A systematic review of outcome measures utilised to assess self-management in clinical trials in patients with chronic pain

Influence of central aspects of pain on self-management in people with chronic low back pain

OBJECTIVE

This observational study investigated whether central aspects of pain are associated with self-management domains in individuals with chronic low back pain (CLBP) undertaking a pain management program.

METHODS

Individuals with CLBP provided pain sensitivity and self-management data at baseline (n = 97) and 3-months (n = 87). Pressure pain detection threshold (PPT) at the forearm, temporal summation (TS) and conditioned pain modulation (CPM), Widespread Pain Index (WPI), and a Central Aspects of Pain factor (CAPf) were considered as central aspects of pain. Self-management was measured using the 8 domains of the Health Education Impact Questionnaire, as well as Pain Self Efficacy and Health Care Utilisation questionnaires.

RESULTS

PPT, CPM, WPI and CAPf predicted worse performance in several self-management domains at 3-months (r = 0.21 to 0.54, p < 0.05 overall). In multivariable regression models (adjusted for baseline scores of self-management, depression, catastrophization, pain and fatigue) low PPT, high TS, and high CAPf at baseline predicted poorer self-management at 3 months (R2 =0.14 to 0.52, β = -0.37 to 0.35, p < 0.05).

CONCLUSIONS

Central aspects of pain are associated with impaired self-management, over and above effects of pain intensity, fatigue, depression and catastrophizing.

PRACTICE IMPLICATIONS

Treatments that target central aspects of pain might help improve self-management in people with CLBP.

Effect of an Artificial Intelligence-Based Self-Management App on Musculoskeletal Health in Patients With Neck and/or Low Back Pain Referred to Specialist Care: A Randomized Clinical Trial

Importance

Self-management is a key element in the care of persistent neck and low back pain. Individually tailored self-management support delivered via a smartphone app in a specialist care setting has not been tested.

Objective

To determine the effect of individually tailored self-management support delivered via an artificial intelligence-based app (SELFBACK) adjunct to usual care vs usual care alone or nontailored web-based self-management support (e-Help) on musculoskeletal health.

Design, Setting, and Participants

This randomized clinical trial recruited adults 18 years or older with neck and/or low back pain who had been referred to and accepted on a waiting list for specialist care at a multidisciplinary hospital outpatient clinic for back, neck, and shoulder rehabilitation. Participants were enrolled from July 9, 2020, to April 29, 2021. Of 377 patients assessed for eligibility, 76 did not complete the baseline questionnaire, and 7 did not meet the eligibility criteria (ie, did not own a smartphone, were unable to take part in exercise, or had language barriers); the remaining 294 patients were included in the study and randomized to 3 parallel groups, with follow-up of 6 months.

Interventions

Participants were randomly assigned to receive app-based individually tailored self-management support in addition to usual care (app group), web-based nontailored self-management support in addition to usual care (e-Help group), or usual care alone (usual care group).

Main Outcomes and Measures

The primary outcome was change in musculoskeletal health measured by the Musculoskeletal Health Questionnaire (MSK-HQ) at 3 months. Secondary outcomes included change in musculoskeletal health measured by the MSK-HQ at 6 weeks and 6 months and pain-related disability, pain intensity, pain-related cognition, and health-related quality of life at 6 weeks, 3 months, and 6 months.

Results

Among 294 participants (mean [SD] age, 50.6 [14.9] years; 173 women [58.8%]), 99 were randomized to the app group, 98 to the e-Help group, and 97 to the usual care group. At 3 months, 243 participants (82.7%) had complete data on the primary outcome. In the intention-to-treat analysis at 3 months, the adjusted mean difference in MSK-HQ score between the app and usual care groups was 0.62 points (95% CI, -1.66 to 2.90 points; P = .60). The adjusted mean difference between the app and e-Help groups was 1.08 points (95% CI, -1.24 to 3.41 points; P = .36).

Conclusions and Relevance

In this randomized clinical trial, individually tailored self-management support delivered via an artificial intelligence-based app adjunct to usual care was not significantly more effective in improving musculoskeletal health than usual care alone or web-based nontailored self-management support in patients with neck and/or low back pain referred to specialist care. Further research is needed to investigate the utility of implementing digitally supported self-management interventions in the specialist care setting and to identify instruments that capture changes in self-management behavior.

Trial Registration

ClinicalTrials.gov Identifier: NCT04463043.

