Patients’ experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review

Francine Toye; Kate Seers; Nick Allcock; Michelle Briggs; Eloise Carr; JoyAnn Andrews; Karen Barker

doi:10.3399/bjgp13X675412

Abstract

Background Musculoskeletal (MSK) pain is one of the most predominant types of pain and accounts for a large portion of the primary care workload.

Aim To systematically review and integrate the findings of qualitative research to increase understanding of patients’ experiences of chronic non-malignant MSK pain.

Design and setting Synthesis of qualitative research using meta-ethnography using six electronic databases up until February 2012 (Medline, Embase, Cinahl, Psychinfo, Amed and HMIC).

Method Databases were searched from their inception until February 2012, supplemented by hand-searching contents lists of specific journals for 2001–2011 and citation tracking. Full published reports of qualitative studies exploring adults’ own experience of chronic non-malignant MSK pain were eligible for inclusion.

Results Out of 24 992 titles, 676 abstracts, and 321 full texts were screened, 77 papers reporting 60 individual studies were included. A new concept of pain as an adversarial struggle emerged. This adversarial struggle was to: 1) affirm self; 2) reconstruct self in time; 3) construct an explanation for suffering; 4) negotiate the healthcare system; and 5) prove legitimacy. However, despite this struggle there is also a sense for some patients of 6) moving forward alongside pain.

Conclusions This review provides a theoretical underpinning for improving patient experience and facilitating a therapeutic collaborative partnership. A conceptual model is presented, which offers opportunities for improvement by involving patients, showing them their pain is understood, and forming the basis to help patients move forward alongside their pain.

INTRODUCTION

Alleviation of pain is a key aim of healthcare,1 yet pain can remain a puzzle2 as it is not always related to a specific pathology.2 Around 25% of adults suffer with moderate or severe pain,3–7 and for 6–14% of these the pain is severe and disabling.2,8 Musculoskeletal (MSK) pain is one of the most predominant types of pain and accounts for a large portion of the primary care workload.2,9 Chronic pain is one of the Royal College of General Practitioners’ clinical priorities for 2011–2014. Although insights from several qualitative syntheses have contributed to a greater understanding of the processes of health care,10–12 in other areas the proliferation of qualitative studies mean that these studies are ‘doomed never to be visited’.13 The aim of this review was to synthesise existing qualitative research to improve understanding and thus best practice for people with chronic non-malignant MSK pain. There are various methods for synthesising qualitative research.13–16 Studies range from those aiming at describing qualitative findings, to studies aiming at being more interpretive and generating theory. Meta-ethnography is an interpretive form of knowledge synthesis, proposed by Noblit and Hare,17 which aims to develop new conceptual understandings.

METHOD

Reports of qualitative studies were included that explored adults’ own experience of chronic non-malignant MSK pain. Chronic was defined as ≥3 months. Exclusion criteria were cancer, neurological, phantom, facial, head, dental and/or mouth, abdominal and/or visceral, menstrual and/or gynaecological, pelvic, duration or site of pain not specified, other chronic pain conditions, auto-ethnography, and individual case studies. Six electronic bibliographic databases were searched from inception until February 2012: Medline, Embase, Cinahl, Psychinfo, Amed, HMIC. As meta-ethnography relies on identifying and defining concepts within each study, the search was limited to English language. A combination of free text terms and thesaurus or subject headings was used. Search terms were used specific to qualitative research available from the InterTASC Information Specialists’ SubGroup (ISSG) Search Filter Resource (www.york.ac.uk/inst/crd/intertasc/). These terms were combined with other relevant subject headings and thesaurus terms (for example, research, qualitative/; attitude to health/; interviews as topic/; focus groups/; nursing methodology research/; life experiences/; pain/; arthritis/; fibromyalgia/; osteoarthritis/; musculoskeletal diseases/). Details of search syntax are available on request from the authors. Contents list of particular journals agreed by the team were hand-searched for 2001–2011. The list of journals is also available on request. Reference lists were searched for further potential studies. Titles, abstracts, or full texts were screened to exclude articles that did not meet the inclusion criteria.

