Chronic Pain Self-Management Program Research Articles

Engagement in Integrative and Nonpharmacologic Pain Management Modalities Among Adults with Chronic Pain: Analysis of the 2019 National Health Interview Survey.

To examine variables associated with engagement in (1) integrative health and medicine (IHM) and (2) nonpharmacologic modalities rather than opioids among United States adults with chronic pain. Using the 2019 National Health Interview Survey, we examined sociodemographic, pain, and mental health predictors of (1) the sum of IHM modalities (ie, chiropractic care, yoga/Tai Chi, massage, or meditation/guided imagery) used to manage pain and (2) exclusive engagement in nonpharmacologic pain management modalities (ie, IHM, a chronic pain self-management program, support groups, or physical, rehabilitative, occupational, or talk therapy) or opioids in the past 3 months. Metropolitan residency, higher family income, higher education levels, increased number of pain locations, and increased frequency of pain limiting life/work activities were associated with increased odds of IHM engagement. Older age, male sex, non-Hispanic Black/African American race/ethnicity, and daily opioid use were associated with decreased odds of IHM engagement. Older age, male sex, and increased depressive symptoms were associated with decreases in the count of IHM modalities used to manage pain. Metropolitan residency, higher family income, and higher education levels were associated with increased odds of exclusive nonpharmacologic modality engagement. Older age and increasing frequency of pain limiting life/work activities were associated with decreased odds of exclusive nonpharmacologic modality engagement. We identified several contrasts between factors prevalent among individuals with chronic pain and factors associated with engagement in nonpharmacologic and IHM modalities. These results support efforts to address barriers to accessing these modalities among subpopulations of adults with chronic pain (eg, older adults, individuals identifying as Black/African American, rural residents, and those with lower levels of education and income).

Remote delivery of self-management education workshops for adults with chronic pain, 2020-2021.

We intended to assess changes in pain-related outcomes among rural adults who completed 6-week self-management programs offered remotely during the COVID-19 pandemic. We offered the Chronic Pain Self-Management Program and Chronic Disease Self-Management Program between May 2020 and December 2021. Delivery mode options included 2½-hour weekly videoconference, mailed toolkit plus 1-hour weekly conference call, and mailed toolkit alone. We conducted pre- and post-workshop surveys including questions on patient activation, self-efficacy, depression and pain disability. We used paired t-tests to compare pre-post differences in outcomes among participants completing 4 or more sessions. Among 218 adults reporting chronic pain, mean age was 57; 83.6% were female; and 49.5% participated via videoconference, 23.4% by phone and 27.1% via mailed toolkit alone. Completion rates were higher among phone (88.2%) versus videoconference (60.2%) workshop participants. Among completers, patient activation (mean change = 3.61, p = 0.01) and self-efficacy (mean change = 3.72, p < 0.0001) increased while depression scores (mean change = -1.03, p = 0.01), pain disability (mean change = -0.93, p = 0.003) and pain symptoms (mean change = -0.61, p = 0.001) decreased over the 6-week period. Self-management programs offered remotely during the pandemic were successful in improving patient activation, self-efficacy, depression, pain disability, and pain symptoms among rural adults experiencing chronic pain.

Neurocognitive predictors of adherence to an online pain self-management program adjunct to long-term opioid therapy

ABSTRACT Introduction While pain self-management programs can significantly improve patient outcomes, poor adherence is common and the need for research on predictors of adherence has been noted. A potential, but commonly overlooked, predictor is cognitive function. Our aim, then, was to examine the relative influence of various cognitive functional domains on engagement with an online pain self-management program. Method A secondary analysis of a randomized controlled trial testing the impact of E-health (a 4-month subscription to the online Goalistics Chronic Pain Management Program) plus treatment as usual, relative to treatment as usual alone, on pain and opioid dose outcomes in adults receiving long-term opioid therapy of morphine equivalence dose ≥20 mg; 165 E-health participants who completed an on-line neurocognitive battery were included in this sub-analysis. A variety of demographic, clinical, and symptom rating scales were also examined. We hypothesized that better processing speed and executive functions at baseline would predict engagement with the 4-month E-health subscription. Results Ten functional cognitive domains were identified using exploratory factor analysis and the resultant factor scores applied for hypothesis testing. The strongest predictors of E-health engagement were selective attention, and response inhibition and speed domains. An explainable machine learning algorithm improved classification accuracy, sensitivity, and specificity. Conclusions The results suggest that cognition, especially selective attention, inhibitory control, and processing speed, is predictive of online chronic pain self-management program engagement. Future research to replicate and extend these findings seems warranted. ClinicalTrials.gov Registration Number NCT03309188

Evaluation of a Peer Led Chronic Pain Self-Management Program in a Rural Population.

