Effects of a pain management programme on occupational performance are influenced by gains in self-efficacy

Abstract

Introduction

The perceived capacity to perform particular activities or skills (i.e. self-efficacy) is paramount in occupational therapy and is thought to be reinforced by actual functional capacity. This study examined whether changes in self-efficacy or confidence to lift weighted items influences changes in occupational performance and disability levels in patients attending a cognitive behavioural therapy pain management programme.

Method

Clients attending an 8-week cognitive behavioural therapy pain management programme (N = 125) completed questionnaires before treatment, at discharge, and at 3-month and 6-month reviews, including measures of pain self-efficacy, disability and self-perceived performance and satisfaction using the Canadian occupational performance measure. Analyses examined disability and occupational performance over time, adjusting for baseline characteristics (age, sex, education), and sought to determine whether self-efficacy or lifting confidence influenced the outcomes.

Results

The level of disability, lifting confidence, self-efficacy and occupational performance all improved over time; however, only occupational performance and lifting confidence maintained improvements up to the 6-month review. Self-efficacy had a greater impact on occupational performance than lifting confidence.

Keywords

Pain self-efficacy function occupational therapy pain management cognitive behavioural therapy pain outcome measurement

Introduction

Chronic pain affects up to 3.2 million Australians, with an annual cost of A$139.3 billion to society (Deloitte Access Economics, 2019). Chronic pain is associated with higher healthcare use, interference in daily activities, disengagement from work and reduced perception of general health (Meredith et al., 2006; Tseli et al., 2019). Multidisciplinary pain management programmes aim to reduce the individual and socioeconomic burden of chronic pain, by developing coping skills based on positive changes in both cognitive and behavioural responses to pain (cognitive behavioural therapy; CBT). The ultimate goal of treatment is to promote self-management skills by maximising an individual’s physical, functional and psychological capacity, and in turn to develop their confidence to cope and participate in daily life despite the ongoing presence of pain (Edwards et al., 2016; Miró et al., 2018; Oliver et al., 2017). While the approach and content of treatment varies between pain management programmes, and it is difficult to define specific active ‘ingredients’ of treatment, these programmes have been found to be more effective than stand-alone therapies (Persson et al., 2013). However, treatment effects on levels of disability, mood, pain severity and catastrophising are often small and not consistently maintained at 6 months post-treatment (Williams et al., 2012). The factors that contribute to the development and maintenance of self-management skills are still open to debate. While self-efficacy and functional potential are often targeted in pain management group programmes in order to reduce disability and improve occupational performance, it is not known whether and how these characteristics enable patients to achieve sustainable treatment outcomes. To address this gap in knowledge the present study investigated the role of pain self-efficacy and functional capacity (measured as the confidence to lift a weighted box) on disability and client perceived occupational performance outcomes after participation in a CBT pain management programme.

Self-efficacy was first described by Albert Bandura in 1977 as a core component of social learning theory, and has a strong association with pain management outcomes (Jensen et al., 1991). Self-efficacy is defined as the belief in one’s capacity to perform a particular activity or skill important to the individual (Bandura, 1994). It includes the confidence to cope with challenging situations, and the level of perseverance one may apply to seek solutions to their situation. Importantly, self-efficacy beliefs are not static and can change in response to experience and circumstance, and are thus an important modifiable target for pain management programmes (Katz et al., 2019).

Pain self-efficacy is positively associated with adjustment to a persistent pain condition (Jensen et al., 1991), enhanced activity engagement and lower disability (Martinez-Calderon et al., 2018; Oliver et al., 2017). However, the positive effects of pain self-efficacy require patients to develop and maintain the motivation to persist with behaviour change despite ongoing pain. According to Bandura’s model people with high self-efficacy embrace challenging situations and view problems as an opportunity for development and mastery of personal strengths (Buckelew et al., 1996). In contrast, people with low self-efficacy view challenges as a threat that may expose or emphasise personal deficiencies. Improvements in self-efficacy can be achieved by allowing the individual to feel challenged but not overwhelmed, experience success and achievement, and not to view failure as catastrophic.

Self-efficacy beliefs have a stronger association with disability and pain behaviour than with pain intensity, per se (Asghari and Nicholas, 2001; Meredith et al., 2006). Moreover, self-efficacy beliefs have been found to have a stronger effect on disability than fear avoidance beliefs (Ayre and Tyson, 2001). While self-efficacy beliefs when entering treatment are important, changes in self-efficacy probably have greater impacts on reductions in disability (Arnstein et al., 1999; Costa et al., 2011; Dobkin et al., 2010), avoidance behaviour (Asghari and Nicholas, 2001) and improvements in physical activity (Buckelew et al., 1996), highlighting that treatment-related gains in self-efficacy are a key treatment goal.

