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Web-based interventions with a focus on behavior change have been used for pain management, but studies of Web-based interventions integrated in clinical practice are lacking. To emphasize the development of cognitive skills and behavior, and to increase activity and self-care in rehabilitation, the Web Behavior Change Program for Activity (Web-BCPA) was developed and added to multimodal pain rehabilitation (MMR).
The objective of our study was to evaluate the effects of MMR in combination with the Web-BCPA compared with MMR among persons with persistent musculoskeletal pain in primary health care on pain intensity, self-efficacy, and copying, as part of a larger collection of data. Web-BCPA adherence and feasibility, as well as treatment satisfaction, were also investigated.
A total of 109 participants, mean age 43 (SD 11) years, with persistent pain in the back, neck, shoulder, and/or generalized pain were recruited to a randomized controlled trial with two intervention arms: (1) MMR+WEB (n=60) and (2) MMR (n=49). Participants in the MMR+WEB group self-guided through the eight modules of the Web-BCPA: pain, activity, behavior, stress and thoughts, sleep and negative thoughts, communication and self-esteem, solutions, and maintenance and progress. Data were collected with a questionnaire at baseline and at 4 and 12 months. Outcome measures were pain intensity (Visual Analog Scale), self-efficacy to control pain and to control other symptoms (Arthritis Self-Efficacy Scale), general self-efficacy (General Self-Efficacy Scale), and coping (two-item Coping Strategies Questionnaire; CSQ). Web-BCPA adherence was measured as minutes spent in the program. Satisfaction and Web-BCPA feasibility were assessed by a set of items.
Of 109 participants, 99 received the allocated intervention (MMR+WEB: n=55; MMR: n=44); 88 of 99 (82%) completed the baseline and follow-up questionnaires. Intention-to-treat analyses were performed with a sample size of 99. The MMR+WEB intervention was effective over time (time*group) compared to MMR for the two-item CSQ catastrophizing subscale (
Adding a self-guided Web-based intervention with a focus on behavioral change for activity to MMR can reduce catastrophizing and increase satisfaction with MMR. Patients in MMR may need more supportive coaching to increase adherence in the Web-BCPA to find it valuable.
Clinicaltrials.gov NCT01475591; https://clinicaltrials.gov/ct2/show/NCT01475591 (Archived by WebCite at http://www.webcitation.org/6kUnt7VQh)
Internet-based medicine or eHealth is under continuous development and considered necessary to provide cost-effective and equal health care [
Approximately 20% of the adult Swedish and European population suffers from persistent musculoskeletal pain with duration of at least 3 months or recurrent episodes of pain [
In the County Council of Norrbotten, Sweden, the development of eHealth care is a strategy to overcome the regional distance between health care providers and citizens. In order to propose an eHealth solution for a biopsychosocial treatment of persistent musculoskeletal pain, the Web-based Behavior Change Program for Activity (Web-BCPA) was developed. The Web-BCPA is a modified version of an existing Web-based program “To Manage Pain” provided by Livanda (a Swedish supplier of Internet-based medicine) [
At the time of this study, there were no interventions combining MMR with a self-guided Web-based intervention for pain management and behavior change. Most studies on Web-based interventions had participants recruited from waiting lists and/or advertising, which indicated that further research needed to focus on integrating Web-based interventions in clinical practice [
The study was a 12-month randomized controlled trial (RCT) with two intervention arms: (1) MMR and the Web-BCPA (MMR+WEB) and (2) MMR with follow-ups at 4 and 12 months. The consecutive recruitment and data collection started in October 2011 and ended in May 2015. The protocol was registered in the clinical trial registry of the US National Institutes of Health (NCT01475591), and approved by the Regional Ethical Review Board of Umeå University, Sweden (Umu dnr 2011-383-31M). This study is part of a larger collection of data and focuses on evaluating Web-BCPA adherence and feasibility, as well as outcomes of self-efficacy, pain intensity, and coping strategies.
Participants were patients eligible for MMR at health care centers in Norrbotten county, northern Sweden. The inclusion criteria were (1) age between 18 and 63 years; (2) persistent musculoskeletal pain with a duration of at least 3 months in back, neck, shoulder, and/or generalized pain; (3) Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ) score ≥90, screening for psychosocial factors that indicates an estimated risk for long-lasting pain conditions and future disability [
We invited 23 primary health care centers in Norrbotten that were certified for MMR to participate in the study. Management and health care staff were briefed and the rehabilitation coordinator (nurse, occupational therapist, or physiotherapist assigned to support a patient in rehabilitation planning) was trained to assist in the recruitment and data collection as well as introducing the participants to self-guide the Web-BCPA.
