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10 Articles in Volume 7, Issue #7
Burning Mouth Syndrome
Chronic Pain Program in a Primary Care Setting
Chronic Persistent Pain Can Kill
Education and Exercise Program for Chronic Pain Patients
Managing Pain in Intensive Care Units
Oxycodone to Oxymorphone Metabolism
Patulous Eustachian Tube: Part 1
Rational, Emotive, Ethical Approaches to Bio-psychosocial Pain Care
Smoking and Aberrant Behavior in Chronic Pain Patients
Structuring Opioid Therapy

Education and Exercise Program for Chronic Pain Patients

Y-Pep, a Canadian community-based program for chronic pain patients, provides hope, improves physical function, pain tolerance, and coping skills.

This article is based on the authors’ poster presentation at the June 2007 International Conference on Pain and Chemical Dependency in New York City.

The incidence of chronic non-cancer pain (CNCP) ranged from 16-36% in a Canadian 2004 survey; 88% of which reported moderate to severe pain.1 CNCP is the most common reason for physician visits in Canada, most often arising from back, neck, and joint pain.2 Usually, chronic pain patients require more time per physician visit, suffer more feelings of distress and more disruption in functioning and use more hospital and other health services.3,4,5 Further, daily occupations of individuals living with chronic pain become restricted due to energy, frequently occurring co-morbidities such as depression, and social repercussions of their illness.6

A vicious positive feedback cycle can develop in chronic pain such that physical changes including decreased activity result from altered pain levels, which in turn cause stress, tension, emotional dysfunction, leading to further pain which then leads to greater physical changes, etc.7 Physical exercise and/or self-management techniques are interventions which have often been used to decrease pain and increase activity level for individuals with CNCP.8 Self-management (behavioural therapy) programs have resulted in improved function,8,9 decreased pain,9,10 enhanced self-efficacy,9,11 improved health behaviours,11 and increased life satisfaction10 in a variety of conditions resulting in chronic pain. Exercise programs have more specifically resulted in improvements in physical function and reductions in pain in a variety of populations with chronic pain12-16 and, in some instances, improved one’s sense of well-being.12

Access to chronic pain specialists is limited Canada-wide.17 Community-based programs to assist individuals in coping with their chronic illnesses have been developed for many conditions (i.e. diabetes, asthma, psychiatric diseases, arthritis, heart disease). However, to our knowledge this is not the case with CNCP. A group of interested health care professionals and the local Kingston Family YMCA partnered to develop a 12-week education and exercise program (Y-PEP) for individuals with CNCP. The purpose of this study was to determine if this program enhanced physical function, psychosocial well-being, and perceived quality of life in individuals with chronic pain. It was hypothesized that following completion of the Y-PEP, individuals with chronic pain would have an improved level of physical function for participation in activities of daily living and an improved quality of life as indicated by lower indices of depression, perceived pain and pain catastrophizing, and enhanced coping ability.

Methods

Subject Selection

Twenty-five subjects were recruited from the practices of the YPEP Advisory Group physicians and their colleagues. In order to participate individuals had to:

  1. be 18 years of age or older,
  2. have had chronic pain for greater than 6 months,
  3. be under physician management of pain,
  4. have medical clearance to participate,
  5. be able to ambulate,
  6. have the capacity to tolerate sitting for >10 min,
  7. be capable of providing informed consent (fluent in English, lack severe cognitive impairment).

To ensure participant safety and appropriateness for entry into the Y-PEP, each individual was required to submit a completed PARMED-X form (© Canadian Society for Exercise Physiology) which was completed by their physician.

Table 1: Participant
Demographic Information
Variable All Particpants (n=10)
Age (years) 45.6 ± 9.9
Primary Diagnosis
Back Pain 8
Fibromayalgia Pain 1
Osteoarthritis Pain 1
Employment status
Long-term disability 7
Unemployed 2
Retired 1
   
Education
Post-secondary 5
Secondary 2
Elementary 2
Unknown 1
   
Marital Status
Married 9
Single 1
   
Medications
(average # per participant)
Narcotic 1.8
Non-Narcotic 1.3
Frequency of Medications
(narcotic & non-narcotic)
None 1
Not every day 1
1-2 times per day 2
3-4 times per day 5
>6 times per day 1
Age and medications are reported as mean ± SD. All other values represent the number of participants in each category

Outcome Measures

Participant Demographics. Demographic information was obtained using a questionnaire to record participant age, height, weight, level of education, marital status, employment status, primary diagnosis, other existing medical conditions, other treatments attempted, medications, and any related side effects of these medications.

