DELIVERY OF PAIN COPING SKILLS TRAINING PROGRAM TO MANAGE
CHRONIC PAIN RELATED TO OSTEOARTHRITIS: THE PRIMARY CARE
PROVIDER ROLE

by

Patricia Obasi
BScN., University of Northern British Columbia, 2016

PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF MASTER OF SCIENCE IN NURSING: FAMILY NURSE
PRACTITIONER

UNIVERSITY OF NORTHERN BRITISH COLUMBIA
August 2021

© Patricia Obasi, 2021

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Abstract
Osteoarthritis (OA) is the primary form of arthritis that affects a large portion of the Canadian
population. With expected increases in OA prevalence over time, the magnitude of outcomes
related to inadequate pain control will place further burdens on society and healthcare resources.
Pain Coping Skills Training (PCST) is an intervention protocol derived from cognitive
behavioural therapy and has traditionally been delivered by clinical psychologists to manage
chronic pain related to OA. However, few providers in the primary care setting are trained in
PCST. The lack of trained primary care providers creates a barrier to patient access in the
community setting, which should be addressed. An integrative literature review has been
conducted to identify if primary care providers, who work in primary care settings, can deliver
PCST interventions to decrease pain interference and improve quality of life outcomes in adult
patients diagnosed with OA. The results are discussed within the context of Canada's primary
care practice. Eleven articles were reviewed using Whittemore and Knafl’s approach to the
integrative literature review. The results suggest that PCST interventions are both practical and
possible among providers that do not possess a background in mental health specialization. Thus,
primary care providers are encouraged to obtain educational competency to deliver this effective
therapy to manage the adverse psychological effects on chronic pain related to OA. This way,
providers can offer a biopsychosocial approach in managing OA while also playing an essential
role in improving access to PCST interventions in the primary care setting. Recommendations
for facilitating the uptake of PCST interventions are discussed, and specific strategies for its use
in primary care are presented.

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Table of Contents
Abstract ........................................................................................................................................... ii
List of Tables and Figures............................................................................................................... v
Acknowledgments.......................................................................................................................... vi
Glossary of Terms ......................................................................................................................... vii
Abbreviations ................................................................................................................................. xi
Chapter One: Introduction .......................................................................................................... 1
Chapter Two: Background and Context .................................................................................... 3
Incidence and Prevalence of Osteoarthritis................................................................................. 3
Pathophysiology of Osteoarthritis............................................................................................... 4
Clinical Manifestations ............................................................................................................... 6
Psychological Impact of Osteoarthritis ....................................................................................... 6
Chronic Non-cancer Pain ............................................................................................................ 8
Associated Concepts and Definitions ....................................................................................... 10
Pain Interference .................................................................................................................. 10
Quality of Life ....................................................................................................................... 11
Catastrophizing and Self- Efficacy ....................................................................................... 13
Management Options ................................................................................................................ 14
Pain Coping Skills Training ...................................................................................................... 16
Theoretical Models Supporting PCST ...................................................................................... 17
The Biopsychosocial Model .................................................................................................. 18
The Cognitive-Behavioral Model Therapy Model ................................................................ 19
The Primary Care Provider Role in Canada ............................................................................. 21
Chapter Three: Methods ............................................................................................................ 24
Selection of Databases .............................................................................................................. 24
Search Terms ............................................................................................................................ 25
Search of Databases .................................................................................................................. 25
Inclusion and Exclusion Criteria ............................................................................................... 26
Search Results ........................................................................................................................... 27
Approach to Analysis ................................................................................................................ 28
Chapter Four: Findings .............................................................................................................. 29
Pain Interference and Quality of Life Outcomes ...................................................................... 30
Pain Interference .................................................................................................................. 30
Quality of Life ....................................................................................................................... 35
Education .................................................................................................................................. 41

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Patient Education.................................................................................................................. 42
Provider Education ............................................................................................................... 44
Delivery Modality ..................................................................................................................... 46
Multidisciplinary Management ................................................................................................. 48
Chapter Five: Discussion ............................................................................................................ 53
Pain Interference and Quality of Life Outcomes ...................................................................... 53
Primary Care Provider Role ................................................................................................. 55
Education .................................................................................................................................. 56
Provider Education ............................................................................................................... 56
PCST Manual ........................................................................................................................ 57
Delivery Modality ..................................................................................................................... 60
Multidisciplinary Management ................................................................................................. 61
Recommendations ..................................................................................................................... 63
Limitations and Recommendations for Future Research .......................................................... 64
Conclusion ................................................................................................................................ 67
References .................................................................................................................................... 69
Appendix A .................................................................................................................................. 79
Appendix B .................................................................................................................................. 79
Appendix C .................................................................................................................................. 79
Appendix D .................................................................................................................................. 80
Appendix E .................................................................................................................................. 81
Appendix F .................................................................................................................................. 82

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List of Tables and Figures
Figure 1: The ABC Model
Table 1: Concept Table for Search Strategy
Table 2: Inclusion and Exclusion Criteria
Table 3: Summary of Recommendations for Primary Care Practice

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Acknowledgments
I would like to express my sincerest gratitude to my project supervisory committee
members, Linda Van Pelt and Lauren Irving. Thank you for your encouragement, wisdom and
guidance through this project.
I would also like to thank my family, whose unwavering support propelled me throughout
the years. To my loving parents, thank you for your emotional, financial and spiritual support
through this journey. I am honoured to be your daughter, and I hope that you are proud of this
accomplishment. To my brothers, Patrick and Paul, thank you for your words of wisdom and
amazing sense of humour shared over the past two years. I am truly blessed to have you all as my
constant supports despite being so far away.
To my partner, Brady, and his caring family, thank you for your unwavering support and
love that has kept me moving forward over the last two years.
To my amazing classmates turned friends, Elizabeth and Joselyn, thank you both for your
support and encouragement over the past two years. I genuinely cherish the bond we created
through this journey.

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Glossary of Terms
Apoptosis: the death of cells that occurs as a regular and controlled part of an organism's growth
or development.
Arthroplasty: an orthopedic surgical procedure where the articular surface of a musculoskeletal
joint is replaced, remodelled, or realigned.
Articular cartilage: the thin white layer of connective tissue that provides a lubricated surface for
low friction joint articulation.
Chondrocytes: cells found in healthy cartilage to maintain tissue homeostasis and integrity of the
cartilage matrix.
Cognitive Behavioural Therapy: an approach to psychotherapy that allows patients to engage in
an active coping process to change maladaptive thoughts and behaviours.
Collagenase: enzymes that break the peptide bonds in collagen.
Collagen fibres: the most common fibrous protein in the extracellular framework essential to
maintain tensile strength.
Cytokine: cell signalling molecules that aid cell to cell communication in immune responses and
stimulate cells' movement towards sites of inflammation, infection, and trauma.
Cytokine interleukin-1β (IL-1β): is a crucial mediator of the inflammatory response essential for
the host-response and pathogens' resistance. It also exacerbates damage during chronic
disease and acute tissue injury.
Intra-articular injections: injections administered into the joint space to provide pain relief in
mild to severe osteoarthritis. Includes corticosteroids, local anesthetics, and hyaluronic
acid.
Joint effusion: the abnormal accumulation of fluid in or around a joint resulting from trauma.

viii
Lipid metabolism: the synthesis and degradation of lipids in cells, involving the breakdown or
storage of fats for energy and the synthesis of structural and functional lipids, such as
those involved in constructing cell membranes.
Lumbosacral spine: the spine comprises five vertebral bodies (L1-L5) that extend from the lower
thoracic spine to the sacrum.
Nitric oxide: an essential endogenous mediator of vasodilatation, platelet function, inflammation,
and pain perception.
Nurse Practitioner: an Advanced Practice Nurse trained at the Masters level who integrate
clinical skills including the diagnosis and management of disease and chronic illness,
prescribing medications, ordering and interpreting diagnostic tests and labs, and initiating
specialist referrals.
Osteophyte: cartilage-capped bony proliferations or bone spurs that most commonly develop at
the margins of a synovial joint as a response to articular cartilage damage, seen in
osteoarthritis.
Pain Coping Skills Training: an intervention protocol derived from cognitive behavioural therapy
and has traditionally been delivered by clinical psychologists to manage chronic pain.
PCST includes four interventions: 1) relaxation response; 2) attention diversion
techniques; 3) altering activity and rest patterns; and 4) cognitive restructuring.
Pain interference: the impact that pain has on the patient’s daily life activities. Higher pain
interference is associated with more depressive or anxiety symptoms, which elicit
negative emotional states that may intensify the unpleasantness of pain and reduce the
patient’s coping capabilities.

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Periarticular muscles: the surrounding muscles across a joint that play a significant role in
ensuring joint stability.
Primary Care Providers: often, a patient’s first point of contact with the health system usually a
family physician or nurse practitioner.
Proteoglycans: protein molecules containing many bound glycosaminoglycans chains. They
regulate many cellular processes, such as adhesion, proliferation, migration,
differentiation, survival, and death.
Quality of Life: incorporates people's emotional, social, and physical well-being and ability to
function in ordinary living tasks.
Sciatica: pain radiating along the sciatic nerve, which branches from the lower back through the
hips and buttocks and down each leg.
Sclerosis: an unusual hardening or thickening of bone that occurs in joints affected by
osteoarthritis. The changes appear as bright, dense areas of bone on radiographs.
Selective serotonin reuptake inhibitors: a type of antidepressant drug that inhibits serotonin's
reabsorption by neurons, which increases the availability of serotonin as a
neurotransmitter.
Stromelysin: a member of the matrix metalloproteinase family that degrades non-collagen
connective tissue components, including proteoglycans, fibronectin, and laminin
Subchondral bone: the layer of bone below the cartilage joint that absorbers shock.
Subchondral cyst: a fluid-filled space that forms inside a joint, caused by stress-induced
microfractures of the subchondral bone noted in osteoarthritis.
Synovial membrane: a specialized connective tissue that lines the inner surface of capsules of
synovial joints and tendon sheath. It has a lubricating function.

x
Synovitis: inflammation of the joint-lining membrane resulting in pain and swelling due to fluid
collection in the synovial sac.
Tricyclic antidepressants: a class of antidepressants also used in the treatment of anxiety, bipolar
disorder, insomnia, fibromyalgia and the control of chronic pain.
Tumour necrosis factor-α (TNF-α) pathways: an inflammatory cytokine produced by
macrophages or monocytes during acute inflammation. It is responsible for a diverse
range of signalling events within cells, leading to necrosis or apoptosis.
.

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Abbreviations
CBT: Cognitive Behavioural Therapy
HRQOL: Health Related Quality of Life
NP: Nurse Practitioner
OA: Osteoarthritis
PCST: Pain Coping Skills Training
PCP: Primary Care Provider
PHC: Primary Health Care
PMR: Progressive Muscle Relaxation
QOL: Quality of Life

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Chapter One: Introduction
Osteoarthritis (OA) is the most common musculoskeletal disorder worldwide (Kean et
al., 2020; McCance & Huether, 2019). It impacts various joints, with hip and knee OA ranked as
the eleventh-highest contributors to global disability (Kean et al., 2020; McCance & Huether,
2019). Osteoarthritis does not result from a single cause but is multifactorial in origin. A wide
range of systemic, genetic, biomechanical, and environmental factors can contribute to OA
development (Fu et al., 2018; Kean et al., 2020; McCance & Huether, 2019). In Canada,
approximately 3.9 million adults over 20 years and older are diagnosed with OA (Government of
Canada, 2020). The genesis of OA involves contributions from both joint- and person-level risk
factors such as joint injuries, occupation, obesity (Kean et al., 2020; McCance & Huether, 2019).
Old age and female gender are thought to be systemic risk factors of OA (Kean et al., 2020;
McCance & Huether, 2019). Reduced range of motion, joint instability, swelling, crepitus,
muscle weakness, and pain-related psychological distress are commonly seen in patients with
OA. Among these symptoms, pain is the most dominant and significant driver for clinical
decision-making (Fu et al., 2018; Turk et al., 2016).
The traditional management of OA involves a combination of self-management strategies
such as exercise, weight management, coupled with medications to assist with joint pain and
inflammation and joint replacement surgery in severe cases (Kean et al., 2020; McCance &
Huether, 2019). However, OA is also associated with negative mental and social consequences
such as depression, anxiety, catastrophizing, isolation, and avoidance behaviors, which are not
addressed by the current management options (Fontaine, n.d; Miettinen et al., 2019; Turk et al.,
2016). Thus, approaching OA management from a biopsychosocial perspective would be a
holistic way to address the psychological effects suffered by patients with OA. The purpose of

2
this paper is to conduct an integrative literature review to answer the following question: “Does
the delivery of Pain Coping Skills Training (PCST) by primary care providers improve pain
interference and quality of life for adult patients with chronic pain related to OA?”
Pain Coping Skills Training is an intervention protocol derived from cognitive behavioral
therapy (CBT) for managing chronic pain related to OA (Broderick et al., 2014; Riddle et al.,
2011). Pain Coping Skills Training teaches attention diversion methods such as relaxation,
imagery, and distraction; activity-rest cycling; cognitive-restructuring; and behavioral rehearsal,
to allow long term application of pain coping skills (Broderick et al., 2014; Riddle et al., 2011).
Few primary care practitioners (PCPs) are trained to deliver PCST, as a clinical psychologist has
traditionally delivered it (Broderick et al., 2014; Riddle et al., 2011). However, the delivery of
PCST by PCPs, such as family physicians and nurse practitioners (NPs), could address gaps in
patient access.
By employing an integrative literature approach, I will analyze the pertinent literature
related to PCP delivery of PCST to patients with OA. A theoretical framework will not be
included to permit flexibility to explore the concepts. However, the biopsychological model and
the cognitive-behavioral therapy model will describe the importance of PCST in the care of
patients with OA. Chapter 3 will outline the methods used for this integrative literature search,
including tables summarizing the search process. Chapter 4 presents the findings of the literature
search and analyzed based on the recurrent themes. This will then be followed by a discussion of
the significance and relevance to PCPs in Chapter 5. Additionally, the limitations of this paper
will be discussed, as well as future practice recommendations and areas requiring further
research.

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Chapter Two: Background and Context
In this chapter, OA's incidence and prevalence in Canada are reviewed, followed by an
overview of OA pathogenesis, the clinical manifestations and psychological impact, which
entails the cognitive and psychological responses to pain. The pathological mechanisms
associated with chronic non-cancer pain will be explored. Relevant associated concepts such as
pain interference, quality of life, pain catastrophizing, and self-efficacy will be defined. The
traditional management options will also be discussed, and PCST rooted in cognitive behavioural
therapy will be discussed as a biopsychosocial treatment option. Theoretical models that support
PCST include The Biopsychosocial Model and The Cognitive-Behavioral Model Theory, which
will be discussed. Finally, the context of primary health care and primary care providers focusing
on the PCP role in Canada will be discussed.
Incidence and Prevalence of Osteoarthritis
Approximately 3.9 million (13.6%) Canadians aged 20 years and older live with
diagnosed OA, and 219,000 were newly diagnosed from 2016 to 2017 (Government of Canada,
2020). The prevalence and incidence of diagnosed OA increase with age and are higher among
females (16.1%) compared to males (11.1%) (Government of Canada, 2020). A study by Sharif
et al. (2015) performed projections on OA burden and estimate an increase in OA prevalence
from 13.8% in 2010 to 18.6% by 2031. With the projected increase of OA prevalence, the
productivity costs of work loss are estimated to increase from $12 billion in 2010 to $17.5 by
2031 (Sharif et al., 2015). Direct health care costs include the annual costs for drugs, visits to
health professionals, tests, hospitalizations, community services, and management of
comorbidities (Sharif et al., 2015). Developing effective and accessible pain management

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interventions will result in substantial savings in direct health care costs and reduce cumulative
productivity losses (Sharif et al., 2017).
Pathophysiology of Osteoarthritis
Osteoarthritis is the most common form of joint disease and is the leading cause of
disability in middle-aged and older adults (McCance & Huether, 2019). The primary
pathogenesis is characterized by the degradation of cartilage and bone remodeling due to an
active response of chondrocytes in the articular cartilage and the inflammatory cells in the
surrounding tissues (Hsu & Siwiec, 2020; Fu et al., 2017; McCance & Huether, 2019). There are
localized areas of progressive loss and damage of articular cartilage, the subchondral bone,
ligaments, capsule, synovial membrane, and periarticular muscles (Fu et al., 2017; McCance &
Huether, 2019). These changes lead to increased remodeling of the articular cartilage and a loss
of smooth, frictionless joint, which is visualized as a yellow-gray or brownish-gray appearance
on radiography (Fu et al., 2017; McCance & Huether, 2019). With the disease's progression,
areas of the articular cartilage begin to flake off and develop longitudinal fissures; this causes the
cartilage to thin out and permits areas of unprotected subchondral bone (Fu et al., 2017;
McCance & Huether, 2019). The unprotected subchondral bone becomes sclerotic and may
develop cysts that communicate with the cartilage's longitudinal fissures (Fu et al., 2017;
McCance & Huether, 2019). The articular cartilage eventually erodes and causes joint deformity
due to the cysts' pressure within the synovial cavity (McCance & Huether, 2019). Additionally,
osteophyte fragments contribute to synovial membrane irritation, which results in synovitis and
joint effusion (McCance & Huether, 2019). Next, the joint capsule becomes thickened and may
adhere to the deformed underlying bone, contributing to the range of motion limitations (Hsu &
Siwiec, 2020; Fu et al., 2017; McCance & Huether, 2019).

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As described by McCance and Huether (2019), the articular cartilage is also lost through
a cascade of cytokine, biochemical, and growth factor pathways. The first step of the enzymatic
processes involves the collagenase breakdown the macromolecules of proteoglycans,
glycosaminoglycans, and collagen into large diffusible fragments. These fragments are taken up
by the chondrocytes and digested by the cells own lysosomal enzymes. The loss of proteoglycans
from articular cartilage is a hallmark of the osteoarthritic process. Enzymatic destruction of
articular cartilage begins in the matrix by destroying proteoglycans and collagen fibers. Next,
stromelysin and collagenase enzymes affect proteoglycans by interfering with the proteoglycan
subunit's assembly or the proteoglycan aggregate, which are markedly elevated in OA. Changes
in the conformation of proteoglycans disrupt water and synovial fluid movement regulation into
and out of the cartilage. The distribution and active redistribution of the water and synovial fluid
evenly disperse the joint load across the cartilage. Thus, without the proteoglycan pump's
regulatory action, cartilage absorbs too much fluid and becomes unable to withstand weightbearing (Hsu & Siwiec, 2020; McCance & Huether, 2019). The proteoglycan content is also
decreased with aging by up to 8%, which affects the cartilage's strength (McCance & Huether,
2019).
Current research has demonstrated that inflammation is one of the critical factors leading
to the destruction of OA cartilage. Inflammatory cytokines IL-1β, IL-6, and TNF-α, apoptotic
molecules (COX – 2, nitric oxide [NO], prostaglandin E2, [PGE2], and prostaglandins play a
significant role in cartilage degradation partly due to induction on NO synthase and increased
NO generation (Barnett, 2018; Hsu & Siwiec, 2020; McCance & Huether, 2019). Furthermore,
Mehana et al. (2019) reports that enzyme matrix metalloproteinase-13 is a major contributor to
the degenerative process in OA. These chemical mediators release and activate proteolytic and

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collagenolytic enzymes, causing an imbalance of cell responses to growth factor activity
(Barnett, 2018; Hsu & Siwiec, 2020; McCance & Huether, 2019). These deposits cause
disequilibrium between inorganic phosphates and mineralization inhibitors while the NO
stimulates apoptosis in chondrocytes, with the resultant cartilage destruction initiates the IL-1β
and TNF-α pathways of inflammation (Barnett, 2018; Hsu & Siwiec, 2020; McCance & Huether,
2019).
Clinical Manifestations
Pain and stiffness are the predominant symptoms of OA. Additional symptoms include
swelling, tenderness, or enlargement/deformity of joints (Buttaro et al., 2021; McCance &
Huether, 2019). The symptoms are usually exaggerated by weight-bearing or use of the joint and
relieved through resting, supporting, bracing, or splinting the joint (Buttaro et al., 2021;
McCance & Huether, 2019). Referred pain may also be experienced. For example, OA of the
lumbosacral spine may mimic sciatica, causing severe pain in the back of the thigh along the
course of the sciatic nerve (Buttaro et al., 2021; McCance & Huether, 2019). Another example is
OA of the hip may cause pain referred to the lower thigh and knee area (Buttaro et al., 2021;
McCance & Huether, 2019). The mechanism of joint pain perception is complex, cartilage lacks
innervation; therefore, the sensation of pain is not experienced from cartilaginous damage alone
(Buttaro et al., 2021; McCance & Huether, 2019).
Psychological Impact of Osteoarthritis
Osteoarthritis often has a profound impact on an individual’s health and well-being since
it is associated with increased pain, decreased function, and elevated disability, with the
concomitant difficulties experienced in maintaining activities of daily living and subsequent
reductions in quality of life (QOL) (Stubbs et al., 2016; Turk et al., 2016). Thus, it is