In all, 17 health care centers actively participated in the study. The rehabilitation coordinator at each health care center selected the participants according to inclusion and exclusion criteria. When patients were considered eligible for study participation, oral and written information about the study was provided and the patient was asked about participation. Once informed consent was obtained, the participants filled in the baseline questionnaire and were then randomly allocated to either the MMR+WEB group or the MMR group by numbered opaque envelopes. An independent statistician provided the allocation sequences by computer-generated random number sequences for each health care center and stratified by sex before inclusion of participants.
Participants in both intervention groups started MMR treatment according to their rehabilitation plan. Participants allocated to the MMR+WEB group were assisted by the rehabilitation coordinator to form their username and to self-select a password to log in to the Web-BCPA. They were instructed about the general setup of the Web-based intervention and informed that the rehabilitation coordinator was available for support. In addition, participants were informed that the time spent on the Web-BCPA was to be monitored and that participants who did not log in to the program would be contacted by the rehabilitation coordinator.
Participants in both study groups were followed up at 4 and 12 months. On both occasions, the participants met with the rehabilitation coordinator at the health care center and filled in a questionnaire. In addition, the participants were asked for consent to review their patient records for data on number of treatments and sick-leave days.
The MMR was characterized by synchronized treatments based on a biopsychosocial perspective of pain and with the patient in focus. The MMR included treatments from at least three health care professionals from different occupations (eg, nurse, occupational therapist, physician, physiotherapist, psychologist, or psychosocial counselor). The health care professionals worked according to the cognitive behavioral approach for behavior change toward activity and participatory goals. In addition, the participants and the health care professionals were supported by a rehabilitation coordinator in the planning of the rehabilitation and in communication with the Swedish Social Insurance Agency (SSIA). The patient and the health care professionals met at team conference meetings to draw up an individualized rehabilitation plan, which included identification of the patient’s resources and restrictions, formulation of goals, planning of treatments, as well as dates for follow-up. The plan was documented by a standard form in the patient record and printed out for the participants. The participants had the opportunity to invite significant others (a relative, an employer, an administrator from the SSIA or the Employment Service) to cooperate in the rehabilitation planning. Mutual decision making and a patient’s active participation in MMR treatments and planning were in focus [
The minimum number of treatments in MMR was specified as two to three times a week for six to eight weeks, including home exercises. The treatments were individual and/or in group sessions. In MMR physical activity (individualized exercise program, warm-water exercise, Basic Body Awareness Therapy), acupuncture, transcutaneous electric nerve stimulation, and manual therapy could be given by physiotherapists. Ergonomics, activity planning, and functional training were provided by occupational therapists. Psychologists and psychosocial counselors were responsible for counseling treatment. Counseling could also be provided by other health care professionals (nurse, occupational therapist, or physiotherapist) trained in cognitive behavioral therapy. The physicians prescribed pharmacological treatment, wrote medical certificates, and made referrals. Patient education, relaxation, mindfulness, and testing disability aids were carried out by health care professionals of various occupations. The MMR treatment period was adjusted according to the patient’s needs and progress. The health care centers were responsible for a patient’s medical rehabilitation to progress in health, but not principally in charge of the work rehabilitation.
The Web-BCPA was administrated via the Livanda website, and was exclusive for this study. Only study participants had access to the Web-BCPA, not other Livanda customers. The participants self-guided through the Web-BCPA, without therapist guidance, and had the freedom to choose from the program content. They had access to the Web-based intervention in their own environment 24/7 for 16 weeks. Without participants’ active work in the Web-BCPA for 20 minutes, they were automatically logged out. At the first log-in, the Web-BCPA contained an overall introduction to cognitive behavioral therapy principles, information of the content and format of the entire program, as well as general advice on how to work in the Web-BCPA (eg, start with reading the texts and then spend time on the assignments). The Web-BCPA consisted of eight modules: (1) pain, (2) activity, (3) behavior, (4) stress and thoughts, (5) sleep and negative thoughts, (6) communication and self-esteem, (7) solutions, and (8) maintenance and progress. They were delivered to the participant one module per week during the first eight weeks. The modules contained information, assignments, and exercises, assimilated via educational texts, videos, and writing tasks. Each module contained 10 to 15 shorter Web pages of information and 10 to 15 pages of assignments and exercises (
Web-BCPA adherence was assessed as minutes spent in each module, which was obtained from the administrative system of Livanda. Total time was calculated.