The Effectiveness of Psychological Interventions for Rheumatoid Arthritis (RA): A Systematic Review and Meta-Analysis

Rheumatoid arthritis (RA) is a long-term disorder that significantly impairs somatic, emotional, and psychological functioning. The objective of this review is to identify, appraise, and synthesize the effects of psychological interventions (e.g., cognitive behavioral therapy (CBT), emotional disclosure (ED), group therapy (GT), mindfulness (M), patient education (PE), and relaxation (R)) on biopsychosocial outcomes in the treatment of rheumatoid arthritis (RA). A systematic search of all relevant existing randomized clinical trials (RCTs) was conducted using the following online bibliographic databases: JSTOR, PubMed, PsycNET, and The Cochrane Library. Reference lists were searched for additional reports. The Cochrane Risk of Bias tool (RoB 2.0) was used to assess the risk of bias in the included studies. After the selection process, 57 articles were included and 392 were excluded. Three separate meta-analyses were conducted involving psychological interventions as the main variables, showing: (1) significant positive medium effect sizes for average values (Hedges-g = 0.399, Z = 0.399, p = 0.009); (2) significant positive large effect sizes for maximum values (Hedges-g = 0.856, Z = 4.223, p < 0.001); and (3) non-significant results for minimum values (Hedges-g = -0.047, Z = -0.335, p = 0.738). These results demonstrate that, when grouped, psychological interventions are, on average, moderately effective in treating RA. Overall, this review shows consistent, supportive evidence that psychological interventions can significantly contribute to the standard medical care of RA patients. However, more high-quality, large-sample RCTs still need to confirm these findings.

Coping with rheumatic stressors (CORS) questionnaire: Spanish translation and cross-cultural adaptation

BACKGROUND

Rheumatic and Musculoskeletal Diseases (RMDs) substantially impact the lives of patients, with complex associations between disease severity and self-perceived health status. In this regard, the Coping with Rheumatic Stressors (CORS) questionnaire was developed to measure how patients with RMDs cope with stressors such as pain, limitations or dependency. The CORS is not currently available in Spanish, and therefore the adaptation of this instrument is needed.

OBJECTIVE

First, to cross-culturally adapt the CORS into Spanish for Spain. Secondly, to test the conceptual equivalence of the translated version in patients with axial spondyloarthritis (axSpA).

METHODS

A translation of the CORS into Spanish was performed adhering to the forward-backward procedure described by Beaton. Two translators produced independent forward translations of the item content, response options, and instructions of the CORS into Spanish. Both versions were harmonized in a consensual version. Another translator back-translated the synthesized version into Dutch. A scientific committee including all the translators, one methodologist and a rheumatologist, held a meeting and reached consensus on discrepancies to develop a final draft version of the Spanish CORS. Then, a field test with cognitive debriefing was conducted, involving a sample of 10 patients with axSpA.

RESULTS

The translation process of the CORS was completed after the discussion of some discrepancies throughout the process. The first translation was done without major complications. Back-translation presented some discrepancies. These led to minor modifications in the wording in one response option and 15 questionnaire items. The scientific committee agreed upon a final version of the questionnaire. Cognitive debriefing, led to minor modifications; for example, three respondents indicated that one of the statements in the instructions was syntactically complex ("indique cuán a menudo usted ha llevado a cabo dicho comportamiento") which led to its adjustment. The process indicated that the final CORS Spanish questionnaire was clear and understandable to all patients.

CONCLUSIONS

The Spanish version of the CORS showed good cross-cultural validity and good face validity according to the field test. Before the Spanish CORS is implemented, further validation is in progress to test the psychometric properties of the instrument in patients with axSpA.

Predictors of self-management in patients with chronic low back pain: a longitudinal study

BACKGROUND

Self-management (SM) is a key recommended strategy for managing chronic low back pain (CLBP). However, SM programmes generate small to moderate benefits for reducing pain and disability in patients with CLBP. The benefits of the SM programme can potentially be optimised by identifying specific subgroups of patients who are the best responders. To date, no longitudinal study has examined the predictive relationships between SM and biopsychosocial factors in patients with CLBP. The aim was to determine whether biopsychosocial factors predict SM and its change over time in patients with CLBP.

METHODS

In this multi-centre longitudinal cohort study, we recruited 270 working-age patients with CLBP (mean age 43.74, 61% female) who consulted outpatient physiotherapy for their CLBP. Participants completed self-reported validated measures of pain intensity, disability, physical activity, kinesiophobia, catastrophising, depression and SM at baseline and six months. SM constructs were measured using eight subscales of the Health Education Impact Questionnaire (heiQ), including Health Directed Activity (HDA), Positive and Active Engagement in Life (PAEL), Emotional Distress (ED), Self-Monitoring and Insight (SMI), Constructive Attitudes and Approaches (CAA), Skill and Technique Acquisition (STA), Social Integration and Support (SIS) and Health Service Navigation (HSN). Data were analysed using General Linear Model (GLM) regression.

RESULTS

Physical activity and healthcare use (positively) and disability, depression, kinesiophobia, catastrophising (negatively) predicted (p < 0.05, R² 0.07-0.55) SM constructs at baseline in patients with CLBP. Baseline depression (constructs: PAEL, ED, SMI, CAA and STA), kinesiophobia (constructs: CAA and HSN), catastrophising (construct: ED), and physical disability (constructs: PAEL, CAA and SIS) negatively predicted a range of SM constructs. Changes over six months in SM constructs were predicted by changes in depression, kinesiophobia, catastrophising, and physical activity (p < 0.05, R² 0.13-0.32).