Self-efficacy is influenced by occupational engagement and opportunity for mastery experiences. Occupational achievements provide a feedback loop in which personal states can be modified and developed either adaptively or maladaptively (Kielhofher and Burke, 1980). While clinical interventions may build general self-efficacy beliefs, client-centred tasks are important for developing and maintaining self-efficacy for everyday activity participation. These important clinical outcomes are, however, poorly understood given that most research on self-efficacy and function following pain treatment evaluate changes in disability using generic or condition-specific pain-related disability questionnaires. To understand associations between self-efficacy, function and pain-related disability it is important that outcomes valued by the individual are also measured.

The present study aimed to explore changes in pain self-efficacy, client-perceived occupational performance, disability and objective functional performance in patients undertaking a multidisciplinary CBT-based pain management programme, and examined whether these changes were maintained over time. It was hypothesised that the CBT pain management programme would improve disability, pain self-efficacy, lifting potential and perceived occupational performance, but that the level of pain self-efficacy over time would be associated with the maintenance of both client-perceived occupational performance and objective functional improvements.

Method

The research was approved by the hospital human research ethics committee, and participants gave written informed consent.

Setting and recruitment

Participants were recruited from an outpatient multidisciplinary pain clinic in a metropolitan hospital in Melbourne, Victoria. A convenience sample of patients invited to an 8-week CBT pain management programme (CBT group) were recruited for the present study. Eligibility criteria for the CBT group included completion of a battery of psychometric questionnaires and an allied health assessment that evaluated occupational performance areas, treatment goals, and potential readiness to embrace a self-management approach. People with limited English or significant psychiatric issues were ineligible for the group programmes. Each weekly session was 5 hours long, and included sessions on movement awareness (e.g. Feldenkrais), relaxation training, a functional conditioning circuit (physiotherapy and occupational therapy) and a structured but interactive CBT-based education programme covering topics on understanding pain, activity pacing, medication, sleep, stress management, mood management and managing change including flare-ups. Patients set clear functional goals based on their occupational performance issues at the start of treatment using the Canadian occupational performance measure (COPM) (defined below), which were then reviewed throughout the programme. The goals set the theme of their individualised functional conditioning circuit to provide an opportunity to practise tasks specific to their lifestyle needs. Consecutive patients over a 2-year period were invited to participate on enrolment in a CBT group programme.

Materials and procedures

Questionnaires were completed at baseline (i.e. pre-treatment), discharge (i.e. treatment completion) and at review appointments 3 and 6 months following treatment completion. Participants provided demographic characteristics (age, sex, years of education) and ratings of their pain severity, self-efficacy, occupational performance and disability, and completed an objective functional task. The questionnaires were selected in order to provide a comprehensive assessment of treatment effects in accordance with the initiative on methods, measurement and pain assessment in clinical trials guidelines (Dworkin et al., 2005).

Pain severity

Pain severity was measured using the brief pain inventory (Cleeland and Ryan, 1994). Participants rated their current, average, least and worst pain intensity in the past week from 0 (no pain) to 10 (pain as bad as you can imagine). A pain severity score was generated by calculating the average of the four pain intensity ratings.

Pain self-efficacy

The pain self-efficacy questionnaire (PSEQ) (Nicholas, 2007) is a 10 question, self-administered questionnaire that measures confidence in performing tasks and behaviours despite pain using a 7-point scale ranging from 0 (not at all confident) to 6 (completely confident). The PSEQ shows good internal consistency in chronic pain samples (Di Pietro et al., 2014; Miles et al., 2011).

Occupational performance

The COPM involves a semi-structured interview in which occupational performance issues are identified for domains of self-care, productivity and leisure. Up to five most important occupational performance issues are identified, and performance and satisfaction with performance of each task is rated from 1 (not able to perform; not satisfied) to 10 (able to perform extremely well; extremely satisfied). The average performance and satisfaction ratings are calculated across all problems identified. The COPM is a valid and reliable client-centred measure of function (Law et al., 1990) that has good sensitivity to change over time (Carswell et al., 2004). The COPM protocol has been embedded into the multidisciplinary assessment to ensure that occupational performance issues are explored as part of routine treatment, and to facilitate client-centred goal setting.

Disability

The Oswestry disability index, version 2 (ODI) (Fairbank et al., 1980) measures low back pain-related disability, and was selected for this study as the patient population typically has a high prevalence of back pain. The ODI comprises 10 questions that ask about limitations in several tasks, such as travelling, social life, sex, walking, sitting, standing, sleeping, personal care and lifting. The ODI has a possible score of 100, with higher scores indicating greater disability. The ODI demonstrates good psychometric qualities (Brodke et al., 2017; Fairbank and Pynsent, 2000).

