Study Limitations, Strengths, and Future Directions
chronic pain, pain
CHRONIC PAIN
This study had several limitations. First, participants were recruited through social media and by collaborating with project partners, which may suggest that the study population consisted of highly motivated individuals. Therefore, it is not clear whether people with chronic pain would, in general, be interested in or benefit from a digital self-management intervention such as EPIO. However, therapeutic interventions are likely mainly effective if the participants are indeed interested in participating, which may support the notion that interested participants may be more likely to benefit from such self-management programs.Second, most participants in this study were female, were White, had higher education, and had lived with chronic pain for many years. Randomization in this study was computerized and stratified by sex to ensure even sex group distribution, but future studies should seek to identify ways to include more balanced proportions of participants (eg, sex, ethnicity, education, and years with pain) in self-management interventions [Third, the EPIO intervention was developed aiming to target chronic pain Fourth, the intervention group was compared with a care-as-usual control group, in which the participants did not receive the EPIO intervention program or any other care from the project team. However, as there was no way of controlling or assessing whether participants in the control group sought any other type of care (eg, self-management courses or mindfulness interventions) during the study period, there is a potential risk that this unknown factor could have impacted the study results. Given this challenge with rather pragmatic RCTs, inquiring about the potential additional external care received by members of the care-as-usual control group might have provided further details about this unknown factor.Fifth, the study did not include a numerical primary outcome measure cut-off score for study inclusion, and it is possible that such a cut-off score (eg, only including participants providing a score above mild pain interference, such as >3 or >5) could have affected the primary outcome results of this study. However, with pain and the interference of pain being an individual and subjective experience, the rationale for excluding people living with chronic pain based on subjective scoring must be thoroughly considered before implementation.Sixth, although the statistical power for the between-group effects was adequate, future studies may consider testing potential moderating effects, for example, related to baseline medical comorbidities, in larger study samples. Finally, this study explored short-term (ie, 3 months) findings from an RCT testing the EPIO intervention program. Future research should examine these long-term findings and follow-up. Qualitative explorations may also, in line with recommendations from the MRC [The fact that the EPIO intervention program was designed and developed based on existing recommendations for digital interventions, including a solid theoretical foundation and development in close collaboration with end users and other stakeholders (eg, health care professionals), is a clear study strength. The simple blended care delivery model used in the study may also guide how such digital interventions could be delivered and implemented in the future, and future research should also aim to test and compare various delivery approaches (eg, blended care delivery vs digital self-management only). This type of research could add value to the understanding of what may constitute the optimal digital intervention and its delivery for those living with chronic pain and also identify the population groups, stages, or types of condition that may benefit from digital pain self-management.