The Prevention Program for Chronic Pain: Solution to a Public and Personal Health Crisis
Empowering Patients Through Self-Care to Prevent Chronic Pain, Disability, and Addiction
Introduction. Chronic pain is the top reason people seek care, the most common cause of disability and addiction, and the primary driver of healthcare utilization, costing more than cancer, heart disease, and diabetes.1-9 The National Health Interview Survey (NHIS) found that 126 million adults (55.7%) experienced a pain condition with 20.1% having daily pain and 31.8% experiencing severe pain with over $600 billion in healthcare costs.7 When the pain condition becomes chronic, it is associated with addiction, depression, missed work, disability, functional interference, and intensive use of high-cost high-risk interventions including opioid analgesics, multiple medications, and surgery.4-14 These problems exist because over fifty percent of the people with common pain conditions continue to have pain five years later despite usual care treatment due to the presence of patient-centered risk factors such poor ergonomics, repetitive strain, social stressors, sleep disorders, anxiety and depression. These risk factors increase peripheral and central pain sensitization and are the primary cause of this delayed recovery and chronic pain and its consequences.14-18 Unfortunately, these risk factors are rarely addressed as part of usual care since health providers lack the time, training, tools, and reimbursement to guide patients in risk reducing self-care.1 If usual care fails, treatments often escalate to passive higher-risk interventions such as opioids, polypharmacy, surgery, or extensive medical and dental treatment instead of training patients to reduce the risk factors that drive pain conditions.12 Thus, the National Academy of Medicine (2011) report on Relieving Pain in America states that health professionals’ primary role for pain conditions should be guiding, coaching, and assisting patients with day-to-day self-care to reduce the patient-centered risk factors that lead to chronic pain. The Prevention Program (www.preventionprogram.com) was developed with funding from the National Institutes of Health to give healthcare providers an easy to implement solution to train and support patients in implementing self-care in their daily lives in addition to treatment. This paper describes the background, framework, development, telehealth coaching, technology platform, implementation strategy and outcomes for the Prevention Program (PP) to prevent the chronic pain, disability, and addiction.
The Impact of Chronic Pain. Chronic pain is characterized by debilitating personal suffering that can lead to depression, anxiety, and decreased quality of life. Individuals report persistent discomfort and emotional distress, significantly affecting their mental health and overall well-being. 41-45
Chronic pain can severely limit an individual's ability to perform daily activities, work, and engage in social interactions. Many individuals report difficulties with mobility, self-care, and recreational activities, leading to increased dependence on others. The economic burden of chronic pain is staggering, with estimates suggesting costs exceeding $600 billion annually in the United States alone, accounting for healthcare expenses, lost productivity, and disability.8 These costs underscore the urgent need for effective pain management strategies. Chronic pain is a leading cause of disability, limiting individuals' ability to work and engage in normative daily functions. The World Health Organization estimates that chronic pain leads to billions of lost workdays each year, contributing to a cycle of unemployment and poverty.19 The healthcare costs associated with treating chronic pain are significant. Patients often incur high expenses for medications, therapy, and medical consultations. Surgical interventions for pain management can also drive costs even higher, with many patients seeking multiple treatment options. Chronic pain can lead to decreased productivity in the workplace. Individuals suffering from chronic pain often experience absenteeism and working while experiencing pain, leading to decreased effectiveness and economic loss for employers.20 The societal implications of chronic pain extend into social conflict, as individuals with chronic pain often struggle with stigmatization and misunderstandings about their condition. This can lead to social isolation and conflict within personal and professional relationships, further exacerbating emotional and psychological burdens.
Preventing the Opioid Crisis. According to the Centers for Disease Control (CDC), the most recent data estimates that 142 Americans die every day from a drug overdose.5 The prevalence of chronic pain has contributed to rising rates of opioid prescriptions, leading to alarming rates of drug misuse and addiction. In the U.S., an estimated 21-29% of patients prescribed opioids for chronic pain misuse them, contributing to the opioid crisis.21 Many of these overdose deaths began with use of prescription opioids from physicians and dentists for pain conditions. Since the opioids are often blamed for this crisis, the solution most providers are currently implementing involves withdrawal and denial of the use opioids for pain conditions. However, as access to opioid prescriptions tightens, consumers in pain increasingly are turning to dangerous street opioids, heroin, and fentanyl. Medication replacement strategies with less addicting opioids is another common strategy to help patients taper off the use of opioid but does not address the continued chronic pain that they may have. It is clear that that a patient-centered multi-modal prevention program approach is needed to prevent both chronic pain and addiction behavior that includes both treatments as well as training of patients in self-management strategies to improves essential factors such as balance in mind, body, and emotions, motivation from having purpose in life, social support, and healthy environments. Prevention programs provide both patient self-management training with treatments to improve the pain with immediate treatment while addressing the risk factors that lead to chronic pain.
Prevalence and Incidence of Pain Conditions. Chronic pain arises from various pain conditions including inflammatory diseases, traumatic injuries, degenerative conditions, and neuropathic disorders. Musculoskeletal disorders such as myofascial pain, fibromyalgia, osteoarthritis and rheumatoid arthritis are the most common conditions involved in of chronic pain.22-23 The following conditions are the most common chronic pain conditions.
• Back pain affects approximately 540 million people globally at any given time. It is particularly prevalent among adults aged 30-50, with lifetime prevalence rates exceeding 80% with 25% of individuals have experienced back pain in the past three months, indicating persistent challenges in managing this condition. 24-25
• Headaches, including tension-type headaches and migraines, affect over 1 billion people globally. 26 Chronic migraine affects approximately 1-2% of the population, with individuals experiencing 15 or more headache days per month. This high prevalence leads to significant personal suffering and healthcare utilization, underscoring the need for effective management strategies.
• Temporomandibular joint disorder (TMJ) and other orofacial pain conditions impact 5-12% of adults.27 These conditions can lead to chronic pain, affecting eating, speaking, and overall quality of life. Women are disproportionately affected, and the incidence of TMJ pain often correlates with stress and bruxism (teeth clenching and grinding).
• Neck pain affects 30% of the population at some point in their lives, with a prevalence of 14.6% suffering from chronic neck pain.28 Similar to back pain, neck pain can be influenced by factors such as poor posture, sedentary lifestyles, and stress.
• Shoulder pain has an estimated prevalence of 10-30%, particularly among people aged 50 and older.29 Conditions such as rotator cuff injuries, adhesive capsulitis, and shoulder osteoarthritis contribute to this burden, impacting daily activities and quality of life.
• Hip pain, particularly associated with osteoarthritis, affects about 14% of individuals over 60.30 This type of chronic pain can limit mobility and significantly reduce overall functional status, leading to a diminished quality of life.
