Abstract
Background
Chronic pain is often accompanied by significant functional disability. Since people with chronic pain often experience a decrease in resilience —as a key psychological factor that significantly impacts pain intensity and disability level — the present study aimed to determine the effect of enhancing pain resilience through a smartphone-based application on pain intensity, and disability in this population.
Methods
In the present randomized controlled trial, 108 patients with chronic pain were randomly assigned to three groups. Control group (A) received routine care, and control group (B) received short text-message–based educational content regarding chronic pain and its influencing factors. The intervention group patients also used the content of the enhancing resilience against chronic pain application for 8 weeks. The participants’ outcomes including pain intensity and disability, were evaluated before, immediately after, and three months after the intervention. To examine the between-group differences in the mean outcome scores, ANOVA and Kruskal–Wallis tests were used. To examine the within-group differences in the mean outcome scores, repeated-measures and Friedman tests were used.
Results
The study results showed a significant difference in the mean pain intensity, and disability scores between the intervention group and control groups immediately and three months after the intervention (P=0.001). The mean pain intensity score and disability score were lower in the intervention group compared to the control groups. The mean pain intensity and disability scores showed significant decreases in the intervention group from before the intervention to immediately and three months after (P=0.001).
Conclusion
The results confirmed the positive effects of the smartphone-based “Enhancing Resilience Against Chronic pain” application on pain intensity, and disability in chronic noncancer pain patients. Given mobile phone accessibility, researchers recommend that healthcare providers, especially nurses, use virtual education to reduce pain and disability in chronic pain patients.
Trial Registration
Number: IRCT20210719051944N1, URL: https://www.irct.ir/trial/57624, date: 31/10/2021.
Keywords: smartphone app, chronic pain, pain intensity, disability
Background
Chronic pain (CP) is one of the most important medical problems globally.1 In the long term, CP has a negative impact on the physical functioning of individuals.2 This condition is accompanied by significant functional disability.3 The Global Burden of Disease study emphasizes that CP and related conditions are the leading causes of disability worldwide. Specifically, low back pain and neck pain are major contributors to international disability, and migraine is the second leading cause of disability.4 Factors such as disability due to pain play a crucial role in the individual’s perception of pain intensity.5 The more severe the pain, the higher the level of disability experienced by the individual.6 Pain reduction contributed to decreased disability by improving depression, catastrophizing, and acceptance.7 Variables such as pain intensity and disability due to pain affect other aspects of an individual’s life, including mental health and social functioning.5 Therefore, CP, as a multidimensional phenomenon, affects the physical, psychological, and social dimensions of the lives of those affected,2,5,8–10 and its proper management is essential.
To manage CP effectively, it is essential to consider not only physical factors but also psychological and social factors that influence pain.11 By addressing these various aspects, a more comprehensive and effective approach to CP management can be achieved.
One of the key psychological factors that significantly impacts the intensity of pain12 and the level of disability in individuals with CP is resilience.13 Resilience is defined as the ability to adapt to changing circumstances and to maintain or restore functionality and vitality when faced with stress or adversity.14 Resilience encompasses a broad range of skills, traits, and abilities, supported by knowledge and experience, that enable individuals to effectively navigate injuries, challenges, and difficult situations.15,16 According to the resilience approach in chronic pain, positive resources—such as acceptance, mindfulness, optimism, positive affect, values, and social support—promote well-being, while factors like fear of movement, anger, catastrophizing, and avoidance lead to disability and negative outcomes.13 Higher resilience is associated with less disability in chronic pain populations.17 Resilience buffers against pain-related functional decline and predicts better long-term outcomes.18 As resilience tends to decrease over time in some individuals struggling with pain, this can increase their vulnerability to pain.19 Low resilience to CP can also lead to undesirable outcomes, such as disability in these patients.13 Given the low levels of resilience observed in individuals with CP,19,20 it is necessary to implement interventions aimed at increasing resilience and promoting positive resilience mechanisms.13 In this regard, teaching resilience-enhancing skills may be helpful in reducing the negative effects of CP in those affected.21,22
It has been established that the use of virtual education methods and the integration of smartphones play a highly effective role in enhancing nursing care and patient education.23 Mobile health solutions based on various technologies are also likely to provide more efficient and personalized healthcare programs for patients.24 The fact that these virtual programs are not limited to the hospital setting, and their flexibility and adaptability to patients’ daily routines, has led to greater satisfaction and commitment from patients in engaging with these programs.25 In the present study, the components of resilience enhancement were delivered to CP patients through a smartphone-based application.