Web-BCPA feasibility was measured at 4 months using a set of items constructed for the purpose of this study. The eight items were:
1. It was easy to use the program
2. It was easy to log in to the program
3. Except for the first introduction, I have self-guided in the program
4. It was easy to comprehend the program
5. The graphical design was...
6. The texts have been of good use
7. The exercises have been of good use
8. The videos have been of good use
The ranking was made on a numeric scale from zero (disagree) to 100 (totally agree). The score for item 5 was zero (not at all appealing) to 100 (appealing).
Participants’ satisfaction with the Web-BPCA was measured at 4 months with three items: (1) I am satisfied with my own efforts in the Web-based intervention, (2) I am satisfied with the administrative support in the Web-based intervention from the rehabilitation coordinator, and (3) I could recommend the Web-based intervention to others in a similar situation as mine.
In addition, participants’ satisfaction with the MMR was assessed at 4 and 12 months using two items: (1) I am satisfied with my multimodal rehabilitation, and (2) I am satisfied with my own efforts in my multimodal rehabilitation. The ratings were on a numeric scale from zero (disagree) to 100 (totally agree).
Data on MMR treatment, health care consumption, and sick leave were collected from the participant’s patient records.
Pain intensity was measured by the 100-mm Visual Analog Scale (VAS) with zero indicating no pain or discomfort and 100 indicating unbearable pain or discomfort [
The certainty to have the capacity to perform a task in relation to pain was measured with two subscales of the Arthritis Self-Efficacy Scale (ASES). The “self-efficacy to control pain” subscale (ASES pain) consisted of five items and the “self-efficacy to control other symptoms” subscale (ASES other symptoms) had six items. The items were scored on a scale from 10 (very uncertain) to 100 (very certain), with a mean score for each subscale computed [
Content of the Web Behavior Change Program for Activity (Web-BCPA).
Module | Educational texts | Assignments and exercises |
1. Pain | Pain mechanism—anatomy and physiology | Life goals and values—health |
Persistent pain | Activity scheduling | |
Pain in the neck, back, and shoulder | ||
2. Activity | Pain mechanism—thoughts, interpretation, behavior | Well-being test |
Pain and physical activity | Life goals and values—work and leisure | |
Life balance | Daily exercise level test | |
Ergonomics in everyday life | Short exercise program | |
Resting positions | Relaxation—breathing exercises | |
Basic Body Awareness Therapy exercises | ||
3. Behavior | Pain and learning behavior | Well-being test |
Pacing | Life goals and values—close relationships, family, social relationships, and personal development | |
An active sick-leave | Planning activity | |
Planning behavior change | ||
Body scan-applied relaxation | ||
Basic Body Awareness Therapy exercises | ||
4. Stress and thoughts | Accepting thoughts | Well-being test |
Stress and stress management | Planning behavior change | |
Stress test | ||
Body scan—conditioned relaxation | ||
Basic Body Awareness Therapy exercises | ||
5. Sleep and negative thoughts | Negative and automatic thoughts | Well-being test |
Sleep, sleep hygiene, and sleep disorders | Challenging negative automatic thinking styles | |
Sleep test | ||
Body scan—conditioned relaxation | ||
Basic Body Awareness Therapy exercises | ||
6. Communication and self-esteem | Communication skills | Well-being test |
Conflict resolution methods | Effective communication training | |
Self-esteem and self-confidence | Setting limits | |
Participation in health care | Dealing with difficult emotions | |
Planning behavior change | ||
Basic Body Awareness Therapy exercises | ||
7.Solutions | Problem-solving methods in relationships | Well-being test |
Problem-solving traps | Problem-solving practices | |
Planning behavior change | ||
Basic Body Awareness Therapy exercises | ||
8. Maintenance and progress | Setbacks and relapses prevention | Well-being test |
Maintenance | Planning behavior change | |
Maintenance plan and strategies | ||
Basic Body Awareness Therapy exercises |
A more general aspect of self-efficacy was assessed by the General Self-Efficacy Scale (GSE), which measures an individual’s beliefs in one’s ability to respond to novel or difficult situations and to deal with associated obstacles or setbacks. The GSE contained 10 items, which were rated on a four-point Likert scale: 1 (not at all true/strongly disagree), 2 (hardly true/partly disagree), 3 (moderately true/partly agree), and 4 (exactly true/strongly agree). The ratings were summarized and divided by 10, resulting in a total score ranging from 1 to 4 [