Background:The Chronic Pain Self-Management Program is an evidence-based intervention that has been shown to be efficacious in reducing symptoms of chronic pain. However, there is a paucity of research examining CPSMP in a predominantly rural population. The purpose was to evaluate patient-reported outcomes of in-person peer-led CPSMP workshops offered in a rural region in 2018 and 2019.Methods:Participants were surveyed at baseline and 6 months post-workshop. Descriptive statistics were used to describe characteristics of CPSMP completers. Paired t-tests were used to analyze change in depression score (PHQ-8), disability (modified Roland-Morris Disability Questionnaire), self-efficacy, and patient activation (PAM-10). Analysis of variance was used to detect differences over time by age group, education, insurance type, self-rated health, and comorbidities.Results:Among the 327 adults who enrolled in a workshop, 73.1% completed. Of completers, 74.9% were female, average age was 65. Significant improvements were observed in pain disability (P = .0008), patient activation (P = .0362), depression (P < .0001), and self-efficacy (P < .0001), at 6 weeks; and pain disability (P = .0030), depression (P = .0015), and self-efficacy (P = .0064) at 6 months post-program. Individuals who rated their health as fair/poor at baseline reported greater improvements in depression scores than individuals who rated their health as good or better (P < .0002). There were also distinct patterns of change in pain disability among the different age groups. No other differences between groups were noted.Conclusions:The CPSMP appears to improve pain self-efficacy, disability, and depression regardless of age, gender, insurance status, education, or comorbidities. Healthcare and community organizations should consider investing in and offering chronic pain workshops in rural areas in order to promote health and wellness.

Remote Delivery of the Chronic Pain Self-management Program Using Self-directed Materials and Small-group Telephone Support: A Pilot Study.

A remote (telephone and tool kit) chronic pain program was studied using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. This 6-week pilot took place in underserved communities in Cleveland, Ohio. We determined reach by the diversity of the population, nearly 50% Black and mostly low income. Effectiveness over 7weeks was shown with validated instruments (depression, pain, sleep, quality of life, self-rated health, and self-efficacy). Changes in pain, depression, and self-efficacy were significant. (p < .01). Remote implementation was accomplished by sending participants a box of materials (book, exercise and relaxation CDs, a self-test, and tip sheets). Participants also participated in peer-facilitated, weekly, scripted telephone calls. Maintenance was demonstrated as the study site has offered nine additional programs with more plan. In addition, 60 additional organizations are now offering the program. This proof-of-concept study offers an alternate to in-person chronic pain self-management program delivery.

Impacts on patient-centered outcomes of a chronic pain self-management program in a rural community: A feasibility study

This study explored if a self-management training program was feasible for a predominantly older rural Latino adults with chronic pain who had limited access to non-pharmacologically based pain treatment. Physical therapy doctoral students delivered the six-week low-literacy low-cost patient-centered program. The intervention was feasible to the participants (n=38) who showed improvement in a majority of the eight outcome measures at 6-week posttest and three measures at 18-week followup. The changes in pain severity, pain interference and pain-related physical functions reached minimally clinically important difference at follow-up. A randomized controlled trial with long-term follow-up is needed to test the program effectiveness in partnership with community health centers to increase access to pain management in rural communities.

A Pilot Study of a Chronic Pain Self-Management Program Delivered by Community Health Workers to Underserved African American Older Adults.