In the current study, participants were able to access the educational content without the need for internet connectivity and without any temporal or spatial constraints. The educational content of the virtual program was designed in accordance with the components extracted from a qualitative study.26 In the mentioned qualitative study, 16 patients with various types of chronic non-cancer pain (such as trauma, spinal cord injury, rheumatoid arthritis, migraine, post-surgical pain, ect.) and four physicians with various pain-related expertise (pain specialist fellowship, neurosurgeon, psychosomatic diseases fellowship and rehabilitation specialist) participated. The participating patients had expressed strategies to enhance resilience against CP based on their experiences of living with CP and managing it. To date, we found no interventional studies — including digital interventions — that developed and implemented a resilience-promoting training program grounded in qualitative findings on the experiences and needs of people with chronic pain. Therefore, this study aimed to investigate the effect of a smartphone-based virtual program to enhance resilience against CP on pain intensity, and disability in patients with CP. This program was designed based on the components of resilience against CP (which can influence the patient’s outcomes such as pain intensity, and disability) derived from a previous qualitative content analysis study.26
Methods
Design
The present parallel-group design randomized controlled trial adhered to the guidelines of the Consolidated Standards of Reporting Trials 2025 (CONSORT 2025)27 to ensure transparency and quality.
Sampling and Recruitment
Initially, 118 patients were evaluated for eligibility to participate in the study from April to November 2023. Of these, 108 individuals were selected using a convenient sampling method. They were recruited from 6 different clinics located in the outpatient facilities affiliated with Shiraz University of Medical Sciences, including pain, orthopedic, rehabilitation, rheumatology, neurology, and neurosurgery clinics. The inclusion Criteria were: age 18 years or older, diagnosed with CP based on the International Classification of Diseases-11th Revision (any type of non-cancer CP), confirmed by a physician’s diagnosis and the CP Questionnaire,28 willingness to participate in the study, ability to read, write, and speak Persian, ownership of a smart mobile phone capable of installing the study application, no participation in psychological therapy or counseling in the past 6 months,29,30 and prior participation in similar research studies. The exclusion criteria were: presence of other chronic physical illnesses such as cancer (self-reported by the patient), presence of known chronic mental illnesses and currently receiving ongoing treatment (self-reported by the patient), diagnosis of mental or physical illness (cancer) during the study period, occurrence of significant adverse life events for the patient’s relatives (eg, severe physical or mental illness, accident, divorce, death) and unwillingness to continue participation during the study.
Sample Size and Allocation
The sample size for the research study was calculated using the Medcalc software and based on the findings from the study by Goli et al,31 The difference in means between the groups was 20.53, and the standard deviations of the control and intervention groups were 15.53 and 12.7, respectively. Considering a type I error of less than 0.01, a type II error of 0.01, a test power of 99%, and an anticipated 30% dropout rate, the required sample size for the present study was estimated to be 33 participants in each group.
A total of 108 patients were randomly assigned to three groups: two control groups and one intervention group. To perform this randomization, a random sequence generation software (to produce a random block list) was utilized. Blocks of 6 were used for the randomization process. Given the calculated sample size, the software generated 18 blocks of 6, and within each block, two participants were allocated to control group A, two to control group B, and two to the intervention group. This sampling method ensured an equal distribution of 36 patients in each of the study groups.
Blinding
The evaluator who assessed the outcomes and the analyst were blinded to the treatment assignments. However, the intervention’s nature made it impossible to blind the participants.
Study Groups
Control group (A): Participants in this group received routine care (attended scheduled medical appointments with their physicians). They were asked to refrain from participating in any educational programs during the study period. At the end of the study, they were sent a link to install the designed application.
Control group (B): In addition to routine care, these participants also received the content of the “virtual program for familiarizing with pain, its causes and influencing factors.” The content of the Control group (B) program included: definition of (chronic) pain, various physical, psychological, and socio-cultural factors affecting pain, consequences of CP, common drugs used in CP management, common side effects of pain medications and care related to pain relievers. This educational content was provided to patients twice a week in the form of short messages (via SMS) during the 8-week period.