Coping strategies were assessed using the two-item Coping Strategies Questionnaire (CSQ), a shorter version of the original CSQ. The two-item CSQ consists of seven subscales, each represented by two items [
Data in this study were part of a larger collection of data and the power calculation to detect a medium effect size difference of the MMR+WEB and MMR group was performed on the work ability index [
There were some missing values and cases in the data collection. Isolated missing values in specific questionnaires were imputed according to guidelines for ASES [
Internal consistency for ASES, GSE, and CSQ was tested within our dataset. Excellent internal consistency was found regarding ASES pain (alpha=.9), ASES other symptoms (alpha=.9), and GSE (alpha=.9). Internal consistency for the CSQ subscales were diverting attention (alpha=.6), reinterpreting pain sensations (alpha=.7), catastrophizing (alpha=.7), ignoring sensations (alpha=.6), praying or hoping (alpha=.5), coping self-statements (alpha=.6), and increased behavioral activities (alpha=.3).
Differences in baseline characteristics were tested with independent-samples
Effect size was assessed between the MMR+WEB group and the MMR group at the time points 4 and 12 months by calculating Cohen
Data analyses were performed using IBM SPSS version 23 (IBM Corporation).
The flow of participants through the study is presented in
A total of 109 participants were randomized to MMR+WEB (n=60) or MMR (n=49). However, five participants in each group did not receive MMR and were excluded from the study. At 4 months, 83 of 99 (84%) participants were followed up. Those lost to follow-up were 12 women and four men, aged between 27 and 58 (mean 42, SD 11) years. The follow-up rate at 12 months was 81% (80/99); 13 women and six men, aged between 31 and 63 (mean 44, SD 11) years, were lost to follow-up. Reasons for not being followed up were either participant’s voluntary discontinuation or organizational failure, such as the changing of rehabilitation coordinator or not being able to make contact with the participant. There were no significant differences of baseline characteristics between participants attending follow-up at 12 months and those lost to follow-up.
Participants’ characteristics at baseline are shown in
Overall, participants had pain duration for a mean 78.5 (SD 97.4) months with a mean pain intensity for last 7 days of 65.5 (SD 16.5). The MMR+WEB group showed a significantly higher ÖMPSQ score (mean 136, SD 20) than the MMR group (mean 125, SD 24,
Participant flow diagram. MMR: multimodal rehabilitation; MMR+WEB: multimodal rehabilitation and Web Behavior Change Program for Activity.
Participants’ characteristics at baseline (N=99) in the multimodal rehabilitation (MMR) and multimodal rehabilitation and Web Behavior Change Program for Activity (MMR+WEB) groups.
Participants’ characteristics | MMR+WEB (n=55) | MMR (n=44) | ||
Age (years), mean (SD) | 44 (10) | 42 (11) | .30 | |
Gender (female), n (%) | 47 (86) | 37 (84) | .85 | |
Married or cohabitating, n (%) | 45 (82) | 36 (82) | >.99 | |
Have children in the household, n (%) | 28 (51) | 23 (52) | .89 | |
.17 | ||||
Elementary (1-9 years) | 8 (14) | 10 (23) | ||
Secondary education (10-12 years) | 30 (55) | 25 (57) | ||
University (≥13 years) | 17 (31) | 9 (20) | ||
Permanent or self-employed | 40 (73) | 28 (64) | ||
Temporary employment | 5 (9) | 3 (7) | ||
Unemployed | 6 (11) | 9 (20) | ||
Student | 1 (2) | 1 (2) | ||
Parental leave | 0 (0) | 0 (0) | ||
Outside the labor market | 3 (5) | 3 (7) | ||
Working ≥25% of time at baseline | 31 (56) | 25 (57) | .96 | |
.47 | ||||
<1 hour per week | 15 (27) | 9 (21) | ||
1-3 hours per week | 14 (26) | 11 (26) | ||
>3 hours per week | 26 (47) | 23 (53) | ||
Body mass index in kg/m2, mean (SD) | 29 (7) | 28 (6) | .20 | |
Smoking, n (%) | 11 (20) | 9 (20) | .96 | |
Pain duration in months, mean (SD) | 79 (97) | 78 (99) | .96 | |
Pain intensity last 7 days (VAS),a mean (SD) | 66 (17) | 65 (16) | .67 | |
ÖMPSQ,b mean (SD) | 136 (20) | 125 (24) | .01 | |
EuroQol VAS,c mean (SD) | 45 (18) | 47d (18) | .54 | |
Previous MMR,e n (%) | 14 (26) | 10 (23) | .82 |
a VAS: Visual Analog Scale. Score between zero (no pain) and 100 (worst imaginable pain).