• Knee pain is highly prevalent in the aging population and impacts 22% of adults aged 50 and above. 31 Chronic knee pain often correlates with osteoarthritis, resulting in functional limitations and an increased risk of disability.
• Other chronic pain conditions, such as fibromyalgia, neuropathic pain, and complex regional pain syndrome, also contribute significantly to the burden of chronic pain. Fibromyalgia, for instance, affects an estimated 2-4% of the population, leading to widespread pain, fatigue, and cognitive impairment. 13
Risk Factors Increase Chronic Pain. An understanding of the multifaceted risk and protective factors involved in chronic pain is vital for healthcare professionals to provide comprehensive prevention strategies.32 The following sections outline key risk factors impacting recovery and the development of chronic pain. These include;
• Repetitive Muscle Strain. Regular strain on the muscles and joints through tensing and poor postural habits will increase tenderness and pain through peripheral sensitization and, if persistent, central sensitization.1-8
• Injury and delayed recovery. Individuals with a history of injury and acute pain are more likely to experience prolonged recovery and the recurrence of pain.34
• Genetic Predisposition. Genetics can influence pain sensitivity and the likelihood of developing chronic pain. Certain alleles associated with pain perception and inflammatory responses have been identified, such as variations in the COMT (catechol-O-methyltransferase) gene.33
• Co-morbid Medical Conditions. Chronic inflammation, autoimmune disorders, and metabolic diseases can complicate pain management and recovery. Conditions such as diabetes mellitus and rheumatoid arthritis are frequently associated with increased pain levels and prolonged recovery times.35
• Emotional Distress. Psychological and emotional variables such as anxiety, depression, and catastrophizing can significantly impact pain through central sensitization. Patients who exhibit high levels of negative emotional states often report exaggerated pain experiences and may be less likely to engage in proactive pain management strategies.35
• Pain-Fear-Avoidance Strain. Fear of re-injury or exacerbation of pain can lead to avoidance behaviors, limiting engaging in physical activity and contributing to increased strain and deconditioning—ultimately risking delayed recovery, prolonged pain and disability.36
• Socioeconomic Strain. Lower socioeconomic status has been linked to a greater risk of chronic pain and delayed recovery. This will limited access to healthcare, financial stress, and lower understanding of the causes of pain can negatively affect health outcomes for treatment of pain conditions.37
• Social Support Strain. The presence or absence of social support can influence an individual's coping mechanisms and pain outcomes. Strong social networks may facilitate self-care and recovery, while lack of support may contribute to feelings of isolation and exacerbated pain.38
• Physical Inactivity. Sedentary lifestyles are considered a significant risk factor for the development of chronic pain conditions, particularly in older adults. Lack of regular physical activity can lead to muscle weakening, joint stiffness, and an increased likelihood of pain recurrence.39
• Substance Misuse. The use of substances, including alcohol and opioids, can complicate recovery processes. Opioid dependence can mask pain and prevent appropriate treatment strategies from being employed.40
Protective Factors Prevent Chronic Pain. The recovery process from pain conditions can significantly benefit from identifying and leveraging protective actions to enhance resilience, promote healing, and prevent the transition to chronic pain and its consequences. These factors encompass biological, psychological, social, and lifestyle elements that, when combined, form a holistic approach to pain management. The following outlines key protective factors and actionable steps to facilitate recovery that can be included in prevention programs.
• Regular Exercise. Structured stretching, strengthening and aerobic exercise programs can support recovery by improving mobility, strength, and endurance while alleviating pain. Programs tailored to individual capacity and limitations maximize benefits and decrease the risk of re-injury.41-45
• Sleep Hygiene. Good sleep practices can reduce pain perception and improve overall health. Quality sleep is associated with better pain management, reduced fatigue, and improved emotional resilience, preventing chronic pain development.45-46
• Balanced Nutrition. A diet rich in anti-inflammatory foods—such as omega-3 fatty acids, fruits, and vegetables—can help manage inflammation and support recovery.47 Proper nutrition also aids in maintaining a healthy weight, which can alleviate stress on joints.
• Mindfulness, Relaxation, and Stress Management Techniques. Practices such as mindfulness meditation and relaxation techniques can decrease muscles strain and tensing, lower stress levels and promote emotional regulation, thereby reducing peripheral sensitization, central sensitization, and pain.48-52
• Cognitive Behavioral Therapy (CBT). CBT is effective in addressing negative thought patterns associated with pain. It helps individuals develop coping strategies, reduce emotional tension, and promote positive behavioral changes that facilitate recovery.48
• Social Support Systems. Engaging with supportive family, friends, and community resources can significantly enhance recovery. A strong social network can provide emotional support and encouragement, aiding in coping with pain and reducing feelings of isolation.53-55
• Access to Multi-disciplinary Healthcare Resources. Timely access to evidence-based healthcare and rehabilitation services is a critical protective factor. Early intervention by healthcare providers can facilitate timely treatment, while multidisciplinary approaches involving physical therapy, psychology, self-care training, health coaching, safe medication, and web-based interventions can enhance recovery outcomes.56-63
Prevention is a National Priority. The US Health and Human Services (USHHS) Strategy to Combat Opioid Abuse, Misuse, and Overdose, the Institute of Medicine and the Institute for Healthcare Improvement (IHI) share core principals to prevent chronic pain and it’s consequences.1-6 They recommend integrating self-management strategies in routine care to engage, educate and empower people in preventing chronic pain and addiction to achieve the IHI’s triple aim of improving the patient’s experience of care, enhancing the health of the patient, and controlling the cost of health care.64 In addition, the IHI has added additional aims of workforce well-being and safety and advancing health equity that can be supported by prevention programs.
However, there are many barriers for health professionals to implement self-management training as part of routine care. The lack of experience and reimbursable tools for preventive training are common hurdles. , and the focus on passive treatments such as medication, injections, and surgery all interfere with implementing self-management in clinical practice. Patient-centered prevention programs (PPs) are designed to overcome these barriers and support the health care system in shifting to patient-centered strategies and early intervention of acute pain to prevent chronic pain.65 PPs can also improve research data collection and analytics to inform a real-time public health response as the crisis evolves. PPs can conduct assessment of risk factors, protective factors, personal characteristics, and outcomes to provide“real-time” actionable data that can be used to personalize self-management strategies and maximize long-term efficacy. An analysis of the cost impact of PPs have demonstrated that the total cost of care for patients with pain conditions can be reduced by 50% or more with estimated minimum 8:1 annual return on investment (ROI) with long-term sustainability in future years.66-67
Development of The Prevention Program. Chronic pain self-management programs to prevent pain and illness have gained traction as effective strategies for empowering patients to manage their pain, improve function, and enhance quality of life. These programs typically focus on pain education, and cognitive behavioral change, stress management, and peer support.
