A randomized controlled trial of an online self-management program for adults with arthritis pain

Peer Support for Chronic Pain in Online Health Communities: Quantitative Study on the Dynamics of Social Interactions in a Chronic Pain Forum

BACKGROUND

Peer support for chronic pain is increasingly taking place on social media via social networking communities. Several theories on the development and maintenance of chronic pain highlight how rumination, catastrophizing, and negative social interactions can contribute to poor health outcomes. However, little is known regarding the role web-based health discussions play in the development of negative versus positive health attitudes relevant to chronic pain.

OBJECTIVE

This study aims to investigate how participation in online peer-to-peer support communities influenced pain expressions by examining how the sentiment of user language evolved in response to peer interactions.

METHODS

We collected the comment histories of 199 randomly sampled Reddit (Reddit, Inc) users who were active in a popular peer-to-peer chronic pain support community over 10 years. A total of 2 separate natural language processing methods were compared to calculate the sentiment of user comments on the forum (N=73,876). We then modeled the trajectories of users' language sentiment using mixed-effects growth curve modeling and measured the degree to which users affectively synchronized with their peers using bivariate wavelet analysis.

RESULTS

In comparison to a shuffled baseline, we found evidence that users entrained their language sentiment to match the language of community members they interacted with (t198=4.02; P<.001; Cohen d=0.40). This synchrony was most apparent in low-frequency sentiment changes unfolding over hundreds of interactions as opposed to reactionary changes occurring from comment to comment (F2,198=17.70; P<.001). We also observed a significant trend in sentiment across all users (β=-.02; P=.003), with users increasingly using more negative language as they continued to interact with the community. Notably, there was a significant interaction between affective synchrony and community tenure (β=.02; P=.02), such that greater affective synchrony was associated with negative sentiment trajectories among short-term users and positive sentiment trajectories among long-term users.

CONCLUSIONS

Our results are consistent with the social communication model of pain, which describes how social interactions can influence the expression of pain symptoms. The difference in long-term versus short-term affective synchrony observed between community members suggests a process of emotional coregulation and social learning. Participating in health discussions on Reddit appears to be associated with both negative and positive changes in sentiment depending on how individual users interacted with their peers. Thus, in addition to characterizing the sentiment dynamics existing within online chronic pain communities, our work provides insight into the potential benefits and drawbacks of relying on support communities organized on social media platforms.

Assessing the Feasibility and Preliminary Effects of a Web-Based Self-Management Program for Chronic Noncancer Pain: Mixed Methods Study

BACKGROUND

In Canada, adults with chronic noncancer pain face a persistent insufficiency of publicly funded resources, with the gold standard multidisciplinary pain treatment facilities unable to meet the high clinical demand. Web-based self-management programs cost-effectively increase access to pain management and can improve several aspects of physical and emotional functioning. Aiming to meet the demand for accessible, fully automated resources for individuals with chronic noncancer pain, we developed a French web- and evidence-based self-management program, Agir pour moi (APM). This program includes pain education and strategies to reduce stress, practice mindfulness, apply pacing, engage in physical activity, identify and manage thinking traps, sleep better, adapt diet, and sustain behavior change.

OBJECTIVE

This study aims to assess the APM self-management program's feasibility, acceptability, and preliminary effects in adults awaiting specialized services from a center of expertise in chronic pain management.

METHODS

We conducted a mixed methods study with an explanatory sequential design, including a web-based 1-arm trial and qualitative semistructured interviews. We present the results from both phases through integrative tables called joint displays.

RESULTS

Response rates were 70% (44/63) at postintervention and 56% (35/63) at 3-month follow-up among the 63 consenting participants who provided self-assessed information at baseline. In total, 46% (29/63) of the participants completed the program. We interviewed 24% (15/63) of the participants. The interview's first theme revolved around the overall acceptance, user-friendliness, and engaging nature of the program. The second theme emphasized the differentiation between microlevel and macrolevel engagements. The third theme delved into the diverse effects observed, potentially influenced by the macrolevel engagements. Participants highlighted the features that impacted their self-efficacy and the adoption of self-management strategies. We observed indications of improvement in self-efficacy, pain intensity, pain interference, depression, and catastrophizing. Interviewees described these and various other effects as potentially influenced by macrolevel engagement through behavioral change.

CONCLUSIONS

These findings provided preliminary evidence that the APM self-management program and research methods are feasible. However, some participants expressed the need for at least phone reminders and minimal support from a professional available to answer questions over the first few weeks of the program to engage. Recruitment strategies of a future randomized controlled trial should focus on attracting a broader representation of individuals with chronic pain in terms of gender and ethnicity.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05319652; https://clinicaltrials.gov/study/NCT05319652.

Prognostic Factors of Perceived Disability and Perceived Recovery After Whiplash: A Longitudinal, Prospective Study With One-year Follow-up

OBJECTIVES

The understanding of the role that cognitive and emotional factors play in how an individual recovers from a whiplash injury is important. Hence, we sought to evaluate whether pain-related cognitions (self-efficacy beliefs, expectation of recovery, pain catastrophizing, optimism, and pessimism) and emotions (kinesiophobia) are longitudinally associated with the transition to chronic whiplash-associated disorders in terms of perceived disability and perceived recovery at 6 and 12 months.

METHODS

One hundred sixty-one participants with acute or subacute whiplash-associated disorder were included. The predictors were: self-efficacy beliefs, expectation of recovery, pain catastrophizing, optimism, pessimism, pain intensity, and kinesiophobia. The 2 outcomes were the dichotomized scores of perceived disability and recovery expectations at 6 and 12 months. Stepwise regression with bootstrap resampling was performed to identify the predictors most strongly associated with the outcomes and the stability of such selection.

RESULTS

Baseline perceived disability, pain catastrophizing, and expectation of recovery were the most likely to be statistically significant, with an overage frequency of 87.2%, 84.0%, and 84.0%, respectively.