How this fits in

Chronic musculoskeletal (MSK) pain accounts for a large portion of the workload in primary care. There is a growing body of qualitative research exploring patients’ experience of chronic MSK pain, but no study that brings together or synthesises this large body of knowledge to make it accessible for clinical practice. Chronic MSK pain is experienced as an adversarial struggle on multiple levels (self, time, relationships, health care). The model in the present study suggests possibilities for helping patients to move forward with chronic pain.

The use of quality criteria for qualitative research is mooted14,18–22 and it is known that quality appraisal does not produce consistent judgements.21 To be utilised within a meta-ethnography, studies must provide adequate description of their concepts.14,17 It was also agreed that papers should provide an adequate methodological report. Checklists were used to provide a focus for team discussion on quality. It was not intended to use these checklists to ‘score’ papers for the purposes of inclusion or exclusion. A full description of the teams’ approach to appraisal for qualitative synthesis has been published elsewhere.22 Three appraisal tools were used: Critical Appraisal Skills Programme (CASP) for appraising qualitative research;23 Qualitative Assessment and Review Instrument (JBI-QARI);24 and finally papers were categorised as key papers (KP) (‘conceptually rich and could potentially make an important contribution to the synthesis’), satisfactory papers (SAT), irrelevant papers, or fatally flawed (FF) papers.21 The concepts fatally FF, SAT, and KP have not been defined, but are global judgements made by a particular appraiser which comprise several unspecified factors. Two team members appraised all papers, and if they did not reach an agreement the paper was sent to two other team members for a decision.

The methods of meta-ethnography17 were used to synthesise the data.14,25,26 Central to meta-ethnography is identification of key ideas or ‘concepts’, and comparison of these concepts across studies.17 A full copy of all papers was uploaded onto QSR International’s NVivo 9 software to help organise the qualitative analysis. NVivo 9 allows for collection, organisation, and analysis of a large body of knowledge by ‘coding’ data under ‘nodes’. It also helps to keep track of developing ideas and theories via ‘memos’. Three members of the team read each paper to identify and describe the concepts in each paper. These independent descriptions were compared and combined descriptions of each concept were constructed. The aim was not to reach consensus but to develop ideas through discussion. These concepts formed the primary data for the meta-ethnography. If team members agreed that there was no clear concept articulated in the original study, then it was labelled ‘untranslatable’. In short, if the original study was more descriptive with no clear ideas, there were no ‘data’ to analyse. Concepts were then collaboratively organised into categories with shared meaning through constant comparison,27 and a conceptual model was developed.17

RESULTS

In total, 24 992 titles, 676 abstracts, and 321 full texts of potentially relevant studies were screened (Figure 1). Of the 321 potential studies, 228 were excluded that did not meet the study aims. Details of reasons for excluding studies are available from the authors. Two team members appraised 93 papers. The ranges of agreement for CASP and JBIQ rank were 52–75% and 29–82% respectively. The team members agreed that five studies were key,28–32 one team member graded a further five as key,33–37 and the other graded a further seven as key.38–44 Full details of the appraisal scoring are also available from the authors. The team members did not agree over 24 papers and sent these to two other team members for a decision. Sixteen studies were excluded after quality appraisal,44–59 hence 77 papers were included reporting 60 studies. These studies explored the experiences of 1168 adults ranging from 18 to 91 years of age. Forty-nine papers (37 studies) explored chronic MSK pain.29–37,39,40,43,48,60–95 Twenty-eight papers (23 studies) focused primarily on fibromyalgia (FM).28,38,41,42,96–119 Studies were included from a range of countries: Iceland (1); Northern Ireland (1); Switzerland (1); Finland (2); the Netherlands (2); New Zealand (2); Australia (3); Canada (4); Norway (8); the US (8); Sweden (19); and the UK (26). Appendix 1 describes the study characteristics.

Figure 1. Number of studies identified, screened, excluded, and included.

Conceptual categories

The overriding theme emerging was an adversarial struggle, giving a sense of being guilty until proven innocent. Patients struggled to with the following.

