Effective delivery styles and content for self-management interventions for chronic musculoskeletal pain: a systematic literature review.

OBJECTIVES: The objective of the study was to report the evidence for effectiveness of different self-management course characteristics and components for chronic musculoskeletal pain. METHODS: We searched 9 relevant electronic databases for randomized, controlled trials (RCTs). Two reviewers selected studies against inclusion criteria and assessed their quality. We classified RCTs according to type of course delivery (group, individual, mixed or remote), tutor (healthcare professional, lay or mixed), setting (medical, community or occupational), duration (more or less than 8 weeks), and the number and type of components (psychological, lifestyle, pain education, mind body therapies, and physical activity). We extracted data on pain intensity, physical function, self-efficacy, global health, and depression and compared these outcomes for self-management and usual care or waiting list control. We used random effects standardized mean difference meta-analysis. We looked for patterns of clinically important and statistically significant beneficial effects for courses with different delivery characteristics and the presence or absence of components across outcomes over 3 follow-up intervals. RESULTS: We included 46 RCTs (N=8539). Group-delivered courses that had healthcare professional input showed more beneficial effects. Longer courses did not necessarily give better outcomes. There was mixed evidence of effectiveness for components of courses, but data for courses with a psychological component showed slightly more consistent beneficial effects over each follow-up period. DISCUSSION: Serious consideration should be given to the development of short (<8 weeks) group and healthcare professional-delivered interventions but more research is required to establish the most effective and cost-effective course components.

Measuring pain self-efficacy.

BACKGROUND: It is likely that people with chronic pain who have low self-efficacy have a worse prognosis. A standard, high-quality measure of self-efficacy in such populations would improve evidence, by allowing meaningful comparisons amongst subgroups and between treatments, and by facilitating pooling across studies in systematic reviews. OBJECTIVES: To identify self-administered pain-related self-efficacy measures used in people with chronic pain and to evaluate the clinimetric evidence of the most commonly used scales systematically. METHODS: We searched 2 databases to identify self-efficacy questionnaires. We evaluated questionnaires identified against previously developed criteria for clinimetric assessment. RESULTS: We identified 13 relevant measurements assessing self-efficacy, and clinimetrically assessed 5 of these. These questionnaires were the Arthritis Self-Efficacy Scale, the Chronic Disease Self-Efficacy Scale, the Pain Self-Efficacy Questionnaire, the Chronic Pain Self-Efficacy Scale, and the Self-Efficacy Scale. None of the questionnaires showed satisfactory results for all properties. All scales were easily scored and dimensionality was assessed in 2 of 6 of the scales. Internal consistency was acceptable for all questionnaires. There was positive evidence for construct validity in 4 of 6 of the questionnaires. None of the studies used the most up-to-date method of test-retest reliability or responsiveness. Information on interpretability of the scores was minimal in all questionnaires. DISCUSSION: Further research should focus on assessing responsiveness and interpretability of these questionnaires. Researchers should select questionnaires that are most appropriate for their study aims and population and contribute to further validation of these scales. Future research should measure outcome expectancy alongside self-efficacy to best predict future behavior.

Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs.

BACKGROUND: There are now several systematic reviews of RCTs testing self-management for those with chronic musculoskeletal pain. Evidence for the effectiveness of self-management interventions in chronic musculoskeletal pain is equivocal and it is not clear for which sub-groups of patients SM is optimally effective. AIMS: To systematically review randomized controlled trials of self-management for chronic musculoskeletal pain that reported predictors, i.e., 'baseline factors that predict outcome independent of any treatment effect'; moderators, i.e., 'baseline factors which predict benefit from a particular treatment'; or mediators i.e., 'factors measured during treatment that impact on outcome' of outcome. METHOD: We searched relevant electronic databases. We assessed the evidence according to the methodological strengths of the studies. We did meta-regression analyses for age and gender, as potential moderators. RESULTS: Although the methodological quality of primary trials was good, there were few relevant studies; most were compromised by lack of power for moderator and mediator analyses. We found strong evidence that self-efficacy and depression at baseline predict outcome and strong evidence that pain catastrophizing and physical activity can mediate outcome from self-management. There was insufficient data on moderators of treatment. CONCLUSIONS: The current evidence suggests four factors that relate to outcome as predictors/mediators, but there is no evidence for effect moderators. Future studies of mediation and moderation should be designed with 'a priori' hypotheses and adequate statistical power.