7
unsurprising that people with OA are at greater risk of experiencing mental health problems.
Psychological comorbidities like anxiety and depression are highly prevalent among patients
with OA (Iijima et al., 2018; Sharma et al., 2016; Turk et al., 2016). These comorbidities are
frequently associated with higher pain and physical limitation, poor outcomes to conservative
and surgical interventions, and increased pharmacotherapy and health care utilization (Iijima et
al., 2018; Sharma et al., 2016; Turk et al., 2016).
A systematic review conducted by Sharma et al. (2016) evaluated the concordance
between OA, anxiety, and depression. The researchers found considerable overlap in reporting
the impact of these psychological conditions on patients with OA, with pain being the critical
central element. The prevalence of anxiety and depression was interrelated to index joint pain,
pain at multiple sites, pain intensity, and OA severity (Sharma et al., 2016). Osteoarthritis pain
was, in turn, associated with depression and its recurrence and predicted future fatigue,
disability, and depressed mood (Sharma et al., 2016). In addition to its impact on OA pain,
concurrent depression was also interrelated to significant participation restriction and physical
limitation (Sharma et al., 2016). This systematic review's findings coincided with a crosssectional study conducted by Iijima et al. (2018), which also indicated an association with
increased joint pain intensity and functional limitations in patients with knee OA.
The findings from both studies indicate the importance of incorporating self-care
management programs to manage these comorbidities. The current management interventions
being used revealed varied results, and this variability in patient care highlights the complicated
relationship between OA, anxiety, and depression (Iijima et al., 2018; Sharma et al., 2016).
However, these comorbidities are commonly overlooked by many PCPs who either solely focus
on the physical aspects of OA or fail to assess patients’ psychological states altogether (Sharma

8
et al., 2016). It is imperative to recognize these comorbidities influence disease course and
management, ultimately affecting functional outcomes. Anxiety and depression can significantly
impair the QOL of patients by altering pain perception and functional capacity. The next section
will explore the pathological mechanisms of chronic non-cancer pain (CNCP).
Chronic Non-cancer Pain
Chronic non-cancer pain is moderate or severe pain that lasts for six or more months,
often attributed to neuropathic pain, rheumatoid arthritis, lower back pain, osteoarthritis, or
fibromyalgia (Genova et al., 2020; Yasaei et al., 2020). Additionally, CNCP can arise from
various stressors such as physical or psychological trauma, an infectious process such as the
Ebstein Barr virus, underlying chronic diseases such as sickle cell anemia, or in the setting of
multiple episodes of acute pain (Yasaei et al., 2020). Chronic pain can be classified as
nociceptive, neuropathic, and central sensitization (Tauben & Stacey, 2020; Yasaei et al., 2020).
Nociceptive pain is caused by stimuli that result from bodily tissue damage (Tauben &
Stacey, 2020). Nociceptive pain is expected after surgical or acute traumatic injury affecting a
range of musculoskeletal and visceral conditions that involve inflammatory, ischemic, infectious,
or mechanical/compressive injury (Tauben & Stacey, 2020). Additionally, chronic pain may
occur with persisting nociceptive signalling from medical disorders despite aggressive treatment
for the underlying cause, such as degenerative, inflammatory, and neoplastic diseases (Tauben &
Stacey, 2020). Pain sensation is due to pronociceptive changes evident when afferent nociceptive
signals are amplified with a lack of descending modulation in the dorsal horn pathway by
serotonin's action norepinephrine (Tauben & Stacey, 2020). Chronic non-cancer pain can occur
from prolonged nociceptive stimulation, nerve injury, inflammation that can sensitize the pain

9
transmission fibres, the death of inhibitory cells, or neuroplastic structural changes (Yasaei et al.,
2020).
Neuropathic pain results from a maladaptive response to the somatosensory nervous
system's damage or pathology and consists of a central and peripheral disorder of pain
modulation (Tauben & Stacey, 2020). Often, damage to the nervous system results in only a loss
of function, such as numbness or weakness; however, with neuropathic pain, there is a gain of
function, which is pain (Tauben & Stacey, 2020). Neuropathic pain can occur in the absence of
an active noxious stimulus or as an exaggerated response to a minor or moderate nociceptive
stimulus (Tauben & Stacey, 2020). Examples of neuropathic pain include diabetic neuropathy,
postherpetic neuralgia, CNS sites of initial injury or disease such as stroke, spinal cord injury,
multiple sclerosis, phantom limb pain, and trigeminal neuralgia (Tauben & Stacey, 2020).
Central sensitization may also play a role in transforming acute pain into chronic pain
resulting in hyperalgesia or allodynia (Tauben & Stacey, 2020; Yasaei et al., 2020). Cortical
processes like alertness activate pain-facilitatory cells in the medulla, while various singlenucleotide-polymorphisms generate more or less pain sensitivity (Tauben & Stacey, 2020).
Pathophysiologic changes in functional MRI studies demonstrated that patients reported different
pain levels for standard stimuli with varied activation of the anterior cingulate gyrus, frontal
cortex, and somatosensory cortex (Tauben & Stacey, 2020). Central sensitization explains
clinical syndromes like fibromyalgia, rheumatic and common musculoskeletal disorders (Tauben
& Stacey, 2020; Yasaei et al., 2020). Visceral hyperalgesia also demonstrates central
sensitization, responsible for obscure pain present with chronic pancreatitis, chronic pelvic pain,
interstitial cystitis, and sickle cell disease (Tauben & Stacey, 2020; Yasaei et al., 2020).

10
As OA falls within CNCP, it is no surprise that it affects its sufferers' quality of life and
socio-economic activities and requires careful attention to management. There is no definitive
cure for chronic non-cancer pain; approximately 20% of patients with CNCP receive an opioid
prescription, however, the use of opioids for long-term treatment of CNCP does not show a
positive effect or improvement in the quality of life for patients and poses risks of dependency
and overdose (Yasaei et al., 2020). Studies suggest a multidisciplinary pain program developed
within a biopsychosocial model as a better approach to managing pain in this population
(Genova et al., 2020; Lachance & McCormack, 2019; Tauben & Stacey, 2020; Yasaei et al.,
2020). Pain Coping Skills Training falls within such a pain program, and although it is geared
towards OA sufferers in this project, it may be beneficial to other chronic pain conditions.
Associated Concepts and Definitions
Pain Interference
Pain interference is defined as the impact that pain has on the patient’s daily life activities
(Miettinen et al., 2019). Studies show that patients with higher pain interference are associated
with more depressive or anxiety symptoms (Miettinen et al., 2019). Depression and anxiety bring
forth negative emotional states that may intensify the unpleasantness of pain, reduce the patient’s
psychological resources, and diminish treatment results (Miettinen et al., 2019). The pain
interference subscale of the Brief Pain Inventory (BPI) is among the most commonly used
measures of this construct. The original BPI Pain Interference Subscale asks patients to indicate
the extent to which pain interferes with seven quality of life domains (general activity, mood,
walking ability, routine work [including housework], relations with other people, sleep, and
enjoyment of life) on 0 to 10 numerical rating scales (Jensen, 2011; Kean et al., 2016).

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Quality of Life
Quality of life incorporates people's emotional, social, and physical well-being and ability
to function in ordinary living tasks (WHO, 2012). It is an individuals’ perception of their
position in life in the context of their culture and value systems concerning their goals,
expectations, standards, and concerns (WHO, 2012). It is a broad-ranging concept affected in a
complex way by the persons’ physical health, psychological state, level of independence, social
relationships, and their relationship to their environment's salient features (WHO, 2012).
Measurement of QOL for individuals with OA offers a way to assess disease effects on daily
living, treatment value, and willingness to adhere to a given therapy (Fontaine, n.d.). This broad
conceptualization of QOL has led to the development of many QOL instruments. Among the
instruments are Health-Related Quality of Life (HRQOL) measures that address symptoms
specific to a disease or health condition (Baird & Sands, 2006; Fontaine, n.d.).
The persistent symptoms of OA can lead to a reduction in HRQOL. The primary physical
symptoms of OA that affect HRQOL are pain and mobility problems (Baird & Sands, 2006;
Fontaine, n.d.; Turk et al., 2016). These symptoms, in turn, can lead to problems with the ability
to perform activities of daily living (ADL) and to carry out instrumental activities of daily living
(IADL), such as shopping and home maintenance (Baird & Sands, 2006; Fontaine, n.d.; Turk et
al., 2016). Other significant components of HRQOL in patients with OA, such as social support
and social activity, are also affected by OA-associated pain and mobility problems (Baird &
Sands, 2006; Fontaine, n.d.; Turk et al., 2016).
Health-Related Quality of Life can be measured by using generic or specific instruments.
Generic instruments are not designed to assess HRQOL relative to a particular medical condition
but rather to provide a general sense of an illness's effects (Baird & Sands, 2006; Fontaine, n.d.).

12
One commonly used instrument is the Medical Outcomes Study Short-Form Health Survey (SF36), which measures HRQOL along with eight different domains: physical functioning, role
limitations due to physical problems, bodily pain, general health perception, vitality, social
functioning, role limitations due to emotional problems, and mental health (Baird & Sands, 2006;
Fontaine, n.d.). Other generic instruments used with arthritis patients include the Satisfaction
with Life Scale, the Extended Satisfaction with Life Scale, and the Quality of Life
Inventory/Scale (Baird & Sands, 2006; Broderick et al., 2016; Fontaine, n.d.). The second
approach to measuring HRQOL involves using instruments specific to a disease, population, or
clinical problem (Baird & Sands, 2006; Fontaine, n.d.). Measures geared toward specific
diseases or populations are likely to be more sensitive and have greater relevance to PCPs. The
Arthritis Impact Measurement Scale (AIMS) is a prime example of an arthritis-specific HRQOL
instrument (Baird & Sands, 2006; Broderick et al., 2016; Fontaine, n.d.). The AIMS measures
pain, mobility, walking and bending, extremity functioning, self-care, household tasks, social
activities and support, work, tension, and mood (Broderick et al., 2016; Fontaine, n.d.).
The major limitation of generic HRQL instruments is that they do not assess potential
condition-specific domains of HRQL (Fontaine, n.d.). Because of this, they may not be sensitive
enough to detect subtle treatment effects (Fontaine, n.d.). For example, an SF-36 assessment of
an arthritis patient will not provide a great deal of information on essential aspects of the illness,
such as joint pain, stiffness, and related symptoms on function, attitude, and mood (Fontaine,
n.d.). Although disease-specific instruments provide more focused assessments of HRQOL, there
is some consensus among QOL researchers that both generic and disease-specific instruments
should be used to provide the most comprehensive assessment of HRQL possible (Fontaine,
n.d.). For this integrative literature review, ‘QOL’ will be used to refer to HRQOL specifically.

13
Additionally, the QOL measures reviewed will include both generic and specific instruments to
ensure a comprehensive assessment.
Catastrophizing and Self- Efficacy
Depression can be exacerbated by other traits, such as catastrophizing and self-efficacy.
Catastrophizing tends to focus on the negative aspects of an experience such as feeling helpless,
ruminating, or exaggerating the threat of a situation (Swift, 2012; Turk et al., 2016). People who
score highly for both catastrophizing and depression tend to experience a synergistic increase in
pain and disability (Swift, 2012; Turk et al., 2016); This demonstrates the relationship between
negative emotion and pain perception. Catastrophizing can deleteriously bias perceptions,
expectations, memories, and experiences (Swift, 2012; Turk et al., 2016). Consequently, such
individuals may develop passive coping styles like rumination and helplessness that further
exacerbate their situation (Swift, 2012; Turk et al., 2016). A large volume of evidence suggests
that catastrophizing about pain plays a significant role in defining the actual pain experience. For
example, in a cross-sectional study on patients with OA of the knee, pain-related fear explained a
large proportion of variance in measures of psychological disability and walking speed (Somers
et al., 2009). This validates the importance of evaluating or assessing pain catastrophizing in
patients suffering from OA.
Catastrophizing is also linked to pain and depression via self-efficacy and the coping
strategies employed by people with OA (Swift, 2012; Turk et al., 2016). Self-efficacy is a belief
in one’s competence or a personal conviction that one can successfully execute a course of action
to produce the desired outcome in a given situation (Swift, 2012; Turk et al., 2016). Examples of
this in OA include a patient's belief about their ability to ambulate prolonged distances or climb
up a flight of stairs. Patients with a high sense of self-efficacy would likely feel capable and

14
confident in accomplishing these tasks; however, a patient with low self-efficacy may be unable
to. Efficacy beliefs are task- and situation-specific. Particularly for assessing chronic pain, they
include self-efficacy beliefs to manage pain, pain-related symptoms, and physical functioning
(Swift, 2012; Turk et al., 2016). Self-efficacy beliefs for people experiencing chronic pain
incorporate the expectation that they can perform a particular activity and their confidence in
accomplishing them despite pain (Swift, 2012; Turk et al., 2016).
Management Options
Standard pharmacological OA management involves a stepwise approach consisting of
initial use of topical analgesics, followed by oral analgesics and injectable agents (Buttaro et al.,
2021; Kean et al., 2020; McCance & Huether, 2019). Topical medications, including over-thecounter rubs, patches, and topical NSAID gel (diclofenac), may also be of some benefit (Buttaro
et al., 2021; Kean et al., 2020). Analgesics such as Acetaminophen used within the
recommended dosing reduces discomfort without the additional risks of anti-inflammatory
medications (Buttaro et al., 2021; Kean et al., 2020; McCance & Huether, 2019). Tramadol is a
non-opioid pain reliever indicated in those who report moderate to moderately severe pain
(Buttaro et al., 2021; Kean et al., 2020; McCance & Huether, 2019). NSAIDs have long been
part of OA's treatment regimen and are believed to be most beneficial for their analgesic rather
than their anti-inflammatory properties (Buttaro et al., 2021; Kean et al., 2020; McCance &
Huether, 2019). Intra-articular injections of exogenous hyaluronan can also help reduce the pain
of OA of the knees (Buttaro et al., 2021; Kean et al., 2020). However, it seems to be most
effective in mild to moderate OA and acts as a lubricant as it improves fluid viscosity within the
joint (Buttaro et al., 2021). Intra-articular corticosteroid injections such as Triamcinolone
acetonide (Kenalog) and methylprednisolone acetate (Depo-Medrol) can also provide significant

15
pain relief for mild to severe disease (Buttaro et al., 2021; Kean et al., 2020; McCance &
Huether, 2019). However, these injections are not recommended more often than every 3 to 4
months (Buttaro et al., 2021). Low-dose, long-acting opioids, gabapentin, selective serotonin
reuptake inhibitors, and tricyclic antidepressants have also been used adjunctively to manage
chronic pain associated with OA (Buttaro et al., 2021; Kean et al., 2020).
Obesity is the most important modifiable risk factor for knee OA; each pound of weight
increases loading across the knee threefold to sixfold (Buttaro et al., 2021; Kean et al., 2020).
The cartilage damage is related to mechanical problems and metabolic factors related to
abnormal lipid metabolism (Buttaro et al., 2021; Kean et al., 2020). Aerobic exercise can help
with cardiovascular conditioning and weight reduction (Buttaro et al., 2021; Kean et al., 2020).
Physical and occupational therapy can improve muscle strength and maintain range of motion
and functional capacity (Buttaro et al., 2021; Kean et al., 2020). Stretching programs can help
reduce contractures that lead to excessive joint wear (Buttaro et al., 2021). Assistive devices,
such as canes, walkers, and orthotics, can help reduce the load from lower extremity joints
(Buttaro et al., 2021; Kean et al., 2020). Heat and ice application may also provide symptomatic
relief and improve exercise tolerance (Buttaro et al., 2021; Kean et al., 2020). Ultimately, when
patients have ongoing symptomatology despite adherence to conservative medical management,
total joint replacement (called arthroplasty) may be recommended (Buttaro et al., 2021; Kean et
al., 2020; McCance & Huether, 2019). Hip and knee arthroplasty are not without risks but are
reported to be highly successful operations that relieve pain and functional status (Buttaro et al.,
2021; Kean et al., 2020; McCance & Huether, 2019). The next section explores PCST
interventions as another potential option in the management of chronic pain related to OA.

16
Pain Coping Skills Training
Pain Coping Skills Training is an intervention protocol derived from cognitive behavioral
therapy and has traditionally been delivered by clinical psychologists to manage chronic pain
related to OA (Broderick et al., 2014; Riddle et al., 2011). On average, patients are taught four
broad coping skills across ten 30 to 45-minute sessions (Broderick et al., 2014; Riddle et al.,
2011). Pain Coping Skills Training includes four interventions: 1) relaxation response; 2)
attention diversion techniques; 3) altering activity and rest patterns; and 4) cognitive
restructuring (Broderick et al., 2014; Riddle et al., 2011). The first applied skill is relaxation
training, which involves concentrating on muscle tension signals and using them as cues to relax
(Broderick et al., 2014; Riddle et al., 2011). In addition to this relaxation exercise, pleasant
imagery is another skill to aid in relaxation and distraction; this requires patients to visualize
various pleasant images to create a mental escape (Riddle et al., 2011). The second applied skill
is activity-rest cycling and pleasant activity scheduling, enabling patients to reduce pain and pace
their activity level (Broderick et al., 2014; Riddle et al., 2011).
In the third skill, activity-rest cycling, patients identify activities that cause overexertion.
This may include activities of daily living, such as housework or grocery shopping (Broderick et
al., 2014; Riddle et al., 2011). After the activities have been identified, the patients are then led
into scheduling sufficient periods of rest and are guided on how to gradually increase their
activity level as they decrease rest periods (Broderick et al., 2014; Riddle et al., 2011). An
essential aspect of this third intervention involves the patients identifying activities or hobbies
they enjoy and scheduling weekly goals (Broderick et al., 2014; Riddle et al., 2011). The fourth
skill is cognitive restructuring, which helps patients recognize the relationships between
thoughts, feelings, and behavior (Broderick et al., 2014; Riddle et al., 2011).

17
These techniques teach patients to identify irrational, maladaptive thoughts and replace
them with alternative, rational coping thoughts such as calming self-statements when in severe
pain (Broderick et al., 2014; Riddle et al., 2011). Also, necessary problem-solving skills
involving problem identification, generation of coping alternatives, evaluation of coping
alternatives, and selecting and implementing a problem solution are presented and practiced
(Broderick et al., 2014; Riddle et al., 2011). After all four interventions are completed, the goal is
for patients to develop a written maintenance plan and apply these learned skills to manage their
pain and enhance their perception of pain control (Broderick et al., 2014; Riddle et al., 2011).
Theoretical Models Supporting PCST
PCST originates from cognitive behavioral therapy, which is the most widely accepted
biopsychosocial treatment for chronic pain (Keefe & Somers, 2010). Pain has traditionally been
evaluated from a biomedical perspective that views pain as a symptom of underlying disease
activity (Keefe & Somers, 2010). This perspective draws attention to the changes in
inflammation and joint damage that can cause arthritis pain, and the medical treatments are
geared towards this underlying pathology (Keefe & Somers, 2010; McCance & Huether, 2019).
Clinical observations, however, reveal several weaknesses of the biomedical model, including
the discrepancies between patients with similar degrees of joint damage, the difference in
treatment response, and the fact that this model does not address the role of psychological factors
in the pain experience (Keefe & Somers, 2010). Chronic pain is viewed as an illness that cannot
be cured but only managed. Therefore, the biopsychosocial perspective is directed at the illness
rather than the disease, and this approach focuses on the diversity and the individual differences
in the overall pain experience (Gatchel & Howard, 2020).