Functional performance: lifting

Dynamic lifting ability was assessed using a modified progressive isonertial lifting evaluation (PILE) (Lygren et al., 2005; Mayer et al., 1988). The standard PILE protocol requires participants to lift a load from waist level to floor and back in standardised increments between 2.25 kg and 4.5 kg (based on gender), with four repetitions per increment until an end point is reached. End points include when the participant declines further weight increases, shows signs of exhaustion, or a maximal load is reached (45–55% of body weight). For this study, irrespective of gender, participants started with an empty box and lifted a load in 2 kg increments, with two repetitions per increment. The highest weight comfortably lifted for two repetitions was recorded. This modified PILE was therefore not a test of maximal lifting capacity, but the load that could be confidently lifted despite pain. This task was not completed at the 3-month review.

Data analysis

Analyses were conducted using IBM SPSS (version 23) and R (version i386 3.1.2). Comparison of characteristics between participants with complete follow-up and partial or complete loss to follow-up were examined using the t-test, Mann–Whitney U test or chi square test. For each comparison we generated the mean (standard deviation; SD), median (interquartile range; IQR) or number (percentage) in each group, respectively.

Multilevel analyses using maximum likelihood estimation and scaled identity covariance examined changes in the primary outcomes (occupational performance, COPM; disability, ODI) over time. To account for lack of independence of measures within subjects, the data were nested within patients (level 1), and time was modelled as a fixed factor with four levels (baseline, discharge, 3-month review, 6-month review). Five multilevel models were tested for each outcome to determine the association between self-efficacy and lifting confidence (kg) and the outcomes of occupational performance and disability (ODI). Model 0 included only the outcome sampling data; model 1 added assessment time; model 2 adjusted for demographic factors (age, sex and education); and model 3 adjusted for the clinical pain covariates (baseline pain intensity, pain duration). As the pain-related characteristics in model 3 did not contribute to change in occupational performance they were dropped from subsequent models; however, baseline pain severity did contribute to the estimation of change in disability, and was retained in models 4 and 5 for the ODI outcome. The effects of pain self-efficacy and lifting confidence (in kg) were tested in model 4a and model 4b, respectively. Improvements in fit between each model were determined through examination of the change in model fit statistics against the critical value for the chi-square test (i.e. evaluating the improvement in – 2 log likelihood statistics relative to the respective increase in degrees of freedom); the magnitude of additional variance explained (i.e. covariance parameters and intraclass correlation coefficient (ICC)); and the magnitude of the fixed effects (Twisk, 2006). To interpret the coefficients, every unit change in the outcome variables (COPM performance, or disability) corresponds to ‘beta’ units of change in the predictor variable. For instance, if beta = 0.74 for age then every additional 0.74 years of age corresponds to a one unit increase in the COPM performance score.

Results

Cohort overview

One hundred and twenty-five patients (91.9% of eligible patients) participated at baseline, of whom 60.3% participated in at least one follow-up assessment, Table 1 and Figure 1. Fifty-five participants had complete follow-up, 50 were lost to follow-up and 20 had partial follow-up. A relatively large proportion of patients did not attend the 3-month review (57.1%) and only 54.0% of patients attended the 6-month review. Participant demographics, pain severity, pain duration and baseline occupational performance and disability measures did not differ between participants with complete follow-up versus partial or complete loss to follow-up. The average age of the cohort was 47.45 years (SD 11.04), and most participants were women (n = 77, 61.6%). The sample had a high level of education (median 15 years, IQR 13–16), and had experienced pain for a median of 5 years (IQR 2–10 years), which was of a moderate intensity (mean 5.99, SD 1.82).

Table 1.

Characteristics of participants with complete follow-up versus participants who were partial or lost to follow-up, N = 125.

		Complete follow-up (N = 55)	Partial/complete loss to follow-up (N = 70)	P value
Age, years	M (SD)	49.55 (10.76)	45.74 (11.13)	0.07
Sex
Female	N (%)	35 (45.5)	42 (54.5)	0.68
Male	N (%)	14 (41.2)	20 (58.8)
Education, years	M (SD)	15.15 (3.00)	13.42 (3.73)	0.07
Years of pain	Med (Q1, Q3)	3.92 (2.00, 10.00)	5.00 (3.00, 10.00)	0.74
Pain severity	M (SD)	5.87 (1.96)	6.06 (1.73)	0.59
Baseline
Lift (kg)	M (SD)	3.71 (3.45)	3.57 (4.11)	0.84
COPM performance	Med (Q1, Q3)	3.40 (2.60, 4.00)	3.00 (2.76, 4.00)	0.23
Pain self-efficacy	M (SD)	30.23 (11.25)	30.36 (12.97)	0.96
Disability (ODI)	M (SD)	48.59 (12.79)	48.42 (15.69)	0.95

COPM: Canadian occupational performance outcome measure; Q1, Q3: 25th and 75th quartiles; M: mean; ODI: Oswestry disability index; SD: standard deviation.