Physical Function/Activity Level— Human Activity Profile (HAP). The HAP was designed by Fix & Daughton18 and is a questionnaire designed to assess general physical activity. It consists of 94 activities ranked in ascending order of energy requirement in which individuals indicate for each activity whether he/she (1) is still doing this activity, (2) has stopped doing this activity, or (3) never did this activity. The Maximal Activity Score (MAS) is the item number (1 through 94) that represents the physical activity with the greatest energy requirement that this person is still doing. An Adjusted Activity Score (AAS) is the difference between the MAS score and the number of less demanding activities that the person has stopped performing due to their impairment. This provides a better indication of the degree to which an individual’s condition/impairment has impinged on his/her ability to perform activities.

Depression. The Primary Care Evaluation of Mental Disorder Brief Patient Health Questionnaire (PHQ) was used to assess the level of depression in individuals before and after participation in the education/exercise program. It provides information on perceived symptoms of (a) depression, (b) anxiety, (c) somatic complaints, and (d) psychological distress.19 We were primarily interested in using the subscale that measures symptoms of depression and anxiety (PHQ) which employs the criteria from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). This scale consists of 9 statements, to which individuals must respond not at all, several days, more than half the days, or nearly every day, which correspond to scores of 0 to 4 respectively and leads to a total score ranging from 0-27 (0-4 no depression, 5-9 mild depression, 10-14 moderate depression, 15-19 moderately severe depression, 20-27 severe depression).

Pain Catastrophizing. The Pain Catastrophizing Scale (PCS) is a commonly used self-report measure which assesses catastrophizing in individuals with chronic pain.20 Catastrophizing is defined as “an exaggerated negative orientation toward noxious stimuli.”21 The scale consists of 13 statements each to be ranked from 0 (not at all) through to 4 (all the time) for a possible total score of 52. The primary sub-scales of the PCS are rumination (maximum score=16), magnification (maximum score=12), and helplessness (maximum score=24).

Pain. The Brief Pain Inventory (BPI) is a 21-item self-report questionnaire which measures both the intensity of pain (sensory dimension) and interference of pain in the patient’s life (reactive dimension).22 The BPI was used to determine perception of pain severity via Questions 3-6 which ask participants to rate their worst, least, average and current pain on a scale from 0-10 (0 being no pain). It was also used to determine pain interference using Question 7 which consists of 7 separate questions regarding activity, mood, walking, work, relationships, sleep and enjoyment of life which participants rank on a scale of 0 to 10 (0 = no interference with their lives).

Protocol

Program. The program was a 12-week education and exercise program provided by the YMCA which was developed by the program team (health care professionals and YMCA staff) of the Y-PEP Advisory Group. There were two 1.5-hour sessions per week containing both educational and exercise components with a greater emphasis on education in the earlier part of the program and a greater emphasis on exercise in the latter part of the program. The education component was based on the Chronic pain Self-Management Program Workbook developed by S. Lefort.23 Each participant received a self-help workbook. Exercise consisted initially of the Range of Motion Dance, relaxation, and walking followed by Yoga, Tai-Chi, Aqua-fit, and use of standard workout equipment. For the program, individuals were required to purchase a 6-month YMCA membership which allowed participants to be involved in the 12-week Y-PEP while, at the same time, having the YMCA facilities available to them with all membership privileges outside of the program time and an additional 3 months which allowed the participants to continue to use the YMCA facilities and activities.

Pre-Program. During the first Y-PEP session, the research component of the program was explained to the participants. Those who volunteered to take part in the research component of the program signed an informed consent form (as approved the Queen’s University, Health Sciences Research Ethics Board) and then completed the 6 outcome measures.