18
The Biopsychosocial Model
The biopsychosocial model was first introduced in medicine by George L. Engel (1977),
tailored towards a holistic approach to addressing medical illness (Gatchel & Howard, 2020;
Turk et al., 2016). Subsequently, Loeser applied this model to pain. From this perspective, there
were four dimensions related to the idea of pain: nociception, pain, suffering, and pain behavior
(Gatchel & Howard, 2020; Turk et al., 2016). Nociception refers to the physiological
components associated with sensory input, such as nerve receptors and fibers, while pain is
described as a subjective perception resulting from sensory input (Gatchel & Howard, 2020).
While nociception and pain provide methods of communication to the central nervous system,
suffering and pain behavior, on the other hand, are described as reactions to those signals that
can be influenced by both previous experiences and anticipation of potential consequences
(Gatchel & Howard, 2020; Turk et al., 2016). Suffering can be seen as a negative affective
response to nociception or pain (Gatchel & Howard, 2020). Often, individuals who experience a
painful encounter will exhibit various emotional responses such as depression, anxiety, and fear
(Gatchel & Howard, 2020; Turk et al., 2016). Pain behavior is described in one’s actions while
suffering from pain. For example, fear of recurrence of pain or injury often leads to inactivity,
social isolation, and avoidance behaviors, which, in turn, can delay the progression of recovery
(Gatchel & Howard, 2020; Turk et al., 2016).
The biopsychosocial model shifts the emphasis from exclusive reliance on the
pathophysiology involved in the initiation of nociception to the involvement of the patient's
cognitive and emotional state and conditioned responses that influence an individual's pain
experiences and subsequent behavior (Gatchel & Howard, 2020; Turk et al., 2016). From this
perspective, assessment, diagnosis, prognosis, and consequently treatment of the patient with

19
persistent pain requires a broad strategy that not only examines the biomedical factors but also
incorporates a wide range of psychosocial and behavioral factors (Gatchel & Howard, 2020;
Turk et al., 2016).
The Cognitive-Behavioral Model Therapy Model
A psychiatrist invented the cognitive-behavioral therapy model, Aaron Beck, in the 1960s
from his observations from patient psychoanalysis (Martin, 2019; McLeod, 2019). He noted that
patients experienced an internal dialogue during these sessions and realized an essential link
between thoughts and feelings (Martin, 2019; McLeod, 2019). He invented automatic
thoughts to describe emotion-filled thoughts that happen without awareness and the need to
identify and manage negative thoughts (Martin, 2019; McLeod, 2019). Beck found that
identifying these thoughts would allow patients to understand and overcome their difficulties
(Cosio & Lin, 2017; Martin, 2019; McLeod, 2019). Cognitive Behavioral Therapy has
traditionally been efficacious in a wide range of conditions like insomnia, anxiety, substance use
disorders, and depression (Centre for Addiction and Mental Health, n.d; Martin, 2019; McLeod,
2019). However, this approach to psychotherapy also allows patients to engage in an active
coping process to change maladaptive thoughts and behaviors that can reduce chronic pain
exacerbation (Cosio & Lin, 2017; Martin, 2019; McLeod, 2019).
Cognitive Behavioral Therapy protocols introduce two aspects: the cognitive aspect and
the behavioral aspect (Cosio & Lin, 2017). The cognitive aspect includes automatic thinking and
cognitive restructuring, while the automatic thinking involves spontaneous “negative” thoughts
that come to mind when a particular situation occurs (Cosio & Lin, 2017). Cognitive distortions
are unconscious operations of the mind that people often act on, causing negative implications
(Cosio & Lin, 2017). This form of negative thinking causes an increase in pain perception (Cosio

20
& Lin, 2017). The first step to changing cognitive distortions is to recognize them. Negative
cognitive distortions fall into overgeneralization, applying mental filters by focusing solely on
negative aspects of an event, making decisions from minimal evidence, or rooted in emotions
(Cosio & Lin, 2017). After recognition of these negative thoughts and responses, cognitive
restructuring begins.
Cognitive restructuring is a useful tool for understanding and changing negative thinking.
It involves observing negative thoughts closely, challenging them, and re-scripting the negative
thinking behind them (Cosio & Lin, 2017). By engaging in this active process, the patient learns
to approach situations in a positive frame of mind (Cosio & Lin, 2017). The key idea behind
cognitive restructuring is the A-B-C model, which claims that the environment (activating EventA) affects cognitions (beliefs about the Event-B), which in turn drives our emotions and bodily
sensations (Consequences-C) (See Figure 1) (McLeod, 2019).

Figure 1. The ABC Model. From “Cognitive Behavioral Therapy,” by S. A. McLeod, 2019
(https://www.simplypsychology.org/cognitive-therapy.html). In the public domain.

Furthermore, CBT protocols introduce behavioral strategies, such as relaxation
techniques, time-based activity pacing, and pleasant activity scheduling, adopted in PCST
interventions (Broderick et al., 2014; Cosio & Lin, 2017; Riddle et al., 2011). Some relaxation
techniques employed in CBT include diaphragmatic breathing, progressive muscle relaxation,
and visual imagery (Cosio & Lin, 2017). Diaphragmatic breathing is the act of performing deep

21
inhalations by flexing the diaphragm, rather than shallow breathing by flexing the rib cage or
raising the shoulders (Cosio & Lin, 2017). This deep breathing optimizes oxygen consumption
and is often used as a therapy for pain management. Progressive muscle relaxation is a technique
for reducing muscle tension and entails both physical and mental components. Progressive
muscle relaxation is initiated by a physical component, in which patients are instructed to keep
their eyes closed and tense and relax different muscle groups in a sequential pattern (Cosio &
Lin, 2017). The mental component focuses on the difference between the feelings of tension and
relaxation. Closing of the eyes allows for focus and concentration on the sensation of tension and
relaxation (Cosio & Lin, 2017). In visual imagery, patients are guided through visualization to
create images that serve as messages from the unconscious to consciousness (Cosio & Lin,
2017). Time-based pacing or activity-rest cycling requires patients to list activities that cause
overexertion, limit the amount of time for the activity, and schedule rest periods (Cosio & Lin,
2017). Pleasant activity scheduling is another way to increase positive emotions by listing
pleasurable activities and scheduling them weekly (Cosio & Lin, 2017). Next, the role of PCPs
will be discussed with regard to OA management in the primary care practice model.

The Primary Care Provider Role in Canada
Patient access to PCST interventions is scarce because it is a therapy that has solely been
delivered by clinical psychologists in hospital settings (Broderick et al., 2014). Few PCPs are
trained to deliver PCST, limiting patient access in the community setting (Broderick et al., 2014).
Despite the lack of trained PCPs available to administer PCST interventions, access to general
health practitioners continues to be an issue in Canada. Many Canadian communities,
particularly those in rural and remote areas, face challenges accessing primary care and retaining
health care providers (Peckham et al., 2018). However, health access is problematic not only in

22
rural and remote areas but also in urban communities. Shah et al.'s (2016) study examined
potential access to care across 14 Canadian urban areas, representing all ten provinces, and found
considerable intra-urban variations in potential geographical accessibility to family physicians.
Furthermore, in 2019, 14.5% of Canadians aged 12 and older (roughly 4.6 million
people) reported that they had no regular HCP when requiring care or advice on their health
(Statistics Canada, 2019). The population most affected was identified as males and females
aged 18 to 34, and those aged 65 and older (Statistics Canada, 2019). The lack of PCPs and
unattached patients raises concerns about adequate and timely access to care for those diagnosed
with OA. This is particularly important to consider because OA's prevalence and incidence
generally increase with age and has been shown to affect Canadian adults from age 20
(Government of Canada, 2020).
Primary Care Providers are considered a patient’s first point of contact with the health
system and are expected to provide continuous care (Peckham et al., 2018). In Canada, the key
PCPs are family physicians and NPs (Peckham et al., 2018). Nurse Practitioners are Advanced
Practice Nurses (APNs) that complete Master’s-level education and are authorized to diagnose
illnesses autonomously, treat conditions, and provide evidence-based health education to their
patients with a population span that encompasses infancy to older adults (British Columbia
College of Nurses and Midwives [BCCNM], n.d.). In Canada, NPs have been proven to improve
access to health care by reducing wait times and alleviating pressures on the health-care system
achieved by providing patients with early diagnosis, preventive and curative interventions,
wellness strategies, and continuity of care in both primary health care settings and acute care
populations (BCCNM, n.d.; Canadian Nurses Association [CNA], 2016). Furthermore, the NP
role explicitly emphasizes implementing self-management and patient education counselling to

23
improve health outcomes in patients suffering from chronic illness and boost interprofessional
collaboration (BCCNM, n.d.; Writers, 2020).
Attaining patient-centred outcomes requires developing a supportive relationship and
ultimately takes time (Heale et al., 2018; Judge-Ellis & Wilson, 2017). Additionally, the amount
of time that providers spend with patients may affect the quality of care provided, especially for
preventive services and education (Judge-Ellis & Wilson, 2017). Interprofessional collaboration
with the primary care practice model may permit the delivery of PCST interventions. If in-person
delivery becomes problematic, PCPs can explore alternative delivery methods with proven
benefits, such as telephone delivery (Allen et al., 2019; Broderick et al., 2014), internet-based
delivery (Bennell et al., 2018; Giacobbi et al., 2015; Lawford et al., 2019), or potentially in a
group setting (Helminen et al., 2015). This time investment is necessary to develop long-term
coping benefits for the patients, which will lead to eventual health care cost savings.
Additionally, the implementation of PCST interventions would be valuable in rural and urban
primary care settings to bridge accessibility.
A comprehensive literature search was conducted to obtain relevant studies for review,
analysis, and synthesis. The search methodology for this process will be described in the next
chapter.

24
Chapter Three: Methods
A comprehensive literature search was performed by adapting Whittemore and Knafl’s
(2005) methodological approach to obtain a wholesome account of evidence salient to my
research question: Does the delivery of Pain Coping Skills Training (PCST) by primary care
providers improve pain interference and quality of life for adult patients with chronic pain related
to OA? The research question was constructed using the Population, Intervention, Comparison,
and Outcome (PICO) framework to guide the search (Gray et al., 2017). The stages included the
rationale for database selection, identification of key search terms, database search, inclusion and
exclusion criteria, a review of the search results, and a critical appraisal of the final selected
articles.
Selection of Databases
This literature search began by searching the University of Northern British Columbia
online library databases: PubMed (Ovid), Cumulative Index to Nursing and Allied Health
Literature (CINAHL EBSCOhost), PsychINFO (EBSCOhost) and the Web of Science
(Clarivate) in November, 2020. The PubMed database was selected as it served as a credible
search interface for biomedical literature (Williamson & Minter, 2019). The CINAHL database
was selected as it provided indexing for more than 3,000 English language journals and
publications in the field nursing, biomedicine, alternative/complementary medicine, consumer
health, and other allied health disciplines (EBSCO Health, n.d.). The PsychINFO database was
selected for its psychological research and applications (EBSCOhost, n.d.-a). The Web of
Science database was selected to review the curated collection of peer-reviewed literature and
resources regarding pain coping skills training (Web of Science, n.d.).

25
Search Terms
The Medical Subject Headings (MeSH) used by the National Library of Medicine
allowed me to utilize the same established search terms in each database. However, there were
slight variations due to the functionality of each program used. Relevant keywords and MeSH
terms were used to create a thorough search strategy which was then applied to the PubMed,
CINAHL, PsycINFO, and Web of Science database. The university librarian was also consulted
to ensure that all applicable MeSH terms and keyword combinations were optimized for this
integrative review. A concept table was created to illustrate the primary search strategy (see
Table1).
Table 1
Concept Table for Search Strategy
Concept

Keyword

MeSH

Primary Care providers

primary care
provider(s) OR nurse
practitioner(s) OR
family nurse
practitioner(s) OR
general practitioner(s)
pain coping OR pain
coping skills training
OR pain management
OR PCST
osteoarthritis OR OA
OR arthritis
quality of life OR
QOL

"Nurse
Practitioners"[Mesh]
OR "Family Nurse
Practitioners"[Mesh]
OR "General
Practitioners"[Mesh]
"Pain
Management"[Mesh]

Pain Coping Skills

Osteoarthritis
Quality of Life

CINAHL
Heading(s)
Physicians, Family
Nurse
Practitioners,
Nurse Practitioners

Pain Management

"Osteoarthritis"[Mesh] Osteoarthritis,
OR "Arthritis"[Mesh] Arthritis
"Quality of
Quality of Life
Life"[Mesh]

Search of Databases
The Boolean operators “AND” and “OR” were used to combine keywords, and
truncation was utilized when applicable to establish focused comprehensive results. Although

26
“Primary Care providers” is a key concept relevant to this integrative literature review, I
discovered that including this concept and the associated key words resulted in no results in the
CINAHL and PsychINFO database. Thus, this concept was exempted at this stage. Each
database search and results are presented in tables in the appendix section (see Appendix A, B,
C, D).
Inclusion and Exclusion Criteria
Eligibility was based on inclusion and exclusion criteria to identify relevant sources for
the integrative literature review. The English language was selected to ensure readability. I
included randomized controlled studies, qualitative studies, mixed methods studies, systematic
reviews, meta-analysis and reviews in peer-reviewed journals as integrative literature reviews
focus on analyzing original research and peer-reviewed journals. I excluded books, documents,
reviews, meeting briefs, commentaries and updates based on the same rationale.
Study populations of adults aged 19 and older were included to capture adults with chronic
pain related to OA. To ensure the generalizability of results, studies incorporating a variety of
ethnic populations were selected. Studies evaluating pediatric and adolescent patients were
excluded as this was not the population focus on this review.
It was important to include all primary care provider delivery of PCST to address the
research question. Studies that involved nurses, nurse practitioners, physicians, and
physiotherapists were included. Studies were excluded if PCST was solely delivered online, over
the phone, by psychologists or by the patient’s spouse. I excluded any results that focused on
acupuncture, dry needling, aquatic exercise, cod liver oil application, joint massage with oils,
pharmacological management or joint replacement surgery to avoid straying from the research
question.

27
To maintain a focus on OA, studies that focused on other causes of chronic pain or solely on
rheumatoid arthritis management were excluded. I included all results that had a focus on pain
coping skills, training, teaching, education, and management to explore other therapies that may
be grouped into the PCST. All results from the year 1976 to 2020 were included as there was
limited literature specifically addressing primary care provider delivery of PCST thus limiting
the time of publication would limit the search results even further. Table 2 depicts the eligibility
criteria utilized in the search.
Table 2
Inclusion and Exclusion Criteria
Inclusion

Exclusion

Publications from 1976 to 2020 were included as there
was limited literature specifically addressing primary
care provider delivery of PCST
Adults aged 19 and older were chosen to capture adults
with chronic pain related to OA
English language publications to ensure readability
RCTs, qualitative, meta-analyses, systematic reviews,
literature review or mixed design peer-reviewed
journals to ensure the highest level of evidence
Interventions delivered by nurses, nurse practitioners,
physicians, and physiotherapists in primary care
settings
Studies that included a diverse patient sample
Studies focused on pain coping skills, training,
teaching, education, or management to explore other
therapies that may be grouped into the PCST

None

Studies focused on OA management of the hip, knee,
and hand

Studies focused on other causes of chronic pain or
solely on rheumatoid arthritis, juvenile idiopathic
arthritis, AIDs, postoperative pain following
arthroplasty, and fibromyalgia

Literature focusing on individuals <19 years of age
Non-English language publications
Unpublished dissertation, editorial, news article,
opinion statement, books, documents, reviews, meeting
briefs, commentaries, and updates
Interventions solely delivered online, over the phone,
by clinical psychologists or by the patient’s spouse
None
Studies focused on acupuncture, dry needling, aquatic
exercise, moxibustion, cryotherapy, cod liver oil
application, laser therapy, joint massage with oils,
pharmacological management, or joint replacement
surgery

Search Results
Following the application of exclusion criteria, the cumulative search yielded 650 articles. The
articles were imported into the Zotero citation manager application to detect any duplicates. The

28
removal of duplicates resulted in 560 sources. Next, screening was performed by reviewing titles
and abstracts with the application of all eligibility criteria; 32 sources remained. The full-text
screening was then performed, and the eligibility criteria were reapplied to improve the
relevancy of the results to the research question. The full-text screening yielded 11 articles.
Additionally, reference lists were searched for relevant citations, however no additional articles
were found to be relevant to the research question. Lastly, to find relevant grey literature, a
Google search was conducted with the keyword’s osteoarthritis and pain management
guidelines. With this search, the American College of Rheumatology (ACR) website was
discovered and a link to their 2019 guidelines for the management of OA of the hand, hip, and
knee was reviewed. The ACR 2019 guideline will be included to aid discussion on psychosocial,
and mind- body approaches. A summary of the full search process with results is illustrated in
Appendix E.
Approach to Analysis
The initial analysis is presented in a literature review matrix that describes the Author(s),
Title, Journal, Year; Purpose/Aim; Methods; Sample; Findings; Strengths; and Limitations (see
Appendix F). A critical analysis of the eleven selected sources was undertaken using the Critical
Appraisal Skills Program (CASP) (2013) checklists to evaluate the strengths, limitations rigor,
validity, and strength of evidence in the included systematic reviews, randomized control trials
(RCTs), and qualitative study. By utilizing the CASP tool, each study’s rating is outlined in the
literature matrix found in Appendix F. Four themes emerged from my analysis: 1) Pain
Interference and Quality of Life Outcomes, 2) Education, 3) Delivery Modality, and 4)
Multidisciplinary management. The thematic analysis of the evidence is discussed in the next
chapter.

29
Chapter Four: Findings
The purpose of this integrative literature review was to explore the current evidence
surrounding the following research question: “Does the delivery of Pain Coping Skills Training
(PCST) by primary care providers improve pain interference and quality of life for adult patients
with chronic pain related to OA?” By following a comprehensive literature search, eleven
articles were selected and included in this review. In this section, the findings of the integrated
literature review will be presented by comparing the data and identifying accurate and
meaningful themes abstracted from the chosen literature.
The existing body of literature related to PCST interventions in the treatment of chronic
pain related to OA was mainly composed of systematic reviews (n=4) (Dixon et al., 2007;
Giacobbi et al., 2015; Ismail et al., 2017; Wang et al., 2020), quantitative studies (n=6) (Allen et
al., 2019; Baird & Sand, 2004; Bennell et al., 2017; Broderick et al., 2014; Helminen et al., 2015;
Riddle et al., 2019) as well as a qualitative study (n=1) (Lawford et al., 2019).
Overall, the participants included in the studies were a mix of Caucasian, Hispanic,
Asian, and African American, low to middle class, and comprised of adult men and women.
Limitations to use PCST were identified within this body of literature and will be discussed in
the next chapter. An in-depth description pertaining to each study’s purpose/aim, methods,
sample, findings, strengths, limitations, and CASP scores can be found in the literature matrix in
Appendix F and referred to while reading this section.
Through a critical analysis of the findings from each study, the following themes
emerged: 1) Pain Interference and Quality of Life Outcomes, 2) Education, 3) Delivery
Modality, and 4) Multidisciplinary management. These themes organize the presentation of
finding and guide the discussion of this review.

30
Pain Interference and Quality of Life Outcomes
The findings regarding the effects of PCST interventions on pain interference and QOL
outcomes were synthesized from two high-quality systematic reviews with meta-analyses (Dixon
et al., 2007; Wang et al., 2020), two systematic reviews (Ismail et al., 2017; Giacobbi et al.,
2015), and six individual studies (Allen et al., 2019; Baird & Sand, 2004; Bennell et al., 2017;
Broderick et al., 2014; Lawford et al., 2019; Riddle et al., 2019). Decreased pain interference and
improved QOL in these studies were reported using effect size, standardized mean difference
(SMD), estimated treatment difference (ETD), and repeated measures analysis of variance
(ANOVA). It is also important to note that there is a significant overlap between pain
interference and QOL outcome measures utilized within this body of literature; however, efforts
have been made to highlight the differences distinctively.
Pain Interference
In the high-quality quantitative RCT by Allen et al. (2019), a comprehensive list of
validated primary and secondary outcomes was measured. Focusing on pain interference, Allen
et al. (2019) utilized the Western Ontario and McMasters Universities Osteoarthritis Index
(WOMAC) pain subscale to measure the severity of pain during the past two weeks for different
activities such as walking, climbing stairs, sitting or lying, and standing. Additionally, the
PROMIS Pain Interference Instrument (Short-Form 6a) was used to report on the consequences
of pain over the past seven days across aspects of life, including social, cognitive, emotional,
physical, and recreational activities (Allen et al., 2019). The PROMIS Pain Interference score did
not differ significantly between both groups at either the 3- or 9-month follow-up (Allen et al.,
2019). At the 3-month follow-up, WOMAC pain scores did not differ significantly between the
PCST group and the waitlist group (ETD 0.63, 95% CI 1.45, 0.18; P 0.128) (Allen et al., 2019).