Figure 1.

Patient and data inclusion chart.

Improvement in function and disability over time

Occupational performance and satisfaction, lifting confidence and disability levels all improved over time, Figure 2. There was substantial improvement in disability (ODI) and self-efficacy up to 3 months post-discharge; however, those two outcomes declined slightly again by 6-months post discharge.

Figure 2.

Average (SE) scores on lifting confidence (kg), occupational performance and satisfaction (Canadian occupational performance measure; COPM), self-efficacy (pain self-efficacy questionnaire; PSEQ) and pain-related disability (Oswestry disability index, version 2; ODI).

Changes in occupational performance

Multilevel analyses using maximum likelihood estimation was used to examine changes in the occupation performance over time. Five multilevel models were evaluated in order to determine the association between self-efficacy and lifting confidence (kg) and occupational performance. These analyses examined improvements in model fit between each model.

For COPM performance scores, model 0 (unconditional means model) showed that 91.4% of the variance in occupational performance scores was attributable to variability between patients. Model 1 reduced the ICC from 0.91 to 0.54, indicating that time explained 41.0% of the variability in occupational performance between subjects. There were relatively modest effects of time between baseline and discharge (b = 0.96, 95% confidence interval (CI) 0.63 to 1.30), and larger effects by 3-month review (b = 1.44, 95% CI 1.05 to 1.82) and 6-month review (b = 1.49, 95% CI 1.13 to 1.84). Model 2 reduced the ICC further (ICC 0.32), with the combined effects of time and demographic characteristics (age, sex and education) explaining 64.7% of the variability between subjects. Women had a greater positive change in occupational performance than men (b = 0.80, 95% CI 0.12 to 1.47). While age (b = –0.03, 95% CI –0.053 to 0.003) and education (b = 0.05, 95% CI –0.036 to 0.14) did not contribute significantly, they did improve the overall fit in the model (Δ–2LL =650.98, P < 0.001), and were therefore retained as covariates in subsequent models.

The results from models 3 to 5 of the multilevel analyses are provided in Table 2. When model 3 included pain duration (b = 0.16, 95% CI –0.23 to 0.56) and baseline pain severity (b = –0.06, 95% CI –0.25 to 0.13) there was only a small improvement in model fit (Δ–2LL = 40.51, P < 0.001) and a marginal change in the ICC from 0.32 to 0.35. Pain severity and duration were therefore not retained in subsequent models. Model 4 showed that including PSEQ improved overall model fit, and now relatively more variance was attributable to between-subject variability such that 40.4% of variance was due to between-subject differences, and time explained 55.8% of the variability between subjects compared with the unconditional means model. Adjusting for PSEQ had marked impacts on occupational performance, reducing the variance attributable to time at discharge (from b = 1.44 to 0.71) and 6 months post-treatment (from b = 1.30 to 0.97). This effect highlights the important covariance for the relationship between perceived capacity to participate in everyday activities despite pain (i.e. self-efficacy) and ratings of occupational performance. In the first four models time-specific effects were generally the highest between pre-treatment and 3-month review, consistent with the highest ratings of occupational performance at 3-month review in Figure 2. The group level reduction in PSEQ between the 3-month and 6-month review is reflected in the reduction in parameter estimates of occupational performance at 6 months when adjusting for self-efficacy (i.e. from b = 1.30 to 0.97).

Table 2.

Multilevel analysis of occupational performance (COPM) over time (coefficients, standard error and model fit statistics).

	Occupational performance (COPM)
	Model 3			Model 4a			Model 4b			Model 5
	b	(SE)	P value	b	(SE)	P value	b	(SE)	P value	b	(SE)	P value
Intercept	3.41	(0.85)	<0.001	0.81	(1.04)	0.44	2.32	(0.87)	0.009	–0.14	(1.07)	0.89
Fixed effects
Age	–0.03	(0.01)	0.03	–0.03	(0.02)	0.10	–0.01	(0.01)	0.339	–0.01	(0.02)	0.59
Sex (female)	0.94	(0.33)	0.006	0.95	(0.35)	0.01	1.46	(0.35)	<0.001	1.60	(0.42)	<0.001
Education	0.04	(0.04)	0.31	0.09	(0.05)	0.08	<0.001	(0.04)	0.962	0.06	(0.05)	0.21
Repeated factor^a
Discharge	1.42	(0.34)	<0.001	0.74	(0.33)	0.03	1.14	(0.32)	0.001	0.71	(0.29)	0.02
6-Month review	1.54	(0.39)	<0.001	1.12	(0.36)	0.003	1.13	(0.36)	0.003	0.81	(0.30)	0.01
Modelled variables
Pain self-efficacy	–	–	–	0.06	(0.01)	<0.001	–	–	–	0.04	(0.01)	0.001
Lift (kg)	–	–	–	–	–	–	0.15	(0.04)	<0.001	0.13	(0.04)	0.004
Random parameter variance
Between-subject variability	0.21	(0.29)		0.30	(0.28)		0.50	(0.34)		0.70	(0.30)
ICC	0.12			0.21			0.31			0.51
Model fit statistics^b	335.19		<0.001	248.31		<0.001	311.26		<0.001	233.42		<0.001

^aRepeated measures data indicate effects at follow-up times relative to baseline.