CONCLUSIONS

Self-reported disability, physical activity, depression, catastrophising and kinesiophobia predicted multiple constructs of SM measured using the heiQ subscales in working-age patients with CLBP. Knowledge of biopsychosocial predictors of SM may help triage patients with CLBP into targeted pain management programmes.

TRIAL REGISTRATION

The study protocol was registered at ClinicalTrials.gov on 22 December 2015 (ID: NCT02636777).

Effects of sociodemographic and health factors on the self-management of non-communicable diseases among Chilean adults during the Covid-19 pandemic

Individuals with non-communicable diseases (NCDs) are potentially at increased vulnerability during the Covid-19 pandemic and require additional help to reduce risk. Self-management is one effective strategy and this study investigated the effect of sociodemographic and health factors on the self-management of some non-communicable diseases, namely hypertension, type 2 diabetes mellitus and dyslipidemia, among Chilean adults during the Covid-19 pandemic. A cross-sectional telephone survey was carried out on 910 participants with NCDs, from Santiago, Chile. An adapted and validated version of the "Partners in Health" scale was used to measure self-management. Exploratory Factor analysis yielded five dimensions of this scale: Disease Knowledge, Healthcare Team Relationship, General Self-Management and Daily Routines, Drug Access and Intake, and Monitoring and Decision-Making. The average of these dimensions was calculated to create a new variable Self-Management Mean, which was used as a dependent variable together with the five separate dimensions. Independent variables included age, gender, years of schooling, number of diseases, the percentage of Multidimensional Poverty Index in the commune of residence, and self-rated health status. Beta regressions and ANOVA for the Beta regression residuals were utilized for analyses. Beta regression model explained 8.1% of the variance in Self-Management Mean. Age, years of schooling, number of diseases and self-rated health status were statistically associated with Self-Management Mean and dimensions related to daily routines and health decision making, such as Disease Knowledge, General Self-Management and Daily Routines, and Monitoring and Decision-Making. Gender and the percentage of Multidimensional Poverty Index in the commune of residence were insignificant. Strategies for self-management of NCDs during a crisis should consider age, years of schooling, number of diseases, and self-rated health status in their design.

Self-Management for Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Knee osteoarthritis (KOA) is a high incidence chronic joint disease that seriously affects patients' quality of life, and current treatment methods have limited efficacy. Self-management may be an effective strategy for KOA, and clinicians have been showing increased interest recently. However, the effectiveness of self-management for KOA remains controversial.

Purpose

This study aims to systematically evaluate the effectiveness of self-management for KOA.

Methods

We screened articles published in MEDLINE, Cochrane Library, EMBASE, and Web of Science until September 17, 2021. The main outcomes included pain, knee function, stiffness, WOMAC (total), physical function, arthritis self-efficacy (ASE-pain), arthritis self-efficacy (ASE-other symptoms), mental health, and quality of life.

Results

Thirteen randomized controlled trials (RCTs) were finally included (n = 1610). Meta-analysis showed differences in pain, knee function, stiffness, ASE-pain, ASE-other symptoms, mental health, and quality of life between the self-management and control groups. Of the nine outcomes evaluated, four were highly heterogeneous, and the quality of evidence ranged from very low to moderate.

Conclusion

The meta-analysis results showed that self-management might help improve the pain, knee function, stiffness, ASE, mental health, and quality of life in patients with KOA. However, it has no significant effect on WOMAC (total) and physical function. Considering that this study has some limitations, we cannot draw clear conclusions based on the results of this study. Nevertheless, we offer much needed insight and encourage more rigorously designed and implemented RCTs in the future to substantiate our conclusions.

"I'm in pain and I want help": An online survey investigating the experiences of tic-related pain and use of pain management techniques in people with tics and tic disorders

OBJECTIVES

Tic disorders (TDs) are complex neurological conditions characterized by involuntary, persistent vocalizations and motor movements called tics. Tics involve brief muscle movements and can impair many aspects of daily functioning and quality of life in patients - and their physical nature can cause pain. Understanding individuals' experiences of tic-related pain and pain management could help explore this under-researched area and identify additional support needs for this population. The aim of this study was to investigate experiences of pain and use of pain management techniques in people with tic disorders.

METHODS

An online survey consisting of multiple choice and open-ended questions exploring experiences of tic-related pain, help-seeking behavior for tic-related pain, and use of pain relief techniques for tic-related pain, was circulated online via international Tourette syndrome patient associations, and one online support group for Tourette syndrome. The online survey was open to adults (≥16 years) with self-reported tics. Open-ended questions were analyzed using thematic analysis.

RESULTS

One hundred eighty-one participants (16-71 years; 58.0% female) from 18 countries completed the online survey. Several aspects of tics were associated with pain, including the physical effort of motor tics (n = 177, 97.8%), repetitive tics (n = 141, 77.9%) and the consequences of tics (n = 131, 72.4%). Nearly two-thirds (n = 118, 64.6%) had sought professional help for tic-related pain. Distraction techniques (n = 126, 69.6%), taking pain relief medication (n = 125, 69.1%) and altering tics (n = 111, 61.3%) were the most commonly-reported methods used to relieve and cope with tic-related pain. Thematic analysis found an interrelated complex relationship between participants' tics, pain, and pain management techniques, reflected in four themes: the "tic-pain" cycle, the impact of pain, the importance of support, and the perceived successfulness of pain management techniques.