CONCLUSION

Individuals with higher expectations of recovery and lower levels of pain catastrophizing and perceived disability at baseline have higher perceived recovery and perceived disability at 6 and 12 months. These results have important clinical implications as both factors are modifiable through health education approaches.

The impact of technology systems and level of support in digital mental health interventions: a secondary meta-analysis

BACKGROUND

The majority of people with a chronic disease (e.g., diabetes, hypertension, COPD) have more than one concurrent condition and are also at higher risk for developing comorbidities in mental health, including anxiety and depression. There is an urgent need for more relevant and accurate data on digital interventions in this area to prepare for an increase demand for mental health services. The aim of this study was to conduct a meta-analysis of the digital mental health interventions for people with comorbid physical and mental chronic diseases to compare the effect of technology systems and level of support.

METHODS

This secondary meta-analysis follows a rapid review of systematic reviews, a virtual workshop with knowledge users to identify research questions and a modified Delphi study to guide research methods: What types of digital health interventions (according to a recognized categorization) are the most effective for the management of concomitant mental health and chronic disease conditions in adults? We conducted a secondary analysis of the primary studies identified in the rapid review. Two reviewers independently screened the titles and abstracts and applied inclusion criteria: RCT design using a digital mental health intervention in a population of adults with another chronic condition, published after 2010 in French or English, and including an outcome measurement of anxiety or depression.

RESULTS

Seven hundred eight primary studies were extracted from the systematic reviews and 84 primary studies met the inclusion criteria Digital mental health interventions were significantly more effective than in-person care for both anxiety and depression outcomes. Online messaging was the most effective technology to improve anxiety and depression scores; however, all technology types were effective. Interventions partially supported by healthcare professionals were more effective than self-administered.

CONCLUSIONS

While our meta-analysis identifies digital intervention's characteristics are associated with better effectiveness, all technologies and levels of support could be used considering implementation context and population.

TRIAL REGISTRATION

The protocol for this review is registered in the National Collaborating Centre for Methods and Tools (NCCMT) COVID-19 Rapid Evidence Service (ID 75).

Internet-based and mobile-based cognitive behavioral therapy for chronic diseases: a systematic review and meta-analysis

Positive adjustment to chronic diseases reduces psychiatric comorbidity and enhances quality of life. Very little is known about the benefit of internet-based and mobile-based Cognitive Behavioral Therapy (IM-CBT) on physical outcomes and its reciprocal interactions with psychiatric outcomes, the active therapeutic elements, and effect moderators among people with major chronic medical conditions. In this systematic review and meta-analysis (PROSPERO: CRD42022265738), CINAHL of Systematic Reviews, MEDLINE, PsycINFO, PubMed, Web of Science are systematically searched up to 1 June 2022, for randomized controlled trials (RCTs) comparing IM-CBT against non-CBT control condition(s) among people with chronic disease(s). Primary outcomes include improvements in psychiatric symptoms (depressive, anxiety, PTSD symptoms, general psychological distress) from baseline to post-intervention and follow-ups. Secondary outcomes include improvements in physical distress (physical symptoms, functional impairment, self-rated ill health, objective physiological dysfunction). Among 44 RCTs (5077 patients with seven different chronic diseases), IM-CBT improves depressive symptoms, anxiety symptoms, and general psychological distress at post-intervention and across follow-ups, and improves physical distress and functional impairment at post-intervention. Preliminary evidence suggests that behavioral modification and problem-solving could be necessary components to reduce psychiatric symptoms in IM-CBT, whereas cognitive restructuring, psychoeducation, and mindfulness elements relate to reduced physical distress. IM-CBT shows stronger benefits in chronic pain, cancer, arthritis, and cardiovascular disease, relative to other conditions. Changes in psychiatric symptoms and physical distress prospectively predict each other over time. IM-CBT is an effective intervention for comprehensive symptom management among people with chronic diseases.

Let's Move with Leon. A randomised controlled trial of a UK digital intervention to improve physical activity in people with a musculoskeletal condition

OBJECTIVE

This article presents a real-world evaluation of a digital intervention, 'Let's Move with Leon', designed to improve physical activity and health-related quality of life (HRQoL) in people with a musculoskeletal condition.

STUDY DESIGN

A pragmatic randomised controlled trial.

METHODS

After randomisation and withdrawals were removed, 184 participants were assigned to receive the digital intervention with 185 assigned to a control group. Self-reported physical activity was the primary outcome. Health-related quality of life, the number of days completing strength-based exercises per week, the capability, opportunity, and motivation to be active, and step count were secondary outcomes. Outcomes were assessed over 4, 8 and 13 weeks.

RESULTS

Significant improvements were seen for self-reported physical activity at 13 weeks, reported strength days at 8 weeks, perceptions of physical capability and automatic motivation to be active at 4 and 8 weeks. No improvements were seen in step count or HRQoL over the control group.

CONCLUSION

Digital interventions such as 'Let's Move with Leon' have the potential to increase physical activity in people with a musculoskeletal condition; however, improvements are likely to be small. Small improvements in physical activity may not be enough to improve HRQoL.

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.

Effects of WeChat platform-based continuing care on self-management and quality of life in patients with arthritis: A quasi-experimental study

Objective

To assess the effects of WeChat platform-based continuing care for arthritis on patients' self-management, self-efficiency, quality of life (QoL), and medication compliance.

Methods

A study was conducted on arthritis patients recruited between December 2017 and February 2018 and divided into two groups. The intervention group received continuing care from the WeChat platform and regular follow-ups, while the control group only received regular follow-ups. The outcomes in both groups were assessed using questionnaires twice: before the study (T0) and eight weeks after T0 (T1), which consists of the evaluation of self-management, QoL, self-efficacy, and medication compliance.