Post-Program. a) Immediately upon completion of the program, participants again completed the 6 outcome measures. The demographics form was modified for individuals to report any changes in medications. Three months post-program (which coincided with the end of the additional 3-month YMCA membership), participants received packages containing the 6 outcome measures which they were asked to complete and return to to the School of Rehabilitation Therapy at Queen’s University.

b) Using an interpretive paradigm, interviews were conducted to gain a deeper understanding of the participants’ lived experience24 and shed light on how participants constructed and assigned meaning to the program experience. Interviews ranged from 20-45 minutes on duration. A semi-structured interview format was used by three interviewers who each interviewed 2 participants.

Data Analysis. Quantitative data are reported as mean ± standard deviation. Differences between time points were determined using a repeated measures of ANOVA with subsequent multiple means analysis using the Bonferroni adjustment. Significance was accepted at p

Results

Quantitative Findings

Twenty-five participants registered to start the program and 17 completed the program; 10 of which participated in the study. The participant’s average age was 45.6±9.9 years, there were 7 women and 3 men, and there was an average of 2 medical diagnoses per participant (see Table 1). As a group these individuals averaged a 10 year history of CNCP and 7 were on long-term disability.

The mean values ± standard deviation for Worst Pain, Least Pain, and Pain Interference from the Brief Pain Inventory are shown in Panels A, B, and C respectively in Figure 1. Individuals reported an average intensity of 8.7 ± 0.8 for their worst pain at the start of the program (Panel A). A significant decrease (21%) was found in this rating upon completion of the program. However, at the 12-week follow-up, the rating for worst pain intensity was no longer different from the pre-program value. The intensity of individuals’ least pain was reported as 5.3 ± 1.8 at the start of the program; no significant changes were observed at post or follow-up (Panel B). Of interest, was the decreasing trend for least pain intensity and pain interference at post-program and at follow-up as compared to the pre- value, however, low statistical power (low subject numbers) prevented the detection of a significant difference.

The mean values ± standard deviation for the Maximal Activity Scores (MAS) and the Adjusted Activity Scores (AAS) of the Human Activity Profile are shown in Panels A and B respectively in Figure 2. The initial MAS value was 61.6 ± 10.1 which did not change significantly post-program, despite a 12% increase (Panel A). The low statistical power associated with low participant number most likely prevented the detection of a significant change. This value at follow-up was within 1.2 units of the pre-value. The AAS (Panel B) pre-study value averaged 44.0 ± 13.5 and increased by 16% at post-study; this was not a significant change, again most likely due to low statistical power. At follow-up, the average AAS value was within 0.1 unit of the pre-study value.

A rating of depression was determined using The Pain and Health Beliefs Questionnaire (PHQ). The pre-study value was 14.4 ± 4.1 which indicated a moderate level of depression (10-14). The depression ratings at post study and at follow-up were 13.6 ± 7.9 and 10.7 ± 7.5, respectively, and were not significantly different than the pre-study value. However, at follow-up, the participants’ depression score placed them at the lowest level of the moderate depression category as compared to the pre-study value which had placed them at the highest level of the moderate depression category.

The pre-study Total Score on the Pain Catastrophizing Scale was 31.1 ± 7.6 relative to a potential maximum score of 52; no changes in this score were observed at post-study or at follow-up. The Rumination sub-scale (Panel B) has a potential maximum score of 16; the pre-study value was 11.4 ± 2.4, and decreased by 17% at post-study and at follow-up, however, these values were not significantly different from pre-study. The pre-study values for the Magnification and Helplessness sub-scales averaged 6 ± 2.7 and 13.6 ± 4.9, respectively, and were not significantly different than the pre-study value