^bSignificance for model fit statistic = change(Δ) in the –2*log likelihood according to the chi-square test.

Change in model fit for models 4a, 4b and 5 are compared with model 3.

To examine the contribution of objective changes in lifting confidence on occupational performance the models were retested excluding data from the 3-month review. Models 4a and 4b examined the impact of PSEQ and lifting confidence, respectively, on occupational performance, adjusting for time, demographics and within-subject change as per the preliminary models. Model 4a showed that PSEQ improved model fit (Δ–2LL = 86.88, P < 0.001) and time, age, sex, education and PSEQ collectively explaining 77.0% of the variability between subjects compared with the unconditional means model. While the magnitude of the effect of PSEQ was small (b = 0.06, P = <0.001), adding PSEQ to the model reduced the magnitude of the effects of time (discharge from b = 1.42 to b = 0.74; 6-month review from b = 1.54 to b = 1.12), highlighting that levels of self-efficacy make important contributions to between-subject variability, increasing the ICC from 0.12 to 0.21. Model 4b showed that adjusting for lifting confidence likewise improved model fit (Δ–2LL = 23.93, P < 0.001) relative to adjusting for time and demographics only. However, lifting confidence explained less variability (66.3%) between subjects than the PSEQ compared with the unconditional means model, and did not impact on the effects of time as much as PSEQ. That is, model 4b brought about smaller changes in the parameter estimates of time than those reported for PSEQ in model 4a, with discharge estimates changing from b = 1.42 to b = 1.12, and 6-month review estimates changing from b = 1.54 to b = 1.14. It therefore appears that the perceived capacity to engage in activities despite pain (i.e. PSEQ) has a stronger relationship with occupational performance than lifting confidence, especially at discharge and 6 months post-treatment.

Finally, model 5 included both lift and PSEQ alongside time and demographics, and improved the fit of the model much more than either factor alone with a Δ–2LL of 148.88 (P < 0.001). Model 5 showed that 50.8% of variability in occupational performance was attributable to between-subject differences, and that time, demographics, lifting confidence and self-efficacy together explained 44.4% of the variability between subjects compared with the unconditional means model. In this final model, the time-specific estimates also reduced markedly more when adjusting for both PSEQ and lifting confidence (discharge Δb = 0.74; 6-month review Δb = 0.71) than when adjusting for PSEQ (discharge Δb = 0.42; 6-month review Δb = 0.68) or lifting confidence (discharge Δb = 0.42; 6-month review Δb = 0.28) alone, when compared with model 3, which only included time and demographics.

Altogether, these results highlight that change in self-efficacy and lifting confidence together play an important role in client-perceived occupational performance both during and after treatment in a pain management programme; however, self-efficacy had a stronger association with longer-term occupational outcomes at the 6-months review than lifting confidence.

Change in disability (ODI)

Similar to the analyses examining client-perceived changes in occupational performance the same multilevel analytical approach was used to examine changes in disability over time. The unconditional means model (model 0) showed that 96.0% of variance in disability was attributable to variability between patients. Model 1 reduced the ICC from 0.96 to 0.59, showing that time explained 38.5% of the variability between subjects. The effects of time were not significant between baseline and discharge (b = −2.90, 95% CI –6.04 to 0.23), but were large between baseline and 3-month review (b = −6.99, 95% CI –10.74 to −3.23) and 6-month review (b = −4.01, 95% CI –7.33 to –0.69). Model 2 increased the ICC to 0.70, such that time and demographic characteristics (age, sex and education) explained 27.6% of the variability between subjects. Only education was associated with significant reductions in disability (b = −1.60, 95% CI –2.65 to –0.55), and age (b = 0.12, 95% CI –0.19 to 0.43) and sex (b = −0.25, 95% CI –7.46 to 6.96) did not contribute to the model. These demographic factors did, however, improve model fit (change in –2LL = 1442.19, P < 0.001) and were therefore retained as covariates in subsequent models. The results from models 3 to 5 of the multilevel analyses are provided in Table 3. In model 3 the inclusion of baseline pain severity (b = 3.87, 95% CI 2.21 to 5.53) brought about small improvements in model fit (change in –2LL = 18.56, P < 0.001) reducing the ICC to 0.58. Model 3 showed that 39.5% of variability between subjects in disability was explained by the factors modelled, and people with less severe pain at baseline had larger reductions in disability. When adjusting for demographic and pain characteristics in model 3, however, the fixed effects for time were no longer significant at discharge (b = 0.52, 95% CI –4.71 to 5.74), 3-month (b = 3.82, 95% CI –2.13 to 9.77) or 6-month reviews (b = 1.06, 95% CI –4.67 to 6.79).