b ÖMPSQ: Örebro Musculoskeletal Pain Screening Questionnaire. Maximum score=210. A score ≥90 indicates a moderate estimated risk for persistent pain and future disability; ≥105 indicates a higher estimated risk.
c Score between zero (worst imaginable health state) and 100 (best imaginable health state).
d n=41.
e History of hospital in-patient multimodal pain rehabilitation.
Adherence to the Web Behavior Change Program for Activity.
Module | Time spent in module (min) | Users per module,a n (%) | |
Mean (SD) | Range | ||
1 | 79 (67) | 0-345 | 54 (98) |
2 | 52 (62) | 0-259 | 43 (78) |
3 | 50 (66) | 0-377 | 41 (74) |
4 | 44 (55) | 0-179 | 37 (67) |
5 | 29 (36) | 0-158 | 32 (58) |
6 | 22 (37) | 0-167 | 27 (49) |
7 | 14 (23) | 0-79 | 25 (46) |
8 | 14 (37) | 0-215 | 20 (36) |
Total time | 304 (267) | 0-1142 |
a The number of participants that opened the module at some point.
Feasibility and treatment satisfaction of the Web Behavior Change Program for Activity (Web-BCPA) for the multimodal rehabilitation and BCPA (BCPA+WEB) group (n=55).
Item | Mean (SD) | n |
It was easy to use the program | 82 (22) | 44 |
It was easy to log in to the programa | 90 (23) | 44 |
Except for the first introduction, I have self-guided the programa | 86 (29) | 44 |
It was easy to comprehend the programa | 90 (17) | 44 |
The graphical design was...b | 84 (21) | 44 |
The texts have been of good usea | 84 (24) | 44 |
The assignments have been of good usea | 73 (27) | 42 |
The videos have been of good usea | 68 (27) | 41 |
Satisfied with my own efforts in the Web-based programa | 62 (32) | 43 |
Satisfied with the administrative support in the Web-based programa,c | 93 (18) | 42 |
I could recommend the Web-based program to others in similar situations to minea | 88 (24) | 43 |
a Score ranging from zero (disagree) to 100 (totally agree).
b Score ranging from zero (not at all appealing) to 100 (appealing).
c Support given by the rehabilitation coordinator.
Satisfaction with multimodal rehabilitation at 4 and 12 months for the multimodal rehabilitation and Web Behavior Change Program for Activity (MMR+WEB) (n=55) and the MMR (n=44) groups.
Itema | MMR+WEB | MMR | |||
Mean (SD) | n | Mean (SD) | n | ||
Satisfied with my multimodal rehabilitation at 4 months | 85 (19) | 46 | 65 (25) | 35 | <.001 |
Satisfied with own efforts in my multimodal rehabilitation at 4 months | 73 (26) | 46 | 66 (26) | 35 | .20 |
Satisfied with my multimodal rehabilitation at 12 months | 82 (24) | 50 | 66 (28) | 39 | .003 |
Satisfied with own efforts in my multimodal rehabilitation at 12 months | 74 (25) | 50 | 67 (24) | 39 | .19 |
a Score ranging from zero (disagree) to 100 (totally agree).