The primary findings of a multiple correlation analysis of relationships between the changes in outcome measures post- versus pre-study are listed in Table 2. Moderate correlations were found between the changes in HAP-Adjusted Activity Score and changes in BPI-Least, BPI-Interference and PHQ pre- to post-program. These relationships were not significant and no such relationships were found for the changes in these variables at follow-up versus pre-study. These associations suggest that as the participants’ activity level increased, their level of depression, the least intensity of pain experienced, as well as their perception of the overall amount of interference the pain had in their lives all decreased. The change in the depression score (PHQ) was strongly correlated with the change in BPI–Interference and moderately correlated with the change in BPI-Least suggesting that as an individual’s depression level decreased, so did his/her perception of least pain and how much their pain interfered with their lives. Strong significant correlations between the change in PHQ and all PCS scores indicated that decreases in depression were strongly correlated with reductions in pain catastrophizing. The changes in BPI-Pain Interference score post-study versus pre-study demonstrated significant moderate and strong associations with changes in pain catastrophizing (PCS), suggesting that when an individual felt that pain interfered less with their life, their level of pain catastrophizing also decreased. These significant associations were also maintained at follow-up.

Table 2: Associations Between Changes In Outcome Measures
Post- Versus Pre-Program
Outcome Measures Moderate Correlation Strong Correlation
AAS BPI – Least (R=-0.55)
BPI – Interference (R=-0.46) (F)
PHQ (R=-0.45)
 
PHQ
(Depression)
BPI – Least (R=0.53) BPI – Interference* (R=0.84)
PCS – Rumination* (R=0.73)
PCS – Magnification* (R=0.86)
PCS – Helplessness* (R=0.78)
PCS – Total Score* (R=0.77)
BPI –
Interference
PCS – Rumination (F) PCS – Magnification* (R=0.84) (F)
PCS – Helplessness* (R=0.76) (F)
PCS – Total Score* (R=0.75) (F)
(*) Significant Correlation At P<0.05. AAS, Adjusted Activity Score, PHQ, Patient Health Questionnaire, BPI, Brief Pain Inventory, PCS, Pain Catastrophizing Scale. (F) Indicates Association Was Maintained At Follow-Up.

Figure 1. The mean values ± standard deviation for Worst Pain (Panel A), Least Pain (Panel B) on a scale of 0 to 10 and Pain Interference (Panel C) on a scale of 0 to 70 as determined by the Brief Pain Inventory. Pre, values obtained at the start of the program; Post, values obtained immediately upon completion of the 12-week program; Follow-up, values obtained at 12 weeks following completion of the program. (*) represents significant difference from pre value at p

Qualitative Findings

Three themes were identified from qualitative analysis of the interviews; namely, (a) acquisition of coping mechanisms, (b) social support, and (c) hope. Many of the participants experienced a shift in their approach of chronic pain from trying to eliminate its manifestations to finding ways to cope with its symptoms. The comments below indicate that skills learned—such as pacing and enhanced communication— helped individuals to better cope with pain and also minimize situations which would exacerbate their symptoms.

“I’ve learned … many different ways of coping and … controlling the way of pacing my activities and my rest … because of the skills that I’ve learned, I’ve actually cut my medication in half, when my activities have increased ten-fold. It’s something I never thought would happen. I figured the more I do, the more medicine I am going to have to take to counteract the pain from the activity, and it hasn’t worked that way at all because I’ve learned how to pace, to listen to my body.” … that’s another huge thing, the guilt is gone … , the ability to say no, I can’t do that and I won’t do that, cause it will hurt.” (P2)

“I was, before the program, I was getting really frustrated and not exploding, but venting, I guess. And, it was definitely a strain on my relationship with my girlfriend. And it’s gotten a lot better since the program started.” (P4)

Social support was a key element identified by all participants. In this context, social support is defined as having the opportunity to talk with other individuals who truly “understood” chronic pain and the vast implications the disability has on the lives of its beholders. The comments below illustrate the importance of social support to the participants.

“Well, I enjoy getting together with the people every week, you know, they understand …” “You don’t wanna’ burden any of your friends anymore cause your sick of talking about it, you don’t want to tell your husband anymore because he’s probably going to get down, or he does get down and he worries too. So, you know, I found, or I find that talking to other people, doesn’t matter what age they are, is so important …” (P5)

A common characteristic among the participants was depression or low feelings. The participants revealed that acquiring a new sense of hope was a turning point which motivated them to engage more frequently in specific coping mechanisms when dealing with symptoms of chronic pain. These positive sentiments usually contained an element of optimism that could not be attributed to any one particular component of the program and are exemplified in the comments below.

