Chronic Pain Self-Management Support With Pain Science Education and Exercise (COMMENCE) for People With Chronic Pain and Multiple Comorbidities: A Randomized Controlled Trial

Published:January 28, 2020DOI:



      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.


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


      Community health center.


      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.


      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.


      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.


      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.


      List of abbreviations:

      COMMENCE (chronic pain self-management support with pain science education and exercise), MD (mean difference), PT (physiotherapist), RCT (randomized controlled trial), SMS (self-management support), WACHC (Woodstock and Area Community Health Center)
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        • Moulin D.E.
        • Clark A.J.
        • Speechley M.
        • Morley-Forster P.K.
        Chronic pain in Canada--prevalence, treatment, impact and the role of opioid analgesia.
        Pain Res Manag. 2002; 7: 179-184
        • Kennedy J.
        • Roll J.M.
        • Schraudner T.
        • Murphy S.
        • McPherson S.
        Prevalence of persistent pain in the U.S. adult population: new data from the 2010 National Health Interview Survey.
        J Pain. 2014; 15: 979-984
        • Langley P.C.
        The prevalence, correlates and treatment of pain in the European Union.
        Curr Med Res Opin. 2011; 27: 463-480
        • Murray C.J.
        • Abraham J.
        • Ali M.K.
        • et al.
        The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.
        JAMA. 2013; 310: 591-608
        • Langley P.
        • Müller-Schwefe G.
        • Nicolaou A.
        • Liedgens H.
        • Pergolizzi J.
        • Varrassi G.
        The impact of pain on labor force participation, absenteeism and presenteeism in the European Union.
        J Med Econ. 2010; 13: 662-672
        • Feuerstein M.
        • Hartzell M.
        • Rogers H.L.
        • Marcus S.C.
        Evidence-based practice for acute low back pain in primary care: patient outcomes and cost of care.
        Pain. 2006; 124: 140-149
        • Nolte S.
        • Osborne R.H.
        A systematic review of outcomes of chronic disease self-management interventions.
        Qual Life Res. 2013; 22: 1805-1816
        • Du S.
        • Yuan C.
        • Xiao X.
        • Chu J.
        • Qiu Y.
        • Qian H.
        Self-management programs for chronic musculoskeletal pain conditions: a systematic review and meta-analysis.
        Patient Educ Couns. 2011; 85: 299-310
        • Kroon F.P.
        • van der Burg L.R.
        • Buchbinder R.
        • Osborne R.H.
        • Johnston R.V.
        • Pitt V.
        Self-management education programmes for osteoarthritis.
        Cochrane Database Syst Rev. 2014; 1 (CD008963)
        • Casarett D.
        Designing pain research from the patient’s perspective: what trial end points are important to patients with chronic pain?.
        Pain Med. 2001; 2: 309-316
        • Louw A.
        • Diener I.
        • Butler D.S.
        • Puentedura E.J.
        The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain.
        Arch Phys Med Rehabil. 2011; 92: 2041-2056
        • Searle A.
        • Spink M.
        • Ho A.
        • Chuter V.
        Exercise interventions for the treatment of chronic low back pain: a systematic review and meta-analysis of randomised controlled trials.
        Clin Rehabil. 2015; 29: 1155-1167
        • Gross A.
        • Kay T.M.
        • Paquin J.P.
        • et al.
        Exercises for mechanical neck disorders.
        Cochrane Database Syst Rev. 2015; 1 (CD004250)
        • Eccleston C.
        • Morley S.J.
        • Williams A.C.
        Psychological approaches to chronic pain management: evidence and challenges.
        Br J Anaesth. 2013; 111: 59-63
        • Williams A.C.
        • Eccleston C.
        • Morley S.
        Psychological therapies for the management of chronic pain (excluding headache) in adults.
        Cochrane Database Syst Rev. 2012; 11 (CD007407)
        • Glynn L.G.
        • Valderas J.M.
        • Healy P.
        • et al.
        The prevalence of multimorbidity in primary care and its effect on health care utilization and cost.
        Fam Pract. 2011; 28: 516-523
        • van Oostrom S.H.
        • Picavet H.S.
        • de Bruin S.R.
        • et al.
        Multimorbidity of chronic diseases and health care utilization in general practice.
        BMC Fam Pract. 2014; 15: 61
        • Eckerblad J.
        • Theander K.
        • Ekdahl A.
        • et al.
        Symptom burden in community-dwelling older people with multimorbidity: a cross-sectional study.
        BMC Geriatr. 2015; 15: 1
        • Kadam U.T.
        • Croft P.R.
        Clinical multimorbidity and physical function in older adults: a record and health status linkage study in general practice.
        Fam Pract. 2007; 24: 412-419
        • Rijken M.
        • van Kerkhof M.
        • Dekker J.
        • Schellevis F.G.
        Comorbidity of chronic diseases: effects of disease pairs on physical and mental functioning.
        Qual Life Res. 2005; 14: 45-55
        • Vos T.
        • Flaxman A.D.
        • Naghavi M.
        • et al.
        Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
        Lancet. 2012; 380: 2163-2196
        • Kuo R.N.
        • Lai M.S.
        The influence of socio-economic status and multimorbidity patterns on healthcare costs: a six-year follow-up under a universal healthcare system.
        Int J Equity Health. 2013; 12: 69