Results

There were 23 people in each of the intervention and control groups completed two outcome measures. At eight weeks, participants in the intervention group showed an improvement in psychological QoL, cognitive symptom management, and self-efficacy, compared to the control group (QoL scores: mean difference in change between groups was 12.29, 95% CI: 4.51, 20.07, p < 0.001; cognitive symptom management: mean difference in change between groups was 0.65, 95% CI: 0.24, 1.05, p < 0.001; self-efficacy: mean difference in change between groups was 0.69, 95% CI: 0.14, 1.24, p < 0.05). Self-management, self-efficacy, and psychological quality of life were significantly improved in the intervention group before and after the intervention (p < 0.05).

Conclusion

Using the WeChat platform for continuing care is useful in improving the psychological state, self-efficacy, and self-management ability of patients with arthritis. The study is relevant to Clinical Practice.

Implementation of Online Behavior Modification Techniques in the Management of Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Purpose: The main aim of this systematic review and meta-analysis (MA) was to assess the effectiveness of online behavior modification techniques (e-BMT) in the management of chronic musculoskeletal pain. Methods: We conducted a search of Medline (PubMed), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, APA PsychInfo, and Psychological and Behavioral Collections, from inception to the 30 August 2021. The main outcome measures were pain intensity, pain interference, kinesiophobia, pain catastrophizing and self-efficacy. The statistical analysis was conducted using RStudio software. To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time and the corresponding 95% confidence interval (CI) for the continuous variables. Results: Regarding pain intensity (vs. usual care/waiting list), we found a statistically significant trivial effect size in favor of e-BMT (n = 5337; SMD = −0.17; 95% CI −0.26, −0.09). With regard to pain intensity (vs. in-person BMT) we found a statistically significant small effect size in favor of in-person BMT (n = 486; SMD = 0.21; 95%CI 0.15, 0.27). With respect to pain interference (vs. usual care/waiting list) a statistically significant small effect size of e-BMT was found (n = 1642; SMD = −0.24; 95%CI −0.44, −0.05). Finally, the same results were found in kinesiophobia, catastrophizing, and self-efficacy (vs. usual care/waiting list) where we found a statistically significant small effect size in favor of e-BMT. Conclusions: e-BMT seems to be an effective option for the management of patients with musculoskeletal conditions although it does not appear superior to in-person BMT in terms of improving pain intensity.

Effectiveness of Telematic Behavioral Techniques to Manage Anxiety, Stress and Depressive Symptoms in Patients with Chronic Musculoskeletal Pain: A Systematic Review and Meta-Analysis

Anxiety, depressive symptoms and stress have a significant influence on chronic musculoskeletal pain. Behavioral modification techniques have proven to be effective to manage these variables; however, the COVID-19 pandemic has highlighted the need for an alternative to face-to-face treatment. We conducted a search of PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, APA PsychInfo, and Psychological and Behavioural Collections. The aim was to assess the effectiveness of telematic behavioral modification techniques (e-BMT) on psychological variables in patients with chronic musculoskeletal pain through a systematic review with meta-analysis. We used a conventional pairwise meta-analysis and a random-effects model. We calculated the standardized mean difference (SMD) with the corresponding 95% confidence interval (CI). Forty-one randomized controlled trials were included, with a total of 5018 participants. We found a statistically significant small effect size in favor of e-BMT in depressive symptoms (n = 3531; SMD = -0.35; 95% CI -0.46, -0.24) and anxiety (n = 2578; SMD = -0.32; 95% CI -0.42, -0.21) with low to moderate strength of evidence. However, there was no statistically significant effect on stress symptoms with moderate strength of evidence. In conclusion, e-BMT is an effective option for the management of anxiety and depressive symptoms in patients with chronic musculoskeletal pain. However, it does not seem effective to improve stress symptoms.

Patient Influencers: The Next Frontier in Direct-to-Consumer Pharmaceutical Marketing

Social media influencers are becoming an increasingly popular strategic communication tactic used across industry verticals, including entertainment, fashion, and beauty, to engage directly with consumers. Pharmaceutical companies have also recently entered the social media marketing arena and—within the bounds of governmental regulations—have found ways to build relationships directly with patients using covert persuasion tactics like partnering with social media influencers. Due to consumers’ negative perceptions of pharmaceutical companies, it makes sense that new marketing tactics are being used to establish and improve relationships with consumers. Previous research well documents the ethical dilemmas of direct-to-consumer advertising, and there is recent burgeoning literature on online covert marketing tactics. The academic and medical literature, however, is behind in regard to social media influencers used in health and medicine. This paper highlights and defines terms used in industry practice, and also calls for more investigation and sets forward a research agenda. As consumers spend more time online and patients continue to consult social media for health information, it is important that this new marketing trend does not go unnoticed.

Internet-delivered cognitive and behavioural based interventions for adults with chronic pain: a systematic review and meta-analysis of randomized controlled trials

ABSTRACT

This study examined the efficacy of Internet-delivered cognitive and behavioural interventions for adults with chronic pain, and explored the role of clinical and study characteristics as moderators of treatment effects. PubMed, Embase, PsycINFO, and CENTRAL and CINAHL were searched to identify randomised controlled trials published up to October 2021. A meta-analysis of 36 studies (5778 participants) was conducted, which found small effect sizes for interference/disability (Hedges' g = 0.28; 95% CI 0.21, 0.35), depression (g = 0.43; 95% CI 0.33, 0.54), anxiety (g = 0.32; 95% CI 0.24, 0.40), pain intensity (g = 0.27; 95% CI 0.21, 0.33), self-efficacy (g = 0.39; 95% CI 0.27, 0.52) and pain catastrophizing (g = 0.31; 95% CI 0.22, 0.39). Moderator analyses found interventions which involved clinician guidance had significantly greater effect sizes for interference/disability (g = 0.38), anxiety (g = 0.39), and pain intensity (g = 0.33) compared to those without (g = 0.16, g = 0.18; g = 0.20, respectively). Studies using an inactive control had greater effects for depression (g = 0.46) compared to active control trials (g = 0.22). No differences were found between treatments based on traditional Cognitive Behaviour Therapy versus Acceptance and Commitment Therapy. Sample size, study year, and overall risk of bias (Cochrane rating) did not consistently moderate treatment effects. Overall, the results support the use of internet-delivered cognitive and behavioural interventions as efficacious and suggest guided interventions are associated with greater clinical gains for several key pain management outcomes.Prospectively registered on OSF Registries (citation: osf.io/cvq3j/).