“I’ve never let it stop me from doing stuff … from the very beginning, I didn’t let it, I didn’t just stay in bed, and ah, let it take over me. I’d make myself do stuff and I’ve always done that. But since the program, I think it’s … I’ve just looked at it differently, that it’s ok, for me to have pain and things will get better. I think that, I’m a little more positive about, about it …”And to have hope that yes, I have chronic pain, but look at these other people … some people here are making big strides so if they can why not me?”(P1)

“I think it has helped me a lot, it’s given me more self-esteem then I had before.”(P5)

Discussion

The purpose of the current study was to determine if the Y-PEP community-based program enhanced physical function and psychosocial well-being in individuals with chronic pain. The quantitative results indicated that the maximal (MAS) and adjusted (AAS) levels of activity increased by 12% and 16% respectively post-program; these increases in activity were associated with decreases in (a) participants’ perception of their pain, (b) the extent to which pain interfered with their daily activities, and (c) depression. Further, decreases in depression among participants were associated with decreases in participants’ perception of their pain and their pain catastrophizing, specifically rumination. Finally, reductions in the extent to which pain interfered with individuals’ daily activities were associated with decreases in pain catastrophizing (rumination and magnification). These findings were echoed by the qualitative investigations which identified, (a) acquisition of coping mechanisms, (b) social support, and (c) hope as the primary benefits that participants received from the program.

To our knowledge, the current pilot program is the first community-based program in Ontario to combine education and exercise for individuals with chronic pain. With our local community YMCA as its sponsor, Y-PEP contained self-help components and guided/instructed components wih outcome measures obtained for both cognitive-behavioural aspects and physical function. Most previously reported group programs for chronic pain have taken place in institutions, were run as self-help groups or as guided programs and, if activity level was measured, it was done so by monitoring activities of daily living (ADL).25,26 Our findings are in agreement with these studies in which the intervention groups made significant short- and long-term improvements in measures including: pain severity, activity levels, mood, coping and experienced fewer catastrophizing thoughts.25,26 In a recent study by Sullivan et al.,27 a community-based psychosocial intervention using the Pain Disability Prevention self-help program was used with clients who had been off work for 2 years or less with a musculoskeletal injury. Although it was accessible in the community, it lacked any guided component and focused on cognitive-behavioural aspects, strictly encouraging physical activity and not monitoring any change.

In the current study, we used the self-report Human Activity Profile rather than document ADL’s. In doing so, we were able to discern the extent of limitiation experienced by the participants and the ability of these individuals to function within this limitation. Pain is a physical entity that can neither be seen nor measured; the extent and intensity of which is primarily determined by self-report. As an external observer, it is difficult for health care practitioners to internalize the extent of the disability imposed by CNCP in their clients. By using a standardized tool, an objective rating was able to be determined and then the extent of physical limitation could be compared to health populations or other clinical populations. Our pre-study values for MAS and AAS were 61.6 ± 10.1 and 44.0 ± 13.5 respectively as compared to 84.8 ± 7.8 and 82.2 ± 8.9 respectively in a healthy individuals.18 Further, values of 55.2 ± 14.9 and 43.6 ± 19.1 for MAS and AAS respectively have been reported for individuals with renal failure.18 As can be seen from these values, our participants displayed a substantive physical limitation (MAS score) and were also limited in the extent to which they could function within this limitation(AAS score); so much so that they approximated values of the renal failure population. These values provide another avenue by which health care individuals can conceptulize the physical and function limitations imposed by CNCP in their clients.