        • Browne A.J.
        • Varcoe C.M.
        • Wong S.T.
        • et al.
        Closing the health equity gap: evidence-based strategies for primary health care organizations.
        Int J Equity Health. 2012; 11: 59
        • Miller J.
        • MacDermid J.C.
        • Walton D.M.
        • Richardson J.
        Chronic pain self-management support with pain science education and exercise (COMMENCE): study protocol for a randomized controlled trial.
        Trials. 2015; 16: 462
        • Swiontkowski M.F.
        • Engelberg R.
        • Martin D.P.
        • Agel J.
        Short musculoskeletal function assessment questionnaire: validity, reliability, and responsiveness.
        J Bone Joint Surg Am. 1999; 81: 1245-1260
        • Amtmann D.
        • Cook K.F.
        • Jensen M.P.
        • et al.
        Development of a PROMIS item bank to measure pain interference.
        Pain. 2010; 150: 173-182
        • Jensen M.P.
        Comparative reliability and validity of chronic pain intensity measures.
        Pain. 1999; 83: 157-162
        • Minnock P.
        • Kirwan J.
        • Bresnihan B.
        Fatigue is a reliable, sensitive and unique outcome measure in rheumatoid arthritis.
        Rheumatology (Oxford). 2009; 48: 1533-1536
        • Sullivan M.J.
        • Bishop S.
        • Pivik J.
        The pain catastrophizing scale: development and validation.
        Psychol Assess. 1995; 7: 432-524
        • Tkachuk G.A.
        • Harris C.A.
        Psychometric properties of the tampa scale for kinesiophobia-11 (TSK-11).
        J Pain. 2012; 13: 970-977
        • Nicholas M.K.
        Self-efficacy and chronic pain. Paper presented at: the Annual Conference British Psychological Society.
        St. Andrews, Scotland, October 1989
        • Nicholas M.K.
        The pain self-efficacy questionnaire: taking pain into account.
        Eur J Pain. 2007; 11: 153-163
        • Kroenke K.
        • Spitzer R.L.
        • Williams J.B.
        The PHQ-9.
        J Gen Intern Med. 2001; 16: 606-613
        • Catley M.J.
        • O’Connell N.E.
        • Moseley G.L.
        How good is the neurophysiology of pain questionnaire? A Rasch analysis of psychometric properties.
        J Pain. 2013; 14: 818-827
        • Huntley A.L.
        • Johnson R.
        • Purdy S.
        • Valderas J.M.
        • Salisbury C.
        Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide.
        Ann Fam Med. 2012; 10: 134-141
        • Elixhauser A.
        • Steiner C.
        • Harris D.R.
        • Coffey R.M.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Sullivan M.J.
        • Scott W.
        • Trost Z.
        Perceived injustice: a risk factor for problematic pain outcomes.
        Clin J Pain. 2012; 28: 484-488
        • Ruggiero K.J.
        Psychometric properties of the PTSD Checklist—Civilian Version.
        J Trauma Stress. 2003; 16: 495-502
        • Conybeare D.
        • Behar E.
        • Solomon A.
        • Newman M.G.
        • Borkovec T.D.
        The PTSD Checklist-Civilian Version: reliability, validity, and factor structure in a nonclinical sample.
        J Clin Psychol. 2012; 68: 699-713
        • Peters S.A.
        • Bots M.L.
        • den Ruijter H.M.
        • et al.
        Multiple imputation of missing repeated outcome measurements did not add to linear mixed-effects models.
        J Clin Epidemiol. 2012; 65: 686-695
        • Demidenko E.
        • Stukel T.A.
        Influence analysis for linear mixed-effects models.
        Stat Med. 2005; 24: 893-909
        • Muller K.E.
        • Edwards L.J.
        • Simpson S.L.
        • Taylor D.J.
        Statistical tests with accurate size and power for balanced linear mixed models.
        Stat Med. 2007; 26: 3639-3660
        • Monticone M.
        • Cedraschi C.
        • Ambrosini E.
        • et al.
        Cognitive-behavioural treatment for subacute and chronic neck pain.
        Cochrane Database Syst Rev. 2015; 5 (CD010664)
        • Eccleston C.
        • Williams A.C.
        • Morley S.
        Psychological therapies for the management of chronic pain (excluding headache) in adults.
        Cochrane Database Syst Rev. 2009; 2 (CD007407)
        • Henschke N.
        • Rwjg O.
        • Mw V.T.
        • et al.
        Behavioural treatment for chronic low-back pain.
        Cochrane Database Syst Rev. 2010; 7 (CD002014)
        • Bernardy K.
        • Klose P.
        • Aj B.
        • Ehs C.
        • Häuser W.
        Cognitive behavioural therapies for fibromyalgia.
        Cochrane Database Syst Rev. 2013; 9 (CD009796)
        • Busch A.J.
        • Schachter C.L.
        • Overend T.J.
        • Peloso P.M.
        • Barber K.A.
        Exercise for fibromyalgia: a systematic review.
        J Rheumatol. 2008; 35: 1130-1144
        • Newcomb L.W.
        • Koltyn K.F.
        • Morgan W.P.
        • Cook D.B.
        Influence of preferred versus prescribed exercise on pain in fibromyalgia.
        Med Sci Sports Exerc. 2011; 43: 1106-1113
        • van Koulil S.
        • van Lankveld W.
        • Kraaimaat F.W.
        • et al.
        Tailored cognitive-behavioral therapy and exercise training for high-risk patients with fibromyalgia.
        Arthritis Care Res (Hoboken). 2010; 62: 1377-1385
        • Peng P.
        • Choiniere M.
        • Dion D.
        • et al.
        Challenges in accessing multidisciplinary pain treatment facilities in Canada.
        Can J Anesth. 2007; 54: 977-984
        • Hogg M.N.
        • Gibson S.
        • Helou A.
        • Degabriele J.
        • Farrell M.J.
        Waiting in pain: a systematic investigation into the provision of persistent pain services in Australia.
        Med J Aust. 2012; 196: 386-390