (100%);⁶⁴ or self-reporting home exercise compliance (75% were highly adherent);⁶² or following restrictions for movement in the morning for 58 minutes.⁵³ Most studies (91%) reported on attrition, and one study that enrolled only 39 participants retained only 42% by the end of the year,⁶⁴ in which the authors used an intent-to-treat analysis using the last observation carried forward approach. The average retention rate across studies was 81%, with six reporting outcomes for up to a year and three reporting outcomes over one and a half years to two and a half years. The high retention is notable given that most lasted a year (n = 6) and several (n = 3) continued for over one and a half years to two and a half years. Although retention was generally high, only two studies^62,64 implemented intent-to-treat analyses.

Online self-management programs

Six studies examined the effect of delivering self-management intervention over the Internet. Three (50%) yielded significantly reduced pain and a fourth reported that the Internet program yielded significant changes in other aspects of pain, including pain attitudes and pain catastrophizing. Only two studies reported about adherence. While Lorig et al⁵⁷ used website analytics to report that participants logged into the website an average of 31.6 ± 24.5 times over six weeks, Carpenter et al⁶³ found that 81% of the group reported completing all six online chapters. All six studies reported on participant attrition, with an average retention rate of 85% across the studies. Two studies used an intent-to-treat approach to address attrition. Effect sizes reported across five studies suggest that these effects were small to moderate (ranged from –-0.31 to –-0.57) for pain, with a large effect size of 1.01 reported for pain control in one study.⁶³

Discussion

This review of the published literature reveals a burgeoning evidence base that has examined the effect of self-management interventions on reducing and managing pain among individuals living with mobility-related disabling conditions. The published evidence reveals substantial heterogeneity in terms of targeted diagnostic groups (eg, chronic low back and other locations, arthritis, other connective tissue diseases, and neurologic disorders), settings (eg, clinic, community, home, and Internet), approaches (eg, intensive multidisciplinary training, combining exercise with CBT, etc.), and countries (eg, US and Canada, Europe, Nordic countries, and Japan). Nevertheless, the collective body of evidence suggests that delivering self-management training often, but not always, yields significant, but small, improvements in participants’ self-reported pain.

This review suggests that educating individuals about their symptoms and using both cognitive and behavioral approaches that emphasize applying self-management strategies to manage symptoms and make lifestyle changes can produce positive outcomes on participants’ self-reported pain. These effects have been achieved through teaching skills in both clinical and community settings, through combining self-management strategies with exercise programs, as well as using an online format. While two studies^38,39 reported that better outcomes are related to participants’ use of self-management skills, only 15 (38%) reviewed studies reported on participants’ adherence with the program delivery or components. Although no single approach emerged as clearly more efficacious than others, it is important to highlight that retention has been high not only in clinic-based studies (81%) but also in community-based (85%) studies and for online settings (85%).

Several shortcomings of the literature are noteworthy. An important limitation is that 70.7% of reviewed studies have moderate-to-high risk of bias, predominantly due to the lack of blinding and concealing participant allocation to groups. While it is feasible to blind testers to participant group assignment in studies that teach self-management skills, it is not possible to blind participants. Yet, this inability to mask participants can introduce response bias, especially when assessing subjective outcomes such as pain. Thus, it is possible that at least some of the observed effects on pain are due to this response bias. A second shortcoming is based on the lack of consistency across measures for specific outcomes of interest. Researchers used an array of outcome measures for pain (eg, visual analog scale, Oswestry Low Back Pain Index, McGill Pain Questionnaire, Modified von Korff Scale, SF-36 bodily pain, Brief Pain Inventory, etc.), which limits the ability to provide direct comparison across studies. Notably most outcome measures used across these studies were given at a single time point to reflect participants’ outcome across a specified period (right now [McGill Pain Inventory], last 24 hours [Brief Fatigue Inventory], last week [Brief Pain Inventory], or last 4 weeks [SF-36]). Only two reviewed studies^53,61 used daily pain diaries to capture fluctuations in pain over the course of the day. Evidence suggests that individuals’ recall of pain intensity over longer periods is higher than observed on momentary reports.^72,73 A third limitation is the fact that studies generally did not measure participants’ adherence to the intervention components, and thus, it is unclear whether the dose received is related to the effect on the outcome. A final shortcoming is that despite substantial heterogeneity across studies in terms of settings, modes of delivery, duration, and intensity, the evidence lacks racial/ethnic diversity as the vast majority of studies have been conducted among Caucasian and female samples. Yet, two studies demonstrated that making culturally appropriate adaptations to self-management programs yielded significantly improved outcomes.^28,29

To summarize, this focused review offers evidence that self-management approaches have successfully been used to reduce pain among individuals living with mobility limitations. While effect sizes were reported in only 40% (n = 16) of the studies, the programs generally yielded small effects on participant pain ratings, although moderate-to-large effects were reported for coping with pain. Of promise is the potential for using the Internet to deliver self-management intervention, as many individuals who live with disabilities face persistent transportation barriers, which can limit attendance for in-person educational meetings. These interventions resulted in significantly improved pain as compared with usual care groups in several studies and across time in others, with similar albeit small effect sizes as reported by clinic-based studies.

Yet, the review reveals that the accumulated studies have moderate-to-high risk of bias, generally due to the lack of allocation concealment and blinding, which may particularly influence subjective outcomes. Nevertheless, it is important to examine intervention approaches that offer potential strategies for reducing pain given its prevalence and impact on the lives of individuals living with mobility impairments. Future studies should increase the methodological rigor to yield stronger evidence about the effectiveness of self-management strategies for reducing pain among those with mobility impairments. Recommendations for future studies include (1) using a control group with no intervention or minimal intervention to increase power to detect treatment effects, (2) using technology such as cell phones to assess pain in real time over multiple times during the day rather than relying on single point in time assessments that reflect a brief, specified time period to determine intervention effects on pain, (3) measuring adherence to the intervention to determine whether there are dose-response relationships, and (4) having authors present effect sizes.

Author Contributions

Conceived and designed the experiments: KFG, SJD, KDS. Analyzed the data: KFG, SJD, KDS. Wrote the first draft of the manuscript: KFG. Contributed to the writing of the manuscript: KFG, SJD, KDS. Agree with manuscript results and conclusions: KFG, SJD, KDS. Jointly developed the structure and arguments for the paper: KFG, SJD, KDS. Made critical revisions and approved final version: KFG, SJD, KDS. All authors reviewed and approved of the final manuscript.

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Self-Management Interventions to Prevent the Secondary Condition of Pain in People with Disability Due to Mobility Limitations

Abstract

Introduction

Methods

Results

Discussion

Keywords

Introduction

Methods

Definitions

Literature search

Review of study bias

Results

Study bias

Participants

Settings

Intervention

Outcome measures

Results

Self-management programs delivered in clinical settings

Self-management programs delivered in community settings

Self-management delivered in a mixed clinical/community settings

Self-management programs combined with exercise

Online self-management programs

Discussion

Author Contributions

References