1. Affirm self

This category incorporates a struggle to affirm my self: Firstly, my body has become alienated from me, and has become a malevolent it.33, 82 I no longer am a body but have a body.120,121 Secondly, although I struggle to prevent the erosion of my old ‘real self’ and not ‘give in’ to my painful body, I face the fact that I am irreparably altered.94 Finally, loss of roles that made me what I am has undermined my self-worth, and I feel guilty because I cannot meet other people’s expectations. Fear of overburdening others, and the desire to appear like my old self, encourage me to hide pain. However, this can be a double-edged sword because people do not necessarily believe what they cannot see.

2. Reconstruct self in time (construction of time altered — unpredictable now and future)

This category shows how the construct of self now and in the future is altered. The day-to-day unpredictability of my pain creates an endless timeless present where my life has become dominated by caution and spontaneity is lost. Plans, expectations, and dreams of the future are irreparably altered and life focuses inwards.

3. Construct an explanation for suffering

This concept describes the struggle to explain pain that does not fit an objective biomedical category.122,124 Diagnosis remains highly valued and is integral to a sense of credibility.123–125 Disbelief by others threatens my personal integrity.117 The discrepancy between culturally accepted explanations and personal experience creates powerful emotions. I feel worthless, afraid, agitated, ashamed, and guilty. Overwhelming doubt permeates my experience at work, my social life, health care, and family.

4. Negotiate the healthcare system

This category describes the struggle to negotiate the healthcare system. I feel ‘like a shuttlecock’ referred back and forth to various health professionals. It describes an ambivalent stance, although reticent to engage in a system that is not meeting my expectations, at the same time I am compelled or ‘trapped in the system’. I continue in health care in hope of a future cure. I need to feel valued as a person within the system. Paradoxically, although I want my body problem to be diagnosed and treated, I also need to be treated as more than just a body. This is central to the therapeutic relationship, not an adjunct.

5. Prove legitimacy

This category describes an etiquette, or ‘right way’, of being in pain to appear credible. It does not imply that pain is not real. I struggle to find the right balance between hiding and showing pain. The pull to hide pain and to appear ‘normal’ is increased by my sense of shame at having medically unexplained pain.31 Paradoxically, hiding pain can further threaten my credibility. I strive to present a picture of myself as a ‘good’ person who is not to blame for my pain.

However despite this struggle, there was a sense of moving forward.

6. Moving forward alongside my pain

Despite the adversarial struggle, our model describes six ways of moving forward alongside pain:

Listening to and integrating my painful body shows a developing relationship of trust and cooperation with the body. The alienated body becomes integrated through listening to, and respecting it. I am no longer at the mercy of the body but a co-expert.
Redefining normal describes a way of moving forward that no longer focuses on losses but on reconstructing an acceptable new self. It describes an acceptance of change and a sense of repairing existence; I have changed but I am still me and can enjoy life. This can be felt alongside grief for the old ‘real self’. This concept supports studies showing that ability to redefine self, or psychological flexibility, might help people move forward with pain and reduce its impact.126,127
Being part of a community of others describes a sense of sharing, being valued and becoming credible. However, despite the benefits of being part of group of others with pain, there is a sense of ambivalence; although I am like the others,28,94,96,113,114 at the same time I am not like them and need to be valued as an individual.
Telling others about my pain describes the release that comes with no longer having to hide pain from others, and the benefits of letting others know about my limitations. I am learning to limit demands from others and manage my resources. There is a sense that I no longer need to gain the approval of others.
Realising that there is no cure for my pain describes the liberation from the ceaseless search for a cure which has hitherto limited possibilities for moving forward. There is a sense that recovery is about becoming someone rather than being what you once were.
Becoming an expert describes becoming less reliant on a healthcare professional to know and meet my needs. I am coming to know my own body, and gain the confidence to experiment and make my own choices.

Table 1 describes these conceptual categories and source studies with a narrative exemplar of each category. Figure 2 shows the conceptual model drawn from conceptual categories 1–5. Figure 3 shows the conceptual model drawn from conceptual category 6 ‘moving forward alongside pain’.