CONCLUSIONS

Tic-related pain was reported to have a significant physical and psychological impact which impacted aspects of daily living in people with tic disorders. The findings add to limited research suggesting tic-related pain is a dominant issue for individuals with tic disorders, potentially impacting upon their quality of life. Increased understanding of tic-related pain and its influence may be helpful in the long-term management of tic disorders, both in terms of clinical management and patients' self-management.

Measurement properties of the Pain Self-Efficacy Questionnaire in populations with musculoskeletal disorders: a systematic review

A higher level of pain self-efficacy has been suggested as a predictor of a better outcome in patients with musculoskeletal disorders. The Pain Self-Efficacy Questionnaire (PSEQ) is one of the most frequently used patient-reported outcome measures for pain self-efficacy. The purpose of this study was to conduct a systematic review that would identify, appraise, and synthetize the psychometric properties of the PSEQ. Embase, MEDLINE, and CINAHL databases were searched for publications reporting on psychometric properties of the PSEQ in populations with musculoskeletal disorders. After applying selection criteria on identified citations, 28 studies (9853 participants) were included. The methodological quality as measured with the COSMIN risk of bias tool varied from adequate to very good for most measurement properties. The results showed a weighted mean intraclass correlation coefficient of 0.86 (range: 0.75-0.93) for test-retest reliability for the original 10-item PSEQ and the minimal detectable change at 95% confidence interval was 11.52 out of 60 points. Effect size and standardized response mean values were 0.53 and 0.63, respectively, whereas the minimal clinically important difference ranged from 5.5 to 8.5 in patients with chronic low back pain. Internal consistency (Cronbach alpha) ranged from 0.79 to 0.95. The results also showed that the PSEQ has low to moderate correlations with measures of quality of life, disability, pain, pain interference, anxiety, depression, and catastrophizing. Finally, the PSEQ has been adapted and validated in 14 languages. Overall, the results demonstrate that the PSEQ has excellent validity, reliability, and responsiveness. Further high-quality studies are needed to determine responsiveness in populations other than chronic low back pain.

Individually tailored self-management app-based intervention (selfBACK) versus a self-management web-based intervention (e-Help) or usual care in people with low back and neck pain referred to secondary care: protocol for a multiarm randomised clinical trial

INTRODUCTION

Low back pain (LBP) and neck pain (NP) are common and costly conditions. Self-management is a key element in the care of persistent LBP and NP. Artificial intelligence can be used to support and tailor self-management interventions, but their effectiveness needs to be ascertained. The aims of this trial are (1) to evaluate the effectiveness of an individually tailored app-based self-management intervention (selfBACK) adjunct to usual care in people with LBP and/or NP in secondary care compared with usual care only, and (2) to compare the effectiveness of selfBACK with a web-based self-management intervention without individual tailoring (e-Help).

METHODS AND ANALYSIS

This is a randomised, assessor-blind clinical trial with three parallel arms: (1) selfBACK app adjunct to usual care; (2) e-Help website adjunct to usual care and (3) usual care only. Patients referred to St Olavs Hospital, Trondheim (Norway) with LBP and/or NP and accepted for assessment/treatment at the multidisciplinary outpatient clinic for back or neck rehabilitation are invited to the study. Eligible and consenting participants are randomised to one of the three arms with equal allocation ratio. We aim to include 279 participants (93 in each arm). Outcome variables are assessed at baseline (before randomisation) and at 6-week, 3-month and 6-month follow-up. The primary outcome is musculoskeletal health measured by the Musculoskeletal Health Questionnaire at 3 months. A mixed-methods process evaluation will document patients' and clinicians' experiences with the interventions. A health economic evaluation will estimate the cost-effectiveness of both interventions' adjunct to usual care.

ETHICS AND DISSEMINATION

The trial is approved by the Regional Committee for Medical and Health Research Ethics in Central Norway (Ref. 2019/64084). The results of the trial will be published in peer-review journals and presentations at national and international conferences relevant to this topic.

TRIAL REGISTRATION NUMBER

NCT04463043.

Effectiveness of self-management interventions in inflammatory arthritis: a systematic review informing the 2021 EULAR recommendations for the implementation of self-management strategies in patients with inflammatory arthritis

Objective

To perform a systematic review (SR) on the effectiveness of self-management interventions, in order to inform the European League Against Rheumatism Recommendations for its implementation in patients with inflammatory arthritis (IA).

Methods

The SR was conducted according to the Cochrane Handbook and included adults (≥18 years) with IA. The search strategy was run in Medline through PubMed, Embase, Cochrane Library, CINAHL Plus with Full Text, and PEDro. The assessment of risk of bias, data extraction and synthesis were performed by two reviewers independently. A narrative Summary of Findings was provided according to the Grading of Recommendations, Assessment, Development and Evaluation.