Intervention group: The study aimed to deliver educational content to patients in the intervention group through a smartphone-based application called “Enhancing Resilience to CP”. The intervention lasted for 8 weeks. The app content consisted of 20 short educational videos (4–7 minutes each) developed based on resilience enhancement strategies identified in a previous qualitative study that was done by the study’s authors on CP patients in Iran.26 This qualitative study aimed to “explain the components of resilience in individuals with CP”. The educational topics covered included understanding CP and its contributing factors, Developing resilience skills, strengthening willpower, accepting pain, finding meaning in pain, spirituality, positive hobbies and attachments, seeking help from others, effective communication, assertiveness, using massage, heat, pressure, and protective devices, positive thinking, stress management, anger management, exercise, Prioritizing sleep and rest, maintaining proper nutrition and weight, creating a supportive environment, and medical treatment adherence.26
The content of the educational program was compiled using books and related articles.32–52 The researcher developed and prepared the educational materials, produced educational videos, and provided these videos along with accompanying questions and exercises to the Tarah3D team. The Tarah3D team, which is endorsed by Shiraz University of Medical Sciences, was responsible for technically developing this Android application. A download link was then sent to participants via SMS for installation on their smartphones.
For each educational topic, a dedicated section titled “Questions/Exercises” was included. To ensure patient engagement, participants were asked to submit photos of the completed question/exercise pages after each module. The researcher also conducted phone check-ins to monitor exercise completion. During the 8-week intervention, each participant typically communicated with the researcher approximately 16 to 20 times through text messages, phone calls, or WhatsApp to submit their responses to the application’s questions. The study measured pain intensity, and disability before, immediately after, and 3 months after the intervention in all three groups.
The feasibility of the program was evaluated based on the percentage of eligible patients who enrolled and were retained in the study. The study was considered feasible if at least 70% of patients adhered to the program.53
Tools Used in the Study
The demographic information form typically includes the following elements: age, gender, marital status, education level, and occupation.
Chronic Pain Questionnaire
In addition to the specialist physician’s diagnosis, the CP Questionnaire was used to measure the patient’s pain. This tool was designed by Shaygan et al (2020) in Iran and is based on the ICD-11 criteria for measuring CP. The questionnaire’s psychometric properties have been thoroughly evaluated and confirmed: impact score ≥1.5, content validity index= 0.89–1.0, content validity ratio > 0.84 and correlation coefficient ≤ 0.72.28
Outcome Measures
Pain Intensity
The numerical rating scale (NRS) was used to assess the average intensity of pain experienced by participants over the last 2 weeks. The NRS is an 11-point scale, with 0 representing “No pain” and 10 representing “Worst possible pain.” Respondents were asked to circle a point on the 0–10 scale to indicate their pain intensity. The NRS is a well-established and widely used tool for measuring pain. It was developed by Jensen et al and has been employed in various studies to assess different types of pain across diverse populations.54
Disability
The Pain Disability Index (PDI) is a self-report instrument developed by Pollard (1984) to assess the impact of CP on an individual’s physical and psychosocial functioning. The initial validity of the PDI was examined and confirmed in patients with chronic low back pain. The PDI is a 7-item scale that measures the degree to which CP interferes with important life activities in the following domains: family/home responsibilities, recreation, social activity, occupation, sexual behavior, self-care and life-support activity. Each item is scored on a graphic rating scale from 0 (no disability) to 10 (total disability). The total PDI score ranges from 0 to 70, with higher scores indicating greater disability.55 The PDI has demonstrated good predictive and construct validity, with an intraclass correlation coefficient of 0.76, indicating strong reliability.56 In an Iranian study, the PDI also showed acceptable convergent validity (Pearson correlation coefficient = 0.64), high internal consistency (Cronbach’s alpha = 0.86) and good test-retest reliability (intraclass correlation = 0.80).57 In the present study, the Cronbach’s alpha was 0.78, further supporting the reliability of the PDI in this context.
Analysis
The process of quantitative data analysis for this study was conducted using the SPSS (version 24). A significance level of less than 0.05 was considered. Descriptive statistics (mean, standard deviation, and frequency) and inferential statistics were employed. To assess the normality of data distribution, the Kolmogorov–Smirnov Test was used. In case of normal distribution, parametric statistical tests were utilized for analysis, and in case of non-normal distribution, the non-parametric equivalents of these tests were employed. To ensure the similarity of groups in terms of demographic information, chi-square tests and one-way ANOVA were used. To compare the mean scores of pain intensity, and disability between the three study groups at different time points, one-way ANOVA and Kruskal–Wallis tests were used. In case of significant differences in mean scores between groups, post hoc Bonferroni and Mann–Whitney tests were used for pairwise comparisons. To compare the within-group mean scores of pain intensity, and disability in the three study groups at different time points, repeated measures ANOVA and Friedman tests were used. To examine the mean difference in scores between the three study groups, the Kruskal–Wallis test was used. In case of significant differences in mean difference scores, the Mann–Whitney test was used for pairwise comparisons between groups. The Levene test was also used to assess the equality of variances.