African American older adults living in disadvantaged communities are disproportionately burdened by disabling pain. To address their needs, we tested the feasibility and potential effects of a cognitive-behavioral chronic pain self-management program delivered by community health workers. A single-group, pre-post evaluation of the STEPS-2 (Seniors using Technology to Engage in Pain Self-management) intervention, in which participants learned pain-management skills through web-based videos. They were also given wearable activity trackers to facilitate incremental increases in walking. In weekly telephone calls, community health workers helped participants apply skills and set goals. Thirty-one adults in Detroit, Michigan (97% African American, 97% female, mean 68.7 years), with chronic musculoskeletal pain. Participants completed telephone surveys at baseline and eight weeks. We measured changes in PROMIS pain interference and pain intensity, as well as Patient Global Impression of Change in pain and functioning. Feasibility indicators included participant engagement and satisfaction, and fidelity to session protocols by community health workers. Participants on average completed 6.6/7 sessions, and 100% agreed or strongly agreed that they improved their understanding of pain management. Average community health worker fidelity score was 1.79 (0 to 2 scale). Pain interference decreased from baseline to post-program (T-score 61.6 to 57.3, P=.000), as did pain intensity (0 to 10 scale, 6.3 to 5.1, P=.004). Approximately 90% of participants reported that pain and function were at least "a little better" since baseline. An intervention combining mobile health tools with support from community health workers holds promise for improving pain outcomes among underserved older adults.

Women RISE: Empowering Women to Manage Chronic Pain and Informing Provider Opioid Prescribing Practices.

The Women RISE program, educating women and health care providers along with technology support, may reduce opioid use. Opioid use presented health concerns for women in Virginia's Central Shenandoah Valley. We evaluated the impact of Women RISE on self-management of chronic pain and opioid use, provider prescribing practices, and opioid reduction within our community. We implemented the Chronic Pain Self-Management Program (CPSMP), educated women and providers, and streamlined access to the Prescription Management Program. Opioid best practice alerts informed providers about their prescribing practices. The CPSMP was beneficial in improving women's coping skills, knowledge about opioid use, and overall quality of life. Opioid prescriptions were reduced 34%. We also reduced unneeded opioid analgesics within our community. Women were better able to manage chronic pain and stressors impacting opioid misuse. Opioid prescribing practices improved, limiting opioid availability in our community.

Physiotherapists' Experiences with and Perspectives on Implementing an Evidence-Based, Chronic Pain Self-Management Programme in Primary Health Care: A Qualitative Study.

Purpose: Evidence suggests that a physiotherapist-led chronic pain self-management programme in primary health care (PHC) improves function for people living with chronic pain; however, implementing a new approach to care can be difficult. In this study, we sought to understand the experiences of physiotherapists who had implemented the ChrOnic pain self-ManageMent support with pain science EducatioN and exerCisE (COMMENCE) programme; its perceived barriers, facilitators, benefits, and drawbacks; and how the physiotherapists tailored the programme to their own clinical contexts. Method: This interpretive description qualitative study used semi-structured interviews with physiotherapists who had implemented the COMMENCE programme in PHC. Results: Themes from 11 interviews included experiences of personal and professional growth, increasing confidence with experience, and changing the culture of pain management. Barriers and drawbacks to implementation included resource intensiveness, balancing programme demands with other clinical work, and challenges with patient attendance and participation. Facilitators included training, programme design and materials, supportive teams, and previous knowledge. Benefits included offering group and individualized support, evidence-based content, and sparking interest in learning more about pain management. The participants made small changes to tailor the programme content and delivery to their context. Conclusions: This study provides a rich understanding of the experiences, barriers, facilitators, benefits, drawbacks, and tailoring related to the COMMENCE programme in PHC. The results will facilitate future implementation of this intervention in PHC settings.

Application of ICD-11 among individuals with chronic pain: A post hoc analysis of the Stanford Self-Management Program.

Chronic primary pain (CPP) is one of seven diagnostic groups within the proposed classification of chronic pain in ICD-11. Our aims were to apply the proposed ICD-11 criteria in a large cohort of chronic pain patients participating in the Chronic Pain Self-Management Program (CPSMP) and further investigate whether participants with CPP differed from participants with chronic secondary pain (CSP) regarding health, health expenditure and the effect of participating in the CPSMP. A secondary analysis of a randomized, controlled trial on the effect of the CPSMP. Four examiners categorized participants' pain according to ICD-11 using register-based medical diagnoses and patients' self-reported symptoms. Afterwards, differences between CPP and CSP were examined. Outof 394 participants, 312 were successfully classified into CPP (n=164) or CSP (n=148) whereas 76 had a mixed pain condition. Participants with CPP were younger, more likely to be women, and had longer pain duration compared to participants with CSP. Participants with CPP reported worse health-related quality of life on the SF-36 Mental Component Summary and subscales of vitality, social functioning and bodily pain. Participants with CSP had more physical comorbidities and higher total health expenditure. None of the groups benefitted from the CPSMP. We successfully applied the new classification of chronic pain in ICD-11 on the basis of ICD-10 medical diagnoses and symptom self-report. Participants with CPP differed significantly from participants with CSP on baseline characteristics, self-reported health measures and total health expenditure. The CPSMP was not effective in any of the groups. The current study applies the proposed new classification of chronic pain in ICD-11 and shares the experiences of the diagnostic rating procedure of individuals with chronic pain. Furthermore, it evaluates the effect of the Stanford Self-Management Program.