Results

From a total 1577 references, 57 were selected for a full-text review, and 32 studies fulfilled the inclusion criteria (19 randomised controlled trials (RCTs) and 13 SRs). The most studied self-management components were specific interactive disease education in ten RCTs, problem solving in nine RCTs, cognitive–behavioural therapy in eight RCTs, goal setting in six RCTs, patient education in five RCTs and response training in two RCTs. The most studied interventions were multicomponent or single exercise/physical activity in six SRs, psychosocial interventions in five SRs and education in two SRs. Overall, all these specific components and interventions of self-management have beneficial effects on IAs-related outcomes.

Conclusions

The findings confirm the beneficial effect of the self-management interventions in IA and the importance of their implementation. Further research should focus on the understanding that self-management is a complex intervention to allow the isolation of the effectiveness of its different components.

Effects of self-management education programmes on self-efficacy for osteoarthritis of the knee: a systematic review of randomised controlled trials

BACKGROUND

Enhancing self-efficacy to manage symptoms and functions is an important aspect of self-management for patients with knee osteoarthritis (OA). Many reports have investigated the effects of self-management education programmes for arthritis patients. However, a study that exclusively focuses on patients with OA in the same joints is required to clarify the effects of self-management programmes because individuals with knee OA experience physical and psychological difficulties different from those experienced by individuals with other arthritis diseases. Furthermore, previous studies have reported a wide range of delivery styles of self-management education programmes. This systematic review aimed to evaluate the effects of group-based and face-to-face self-management education programmes conducted by health professionals targeting self-efficacy for knee OA exclusively.

METHODS

The MEDLINE, CENTRAL, EMBASE, CINAHL, Web of Science, and PEDro databases were searched to identify quantitative measures used in randomised controlled trials (RCTs) to assess the effects of self-management education programmes targeting self-efficacy in patients with knee OA. We included studies in which medical professional-delivered self-management education programmes were conducted in a group-based and face-to-face manner in community or outpatient settings.

RESULTS

Seven RCTs from five countries were included in this review. Our retrieved studies included various types of self-management education programmes such as cognitive behavioural counselling, pain management education, physical education, weight management education, and arthritis self-efficacy management education, and control arms. They assessed various aspects of self-efficacy, including pain, physical function, arthritis symptoms excluding pain, weight management, mobility, and self-regulation. The total score of the Arthritis Self-Efficacy Scale was also measured. Some studies have reported beneficial effects of group-based and face-to-face self-management education programmes on self-efficacy for management of pain and other symptoms and for self-regulatory, knee OA. However, the results of the included studies were varied and inconsistent.

CONCLUSIONS

The current review only included seven studies, and there was a wide range of clinical heterogeneity among these studies. Thus, the effects of group-based and face-to-face self-management education programmes conducted by health professionals on self-efficacy for knee OA exclusively are inconclusive to date. Therefore, high-quality studies are required to provide significant information on clinicians, patients, and healthcare professionals in the future.

Reliability and smallest detectable change of the Danish version of the Pain Self-Efficacy Questionnaire in patients with chronic low back pain

OBJECTIVES

Low back pain (LBP) is the leading cause of disability and a global public health concern. Studies indicate that pain self-efficacy is associated with the development of disability in chronic LBP (CLBP) patients. The Pain Self-Efficacy Questionnaire (PSEQ) is a commonly used questionnaire to assess pain self-efficacy in patients with CLBP. It is essential to examine the psychometric properties of the PSEQ in the population in which it is to be used. Thus, the aim of this study is to evaluate the reliability and smallest detectable change of the Danish version of the Pain Self-Efficacy Questionnaire (PSEQ-DK) in patients with CLBP before implementing it as an outcome measure in an inpatient rehabilitation context.

METHODS

This observational study including 92 patients with CLBP was conducted in a multidisciplinary rehabilitation facility in Denmark. The psychometric properties statistically tested included reliability, smallest detectable change and floor and ceiling effect of the PSEQ-DK.

RESULTS

The reliability analysis included 92 patients and revealed an weighted kappa of 0.82 (95% Cl 0.75; 0.88) and Intraclass correlation coefficient of 0.83 (95% CI 0.75; 0.88), which corresponds to a good reliability. The smallest detectable change was 12.67.

CONCLUSIONS

The present study demonstrated that the PSEQ-DK had a good reliability in patients with CLBP in an inpatient rehabilitation context. The current results expand our knowledge of the reliability and smallest detectable change of the PSEQ-DK. In order to implement PSEQ-DK in a rehabilitation context for evaluative purposes future studies should focus on examining responsiveness and interpretability.

Behavioral Activation and Inhibition Systems: Further Evaluation of a BIS-BAS Model of Chronic Pain

OBJECTIVES

The role of the behavioral inhibition system (BIS) and behavioral activation system (BAS) in function has been evaluated in a wide range of populations. However, research on the role of the BIS and BAS in pain is in its early stages. This study sought to evaluate the utility of a BIS-BAS model of chronic pain.