Results
Of 118 individuals with CP who were assessed for eligibility, 108 were enrolled in the study, with 36 patients assigned to each group (Figure 1). The ANOVA test showed no significant difference between the mean age of the study groups (P > 0.05). The mean age of the participants was 46.79 (±10.10). The frequency and percentage of gender and marital status, were compared across the three groups—control A, control B, and intervention—using the chi-square test. The results indicated that the three study groups did not differ significantly in the distribution of demographic characteristics of the samples (P > 0.05). The largest number of samples examined were women (90 individuals, 83.3%) and married participants (90 individuals, 83.3%). Education level, occupation, and clinical characteristics of CP in the study groups are presented in Table 1.
Figure 1.
Participants flow diagram.
Table 1.
Comparison of the Participants’ Demographic and Chronic Pain Clinical Characteristics in Three Study Groups
| Group Variable |
Control A | Control B | Intervention | Total | Test Results | ||
|---|---|---|---|---|---|---|---|
|
Occupation N (%) |
Housewife/househusband | 18 (50.0) | 22 (61.1) | 24 (66.7) | 64 (59.3) | χ2 = 8.589 P= 0.378 |
|
| Employed | 6 (16.7) | 5 (13.9) | 2 (5.6) | 13 (12.0) | |||
| Worker | 4 (11.1) | 3 (8.3) | 0 (0.0) | 7 (6.5) | |||
| Unemployed | 4 (11.1) | 4 (11.1) | 4 (11.1) | 12 (11.1) | |||
| Retired | 4 (11.1) | 2 (5.6) | 6 (16.7) | 12 (11.1) | |||
|
Education N (%) |
School | 27 (75.0) | 27 (75.0) | 24 (66.7) | 78 (72.2) | χ2 =0.831 P= 0.660 |
|
| University | 9 (25.0) | 9 (25.0) | 12 (33.3) | 30 (27.8) | |||
| Main pain characteristics | Onset | 3-12 Months ago | 6 (16.7) | 6 (16.7) | 8 (22.2) | 20 (18.5) | χ2 = 0.419 P= 0.782 |
| >12 Months ago | 30 (83.3) | 30 (83.3) | 28 (77.8) | 88 (81.5) | |||
| Location N (%) |
Head & neck | 16 (25.4) | 19 (36.5) | 14 (22.9) | 49 (27.8) | χ2 = 6.185 P= 0.627 |
|
| Back | 13 (20.6) | 9 (17.3) | 13 (21.3) | 35 (19.1) | |||
| Joints | 20 (31.7) | 12 (23.0) | 16 (26.2) | 48 (27.3) | |||
| Hand & foot | 14 (22.2) | 11 (21.1) | 18 (29.5) | 43 (24.4) | |||
| Muscles | 0 (0.0) | 1 (1.9) | 0 (0.0) | 1 (0.5) | |||
| Etiology N (%) |
Spinal cord | 10 (20.0) | 10 (22.2) | 14 (27.4) | 34 (21.8) | χ2 = 13.434 P= 0.765 |
|
| Migraine | 9 (18.0) | 11 (24.4) | 10 (19.6) | 30 (19.2) | |||
| Rheumatoid arthritis | 9 (18.0) | 8 (17.7) | 12 (23.5) | 29 (18.6) | |||
| Injury | 9 (18.0) | 6 (13.3) | 5 (9.8) | 20 (12.8) | |||
| Knee osteoarthritis | 4 (8.0) | 1 (2.2) | 3 (5.9) | 8 (5.1) | |||
| Post-surgical | 3 (6.0) | 3 (6.6) | 2 (3.9) | 8 (5.1) | |||
| Calcaneal spur | 1 (2.0) | 0 (0.0) | 3 (5.9) | 4 (2.5) | |||
| Fibromyalgia | 0 (0.0) | 1 (2.2) | 0 (0.0) | 1 (0.6) | |||
| Osteoporosis | 2 (4.0) | 2 (4.4) | 2 (3.9) | 6 (3.8) | |||
| Unknown | 3 (6.0) | 3 (6.6) | 0 (0.0) | 6 (3.8) | |||