Structured education programs provide information about the nature of pain, pain mechanisms, responsible medication management, coping strategies, the role of physical activity, the importance of self-monitoring and other information. 100 The knowledge about pain and its management can improve understanding and ability to cope while reducing anxiety. Participants often report decreased pain intensity and disability.. The effectiveness may depend on the quality of the educational content and the participant's engagement.
Cognitive Behavioral Therapy (CBT) approaches help patients modify negative thought patterns and pain behaviors to develop problem-solving skills for improved coping with pain. These can be delivered in group settings or one-on-one with trained therapists and may also include online formats. Studies have reported reductions in pain intensity, emotional distress, and improved coping strategies and functional status. 101-103 CBT requires access to trained therapists and can be time-intensive with outcomes varying based on individual engagement and motivation.
Stress reduction strategies can also improve chronic pain by incorporating mindfulness practices, yoga, and meditation to increase awareness of risk factors and promote relaxation.They are often delivered in group settings or through mobile applications and online platforms. They have shown significant improvements in pain perception, stress levels, emotional well-being, pain-related anxiety, and quality of life. 103-104. Similar to other self-care strategies, it requires discipline, regular practice with outcomes that vary based on individual responsiveness.
Another prevention strategy involves the use of peer support within community programs. These facilitate connections between individuals experiencing similar pain conditions through support groups or online forums with peer facilitators.105. The focus is on sharing experiences, advice, and encouragement among participants to reduce feelings of isolation and improve coping strategies. Participants often report feeling more empowered and less distressed. Success can depend on the quality of the group dynamics and the commitment of the participants.
Patient-centered technology platforms have been used in chronic pain programs and allow for assessments, education modules, progress tracking, and virtual counseling sessions. Users report Increased accessibility and adherence; high satisfaction with reduced pain intensity and improved self-efficacy. 106-110. This solution does requires technological literacy and access to the necessary technology.
Each of these strategies have been included in the development of the Prevention Program to provide a more comprehensive solution that is supported with technology with access by computer, mobile apps, telehealth, and online platforms. However, implementation of comprehensive self-care training to prevent chronic pain by any healthcare providers including physicians, dentists, physical therapies, mental health professionals, and public health policymakers requires a solution that is easy to implement, add minimal time to daily schedule, improve patient outcomes and satisfaction, and be reimbursed by health plans.
Prevention Program Framework. The Prevention Program uses the Chronic Care Model (CCM) as the primary framework for the PP.76 The CCM has documented evidence of its efficacy for many chronic conditions in more than 100 healthcare organizations. 77-80 The Prevention Program uses each of the 12 principles of implementing evidence-based self-management as part of routine patient care including; 1) brief targeted assessment, 2) evidence-based information to guide shared decision-making, 3) use of a nonjudgmental approach, (4) collaborative priority and goal setting, 5) collaborative problem solving, (6) self-management support by diverse providers including health coaches, 7) self-management interventions delivered by easy to use format, 8) patient self-efficacy measured and trained, 9) active follow-up, reminders, and reinforcement, 10) guideline-based case management for selected patients, 11) linkages to social support and community programs, and 12) multi-faceted interventions.76 Using the CCM as a framework, the basic components of a PP including pain and risk assessments, immediate self-care for all benign pain conditions, and educational modules to provide patients with both understanding, rationale, reduction of the risk factors, and implementation of protective factors. This framework also supports biological health, mental health, social connections, and healthy lifestyle choices as part of a comprehensive prevention program.
Telehealth Coaching. Telehealth coaches were used to support patients within the PP. They are trained with advanced health coaching degrees and can be nationally board certified by the National Board of Health and Wellness Coaching (www.nbhwc.org). Health coaching is a relationship-centered, client-driven process designed to facilitate and empower a client to achieve self-determined goals related to health and overall well-being. While client goals may be informed by or suggested by others, such as an individual’s physician or other health provider, the selection of the goal and exploration where one is relationship to the goal is up to the client. Telehealth Coaches collaborate directly with the referring provider as part of the interdisciplinary team for pain management similar to health psychologists and physical therapist. Telehealth Coaches are trained to review risk assessments and provide self-management training and support to patients with pain conditions to facilitate their knowledge and skills necessary for self- management.
Systematic reviews of social support and health coaching show they improve functional recovery from chronic pain.81-85 Health coaching provides a safe and consistent space to evaluate readiness for change and support positive change in health and well-being. Clients can explore their thoughts, emotions, and actions, in a way that allows them to recognize the power of their own choices to impact their wellness. Health Coaching is a methodology that differs from health education or counseling or therapy, though it can work well in combination with those other practices. Health Coaches assume that people have strong intrinsic resources and strengths, can access the self-motivation needed to function autonomously and competently, and are able to realize positive change within a safe and confidential alliance, where they are inspired, respected, and supported. By applying clearly defined knowledge and skills, they support individuals or groups in mobilizing their internal strengths and external resources to achieve sustainable changes in beliefs or behaviors. Health Coaching has the potential to help individuals, families, and groups achieve improved health and well-being with several strategies including setting goals, practice grounding, mindful calming, facilitating mindset and lifestyle change, empowering and engaging responsibly in achieving their goals. By applying clearly defined knowledge and skills, the health coach can support individuals or groups in mobilizing their internal strengths and external resources to achieve sustainable changes in thoughts, emotions, and behaviors to achieve their goal of improved health and wellbeing.
Patient Engagement Platform (PEP). An on-line technology platform was developed to facilitate implementation and engagement in the PP using strategies from previous research in web-based care solutions. 86-90. The PEP at www.prevention program.com is accessible by on-line devices including computer and mobile apps with following components:
• Pain Assessment. Digitally delivered validated assessments reviews patient signs, symptoms, pain severity, impact, functional status, past treatment, and current self-care to better understand a person’s personal characteristics, risks, and outcomes associated with algorithms to identify specific chronic condition and develop personalized care programs.
• Risk Assessment. Digitally delivered validated assessments reviews patient risk and protective factors in all areas of a patient’s life, their readiness to change, and adherence to training. These innovative assessments were developed and tested for use by health coaches and health providers to better understand a person’s personal characteristics, risks, and outcomes associated with a specific chronic condition and develop personalized care programs.