METHODS

Participants were 164 individuals with chronic pain who responded to an online survey. Participants provided information about pain location, intensity, and frequency and completed questionnaires assessing behavioral inhibition and activation sensitivity, pain catastrophizing, pain interference, activity engagement, pain willingness, hope, and pain self-efficacy. Seven hierarchical regression analyses were conducted to test hypothesized associations between BIS and BAS sensitivity and measures of participant function.

RESULTS

BIS scores were significantly and positively associated with pain catastrophizing, anxiety, depression, and pain interference and were negatively associated with activity engagement, hope, and pain self-efficacy (P<0.01). BAS scores showed significant and positive associations with activity engagement and hope and showed significant negative associations with pain catastrophizing and anxiety (P<0.05). Furthermore, BIS sensitivity evidenced stronger associations with all the other study measures than did BAS sensitivity.

CONCLUSIONS

The findings provide important new information regarding the utility of the BIS-BAS model of chronic pain. Our results support the idea that BIS activation is more important than BAS activation in explaining a variety of pain-related outcomes, including positive and negative responses to pain, and suggest that modification of the model may be indicated. These results have several theoretical and clinical implications.

Mobile Neurofeedback for Pain Management in Veterans with TBI and PTSD

OBJECTIVE

Chronic pain is common in military veterans with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Neurofeedback, or electroencephalograph (EEG) biofeedback, has been associated with lower pain but requires frequent travel to a clinic. The current study examined feasibility and explored effectiveness of neurofeedback delivered with a portable EEG headset linked to an application on a mobile device.

DESIGN

Open-label, single-arm clinical trial.

SETTING

Home, outside of clinic.

SUBJECTS

N = 41 veterans with chronic pain, TBI, and PTSD.

METHOD

Veterans were instructed to perform "mobile neurofeedback" on their own for three months. Clinical research staff conducted two home visits and two phone calls to provide technical assistance and troubleshoot difficulties.

RESULTS

N = 36 veterans returned for follow-up at three months (88% retention). During this time, subjects completed a mean of 33.09 neurofeedback sessions (10 minutes each). Analyses revealed that veterans reported lower pain intensity, pain interference, depression, PTSD symptoms, anger, sleep disturbance, and suicidal ideation after the three-month intervention compared with baseline. Comparing pain ratings before and after individual neurofeedback sessions, veterans reported reduced pain intensity 67% of the time immediately following mobile neurofeedback. There were no serious adverse events reported.

CONCLUSIONS

This preliminary study found that veterans with chronic pain, TBI, and PTSD were able to use neurofeedback with mobile devices independently after modest training and support. While a double-blind randomized controlled trial is needed for confirmation, the results show promise of a portable, technology-based neuromodulatory approach for pain management with minimal side effects.

The pain self-management paradox: why do we focus on the individual when life context plays such a major role?

Although there has been a drive toward pain self-management, self-management has not yet in my opinion been successfully defined or evaluated and neither has it been consistently translated from idea to practice. In this perspective article, I identify gaps in our approach to pain management and argue that even though we know life context plays a huge role in influencing our health, by and large we fail to take this into account. I argue for a shift in focus away from the 'self' and explore how we might be able to do this within the constraints of our tired and over-stretched health system.

Assessing health empowerment - Brazilian cross-cultural adaptation and validity testing of the health education impact questionnaire (heiQ) among people with chronic low back pain

BACKGROUND

There is no patient reported outcome measure available in Brazilian Portuguese to comprehensively assess outcomes following administration of patient education programs for people with chronic conditions.

OBJECTIVE

To describe the cross-cultural adaptation and measurement properties of the Brazilian Portuguese version of the Health Education Impact Questionnaire (heiQ), a multidimensional questionnaire designed for the evaluation of patient education programs, which was tested in people with chronic low back pain (LBP).

METHODS

One hundred thirty-seven individuals with non-specific chronic LBP (age: 38.7 ± 13.2) were enrolled in the study. The translation was performed according to international standards. Intraclass correlation coefficient (ICC) was used to assess test-retest reliability, Cronbach's α to assess internal consistency, Pearson rank correlation to compare the heiQ scales with comparator scales, and confirmatory factor analysis (CFA) for structural validity.

RESULTS

The test-retest analysis yielded ICC values ranging from 0.75 to 0.91. Cronbach's alphas for the seven scales ranged from 0.70 to 0.89. Significant correlations between affective and general health constructs and the heiQ scales (72%) were observed. For the majority of the scales, the CFA fit statistics showed to be good to excellent.

CONCLUSION

Overall, the Brazilian Portuguese version of the heiQ showed acceptable reliability, internal consistency, construct validity, and structural validity in individuals with chronic LBP. The heiQ scales may serve as direct outcomes to assess education and self-management programs for the Brazilian Portuguese speaker population.