| Additional pain characteristics | Additional pain presence | 14 (38.9) | 16 (44.4) | 12 (33.3) | 42 (38.9) | χ2= 0.935 P= 0.627 |
|
| Location N (%) |
Back | 4 (28.5) | 8 (50.0) | 6 (50.0) | 18 (42.8) | χ2= 7.215 P= 0.514 |
|
| Hand & foot | 6 (42.8) | 6 (37.5) | 5 (41.7) | 17 (40.8) | |||
| Head & neck | 2 (14.3) | 1 (6.25) | 1 (8.3) | 4 (9.5) | |||
| Pelvic | 2 (14.3) | 0 (0.0) | 0 (0.0) | 2 (4.8) | |||
| Joints | 0 (0.0) | 1 (6.25) | 0 (0.0) | 1 (2.4) | |||
The results of the study indicated that there were significant differences in the mean scores of pain intensity, and disability among the three groups immediately after the intervention and three months later (p = 0.001). Additionally, the results of the post-hoc Bonferroni and Mann–Whitney tests revealed that there were no significant differences in the mean scores of pain intensity, and disability between Control Group A and Control Group B at both time points. However, there were significant differences in these mean scores between the intervention group and both Control Group A and Control Group B (p = 0.001) at the specified times (Table 2) and Figure 2 also compares the mean pain intensity and disability scores of participants in the three study groups at different time points.
Table 2.
Comparison of the Pain Intensity and Disability in Three Study Groups
| Group Variable |
Control A | Control B | Intervention | Between Group P-value |
Partial ɳ2 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Mean (SD) | Within Group P-value | Mean (SD) | Within Group P-value |
Mean (SD) | Within Group P-value | ||||||||||
| Before | Immediately After | 3 Months After | Before | Immediately After | 3 Months After | Before | Immediately After | 3 Months After | |||||||
| Pain intensity | 6.44 (2.04) |
6.85 (2.08) | 6.38 (2.11) | d 0.491 | 6.86 (1.82) | 6.25 (1.82) | 6.22 (1.97) | d 0.085 | 6.36 (1.62) | 3.77 (1.88) | 3.82 (1.78) | d 0.001 | c0.001 | ||
| Mean difference (SD) | Before/Immediately | 0.235 (1.89) | −0.628 (1.64) | −2.529 (1.65) | c 0.001 | 0.311 | |||||||||
| Before/3 months after | −0.147 (1.65) | −0.600 (1.88) | −2.44 (2.51) | c 0.001 | 0.194 | ||||||||||
| Immediately/3 months after | −0.382 (2.21) | 0.028 (1.87) | 0.088 (2.00) | c 0.406 | 0.011 | ||||||||||
| Disability | 27.33 (11.27) | 28.00 (11.36) | 27.05 (11.47) | b 0.582 | 28.72 (11.64) | 26.08 (11.14) | 27.85 (12.06) | b 0.060 | 26.83 (12.47) | 14.17 (10.17) | 16.20 (10.30) | b 0.001 | a 0.001 | ||
| Mean difference (SD) | Before/ Immediately |
−0.121 (3.16) | −2.62 (5.63) | −12.38 (10.07) | c 0.001 | 0.390 | |||||||||
| Before/3 months after | −0.848 (5.11) | −0.714 (8.85) | −10.23 (10.09) | c 0.001 | 0.230 | ||||||||||
| Immediately/3 months after | −0.727 (6.34) | 1.91 (6.89) | 2.14 (4.45) | c 0.024 | 0.046 | ||||||||||
Note: aANOVA, bRepeated Measurement, cKruskal–Wallis, dFriedman.
Figure 2.
Comparison of mean (a) pain intensity and (b) disability scores across the three study groups at different time points.