A major finding of this study was that increased activity levels were associated with decreases in pain perception, the degree to which pain interfered with participants’ daily activities and depression. Activity levels increased on average 16% (adjusted activity score), which was not significant due to low participation numbers in the study. These changes are, however, comparable to those found in other programs. Individuals with CNCP (n=39) significantly improved various ADL’s anywhere from 11% to 24% (part 3 of LHY MPI Activity Scale) at the conclusion of the program, whereas at the conclusion of a 6-week institutional progam; few of these remained significantly elevated at 6 and 12 months post-program.25 These improvements in daily function occurred simultaneously with significant improvement in depression scores (23% at end program but these improvements were not maintained at 6 and 12 months post program), pain interference and pain severity (12% respectively, which were maintained at 6 and 12 months post program). The team of Turner-Stokes et al.26 studied a chronic pain outpatient program (including adults who had experienced pain affecting any part of the body for more than 6 months) which provided cognitive-behavioral therapy (including education, relaxation, use of cognitive coping strategies, pacing and exercise) delivered in a group-based multidisciplinary program or in an individual therapy program. Treatment resulted in significant increases in general activity (24%; as per the WHY MPI); as well in significant decreases in pain severity (26%), depression (56%) and pain interference (28%). No correlational analysis between outcome measures was performed in eith study. Implementation of the program by Turner-Stokes et al.26 required the involvement of many health care professionals with program costs ranging from $150-$350 per hour; a cost which would be substantially reduced if a community-based program were used.

Figure 2. The mean values ± standard deviation for the Maximal Activity Score (Panel A) and the Adjusted Activity Score (Panel B) on a scale from 1 to 94 as determined by the Human Activity Profile. Pre, values obtained at the start of the program; Post, values obtained immediately upon completion of the 12-week program; Follow-up, values obtained at 12 weeks following completion of the program.

Our findings are in agreement with others with respect to improvements in depression, pain perception and catastrophizing. In rehabilitation center-based programs with medical professionals supervising and acting as instructors, pain catastrophizing decreased approximately 32% and pain severity decreased 5-10%.25,27 Smeets et al.28 performed a study which consisted of an active treatment group, a cognitive-behavioural treatment group, and a combined treatment group. The active group performed 30 minutes of aerobics and 75 min of endurance and weights for the back and legs, 3 times per week for 10 weeks. The cognitive-behavioural group did problem solving training (one 1.5-hour session per week) and education on graded activity (two 30-min sessions per week). The combined treatment consisted of both programs. Pain catastrophizing was associated with decreases in patient’s current pain (self-reported) in only the active treatment group and these decreases were accompanied by reductions in depression (Beck Depression Inventory). These findings support the use of exercise and cognitive-behavioural programs as opposed to cognitive-behavioural therapy alone.

Figure 3. A schematic representation of the three themes (hope, acquisition of coping mechanisms, social support) which emerged from the qualitative analysis that contributed to enhanced quality of life and ultimately increased occupation.

Another major finding of the current study was that the reduction in how much pain interfered with individuals’ daily activities was correlated with decreases in pain catastrophizing (rumination by 17%). Similar decreases in measures of pain catastrophizing (22%-26%) in pain interference (12%-17%).25,29 In the study by Johansen et al,29 36 participants via physician referral underwent a 4-week, inpatient, group/individual multidisciplinary treatment program at the Department of Rehabilitation Medicine in Sweden which included education, goal setting, graded activity training, individual tailored muscle training, pacing, relaxation, cognitive techniques, social skills, drug reduction methods, management of pain behaviours, return to work and exercise. Similarily, Martin et al20 collected data on 39 patients who completed a 6-week outpatient cognitive behavioural management programme comprised of ten half day sessions.

The stories told by our participants paint a compelling picture about the challenges of living with chronic pain. They substantiate the findings of a plethora of previous studies that reveal the impact of chronic pain on every aspect of one’s life.16,30 Its reverberations are felt by those close to the individual dealing with chronic pain and by the broader community. The myriad of negative effects of chronic pain reported by our participants included reduced quality of life, social disability, work loss, and early retirement. Participants detailed accounts of their physical symptoms, including loss of sleep, frequent headaches, and difficulty with movement due to extreme pain. Many of the participants also reported loss of hope, disillusionment, and depression in general.