The multimodal rehabilitation consisted of a mean 30 (SD 8) treatment sessions in the MMR+WEB group and mean 26 (SD 6) in the MMR group. In the MMR+WEB group, 96% (53/55) of the participants had physiotherapy treatment; in the MMR group, it was 95% (42/44). Occupational therapy was attended by 93% (51/55) of the participants in the MMR+WEB group compared to 86% (38/44) in the MMR group. Overall, 78% (43/55) of participants in the MMR+WEB group and 80% (35/44) in the MMR group were treated with psychosocial counseling. In the MMR+WEB group, 96% (53/55) of the participants had treatments by a physician compared to 98% (43/44) in the MMR group; 7% of participants in both the MMR+WEB group (4/55) and the MMR group (3/44) were treated by nurse. The number of team conference meetings were a mean 3 (SD 1) for the MMR+WEB group and mean 2 (SD 1) for the MMR group. In both study groups, 75% (74/99) of all treatments were given during the first 4 months of rehabilitation. At 4 months, 60% (33/55) of the participants in the MMR+WEB group and 70% (31/44) in the MMR group had completed the MMR. At 12 months, the percentage of participants that had completed their rehabilitation was 91% (50/55) in the MMR+WEB group and 95% (42/44) in the MMR group.
The mean time spent in the Web-BCPA for all eight modules was 304 minutes (SD 267) or approximately 5 hours. The mean number of modules opened was 5.1 (SD 2.9). A total of 20 of 55 (36%) persons opened all eight modules in the program. The number of users, as well as time spent, decreased with each module. In module 1, mean time spent was 79 (SD 67) minutes, whereas in module 8 the mean time was only 14 (SD 37) minutes. One participant did not open any module (
Participants rated easiness to comprehend and to log in to the Web-BCPA 90/100. Easiness to use the program and guiding themselves in the program, as well as the graphical design of the Web-BCPA and the applicability of the texts, were rated between 82/100 to 86/100. The lowest mean score was found on the applicability of the exercises and videos (
Participants assessed satisfaction with the administrative support in the Web-BCPA from the rehabilitation coordinator as 93/100 and that the Web-based intervention could be recommended to others in similar situation was rated 88/100. Satisfaction with own efforts in the Web-BCPA had the lowest rating (
Satisfaction with the MMR was rated significantly higher in the MMR+WEB group at 4 months (
Descriptive statistics of mean, minimum, and maximum pain in last 7 days are presented in
Effects of multimodal rehabilitation and Web Behavior Change Program for Activity (MMR+WEB) on pain intensity as measured with the Visual Analog Scale (VAS) at baseline, 4 months, and 12 months, and mean differences between intervention groups with effect sizes (Cohen
Outcome measures | MMR+WEB (n=55) | MMR (n=43) | Difference MMR+WEB–MMR | Effect size ( |
||||
Mean (SD) | Mean (SD) | Time*group | Time | Mean (95% CI) | ||||
.52 | <.001 | |||||||
Baseline | 66.1 (16.7) | 64.7 (16.2) | ||||||
4 months | 59.6 (21.0) | 54.8 (21.9) | 3.4 (–10.2 to 3.4) | .32 | –0.22 | |||
12 months | 57.9 (21.8) | 56.9 (22.0) | –0.4 (–7.2 to 7.9) | .92 | 0.02 | |||
.27 | .47 | |||||||
Baseline | 42.1 (24.3) | 32.8 (23.8) | ||||||
4 months | 41.5 (25.6) | 29.1 (23.7) | 3.1 (–10.5 to 4.3) | .40 | –0.13 | |||
12 months | 40.3 (26.6) | 34.3 (24.9) | –3.2 (–4.9 to 11.3) | .43 | 0.14 | |||
.55 | .002 | |||||||
Baseline | 82.5 (13.5) | 79.7 (18.1) | ||||||
4 months | 75.8 (19.2) | 73.8 (21.3) | –0.8 (–6.4 to 8.0) | .83 | 0.05 | |||
12 months | 75.5 (17.2) | 76.5 (18.8) | –3.9 (–3.9 to 11.6) | .32 | 0.24 |
a Pain intensity in last 7 days; zero=no pain or discomfort, 100=unbearable pain or discomfort.