According to the results from the Friedman test for within-group comparisons of mean pain intensity scores at the same time points, no significant differences were found in Group A control (P=0.491) and Group B (P=0.085), while a significant difference was noted in the intervention group (P=0.001). Additionally, the repeated measures analysis for within-group comparisons of mean disability scores at the three time points revealed no significant differences in control groups A (P=0.528) and B (P=0.060), but a significant difference was found in the intervention group (P=0.001) (Table 2). Furthermore, the mean differences in pain intensity, and disability scores across the intervals of before/immediately after the intervention, before/three months after the intervention, and immediately after/three months after the intervention were significant among the three groups studied (P=0.001) (Table 2). Significant group × time interactions were observed for the mean disability score, indicating that the changes in this measure differed between the study groups at the assessed time points (Table 3).
Table 3.
Repeated Measures ANOVA
| variable | Source | F(df) | P-value |
|---|---|---|---|
| Disability | Time | 28.04 | 0.001 |
| Group | 16.42 | 0.001 | |
| Time*group | 7.33 | 0.001 |
Note: * Interaction effect.
Discussion
The results of this study demonstrate that the virtual program “Enhancing Resilience to CP” significantly reduced participant’s pain intensity and disability.
The implementation of a virtual educational program for resilience enhancement can significantly contribute to increasing the resilience of patients with CP.58 Resilience skills and psychological interventions can enhance resilience by reducing negative emotions and fostering positive ones.59 several studies have indicated that higher levels of resilience are associated with a reduced likelihood of experiencing CP, fewer pain sites, and a decreased need for pain medication.17 The results of the present study show that the mean pain intensity score in the intervention group was significantly lower than in the control groups both immediately and three months after the intervention. In a similar vein, a clinical trial conducted by Shaygan et al,(2022) found that before and immediately after the intervention, the mean pain intensity score in the intervention groups (Multimedia pain management education group and face-to-face pain management education group) differed significantly from that of the control group, which received routine cares (partial ɳ2: 0.116). However, one month after the intervention, there was no significant difference in pain intensity scores among the intervention groups or between them and the control group.60 Consistent with the findings of this study, several studies have demonstrated that pain management programs61 and mindfulness-based education62 can have positive effects on reducing pain intensity in patients with CP. Given that resilience is a key psychological factor influencing pain intensity,12 it is recommended that the resilience-enhancing strategies against pain presented in this study be utilized to increase resilience and, consequently, reduce pain intensity in patients.
In contrast to the findings of the present study and similar research, some studies have shown that the variable of pain intensity in intervention groups did not exhibit significant reduction immediately and six months after internet-based psychological interventions63 and a mindfulness-based stress reduction program,64 compared to the control group. A study by Seng et al,(2019) in the United States found no significant difference in the mean number of days with headaches and headache intensity from month 0 to month 4 between the intervention (Mindfulness-Based Cognitive Therapy) and control groups (received usual treatments).65 Other researchers in the United States also observed positive effects of implementing an online health education intervention on reducing the mean pain intensity of patients, although these changes were not statistically significant.66 The contradictory results regarding pain intensity after interventions in various studies may be attributed to the fact that these studies typically employed only one or two interventions, which were either purely physical or psychological. In contrast, the present study utilized a comprehensive approach, incorporating physical, spiritual, psychological, and social strategies to enhance resilience against pain. This multifaceted approach may explain why our study observed a reduction in pain intensity in the intervention group.
Resilience is a crucial psychological factor that significantly influences the level of disability experienced by individuals with CP.13,19 A comprehensive review of multiple studies reveals that resilience enhances self-management skills and capabilities in those suffering from CP, thereby contributing substantially to pain reduction.67 Furthermore, higher levels of resilience are positively correlated with improved physical, psychological, and social functioning.17
In the present study, the disability score in the intervention group was significantly lower compared to the control groups both immediately and three months after the intervention. Additionally, a substantial effect size was observed post-intervention compared to pre-intervention. The findings of this study align with those reported by Pagan-Ortiz et al 2021,66 Seng et al 2019,65 and Okvat et al 2022,62 although the latter study specifically included female veterans experiencing CP.62 Given the positive correlation between higher resilience levels and physical function in individuals with CP,68 it appears that implementing a resilience-enhancement program for managing pain could significantly contribute to improving patients’ physical capabilities and physical function by offering multiple practical strategies.