31
At the 9-month follow-up, WOMAC pain scores in the PCST group decreased from 3 months
but were not statistically different from the waitlist group (ETD 0.84, 95% CI 1.73, 0.06; P
0.068) (Allen et al., 2019). The Complier average causal effect (CACE) methods showed that
receipt of at least seven PCST sessions resulted in more significant and clinically meaningful
improvements (Allen et al., 2019). However, it was not statistically different from the control
group at either 3 or 9 months (difference in CACE estimated mean change 1.2,95% CI 2.4, 0.2
for three months and 1.4, 95% CI 2.8,0.1 for nine months) (Allen et al., 2019).
Baird and Sand (2004) studied tools to measure pain and physical activity, focusing on
mobility. The Arthritis Impact Measures (AIMS2) was used to measure Perceived pain. The
AIMS2 is a seven-item scale that measured current and usual pain, frequency of severe pain,
frequency of pain in more than two joints, persistent morning stiffness, pain interfering with
sleep, and fatigue (Baird & Sand, 2004). Mobility difficulties were assessed through seven items;
four items measured walking ability, and three items measured bending ability (Baird & Sand,
2004). A scaled score was obtained by summing responses across the seven items (Baird &
Sand, 2004). Repeated-measures ANOVA revealed a significant difference between the two
groups in how much change in pain the participants experienced over the 12 weeks (F =
4.406, df = 26; P = 0.046) (Baird & Sand, 2004). The 17 participants in the intervention group
reported a significant reduction in pain (P < 0.001) at week 12 compared to the control group,
whose members reported no change in pain (Baird & Sand, 2004). Repeated-measures ANOVA
revealed a significant difference between the two groups in how much change in mobility the
women experienced over the 12 weeks (F = 9.619, df = 22; P = 0.005) (Baird & Sand, 2004).
The participants in the intervention group reported a significant reduction in mobility difficulty

32
at week 12 (P < 0.001), while those in the control group had increases in mobility difficulty at
week 12 (Baird & Sand, 2004).
In the meta-analysis of twenty-seven RCTs by Dixon et al. (2007), fifteen studies
assessed the pain of arthritis patients post treatment using a visual analog scale (VAS) or other
pain measures. The overall effect size was 0.177 (95% CI0.259–0.094), indicating that patients
who received PCST type interventions reported significantly lower pain posttreatment than
patients in control conditions (combined p < 0.01) (Dixon et al., 2007). The authors also
conducted a meta-analysis restricted to studies that used the VAS to assess pain (n=9) and found
a combined effect size of 0.162 (95% CI0.257–0.067; p0.001), favouring the psychosocial
interventions.
Bennell et al. (2018) also utilized the WOMAC pain subscale measured at 8, 24, and 52
weeks. Results from this quantitative RCT by Bennell et al. (2017) showed that at three months,
the intervention group reported significantly greater improvement in pain (mean difference, 1.6
units [CI, 0.9 to2.3 units]) and WOMAC physical function (mean difference, 9.3 units [CI, 5.9 to
12.7 units]) compared to the control group. These results were further sustained at nine months
(mean differences, 1.1 units [CI, 0.4 to 1.8 units] and 7.0units [CI, 3.4 to 10.5 units],
respectively) (Bennell et al., 2017). Both groups showed significant improvements from baseline
at 3 and 9 months, with a significantly greater proportion of participants in the intervention group
exceeding minimum clinically significant differences (MCIDs) at both time points (Bennell et
al., 2017). All secondary outcomes except coping attempts at three months and self-efficacy at
nine months showed significant between-group differences favouring the intervention (Bennell et
al., 2017). The intervention group had significant improvements in all secondary outcomes at
both time points. In contrast, the control group improved only on WOMAC pain at three months

33
and WOMAC pain and self-efficacy at nine months (Bennell et al., 2017). At both time points,
significantly more participants in the intervention group reported global improvements (Bennell
et al., 2017). The overall benefits in this study were attributed to a combination of exercise and
PCST intervention which emphasizes the benefits of addressing the biological and psychosocial
factors to optimize health outcomes.
This was further described in the results from the systematic review by Ismail et al.
(2017), which included four RCTs to compare the effect of CBT and PCST with usual care,
placebo and the combination with usual care. The selected pain interference outcome measure
used was the WOMAC pain subscale (Ismail et al., 2017). The studies that provided PCST
combined with Behavioural Weight Management (BWM) interventions had attained a moderate
to large effect size (0.77) (Ismail et al., 2017). The researchers determined that patients
diagnosed with knee OA who receive PCST with BWM for pain management are 69% more
likely to reduce pain than patients who solely received standard (Ismail et al., 2017). The other
intervention groups in the review had small effect sizes (ranged from 0.06 to 0.25) compared to
control groups (Ismail et al., 2017).
In the quantitative RCT by Broderick et al. (2014), the researchers utilized the AIMS2
questionnaire to measure the impact of pain, mobility, walking and bending, extremity
functioning, self-care, household tasks, social activities and support, work, tension, and mood.
The BPI and the WOMAC pain subscale were also utilized (Broderick et al., 2014). Broderick et
al. (2014) performed omnibus tests across all follow-up assessments which yielded significant
group differences, indicating improvement with treatment on: pain intensity (F(3, 233) = 2.75,
P= 0.044), and physical functioning (F(3, 233) = 3.11, P= 0.027). Two of the 4 secondary
outcomes yielded significant treatment effects: fatigue (F(3, 233) = 5.14, P= 0.002) and AIMS

34
satisfaction with health (F(3, 232) = 3.12, P= 0.027); AIMS2 family/friend support showed a
trend (F(3, 232) = 2.54, P= 0.057), and the effect for AIMS2 social activities was not significant
(F(3, 232) = 0.58, P= 0.631) (Broderick et al., 2014). The patients in the PCST group reported
less pain (F(3, 231) = 9.22, P <0 .001), less activity interference due to pain (F(3, 231) = 5.68,
P=0 .001), and reduced use of pain medication (F(3,231) = 3.09, P=0 .028) across the 3 followup assessments compared with the usual care control group (Broderick et al., 2014). Changes in
daily ratings of life satisfaction (F(3, 231) = 0.43, P=0 .728) and need to cancel activities (F(3,
230) = 1.19, P= 0.315) did not differ between the groups (Broderick et al., 2014). Overall, NP
delivery of PCST interventions produced improvements in various pain-related outcomes: pain
intensity, coping with pain, self-efficacy for controlling pain, activity interference due to pain,
and decreased use of pain medication when compared with usual care. Additionally, these
improvements were sustained 12 months after the intervention.
In the meta-analysis of ten RCTs by Wang et al. (2020), pain interference was measured
using the WOMAC pain subscale, the AIMS and AIMS2. The intervention group had significant
differences in pain (SMD = −0.18; 95% CI −0.29 to −0.06) compared to the control group (Wang
et al., 2020). Between-group differences measured by the WOMAC subscales of pain (MD =
−0.62; −1.48 to 0.24) were not statistically significant and did not reach the minimal clinically
important differences that have been established (Wang et al., 2020).
In the quantitative RCT by Riddle et al. (2019), pain interference outcomes included the
highly reliable and valid WOMAC Pain Scale, a 4-item knee pain intensity scale, and a global
rating-of-change scale. Performance-based outcome measures were the Short Physical
Performance Battery (SPPB) to gauge physical performance and the 6-minute walk test to assess
walking endurance and speed (Riddle et al., 2019). There was no effective treatment (p=0.60) or

35
group-by-time interaction (p=0.73), indicating no significant difference between groups
(collapsed over time) or in the trajectories of the WOMAC pain score (Riddle et al., 2019). No
significant group or group-by-time interactions (p > 0.05) were found among composite pain or
SPPB scores (Riddle et al., 2019). Additionally, there was a significant group effect on 6-minute
walk scores (p=0.04) but no significant interaction (p=0.96) (Riddle et al., 2019). Overall, among
adults with pain catastrophizing undergoing knee arthroplasty, PCST did not confer pain or
functional benefit beyond the extensive improvements achieved with usual surgical and
postoperative care. Thus, patients awaiting knee arthroplasty are likely not appropriate
candidates for PCST interventions except if they experience persistent function-limiting pain
postoperatively (Riddle et al., 2019).
Furthermore, in the systematic review of seven RCTs by Giacobbi et al. (2015), four
RCTs relied on self-report surveys to measure pain using the AIMS2, McGill Pain
Questionnaire, WOMAC pain subscale, or VAS. All seven included RCTs reported results that
support the use of guided imagery as a therapeutic tool for the treatment of pain (Giacobbi et al.,
2015).
Quality of Life
Various valid and reliable tools were utilized within the literature to measure QOL
outcomes focusing on the five main QOL dimensions: Physical activities, Mental health, Pain,
Social support, and Social functioning (Goetz et al., 2011; Mahmoud et al., 2019).
To examine the effects of physical activity, pain, mental health and functioning, Allen et
al. (2019) utilized various surveys. The Western Ontario and McMasters Universities
Osteoarthritis Index (WOMAC) function subscale was used to measure pain, stiffness and
functionality. All items are listed rated on a Likert scale of 0 (no symptoms) to 4 (extreme

36
symptoms), with ranges of 0 to 96 for the total score and 0 to 68 for the function subscale (Allen
et al., 2019). The Short-Form 12 Health Survey (SF-12) was used to cover domains of general
health, physical health, work and activity limitations (Allen et al., 2019). The Patient Health
Questionnaire-8 (PHQ-8) was used to calculate depressive symptoms. The Yale physical activity
survey was used to assess activities such as housework, yard work, leisure activity, moderateintensity physical activity, caretaking, and recreational activity performed during a typical week.
The Pain Catastrophizing Scale was used to measure participant's thoughts and feelings when in
pain, assess domains of rumination, magnification, and helplessness, which coincided with the
degree of pain interference (Allen et al., 2019). Other outcome measures included the Coping
Strategies Questionnaire, Arthritis Self-Efficacy, Yale Physical Activity Survey, and Patient
Global Impression of Arthritis Symptom Change (Allen et al., 2019). There were no significant
differences noted in any of the listed scores between the PCST and control groups either at three
or nine months (Allen et al., 2019).
The WOMAC total and function scores, and the SF-12 Mental and Physical Health
Component Scores did not differ significantly between PCST and waitlist groups at either 3 or 9
months (Allen et al., 2019). The CSQ Pain Coping Attempts score increased more in the PCST
group than in the waitlist control group at both three months (ETD 15.31,95% CI 9.09, 21.53; P
0.001) and nine months (estimated treatment difference 11.67, 95% CI 5.08, 18.27; P 0.001)
(Allen et al., 2019). Pain Catastrophizing Scale scores (PCS) decreased more in the PCST group
than in the waitlist group at three months (ETD 3.03, 95% CI 5.25, 0.80; P 0.008) (Allen et al.,
2019). At nine months, PCS scores continued to decline in the PCST group, but the difference
compared with the usual care waitlist control group was smaller and no longer statistically
significant (P 0.273) (Allen et al., 2019). The PHQ-8 scores did not differ between PCST and

37
waitlist control groups at either time point (Allen et al., 2019). The Arthritis Self-Efficacy scores
improved more in the PCST group than in the waitlist control group at both 3 months (ETD
1.01,95% CI 0.61, 1.41; P 0.001) and 9 months (ETD 0.67, 95% CI 0.24, 1.09; P 0.02) (Allen et
al., 2019). The Yale Physical Activity Survey scores did not differ between groups at either 3 or
9 months (Allen et al., 2019). The Patient Global Impression of Arthritis Symptom Change
scores were lower, indicating more improvement since baseline in the PCST group than in the
waitlist control group at both 3 months (ETD 1.27, 95% CI 1.60, 0.95; P,0.001) and 9 months
(ETD 0.87, 95% CI 1.24, 0.51; P,0.001) (Allen et al., 2019). Overall, although there was no
significant effect of PCST on the primary outcome of pain severity in this study, the participants
experienced an improvement in key measures of pain coping and perceived ability to manage
pain.
In Bennell et al. (2018), secondary outcomes included measures of QOL using the
Assessment of Quality-of-Life instrument. Psychological health was measured using the
Depression, Anxiety, and Stress Scale (DASS-21) (Bennell et al., 2018). The Physical Activity
Scale coupled with the WOMAC function subscale was used to measure the level of physical
activity of the participants (Bennell et al., 2018). At week 24, there was also no between-group
difference in change in WOMAC function (−0.9 units; 95% CI, −4.8 to 2.9), which remained the
same when dichotomized on MCID (PCST 64% vs comparison 57%, odds ratio 0.70, 95% CI
0.34-1.42) (Bennell et al., 2018). The frequency of use of pain coping skills was significantly
higher for the PCST group than the comparison group at every time point (mean [95% CI]
between-group difference: week 8, 11.5 [5.3-19.7]; week 24, 11.7 [2.9-20.5]; and week 52, 15.3
[4.4-26.2]) (Bennell et al., 2018). There was a significant between-group difference for change in
WOMAC function (−3.2 units; 95% CI, −6.2 to −0.1) at week 8 favouring PCST, and more

38
participants in this group reported improvement overall and in pain and function at week 8
(Bennell et al., 2018).
The meta-analysis of ten RCTs by Wang et al. (2020) supported the effectiveness and
safety of PCST for managing OA in pain, function, and psychological aspects. Outcome
measurement tools included the WOMAC function subscale. Psychological outcomes were
measured using the PCS, CSQ, and the Arthritis Self-Efficacy Scale (Wang et al., 2020). The
intervention group had significant differences in function (SMD = −0.19; −0.30 to −0.07), coping
attempts (SMD = 0.37; 0.24 to 0.49), pain catastrophizing (SMD = −0.16; −0.29 to −0.02), and
self-efficacy (SMD = 0.27; 0.07 to 0.46) compared to the control group (Wang et al., 2020).
Between-group differences measured by the WOMAC subscales of function (MD = −3.01; −6.26
to 0.24) were not statistically significant and did not reach the minimal clinically important
differences that have been established (Wang et al., 2020). Overall, findings from this study
supported the effectiveness and safety of PCST for managing OA in pain, function, and
psychological aspects (Wang et al., 2020). Interestingly, the researchers also discovered that
exercise did not add any benefits when combined with PCST interventions (Wang et al., 2020).
In the study by Broderick et al. (2014) QOL scale, a 16-item instrument was used to
measure QOL across different life domains. Other outcome measures relevant to QOL included
the CSQ, Beck Depression Inventory (BDI), Arthritis Self-Efficacy Scale, Brief Fatigue
Inventory (BFI) and the End-of-day symptom diaries recorded on interactive voice recording
(Broderick et al., 2014). Omnibus tests across all follow-up assessments were performed and
yielded significant group differences, indicating improvement with treatment on: psychological
distress (F(3,233) = 2.83, P= 0.039), use of pain coping strategies (F(3, 233) =4.97, P= 0.002),
self-efficacy (F(3, 232) = 10.59, P < 0.001), catastrophizing (F(3, 233) = 2.47, P= 0.063), and the

39
effect on QOL was not significant (F(3, 233) = 1.97, P=0 .119). However, the patients in the
PCST group reported less fatigue (F(3,231) = 2.95, P=0 .033) across the three follow-up
assessments compared with the usual care control group (Broderick et al., 2014).
In the meta-analysis of twenty-seven RCTs by Dixon et al. (2007), the specific
measurement scales for QOL outcomes were not mentioned; however, five studies assessed
anxiety pre-and postintervention resulting in the overall effect size of 0.282 (95% CI0.455–
0.110), indicating significantly lower posttreatment anxiety in the intervention group compared
to patients in control conditions (combined p 0.01) (Dixon et al., 2007). Seven studies assessed
depression pre-and post-intervention resulting in an overall effect size of 0.208 (95% CI0.363–
0.052), indicating that patients receiving psychosocial interventions reported significantly lower
posttreatment depression than patients in control conditions (combined p 0.01) (Dixon et al.,
2007). Additionally, patients reported significantly lower posttreatment psychological disability
than patients in control conditions (combined p 0.01) (Dixon et al., 2007). Five studies assessed
active coping pre-and post-intervention resulting in an overall effect size of 0.716 (95%
CI0.490–0.941), indicating higher levels of active coping following in the intervention group
compared to patients in control conditions (combined p 0.01) (Dixon et al., 2007). Four studies
assessed the pain self-efficacy pre-and post-intervention resulting in an overall effect size of
0.184 (95% CI0.031–0.336), indicating that patients receiving psychosocial interventions
reported significantly higher posttreatment pain self-efficacy than patients in control conditions
(combined p 0.05) (Dixon et al., 2007). Eleven studies assessed the physical disability of arthritis
patients pre-and post-intervention, resulting in an overall effect size of 0.152 (95% CI0.242–
0.062), indicating significantly lower posttreatment physical disability compared to patients in
control conditions (combined p 0.01) (Dixon et al., 2007).

40
In the high-quality qualitative study by Lawford et al. (2019), five themes arose: 1) easy
to understand and follow, 2) better able to cope with pain, 3) anonymity and flexibility, 4) not
always relatable or engaging, and 5) support from clinician desirable. Focusing on the second
theme, most participants believed the pain coping techniques they learned helped them better
control their pain and no longer felt overwhelmed by it, ultimately improving their QOL
(Lawford et al., 2019). Participants had different perceptions about which techniques were most
beneficial for them, and many found that the relaxation techniques helped alleviate muscle
tension and reduce stress (Lawford et al., 2019). Participants valued the activity-pacing
technique, finding that it helped them avoid flares in pain and break activities into smaller, more
manageable segments (Lawford et al., 2019). One participant stated:
I have, I think, learnt from [the PCST program] that you can actually ride the pain out as
it where, you can actually deal with it, whereas, before that it was always you were
scared of pain because you thought you couldn’t deal with it but now I know you can
actually deal with it in some way, you have some control. I mean you can’t get rid of it
but you can deal with it. (Lawford et al., 2019, p. 1742)
These findings suggest that individuals with knee OA generally had positive experiences using
the PCST program, suggesting that virtual delivery is a broadly acceptable and accessible way to
help individuals with OA manage their pain and improve their QOL.
In the quantitative RCT by Riddle et al. (2019), QOL outcomes included the WOMAC
Physical Function Scale and the Pain Catastrophizing Scale. There were no significant group or
group-by-time interactions (p > 0.05) found among WOMAC physical function or pain
catastrophizing scores (Riddle et al., 2019). However, there were substantial improvements over

41
12 months for WOMAC physical function scores (pooled effect size, 1.8) and pain
catastrophizing (pooled effect size,2.0) (Riddle et al., 2019).
In the systematic review by Giacobbi et al. (2015), measurement of QOL, psychological
well-being, anxiety, and depression was noted in five of the included RCTs. Tools utilized
included the HRQOL scale, Anxiety (STAI-T), depression (BDI), and automatic negative
thoughts (ATQ-30) (Giacobbi et al., 2015). Other outcomes relating to QOL included the
arthritis self-efficacy scale and assessment to measure medication usage (Giacobbi et al., 2015).
All seven included RCTs reported results that support the use of guided imagery as a therapeutic
tool for improved psychological well-being, improved mobility, reduced anxiety, and increased
self-efficacy in managing pain (Giacobbi et al., 2015). The findings provide evidence that guided
imagery with progressive muscle relaxation, a part of PCST protocol, may be an effective selfmanagement technique for coping with daily pain and mobility limitations associated with OA.
Overall, although psychosocial interventions appear to have some effects on pain, PCST
interventions are most likely to enhance patient’s QOL by producing improvements in coping,
anxiety, pain self-efficacy, depression, and physical disability (Allen et al., 2019; Baird & Sand,
2004; Bennell et al., 2017; Broderick et al., 2014; Dixon et al., 2007; Giacobbi et al., 2015;
Lawford et al., 2019; Riddle et al., 2019; Wang et al., 2020).
Education
Traditionally, PCST interventions usually consist of three phases: (1) an education
segment in which patients are taught about the biopsychosocial model of pain; (2) a skillstraining component in which participants are trained in a variety of cognitive-behavioural pain
coping skills (relaxation training, activity pacing, pleasant activity scheduling, imagery
techniques, distraction strategies, cognitive restructuring, problem-solving, or goal setting); and

42
(3) an application phase in which patients practice and apply their skills in real-life situations
(Dixon et al., 2007). The second theme outlines the importance of patient and provider
education, which was a thread in all selected articles and was achieved using various approaches.
Patient Education
Patients received education on various cognitive-behavioral pain coping skills such as
relaxation training, activity pacing, pleasant activity scheduling, guided imagery techniques,
distraction strategies, cognitive restructuring, problem-solving, or goal setting, and behavioural
rehearsal to enable lasting results. The various tools and mediums used to aid in PCST patient
education were described in ten studies (Allen et al., 2019; Baird & Sand, 2004; Bennell et al.,
2017; Broderick et al., 2014; Giacobbi et al., 2015; Helminen et al., 2015; Ismail et al., 2017;
Lawford et al., 2019; Riddle et al., 2019; Wang et al., 2020).
In the systematic review by Giacobbi et al. (2015), all seven included RCTs employed
patient education on guided imagery interventions in patients with arthritis and other rheumatic
diseases (AORD), often beginning with breathing or progressive muscle relaxation exercises and
then images of movement and physical activity free of pain and stiffness. All patients were given
an instructional audio player, which they listened to once or twice daily. To expand on how
guided imagery interventions were delivered, the pilot study by Baird and Sand (2004) describes
composing guided imagery with progressive muscle relaxation scripts often beginning with
describing a relaxing scene, then urging patients to smell aromas, hear sounds and feel the
warmth of the air and breeze, then finally verbally guiding patients to visualize moving
extremities in the scene without stiffness, hesitancy, or pain (Baird & Sands, 2004). The
participants were asked to complete a journal three times a week with information about
symptoms and the number of times a day they used guided imagery. Additionally, participants

43
were called biweekly to navigate any difficulties that arose using guided imagery with
progressive muscle relaxation (Baird & Sands, 2004).
In the study by Helminen et al. (2015), the CBT group interventions were based on
Linton’s Model. Each session lasted two hours with a 15−20-minute break to enhance peer
support and social bonding. The outline of the sessions included an introduction (15 minutes),
lecture (knowledge and insight, max 15 minutes), problem-solving (in pairs/teams, 15−20
minutes), skills training (15−20 minutes), homework assignments (15 minutes), and a résumé
(feedback) of the session (15 minutes) (Helminen et al., 2015). Similarly, the study by Broderick
et al. (2014) taught four broad coping skills across the ten 30 - 45-minute sessions, which were
outlined in detail in a treatment manual and followed a format of a review of home practice
assigned at the last session, instruction in a new coping skill, guided practice in that skill, and a
home practice assignment. Patients were provided with a treatment binder divided into sections
for each session, handouts and logs to record the home practice of the skill, and were reviewed at
each session by the NP (Helminen et al., 2015).
In the study by Allen et al. (2019), the PCST program involved 11 weekly sessions,
approximately 30-45 minutes each, delivered through telephone by a trained counsellor. The
counsellor provided instructions on cognitive and behavioural pain coping skills and led
participants in guided rehearsals of these skills (Allen et al., 2019). Participants were encouraged
to engage in the home-based practice of the skills to enhance their application in pain-related
situations (Allen et al., 2019). Additionally, the counsellor reviewed participants’ home practice,
including successes and barriers, encouraged problem-solving, and set goals for applying skills
(Allen et al., 2019). Participants were given handouts to facilitate each session, along with an
audio recording to guide progressive muscle relaxation.