Online psychological interventions to reduce symptoms of depression, anxiety, and general distress in those with chronic health conditions: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Over the past 15 years, there has been substantial growth in web-based psychological interventions. We summarize evidence regarding the efficacy of web-based self-directed psychological interventions on depressive, anxiety and distress symptoms in people living with a chronic health condition.

METHOD

We searched Medline, PsycINFO, CINAHL, EMBASE databases and Cochrane Database from 1990 to 1 May 2019. English language papers of randomized controlled trials (usual care or waitlist control) of web-based psychological interventions with a primary or secondary aim to reduce anxiety, depression or distress in adults with a chronic health condition were eligible. Results were assessed using narrative synthases and random-effects meta-analyses.

RESULTS

In total 70 eligible studies across 17 health conditions [most commonly: cancer (k = 20), chronic pain (k = 9), arthritis (k = 6) and multiple sclerosis (k = 5), diabetes (k = 4), fibromyalgia (k = 4)] were identified. Interventions were based on CBT principles in 46 (66%) studies and 42 (60%) included a facilitator. When combining all chronic health conditions, web-based interventions were more efficacious than control conditions in reducing symptoms of depression g = 0.30 (95% CI 0.22-0.39), anxiety g = 0.19 (95% CI 0.12-0.27), and distress g = 0.36 (95% CI 0.23-0.49).

CONCLUSION

Evidence regarding effectiveness for specific chronic health conditions was inconsistent. While self-guided online psychological interventions may help to reduce symptoms of anxiety, depression and distress in people with chronic health conditions in general, it is unclear if these interventions are effective for specific health conditions. More high-quality evidence is needed before definite conclusions can be made.

Changing Pain Management Strategy from Opioid-Centric towards Improve Postoperative Cognitive Dysfunction with Dexmedetomidine

OBJECTIVE

This study was aimed to investigate the effectiveness of dexmedetomidine (DEX) on improving the level of pain and disability to find out the possible correlation between psychological factors with pain management satisfaction and physical function in patients with femoral neck fractures.

METHODS

One hundred twenty-four adult patients with stable femoral neck fractures (type I and II, Garden classification) who underwent internal fixation, were prospectively enrolled including 62 patients in the DEX group and 62 patients in the control group. The magnitude of disability using Harris Hip Score, Postoperative Cognitive Dysfunction (POCD) using Mini-Mental State Examination (MMSE score), Quality of Recovery (QoR-40), pain-related anxiety (PASS-20), pain management and pain catastrophizing scale (PCS) were recorded on the first and second day after surgery.

RESULTS

The DEX group on the first and second days after surgery exhibited higher quality of recovery scores, greater satisfaction with pain management, low disability scores, less catastrophic thinking, lower pain anxiety, greater mini mental state examination scores and less opioid intake and the differences were statistically significant compared with the control group (P<0.001). Emergence agitation and incidence of POCD were significantly less in the DEX group (P<0.001). Decreased disability was associated with less catastrophic thinking and lower pain anxiety, but not associated with more opioid intake (P<0.001). Higher QoR-40 scores had a negative correlation with more catastrophic thinking and more opioid intake (P<0.001). Greater satisfaction with pain management was correlated with less catastrophic thinking and less opioid intake (P<0.001).

CONCLUSION

Using DEX as an adjunct to anesthesia could significantly improve postoperative cognitive dysfunction and the quality of recovery and these improvements were accompanied by decrease in pain, emergence agitation, and opioid consumption by DEX administration. Since pain relief and decreased disability were not associated with prescribing greater amounts of opioid intake in the patients, improving psychological factors, including reducing catastrophic thinking or self-efficacy about pain, could be a more effective strategy to reduce pain and disability, meanwhile reducing opioid prescription in the patients. Our findings showed that DEX administration is safe sedation with anti-inflammatory, analgesic and antiemetic effects and it could help change pain management strategy from opioid-centric towards improved postoperative cognitive dysfunction.

Pain coping skills training un-locks patient-centered pain care during the COVID- 19 lockdown

BACKGROUND

In 2020, the COVID-19 virus sparked a crisis constituting a nationwide public health emergency that rapidly altered the provision of healthcare services for all Americans. Infectious disease mitigation led to widespread lockdowns of perceived nonessential services, programs, and non-emergent healthcare interventions. This lockdown exacerbated the public health dyad of uncontrolled pain and the opioid epidemic, which was already in a crisis state. Current literature supports the management of uncontrolled pain with a biopsychosocial approach, empowering patients to explore self-care to enhance activities of daily living. Pain Coping Skills Training (PCST) delivers real-life strategies that improve quality of life and strengthen self-efficacy. Self-efficacy has been identified as a patient outcome measure that demonstrates improved patient-perceived function and quality of life despite pain intensity. Studies have shown that nurse practitioners (APRN) are well-positioned to provide PCST to chronic pain sufferers.

METHODS

A pretest-posttest design was utilized for this project to enhance pain self- efficacy through an APRN-led community-based intervention.

INTERVENTION

Community-dwelling adults treated in a specialty pain management practice were self-selected to participate in a 6-week telehealth delivered PCST Program. This APRN delivered program presented basic pain education and a broad range of evidence-based nonpharmacologic pain management self-care tools. The primary outcome was improved Pain Self-efficacy measured with the pain self-efficacy questionnaire (PSEQ), with secondary outcomes of improved perceived pain intensity and function measured with the pain, enjoyment, and general activity (PEG) scale tracked weekly.

RESULTS

Baseline PSEQ and weekly PEG scores were obtained and compared to scores after the program. Collateral data points included confidence in using complementary and alternative nonpharmacologic interventions, satisfaction with the program, and a qualitative patient statement regarding pre-and post-intervention participation.