The cognitive-behavioral component of the program was evaluated as instrumental by the participants. The major goal of any cognitive-behavioral intervention is to promote the acquisition of a constructive problem-solving set of skills.31 Ideally, a cognitive-behavioral intervention will generate a shift from helplessness to personal mastery, responsibility, confidence, and self-control. Cognitive-behavioral interventions encompass a spectrum of therapeutic techniques that aim to improve the individual’s skills to self manage his/her pain. These specific techniques include education, relaxation training, coping skills training, cognitive restructuring, assertiveness, and communication training.32

Most of the participants experienced a sense of renewed hope after being enrolled in the program. This sense of hope evolved throughout the program. Initially, this new sense of hope was the motivating factor for adopting and implementing specific coping skills (acquired throughout the program). Engaging in these activities and the benefits of the social support network that emerged were essential factors that balanced the motivation and sense of hope experienced by the participants. The positive results of assuming a more active role in managing pain (e.g. increased endurance and flexibility, learning to pace, increased engagement in valued occupations, effective communication skills, etc.) acted as a feedback loop directly affecting the participants’ motivation.

The quality of the social supports the participants had following program termination had a significant impact on the extent to which the participants maintained the coping skills beyond the end of the program. During the focus group it became evident that the participants who maintained their social support network tended to be more proactive and in control relative to managing their pain. They engaged more often in the management of their pain by using specific coping mechanisms as well as through increased participation in various physical activities. Overall, the participants and the authors of this study felt that hope was a dynamic variable that was directly modulated by the quality and structure of social support and the extent of practicing the acquired coping mechanisms.

One limitation of the current study was that all participants in the pilot program, while not directly referred by their family physician, were recruited via physician practices. Some individuals may have participated in the program at the urging of their physician and may not have been personally highly motivated to participate in the program. This lack of motivation may have played a role in attrition rates in the study and may have contributed to the poor response to the program by some individuals. The low participation numbers also affected the statistical power of the study. Some participants required approximately 2 hours to complete the outcome measure forms. Although they were instructed to take their time completing the forms, some individuals indicated they attempted it in one sitting, and this increased their pain. This induced pain resulted in more adverse scores on various outcome measures (i.e. average pain would be ranked as being worse). Moreover, many of the participants7 were on long term disability, and despite being informed of the confidentiality of the findings, many still feared that their data may be released to their family physician or a government body, with their disability funding being affected by any improvements in pain levels and functional ability. This fear would also likely have affected their scores on the questionnaires.

In conclusion, the current study provided the first evidence of the beneficial effects of a community-based, education and exercise program on physical function and psycho-social well-being in individuals with chronic pain. Increases in both maximal (MAS) and adjusted (AAS) levels of activity were associated with decreases in participants’ perception of pain, the extent of pain interference in their daily activities, and decreased depression. Further, a reduction in depression scores was associated with decreases in perception of pain and pain catastrophizing, specifically rumination. Stories from participants indicated that they valued the acquisition of coping mechanisms and the social support received in the program but, most of all, they valued the experience of a new sense of hope.

The incorporation of the local YMCA in a community-based initiative for individuals with CNCP has shown promising results. The findings of the pilot program held in 2006 have lead to minor adjustments in the program and in data collection procedures. The Y-PEP has been offered in 2007 purely as a community-based endeavour, without physician input in the recruitment process. The program is now 10 weeks in length. Data packages are explained to the participants in the first session of the program and then participants are given one week to complete the questionnaires. This allows the participants to minimize the pain associated with long periods of sitting in order to complete the questionnaires. Also, a better reporting system for medications was provided. As of the writing of this article, two of the 3 Y-PEP sessions for 2007 have occurred and data collection continues. The interest from the community has sky-rocketed with a two-page list of individuals wishing to register for Y-PEP in the fall of 2007!

“Most of the participants experienced a sense of renewed hope after being enrolled in the program. This sense of hope evolved throughout the program.”

Acknowledgements

The following pharmaceutical companies are gratefully acknowledged for their contributions in support of the implementation of the pilot project and for travel support for conference presentations: Valeant Canada, Sanofi Aventis, Purdue Pharma, Norvartis, Pfizer.

We wish to thank the individuals at the Kingston Family YMCA for their contribution and support in the planning and implementation of the Y-PEP program and special thanks to Tarey Gillard, the Y-PEP instructor who won the hearts of all participants.

Finally, we would like to thank Sandra LeFort for her encouragement and support of our endeavour. She graciously provided consent for us to use the Chronic Pain Self-Management Program Workbook and Leadership Manual in the development of the Y-PEP.

Last updated on: February 26, 2013
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