Development And Implementation Of Pain Self-management Program For Patients With Axial Spondyloarthritis

BackgroundChronic low back pain is one of the prominent symptoms of patients with axial Spondyloarthritis(axSpA),which seriously affects their work and quality of life.Pain relief is one of objectives in axSpA management.Self-management program helps to alleviate pain and improve clinical outcomes.However,researches showed that the self-management ability of axSpA patients is inadequate.There are few studies on self-management program for axSpA patients.The self-management programs in previous studies were time consuming,unsystematic,and with uncomprehensive outcome measures.ObjectivesTo develop and implement a pain self-management program for patients with axSpA,and to evaluate its effects on pain self-management,pain intensity and its interference,spinal mobility,disease activity,and quality of life.Methods1.ParticipantsA total of 100 patients with axSpA treated at the Department of Rheumatology and Immunology of a grade Ⅲ hospital in Guangzhou from November 2018 to October 2019 were recruited by convenient sampling.Patients were divided into the intervention group(n=52)and the control group(n=48)before and after the implementation of program.Patients in the control group received routine care,while the intervention group participated in pain self-management program.2.Development of pain self-management program for patients with axSpABased on Delphi expert consultation method,the pain self-management program for patients with axSpA were developed,including six topics of understanding the disease,self-management of symptoms,medication,exercise,daily life,and continuous self-management.3.Implementation of the pain self-management program for patients with axSpAPatients in the intervention group attended a daily 30-minute self-management training sesseion by a researcher and a chief physician over five days during hospitalization.The training methods included didactic lectures,method demonstration,peer support,and providing ongoing health education support via WeChat.After discharge,they were followed up monthly for 15 minutes through WeChat for three months by one researcher.Outcome measures were collected on the day of admission and at three-month follow-up by a researcher.4.Outcome measures4.1 PainThe Pain Stages of Change Questionnaire(PSOCQ)was used to assess‘readiness to change’,with respect to self-managed pain-relevant behaviors.It includes 30 items,and is divided into four subscales:pre-contemplation,contemplation,action and maintenance.Patients were classified according to their highest PSOCQ score.The Brief Pain Inventory(BPI)consisting of 11 items with a total score ranged from 0 to 10 was used to assess pain intensity and its interference.The Pain Self-Efficacy Questionnaire(PSEQ)consisting of 10 items with a total score of 0 to 60 was used to assess confidence in pain management.4.2 Spinal mobility,physical function,and disease activityThe Bath Ankylosing Spondylitis Metrology Index(BASMI),finger to floor distance,and chest expansion were used to assess spinal mobility.Physical function was assessed by the Bath Ankylosing Spondylitis Functional Index(BASFI).The Bath Ankylosing Spondylitis Disease Activity Index(BASDAI)and Patient Global Assessment(PGA)were used to assess disease activity.4.3 Quality of lifeThe Ankylosing Spondylitis Quality of Life Scale(ASQoL)consisting of 18 items with total score ranging from 0 to 18 was used to measure patients’ quality of life.Results1.Scientificness of the pain self-management program for patients with axSpAFifteen experts were included.The authority coefficient of experts was 0.937.The positive coefficient of experts in the two rounds were 88.2%and 100%,respectively,and the Kendall’s coefficients of concordance were 0.276 and 0.197,respectively(both P<0.005).The coefficient of variation of two rounds were 0～0.21 and 0～0.14,respectively.2.Effects of self-management interventions on stages of pain self-managementThere was no significant difference in stages of pain self-management between baseline and three months in the control group.After three months,the distribution of stages of pain self-management in the intervention group were significantly better than baseline(Z=-4.672,P<0.001),the number of patients in the contemplation stage decreased by 51.1%,in the action stage increased by 11.1%,and in the maintenance stage increased by 42.2%.3.Effects of self-management interventions on pain intensity and interferenceScores of pain intensity(worst pain,least pain,average pain,and current pain),and overall pain interference(general activity,mood,walking,work,relations with others,sleep,and enjoyment of life)in the intervention group improved after three months.The above scores in the control group also significantly improved,excluding the relations with others.4.Effects of self-management interventions on pain self-efficacyScores of PSEQ of two groups significantly improved after three months.The improvement of pain self-efficacy in the intervention group was greater than that in the control group,but the difference was not statistically significant.[-7.0(-20.0,-1.5)vs-6.0(-20.5,4.0),Z=-0.709,P=0.478].5.Effects of self-management interventions on spinal mobility,functional ability,and disease activityThe BASMI,finger to floor distance,chest expansion,BASFI,BASDAI,PGA,in the intervention group all improved after interventions.The above scores in the control group also significantly improved,excluding the BASMI and chest expansion.6.Effects of self-management interventions on.quality of lifeScores of ASQoL of two groups significantly improved after three months.The improvement of quality of life in the intervention group was greater than that in the control group,but the difference was not statistically significant[(4.53±3.91)vs(3.61±4.27),t=-1.047,P=0.298].ConclusionsThe pain self-management program for patients with axSpA based on Delphi method is scientific and feasible.Implementating pain self-management program could improve patients’ readiness to change and self-managed pain-relevant behaviors at three-month follow-up,but did not show significant effects on pain intensity and interference,spinal mobility,disease activity,and quality of life.