In contrast to the findings of the present study and similar studies, some research indicates that patients’ physical performance showed no significant improvement immediately and six months after internet-based psychological interventions63 and standard mindfulness programs64 compared to the control group. Researchers noted that while psychological interventions did lead to reported reductions in disability, these effects often appeared to be short-lived.63 The significant reduction in disability observed at various times post-intervention in the intervention group of the present study may be attributed to the comprehensive nature of the program, which addressed all physical, emotional, psychological, and social aspects of enhancing resilience. For instance, the “exercise and activity” component may have motivated some participants to enroll in sports classes, which could gradually enhance their physical capabilities and improve their physical functioning over time. Furthermore, the follow-up period for variables in the present study was three months post-intervention, whereas another study followed participants for six months. In this context, participation in sports classes by patients in the present study may have also contributed to increased motivation and vitality, which in turn supported their physical ability.
The findings of this study indicate that there was no significant difference in the mean scores of pain intensity, and disability between control groups A and B, both immediately and three months after the intervention. The lack of significance suggests that the CP familiarization program is not more effective than routine care in enhancing resilience or reducing pain intensity and disability. However, the educational text messages received by control group B did contribute to short-term improvements in resilience and reductions in pain intensity and disability (immediately following the intervention). Nevertheless, compared to the resilience enhancement program, these text messages failed to produce lasting changes that persisted up to three months after the intervention.
One of the key strengths of this study is that the educational program was tailored to meet the needs of patients, based on strategies they provided during qualitative interviews. Furthermore, the program’s educational content was delivered virtually to participants, maximizing its accessibility by eliminating the need for continuous internet access and removing time and location constraints. Another significant strength of this study is its design as a randomized controlled trial with three arms and two control groups, which provided reliable data on the effects of resilience-enhancing strategies on physical outcomes such as pain intensity and disability among patients with CP. The absence of substantial changes in the control group B patients reduces the supportive effects of the research, thereby increasing the confidence that improvements in outcomes in the intervention group can be attributed to the educational program implemented during the study. The program’s comprehensiveness and thoroughness-addressing CP from a biopsychosocial perspective-are key strengths. This holistic approach distinguishes it from many comparative studies, which often focus solely on either psychological interventions or physical exercises. Additionally, the study sample was drawn from patients experiencing various types of chronic non-cancer pain (such as trauma, spinal cord injury, migraine, rheumatoid arthritis, post-surgical pain, etc.) from six different clinics, which enhances its representativeness of the broader population of patients with CP and increases the applicability of the application used in this population. However, one limitation of the study is that the researchers were only able to monitor the outcomes of the application for three months, and it was not possible to assess the long-term sustainability of the intervention’s effects. Also, Responses provided by patients on symptom assessment questionnaires may be prone to bias.69
Conclusion
Overall, it can be concluded that the resilience-enhancing application for CP implemented in this study made significant contributions to reducing the severity of pain and disability. Notably, this virtual program addressed all biological, psychological, and social aspects of CP. Therefore, it is recommended that the resilience-enhancing components used in this study be utilized for planning and developing various strategies to manage CP in hospitals and clinics that treat patients with different types of chronic non-cancer pain. Additionally, we would like to recommend the inclusion of weekly challenges, reward badges, and reminder features within the application, aiming to deliver enhanced version to the target population in future.
Acknowledgment
The authors sincerely thank Mr. Keshtvarz, the statistical consultant at the Clinical Research Development Center, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran, for his invaluable support and collaboration throughout this research. We also extend our heartfelt gratitude to the individuals with CP who generously participated in the study.
Funding Statement
This work was supported by the vice-chancellery for research affairs at Shiraz University of Medical Sciences, Shiraz, Iran (Grant number: 22993). The funder had no role in the design, conduct, analysis, and reporting of the trial.
Abbreviations
CP, Chronic Pain, SPSS, Software package used for Statistical Analysis.
Data Sharing Statement
The datasets during the current study and individual deidentified participants data are not publicly available due to confidentiality of the patients’ data, but they will be available from the corresponding author on reasonable request.
Ethics Approval and Consent to Participate
The study was approved by the Ethics Committee of Shiraz University of Medical Sciences, Shiraz, Iran (Approval code: IR.SUMS.NUMIMG.REC.1400.011). Written and informed consent was obtained from all participants after describing the study’s purpose and methodology. Confidentiality was observed in all research steps, and participants were assured that they could withdraw from the study at any time. All methods were carried out in accordance with relevant guidelines and regulations. Our study complies with the Declaration of Helsinki.
Consent for Publication
This was deemed not applicable.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
There are no conflicts of interest.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets during the current study and individual deidentified participants data are not publicly available due to confidentiality of the patients’ data, but they will be available from the corresponding author on reasonable request.