title: Effects of the Web Behavior Change Program for Activity and Multimodal Pain Rehabilitation: Randomized Controlled Trial.
abstract: 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 (P=.003), with an effect size of 0.61 (Cohen d) at 12 months. There were no significant between-group differences over time (time*group) regarding pain intensity, self-efficacy (pain, other symptoms, and general), or regarding six subscales of the two-item CSQ. Improvements over time (time) for the whole study group were found regarding mean (P<.001) and maximum (P=.002) pain intensity. The mean time spent in the Web-based program was 304 minutes (range 0-1142). Participants rated the items of Web-BCPA feasibility between 68/100 and 90/100. Participants in the MMR+WEB group were more satisfied with their MMR at 4 months (P<.001) and at 12 months (P=.003).
  
  
  
  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).
authors.affiliation: Department of Health Science, Division of Health and Rehabilitation, Luleå University of Technology, Luleå, Sweden. Catharina.Nordin@nll.se.
authors.forename: Catharina A
authors.identifier: 0000-0001-6032-665X
authors.initials: CA
authors.lastname: Nordin
authors.forename: Peter
authors.identifier: 0000-0003-0112-4657
authors.initials: P
authors.lastname: Michaelson
authors.forename: Gunvor
authors.identifier: 0000-0001-6975-8344
authors.initials: G
authors.lastname: Gard
authors.forename: Margareta K
authors.identifier: 0000-0001-8963-2247
authors.initials: MK
authors.lastname: Eriksson
mesh_terms: D000328:Adult; D001521:Behavior Therapy / Q000379:methods*; D005260:Female; D006801:Humans; D020407:Internet; D008297:Male; D059408:Pain Management / Q000379:methods*; D012648:Self Care; D011795:Surveys and Questionnaires
keywords: Web-based intervention; coping behavior; pain; patient compliance; patient satisfaction; rehabilitation; self-efficacy