44
In the multisite randomized clinical trial conducted by Riddle et al. (2019), the
participants randomized to either PCST or arthritis education received eight 50-minute individual
sessions over an approximately 2-month period beginning two weeks preoperatively and ending
six weeks postoperatively. The physical therapists were provided with a detailed manual to guide
treatment delivery (Riddle et al., 2019). However, it was not clear if participants were provided
with any resources or tools to facilitate learning.
The systematic review by Ismail et al. (2017) included four RCTs with slightly different
protocols in providing PCST. On average, the sessions lasted for 62 minutes and were delivered
weekly or biweekly (Ismail et al., 2017). Also, two studies had examined the effect of PCST
independently and PCST combined with behavioural weight management and exercise (Ismail et
al., 2017). This was similar to the systematic review by Wang et al. (2020), which included ten
RCTs that provided PCST patient education with some combination of exercise guidance and
educational materials.
In the studies by Bennell et al. (2017) and Lawford et al. (2019), the participants received
educational material about exercise and physical activity, pain management, emotions, healthy
eating, complementary therapies, and medications. Participants were asked to complete eight 35to 45-minute modules (1 per week commencing in week 1) and practice pain-coping skills daily
(Bennell et al., 2017; Lawford et al., 2019). The participants were also given an instructional
manual and workbook that included information on each session and password access to the
program (Bennell et al., 2017; Lawford et al., 2019).
Provider Education
The importance of provider education was discussed in three studies (Allen et al., 2019;
Broderick et al., 2014; Riddle et al., 2019). Broderick et al. (2014) clearly described how

45
provider education and competence were attained. In this study, NPs received a two-day training
workshop in PCST and additional training to ensure satisfactory competency levels with the
treatment delivery (Broderick et al., 2014). Eligibility for these positions required a registered
nurse license and working or engaged in the study as adult health or family practice NP
(Broderick et al., 2014). Although not specializing in mental health, the nurses’ training
systematically addressed pain's emotional underpinnings (Broderick et al., 2014). After the initial
training, NPs continued training with the instructors at their site to reach competency with the
delivery of the treatment (Broderick et al., 2014). Next, each NP delivered PCST treatment to 2
to 3 OA pilot patients, and NPs did not begin to see patients in the clinical trial until adherence
and therapist competence were confirmed (Broderick et al., 2014). Competence was defined as
the NP consistently achieving a score of 3 (satisfactory) to 5 (excellent) on a rating of therapist
performance (1 = poor, 5 = excellent) (Broderick et al., 2014). Using audiotapes of the sessions,
ratings were made on specific items including: (1) establishing and maintaining rapport, (2)
showing professionalism and clinical judgment, (3) covering the protocol in a way that meets
patient needs, (4) encouraging active patient engagement in the session, (5) applying the protocol
to the patient’s unique challenges and needs, (6) using time efficiently and appropriately pacing
the session, and (7) overall performance (Broderick et al., 2014).
The study by Allen et al. (2019) discusses how PCST counsellors received training that
included role-play sessions from experienced clinical psychologists, therapist certification
achieved upon delivery of 11 study sessions to mock participants audio-recorded and rated by a
trained counsellor. The therapists were required to receive a rating of at least a 4 out of 5 for both
qualities of intervention delivery and adherence to the study protocol (Allen et al., 2019).

46
Additionally, the training also included cultural sensitivity issues (Allen et al., 2019), an essential
component not discussed in other studies.
In the study by Riddle et al. (2019), PCST interventions were delivered by physical
therapists who completed a 2-day training session conducted by clinical psychologists highly
experienced in the delivery of PCST. Additionally, physical therapists received a detailed
training manual to guide treatment delivery, and all treatment sessions were audio-recorded
(Riddle et al., 2019). The local clinical psychologists held monthly conference calls with
physical therapists and monitored treatment delivery by listening to audiotapes throughout the
study (Riddle et al., 2019). For the participant group receiving arthritis education solely,
registered nurses with at least two years of experience in the care of patients with OA were
trained by one author using a detailed manual (Riddle et al., 2019).
Also noted in Bennell et al. (2017), although PCST was delivered using an automated
program, the physiotherapists attended a 1-day training course conducted by the researchers and
were given an exercise manual. They also were provided with an overview of the PainCOACH
program and were asked to encourage participants to complete modules and practice skills;
however, the physiotherapist did not achieve competency in PCST training, nor were they
expected to deliver this intervention to the participants. Additionally, the four RCTs included in
the systematic review by Ismail et al. (2017) discuss PCST and CBT interventions, which health
professionals delivered, but it is unclear how provider competence was determined.
Delivery Modality
The third theme was the delivery modality of PCST programs, which was often related to
the traditional in-person, telephone or web-based delivery format (Allen et al., 2019; Lawford et

47
al., 2019), while some studies utilized a combination of settings (Bennell et al., 2017; Broderick
et al., 2014; Giacobbi et al., 2015; Riddle et al., 2019).
The study by Broderick et al. (2014) utilized an in-person delivery format consisting of
ten PCST sessions with up to four sessions conducted over the phone. In the systematic review
by Giacobbi et al. (2015), one study delivered guided imagery interventions in a clinic setting
while the remaining six studies were home-based imagery practice. Similarly, in the study by
Allen et al. (2019), the PCST program involved eleven weekly sessions, approximately 30-45
minutes each, delivered through telephone by a trained counsellor. In the study by Riddle et al.
(2019), the first session was an in-person appointment, and the remaining seven sessions
occurred over the telephone.
Bennell et al. (2017) conducted an innovative online intervention combining an
interactive PCST program and physiotherapist-prescribed home exercises in patients with OA,
which resulted in substantial clinical benefits. Another study using web-based delivery of PCST
was conducted by Lawford et al. (2019); participants from this qualitative study reported
favourable outcomes due to flexibility, accessibility, and anonymity. Although online PCST
programs can be a low-cost and more accessible way to manage osteoarthritic pain, several
limitations to this delivery format have been reported. First, computer-illiterate individuals may
struggle with accessing this therapy (Bennell et al., 2017). Secondly, clinician guidance during
PCST interventions may improve adherence and boost treatment effectiveness, as suggested by
participants (Lawford et al., 2019).
Although the body of literature demonstrated that overall, PCST interventions embedded
within primary care practice settings are reasonable, there is evidence also to consider web or
telephone-based delivery formats in addition to in-person sessions. However, to ensure success,

48
there must be a partnership with IT support and training providers to guide patients. This
approach will mitigate accessibility issues for patients residing in rural or remote areas and lack
computer literacy.
Multidisciplinary Management
Although PCPs have been defined as GPs and NPs within this review, various providers
supply healthcare within the primary care setting and warrant further evaluation. Pain Coping
Skills Training were delivered by primary healthcare therapists, which included counsellors and
therapists (Allen et al., 2019; Giacobbi et al., 2015; Ismail et al., 2017); NPs (Broderick et al.,
2014); and physiotherapists (Helminen et al., 2015; Riddle et al., 2019). In the systematic review
by Wang et al. (2020), a mix of trained counsellors, physical therapists, NPs, therapist teams, and
clinical psychologists were included as teachers of PCST.
In the study by Riddle et al. (2019), PCST was delivered by psychologist-trained physical
therapists with at least two years of clinical experience treating patients with knee arthroplasty.
To ensure intervention fidelity, upon study completion, an external pain psychologist reviewed a
random set of 5% of PCST audiotapes and rated proficiency of care delivery based on the
treatment manual, on a 5-point scale (1=poor to 5=excellent) (Riddle et al., 2019). A joint
arthroplasty nurse not affiliated with the study used a similar rating for arthritis education
audiotapes. The mean quality rating was 4.0 (range, 3.5 to 4.5) for PCST and 3.8 (range, 2.0 to
5.0) for arthritis education training (Riddle et al., 2019).
In the study by Broderick et al. (2014), PCST was delivered by trained NPs. Across the
five years of the clinical trial and the clinical sites, 6 NPs provided PCST to the study patients.
Two clinicians reviewed 18% of the audiotaped treatment sessions and rated proficiency on a 5point scale (1 = poor, 3 = satisfactory, 5 = excellent) in delivering the PCST intervention for that

49
session per the PCST manual (Broderick et al., 2014). The ratings of NPs across each session
was averaged, and none of the NPs received ratings less than satisfactory (Broderick et al.,
2014). Among the 129 PCST patients, 45% received treatment from a NP with a rating of 3
(satisfactory), 21% a rating of 4, and 34% a rating of 5 (excellent) (Broderick et al., 2014). Using
an ANCOVA model, the researchers also examined whether NP level of proficiency in
delivering PCST was associated with the level of improvement that patients achieved (Broderick
et al., 2014). Consistent with the main analyses, across seven primary, four secondary, and six
daily outcome measures, there were no significant differences in outcome by nurse proficiency at
the post-treatment assessment (Broderick et al., 2014). Overall, the NP-delivered PCST protocol
produced substantial improvements in a range of pain-related variables, including pain intensity,
coping with pain, self-efficacy for controlling pain, activity interference due to pain, and the use
of pain medication when compared with usual care (Broderick et al., 2014).
Interestingly the study by Baird and Sand (2004) focused on guided imagery with
progressive muscle relaxation as an easy-to-use self-management intervention eliminating the
need for the primary care provider. This was done to mitigate class attendance or one-on-one
sessions that may not be feasible for some patients due to pain and mobility difficulties. The 17
participants in the intervention group reported a significant reduction in pain (P<.001) and a
substantial reduction in mobility difficulty at week 12 (P<.001) compared to the control group,
who had no change in pain but increases in mobility difficulty at week 12. However, this study
had a Low CASP score related to several limitations such as the uneven distribution of
participants, small sample size, and the sole inclusion of participants over 65 who were highly
educated.

50
In the study by Helminen et al. (2015), a psychologist and physiotherapist worked
collaboratively to deliver a group-based CBT pain program. The psychologist was the principal
leader of the cognitive–behavioural intervention while the physiotherapist’s tasks were to lead
the relaxation exercises, provide information on osteoarthritis pain mechanisms, offer advice
about suitable exercises, and facilitate the group when needed (Helminen et al., 2015). Although
this single-blinded RCT could not confirm the hypothesized advantage of a group-based CBT
programme over ordinary GP care in knee OA pain patients, it poses the question of the benefits
of a multidisciplinary approach in delivering PCST interventions as opposed to limiting this to
GPs and NPs.
In the study by Riddle et al. (2019), PCST was delivered by local physical therapists with
at least two years of clinical experience treating patients with knee arthroplasty who also
received training by clinical psychologists. Additionally, arthritis education was taught by
registered nurses with at least two years of experience in the care of patients with OA (Riddle et
al., 2019). After study completion, a pain psychologist not involved with the study reviewed a
random set of 5% of PCST audiotapes and rated care delivery proficiency, based on the
treatment manual, on a 5-point scale (1=poor to 5=excellent) (Riddle et al., 2019). A joint
arthroplasty nurse not affiliated with the study used a similar rating for arthritis education
audiotapes (Riddle et al., 2019). The mean quality rating was 4.0 (range, 3.5 to 4.5) for PCST
and 3.8 (range, 2.0 to 5.0) for arthritis education training (Riddle et al., 2019). The quality ratings
support intervention treatment fidelity and the benefit of including a multidisciplinary approach
to managing chronic pain related to OA.
In the systematic review by Wang et al. (2020), an interactive automated program and
trained physical therapists were used to teach PCST interventions to patients. Therefore, it is

51
vitally important to determine the role of physiotherapists in PCST delivery. Similarly, in
Bennell et al. (2017), PCST and education materials were provided to the participants; the
participants also received seven skype sessions with a physiotherapist over 12 weeks which
lasted between 12 - 45 minutes. The physiotherapist performed a brief assessment, prescribed an
individualized lower-limb–strengthening home exercise program, instructions, video
demonstrations, and equipment (Bennell et al., 2017). Additionally, the fifth theme that arose in
the qualitative study by Lawford et al. (2019) emphasized the provision of support from a
clinician as important. It was clear that the program worked effectively in tandem with the
physical therapist–prescribed exercise program (Lawford et al., 2019).
This body of literature supports the overall effectiveness of NPs, physical therapist, and
nurses not explicitly trained in mental health interventions can effectively deliver PCST
interventions in the primary care setting. However, it is essential to evaluate potential barriers for
PCPs integrating PCST interventions into their primary care practices and strategies to mitigate
them. Exploration of the roles of registered nurses, counsellors and physiotherapists should also
be considered. The strategies needed to facilitate delivery of PCST interventions in the primary
care setting will be explored further in the discussion section and help develop appropriate
practice recommendations.
In summary, this analysis has provided a critical review of common themes within the
literature gathered on the delivery of Pain Coping Skills Training by Primary Care Providers to
patients suffering chronic pain related to OA. In consideration of the research question, this
analysis explores pain interference and QOL outcomes, patient and provider education, primary
care providers, appropriate delivery modalities, and the importance of multidisciplinary

52
management. The next chapter discusses these findings and includes recommendations for
clinical practice, practice implications, limitations, and recommendations for future research.

53
Chapter Five: Discussion
The purpose of this integrative literature review is guided by the following question
“Does the delivery of Pain Coping Skills Training (PCST) by primary care providers improve
pain interference and quality of life for adult patients with chronic pain related to OA?” A
literature search was completed to answer the posed research question and identified 11 relevant
articles for inclusion in this review. The findings from the 11 articles were analyzed in the
previous chapter and provide PCPs with the current evidence for the integration of PCST
interventions in their respective primary care practices.
Four key findings were identified within the literature analysis to answer the research
question. They included: 1) Pain Interference and Quality of Life Outcomes, 2) Patient and
Provider Education, 3) Delivery Modality, and 4) Multidisciplinary management. This section
aims to illustrate how the synthesis of the findings led to the development of practice
recommendations for PCPs. Furthermore, the limitations to this integrative literature review will
be discussed and the direction for future research.
Pain Interference and Quality of Life Outcomes
Osteoarthritis is related to various psychosocial and functional consequences,
exacerbating the patient's pain experience, decreasing responsiveness and participation to
treatment, increasing disability, and negatively affecting health-related quality of life (Allen et
al., 2019; Baird & Sand, 2004; Bennell et al., 2017; Broderick et al., 2014; Dixon et al., 2007;
Lawford et al., 2019; Riddle et al., 2019). Pain interference was reported as a significant
contributor affecting activities of daily living. One commonly used tool utilized within the
articles to measure pain interference is the Brief Pain Inventory (BPI). The BPI measures the
extent to which pain interferes with seven quality of life domains (general activity, mood,

54
walking ability, routine work [including housework], relations with other people, sleep, and
enjoyment of life) (Jensen, 2011; Kean et al., 2016).
Measurement of QOL outcomes was a deliberate choice by the author as I believe it is
essential to assess disease effects on daily living in relation to critical aspects of each patient's
life. This assessment can then lead to a discussion of treatment value and the patient’s
willingness to adhere to therapies. Quality of life is a broad complex concept that incorporates a
persons' physical health, psychological state, level of independence, social relationships,
personal beliefs, and relationships to the environment's salient features (WHO, 2012). It is
difficult to capture these factors using one tool, and this perhaps explains why researchers did not
use one specific tool to capture the measure of QOL within the selected studies. One QOL
instrument utilized within the selected articles includes the AIMS, an arthritis-specific QOL
instrument (Baird & Sands, 2006; Broderick et al., 2016). The AIMS tool was used to measure
pain, mobility, walking and bending, extremity functioning, self-care, household tasks, social
activities and support, work, tension, and mood. Additionally, the Short-Form Health Survey
(SF-36) was also utilized and measures physical functioning, role limitations due to physical
problems, bodily pain, general health perception, vitality, social functioning, role limitations due
to emotional problems, and mental health (Baird & Sands, 2006).
There remains uncertainty about whether generic or disease-specific instruments should
be used to attain the most comprehensive assessment of health-related quality of life (Fontaine,
n.d.). For example, the SF-36 on an OA patient will not provide information on joint pain,
related symptoms of function, attitude and mood. In this case, the AIMs or WOMAC function
subscale tool would be more beneficial for OA patients. The major domains of QOL: Physical
activities, Mental health, Pain, Social support, and Social functioning, were all reported in the

55
studies and were found to have overlapping results to pain interference. Analysis of this body of
literature has demonstrated that overall PCST interventions had a positive impact of reducing
pain interference and improving reports of QOL outcomes which was primarily influenced by
the patient’s ability to cope and their self-efficacy (Allen et al., 2019; Baird & Sand, 2004;
Bennell et al., 2017; Broderick et al., 2014; Dixon et al., 2007; Giacobbi et al., 2015; Ismail et
al., 2017; Lawford et al., 2019; Wang et al., 2020). Riddle et al. (2019) found that patients
awaiting knee arthroplasty are likely not appropriate candidates for PCST interventions except if
they experience persistent function-limiting pain postoperatively. This is valuable information to
consider during the baseline patient assessment; however, it prompts further questions regarding
the effects on patients with varying OA severity levels. Further research is needed to determine if
there are favourable advantages to PCST interventions in patients with advanced severity of OA
who may not necessarily require arthroplasty.
Primary Care Provider Role
The PCP role would be essential here to administer baseline surveys to assess what effect
OA has on each patient's QOL and the extent of pain interference on their activities of daily
living. Once this information is gathered, the advanced knowledge possessed by PCPs will
enable them to aid patients in developing an appropriate plan. Utilizing tools such as the BPI for
measurement of pain interference and the WOMAC function subscale for measurement of QOL
can be used as an introduction to discuss the impact of OA, which is a valuable addition to the
health assessment. Based on this information and the severity of OA, decisions can be made if
PCST is an appropriate intervention. If not, PCPs are well suited to provide any required
medications and referrals to appropriate specialists.