CONCLUSIONS

This project concluded that a Nurse Practitioner delivered PCST program via telehealth technology could provide community-dwelling adults with an intervention that improves pain self-efficacy, enhances self-reported PEG measures, and meets the social distancing requirements that continue to impact patients during the COVID-19 pandemic.

Support for a non-therapist assisted, Internet-based cognitive-behavioral therapy (iCBT) intervention for mental health in rheumatoid arthritis patients

BACKGROUND

Anxiety is common in patients with rheumatoid arthritis (RA) and associated with worse RA outcomes. This study assessed the feasibility and preliminary health impacts (mental and physical) of a non-therapist assisted, online mental health intervention targeting anxiety in this population.

METHODS

Participants with confirmed RA and elevated anxiety symptoms were enrolled into the Worry and Sadness program, an Internet-based cognitive-behavioral therapy (iCBT) intervention for anxiety and depression shown to be effective in the general population. Validated self-report measures of anxiety, depression, pain interference, fatigue, physical health-related quality of life, functional status, and patient-reported disease severity were collected at baseline, post-intervention, and at three-month follow-up. Emotional distress scores were tracked between lessons. Participants provided qualitative feedback in writing post-intervention.

RESULTS

We analyzed the responses of 34 participants; the majority was female (86%) and the mean age was 57 (SD = 13). Of these, 80% (n = 28) completed the study in its entirety. Among these completers, 94.1% described the program as worthwhile. We found statistically significant improvements in anxiety, depression and fatigue from baseline to three-month follow-up, with small to large effect sizes (d = 0.39-0.81). Post-hoc analyses revealed that statistically significant change occurred between baseline and post-intervention for anxiety and depression and was maintained at three-month follow-up, whereas statistically significant change occurred between baseline and three-month follow-up for fatigue. Statistically significant reductions in emotional distress occurred across the program, with a large effect size (d = 1.16) between the first and last lesson.

CONCLUSION

The Worry and Sadness program shows promise as a feasible resource for improving mental health in RA.

Nonpharmacologic Pain Management in Inflammatory Arthritis

This article provides an overview of nonpharmacologic options for the treatment of pain in patients with inflammatory arthritis, such as peripheral spondyloarthritis, psoriatic arthritis, ankylosing spondylitis, and rheumatoid arthritis. The experience of pain in chronic disease is a complex process influenced by multiple domains of health. The discussion focuses on the establishment of a framework for pain control that engages with factors that influence the experience of pain and explores the evidence base that supports specific modalities of nonpharmacologic pain control, such as mindfulness, cognitive behavioral therapy, exercise, massage, splinting, and heat therapy. Rheumatoid and spondyloarthritides are considered separately.

Early Experience of a Multidisciplinary Group Pain Program with Cognitive Behavioural Strategies, Physiotherapy and Peer Support for Patients with Chronic Noncancer Pain

BACKGROUND

Chronic non-cancer pain affects about 20% of the population worldwide. The effect of medical treatment in isolation is often limited. A multidisciplinary approach has been strongly advocated to help manage patients' pain more effectively.

AIMS

The primary purpose was to reduce pain severity, pain interference on patients'daily activities and improve their levels of self-efficacy despite pain. The secondary aim was to evaluate the possible changes in patients' depression, anxiety, and stress symptoms after amultidisciplinary group pain program. The program content and structure were also evaluated.

DESIGN

This scholarly project used within-subject pre- and post-test design.

SETTINGS/SUBJECTS

Fifty-six patients were recruited from the project center pain clinic.

METHODS

An evidence-based eight-hour multidisciplinary group pain program was implemented. Data was collected before and 3 months after the program.

INTERVENTIONS

The program covered pain physiology, cognitive behavioural strategies, demonstration of various exercises, self-management skills, medication management, and peer support.

RESULTS

Three months postprogram, there was a statistically significant improvement in patients' pain severity (β = -0.9, 95% CI: -1.73 to -0.14, p = .023) and self-efficacy (β = 5.6, 95% CI: 0.85 to 10.41, p = .023). Pain interference on their daily activities was also significantly reduced (β = -2.0, 95% CI: -2.90 to -0.83, p = .001). Patients provided positive and encouraging feedback about the program.

CONCLUSION

Initial improvements in patients' ability to cope with pain and to perform daily activities were demonstrated following participation in the brief multidisciplinary group pain program. Future randomized controlled trials are needed to confirm that the results are due to patients' participation in the program.

Prevalence and predictors of chronic pain intensity and disability among adults with sickle cell disease

Among 170 adults with sickle cell disease, we evaluated chronic pain impact and disability prevalence, assessed age and gender differences, and identified psychosocial predictors of chronic pain intensity and disability. Most participants had a high level of disability. Chronic pain intensity and disability were significantly associated with pain catastrophizing and chronic pain self-efficacy, and worsened with age. Further research is needed to confirm study findings and develop interventions, including palliative care approaches that address catastrophizing and disability, particularly for young women and middle-aged adults with sickle cell disease. Moreover, consistent clinical assessment of chronic pain and psychosocial health should be implemented.

My joint pain, a web-based resource, effects on education and quality of care at 24 months

Objective

To evaluate the effects of the updated version of an evidence-based osteoarthritis (OA) resource and consumer hub, ‘My Joint Pain’ website, on health education and quality of care over 12 months.

Methods

Using a classic quasi-experimental design, participants with symptomatic hip or knee OA were recruited across Australia to evaluate the ‘My Joint Pain’ website, compared to a control group of non-users from 12 to 24 months. Outcome measures included the Health Education Impact Questionnaire (HEIQ) and the OA Quality Indicator (OAQI) questionnaire. The changes from 12 to 24 months in the HEIQ were evaluated using a generalised linear model. The differences between users and non-users in the OAQI were evaluated using a chi-square test.

