ReviewSelf-management programs for chronic musculoskeletal pain conditions: A systematic review and meta-analysis
Introduction
Chronic musculoskeletal pain is now an important issue in the heath-care area. It can be the consequence of a pathological process in the musculoskeletal system and the most common problems include osteoarthritis (OA), rheumatoid arthritis (RA), and spine-related neck and low back conditions [1], [2], [3], [4], [5]. Chronic musculoskeletal pain is a world-wide health problem and has resulted in huge negative effects on people's well-being and cost to society. In industrialized countries, chronic musculoskeletal pain has been viewed as a major public health problem afflicting about 1/3 of the adults and reported as an international health priority [1], [2], [6]. As a developing country, China also possesses a huge number of patients with chronic musculoskeletal pain, both in urban and rural areas [7], [8], [9]. The major complaints of patients with chronic musculoskeletal pain are persistent pain and disability, with further consequences of reduced productivity and high costs for both families and society [5], [10], [11]. According to International Association for the Study of Pain (IASP), “at the chronic level, musculoskeletal pain is typically managed, but not cured” [3]. It is of vital importance to manage chronic musculoskeletal pain with effective, safe and low-cost approaches [1]. As one of these approaches, self-management model may play important role.
Self-management, as defined by Barlow et al. [12], refers to “the individual's ability to manage the symptoms, treatment, physical and psychological consequences and lifestyle changes inherent in living with a chronic condition” (p. 178). Social cognitive theory (SCT) and self-efficacy theory are two important theories that explain the principles of self-management [13], [14]. Unlike the traditional medical model, self-management emphasizes the importance of interactive, collaborative care between patient and health care professional rather than one-way, passive care from expert to patient [12]. In this model, personal responsibility is advocated for one's day-to-day management over the duration of illness [15]. Despite the fact that such interventions are overlapped with educational, psychological, or rehabilitation interventions [16], self-management model has its unique characteristics and lays emphasis on following essential process elements [15], [17], [18], [19], [20], [21]: (a) self-efficacy building; (b) self-monitoring; (c) goal-setting and action-planning; (d) decision-making; (e) problem-solving; (f) self-tailoring; and (g) partnership between the views of patients and health professionals. Besides, according to Lorig and Holman [15], self-management programs should be community-based and close to home so that a large number of patients have access to the interventions. These eight features make self-management programs distinguished from traditional patient education.
Enthusiasm is growing for the role of self-management program in managing chronic musculoskeletal pain conditions. A large number of trials have been performed; however, the conclusions are not consistent with each other. Several recent reviews have been published to clarify this issue, mainly on arthritis-related pain and disability [10], [18], [20], [22], [23], [24], [25]. To our knowledge, however, here are two issues which need exploring further. Firstly, published meta-analyses usually calculated summary estimates from primary studies at a particular time point (relevant time-point meta-analysis, RTM) or at final time point (final time-point meta-analysis, FTM). None of them have applied all time-points meta-analysis (ATM) of repeated measures to capture the trend of effectiveness of self-management programs over the time [26]. In fact, for non-pharmacological management of chronic musculoskeletal pain, it is more important to explore the effects at a long-term level than those at single, limited time point [1]. Secondly, none of the published reviews have considered what are primary outcomes and secondary outcomes in each individual trial. It is considered to be dangerous to compare primary and secondary outcomes in a review because different choice of the primary outcomes in each trial may reflect different contents of intervention [27].
Considering these questions, we sought to quantitatively assess the effects of self-management programs for chronic musculoskeletal pain conditions on a more basis using systematic review. We would focus on the two major complaints: pain and disability [5], [10], [11]. In this systematic review, if possible, ATM would be innovatively used for meta-analysis.
Section snippets
Selection strategy
The English databases Medline and Embase have been checked up to March 2010 from 1970s when self-management model originated [15], with the following Mesh terms and text words: (“chronic musculoskeletal pain” OR “arthritis” OR “osteoarthritis” OR “rheumatoid arthritis” OR “fibromyalgia” OR “back pain” OR “neck pain” OR “shoulder pain”) AND (“self-management” OR “self-care” OR “patient education”) AND (“randomized controlled trial” OR “random*”). Appendix A shows the exact searching strategy.
Search process
The results of search process are presented in Fig. 1. The literature search of databases resulted in 611 potentially relevant articles. Excluded on duplicate, title, and abstract were 517 articles, leaving 94 articles requested for full texts. With 3 studies that could not be found, 91 articles with full texts were available. These retrieved articles were subsequently evaluated further according to the inclusion criteria, with 74 of them excluded in this stage. Meanwhile, another 2 articles
Discussion
On the whole, this study shows that self-management programs probably have a beneficial effect on pain and disability for chronic musculoskeletal conditions. Specifically, for arthritis, results of meta-analyses indicate that self-management programs have a small to moderate effect in reducing pain within 1 year. By contrast, self-management programs have a long-term small effect in improving arthritis-related disability; however, the medium-term effect is not so significant. For chronic back
Conflict of interest
The authors have no conflict of interest.
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