Using Illness Perceptions to Cluster Chronic Pain Patients: Results From a Trial on the Chronic Pain Self-Management Program.

The aims of our study were (1) to identify possible subgroups of individuals with chronic pain based on their illness perceptions (IPs); (2) to examine whether these subgroups differed in health status and health expenditure; and (3) to examine whether the subgroups differed in their response to participation in a lay-led Chronic Pain Self-Management Program (CPSMP). Four hundred twenty-four participants in a randomized controlled trial on the CPSMP completed a questionnaire on their perceptions of their chronic pain condition at baseline. In addition, they completed a range of health status measures at baseline and 3 months after end of participation in the CPSMP. Health care expenditure was obtained from Danish health registers. We performed cluster analyses to identify possible subgroups based on the participants' perceptions of their chronic pain condition. Cluster analysis of IPs resulted in 3 meaningful clusters, classified as "distressed, certain cause," "distressed, uncertain cause," and "nondistressed, certain cause," respectively. The 2 distressed groups had significantly higher scores on pain catastrophizing, illness worry, and emotional distress than did the nondistressed. Moderator analyses showed, that the "distressed, certain cause" had significant positive effect of participating in the CPSMP on pain catastrophizing and emotional distress, whereas the "distressed, uncertain cause" had a decrease and the "nondistressed, certain cause" an increase in primary health expenditure. Clusters based on IPs meaningfully distinguished individuals with chronic pain on health measures and outcome of participating in the CPSMP, and may prove useful in future studies to understand responses to treatment.

Randomized Trial of a Low-Literacy Chronic Pain Self-Management Program: Analysis of Secondary Pain and Psychological Outcome Measures

Based on input of rural, largely Hispanic persons with chronic pain, a low-literacy, 6-month self-management program was developed, drawing on elements of existing pain toolkits. In a randomized trial, low-income, primarily Hispanic patients with chronic pain received the program in 6 sessions of 1-on-1 meetings with a trained health educator in clinic or in 8 group lectures by experts in the community. Intention-to-treat analyses in linear mixed-effects models were conducted for 5 secondary outcomes at 6 months, including Brief Pain Inventory pain severity and interference, Patient Health Questionnaire-9, 12-Item Short-Form Survey Mental Component Summary, and Tampa Scale for Kinesiophobia-11. A total of 111 participants were randomized (15.9% of 700 initially eligible from 3 clinics), and 67 (60.4%) completed 6-month measures. Among completers, the clinic arm improved on 4 measures and community arm on 3 measures (all P < .05). Effect sizes were small to moderate (.41–.52). In intention-to-treat analyses, both arms improved on 4 of 5 measures (all P ≤ .001) versus baseline, with clinically significant changes in Brief Pain Inventory pain severity and interference. Improvement in multiple outcomes after this chronic pain self-management program for low-income patients warrants further study. PerspectiveIn an evaluation of a low-literacy, 6-month chronic pain self-management program, similar improvements were observed among primarily Hispanic participants whether the intervention was delivered by a health educator or in groups with lectures from experts.

Capsule Commentary on Turner et al., Randomized Trial of Chronic Pain Self-management Program in Community or Clinic for Low-Income Primary Care Patients.

Capsule Commentary on Turner et al., Randomized Trial of Chronic Pain Self-management Program in Community or Clinic for Low-Income Primary Care Patients.