Results

A total of 277 eligible participants with symptomatic hip or knee OA were recruited at baseline, and 122 participants completed the 24-month surveys (users: n = 35, non-users: n = 87). There was no significant difference between users and non-users for the HEIQ scores at 24 months after adjustments for age, sex and body mass index (BMI). Users had higher emotional distress scores than non-users in univariable analysis. When compared with non-users in the OAQI, users showed favourable changes in receiving information about “self-management” and “acetaminophen” and “non-steroidal anti-inflammatory drugs (NSAIDs)” from 12 to 24 months.

Conclusion

The evaluation of the updated ‘My Joint Pain’ website didn’t find significant improvements in terms of health education, but it may help delivering useful information about self-management and appropriate use of pharmacological treatments. More strategies are needed to facilitate the uptake of evidence-based self-management and education online resources for OA consumers.

Do pain management websites foster self-management support for people with persistent pain? A scoping review

OBJECTIVES

To evaluate if the contents of pain management websites include the current best practice self-management support strategies for people with persistent pain, are cultural tailored and to determine the website quality.

METHODS

Websites were searched from three major search engines (Google, Bing, and Yahoo). Websites providing information on self-management strategies and websites that were freely available to the public were included. The website contents were evaluated using a 14-item self-management support (SMS-14) checklist. Website quality was assessed using the Health On the Net code (HONcode) certification.

RESULTS

Of the twenty-seven websites evaluated, the websites scored a median of nine items (range 1-13) from the SMS-14 checklist. The websites LivePlanBe, ACI Pain Management Network and MyJointPain top-scored (13/14) from the SMS-14 checklist. One website (ACI Pain Management Network) provided culturally tailored information and HONcode certification was present in six websites.

CONCLUSIONS

The review identified 27 contemporary pain management websites that could be used for self-management skills training.

PRACTICE IMPLICATIONS

Clinicians could refer people with persistent pain to top ranked websites - LivePlanBe, ACI Pain Management Network, and MyJointPain for enabling self-management skills, with the caveats that most websites lacked cultural tailoring, and have limited or no evidence of clinical efficacy.

Engagement in online pain self-management improves pain in adults on medication-assisted behavioral treatment for opioid use disorders

INTRODUCTION

Persistent pain has been recognized as an important motivator that can lead individuals to misuse opioids. New approaches are needed to test pain treatments that can improve outcomes for people with persistent pain in medication-assisted behavioral treatment for opioid use disorder. This study piloted an online pain self-management program to explore acceptability and treatment effects.

METHODS

A sample of 60 adults diagnosed with chronic non-cancer pain and receiving medication-assisted behavioral treatment at one of two clinics were randomized into either treatment group with access to an online pain management program or waitlist attention control. Participants received online surveys via email at baseline and post-treatment at week 8.

RESULTS

The majority of participants (n = 44; 73%) reported that their first use of opioids was in response to a painful event. Those who engaged in the online program had significantly lower pain interference, pain severity, opioid misuse measures, and depressive symptoms after eight weeks while pain self-efficacy was increased.

CONCLUSION

Our results suggest the online pain self-management program content may be helpful for managing physical and emotional symptoms experienced by individuals with co-occurring pain and opioid use disorders. To improve online engagement, more support is necessary to assist with technology access and completion of online activities.

Internet-delivered cognitive behaviour therapy for chronic health conditions: a systematic review and meta-analysis

This systematic review and meta-analysis aims to evaluate the effectiveness of internet-delivered cognitive behavioural therapy (ICBT) on anxiety and depression among persons with chronic health conditions. A systematic database search was conducted of MEDLINE, CINAHL, PsycInfo, EMBASE, and Cochrane for relevant studies published from 1990 to September 2018. A study was included if the following criteria were met: (1) randomized controlled trial involving an ICBT intervention; (2) participants experienced a chronic health condition; (3) participants ≥ 18 years of age; and (4) effects of ICBT on anxiety and/or depression were reported. The Cochrane Risk of Bias tool was used to assess the risk of bias on the included studies. Pooled analysis was conducted on the primary and condition specific secondary outcomes. Twenty-five studies met inclusion criteria and investigated the following chronic health conditions: tinnitus (n = 6), fibromyalgia (n = 3), pain (n = 7), rheumatoid arthritis (n = 3), cardiovascular disease (n = 2), diabetes (n = 1), cancer (n = 1), heterogeneous chronic disease population (n = 1), and spinal cord injury (n = 1). Pooled analysis demonstrated small effects of ICBT in improving anxiety and depression. Moderate effects of therapist-guided approach were seen for depression and anxiety outcomes; while, self-guided approaches resulted in small effects for depression and moderate effects in anxiety outcomes. ICBT shows promise as an alternative to traditional face-to-face interventions among persons with chronic health conditions. Future research on long-term effects of ICBT for individuals with chronic health conditions is needed.

Trial Registration PROSPERO registration number: CRD42018087292.

The effect of interactive digital interventions on physical activity in people with inflammatory arthritis: a systematic review

The aim of this systematic review was to evaluate the evidence from randomised controlled trials (RCTs) evaluating the effectiveness of interactive digital interventions (IDIs) for physical activity (PA) and health related quality of life (HRQoL) in people with Inflammatory Arthritis [rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA) axial Spondyloarthritis (AS) and psoriatic arthritis (PsA)]. Seven electronic databases identified published and unpublished studies. Two reviewers conducted independent data extraction and quality assessment using the Cochrane risk of bias tool (RoB). The primary outcome was change in objective PA after the intervention; secondary outcomes included self-reported PA and HRQoL after the intervention and objective or self-reported PA at least 1 year later. Five manuscripts, reporting four RCTs (three high and one low RoB) representing 492 (459 RA, 33 JIA) participants were included. No trials studying PsA or AS met the inclusion criteria. Interventions ranged from 6 to 52 weeks and included 3-18 Behaviour Change Techniques. Due to heterogeneity of outcomes, a narrative synthesis was conducted. No trials reported any significant between group differences in objective PA at end of intervention. Only one low RoB trial found a significant between group difference in self-reported vigorous [MD Δ 0.9 days (95% CI 0.3, 1.5); p = 0.004], but not moderate, PA in people with RA but not JIA. There were no between group differences in any other secondary outcomes. There is very limited evidence for the effectiveness of IDIs on PA and HRQoL in RA and JIA and no evidence for their effectiveness in PsA or AS.