56
Education
The second finding that emerged from the literature analysis is centred on patient and
provider education. Providing education that addresses OA expands the knowledge of adult
patients and enables them to understand the associated risks and consequences of delayed
intervention and the impact of OA. A personalized education approach was suggested by Dixon
et al. (2007) to aid in the self-management of OA. Through the explorations of patient’s
knowledge and perception of their risk, tailored education and specific PCST components can be
provided to support the patient. Additionally, reinforcement with repeated education and followup at subsequent visits encourages sustainable coping strategies. It will be necessary to set up
standardized PCST manuals, adapt therapy based on individual patient needs, and implement
home practice/assignments to foster patient education. However, before patient education can
occur, PCPs must have the required knowledge around PCST interventions to manage OA's
physical and psychological effects.
Provider Education
Provider education was only discussed in three studies (Allen et al., 2019; Broderick et
al., 2014; Riddle et al., 2019). The three studies that discussed provider education included NPs,
nurses, and physical therapists who did not possess mental health specialization but achieved
competency in delivering PCST interventions. In these articles, the providers took a training
workshop that was taught and monitored by trained clinical psychologists highly experienced in
delivering PCST. Developing a standardized provider education workshop or program will be an
essential aspect that will facilitate the delivery of PCST interventions, especially for providers
who have a large number of patients diagnosed with OA in their panel. This may be achieved by
partnering with Pain BC who currently offers a virtual chronic pain program. This finding

57
illustrates that delivering PCST interventions depends not on the provider's background but
mainly on obtaining the required training.
Additionally, having a specialized psychologist available during the training and
afterwards likely increased the provider's confidence with PCST delivery. However, I
acknowledge that support from a clinical psychologist may not be readily available to PCPs,
which warrants the need for other resources and tools such as a standardized PCST manual.
Additionally, for PCPs who cannot integrate PCST interventions into their current practice,
initiating a referral to a specialized psychologist remains an appropriate option.
PCST Manual.
The use of a PCST manual or treatment protocol was described in the literature as a
consistent strategy that facilitated the uptake of PCST interventions by each provider (Allen et
al., 2019; Baird & Sand, 2004; Bennell et al., 2017; Broderick et al., 2014; Dixon et al., 2007;
Giacobbi et al., 2015; Helminen et al., 2015; Ismail et al., 2017; Lawford et al., 2019; Riddle et
al., 2019; Wang et al., 2020). An example of a PCST manual available to primary care providers
is the Cognitive Behavioural Therapy for Chronic Pain (CBT-CP) therapist manual (Murphy et
al., 2020). Similar to the goal of PCST interventions, the CBT-CP approach encourages patients
to adopt an active, problem-solving approach to cope with the various challenges associated with
chronic pain (Murphy et al., 2020). This manual is divided into two parts; the first part focuses
on foundational information regarding pain, especially chronic pain, including common
conditions and treatments (Murphy et al., 2020). It further provides education on CBT, its
application in managing chronic pain, and an introduction to case conceptualization and the
therapeutic alliance (Murphy et al., 2020). The second part of the manual focuses on
understanding and implementing each session (Murphy et al., 2020).

58
The CBT-CP manual was developed specifically for veterans; however, it is approved in
the management of various pain conditions such as low back pain, middle and upper back pain,
neck pain, osteoarthritis, rheumatoid arthritis, tendonitis/bursitis, pelvic floor disorders, gout,
peripheral neuropathic pain, radicular pain, phantom limb pain, fibromyalgia, complex regional
pain syndrome, and headaches (Murphy et al., 2020). Within the CBT-CP manual, there are
twelve sessions. The first three sessions are called the initial treatment phase, comprised of
assessment and interview, rapport building, preparing for treatment, orientation to CBT and goal
setting (Murphy et al., 2020). Sessions four to ten involve cognitive and behavioural skillbuilding, including physical activation, relaxation techniques, pleasant activities, cognitive
strategies, and sleep (Murphy et al., 2020). The final discharge phase is from sessions eleven to
twelve and includes strategies to maintain treatment gains, anticipating obstacles, discharge plan,
and follow-up session (Murphy et al., 2020).
Although this is a USA-developed therapist manual for veterans, adopting a standard
PCST manual similar to the CBT-CP will provide PCPs with a resource that can be referred to
when questions concerning delivery arise. The CBT-CP manual provides a standardized
approach to delivering PCST interventions based on the key components (Murphy et al., 2020).
Thus, utilizing a standardized PCST treatment manual will allow for a stepped approach in
educating, planning, and supporting patients through PCST interventions.
Individualized Plans/Adapting Therapy.
The benefit of utilizing a standardized PCST therapist manual has been discussed in the
previous section as a facilitator to the uptake by PCPs. Another important facilitator is the ability
for providers to adopt PCST interventions based on each patients’ specific needs (Allen et al.,
2019; Baird & Sands, 2004; Broderick et al., 2014; Helminen et al., 2015). It is important to note

59
that every patient’s experience of chronic pain related to OA differs, and each patient may find
various PCST skills more beneficial than the other. This was evident in the study by Broderick et
al. (2014), where the participants reported progressive muscular relaxation, mini practices of
relaxation, and activity pacing to be most beneficial, and only 40% found pleasant imagery and
distraction techniques to be helpful.
Furthermore, Helminen et al. (2015) report that a predisposition to treating all chronic
pain patients with the same methods leads to inaccurate conclusions regarding the treatment
efficacy. Variables such as the point of time for intervention, the duration of symptoms,
psychological stress, low levels of physical activity, and reduced self-rated health may affect the
treatment effect (Helminen et al., 2015).
In the study by Allen et al. (2019), the providers were encouraged to use active listening
to identify opportunities to demonstrate that pain coping skills are compatible with the
participant's cultural, spiritual, religious, or other values. In the context of cognitive
restructuring, if a participant described religious beliefs or values, the provider would explore
how those beliefs could be integrated into new, more adaptive thoughts about pain coping (Allen
et al., 2019). Another adaptive approach was noted in the study by Baird and Sands (2004), in
which the movement exercises were tailored based on the types of joint pain or mobility
concerns reported by the participants. These studies highlight the importance of adapting PCST
interventions based on patient’s needs, which leads to better patient adherence and efficacy of
the tailored interventions.
PCST Home Practice/Assignment.
One facilitator to PCST interventions noted in the articles was the importance of home
activities. The homework assignments are an integral component of PCST, followed by review

60
and problem-solving in the subsequent session (Allen et al., 2019; Bennell et al., 2017; Broderick
et al., 2014; Helminen et al., 2015; Lawford et al., 2019). Although participants are taught new
skills at each PCST session, the most significant change occurs between sessions and when the
patients are in their home setting or performing regular activities that require them to implement
PCST skills. This is a crucial aspect of PCST and aids in building coping and self-efficacy (Allen
et al., 2019; Bennell et al., 2017; Broderick et al., 2014). Participants in Giacobbi et al. (2015)
were provided with an instructional audio player to guide their home activities which they played
once or twice daily. Other studies report having assigned homework assignments or home
practice to the participants after each PCST session (Allen et al., 2019; Bennell et al., 2017;
Broderick et al., 2014; Helminen et al., 2015; Lawford et al., 2019). The importance of these
home activities must be discussed at the start of PCST treatment. Adherence to these activities is
an indicator of if patients will have long-lasting, sustainable coping skills.
Delivery Modality
The studies utilized traditional in-clinic delivery, virtual/telephone delivery, and a
combination of both. Virtual delivery was proven to be an effective method to deliver PSCT
interventions and was also utilized to accommodate patients’ illness, physical functioning, and
scheduling challenges (Allen et al., 2019; Baird & Sands, 2004; Bennell et al., 2017; Broderick
et al., 2014; Giacobbi et al., 2015; Lawford et al., 2019; Riddle et al., 2019).
Additionally, during the writing of this review, the world was hit with the coronavirus
disease 2019 (COVID-19) pandemic. Thus, in shifting towards a virtualized care approach in
response to the COVID-19 pandemic, health care planners worldwide have employed various
telehealth technologies to meet the needs of patients without compromising their safety
(Webster, 2020; Zulman & Verghese, 2021). Some noted benefits of virtual care include

61
improved access and convenience for individuals residing in remote locations, those with severe
mobility limitations, and those with intense work or caregiving demands (Allen et al., 2019;
Riddle et al., 2019; Zulman & Verghese, 2021).
Overall, the body of literature supports all delivery modalities as reasonable options and
poses no harm; however, addressing other barriers such as computer literacy level and cell or
internet connectivity issues pose barriers to virtual and telephone delivery formats. However,
knowing that there are beneficial outcomes regardless of what delivery modality is employed,
PCPs should allow patients to choose based on their needs and preferences.
Multidisciplinary Management
Various providers such as physiotherapists, physical therapists, registered nurses,
counsellors, and NPs, were able to deliver PCST interventions within the primary care setting
(Allen et al., 2019; Bennell et al., 2017; Broderick et al., 2014; Giacobbi et al., 2015; Helminen
et al., 2015; Ismail et al., 2017; Lawford et al., 2019; Riddle et al., 2019; Wang et al., 2020).
Successful provider competency and training were also highlighted in the studies by Riddle et al.
(2019) and Broderick et al. (2014), further supporting the benefit of PCST delivery by providers
other than a clinical psychologist. Thus, it is likely that with the required educational training,
PCPs can successfully deliver PCST interventions to adult patients suffering chronic pain related
to OA. This is likely because the providers that delivered PCST interventions in the studies did
not have background training in mental health. Thus, it is not a prerequisite for the successful
delivery of the intervention. However, the delivery of PCST interventions is dependent on the
application of appropriate education and support (Allen et al., 2019; Bennell et al., 2017;
Broderick et al., 2014; Riddle et al., 2019).

62
The management of chronic pain related to OA is complex and is best managed with a
multidisciplinary team. For example, in the study by Helminen et al. (2015), the physiotherapists
taught components of pain coping skills and recommended individualized adjunct exercises to
the participants. The psychotherapists’ role in managing OA is of high importance; according to
the Centre for Effective Practice (CEP, 2017), incorporating exercises, joint protection, and
assistive devices is part of the non-pharmacological management for OA affecting the hip, knee
or hand. Additionally, the 2019 American College of Rheumatology/Arthritis Foundation
Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee, support selfmanagement programs that utilize a multidisciplinary approach coupled with exercises as strong
recommendations for patients with knee, hip, or hand OA (Kolasinski et al., 2020).
In the study by Riddle et al. (2019), registered nurses performed the arthritis education
component to the participants while the therapists delivered PCST interventions. This type of
collaborative effort will be necessary and permits health professionals to administer components
of PCST that fall within their scope of practice. This approach would also likely reduce the
provider burden. The PCP role is uniquely set to not only deliver PCST interventions but also to
address other needs such as prescribing medications, making referrals to physiotherapists,
occupational therapists, orthopedic surgeon, rheumatologist or pain specialist (Egerton et al.,
2018; Peckham et al., 2018; Sasek, 2015).
Although only two studies (Broderick et al., 2014; Wang et al., 2020) utilized trained NPs
to deliver PCST interventions, the success of physiotherapists, counsellors, registered nurses and
physical therapists indicates that the delivery of PCST interventions is feasible and effective in
the primary care setting. Offering PCST interventions to manage chronic pain related to OA

63
permits using a biopsychosocial approach to care. The recommendations for clinical practice are
summarized in Table 3.
Recommendations
Based on the findings, six recommendations have been made to assist PCPs in the
delivery of PCST. The purpose of these recommendations is to facilitate the PCPs ability to
integrate components of PCST into routine primary care visits.
Table 3. Summary of Recommendations for Primary Care Practice
Recommendations
PCPs to undertake educational
competency in delivering PCST
interventions

•

•
•

Assess and implement PCST
interventions during primary care
visits

•

•

•
•
•

Utilize a Standardized PCST
Manual

•
•
•

Implementation within PCP
Practice
Partnership with clinical
psychologists, Pain BC and
CEP
Attend PCST training course
Maintain competency by
completing continual
recertification and educational
opportunities
Provide counseling, education,
and assessments to patients
suffering chronic pain related
to OA
Identify patient goals, and
effect of chronic pain (BPI and
WOMAC function subscale)
Develop and sustain
therapeutic relationships
Provide biomedical treatments
(i.e., Steroids, Analgesics)
Provide nonpharmacotherapeutics
treatment options (PCST)
Utilize manuals with clear and
concise approach
Attend PCST training course
Focus first on PCST
interventions best suited to
manage patients’ chief
complaints

Evidence
•

Allen et al., 2019; Broderick et
al., 2014; Dixon et al., 2007;
Riddle et al., 2019.

•

Allen et al., 2019; Baird &
Sands, 2004; Broderick et al.,
2014; CEP, 2017, 2020;
Helminen et al., 2015.

•

Allen et al., 2019; Baird &
Sand, 2004; Bennell et al.,
2017; Broderick et al., 2014;
Dixon et al., 2007; Giacobbi et
al., 2015; Helminen et al.,
2015; Ismail et al., 2017;
Lawford et al., 2019; Murphy
et al., 2020; Riddle et al., 2019;
Wang et al., 2020.

64
Educate on and administer PCST
Home Activities/Assignments
/Practice

•
•
•

Tailor delivery modality based on
patients’ needs and preference

•

•

•

Adopt a multi-disciplinary
approach

•

•

Provide clear guidance on
activities to practice at home
Detailed description of each
activity in patient manuals
Provide opportunity to follow
up on completion status
Inform patients of efficacy
with all delivery modality
types
Consider mobility concerns,
rural/remote area, and
computer literacy level
Obtain support from IT
services to set up virtual
delivery
Consider aspects of PCST that
fall within each team members
scope (i.e., Nurses may
complete initial arthritis
education)
Involve PT, OT, pain
specialist, orthopedic surgeon,
rheumatologists, and mental
health clinicians in patients
care

•

Allen et al., 2019; Bennell et
al., 2017; Broderick et al.,
2014; Helminen et al., 2015;
Lawford et al., 2019.

•

Allen et al., 2019; Baird &
Sands, 2004; Broderick et al.,
2014; Helminen et al., 2015;
Webster, 2020; Zulman, &
Verghese, 2021.

•

Allen et al., 2019; Bennell et
al., 2017; Broderick et al.,
2014; CEP, 2017; Giacobbi et
al., 2015; Helminen et al.,
2015; Ismail et al., 2017;
Kolasinski et al., 2020;
Lawford et al., 2019; Riddle et
al., 2019; Wang et al., 2020.

Limitations and Recommendations for Future Research
A review of limitations allows planners to identify and improve aspects when introducing
new interventions such as those within primary care practice (Ross & Bibler Zaidi, 2019). By
addressing the identified limitations, appropriate next steps can be established to initiate PCST
delivery to eligible patients in the community setting.
The included studies displayed a diverse range of participants, including Caucasians,
Hispanics, African Americans, and Asians, similar to the ethnically diverse population in
Canada. However, only studies written in the English language were included in the integrative
review. Thus, it is likely that applicable studies not available in the English language were
excluded in this review. Furthermore, as one author conducted the literature search, the

65
possibility of publication bias or unintended omissions of relevant studies may have been
introduced.
Additionally, of the eleven studies included in this review, seven were conducted in the
USA, one in Finland, two in Australia, and one in West China. Although these settings represent
the diverse population in Canada, it is relevant to acknowledge the sociopolitical and healthcare
system differences, which may affect the generalizability of findings between each country.
Thus, my first recommendation is to further research PCP delivery of PCST for adult patients
suffering chronic pain related to OA that applies to the Canadian context.
As evidenced by this review's findings, there remains uncertainty regarding the benefit of
using generic or disease-specific measurement instruments to attain the most comprehensive
assessment of pain interference and QOL. It is essential to utilize appropriate screening tools that
capture the extent of pain interference and effects on QOL for each patient suffering OA. With
the administration of screening instruments such as the BPI for pain interference and the AIMS
for QOL, future research needs to investigate the appropriateness of each instrument balanced by
respondent and provider burden. By establishing appropriate and standardized screening
instruments tailored to patients affected by OA, the impact of PCST interventions can be
monitored at various time points and compared to treatment effects using other interventions.
While education was revealed to be an essential aspect of facilitating PCST uptake,
limited studies described how provider competency was attained. Further research is needed to
develop appropriate PCP competency/educational training on PCST delivery interventions.
Training centres could teach skills for delivering PCST, provide monitoring of intervention
competence, and offer certification of competency. This may be achieved by partnering with
organizations such as the Pain BC society who currently offer free educational webinars to health

66
professionals on topics such as the biopsychosocial model of pain and pain foundations for PCPs
to build provider competency.
Additionally, although the studies support the utility of PCST treatment manuals, there
was no clear direction on what manual or treatment protocol would be best utilized. The
development of a treatment manual to assist PCPs may be achieved by the partnership with the
Centre for Effective Practice (CEP), an organization responsible for knowledge translation for
primary care in Canada. The CEP currently has a tool for managing chronic non-cancer pain but
no specific guidance on how to implement PCST interventions in practice other than referring
patients to a psychotherapist (CEP, 2020). With the example of the CBT-CP therapist manual,
further research will be needed to develop a standardized manual or treatment protocol that can
facilitate PCST delivery in the primary care setting.
Although the findings from the literature provide insight into the results of PCST
interventions on pain interference and QOL outcomes, a significant limitation was the lack of
literature specific to the PCP role. The research results can be discussed within the context of a
primary care setting; however, further research is needed to examine the outcomes of NP and
physician delivery of PCST interventions. This research would provide valuable insight into the
PCP's role in delivering PCST interventions.
Finally, the number of PCST sessions and the timing of each session ranged from 15-90
minutes per session and 6-12 sessions. However, the optimal dose of PCST or the minimum
required sessions needed to achieve treatment effects is uncertain. To optimize dissemination in
primary care practice, treatment will need to be brief and streamlined. Thus, future studies are
needed to explore shorter (under six sessions) effects compared to the currently reported (6-12
sessions) PCST protocols.

67
Conclusion
It is estimated that the incidence of OA is projected to affect 9 million people by 2040
(Arthritis Society, 2019). Pain Coping Skills Training is an intervention protocol derived from
CBT to address patients' psychological and physical effects with OA. However, access to PCST
interventions is scarce, as clinical psychologists solely deliver it in hospital settings. By offering
PCST interventions within the primary care setting delivered by PCPs is a proposed strategy to
mitigate gaps in PCST service access. The current guidelines for arthritis care are limited in the
support they provide for delivering PCST in primary care and only advise on referral to mental
health specialists. However, without adequate resources, guidelines and treatment manuals, such
as the CBT-CP utilized in the USA, PCPs will experience difficulties when offering PCST
interventions.
The integrative literature review synthesized evidence to answer the following question
“Does the delivery of Pain Coping Skills Training (PCST) by primary care providers improve
pain interference and quality of life for adult patients with chronic pain related to OA?” A
comprehensive search of the literature was undertaken, and eleven studies were selected for this
review. The evidence from these eleven articles was critically appraised using the CASP (2013)
checklist to evaluate the strengths, limitations, rigor, validity, and strength of evidence in the
included studies. Key findings from this integrative review included: 1) Pain Interference and
Quality of Life Outcomes, 2) Education, 3) Delivery Modality, and 4) Multidisciplinary
management.
Based on this review, PCST interventions can be successfully delivered within the
primary care setting by physiotherapists, physical therapists, registered nurses, counsellors, and
NPs (Allen et al., 2019; Bennell et al., 2017; Broderick et al., 2014; Giacobbi et al., 2015;

68
Helminen et al., 2015; Ismail et al., 2017; Lawford et al., 2019; Riddle et al., 2019; Wang et al.,
2020). Additionally, successful delivery and competency were achieved by providers who did
not have specific mental health background (Allen et al., 2019; Bennell et al., 2017; Broderick et
al., 2014; Riddle et al., 2019).
To address the psychological effects of OA, management plans should include safe,
accessible, and cost-effective interventions. With the introduction of PCST interventions,
patients reported improvement in self-efficacy for controlling pain, decreased activity
interference due to pain, increased physical functioning, and decreased psychological distress
(Allen et al., 2019; Baird & Sand, 2004; Bennell et al., 2017; Broderick et al., 2014; Dixon et al.,
2007; Giacobbi et al., 2015; Helminen et al., 2015; Ismail et al., 2017; Lawford et al., 2019;
Riddle et al., 2019; Wang et al., 2020). This body of evidence provides a substantial rationale for
the benefit of PCP delivery of PCST interventions to patients suffering chronic pain related to
OA.
Finally, in keeping with the integrative review process, limitations and recommendations
for future research were highlighted. The recommendations for future research will be essential
to provide further rationale for GPs and NPs to adopt strategies that will allow integration of
PCST interventions within their management plans for adult patients who suffer from chronic
pain related to OA.