• On-line Training Modules. Systematic reviews of studies evaluating each component of the PP including healthy habits, mindful pauses, and calming relaxation using on-line training has demonstrated clear evidence-based outcomes. For example, systematic reviews of randomized clinical trials of mindfulness-based stress reduction, web-based cognitive behavioral therapy, exercise, and lifestyle changes show significant improvement with chronic pain.91-98
• Remote Monitoring Dashboard. A dashboard presents data to health coaches, health professionals, patients, and support team to better understand the personal characteristics of patients and track their progress. The dashboard includes results of baseline assessment of each patient’s personal characteristics, pain characteristics, current self-care, risk factors, protective actions, patient engagement, pain severity, and life interference. In addition, follow-up assessments provide detailed data on patient progress in both engagement in self-management as well as improvement in pain and interference.
• Predictive Data Analytics. Data algorithms and artificial intelligence leverage the data collected from the PP assessments and outcomes to identify the strategies and specific risk factors and protective actions that can best improve long-term outcomes for a specific patient.
• Artificial intelligence (AI). AI with the platform supports patient-centered engagement and self-care. AI is the simulation of human intelligence processes by computers using datasets, machine learning, and Natural Language Processing to improve education and engagement. Based on the pain and risk assessments, a validated evidence-based recommendations for prevention and self-management is provided. Both provider and patient solutions via chat-based interaction can leverage and integrate clinical data and patient-centered data from psychometrically derive patient assessments. The data can also be analyzed for correlations and patterns using clinical decision-making to make predictions barriers and present care solutions to improve outcomes.
Implementation Strategy. To expand the use of prevention programs, strategies were developed to easily implement PPs in routine care by providers.75 After a comprehensive evaluation by the provider to establish the diagnosis and treatment plan for the pain condition, the following steps have been developed to facilitate implementation of prevention program in addition to treatment;
• Training of Health Professionals in Prevention. Training programs are available for both health professionals and health coaches at https://www.centerwithin.com/courses-with-michele/#CEapproved. In addition, the on-line course at www.coursera.org/learn/chronic-pain provides consumers and health professionals with a review of risk and protective factors for chronic pain conditions and the supporting research. 68
• Consumer Awareness. Both consumers and health professional can be made aware of prevention programs through journal articles, website search engine articles, social media, and clinic brochures for patients and referring doctors. Interested participants can review the website at www.preventionprogram.com that describes the benefits of participating in the prevention program and reviews from participants .
• Shared decision-making (SDM). SDM is a collaborative process where patients and providers work together to make informed choices about the best treatment options.99 This approach emphasizes the patient's values, preferences, and individual circumstances alongside clinical evidence and expertise to facilitate a dialogue that leads to a joint decision including prevention. By empowering patients to participate actively in their care, SDM enhances patient satisfaction, promotes adherence to treatment plans, and can lead to improved health outcomes.
• Order Set for Electronic Health Record (EHR). Providers who choose to engage their patients in a prevention program can prescribe PP with a simple EHR order set. This will send a message to the patients to schedule their first visit to begin the process of self-management preventive care.
• Speed to Treat Self-care for Acute Pain Conditions. Timely self-care interventions are provided by the PP to begin the healing process for acute pain conditions. These recommendations can significantly address acute pain and prevent the transition from acute to chronic pain to improve long-term outcomes.88
• Avoid Opioid Medication. To combat the opioid crisis, it is crucial to focus on non-opioid interventions for managing chronic pain. Approaches such as physical therapy, cognitive-behavioral therapy, acupuncture, and mindfulness can provide effective alternatives to opioids.91
· Shift to Patient-Centered Concepts. The PP will help the patient, health professional, and the health care system shift to patient-centered clinical paradigms that facilitates patient engagement and empowerment in self-management resulting improved long-term outcomes (Table 1).
• Provide Whole-Person Care. The PP can help implement whole-person care to enhance the effectiveness of pain management strategies. Integrating physical, cognitive, emotional, spiritual, lifestyle, social, and environmental, aspects of health in treatment plans fosters comprehensive management that addresses underlying issues contributing to chronic pain.90
· Enrollment and Initial Visit. Participants can enroll in the PP either through self-referral to the website or through their health care clinic. Participants can enroll in the PP using the registration process at www.preventionprogram.com. At the health coach evaluation, the health coach will review the participants past history and diagnoses, ask the patient what their goals are, and introduce them to the PP. The HC will review the PP to help the patient focus on achieving their goals by reducing risk factors through protective actions in each of the seven realms of the person life. To bill the visit through a health plan, participants will also be scheduled with the PP’s healthcare provider to evaluate and explain the program. At the evaluation, the provider will review the patient’s signs and symptoms, past history and diagnoses, confirm the diagnoses, review criteria for participation in the PP, provide initial preventive medicine counseling to help the patient begin self-care and healing the pain condition. The healthcare provider will then schedule a 3 month follow to monitor patients engagement and success in the PP.
· Simple Action Plans. An action plan that is generated for each module includes 3 components: Healthy HABITS, daily PAUSEs, and CALMING practice. These action plans use evidence-based strategies to reduce risk factors for each realm of a person’s life including the mind, body, lifestyle, emotions, motivation, social life, and environment. This action plan reduces the strain to the muscles, joints and nerves to encourage healing. Overcoming barriers are also discussed to help completing the action plans. The PP has many resources that provide both on-line education and written handouts for each lesson including an action plan summary, a daily log, and worksheets for each lesson.
· Support by Family and Friends. Having friend or family team members who can support participants and encourage them along their journey. Each participant can sign up supporters at the beginning or at any time using the team link of the dashboard. Supporters will then receive communication on how to support the patients in the PP.
· Tracking Participant Engagement. Once the participant confirms their interest and is enrolled by the health coach, the participant can access the PP digital patient engagement platform (PEP) including the interactive website. The PP will sends out reminders to the participant to reinforce success and encourage completion of the program. The health coach will also schedule visits at 1 every 2 weeks intervals with the patient over the next months to complete and implement the whole program. The health coach communicates to the referring provider with regular documentation for billing. The visit times are typically schedule each week at the same time and day of the week. Reminders from both the PP platform and EHR can encourage patients to engage in the program. Patient are sent monthly progress assesments to track engagement and progress in achieving the patient’s goals. The Health coach will then review the progress to determine engagement in self-care, change in risk factors, overcome barriers, and improvement in the condition.
Outcomes and Billing.
With funding from the National Institutes of Health, the prevention program (PP) (www.preventionprogram.com) was developed to improve implementation of patient-centered self-care in routine medical and dental care. Initial outcomes research including a randomized clinical trial with the PP demonstrated positive recruitment, engagement, and improved pain and functional status. 68-75. Table 2 provides the structure and content of the program. Patients were introduced to the Prevention Program within a clinical setting with the simple request; “I am happy to provide treatment but it is more successful long-term if we also support you in reducing the causes of the pain. Are you interested?” With this question, most patients who were introduced to the PP wanted to participate. PP was implemented in three phases with shared decision-making at each visit including; 1) Initial patient-centered focused clinical evaluation with treatment planning, 2) PP implementation with assessment and telehealth coaching, and 3) Follow-up visits including preventive medicine counseling. Pre- and post- data that was collected for pain severity, personal impact, life interference, and prior health care use. In addition, data was collected for the mean number of medications taken for their condition, healthcare visits, healthcare use, and healthcare costs. The outcomes of the preventive program was evaluated with 604 patients. Table 3 provides the outcomes of a sample of these patients participating. The pain severity, interference and healthcare use were significantly improved.