Table 3.

Multilevel analysis of change in disability (Oswestry disability index, ODI) over time (coefficients, standard error and model fit statistics).

	Disability (ODI)
	Model 3			Model 4a			Model 4b			Model 5
	b	(SE)	P value	b	(SE)	P value	b	(SE)	P value	b	(SE)	P value
Intercept	35.65	(10.69)	0.002	51.74	(11.84)	<0.001	46.37	(10.91)	<0.001	63.94	(11.66)	<0.001
Fixed effects
Age	0.14	(0.13)	0.305	0.26	(0.15)	0.088	0.04	(0.13)	0.743	0.13	(0.14)	0.354
Sex (female)	–1.30	(3.03)	0.669	0.50	(3.25)	0.879	–4.73	(3.14)	0.139	–4.79	(3.47)	0.174
Education	–1.16	(0.45)	0.013	–1.61	(0.49)	0.002	–0.97	(0.44)	0.031	–1.54	(0.46)	0.001
Pain severity (baseline)	3.90	(0.81)	<0.001	3.15	(0.82)	<0.001	3.38	(0.79)	<0.001	2.72	(0.76)	0.001
Repeated factor^a
Discharge	0.91	(2.94)	0.758	3.38	(2.87)	0.246	1.59	(3.10)	0.611	3.62	(2.93)	0.223
Review 2 (6 months)	1.60	(3.25)	0.626	3.90	(3.15)	0.223	3.46	(3.35)	0.308	5.54	(3.16)	0.087
Modelled variables
Pain self-efficacy	–	–	–	–0.38	(0.12)	0.002	–	–	–	–0.28	(0.12)	0.020
Lift (kg)	–	–	–	–	–	–	–0.90	(0.34)	0.011	–1.06	(0.36)	0.005
Random parameter variance
Within subjects	59.74	(31.63)		59.07	(26.45)		43.78	(32.56)		41.09	(23.55)
ICC (within subject)	0.43			0.47			0.34			0.37
Model fit statistics^b	700.93		<0.001	583.76		<0.001	680.80		<0.001	568.71		<0.001

^aRepeated measures data indicate effects at follow-up times relative to baseline.

^bSignificance for model fit statistic = change(Δ) in the –2*log likelihood according to the chi-square test.

Change in model fit for models 4a, 4b and 5 are compared with model 3.

In model 4 pain self-efficacy improved model fit (change in –2LL = 144.25, P < 0.001), but slightly more variance (40.4%) was attributable to between-subject variability, with 40.4% of variance, and time explained 57.2% of the variability between subjects compared with the unconditional means model. Adjusting for PSEQ had marked impacts on disability, but only at the 3-month review (b = 6.95, 95% CI 0.87 to 13.03), and there were no significant effects at discharge (b = 3.22, 95% CI –1.99 to 8.43) or 6-month review (b = 3.72, 95% CI –1.96 to 9.41).

Model 4a excluded the 3-month review, as above, and adjusted for PSEQ in addition to time, demographics (age, sex, education) and baseline pain severity, and significantly improved model fit (change in –2LL = 1635.28, P < 0.001) compared with the unconditional means model. In model 4a 46.6% of variability in disability was attributable to between-subject differences, and time, age, sex education, baseline pain severity and PSEQ collectively explained 51.8% of the variability between subjects compared with the unconditional means model. Altogether, however, only education (b = −1.61, 95% CI –2.60 to –0.63), baseline pain severity (b = 3.15, 95% CI 1.50 to 4.80) and PSEQ (b = −0.38, 95% CI –0.60 to –0.15) were associated with disability. Adjusting for PSEQ increased the level of between-subject variability explained to 0.47. Time-specific effects were, again, not significant when adjusting for PSEQ. Model 4b showed that adjusting for lifting confidence instead of PSEQ likewise significantly improved model fit (change in –2LL = 1538.24, P < 0.001) relative to adjusting for time, demographics and pain severity only. In model 4b, 34.1% of variability in disability was attributable to between-subject differences, and time, age, sex, education, pain severity and lifting confidence explained 64.8% of the variability between subjects compared with the unconditional means model.

Finally, model 5 included both lifting confidence and PSEQ alongside demographic and pain characteristics, and showed that these factors improved model fit more than either factor alone (change in –2LL = 1650.33, P < 0.001) relative to the unconditional means model. In model 5, 37.2% of variability in disability was attributable to between-subject differences, and time, demographics, pain severity, lifting confidence and perceived capacity (PSEQ) together explained 61.5% of the variability between subjects. In this final model, however, time-specific estimates were again not significant.