Web-Based Patient Education in Orthopedics: Systematic Review

Background

Patients with orthopedic conditions frequently use the internet to find health information. Patient education that is distributed online may form an easily accessible, time- and cost-effective alternative to education delivered through traditional channels such as one-on-one consultations or booklets. However, no systematic evidence for the comparative effectiveness of Web-based educational interventions exists.

Objective

The objective of this systematic review was to examine the effects of Web-based patient education interventions for adult orthopedic patients and to compare its effectiveness with generic health information websites and traditional forms of patient education.

Methods

CINAHL, the Cochrane Library, EMBASE, MEDLINE, PsycINFO, PUBMED, ScienceDirect, Scopus, and Web of Science were searched covering the period from 1995 to 2016. Peer-reviewed English and Dutch studies were included if they delivered patient education via the internet to the adult orthopedic population and assessed its effects in a controlled or observational trial.

Results

A total of 10 trials reported in 14 studies involving 4172 patients were identified. Nine trials provided evidence for increased patients’ knowledge after Web-based patient education. Seven trials reported increased satisfaction and good evaluations of Web-based patient education. No compelling evidence exists for an effect of Web-based patient education on anxiety, health attitudes and behavior, or clinical outcomes.

Conclusions

Web-based patient education may be offered as a time- and cost-effective alternative to current educational interventions when the objective is to improve patients’ knowledge and satisfaction. However, these findings may not be representative for the whole orthopedic patient population as most trials included considerably younger, higher-educated, and internet-savvy participants only.

Web-based rehabilitation interventions for people with rheumatoid arthritis: A systematic review

BACKGROUND

Rehabilitation approaches for people with rheumatoid arthritis include joint protection, exercises and self-management strategies. Health interventions delivered via the web have the potential to improve access to health services overcoming time constraints, physical limitations, and socioeconomic and geographic barriers. The objective of this review is to determine the effects of web-based rehabilitation interventions in adults with rheumatoid arthritis.

METHODS

Randomised controlled trials that compared web-based rehabilitation interventions with usual care, waiting list, no treatment or another web-based intervention in adults with rheumatoid arthritis were included. The outcomes were pain, function, quality of life, self-efficacy, rheumatoid arthritis knowledge, physical activity and adverse effects. Methodological quality was assessed using the Cochrane Risk of Bias tool and quality of evidence with the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Six source documents from four trials ( n = 567) focusing on self-management, health information or physical activity were identified. The effects of web-based rehabilitation interventions on pain, function, quality of life, self-efficacy, rheumatoid arthritis knowledge and physical activity are uncertain because of the very low quality of evidence mostly from small single trials. Adverse effects were not reported.

CONCLUSION

Large, well-designed trials are needed to evaluate the clinical and cost-effectiveness of web-based rehabilitation interventions in rheumatoid arthritis.

Is Use of a Psychological Workbook Associated With Improved Disabilities of the Arm, Shoulder and Hand Scores in Patients With Distal Radius Fracture?

BACKGROUND

Symptom intensity and magnitude of limitations correlate with stress, distress, and less effective coping strategies. It is unclear if interventions to target these factors can be used to improve outcomes after distal radius fracture in either the short- or longer term.

QUESTIONS/PURPOSES

(1) Are there any factors (including the use of a workbook aimed at optimizing psychological response to injury, demographic, radiographic, medical, or psychosocial) associated with improved Disabilities of the Arm, Shoulder and Hand (DASH) and Numerical Rating Scale pain (NRS pain) scores at 6 weeks after management of distal radius fracture? (2) Are any of these factors associated with improved DASH and NRS pain scores at 6 months after management of distal radius fracture?

METHODS

We conducted a double-blind randomized controlled trial comparing a workbook designed to optimize rehabilitation by improving psychological response to injury using recognized psychological techniques (the LEARN technique and goal setting) versus a workbook containing details of stretching exercises in the otherwise routine management of distal radius fracture. Patients older than 18 years of age with an isolated distal radius fracture were recruited within 3 weeks of injury from a single academic teaching hospital between March and August 2016. During recruitment, 191 patients who met the inclusion criteria were approached; 52 (27%) declined participation and 139 were enrolled. Eight patients (6%) were lost to followup by 6 weeks. The remaining cohort of 129 patients was included in the analysis. DASH scores and NRS pain scores were recorded at 6 weeks and 6 months after injury. Multivariable regression analysis was used to identify factors associated with outcome scores.

RESULTS

At 6 weeks after distal radius fracture, when compared with an information-only workbook, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 38 [range, 21-48]; control DASH: 35 [range, 21-53]; difference of medians: 3; p = 0.949) nor NRS pain scores (workbook NRS: 3 [range, 1-5]; control NRS: 2 [range, 1-4]; difference of medians: 1; p = 0.128). Improved DASH scores were associated with less radial shortening (β = 0.2, p = 0.009), less dorsal tilt (β = 0.2, p = 0.035), and nonoperative treatment (β = 0.2, p = 0.027). Improved NRS pain scores were associated with nonoperative treatment (β = 0.2, p = 0.021) and no posttraumatic stress disorder (PTSD) (β = 0.2, p = 0.046). At 6 months, use of a psychologic workbook was not associated with improved DASH (workbook DASH: 11 [range, 5-28]; control DASH: 11 [range, 3-20]; difference of medians: 0; p = 0.367) nor NRS pain scores (workbook NRS: 1 [range, 0-2]; control NRS: 1 [range, 0-2]; difference of medians: 0; p = 0.704). Improved DASH score at 6 months was associated with having fewer medical comorbidities (β = 0.3, p < 0.001) and lower enrollment PTSD (β = 0.3, p < 0.011). Lower NRS pain scores at 6 months were associated with having fewer medical comorbidities (β = 0.2, p = 0.045), lower enrollment PTSD (β = 0.3, p = 0.008), and lower enrollment Tampa Scale for Kinesiophobia (β = 0.2, p = 0.042).