The Prevention Program has also been billed through the participants health plan using the clinic’s electronic health record. All necessary documentation and billing codes are provided by the health coach and then submitted through the referring healthcare provider. Health plans including Medicare and Medicaid recognize the value of patient-centered prevention and have supported the prevention program using different CPT codes and documentation.92. Depending on the health plans, the CPT codes can billed under preventing substance misuse, chronic care management (CCM), or behavioral counseling. The use the CPT codes for Screening, Brief Intervention and Referral for Treatment to prevent chronic pain and associated substance misuse (SBIRT CPT 99409 and 99408 for Commercial and CPT G0397 for Medicare) has been supported by most health plans. In addition, Behavioral Health Management Support (CPT 90792, 90834 and 90837) and Chronic care management (CPT G0506, 99487, G2065, and 99358. Data from 1,684 claims submitted for PP reimbursement showing a mean 71% in-network reimbursement rate.92
Participant Comments. The experiences of Jessica, a 28-year old healthcare worker can help understanding the development and successful management of pain conditions. Jessica had neck and shoulder pain, migraine headaches and a temporomandibular pain disorder since her teen years. Recently, she was verbally abused at work because of her poor performance, which lead to post-traumatic stress, anxiety, depression, and more pain. In addition, her work position in a medical center call center forced her into poor posture with repetitive strain from talking, clenching her teeth, and extending her neck most of the day. The pain kept her up at night and her resultant fatigue, high caffeine use, and tensing caused more pain and headaches. When the pain flared, she went to the urgent care to help her control the pain and was prescribed anti-anxiety, anti-depressants, and opioid pain medications for years. She often over-used these medication and with side effects. Because of the persistent pain and anxiety, she requested a 3-month medical leave to recover from the pain and stress at work. She had many pain cycles that were sustaining her pain. Then, she was referred to the pain clinic that included a 4-month prevention program supported by health coach to understand the big picture of what was causing her pain and how to reduce the risk factors that was driving her pain cycle. By becoming empowered and engaged in her own health, she was able to maintain her healthy habits (exercise, posture, diet, sleep), pauses (mindfulness), and calming practice (relaxation) each day. She gained confidence in self-managing her own pain and was able shift away from medication and passive treatments. She returned to the workforce with a job that she enjoyed and avoided repetitive strain. She is also much happier with better relationships and a brighter future.
Other patients who have participated in the prevention program have provided comments to share. Kathy age 38 years with years of headache and neck pain stated, “PP was the most valuable part of my treatment plan and taught me many self-management strategies that do regularly to relieve and prevent my pain.” Monica, age 24 year with chronic facial pain commented, “PP has provide me confidence that I can self-manage my pain with some simple strategies and avoid the ongoing treatments and medications for pain that I have used for years.” Zoe, age 62 with chronic headaches, neck, and shoulder pain commented, “PP is incredibly helpful. I expect that in 10 years every doctor in the country will be using PP as part of their treatment for pain.” Steve, a 71 year old male with 20 years of chronic pain and 10 years of daily opioid use. “ I am off opioids in the past 3 weeks for the first time in years because I learned how to manage the pain myself. The health coaching has been great and I practice calming and stretching every day. It works to reduce my pain.” Marlene, a 76 year old female with severe pain from being hit by a car 2 years ago. “Each PP lesson is so valuable to help me reduce my pain. I print out each handout and take notes from each lesson. I follow the action plan daily and it works. The coaching has been also so helpful. I am now able to manage my pain.” Lisa, 17 years of age had severe pain in the jaw, head, and neck for the past 2 years. During her initial conversation with her health coach, she said pain was so severe, she could not take it anymore and considered suicide. She recovered and provided this comment.“The self-care has helped my pain so much and I’m not feeling sad about it anymore. Thank you.”
Summary. Chronic pain and other chronic illnesses are the big elephant in the room of health care. It is the top reason people seek care, the #1 cause of disability and addiction, and the primary driver of healthcare utilization, costing more than cancer, heart disease, and diabetes. The National Academy of Medicine (2011) report on Relieving Pain in America recommends that health professionals’ primary role for pain conditions should be guiding, coaching, and assisting patients with day-to-day self-care to reduce these risk factors using transformative care model. Prevention programs employ a variety of strategies, each with unique outcomes. Evidence suggests that preventive self-management programs can significantly empower individuals to successfully manage their chronic pain. While these programs yield positive results, the effectiveness and engagement can differ among individuals based on accessibility, engagement, and personal motivation. The Prevention Program (PP) has been developed and tested in randomized clinical trial and now in this case series. The studies demonstrate that preventing chronic pain and its consequences can be accomplished by providing patient-centered personalized training with telehealth coaching. Digital patient engagement platform also support prevention programs with assessments, participant engagement, risk-reduction training lessons, telehealth coaching, remote monitoring, and self-management support. This Prevention program at www.preventionprogram.com is ready for broad scale implementation and dissemination to identify broad scale outcomes, overcoming barriers and successful reimbursement by health plans.
References
1. Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. National Academies Press, Washington, DC; June 29, 2011.
2. Interagency Pain Research Coordinating Committee. National pain strategy: a comprehensive population health-level strategy for pain. Washington, DC: US Department of Health and Human Services, National Institutes of Health; 2016 at http://iprcc.nih.gov/docs/DraftHHSNationalPainStrategy.pdf. Accessed on January 10, 2016.
3. Institute for Clinical Systems Improvement. Guidelines for Chronic Pain. https://www.icsi.org/_asset/bw798b/ChronicPain.pdf. Access Feb. 11, 2106
4. Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, Myers C, Noonan MP, Owens J, Saeger L, Schweim K, Shteyman G, Walker N. Institute for Clinical Systems Improvement. Assessment and Management of Chronic Pain. Updated November 2013 at https://www.icsi.org/_asset/bw798b/ChronicPain.pdf. Access Feb. 11, 2016
5. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016. JAMA. 2016;315(15):1624–1645. doi:10.1001/jama.2016.1464
6. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Strategy to Combat Opioid Abuse, Misuse, and Overdose. A Framework Based on the Five Point Strategy. www.hhs.gov/opioids/sites/default/files/2018-09/opioid-fivepoint-strategy-20180917-508compliant.pdf
7. Dahlhamer J, Lucas J, Zelaya, C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults — United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1001–1006. DOI: http://dx.doi.org/10.15585/mmwr.mm6736a2external icon.