Effects of ultimodal rehabilitation and Web Behavior Change Program for Activity (MMR+WEB) on self-efficacy as measured with the Arthritis Self-Efficacy Scale (ASES) and the General Self-Efficacy Scale (GSE) at baseline, 4 months, and 12 months, and mean differences between intervention groups with effect sizes (Cohen
Outcome measures | MMR+WEB (n=55) | MMR (n=44) | Difference MMR+WEB–MMR | Effect size ( |
||||
Mean (SD) | Mean (SD) | Time*group | Time | Mean (95% CI) | ||||
.04 | .28 | |||||||
Baseline | 45.8 (21.6) | 49.0 (20.4) | ||||||
4 months | 50.0 (23.4) | 49.3 (21.9) | 3.9 (–2.5 to 10.3) | .23 | 0.19 | |||
12 months | 53.2 (22.3) | 46.9 (22.2) | 9.5 (1.2 to 17.7) | .02 | 0.45 | |||
.89 | .01 | |||||||
Baseline | 52.6 (19.2) | 52.0 (16.7) | ||||||
4 months | 58.1 (21.5) | 56.1 (19.8) | 1.4 (–4.7 to 7.5) | .65 | 0.08 | |||
12 months | 57.5 (20.5) | 55.8 (21.8) | 1.2 (–6.7 to 9.0) | .78 | 0.06 | |||
.30 | .12 | |||||||
Baseline | 2.90 (0.60) | 2.97 (0.46) | ||||||
4 months | 2.88 (0.58) | 3.06 (0.53) | –0.10 (–0.22 to 0.02) | .11 | –0.10 | |||
12 months | 2.93 (0.62) | 3.08 (0.56) | –0.07 (–0.22 to 0.07) | .33 | –0.15 |
a MMR+WEB group (n=54) and MMR group (n=43).
Effects of multimodal rehabilitation and Web Behavior Change Program for Activity (MMR+WEB) on coping as measured with the two-item Coping Strategies Questionnaire (CSQ) at baseline, 4 months, and 12 months, and mean differences between intervention groups with effect sizes (Cohen
CSQ subscales | MMR+WEB (n=54) | MMR (n=44) | Difference MMR+WEB–MMR | Effect size ( |
||||
Mean (SD) | Mean (SD) | Time*group | Time | Mean (95% CI) | ||||
.61 | .14 | |||||||
Baseline | 2.9 (1.4) | 2.8 (1.5) | ||||||
4 months | 3.2 (1.4) | 2.9 (1.7) | 0.2 (–0.2 to 0.6) | .36 | 0.14 | |||
12 months | 3.1 (1.5) | 3.0 (1.7) | –0.0 (–0.6 to 0.5) | .92 | –0.00 | |||
.63 | .12 | |||||||
Baseline | 1.8 (1.4) | 1.7 (1.4) | ||||||
4 months | 2.1 (1.3) | 1.8 (1.4) | 0.2 (–0.3 to 0.6) | .46 | 0.14 | |||
12 months | 2.1 (1.4) | 2.0 (1.4) | –0.0 (–0.6 to 0.6) | .98 | –0.00 | |||
.003 | .002 | |||||||
Baseline | 3.2 (1.4) | 2.8 (1.2) | ||||||
4 months | 2.8 (1.4) | 2.8 (1.4) | –0.4 (–0.9 to 0.0) | .06 | 0.31 | |||
12 months | 2.4 (1.4) | 2.8 (1.4) | –0.8 (–0.3 to –1.3) | .001 | 0.61 | |||
.03 | .30 | |||||||
Baseline | 2.7 (1.2) | 2.8 (1.2) | ||||||
4 months | 2.9 (1.1) | 2.9 (1.3) | 0.1 (–0.3 to 0.5) | .06 | 0.08 | |||
12 months | 3.0 (1.3) | 2.5 (1.3) | 0.6 (0.1 to 1.0) | .02 | 0.50 | |||
.78 | .33 | |||||||
Baseline | 2.7 (1.6) | 2.6 (1.5) | ||||||
4 months | 2.8 (1.6) | 2.5 (1.7) | 0.2 (–0.3 to 0.6) | .52 | 0.13 | |||
12 months | 2.6 (1.6) | 2.4 (1.5) | 0.1 (–0.4 to 0.6) | .77 | 0.06 | |||
.48 | .42 | |||||||
Baseline | 3.1 (1.1) | 3.1 (1.3) | ||||||
4 months | 3.0 (1.2) | 2.9 (1.3) | 0.0 (–0.4 to 0.4) | .93 | 0.25 | |||
12 months | 3.2 (1.3) | 2.9 (1.4) | 0.2 (–0.2 to 0.7) | .32 | 0.13 | |||
.10 | .15 | |||||||
Baseline | 3.3 (1.1) | 3.3 (1.2) | ||||||
4 months | 3.4 (1.0) | 3.1 (1.3) | 0.4 (0.00 to 0.8) | .047 | 0.26 | |||
12 months | 3.5 (1.0) | 3.4 (1.4) | 0.2 (–0.2 to 0.1) | .39 | 0.09 |
a MMR group (n=43).
b MMR+WEB group (n=53).
