Chronic pain is one of the most frequent reasons for a primary health care visit and people with pain identify improved function as an important goal. Self-management support provides an opportunity to improve function for people with chronic pain, but existing evidence suggests negligible changes in function. This thesis includes five manuscripts with overarching objectives of improving the understanding of reductions in function related to pain and evaluating a new self-management program aimed at improving function for people with chronic pain. The first manuscript is a cross-sectional evaluation of factors associated with reduced function in people with chronic pain referred for self-management support in primary health care. The findings suggest number of medications, depressive symptoms, cognitive factors associated with pain, mechanical hyperalgesia, and duration of symptoms explain 63% of the variance in function in people with chronic pain, multiple comorbidities, and barriers to accessing healthcare. The second manuscript is a case-series describing the participation and outcomes of six participants in Chronic pain self-management support with pain science education and exercise (COMMENCE). This study contributes to the literature by detailing the COMMENCE intervention and describing the varied responses of six participants. The third and fourth manuscripts are a protocol for a randomized controlled trial (RCT) and a completed RCT evaluating the effectiveness of COMMENCE in comparison to a wait-list control. The results suggest COMMENCE improves function for people with chronic pain (mean difference = -8.0 points on the Short Musculoskeletal Function Assessment; 95% confidence interval: -14.7 to -1.3). The fifth manuscript is a planned secondary analysis of the RCT described above. This study suggested people with a greater number of comorbidities are likely to have poorer function at the end of COMMENCE after controlling for age, gender, and baseline function. Together, these factors explained 63% of the variance in function. / Thesis / Doctor of Philosophy (PhD) / Chronic pain is associated with suffering, disability, and health care costs. This thesis includes five papers aimed at better understanding reduced function and evaluating a new self-management program for people living with chronic pain. The results of this research suggests people with more medications, longer lasting pain, negative thoughts and emotions related to their pain, and sensitivity to pressure are more likely to have poor functional abilities. A new self-management approach, Chronic pain self-management support with pain science education and exercise (COMMENCE), is described and evaluated. The results suggest people with chronic pain participating in COMMENCE experience greater improvements in function than people on a wait-list for the program. It appears people living with more chronic health conditions are likely to have poorer function at the end of the program. The findings of this thesis may help to inform management of chronic pain in primary healthcare.

D.Phil. / Chronic pain is a devastating problem and one of the leading causes of disability internationally with an estimated 25-30% of people in industrialised nations suffering from it. Various approaches are available for the treatment of chronic pain with exercise therapy is often the last resort, after all else has failed. The present study was motivated by the growing prevalence of chronic pain patients and the recent progress in pain science. This study made use of a quasi-experimental design where randomization was a function of participant convenience. It made use of a Pre-Test Post-Test battery consisting both of self-report questionnaires and of a physical assessment evaluating components of chronic pain patients’ experience prior to and following a combined therapeutic intervention programme of 12 sessions. Follow- up was at 12 months. The objectives were to integrate patient reconceptualization of pain by means of an active approach combining pain education and exercise therapy, and to determine the effect of a change in pain cognition on the outcome compared to a control group receiving exercise therapy only. A heterogeneous group of chronic pain patients were randomized into 2 groups who both received exercise therapy twice per week: the experimental group (80) received exercise therapy and a specific 3 hour pain education session with the active control group (74) only receiving exercise therapy. There were no differences in pain related or demographic characteristics between groups at baseline. Both groups had a significant reduction in pain perception after 12 exercise therapy sessions (P<0.05). After a follow up period of 12 months the experimental group sustained the same level of pain reduction (P<0.05). The control group maintained only some the acquired reduction in pain perception. In the experimental group an increased participation in physical activity was also found 12 months after the intervention. Exercise therapy significantly reduces the perception of pain in chronic pain patients after 12 therapy sessions, but the combination of pain education and exercise therapy better maintain these effects after a year. Key Words: chronic pain, exercise, pain education.

Purpose: To explore perceptions and initial outcomes of patients with rotator cuff-related pain to a pain education session. Materials and Methods: Ten individuals with persistent rotator cuff-related pain (≥3 months duration) attended an individual pain education session. They completed patient-reported outcomes measures on a weekly basis, three weeks prior and three weeks following the session. Individual semi-structured interviews were conducted three weeks following the pain education. Interviews were recorded, transcribed verbatim, and analyzed using the General Inductive Approach. Results: There were two over-arching key themes: firstly, ‘Participants’ Perspectives’ of the session generated four themes: Improved understanding of ‘the whole’; Mindful self-awareness; Taking charge; “The pain is still there”. Their understanding of pain was reconceptualised, evident by their ability to describe the role of neurophysiological mechanisms, stress and general well-being towards their pain. The second over-arching key theme, ‘Participants’ Recommendations’, had two themes: Integrating neuroscience with pathoanatomical knowledge and Educating other health professionals. Pain levels decreased post-pain education compared to pre-pain education. Conclusions: Following the pain education session, participants had greater understanding of factors influencing their shoulder pain. Pain education, in addition to pathoanatomical information may be useful as part of treatment for persistent rotator cuff-related pain.

Acute and chronic pain conditions have a significant impact on the individual who is experiencing pain and resolution of pain continues to present a challenge to nurses and other health care professionals. It is widely accepted that pain education for nurses is necessary if nurses are to deliver effective, evidenced based pain care. Although it has been shown that participation in pain education improves nurses’ pain knowledge, very little is known about the way in which nurses use their improved pain knowledge in their practice or about the conditions that promote application of that pain knowledge. The aims of this study are (a) to explore the transfer of pain knowledge from a continuing education nursing course into practice, and (b) to investigate the impact that the nurses’ participation in action research has on their ability to improve aspects of their pain practice. Participants are 14 registered nurses who successfully completed two accredited pain course units as part of their BSc / BN degree in Nursing. The nurses formed two groups of inquiry, who used both their participation in the pain course and in action research to investigate and change aspects of pain assessment and management practices within their clinical areas. The inquiry groups were located in two different Health Board locations in Scotland. Following involvement in a pain course, the strategies used by the participating nurses to enhance their pain assessment and management practices are examined. Qualitative data was obtained through individual and group interviews, and analysis of significant incidents. An action research approach contributes to an understanding of conditions that promote application of pain knowledge into practice following participation in the course, and focuses on the possibilities for action and improvement of pain care. The findings from this study demonstrate how nurses develop a more patient-centred approach to pain care and become more accountable for their pain practice. The research also identifies a range of strategies used by nurses to improve collaborative working practices with their colleagues that help to reduce some of the obstacles to delivery of effective pain care. From the outcomes of the inquiry, it is evident that these nurses’ participation in action research has increased the possibilities of their involvement in pain practice interventions. Conditions are created through pain course participation and involvement in action research, which supports nurses’ transfer of pain knowledge into practice Additionally, findings demonstrate the potential action research has for identifying problems with pain care and its potential for helping to develop relevant and workable solutions for improving aspects of care. The findings from this study are significant because they inform teaching and learning approaches which can be used with pain education that helps to prepare nurses to deliver more effective pain care within their health care settings.