8. Appendix C. The Economic Costs of Pain in the United States by Darrell J. Gaskin, Ph.D. and Patrick Richard, Ph.D., M.A. in the Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington DC: National Academies Press; 2011.
9. Park PW, Dryer RD, Hegeman-Dingle R, Mardekian J, Zlateva G, Wolff GG MPH, Lamerato LE. Cost Burden of Chronic Pain Patients in a Large Integrated Delivery System in the United States. Pain Practice, Volume 16, Issue 8, 2016 1001–1011
10. Hestbaek L, Leboeuf-Yde C, Manniche C. Low-back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J 2003 Apr;12(2):149-65.
11. Deyo, RA; Mirza, SK; Turner, JA; Martin, BI (2009). Over-treating chronic back pain: time to back off? Journal of the American Board of Family Medicine: JABFM 22 (1): 62–8.
12. Wilco, et al Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J. 2011;20: 513–522
13. Yunus MB. Central sensitivity syndromes: a new paradigm and group nosology for fibromyalgia and overlapping conditions, and the related issue of disease versus illness. Semin Arthritis Rheum. 2008; 37(6): 339-52.
14. McGreevy K Bottros MM, Raja SN. Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and their Efficacy. Eur J Pain Suppl. 2011; 11:365-372.
15. Aggarwal VR, Macfarlane GJ, Farragher TM, McBeth J. Risk factors for onset of chronic oro-facial pain-results of the North Cheshire oro-facial pain prospective population study. Pain. 2010; 149(2): 354-9.
16. Scher AI, Stewart WF, Ricci JA, Lipton RB. Factors associated with the onset and remission of chronic daily headache in a population-based study. Pain 2003;106:1-2, 81-8
17. Cote P, Cassidy JD, Carroll LJ, Kristman V, The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain. 112 (2004) 267–273.
18. Scher AI, Stewart WF, Ricci JA, Lipton RB. Factors associated with the onset and remission of chronic daily headache in a population-based study. Pain. 2003;106:1-2, 81-89
19. Bhatia, A., Mahajan, R., & Bhargava, A. (2021). The impact of comorbid conditions on chronic pain: A systematic review. Pain Physician, 24(2), E135-E142. WHO (World Health Organization). (2019). Health and Well-Being: Chronic Pain. Retrieved from [WHO website link].
20. Loeppke, R., et al. Health and Productivity as a Business Strategy. Journal of Occupational and Environmental Medicine, 2006: 45(3), 299-305.
21. Volkow, N. D., et al. Prescription opioid and heroin abuse: A growing epidemic. JAMA, 2014:311(18), 1868-1869.
22. Rosomoff HL, Fishbain DA, Goldberg M, Santana R, Rosomoff RS. Physical findings in patients with chronic intractable benign pain of the neck and/or back [see comments]. Pain 1989;37(3):279-87.
23. Skootsky S, Jaeger, B, Oye, RK. Prevalence of myofascial pain in general internal medicine practice. Western Journal of Medicine 1989;151(2):157-60.
24. Buchbinder, R., et al. Low back pain. BMJ, 2018:363, k3274.
25. Manchikanti, L., et al. Epidemiology of low back pain in the United States. Pain Physician, 2014: 17(1), E67-E92.
26. Fei, Y., et al.. Global Burden of Headache Disorders: A Systematic Analysis. The Journal of Headache and Pain, 2020: 21(1), 150.
27. Schiffman, E., et al. (2014). The prevalence and severity of temporomandibular disorders: the Taub study. The Journal of Clinical Periodontology, 28(5), 685-694.
28. Katz, J. N., et al. Prevalence of neck pain in the United States. Neurology, 2015: 85(21), 1859-1866.
29. Pope, M. H., et al. The underpinnings of shoulder pain. Clinical Orthopaedics and Related Research, 2012: 470(9), 2792-2801.
30. Bisschops, M., et al. (2019). The Prevalence of Hip Osteoarthritis: A Systematic Review. PLOS ONE, 14(8), e0214191.
31. Li, E. C., et al. Epidemiology of knee pain in the United States. Orthopedic Clinics of North America, 2019: 50(1), 25-32.
32. Schmidt, C. O., et al. (2015). Psychological risk factors for chronic pain: A systematic review and meta-analysis. Health Psychology Review, 9(2), 246-265.
33. Heim, C., & Nemeroff, C. B. The role of genetic factors in chronic pain. Pain Research and Management, 2018.
34. Häuser, W., Bernardy, K., & Klose, P. Predictors of chronic pain after acute pain: A systematic review. Pain Practice, 2019:19(3), 300-307.
35. Tsaousides, T., & Gordon, W. A. Psychosocial factors in chronic pain: A comprehensive evaluation. Pain Management, 2009:1(4), 511-527.
36. Lee, J.H., Lee, M.H., & Lee, H.J. The role of fear-avoidance beliefs in chronic pain: A meta-analysis. European Journal of Pain, 2020:24(6), 985-996.
37. Turvey, C. L., et al. Socioeconomic status and chronic pain in older adults. The Journal of Pain, 2012:13(8), 810-817.
38. Valderas, J. M., et al. Social support and chronic pain: The role of the healthcare provider. Journal of Pain Research, 2014: 7, 273-283.
39. Sullivan, M. J. L., Martel, M. O., & Tripp, D. A. Physical activity and its relationship to pain and disability in chronic pain conditions. Pain, 2016:157(7), 1504-1510.
40. Dowell, D., et al. (2016). CDC Guideline for Prescribing Opioids for Chronic Pain. MMWR Recommendations and Reports, 65(1), 1-49.
41. Gordon R, Bloxham S. A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare (Basel). 2016 Jun; 4(2):22
42. Marley J, Tully MA, Porter-Armstrong A, Bunting B, O’Hanlon J, McDonough SM. A systematic review of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain—protocol. Systematic Reviews. 2014,3:106
43. Cramer H, Lauche R, Haller H, Dobos G. A systematic review and meta-analysis of yoga for low back pain. Clinical J of Pain. 2013; 29:450-460.
44. Hayden JA, van Tulder MW, Tomlinson G. Systematic Review: Strategies for Using Exercise Therapy To Improve Outcomes in Chronic Low Back Pain. Ann Intern Med. 2005;142:776-785
45. Cohen, S., et al. (2021). Sleep and pain: A bidirectional relationship. Pain Reports, 6(4), e861.
46. Tang NK, Lereya ST, Boulton H, Miller MA, Wolke D, Cappuccio FP. Nonpharmacological Treatments of Insomnia for Long-Term Painful Conditions: A Systematic Review and Meta-analysis of Patient-Reported Outcomes in Randomized Controlled Trials. Sleep, 2015, 38(11):1751-64
47. Gonzalez, A.J., et al. (2020). The effects of diet on chronic pain: A review of the evidence. Journal of Pain Research, 13, 1463-1475.