69
References
Allen, K. D., Somers, T. J., Campbell, L. C., Arbeeva, L., Coffman, C. J., Cené, C. W., Oddone,
E. Z., & Keefe, F. J. (2019). Pain coping skills training for African Americans with
osteoarthritis: Results of a randomized controlled trial. Pain, 160(6), 1297–1307.
https://doi.org/10.1097/j.pain.0000000000001525
Arthritis Society. (2019). Arthritis facts and figures. Retrieved February 7, 2021, from
https://arthritis.ca/about-arthritis/what-is-arthritis/arthritis-facts-and-figures
Baird, C. L., & Sands, L. (2004). A pilot study of the effectiveness of guided imagery with
progressive muscle relaxation to reduce chronic pain and mobility difficulties of
osteoarthritis. Pain Management Nursing, 5(3), 97-104.
https://doi.org/10.1016/j.pmn.2004.01.003
Barnett, R. (2018). Osteoarthritis. Lancet, 391(10134), 1985. https://doi.org/10.1016/S01406736(18)31064-X
Bennell, K. L., Nelligan, R. K., Rini, C., Keefe, F. J., Kasza, J., French, S., Forbes, A., Dobson,
F., Abbott, J. H., Dalwood, A., Harris, A., Vicenzino, B., Hodges, P. W., & Hinman, R.
S. (2018). Effects of internet-based pain coping skills training before home exercise for
individuals with hip osteoarthritis (HOPE trial): A randomised controlled trial. Pain,
159(9), 1833–1842. https://doi.org/10.1097/j.pain.0000000000001281
British Columbia College of Nurses and Midwives. (n.d.). Nurse practitioner. Retrieved
December 15, 2020, from https://www.bccnm.ca/NP/Pages/Default.aspx
Broderick, J. E., Keefe, F. J., Bruckenthal, P., Junghaenel, D. U., Schneider, S., Schwartz, J. E.,
Kaell, A. T., Caldwell, D. S., McKee, D., Reed, S., & Gould, E. (2014). Nurse
practitioners can effectively deliver pain coping skills training to osteoarthritis patients

70
with chronic pain: A randomized controlled trial. Pain, 155(9), 1743-1754.
https://doi.org/10.1016/j.pain.2014.05.024
Broderick, J. E., Keefe, F. J., Schneider, S., Junghaenel, D. U., Bruckenthal, P., Schwartz, J. E.,
Kaell, A. T., Caldwell, D. S., McKee, D., & Gould, E. (2016). Cognitive behavioral
therapy for chronic pain is effective, but for whom? Pain, 157(9), 2115-2123.
https://doi.org/10.1097/j.pain.0000000000000626
Buttaro, T. M., Polgar-Bailey, P., Sandberg-Cook, J., & Trybulski, J. (Eds.). (2021). Primary
care: Interprofessional collaborative practice (6th ed.). Elsevier.
Canadian Nurses Association. (2016). The nurse practitioner: CNA position. Retrieved
November 21, 2020, from https://www.cna-aiic.ca/-/media/cna/page-content/pdfen/the-nurse-practitioner-positionstatement_2016.pdf?la=en&hash=B13B5142C8D02990439EF06736EA284126779BC
C
Centre for Effective Practice. (2017). Osteoarthritis tool. Retrieved May 5, 2021, from
https://cep.health/media/uploaded/CEP_OATool_2017.pdf
Centre for Effective Practice. (2020). Management of chronic non-cancer pain. Retrieved May 5,
2021, from https://tools.cep.health/tool/management-of-chronic-non-cancer-pain/#nonpharmacological-therapies
Cosio, D., & Lin, E. H. (2017). Behavioral medicine: How to incorporate into pain management.
Practical Pain Management, 16(7), 1-11.
https://www.practicalpainmanagement.com/treatments/psychological/cognitivebehavioral-therapy/behavioral-medicine-how-incorporate-pain

71
Critical Appraisal Skills Programme. (2013). CASP checklists. Retrieved March 3, 2021, from
http://www.casp-uk.net/#!casp-tools-checklists/c18f8
Davies, B., & Logan, J. (2018). Reading research: A user-friendly guide for health professionals
(6th ed.). Elsevier.
EBSCOhost. (n.d.-a). APA PsycInfo. Retrieved November 26, 2020, from
https://www.ebsco.com/products/research-databases/apa-psycinfo
EBSCO Health. (n.d.). CINAHL database. Retrieved November 26, 2020, from
https://health.ebsco.com/products/the-cinahl-database
Egerton, T., Nelligan, R. K., Setchell, J., Atkins, L., & Bennell, K. L. (2018). General
practitioners' views on managing knee osteoarthritis: A thematic analysis of factors
influencing clinical practice guideline implementation in primary care. BMC
Rheumatology, 2, 30. https://doi.org/10.1186/s41927-018-0037-4
Fontaine, K. (n.d.). Arthritis and health-related quality of life. Johns Hopkins Arthritis Center.
Retrieved November 24, 2020, from https://www.hopkinsarthritis.org/patientcorner/disease-management/quality-of-life-and-arthritis/#ref8
Fu, K., Robbins, S. R., & McDougall, J. J. (2018). Osteoarthritis: The genesis of pain.
Rheumatology, 57(4), 43-50. https://doi.org/10.1093/rheumatology/kex419
Gatchel, R. J., & Howard, K. J. (2020). The biopsychosocial approach. Practical Pain
Management, 8(4), 1-9.
https://www.practicalpainmanagement.com/treatments/psychological/biopsychosocialapproach
Genova, A., Dix, O., Thakur, M., & Sangha, P. S. (2020). Chronic non-cancer pain management
and addiction: A review. Cureus, 12(2), 1-7. https://doi.org/10.7759/cureus.6963

72
Giacobbi, P. R., Jr, Stabler, M. E., Stewart, J., Jaeschke, A. M., Siebert, J. L., & Kelley, G. A.
(2015). Guided Imagery for arthritis and other rheumatic diseases: A systematic review
of randomized controlled trials. Pain Management Nursing, 16(5), 792–803.
https://doi.org/10.1016/j.pmn.2015.01.003
Goetz, C., Ecosse, E., Rat, A. C., Pouchot, J., Coste, J., & Guillemin, F. (2011). Measurement
properties of the osteoarthritis of knee and hip quality of life OAKHQOL
questionnaire: An item response theory analysis. Rheumatology (Oxford, England),
50(3), 500–505. https://doi.org/10.1093/rheumatology/keq357
Government of Canada. (2020). Osteoarthritis in Canada. Retrieved November 16, 2020, from
https://www.canada.ca/en/public-health/services/publications/diseasesconditions/osteoarthritis.html
Gray, J. R., Grove, S. K., & Sutherland, S. (2017). The practice of nursing research: Appraisal,
synthesis, and generation of evidence (8th ed.). Elsevier.
Heale, R., James, S., Wenghofer, E., & Garceau, M. L. (2018). Nurse practitioner's perceptions
of the impact of the nurse practitioner-led clinic model on the quality of care of
complex patients. Primary Health Care Research & Development, 19(6), 553–560.
https://doi.org/10.1017/S1463423617000913
Helminen, E. E., Sinikallio, S. H., Valjakka, A. L., Väisänen-Rouvali, R. H., & Arokoski, J. P.
(2015). Effectiveness of a cognitive-behavioural group intervention for knee
osteoarthritis pain: A randomized controlled trial. Clinical Rehabilitation, 29(9), 868–
881. https://doi.org/10.1177/0269215514558567
Hsu, H., & Siwiec, R. M. (2020). Knee osteoarthritis. StatPearls Publishing. Retrieved March 3,
2021, from https://www.ncbi.nlm.nih.gov/books/NBK507884/

73
Iijima, H., Aoyama, T., Fukutani, N., Isho, T., Yamamoto, Y., Hiraoka, M., Miyanobu, K.,
Jinnouchi, M., Kaneda, E., Kuroki, H., & Matsuda, S. (2018). Psychological health is
associated with knee pain and physical function in patients with knee osteoarthritis: An
exploratory cross-sectional study. BMC Psychology, 6(1), 19.
https://doi.org/10.1186/s40359-018-0234-3
Ismail, A., Moore, C., Alshishani, N., Yaseen, K., & Alshehri, M. A. (2017). Cognitive
behavioural therapy and pain coping skills training for osteoarthritis knee pain
management: A systematic review. Journal of Physical Therapy Science, 29(12),
2228–2235. https://doi.org/10.1589/jpts.29.2228
Jensen, M. P. (2011) Measuring pain interference. In: The pain stethoscope: A clinician’s guide
to measuring pain. Springer Healthcare. https://doi.org/10.1007/978-1-908517-43-2_6
Kean, J., Monahan, P. O., Kroenke, K., Wu, J., Yu, Z., Stump, T. E., & Krebs, E. E. (2016).
Comparative responsiveness of the PROMIS pain interference short forms, brief pain
inventory, PEG, and SF-36 bodily pain subscale. Medical Care, 54(4), 414-421.
https://doi.org/10.1097/MLR.0000000000000497
Kean, W. F., Kean, C. A., & Hogan, M. G. (2020) Osteoarthritis. Compendium of Therapeutic
Choice. Canadian Pharmacists Association
Keefe, F. J., & Somers, T. J. (2010). Psychological approaches to understanding and treating
arthritis pain. Rheumatology, 6(4), 210-216. https://doi.org/10.1038/nrrheum.2010.22
Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J., Callahan, L.,
Copenhaver, C., Dodge, C., Felson, D., Gellar, K., Harvey, W. F., Hawker, G., Herzig,
E., Kwoh, C. K., Nelson, A. E., Samuels, J., Scanzello, C., White, D., Wise, B., …
Reston, J. (2020). 2019 American College of Rheumatology/Arthritis Foundation

74
guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis
Care & Research, 72(2), 149–162. https://doi.org/10.1002/acr.24131
Lachance, C. C., & McCormack, S. (2019). Mindfulness training for chronic non-malignant pain
management: A review of the clinical effectiveness, cost-effectiveness and guidelines.
Canadian Agency for Drugs and Technologies in Health. Retrieved March 1, 2021,
from http://europepmc.org/article/NBK/NBK546001#free-full-text
Lawford, B. J., Hinman, R. S., Nelligan, R. K., Keefe, F., Rini, C., & Bennell, K. L. (2020). "I
could do it in my own time and when I really needed it": Perceptions of online pain
coping skills training for people with knee osteoarthritis. Arthritis Care & Research,
72(12), 1736–1746. https://doi.org/10.1002/acr.24093
Mahmoud, G. A., Moghazy, A., Fathy, S., & Niazy, M. H. (2019). Osteoarthritis knee hip quality
of life questionnaire assessment in Egyptian primary knee osteoarthritis patients:
Relation to clinical and radiographic parameters. Egyptian Rheumatologist, 41(1), 6569. https://doi.org/10.1016/j.ejr.2018.05.001
Martin. B. (2019). In-depth: Cognitive behavioral therapy. Psych Central. Retrieved November
18, 2020, from https://psychcentral.com/lib/in-depth-cognitive-behavioral-therapy/
McCance, K. L., & Huether, S. E. (Eds.). (2019). Pathophysiology: The biologic basis of disease
in adults and children. (8th ed.). Elsevier.
McLeod, S. A. (2019). Cognitive behavioral therapy. Simply Psychology. Retrieved November
18, 2020, from https://www.simplypsychology.org/cognitive-therapy.html
Mehana, E. E., Khafaga, A. F., & El-Blehi, S. S. (2019). The role of matrix metalloproteinases in
osteoarthritis pathogenesis: An updated review. Life Sciences, 234, 116786.
https://doi.org/10.1016/j.lfs.2019.116786

75
Murphy, J. L., Cordova, M. J., & Dedert, E. A. (2020). Cognitive behavioral therapy for chronic
pain in veterans: Evidence for clinical effectiveness in a model program. Psychological
Services, Advance online publication. https://doi.org/10.1037/ser0000506
Peckham, A., Ho, J., & Marchildon, G. (2018). Policy innovations in primary care across
Canada. North American Observatory on Health Systems and Policies. Retrieved
November 18, 2020, from https://ihpme.utoronto.ca/wpcontent/uploads/2018/04/NAO-Rapid-Review-1_EN.pdf
Riddle, D. L., Keefe, F. J., Nay, W. T., McKee, D., Attarian, D. E., & Jensen, M. P. (2011). Pain
coping skills training for patients with elevated pain catastrophizing who are scheduled
for knee arthroplasty: A quasi-experimental study. Archives of Physical Medicine and
Rehabilitation, 92(6), 859-865. https://doi.org/10.1016/j.apmr.2011.01.003
Riddle, D. L., Keefe, F. J., Ang, D. C., Slover, J., Jensen, M. P., Bair, M. J., Kroenke, K., Perera,
R. A., Reed, S. D., McKee, D., & Dumenci, L. (2019). Pain Coping Skills Training for
patients who catastrophize about pain prior to knee arthroplasty: A multisite
randomized clinical trial. The Journal of Bone and Joint Surgery, 101(3), 218–227.
https://doi.org/10.2106/JBJS.18.00621
Rini, C., Porter, L. S., Somers, T. J., McKee, D. C., DeVellis, R. F., Smith, M., Winkel, G.,
Ahern, D. K., Goldman, R., Stiller, J. L., Mariani, C., Patterson, C., Jordan, J. M.,
Caldwell, D. S., & Keefe, F. J. (2015). Automated internet-based pain coping skills
training to manage osteoarthritis pain: A randomized controlled trial. Pain, 156(5),
837–848. https://doi.org/10.1097/j.pain.0000000000000121
Ross, P. T., & Bibler Zaidi, N. L. (2019). Limited by our limitations. Perspectives on medical
education, 8(4), 261–264. https://doi.org/10.1007/s40037-019-00530-x

76
Sasek, C. (2015). An update on primary care management of knee osteoarthritis. Official Journal
of the American Academy of Physician Assistants, 28(1), 37–43.
https://doi.org/10.1097/01.JAA.0000458853.38655.02
Shah, T. I., Bell, S., & Wilson, K. (2016). Spatial accessibility to health care services:
Identifying under-serviced neighbourhoods in Canadian urban areas. PloS One, 11(12),
1-22. https://doi.org/10.1371/journal.pone.0168208
Sharif, B., Garner, R., Hennessy, D., Sanmartin, C., Flanagan, W. M., & Marshall, D. A. (2017).
Productivity costs of work loss associated with osteoarthritis in Canada from 2010 to
2031. Osteoarthritis and Cartilage, 25(2), 249-258.
https://doi.org/10.1016/j.joca.2016.09.011
Sharma, A., Kudesia, P., Shi, Q., & Gandhi, R. (2016). Anxiety and depression in patients with
osteoarthritis: Impact and management challenges. Open Access Rheumatology:
Research and Reviews, 8, 103-113. https://doi.org/10.2147/OARRR.S93516
Somers, T. J., Keefe, F. J., Pells, J. J., Dixon, K. E., Waters, S. J., Riordan, P. A., Blumenthal, J.
A., McKee, D. C., LaCaille, L., Tucker, J. M., Schmitt, D., Caldwell, D. S., Kraus, V.
B., Sims, E. L., Shelby, R. A., & Rice, J. R. (2009). Pain catastrophizing and painrelated fear in osteoarthritis patients: Relationships to pain and disability. Journal of
Pain and Symptom Management, 37(5), 863-872.
https://doi.org/10.1016/j.jpainsymman.2008.05.009
Statistics Canada. (2019). Primary health care providers, 2019. Retrieved November 18, 2020,
from https://www150.statcan.gc.ca/n1/pub/82-625-x/2020001/article/00004-eng.htm

77
Stubbs, B., Aluko, Y., Myint, P. K., & Smith, T. O. (2016). Prevalence of depressive symptoms
and anxiety in osteoarthritis: A systematic review and meta-analysis. Age and Ageing,
45(2), 228-235. https://doi.org/10.1093/ageing/afw001
Tauben, D., & Stacey, R. B. (2020). Evaluation of chronic non-cancer pain in adults. UpToDate.
Retrieved March 1, 2021, from https://www.uptodate.com/contents/evaluation-ofchronic-non-cancer-pain-in-adults#references
Turk, D. C., Fillingim, R. B., Ohrbach, R., & Patel, K. V. (2016). Assessment of psychosocial
and functional impact of chronic pain. The Journal of Pain: Official Journal of the
American Pain Society, 17(9), 21-49. https://doi.org/10.1016/j.jpain.2016.02.006
Wang, L., Zhang, L., Yang, L., & Cheng-Qi, H. (2021). Effectiveness of pain coping skills
training on pain, physical function, and psychological outcomes in patients with
osteoarthritis: A systemic review and meta-analysis. Clinical Rehabilitation, 35(3),
342–355. https://doi.org/10.1177/0269215520968251
Web of Science. (n.d.). Web of science core collection: Introduction. Retrieved November 26,
2020, from https://clarivate.libguides.com/woscc
Webster, P. (2020). Virtual health care in the era of COVID-19. Lancet (London, England),
395(10231), 1180–1181. https://doi.org/10.1016/S0140-6736(20)30818-7
Whittemore, R., & Knafl, K. (2005). The integrative review: Updated methodology. Journal of
Advanced Nursing, 52(5), 546-553. https://doi.org/10.1111/j.1365-2648.2005.03621.x
Williamson, P. O., & Minter, C. (2019). Exploring PubMed as a reliable resource for scholarly
communications services. Journal of the Medical Library Association, 107(1), 16-29.
https://doi.org/10.5195/jmla.2019.433

78
World Health Organization. (2012). Programme on mental health: WHOQOL user manual.
Retrieved November 20, 2020, from
https://apps.who.int/iris/bitstream/handle/10665/77932/WHO_HIS_HSI_Rev.2012.03_
eng.pdf?sequence=1&isAllowed=y
Writers, S. (2020). What is a nurse practitioner? Retrieved December 15, 2020, from
https://www.nursepractitionerschools.com/faq/what-is-np/
Yasaei, R., Peterson, E., & Saadabadi, A. (2020). Chronic pain syndrome. StatPearls Publishing.
Retrieved March 1, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK470523/
Zulman, D. M., & Verghese, A. (2021). Virtual care, telemedicine visits, and real connection in
the era of COVID-19: Unforeseen opportunity in the face of adversity. JAMA, 325(5),
437–438. https://doi.org/10.1001/jama.2020.27304

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Appendix A
PubMed Search and Results (November 25, 2020)
#1
"Pain Management"[Mesh]
OR “pain coping” OR “pain
coping skills training” OR
“pain management” OR
“PCST”
#2
"Osteoarthritis"[Mesh] OR
"Arthritis"[Mesh] OR
“osteoarthritis” OR “OA” OR
“arthritis”
#3
"Quality of Life"[Mesh] OR
“quality of life” OR “QOL”
#4
#1 AND #2 AND #3 AND #4
AND #5

62,595

381,813

346,496
TOTAL = 420

Appendix B
CINAHL Search and Results (November 25, 2020)
#1
(MM "Pain
Management") OR “pain
coping” OR "pain coping
skills training" OR "PCST"
#2
(MH "Osteoarthritis+") OR
(MH "Arthritis+") OR “OA”
#3
(MH "Quality of Life+") OR
“quality of life” OR “QOL”
#4
#1 AND #2 AND #3

4,932

80,037
198,033
TOTAL = 53

Appendix C
PsychINFO Search and Results (November 25, 2020)
#1
MM “Pain Management” OR
PCST OR pain coping OR pain
coping skills training OR pain
management
#2
DE “Arthritis” OR DE
"Rheumatoid Arthritis"
OR Osteoarthritis
#3
DE "Quality of Life" OR DE
"Health Related Quality of Life"
OR DE "Quality of Work Life"
OR QOL OR quality of life
#4

#1 AND #2 AND #3

24,958

5,454

98,410

Total = 106

80
Appendix D
Web of Science Search and Results (November 25, 2020)
#1
TITLE: “pain coping” OR
“pain coping skills training”
OR “pain management” OR
“PCST”
#2
TOPIC: “osteoarthritis” OR
“OA” OR “arthritis”
#3
TOPIC: “quality of life” OR
“QOL”
#4
#1 AND #2 AND #3

8.410

361,886
407,709
Total = 71

81
Appendix E
Literature Search Strategy

PubMed (Ovid)
No limits
420 Citation(s)

CINAHL
(EBSCOhost)
No limits
53 Citation(s)

PsychINFO
(EBSCOhost)
No limits
106 Citation(s)

Web of Science
(Clarivate)
No limits
71 Citation(s)

560 Non-Duplicate Citations from Database
Searches

Titles and Abstracts Screened using
Inclusion/Exclusion Criteria
Criteria’s Applied

528 Articles Excluded
After Title/Abstract
Screen

32 Articles Remaining

Full Text Screened using
Inclusion/Exclusion Criteria

11 Articles Selected for Inclusion

21 Articles Excluded After
Full Text Screen

Guided imagery for
arthritis and other
rheumatic diseases:
A systematic review
of randomized
controlled trials.