An overall significant improvement over time (time) was found in the whole study group for mean (
There were no improvements over time (time) for the whole study group regarding ASES pain (
Descriptive statistics for the seven subscales of the two-item CSQ is presented in
Treatment effects over time (time) for the whole study group was found regarding catastrophizing (
This RCT studied the effects of the self-guided Web-BCPA in combination with MMR for participants with persistent musculoskeletal pain in primary health care. Overall, we found decreased catastrophizing in the MMR+WEB group compared to the MMR group. Previously, both self-guided [
Decreased pain intensity has previously been demonstrated from self-guided Web-based interventions for pain management compared with standard care by physician [
We found that participants in the MMR+WEB group were more satisfied with their MMR both at 4 and 12 months (mean 82/100, SD 24,
The strengths in our study are the RCT design and that the Web-BCPA was implemented in a MMR context in primary health care, which to our knowledge is the first reported in the field. However, the number of participants in the analysis reached 77% of the calculated number needed, thus the study is underpowered to detect small improvements in outcome variables and increases the risk of type II errors. Because the dropout rate at 12 months was modest (18%) and we used ITT analysis, our findings may be less prone to bias. But all missing data mean uncertainty and reduced reliability and interpretability of the results. In this study, we had an ITT approach and used the LOCF method for imputation of data. LOCF has limitations, but handles data in a conservative way by assuming no treatment effects over time, which reduces the risk of overestimating of results. Because LOCF underestimates variance, it is possible that methods such as multiple imputation would generate more appropriate results. For exploratory reasons, we also performed per protocol analyses, which generated similar results as the LOCF analyses. We also decided to be more conservative with a significance level of
The Web-BCPA was redesigned with alterations made to fit participants with persistent pain in an early stage, with less developed chronicity [
The two-item CSQ was used to assess the participant’s coping strategies and, to our knowledge, this is the first time it was tested on a Swedish population. The internal consistency of the catastrophizing and reinterpreting pain sensations subscales was acceptable (alpha=.7), but the other five subscales did not have a satisfying Cronbach alpha. Considering this, our results must be regarded with caution. The two-item CSQ needs to be further tested for reliability and validity.
In this study, the self-guided Web-BCPA was added to MMR. There were no treatment effects regarding self-efficacy, perceived pain intensity, or most coping strategies in this study group of persons with long-lasting pain conditions. However, participants treated with MMR in combination with the Web-BCPA reduced their catastrophic thinking compared to participants in MMR. In addition, they were more satisfied with their MMR. The Web-BCPA adherence was low and may have been influenced by participants’ baseline characteristics and their symptom panorama. It may be important to consider the individual’s motivation and ability when suggesting a Web-based intervention. Adding counseling to the Web-BCPA might increase adherence and the use of the Web-based intervention.
Screenshot of the web-BCPA.
Video file of the web-BCPA.
Arthritis Self-Efficacy Scale
body mass index
Coping Strategies Questionnaire
General Self-Efficacy Scale
intention-to-treat
last observation carried forward
multimodal rehabilitation
multimodal rehabilitation and Web-BCPA
Örebro Musculoskeletal Pain Screening Questionnaire
randomized controlled trial
Visual Analog Scale
Web Behavior Change Program for Activity
This paper is included in a research project entitled Effects of a Web Behavior Change Program for Activity (Web-BCPA) for Persistent Pain in Primary Health Care and is included in the REHSAM (REHabilitering och SAMordning) national research project in Sweden. The study was performed in cooperation between Luleå University of Technology and the County Council of Norrbotten, and was financed by the REHSAM research project, a cooperation between the Swedish Social Insurance Agency, the Ministry of Health and Social Affairs, the Swedish Association of Local Authorities and Regions, and the Vårdal Foundation.
None declared.