48. Harris P, Loveman E, Clegg A, Easton S, Berry N. Systematic review of cognitive behavioural therapy for the management of headaches and migraines in adults. Br J Pain. 2015 Nov; 9(4): 213–224.
49. Hilton L, Hempel S, Ewing BA, Apaydin E, Xenakis L, Newberry S, Colaiaco B, Maher AR, Shanman RM, Sorbero ME, Maglione MA. Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis. Ann Behav Med. 2016 Sep 22.
50. Garmon B, Philbrick J, Becker D, Schorling J, Padrick M, Goodman M, Owens JE. Mindfulness-based stress reduction for chronic pain: a systematic review. J of Pain Management. 2014; 7:23-36.
51. Galante J, Galante I, Bekkers MJ, Gallacher J. Effect of kindness-based meditation on health and well-being: a systematic review and meta-analysis. J Consult Clin Psychol. 2014 Dec;82(6):1101-14
52. Leppin AL, Gionfriddo MR, Sood A, Montori VM, Erwin PJ, Zeballos-Palacios C, Bora PR, Dulohery MM, Brito JP, Boehmer KR, Tilbur JC. The efficacy of resilience training programs: A systematic review protocol. Systematic Reviews. 2014; 3(1):20
53. Campbell P, Wynne-Jones G, Dunn KM. The influence of informal social support on risk and prognosis in spinal pain: A systematic review. European journal of pain. 2010, 15(5):444, e1-14
54. Fisher, E. B., et al. (2017). Family involvement in chronic pain management. Health Expectations, 20(2), 157-173.
55. Penington, A., & Wong, W. (2020). The role of social support in chronic pain management: A longitudinal review. Psychology and Health, 35(10), 1236-1251.
56. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets R J E M, Ostelo R W J G, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 2015; 350.
57. Weinstein, J. N., et al. (2018). Evidence-based practice in the management of chronic pain. Archives of Internal Medicine, 168(12), 1346-1352.
58. Holden J, Davidson M, O'Halloran PD. Health coaching for low back pain: a systematic review of the literature. Int J Clin Pract. 2014 Aug;68(8):950-62
59. Garg S, Garg D, Turin TC, Chowdhury MFU. Web-Based Interventions for Chronic Back Pain: A Systematic Review. J Med Internet Res. 2016 Jul; 18(7)
60. Buhrman M, Gordh T, Andersson G. Internet interventions for chronic pain including headache: A systematic review. Internet Interventions. 2016, 4(1):17–34
61. Gatchel, R. J., et al.. The biopsychosocial approach to chronic pain: Theory and practice. Psychological Bulletin, 2007: 133(4), 581-624.
62. Bair, M. J., Robinson, R. L., Katon, W., & Kroenke, K. (2003). Depression and pain comorbidity: a literature review. Archives of Internal Medicine, 2003: 163(20), 2433-2445.
63. Tavares, S., et al. (2021). Effectiveness of physical therapy interventions on pain management: A systematic review. Journal of Sports Medicine, 11(2), 195-210.
64. Institute for Healthcare Improvement’s (IHI) Triple Aim found at https://www.ihi.org/improvement-areas/improvement-area-triple-aim-and-population-health Accessed Jan. 11, 2025
65. Cameron, P.A., et al. (2019). The role of early intervention in the recovery of individuals with acute pain. Pain Medicine, 20(3), 511-520.
66. Miles CL, Pincus T, Carnes D, et al. Can we identify how programmes aimed at promoting self-management in musculoskeletal pain work and who benefits? A systematic review of sub-group analysis within RCTs. Eur J Pain. 2011;15(8):775.e771-711.
67. Clark, TS. Interdisciplinary treatment for chronic pain: is it worth the money? Proc (Bayl Univ Med Cent). 2000 Jul; 13(3): 240–243.
68. Fricton, JR, Anderson K, Clavel A, et al. Preventing Chronic Pain: A Human Systems Approach—Results From a Massive Open Online Course. Global Adv Health Med. 2015;4(5):23-32
69. Fricton, JR. The Need for Preventing Chronic Pain. Global Advances in Health and Medicine. 2015: 4(1), 6-7.
70. Fricton, JR, Gupta A, Weisberg MB, Clavel A. Can we Prevent Chronic Pain? Practical Pain Management. 2015; December:1-9
71. Fricton, J, Clavel A, Weisberg M. Transformative Care for Chronic Pain. Pain Week Journal. 2016, pp44-57.
72. Fricton J, Whitebird R, Vazquez-Benitez G, Grossman E, Ziegenfuss J, Lawson K. Transformative Self-Management for Chronic Pain Utilizing Online Training and Telehealth Coaching. Health Care Systems Research Conference; Apr 11, 2018; Minneapolis.
73. Grossman E, Vazquez-Benitez G, Whitebird R, Lawson K, Fricton J. A Self-Management Program for Chronic Pain utilizing Online Education and Telehealth Coaching, Findings of the Pilot Study. Health Care Systems Research Conference; Apr 12, 2018; Minneapolis.
74. Sour E, Ziegenfuss J, Grossman E, Vazquez-Benitez G, Whitebird R, Fricton J. Highly Motivated Population Provides Two Successful Recruitment Methods into the TMD Self-Care Study and PP Program. Health Care Systems Research Conference; Apr 11, 2018; Minneapolis.
75. Fricton J, Lawson K, Gerwin R (2024) Pain Prevention Program: Background and Outcomes to Prevent Chronic Pain, Addiction and Disability with Transformative Care. Adv Prev Med Health Care 7: 1061. DOI: 10.29011/2688-996X.001061
76. Battersby M; Von Korff M; Schaefer J; Davis C, Ludman E, Greene SM, Parkerton M, Wagner EH. Twelve Evidence-Based Principles for Implementing Self-Management Support in Primary Care. The Joint Commission Journal on Quality and Patient Safety. 2010, 36(12):561-570(10)
77. Russell E. Glasgow et al. Implementing Practical Interventions to Support Chronic Illness Self-Management. Joint Commission Journal on Quality and Patient Safety via Jt Comm. J Qual Patient Saf. 2003 29(11):563-574.