Moving With Pain: What Principles From Somatic Practices Can Offer to People Living With Chronic Pain

This article brings together research from the fields of chronic pain management and somatic practices to develop a novel framework of principles to support people living with persistent pain. These include movement-based approaches to awareness of the internal body (interoception), the external environment (exteroception) and movement in space (proprioception). These significantly work with the lived subjective experiences of people living with pain, to become aware of body signals and self-management of symptoms, explore fear and pleasure of movement, and understand how social environments impact on pain. This analysis has potential to create new ways of supporting, understanding and articulating pain experiences, as well as shaping the future of somatic practices for chronic pain.

Patient-reported outcome measures for hip-related pain: a review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018

Hip-related pain is a well-recognised complaint among active young and middle-aged active adults. People experiencing hip-related disorders commonly report pain and reduced functional capacity, including difficulties in executing activities of daily living. Patient-reported outcome measures (PROMs) are essential to accurately examine and compare the effects of different treatments on disability in those with hip pain. In November 2018, 38 researchers and clinicians working in the field of hip-related pain met in Zurich, Switzerland for the first International Hip-related Pain Research Network meeting. Prior to the meeting, evidence summaries were developed relating to four prioritised themes. This paper discusses the available evidence and consensus process from which recommendations were made regarding the appropriate use of PROMs to assess disability in young and middle-aged active adults with hip-related pain. Our process to gain consensus had five steps: (1) systematic review of systematic reviews; (2) preliminary discussion within the working group; (3) update of the more recent high-quality systematic review and examination of the psychometric properties of PROMs according to established guidelines; (4) formulation of the recommendations considering the limitations of the PROMs derived from the examination of their quality; and (5) voting and consensus. Out of 102 articles retrieved, 6 systematic reviews were selected and assessed for quality according to AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews). Two showed moderate quality. We then updated the most recent review. The updated literature search resulted in 10 additional studies that were included in the qualitative synthesis. The recommendations based on evidence summary and PROMs limitations were presented at the consensus meeting. The group makes the following recommendations: (1) the Hip and Groin Outcome Score (HAGOS) and the International Hip Outcome Tool (iHOT) instruments (long and reduced versions) are the most appropriate PROMs to use in young and middle-aged active adults with hip-related pain; (2) more research is needed into the utility of the HAGOS and the iHOT instruments in a non-surgical treatment context; and (3) generic quality of life measures such as the EuroQoL-5 Dimension Questionnaire and the Short Form Health Survey-36 may add value for researchers and clinicians in this field. We conclude that as none of the instruments shows acceptable quality across various psychometric properties, more methods studies are needed to further evaluate the validity of these PROMS—the HAGOS and iHOT—as well as the other (currently not recommended) PROMS.

Outcomes in patient education programmes for people with rheumatic diseases: Results from a Delphi process and a study of feasibility and responsiveness

BACKGROUND

Patient education (PE) is recommended as an integral part of disease management for people with chronic inflammatory arthritis (IA). There is no consensus on how PE should be evaluated and which outcome measures should be used.

OBJECTIVES

This study had three aims: (a) to identify core aspects that PE for patients with IA may impact on; (b) to identify outcome measures to assess changes in these aspects; (c) to test the feasibility and responsiveness of the identified outcome measures.

METHODS

A Delphi process was conducted to identify core aspects and outcome measures. Feasibility and responsiveness were tested in a pre-/post-test study with 3 months follow-up, including 104 patients attending PE programmes.

RESULTS

Seven core aspects were identified: communication with health professionals, coping strategies, empowerment, knowledge about healthy life style, self-efficacy, understanding disease and treatment, and sharing experiences. Four outcome measures were identified; Arthritis Self Efficacy Scale (ASES-11), Effective Consumer scale (EC-17), Health Education Impact Questionnaire (heiQ) and Patient Activation Measure (PAM). At baseline, all measures had low rates of missing data. All measures except two heiQ subscales exhibited ceiling effects. Internal consistency was acceptable. At follow-up, statistically significant, but small improvements were found in EC-17 and three heiQ subscales.

CONCLUSION

ASES and EC-17 were found to be the most valid and feasible outcome measures to evaluate the identified core aspects of PE and can be recommended as outcome measures to assess PE programmes for patients with IA.

Study protocol for an investigation of the effectiveness of the pain toolkit for people with low back pain: double-blind randomised controlled trial

INTRODUCTION

The Pain Toolkit is a self-management tool for people with persistent pain. It is available for use worldwide in multiple formats. To date, no studies have investigated the effectiveness of this intervention. This study aims to investigate the effectiveness of the Pain Toolkit in comparison with a simple education control for people with low back pain.