CONCLUSIONS

Our study demonstrates that there is no benefit from the untargeted use of a psychological workbook based on the LEARN approach and goal-setting strategies in patients with distal radius fracture. Future research should investigate if there is a subgroup of patients with a negative psychological response to injury that benefits from psychological intervention and, if so, how best to identify these patients and intervene.

LEVEL OF EVIDENCE

Level II, therapeutic study.

The effectiveness of interventions aimed at increasing physical activity in adults with persistent musculoskeletal pain: a systematic review and meta-analysis

BACKGROUND

Individuals with persistent musculoskeletal pain (PMP) have an increased risk of developing co-morbid health conditions and for early-mortality compared to those without pain. Despite irrefutable evidence supporting the role of physical activity in reducing these risks; there has been limited synthesis of the evidence, potentially impacting the optimisation of these forms of interventions. This review examines the effectiveness of interventions in improving levels of physical activity and the components of these interventions.

METHODS

Randomised and quasi-randomised controlled trials were included in this review. The following databases were searched from inception to March 2016: CENTRAL in the Cochrane Library, Cochrane Database of Systematic Reviews (CDSR), MEDLINE, Embase, CINAHL, PsycINFO and AMED. Two reviewers independently screened citations, assessed eligibility, extracted data, assessed risk of bias and coded intervention content using the behaviour change taxonomy (BCTTv1) of 93 hierarchically clustered techniques. GRADE was used to rate the quality of the evidence.

RESULTS

The full text of 276 articles were assessed for eligibility, twenty studies involving 3441 participants were included in the review. Across the studies the mean number of BCTs coded was eight (range 0-16); with 'goal setting' and 'instruction on how to perform the behaviour' most frequently coded. For measures of subjective physical activity: interventions were ineffective in the short term, based on very low quality evidence; had a small effect in the medium term based on low quality evidence (SMD 0.25, 95% CI 0.01 to 0.48) and had a small effect in the longer term (SMD 0.21 95% CI 0.08 to 0.33) based on moderate quality evidence. For measures of objective physical activity: interventions were ineffective - based on very low to low quality evidence.

CONCLUSIONS

There is some evidence supporting the effectiveness of interventions in improving subjectively measured physical activity however, the evidence is mostly based on low quality studies and the effects are small. Given the quality of the evidence, further research is likely/very likely to have an important impact on our confidence in effect estimates and is likely to change the estimates. Future studies should provide details on intervention components and incorporate objective measures of physical activity.

Participant Perspectives on Benefits and Challenges of Engaging in an Online Pain Self-Management Program

The purpose of this study was to evaluate participants' perspectives after engaging in an 8-week online pain self-management program. Unexplored qualitative data for this analysis were collected via secure online surveys distributed during a previously published randomized controlled trial. Participants for the present study were 47 adults prescribed opioid medicines for chronic pain. A qualitative descriptive approach using content analysis methods was used to identify common themes regarding online participation. Three themes described the benefits of the program and included: positive reframing, improved accountability, and feeling supported. Two themes described how participants would like to improve the program experience and included: ease of use and desire for personalizing. Participants' insights can assist health care providers and program developers in understanding how online programs may improve chronic disease self-management for a multitude of health problems.

The use of social media by arthritis health professionals to disseminate a self-management program to patients: A feasibility study

Objective

The objective of this study was to determine the feasibility of Facebook as a dissemination strategy for the People Getting a Grip on Arthritis self-management program by arthritis health professionals to their patients.

Methods

The feasibility study comprised a single arm, pre-post design that included a convenience sample of 78 arthritis health professionals across Canada. Assessments were performed at baseline, two-weeks post-intervention, and at three-months follow-up using online questionnaires. The primary outcome measure was change in perceived usability of Facebook as a dissemination strategy for the People Getting a Grip on Arthritis program with patients at two-weeks post-intervention using an instrument based on an extended version of the Technology Acceptance Model 2. Comparisons with baseline were assessed using t-test analyses.

Results

Statistically significant improvements from baseline were seen for all items of the Technology Acceptance Model 2 domains: perceived ease of use (four items), intention to use (two items) and output quality (two items) domains. Variable results were seen for the job relevance, perceived usefulness, voluntariness, and result demonstrability domains of the Technology Acceptance Model 2. There were no statistically significant improvements for the subjective norm and image domains.

Conclusions

Facebook may provide arthritis health professionals with an additional option of how to best share evidence-based information to allow their patients to successfully self-manage their arthritis.

Psychosocial management of chronic pain in patients with rheumatoid arthritis: challenges and solutions

There are numerous reviews and meta-analyses that confirm that psychological therapy is efficacious for patients with rheumatoid arthritis (RA) in terms of managing pain. Therefore, the literature has moved on to answer additional questions: 1) What types of interventions are most strongly supported by the current evidence? 2) Do different patients benefit from different approaches? 3) When is it best to intervene? 4) What modalities are best for administering the intervention? 5) What model of care should we be proposing that will result in widespread implementation and will ensure access for patients with RA? This review concludes that cognitive behavioral therapy (CBT) is the most efficacious treatment for pain management in RA; however, there are indications that mindfulness may have particular benefits for patients with a history of depression. CBT is most effective when administered early in the course of the disease. However, there is at present little evidence to confirm whether or not psychosocial interventions are effective for patients with comorbid psychological disorders. One of the major challenges is ensuring access to effective interventions for patients, particularly early on in the course of the disease, with a view to preventing physical and psychological morbidity. A stepped-care model is proposed; however, we urgently need more, better-quality trials of minimal interventions, particularly in Internet-delivered CBT, which appears promising and may form the cornerstone of future stepped-care models for providing psychosocial care to patients with RA.