These results show that, compared with client-perceived occupational performance outcomes, it appears that baseline characteristics (especially years of education and pain severity) have a stronger relationship with disability, which does not vary over time when accounting for demographic and pain characteristics. In baseline models, however, treatment only led to significant effects on disability at the 3-month review, whereas occupational performance significantly improved over all time points, with improvements in performance especially notable in women.

Discussion

The present study examined the effects of a multidisciplinary CBT-based group pain management programme on client-centred and disability-based functional outcomes during and up to 6 months post-treatment. We specifically examined the time-varying effects of pain self-efficacy and confidence in performing a functional task (lifting) on perceived occupational performance and disability. Overall, we found the greatest improvements in occupational performance, and reductions in disability between baseline and the 3-month review, with the magnitude of effects plateauing or reducing by 6 months post-discharge. This observation is similar to the findings in a systematic review of psychological therapies for chronic pain that showed that CBT-based treatment led to moderate improvements in disability, mood, pain and catastrophising, but that most effects were reduced by 6 months post-treatment (Williams et al., 2012). We found that broader appraisals of self-efficacy were a better predictor of occupational performance than performing a specific functional task (i.e. lifting a weighted box); however, both measures when considered together had the greatest capacity to predict functional outcomes.

Baseline characteristics (especially education and pain severity) were associated with disability but not with occupational performance. Effects of treatment on disability, however, were only observed at 3 months post-treatment completion. On the contrary, occupational performance significantly improved over all time points, with improvements in performance especially notable in women.

Both self-efficacy and lifting confidence varied synergistically with occupational performance and disability. These findings suggest that patient-centred assessments such as the COPM enable the identification of pertinent functional issues that treatment should target, and that these may lead to improvements in general appraisals of self-efficacy. It appears that practising and building confidence in a specific element, like lifting a weighted box, may not be sufficient to change broader perceptions of performance and disability as measured by the ODI. Rather, treatment appears to be more effective when it focuses on building mastery over personally significant activities despite the aversive effects of pain, which was the focus of the occupational therapy component of the CBT group programme for patients participating in this study. The experience of mastery during treatment appears to have enabled patients to build confidence to self-manage their pain and maintain function after leaving the supportive group setting. Targeting therapy on tasks relevant to the individual may reinforce self-management techniques in a more meaningful way that can be retained over time. This, in turn, improves confidence and a sense of mastery over pain and daily function leading to better long-term success in maintaining occupational performance.

Mastery is considered to be a central engine to motivation and task achievement that is generally transferable to a variety of settings. The present findings highlight that rehearsal and mastery during a CBT pain management programme, and subsequent maintenance of task performance, plays an important role in the synergistic gains observed between self-efficacy, lifting confidence and occupational performance. These findings have significant clinical implications for CBT-based pain management programmes to combine rehearsal (behavioural element) of task components that are relevant to patient-centred issues to enhance the internal sense of confidence (cognitive element), and for maintenance of functional improvements beyond completion of the programme.

The relationship between pain intensity and functional outcomes has been studied extensively, and many studies have shown that CBT-based programmes provide small to moderate, short-term effects on pain intensity (Williams et al., 2012). Other studies have shown that pain intensity is a tenuous predictor of functional outcomes, and this is not usually a primary target for behaviour change when treating persistent disabling pain (Sullivan and Ballantyne, 2016). In the present study baseline pain-related characteristics were not consistently associated with changes in occupational performance. In marked contrast, baseline pain severity was associated with pain-related disability such that people with less severe pain at baseline had greater reductions in pain-related disability. Moreover, improvements in pain-related disability were greatest at 3 months post-group, and were not significantly better than initial disability levels at discharge or 6 months post-group. However, it is notable that only five of the 10 items on the ODI are related to occupational performance issues (i.e., personal care, sleep, sex, social and travel), and there is no reference to work, house duties, driving, or community tasks and leisure, which are commonly identified as an issue by clients with chronic pain (Carpenter et al., 2001; Persson et al., 2013). When taken together, the present findings suggest that improvements in occupational performance may be associated with gains in mastery and self-efficacy, whereas reductions in disability are greater in people with less severe pain prior to treatment.

Occupational participation can be defined as engaging in tasks that are personally and socially significant where participation is both subjective and performance based and is dynamically influenced by external factors in the environment, the difficulty of the task, the skills of the individual and the social milieu (Peolsson et al., 2000). While people with chronic pain may be challenged by the complexity of everyday occupational tasks, performing routine tasks has a positive impact on subjective wellbeing (van Huet et al., 2009). For example, taking initiative, doing something physical, doing something for others and doing something social are important subjective determinants of quality of life for people with chronic pain (Borell et al., 2006). These themes highlight the significance of client-centred goal setting in facilitating meaningful participation in daily life that in turn leads to successful self-management. The present results suggest that the major gains from treatment were specific to occupational tasks that had meaning to the client, implicating personal investment to continue engaging in the task and achieving mastery.