METHODS AND ANALYSIS

Participants who have been discharged from the North of England Regional Back Pain Pathway will be randomised using sealed, consecutively numbered opaque envelopes to receive either the Pain Toolkit and the Back Book (intervention group) or the Back Book only (control group). Both the therapist and the participant will be blind to group allocation. The primary outcome measure will be disability (Oswestry Disability Index (ODI)). Secondary outcome measures will be pain (0-10 numerical scale), healthcare use (number of healthcare professional visits) and quality of life (EuroQol-5D). Outcome measures will be completed at baseline and at 6 and 12 months. Data will be analysed using analysis of covariance, adjusting for baseline values. A change of 10 points in the ODI will be considered a clinically important change. Additionally, a subsample of participants from the intervention group will undergo semistructured interviews to explore individuals' experience of the Pain Toolkit. Participants will be asked questions about the ease of use and acceptability of the Pain Toolkit and also for how long they used the Toolkit. The qualitative data will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

Approval for the study was given by the Health Research Authority and the North East Newcastle, North Tyneside 2 Regional Ethics Committee (reference 18/NE/0144) and Teesside University (reference 176/17). Findings will be disseminated through peer-reviewed journals and presentation at relevant patient groups, and local, national and international conferences.

TRIAL REGISTRATION NUMBER

NCT03791164; Pre -results.

Development and psychometric properties of a self-care behaviors scale (SCBS) among patients with rheumatoid arthritis

Background

The role of self-care behaviors in promoting physical function, pain management, health status and quality of life among patients with Rheumatoid Arthritis (RA) is well documented. However, there is no valid and reliable instrument in the literature to assess such behaviors among the patients. In the present study, we aimed to develop and assess the psychometric properties of a Self-care Behaviors Scale (SCBS) among patients with RA.

Methods

In 2017, applying a cross-sectional design, we recruited a convenient sample of 436 RA patients in Hamadan, Iran, to participate in the study. We developed the initial scale, including 30 items, after literature review, and having recommendations from an expert panel. Face, content, construct and convergent validity, as well as reliability of the scale were investigated.

Results

In Exploratory Factor Analysis, the optimal solution comprising 25 items and 7 factors was emerged, which explained 62.5% of all variances between the items. In Confirmatory Factor Analysis, the measurement model fit the data well, and all subscales were significant within an acceptable range (χ2 [233] = 428.654, p < 0.0001, comparative fit index = 0.942, normed fit index =0.907, Tucker-Lewis index =0.916, and root mean square error of approximation = 0.043[(0.037-0.05]).

Conclusion

The Self-care Behaviors Scale was found with appropriate validity, reliability, functionality and simplicity. To our knowledge, this scale is the only valid and reliable RA specific self-care behavior scale in the literature. Healthcare providers and health practitioners may apply the English version of this suitable instrument to find more valid and reliable data on RA self-care behaviors during primary assessments of the behaviors in educational interventions for the patients.

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence

BACKGROUND

Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain.

METHODS

GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created.

RESULTS

Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions.

CONCLUSION

From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

How to best distribute written patient education materials among patients with rheumatoid arthritis: a randomized comparison of two strategies

BACKGROUND

The aim of this randomized controlled trial was to evaluate the effect of a 'supply on demand'-distribution strategy, compared to an 'unsolicited supply'-distribution strategy, on the use of a care booklet and clinical outcomes among patients with rheumatoid arthritis (RA). In addition, differences in socio-demographic and clinical characteristics between users and non-users were explored.

METHODS

As part of regular care the care booklet was distributed among RA-patients of two hospitals in the Netherlands. 1000 patients received the care booklet by mail, whereas another 1000 received an information letter with the option to order the care booklet. Four months after distribution, a random sample of 810 patients (stratified by hospital and distribution method) received a questionnaire on the use of the booklet, social-demographic and clinical characteristics. To compare effects between the two distribution strategies and differences between users and non-users univariate and multilevel regression analyses were performed. Secondary analysis included a per-protocol analysis (excluding participants who did not order the care booklet).

RESULTS

One hundred ninety four patients in the 'unsolicited supply' and 176 patients in the 'supply on demand' group (46%) returned the questionnaire. In the 'supply on demand' group 106 (60.2%) participants ordered the care booklet. In total, no difference was found in use between the 'unsolicited supply'-group (23.2%) and the 'supply on demand'-group (21.6%) (OR 0.9 CI:0.6-1.5). However, the proportion of users among patients in the 'supply on demand'-group who ordered the booklet (35%) was significantly higher than in the 'unsolicited supply'-group (OR 1.9 CI:1.1-3.2). Regardless of distribution method, use of the care booklet was associated with being married (OR 2.4 CI:1.2-4.6), higher disease activity (mean difference 0.5 CI: 0.0-1.1), more activity limitations (mean difference 0.2 CI: 0.1-0.4), use of corticosteroids (OR 1.9 CI:1.0-3.5), perception of disease course as fluctuating (mean difference 1.4 CI:0.5-2.3) and higher educational needs (mean difference 9.7 CI: 2.9-16.6).

CONCLUSIONS

From an economic and environmental perspective a 'supply on demand'-distribution strategy could be recommended. Results of this study provide starting points to optimize further implementation strategies of a care-booklet in routine care.

TRIAL REGISTRATION

ISRCTN registry ( ISRCTN22703067 ). Retrospectively registered 27 March 2017.