Miller J, MacDermid JC, Walton DM, et al. Chronic Pain Self-Management Support With Pain Science Education and Exercise (COMMENCE) for People With Chronic Pain and Multiple Comorbidities: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2020 May;101(5):750-761. doi: 10.1016/j.apmr.2019.12.016. Epub 2020 Jan 29. (Original study)

OBJECTIVE: To investigate the effectiveness of chronic pain self-management support with pain science education and exercise (COMMENCE) on improving function, pain interference, work status, pain intensity, fatigue, psychological factors associated with pain, health care visits, satisfaction, and perceived change compared with usual care.

DESIGN: Parallel group randomized controlled trial with 1- and 12-week follow-ups.

SETTING: Community health center.

PARTICIPANTS: Adults (N=102) with chronic noncancer pain referred for self-management support. Eighty of 102 participants completed 12-week follow-up assessments. No participants withdrew with adverse events.

INTERVENTIONS: Participants were randomized to COMMENCE or usual care.

MAIN OUTCOME MEASURES: Primary: Function measured using the Short Musculoskeletal Function Assessment-Dysfunction Index. Secondary: Short Musculoskeletal Function Assessment-Bother Index, Patient Reported Outcomes Measurement Information System pain interference, work status, numeric pain, and fatigue rating scales, Tampa Scale of Kinesiophobia, Pain Catastrophizing Scale, Pain Self-Efficacy Scale, Neurophysiology of Pain Questionnaire, number of health care visits, satisfaction, and global rating of change.

RESULTS: COMMENCE resulted in greater improvements in function (mean difference [MD] at 12-wk follow-up=-8.0; 95% CI, -14.7 to -1.3), bother with functional difficulties (MD, -12.0; 95% CI, -20.8 to -3.2), pain intensity (MD, -1.0; 95% CI, -2.1 to -0.1), catastrophizing (MD , -8.2; 95% CI, -14.5 to -2.0), self-efficacy (MD, 7.0; 95% CI, 0.8-13.2), knowledge (MD, 2.8; 95% CI, 1.6-3.9), satisfaction (MD, 1.2; 95% CI, 0.7-1.8), and perceived change (MD, 1.4; 95% CI, 0.8-2.1). There were no significant between-group differences in pain interference, work, fatigue, depressive symptoms, or health care visits.

CONCLUSION: COMMENCE is more effective than usual care at improving function, pain, catastrophic thinking, self-efficacy, pain knowledge, satisfaction, and perceived change but not pain interference, work status, fatigue, depressive symptoms, or health care visits.

Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Physician 5 / 7
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Comments from MORE raters

Physician rater

As an Internist, I would consider a self management system...SMS. The loss to follow up is worrying given the small sample.

Physician rater

Patients with chronic pain require careful management. Patients have chronic suffering, frequent use of health care services, and loss of confidence. Patients often face barriers to chronic care management. The intervention was a standard group format set of lectures about self-management, pain science and cognitive behavioral advice followed by individual sessions to develop management plans and an exercise program tailored to the individual.

Physician rater

This is a small double blind study of a multi-modality program of education and exercises to help patients with chronic pain. It demonstrated that they felt better functioned better and had less pain. However, the studies were based on rating scales that were unknown to me and interestingly did not ascertain if the patients were able to reduce their chronic pain medications.

Physician rater

This is an unblinded parallel RCT Study with random allocation. The primary and secondary outcomes were self-reported, in marginalized populations, on people with low income, with lack of health insurance, addiction and/or mental health concerns, and isolated seniors with barriers to access health care. They used a CONSORT Flow diagram. This study suggested improved function, pain intensity, pain knowledge, self-efficacy, satisfaction with health care, and global rating of change but did not improve pain interference, work status, fatigue, depressive symptoms, or health care utilization in comparison with usual treatment. One of the most important goals in medicine is to achieve wellness and improve function for people with chronic pain, and barriers to specialized care. Even though this doesn’t mean one is cured from an illness, it does improve day to day well-being. This is what this study found, based on the subjective results of the outcome.

Physician rater

This well done and conceived study is relevant to all looking for alternatives to opioid treatments for chronic pain. Unfortunately the multiple scales used here, while validated, are unfamiliar to most and the modest positive results are of questionable clinical significance.

Rehab Clinician (OT/PT) rater

Interesting choice of measures. It would have been helpful to know the longer-term effects (ie, did the COMMENCE Program have long-lasting effects?).

Rehab Clinician (OT/PT) rater

There is clear and readable content; it's easy for clinicians to follow.
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