Giacobbi, Stabler,
Stewart, Jaeschke,
Siebert, & Kelley.
(2015).

Psychological
interventions for
arthritis pain
management in
adults: A metaanalysis. Health
Psychology:
American
Psychological
Association.

Dixon, Keefe,
Scipio, Perri, &
Abernethy. (2007).

Systematic Reviews
Author(s), Title,
Journal, Year

- To conduct a
systematic review
of RCTs that
examined the
effects of guided
imagery in adults
with AORD in
order to determine
whether this
intervention
approach is

- To explore the
effects of
psychosocial
interventions on
psychological,
physical, and
biological
functioning

-To examine
empirical studies
investigating the
efficacy of
psychosocial
interventions for
OA and RA.

Purpose/
Aim

- Databases:
Academic Search
Complete, Medline,
PsycInfo, Scopus,
SPORTDis- cus,
Cochrane Central
Register of

- English language
publications.
Dates:1985-2006.
- Systematic review
of qualitative
literature.

- Inclusion criteria:
adults >18 years,
diagnosis of OA
and/or RA, reported
pain as an outcome,
and tested one
psychosocial
intervention.

- Databases:
Cochrane
Controlled Trials,
EMBASE, Ovid
MEDLINE, and
Ovid PsycINFO.

- Meta-analysis of
quantitative
literature (RCTs).

Method

Results= 1935,
Duplicates
removed=1313,
Title and abstract
screen=441,
Full-text
screen=322,
Eligibility reapplied=7,
N=7 studies
included.

Results=233 Initial
screen=63 Full text
screen=37
Eligibility reapplied=27, N=27
studies included.

Sample

Appendix F
Literature Matrix

- All seven studies
support the use of
guided imagery as a
therapeutic tool for
the treatment of
pain, improved
psychological wellbeing improved
mobility reduced
anxiety and
increased self-

- Psychosocial
interventions were
associated with
higher levels of
active coping and
significantly lower
post-treatment
physical disability.

- Intervention group
reported
significantly lower
levels of pain, lower
post-treatment
anxiety, depression,
and psychological
disability.

Findings

- Six RCTs were
rated to have low

- Researchers
followed the
Cochrane
Collaboration
guidelines for
coding risk of bias.

CASP High

- Studies were of
high quality.

- External validity
was assessed based
on clear description
of population;
description of
provider training;
standardisation of
treatment; clear
description of study
methods; and
adequately reported
outcome data.

- Internal validity
was assessed
according to an
adapted Jadad scale.

Strengths

- Breakdown by
gender was
disproportionate
because only two of
the seven studies
included men.

- Findings are
limited by publish
date.

- Findings are
limited by publish
date.

- Differences in
patient
characteristics,
outcome measures
and interventions
which may affect
the reliability of the
pooled effect sizes.

- The methods were
not fully stated.

- Majority (18) of
the studies included
were carried out in
RA patients.

Limitations

82

To investigate the
effectiveness of
CBT and PCST on
perceived pain level
in adults with knee
osteoarthritis
(KOA) in
comparison with
usual care.

Ismail, Moore,
Alshishani, Yaseen,
& Alshehri. (2017).

Cognitive
behavioural therapy
and pain coping
skills training for
osteoarthritis knee
pain management:
A systematic
review. Journal of
Physical Therapy
Science.

effective at
reducing pain,
increasing function,
or improving other
outcomes such as
anxiety, depression,
and quality of life.

Official Journal of
the American
Society of Pain
Management
Nurses.

- Dates: 20122016.

- English language
only.

- Search terms:
“pain”,
“osteoarthritis”,
“knee”,
“psychological
therapy”, “cognitive
therapy” and “pain
coping”.

- Databases:
MEDLINE,
PsychINFO,
EMBASE,
CINAHL, and JBI.

- All English
language
publications
Dates: January 1,
1960 - June 1, 2013.
- Systematic review
of quantitative
literature (RCTs).

- Clear description
of inclusion criteria.

Controlled Clinical
Trials, CINAHL,
Physiotherapy
Evidence Database,
Web of Science,
and ERIC.

Results=29,
Duplicates
removed=18,
Full-text screen=6,
Eligibility reapplied=4,
N=4 studies
included

-Improvement
noted when
delivered with
adjunct
rehabilitation
intervention.

- No statistically
significant evidence
and lack of
improvement in the
WOMAC pain
index in treatment
groups.

CASP Moderate

-Methodological
quality determined
by the
Physiotherapy
Evidence Database
scale which
assessed selection
bias, performance
bias & detection
bias.

- The WOMAC
index was used as
outcome measure.

CASP Moderate
- Clear outline of
the methods and
sample selection
process.

- Results reported
for pain, physical
function, anxiety,
depression, or
quality of life.

- None of the seven
studies performed a
cost-benefit
analysis.

- CBT and PCST
were not
recommended as
sole interventions
for managing KOA
pain.

risk of bias; one
RCT was unclear.

efficacy managing
pain.

- Lack of
participant and
assessor blinding in
3 RCTs.

- Lacks pain-related
functional and
psychological
outcome measures.

- Possible selection
bias as one
researcher
conducted the
primary database
search.

- Low evidence
based on the
Grading of
Recommendations
Assessment,
Development and
Evaluation.

83

Effectiveness of
pain coping skills
training on pain,
physical function,
and psychological
outcomes in
patients with
osteoarthritis: A
systemic review and
meta-analysis.
Clinical
Rehabilitation.

Wang, Zhang,
Yang, & Cheng-Qi.
(2020).

- To compare the
effectiveness of
PCST between the
intervention
involving exercise.

- To investigate the
effectiveness of
PCST in pain,
function, and
psychological
outcomes for
patients with OA,
compared to the
control group.

- Clear description
of eligibility
criteria.

- Databases:
PubMed, Embase,
the Cochrane
Library, PEDro,
Clinical Trials, and
the WHO Clinical
Trials Registry
Platform (to 30
September 2020).

- Meta-analysis of
quantitative
literature (RCTs).

- Results=199,
Duplicates
removed=84, Fulltext
screen=28Eligibilit
y re-applied=10,
N= 10 studies
included.

- Group differences
measured by the
McMaster
Universities
Osteoarthritis Index
subscales of pain
were not
statistically
significant.

- PCST group had
significant
improvement in
pain, function,
coping attempts,
pain
catastrophizing, and
self-efficacy
compared to the
control group.

CASP High

-Outcomes:
WOMAC, PCS
, CSQ
Arthritis SelfEfficacy Scale.

- Most recent
systematic review
on PCST and OA.

- Risk of bias
assessed by two
independent
reviewers based on
the Cochrane
Handbook for
Systematic Reviews
of Interventions.

- Clear outline of
the methods and
sample selection
process.

- Exclusion of
relevant studies
(i.e., Somers et al.,
2012).

- Varying follow-up
time frames
between included
RCTs.

- Likely biased
results as trials were
conducted by the
same researchers at
different times.

84

Pain coping skills
training for African
Americans with
osteoarthritis:
results of a
randomized
controlled trial.
Pain.

Allen, Somers,
Campbell, Arbeeva,
Coffman, Cené,
Oddone, & Keefe.
(2019).

To examine the
effectiveness of this
pain CST program
among African
Americans with
OA, relative to
usual OA care.

Individual Research Studies
Author(s), Title,
Purpose/
Journal, Year
Aim

- Follow-up
assessment at 3 and
9 months.

- Sessions were
audio-recorded.

- Coping skills
training counselors
received training in
the PCST protocol,
from experienced
coinvestigators
prior to study.

- 11 weekly PCST
sessions, each 30 45 minutes,
delivered via
telephone by a
trained counselor.

- A parallel-group
design, randomized
controlled trial.

Method

- 248 participants,
randomized into
pain CST group
(N=124) and a
usual care, wait list
control group
(N=124).

- Screening based
on described
inclusion and
exclusion criteria.

- Recruitment of
patients with
evidence of knee or
hip OA in Durham
Veterans Affairs
Medical Center and
East Carolina
University
medical records;
advertisements at
study sites and
surrounding
communities; and
referrals from
HCPs.

Sample

- Decreased pain
catastrophizing, and
increased selfefficacy, relative to
the WL group.

- PROMIS Pain
Interference, SF-12,
PHQ-8, and Yale
Physical Activity
Survey showed
favorable changes
in the PCST group.

- Improvement in
pain coping and
perceived ability to
manage pain in
PSCT group.

- Complier average
causal effect
analyses showed
that intervention
effects on WOMAC
pain were more
robust for
participants who
received >7 visits.

- No statistically
significant changes
in WOMAC pain
score compared
with control group.

Findings

CASP High

- Valid and reliable
measures
(WOMAC, Pain
Interference
Instrument, ShortForm 12 Health
Survey, Coping
Strategies
Questionnaire,
PCS).

- Ensured quality
assurance as
PSCT sessions were
reviewed weekly by
experienced
investigators.

- Thoroughly
described how
counsellors’
competency was
achieved.

- Adequate diverse
sample size and
randomization of
participants.

Strengths

- Lack of de novo
radiographs to
confirm OA status.

- Only 35% of
participants (43 of
124) completed less
than 7/11 sessions
in the PCST group.

- Likely biased
reporting as
participants were
paid $50 for
completing baseline
and 3-month
assessments and
$25 for completing
9-month
assessments.

- The study coordinator and PCST
counselor were not
blinded to treatment
assignment.

Limitations

85

Nurse practitioners
can effectively
deliver pain coping
skills training to
osteoarthritis
patients with
chronic pain: A

Broderick, Keefe,
Bruckenthal,
Junghaenel,
Schneider,
Schwartz, Kaell,
Caldwell, McKee,
Reed, & Gould.
(2014).

Pilot study of the
effectiveness of
guided imagery
with progressive
muscle relaxation to
reduce chronic pain
and mobility
difficulties of
osteoarthritis. Pain
Management
Nursing.

Baird, & Sands.
(2004).

To evaluate the
effectiveness of a
health care delivery
model that trains
nurse practitioners
(NP) to deliver
PCST to OA
patients in
community
practices.

To determine
whether Guided
Imagery (GI) with
Progressive Muscle
Relaxation (PMR)
would reduce
chronic pain and
mobility difficulties
in patients with OA.

- Analyses
conducted with the
intention-to-treat
principle.

- Audiotaped
treatment sessions.

- 10 PCST sessions
delivered by trained
NPs in community
primary care
offices.

- Quantitative
multisite, RCT.

- Repeatedmeasures
(ANOVA) used to
examine treatment
effect.

-Perceived pain
measured using the
AIMS2.

-Personalized
audiotaped
instructions on
using GI and PMR
with journaling
three times a week.

- Quantitative
longitudinal,
randomized clinical
trial.

- 256 selected
patients randomized
into treatment
(N=129) and

1) Pain intensity

- Screening based
on described
inclusion and
exclusion criteria.

2) Coping with
pain, self-efficacy
for controlling pain

- NP delivery of
psychosocial
interventions
produced
improvements in
various pain-related
outcomes:

- Intervention group
reported a
significant
reduction in pain
(P<0.001) and
mobility
difficulties (P<0.00
1) at week 12
compared to the
control group who
experienced
increased mobility
difficulties.

- Significant
difference between
the two groups in
pain experienced
over the 12 weeks
(F = 4.406, df =
26; P = 0.046).

- Recruited from
community primary
care and
rheumatology
practices in three
states.

- 28 selected
women randomized
into treatment
(N=18) and control
groups (N=10).

- Screening based
on described
inclusion and
exclusion criteria.

- Recruited via
Central Midwestern
senior citizen
centers, fitness
centers, churches,
wellness fairs,
newspapers and
wellness
newsletters.

- Ethical rigour
based on the
confidential
handling of data
and confirmation of
consent.

- Sample size
ensured adequate
power to detect an
intervention effect.

CASP LowModerate
- Adequate
randomization of
participants.

- Clear description
of methods, and
analysis.

- The researchers
clearly identified
limitations.

- Reliable and valid
outcome
measurement using
the AIMS2.

- Grouping of
participants from
the same location to
limit contamination.

- Threat to external
and internal validity
due to attrition rate
of 29% at the 12
month follow up.

- Assessor blinding
may have been
compromised as
patients sometimes
revealed their
experimental
condition.

- All participants
were over 65 and
were highly
educated creating a
threat to the
external validity.

- Small sample size.

- Uneven
distribution of
participants.

86

Effectiveness of an
internet-delivered
exercise and paincoping skills
training
intervention for
persons with
chronic knee pain:
A randomized
trial. Annals of
Internal Medicine.

Bennell, Nelligan,
Dobson, Rini,
Keefe, Kasza,
French, Bryant,
Dalwood, Abbott,
& Hinman. (2017).

randomized,
controlled
trial. Pain.

To investigate
whether a 12-week
physical therapist–
delivered combined
pain coping skills
training (PCST) and
exercise
(PCST/exercise) is
more efficacious
and cost effective
than either
treatment alone for
KOA.
- Analyses
conducted with the
intention-to-treat
principle.

- Educational
materials, 7
physiotherapist led
Skype sessions, and
eight 35-45-minute
PCST modules
(PainCOACH).

- Quantitative
parallel pragmatic
RCT.

- Follow-up
assessment
completed at 6 and
12 months.

- Repeatedmeasures
ANCOVA models
used to examine
treatment effects.

- 148 selected
patients randomized
into treatment
(N=74) and control
groups (N=74).

- Screening based
on described
inclusion and
exclusion criteria.

- Recruited via
print, radio, and
social media
advertisements and
the researcher’s
database.

control groups
(N=127).

- Researchers report
strengths:
1) Treatment
delivery by
practicing
physiotherapists.
2) Cost effective
accessible
technology not
requiring
clinician input

- Pain
improvement
effects were
sustained at 9
months.

3) Diverse
participants.

- Reliable and valid
outcome
measurements used.

- Various PCST
interventions were
included.

CASP High

- All outcome
measures used
showed adequate
validity and
sensitivity; the
researchers
indicated the
internal consistency
for each outcome
measure.

- At 3 months,
intervention group
showed significant
improvement in
pain (mean
difference, 1.6 units
[CI, 0.9 to 2.3
units]) and physical
function (mean
difference, 9.3 units
[CI, 5.9 to 12.7
units]) compared
with the control
group.

- There were
beneficial effects
lasting at least 12
months beyond the
intervention.

4) decreased use of
pain medication
when compared
with usual care.

3) activity
interference due to
pain

- No clinical
examination or
radiography
confirmed OA
diagnosis in
participants; posing
threats to external
validity.

- Likely biased
reporting as
$50AUD gift
vouchers was used
as an incentive to
complete
questionnaires.

- Possible
performance bias as
participants and
physiotherapists
were unblinded.

87

Effectiveness of a
cognitivebehavioural group
intervention for
knee osteoarthritis
pain: a randomized
controlled trial.
Clinical
Rehabilitation.

Helminen,
Sinikallio,
Valjakka, VäisänenRouvali, &
Arokoski.
(2015).

- To assess the
effectiveness of a
six week cognitive–
behavioural group
intervention in
patients with knee
osteoarthritis pain
compared to routine
GP care.
- Screening based
on described
inclusion and
exclusion criteria.
- 111 participants
randomized into
treatment (N=55),
and control groups
(N=56).

- Two-hour
sessions, with clear
outline of each
session.

- Recruited from
PCPs in Kuopio
area by
advertisements in
surrounding clinics
and mailed out
recruitment letters.

- Six group based
weekly sessions
supervised by an
experienced
psychologist and a
physiotherapist.

- 3- and 12-month
follow-up
assessments.

- Single-blinded
RCT.

- Significant
difference between
groups was found in
the Pain SelfEfficacy
Questionnaire (Pr =

- Among healthrelated quality of
life instruments, no
significant
differences were
found between the
study groups.
- In the RAND-36 a
significant
difference was
detected in the
emotional wellbeing multi-item
subscale in favour
of the intervention
group (Pr =0.038).

- No significant
difference between
intervention and
control group for
any outcome
measures of pain or
function.

- Adequate sample
size based on power
calculation.

- Radiographic xrays to confirm the
OA diagnosis, and
the use of intent-totreat.

- Appropriate
participant and
accessor blinding
until after 12-month
follow-up.
- Great participant
retention for
duration of study.

- Valid and reliable
outcome measures
including
WOMAC, healthrelated quality of
life, and self-reports
of pain and physical
function.

CASP Moderate

4) Longer followup, retention and
adherence.

- Participants had
an average of 5
comorbidities that
may have affected
study results.

- Mean age of
participants was 63
years old likely
affecting
generalizability of
findings.

88

"I could do it in my
own time and when
I really needed it":
Perceptions of
online pain coping
skills training for
people with knee
osteoarthritis. Arthri
tis Care &
Research.

Lawford, Hinman,
Nelligan, Keefe,
Rini, & Bennell.
(2019).

To explore the
perceptions and
experiences of
people with OA
who completed an
online PCST
program.
- Sample size
dictated by
theoretical
saturation.
- (N=12).

- One 35-45-minute
online module per
week for 8 weeks.
- Audio recorded
semi-structured
interviews.
- Thematic analysis
of the interviews.

- Purposive
sampling via media
campaigns,
advertisements, and
the use of a research
volunteer database.

- Qualitative design
based on the
interpretivism
paradigm embedded
within a randomised
controlled trial.

5) “support from
clinician desirable”

4) “not always
relatable or
engaging,” and

3) “anonymity and
flexibility,”

2) “better able to
cope with pain,”

1) “easy to
understand and
follow,”

- Five themes:

- No significant
differences between
the groups in the
use of pain
medication, number
of doctor
appointments,
physiotherapist
appointments, or
sick-leave days
owing to OA.

0.022) in favour of
the control group.

CASP High

- Findings are
consistent with past
studies (Broderick
et al., 2014).

- Achieving data
saturation.

- Diverse sample.

These factors
contribute to the
trustworthiness and
transferability of the
results:

CASP High

- Possible
confirmation bias in
data collection, as
only one researcher
performed initial
analysis.

- Possible inclusive
bias because
participants
volunteered to
participate in the
study.

89

Pain Coping Skills
Training for
Patients Who
Catastrophize
About Pain Prior to
Knee Arthroplasty:
A Multisite
Randomized
Clinical Trial. The
Journal of bone and
joint surgery.
American volume.

Riddle, Keefe, Ang,
Slover, Jensen,
Bair, Kroenke,
Perera, Reed,
McKee, &
Dumenci. (2019).

- To determine if
PCST in OA
patients with
moderate to high
pain catastrophizing
undergoing knee
arthroplasty
improves
postoperative
outcomes compared
with usual care or
arthritis education.

- Follow-up at 2, 6
and 12 months.

- PCST was not an
effective
perioperative
treatment for
patients who are
undergoing knee
arthroplasty and
catastrophize about
pain.

- Arthritis education
was taught by
experienced
registered nurses.

- No differences
between WOMAC
pain scores at 12
months for the pain
coping skills and
arthritis education
groups or between
the pain coping and
usual-care groups.

- All 3 treatment
groups had large
improvements in
12-month WOMAC
pain scores with no
significant
differences among
the 3 treatment
arms.

- Secondary
outcomes also
showed no
significant
differences among
the 3 groups.

- 402 participants
randomized into
usual care (N=137),
arthritis education
(N=135), and PCST
group (N=130).

- Recruited from
academic medical
centers.

- Screening based
on described
inclusion and
exclusion criteria.

- PCST was
delivered by
physical therapists
(PTs) trained by
clinical
psychologist.

- First session was
in -person and rest
was via telephone.

- A 3-arm RCT
conducted at: Duke
University, New
York University
Medical Center,
Virginia
Commonwealth
University, Wake
Forest University,
and Southern
Illinois University.
- Eight 50 minute
audio recorded
sessions over 2
months.

CASP Moderate

- Intention-to-treat
approach.

- Adequate sample
to detect
meaningful
differences between
groups.

- Diverse sample.

- Valid and reliable
measures
(WOMAC, Pain
Catastrophizing
Scale, Short
Physical
Performance
Battery [SPPB] and
the 6-minutewalk
test).

- Methods
employed to
provide intervention
fidelity.
-Blinded data
collectors.

- Utilized the
Research Electronic
Data Capture
(REDCap) web
interface to reveal
randomized group
assignments.

- Results may not
generalize to
individuals with
low levels of pain
catastrophizing.

- Possible reporting
bias as participants
were compensated
$50 at baseline and
$80 for completing
all follow-up
assessments.

- Participants and
interventionists
were not blinded.

- Participants were
over 45 years of
age.

90