Randomized Trial of Chronic Pain Self-Management Program in the Community or Clinic for Low-Income Primary Care Patients

BackgroundPatients with chronic pain often lack the skills and resources necessary to manage this disease.ObjectiveTo develop a chronic pain self-management program reflecting community stakeholders’ priorities and to compare functional outcomes from training in two settings.DesignA parallel-group randomized trial.ParticipantsEligible subjects were 35–70 years of age, with chronic non-cancer pain treated with opioids for >2 months at two primary care and one HIV clinic serving low-income Hispanics.InterventionsIn one study arm, the 6-month program was delivered in monthly one-on-one clinic meetings by a community health worker (CHW) trained as a chronic pain health educator, and in the second arm, content experts gave eight group lectures in a nearby library.Main MeasuresFive times Sit-to-Stand test (5XSTS) assessed at baseline and 3 and 6 months. Other reported physical and cognitive measures include the 6-Min Walk (6 MW), Borg Perceived Effort Test (Borg Effort), 50-ft Speed Walk (50FtSW), SF-12 Physical Component Summary (SF-12 PCS), Patient-Specific Functional Scale (PSFS), and Symbol–Digit Modalities Test (SDMT). Intention-to-treat (ITT) analyses in mixed-effects models adjust for demographics, body mass index, maximum pain, study arm, and measurement time. Multiple imputation was used for sensitivity analyses.Key ResultsAmong 111 subjects, 53 were in the clinic arm and 58 in the community arm. In ITT analyses at 6 months, subjects in both arms performed the 5XSTS test faster (−4.9 s, P = 0.001) and improved scores on Borg Effort (−1, P = 0.02), PSFS (1.6, P < 0.001), and SDMT (5.9, P < 0.001). Only the clinic arm increased the 6 MW (172.4 ft, P = 0.02) and SF-12 PCS (6.2 points, P < 0.001). 50ftSW did not change (P = 0.15). Results were similar with multiple imputation. Five falls were possible adverse events.ConclusionsIn low-income subjects with chronic pain, physical and cognitive function improved significantly after self-management training from expert lectures in the community and in-clinic meetings with a trained health educator.

Evaluation of uptake and effect on patient-reported outcomes of a clinician and patient co-led chronic musculoskeletal pain self-management programme provided by the UK National Health Service.

In the United Kingdom, chronic pain affects approximately 28 million adults, creating significant healthcare and socio-economic costs. The aim was to establish whether a programme designed to use best evidence of content and delivery will be used by patients with significant musculoskeletal pain problems. Of 528 patients recruited, 376 participated in a 7-week-long group-based self-management programme (SMP) co-delivered by clinical and lay tutors. Of these, 308 patients (mean age, 53 years; 69% females, 94% White) completed at least five SMP sessions. Six months after pre-course assessment, participants reported significantly improved patient activation and health status, lower depression and anxiety scores, decreased pain severity and interference, and improved self-management skills. There were no improvements in health state and pain self-efficacy. Uptake rate was 71% and completion 82%. The results should be of value to commissioners of pathways of care for the large numbers of patients attending the English NHS for chronic musculoskeletal pain.

The effect of a lay-led, group-based self-management program for patients with chronic pain: a randomized controlled trial of the Danish version of the Chronic Pain Self-Management Programme.

The Stanford Chronic Pain Self-Management Programme (CPSMP) consists of 6 2½-hour weekly workshops focusing on how to manage pain in daily life. The workshops are facilitated by 2 workshop leaders of whom at least 1 must suffer from a long-term pain condition. The program is highly structured and manualized. Only few controlled trials testing the effect of CPSMP exist. Enrolled in the study were 424 adults from 19 Danish municipalities, (72% women; age: 25-93 years) with pain of any etiology and great variation in pain history (0-50 yrs). Of these, 216 were randomized to a lay-led version of the CPSMP. The primary outcome was pain-related disability. Secondary outcomes were pain, pain catastrophizing, self-efficacy, emotional distress, physical symptoms, and illness worry. Outcomes were measured before randomization, immediately after the CPSMP (response rate: 94%), and at 3-month follow-up (response rate: 92%). National register data on health expenditure were obtained to examine effects on health care use. ClinicalTrials.gov Identifier: NCT01306747. The CPSMP had no effect on the primary outcome pain-related disability or on health expenditure during intervention and follow-up period. Small positive effects on emotional distress and illness worry 3 months after CPSMP were observed. Lay-led CPSMP is not recommended as treatment for chronic pain-related disability. This heterogeneous group of patients with pain did not benefit from the CPSMP except for a small, but clinically insignificant improvement in psychological well-being.