Strengths and limitations

We found significant treatment effects from participating in a group programme; however, it remains unclear whether it is the programme as a whole or a specific component of the programme that generated those effects. Although most treatment effects had plateaued or reduced again by 6 months post-treatment, disability and occupational performance were still better than pre-treatment, suggesting that the CBT-based programme taught knowledge and skills to maintain some of the functional gains that were achieved within the programme. Whether these benefits arose due to the provision of structured self-care interventions, the presence of group dynamics and social support, the embryonic cognitive behavioural change that occurs within a CBT-based programme, the development of mastery, or all of these factors is not known. However, given that a key focus of CBT programmes and occupational therapy is to facilitate independent self-management it is promising that this cohort showed maintenance of functional improvements over time. Future research is required to better understand the most effective ‘ingredients’ in a CBT pain management programme, with a particular focus on the role of mastery and participation in meaningful activity versus non-meaningful rehearsal of skills. Moreover, future research could examine the distinction between disability and actual functional performance, and varying treatment effects for those respective clinical outcomes. Occupational therapists often have a limited role in the field of pain management both as clinicians and researchers, but they have a unique and valuable skill set focused on broad occupational engagement, and could make a significant contribution to leading advancements in evidence-based clinical practice (Lagueux et al., 2018).

Some other limitations with this study should be considered. The study involved a convenience sample of patients attending routine care. As such, clients were not randomly allocated to treatment, and were not compared with a control group. Previous research has shown that active CBT programmes are more effective than waitlist controls (Flor et al., 1992) and, although our lack of a control group is a limitation in the scientific rigour of the present study, we can nonetheless make generalisations to the effectiveness of clinical programmes in multidisciplinary pain management services.

The sample was heterogeneous, and reflected a typical pain management service; however, it was notable that participants had a relatively high level of education. While there was a high rate of loss to follow-up, the use of multilevel analyses allowed for the inclusion of all available data that is not possible in other repeated measures analytical approaches. Client-centred measures such as the COPM may have higher risk of response biases; however, the COPM is often used in pain research to measure patient-centred functional gains (Mead et al., 2007; Persson et al., 2013; van Huet and Williams, 2007), and varied over time in a similar pattern to self-efficacy and lifting confidence suggesting that the occupational performance appraisals from the COPM were true effects.

In conclusion, we found that patients had significant improvements in pain self-efficacy and function after participating in a CBT pain management programme, and that these improvements were maintained up to 6 months after group completion. The client-centred measure of occupational performance (i.e. the COPM) was the only outcome that continued to improve after completion of the group programme, and suggests that we need to consider what is important to the individual patient in treatment. On the contrary, patients did not have continued improvements when we measured disability with a generic disability measure. We suggest that these generic disability measures include many tasks that may not be relevant to the individual, and may fail to capture clinical gains that were important to the patient. The present findings highlight that the COPM, which aligns with Bandura’s theory on self-efficacy (Bandura and Schunk, 1981), was a clinically useful tool that could be integrated into routine care throughout a pain management programme. The use of the COPM as a clinically integrated tool may have provided additional clinical benefit as it allows clients to identify functional issues that matter in their everyday lives. This can then be used to develop a tailored programme that thereby enhances perseverance and goal achievement not only during treatment, but well beyond discharge.

Key findings

Participation in a multidisciplinary CBT-based pain management programme led to clinical improvements from baseline to 3 months post-group; however, only performance as measured on the COPM was sustained at 6 months post-treatment.

There is a co-varying relationship between confidence to function despite pain (self-efficacy) and perceived occupational performance, and this relationship was stronger than actual performance capacity.

Task mastery appears to have a greater influence on perceived occupational performance than just functional rehearsal.

What the study has added

This study has contributed to our understanding of the effects of a CBT-based pain management programme on pain self-efficacy, client-perceived occupational performance, disability and confidence in a physical task (lifting) over time.

Footnotes

Research ethics

The project was approved by the Alfred Health Human Research Ethics Committee (ID: 243/10, approval date: 9 September 2011).

Consent

All research participants provided written consent prior to using their data for research purposes. This is stated in the first paragraph of the method section.

Declaration of conflicting interests

The author(s) have no conflicts of interest to declare.

Funding

This project received support from a Caulfield Hospital small project grant.

Contributorship

The authors contributed to the research process from inception (FT, SJG, CAA, MJG), data collection (FT), data analysis (FT, MJG), writing the manuscript (FT, MJG), and editing and approval of the final manuscript (FT, SJG, CAA, MJG).

ORCID iD

Fiona Thomas

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