78. Gee PM, Greenwood DA, Paterniti DA, Ward D, Miller LMS. The eHealth Enhanced Chronic Care Model: A Theory Derivation Approach. J Med Internet Res. 2015;17(4):e86
79. Gammon D, Berntsen GKR, Koricho AT, Sygna K, Ruland C. The Chronic Care Model and Technological Research and Innovation: A Scoping Review at the Crossroads. J Med Internet Res. 2015;17(2):e25
80. Hamine S, Gerth-Guyette E, Faulx D, Green BB, Ginsburg AS. Impact of mHealth Chronic Disease Management on Treatment Adherence and Patient Outcomes: A Systematic Review. J Med Internet Res. 2015;17(2):e52
81. Bennett HD, Coleman EA, Parry C, Bodenheimer T, Chen EH. Health Coaching for Patients With Chronic Illness. Does your practice “give patients a fish” or “teach patients to fish”? Fam Pract Manag. 2010, 17(5):24-29
82. Gensichen J, von Korff M, Peitz M, et al. Case management for depression by health care assistants in small primary care practices. Ann Intern Med. 2009;151:369–378.
83. Vale MJ, Jelinek MV, Best JD, et al. Coaching patients on achieving cardiovascular health (COACH): A multicenter randomized trial in patients with coronary heart disease. Arch Intern Med. 2003;163:2775–2783.
84. Gary TL, Bone LR, Hill MN, et al. Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans. Prev Med. 2003;37:23–32.
85. J. Holden J, Davidson M, O'Halloran PD et al Health coaching for low back pain: a systematic review of the literature. Int J Clin Pract. 2014; 68:950-62.
86. Wantland DJ, Portillo CJ, Holzemer WL, Slaughter R, McGhee EM. The effectiveness of Web-based vs. non-Web-based interventions: a meta-analysis of behavioral change outcomes. J Med Internet Res. 2004; 6(4):e40.
87. Paul CL, Carey ML, Sanson-Fisher RW, Houlcroft LE, Turon HE. The impact of web-based approaches on psychosocial health in chronic physical and mental health conditions. Health Educ Res. 2013; 28(3):450-71
88. Lau PW, Lau EY, Wong del P, Ransdell L. A systematic review of information and communication technology-based interventions for promoting physical activity behavior change in children and adolescents. J Med Internet Res. 2011 Jul 13;13(3).
89. Debora Duarte Macea, Krzysztof Gajos, Yasser Armynd Daglia Calil, Felipe Fregni. The Efficacy of Web-Based Cognitive Behavioral Interventions for Chronic Pain: A Systematic Review and Meta-Analysis. The Journal of Pain. 2010 11(10): 917-929.
90. van den Berg MH, Schoones JW, Vliet Vlieland TP. Internet-based physical activity interventions: a systematic review of the literature. J Med Internet Res. 2007; 9(3):e26.
91. Kabat-Zinn, J., et al. Mindfulness-based interventions for chronic pain: A systematic review and meta-analysis." Journal of Pain, 2016: 17(7), 827-841. DOI: 10.1016/j.jpain.2016.03.009
92. Häuser, W., et al.. The role of exercise in chronic pain: A systematic review. Pain Research and Management, 2019, Article ID 5046425.
93. Fricton, J, Velly, A. Ouyang W., Look, J. Does exercise therapy improve headache? A systematic review with meta-analysis. Current Pain & Headache Reports. 13(6):413-419, 2009.
94. Lindsay, M., Main, C. J., & Foster, N. E.. Education for preventing chronic pain: A systematic review. BMJ Open, 2021:11(2), e043632.
95. Overland, K. S., et al. (2020). Peer Support Programs in Chronic Pain: A Systematic Review. Pain Medicine, 21(7), 1708-1717. DOI: 10.1093/pm/pnz295
96. Macea, Gajos K, Calil YAD, Fregni F, The efficacy of Web-based cognitive behavioral interventions for chronic pain: a systematic review and meta-analysis. J Pain. 2010;11:917–29
97. Bender JL, Radhakrishnan A, Diorio C, Englesakis M, Can pain be managed through the Internet? A systematic review of randomized controlled trials. Pain. 2011;152:1740–50.
98. Gordon, A. D., et al. (2020). Web-based self-management for chronic pain: Evidence review and clinical recommendation." Pain Physician, 23(3), 161-175.
99. American College of Physicians (ACP) (2019).Shared Decision-Making in Clinical Practice: A Practical Guide. ACP Guidance (https://www.acpjournals.org/doi/abs/10.7326/M18-1413)
100. Lorig, K. R., and Holman, H. R. (2013). Self-management education: History, definition, outcomes, and mechanisms. Preventing Chronic Disease, 10, E250. Available at: https://www.cdc.gov/pcd/issues/2013/12_0098.htm
101. Eccleston, C., et al. (2014). Delivering CBT for Chronic Pain: A Controlled Trial of a Therapist-Supported Internet Intervention. Pain, 155(1), 678–687. DOI: 10.1016/j.pain.2013.10.005
102. Cherkin DC, Sherman KJ, Balderson BH; et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA. 2016;315(12):1240-1249
103. Vowles, K. E., & McCracken, L. M. (2016). Acceptance and Commitment Therapy for chronic pain: A systematic review and meta-analysis. Pain, 157(11), 311-319. DOI: 10.1097/j.pain.0000000000000612
104. Gatchel, R. J., and Turk, D. C. (2016). The biopsychosocial approach to chronic pain: Theory and evidence. Psychological Bulletin, 142(8), 777-802. DOI: 10.1037/bul0000065
105. Overland, K. S., et al. Peer Support Programs in Chronic Pain: A Systematic Review. Pain Medicine, 2020: 21(7), 1708-1717. DOI: 10.1093/pm/pnz295
106. Woodford, H., and Bunt, L.. An Overview of Internet-Delivered Pain Management Programs: Clinical Effectiveness and Considerations for Practice." Pain Medicine, 2016: 17(8), 1473-1487. DOI: 10.1093/pm/pnw041
107. Eaton LH, Doorenbos AZ, Schmitz KL, Carpenter KM, McGregor BA. Establishing treatment fidelity in a web-based behavioral intervention study. Nurs Res. 2011; 60(6):430-5.
108. O'Sullivan, S. B., and Schmitz, T. (2015). Physiotherapy Management of Chronic Pain In Physical Rehabilitation, 6th Edition. F.A. Davis Company.
109. Bartholomew, LK, Mullen, PD. Five roles for using theory and evidence in the design and testing of behavior change interventions. Journal of Public Health Dentistry. Special Issue: Behavioral and Social Intervention Research Essentials. 2011; 71( s1): 1752-7325
110. Fry JP, Neff RA. Periodic prompts and reminders in health promotion and health behavior interventions: systematic review. J Med Internet Res. 2009 May 14;11(2):e16. doi: 10.2196/jmir.1138