(376) Impact of the Harborview Chronic Pain Self-Management Program on participants’ quality of life, confidence and pain experience

(376) Impact of the Harborview Chronic Pain Self-Management Program on participants’ quality of life, confidence and pain experience

Adolescent and Parent Treatment Goals in an Internet-Delivered Chronic Pain Self-Management Program: Does Agreement of Treatment Goals Matter?

To assess whether adolescent-parent agreement on treatment goals as part of an Internet-delivered cognitive-behavioral pain intervention was associated with adolescent outcomes. 122 adolescent-parent dyads selected two treatment goals. Pain intensity and pain-related disability were assessed at pre-treatment, post-treatment, and 6- and 12-month follow-ups. We compared dyads who had goal agreement versus no agreement. 74 dyads (61%) agreed on one or more treatment goals, most commonly going to school, sports, and sleep. In dyads who chose the same goal, regardless of the content, adolescents had lower pain intensity post-treatment and at follow-up. When goals were categorized by domain, in dyads who agreed on physically active goals, adolescents were more likely to report lower pain intensity compared with other groups. Agreement of goals was not associated with changes in pain-related disability. Agreement on treatment goals may be an important treatment process to maximize outcomes in self-management therapies.

Supporting Teens with Chronic Pain to Obtain High School Credits: Chronic Pain 35 in Alberta.

Chronic pain is a significant problem in children and teens, and adolescents with chronic pain often struggle to attend school on a regular basis. We present in this article a novel program we developed that integrates attendance at a group cognitive-behavioural chronic pain self-management program with earning high school credits. We collaborated with Alberta Education in the development of this course, Chronic Pain 35. Adolescents who choose to enroll are invited to demonstrate their scientific knowledge related to pain, understanding of and engagement with treatment homework, and demonstrate their creativity by completing a project, which demonstrates at least one concept. Integrating Chronic Pain 35 into an adolescent’s academic achievements is a creative strategy that facilitates the engagement of adolescents in learning and adopting pain coping techniques. It also helps teens to advocate for themselves in the school environment and improve their parents’ and teachers’ understanding of adolescent chronic pain. This is one of the first successful collaborations between a pediatric health program and provincial education leaders, aimed at integrating learning and obtaining school credit for learning about and engaging in health self-management for teens. The authors hope this paper serves as an effective reference model for any future collaborating programs aimed at supporting teens with chronic pain to obtain high school credits.

Informing the development of an Internet-based chronic pain self-management program

BackgroundSelf-management can optimize health outcomes for individuals with chronic pain (CP), an increasing fiscal and social burden in Canada. However, self-management is rarely integrated into the regular care (team activities and medical treatment) patients receive. Health information technology offers an opportunity to provide regular monitoring and exchange of information between patient and care team. ObjectiveTo identify information needs and gaps in chronic pain management as well as technology features to inform the development of an Internet-based self-management program. MethodsTwo methods were used. First was a structured literature review: electronic databases were searched up to 2015 with combinations of MeSH terms and text-words such as chronic pain, self-management, self-efficacy, technology, Internet-based, patient portal, and e-health. A narrative synthesis of the characteristics and content of Internet-based pain management programs emerging from the literature review and how they relate to gaps in chronic pain management were completed. Second, four audiotaped focus group sessions were conducted with individuals with chronic pain and caregivers (n=9) and health professionals (n=7) recruited from three multidisciplinary tertiary and rehabilitation centres. A thematic analysis of the focus group transcripts was conducted. ResultsThirty-nine primary articles related to 20 patient-oriented Internet-based programs were selected. Gaps in CP management included lack of knowledge, limited access to health care, suboptimal care, and lack of self-management support. Overall, 14 themes related to information needs and gaps in care were identified by both health professionals and patients, three were exclusive to patients and five to health professionals. Common themes from the focus groups included patient education on chronic pain care, attitude-belief-culture, financial and legal issues, end-of-program crash, and motivational content. ConclusionsInternet-based programs contain automated, communication and decision support features that can address information and care gaps reported by patients and clinicians. However, focus groups identified functionalities not reported in the literature, non-medical and condition- and context-specific information, integration of personal health records, and the role of the different health professionals in chronic pain management were not identified. These gaps need to be considered in the future development of Internet-based programs. While the association between the mechanisms of Internet-based programs’ features and outcomes is not clearly established, the results of this study indicate that interactivity, personalization and tailored messages, combined with therapist contact will maximize the effectiveness of an Internet-based chronic pain program in enhancing self-management.