View this table:

Table 1.

Conceptual categories and source studies with example of narrative from primary studies

Figure 2. Conceptual model: a constant adversarial struggle.

Figure 3. Conceptual model: moving forward alongside pain.

DISCUSSION

Summary

This research presents a significant advance over previous studies in that it provides a unique and extensive conceptual synthesis of qualitative research exploring chronic MSK pain using meta-ethnography. The present model presents a line of argument that highlights the adversarial experience of people with chronic MSK pain, but also offers an understanding of how some aspects can be surmounted. The innovation is to show that struggle pervades multiple levels of the person’s experience, sense of body and self, biographical trajectory, reciprocal relationships, and experience of healthcare services. The struggle to keep hold of a sense of self while feeling misunderstood and not believed was described. Despite this adversarial struggle, the present model offers an understanding of how a person with chronic MSK pain can move forward alongside their pain. This adversarial experience is central to the present model, and more research exploring similarities and differences between the experience of MSK and other types of chronic pain (such as cancer pain, headache, or visceral pain) would help to understand the experience of chronic pain.

Strengths and limitations

The findings of qualitative research are an interpretation of data. This centrality of interpretation is the strength of qualitative research that aims at challenging and developing ideas. The present model is based on a rigorous collaborative process over 2 years. The delay between final search and publication is not a limitation of this study. As qualitative syntheses do not aim to summarise the entire body of available knowledge, meta-ethnographers do not advocate an exhaustive literature search.14,17 Some argue that including too many studies makes conceptual analysis ‘unwieldy’ or makes it difficult to maintain insight or ‘sufficient familiarity’.14

There are very few meta-ethnographic syntheses that include such a large number of studies;14,26 some suggest that meta-ethnography is more suited for smaller syntheses.14 The present study specifically focused on the experience of MSK pain, which might mean that papers were excluded in which the study sample included chronic pain from other sites (such as visceral pain or headache). However, the present model may be transferable to other chronic pain conditions, and further research comparing this model with other experiences of pain would be useful.

Qualitative syntheses do not tend to use checklists and cut-off scores to determine study inclusion,14 and the present results support the finding that there is limited agreement about what makes a good qualitative study.21 This raises issues about how to decide what to usefully include in qualitative systematic reviews.22 The authors remain convinced that checklists will continue to produce inconsistent judgements regarding quality. One of the issues is that although both methodological and conceptual rigour contribute to the quality of research, checklists tend to focus on methods rather than conceptual insight.22

Comparisons with existing literature

This study’s findings resonate with other qualitative syntheses. For example, in rheumatoid arthritis, the need to explain symptoms, the unpredictability of symptoms, the disruption to self, fear of the future, and the negative effects on social participation.14 In low back pain, the impact of pain on self and relationships with family and health professionals.128 In fibromyalgia,129 the unrelenting quality of pain, isolation, lost legitimacy, and the search for an explanation. However, these studies report very few successful strategies. The present innovation is to present a new and internationally relevant model that highlights the all-pervading adversarial experience of people with chronic MSK pain, and offers an understanding of how some aspects can be surmounted.

Implications for research and practice

The present model provides a theoretical underpinning for improving the patient experience and enhancing the relationship between patient and healthcare professional as a ‘collaborative partnership’ to empower self-management. Discussion of this model with patients has the potential to show them that their pain is understood and believed, forming a basis for considering ways of moving forward. People with chronic MSK pain do not feel believed and this has clear implications for clinical practice and education. The present study highlights the need for educational strategies to improve patients’ and clinicians’ experience of care.130 The model suggests that central to the relationship between patient and practitioner is the recognition of the patient as a person whose life has been deeply changed. Affirming a person’s experience and allowing an empathetic interpretation of their story is not an adjunct, but integral to care. The model also suggests possibilities for helping patients to move forward. Importantly, the line of argument supports a model of health care where the healthcare professional sits alongside the person as a collaborative partner. This collaborative focus is recognised as important in commissioning appropriate health care; ‘good commissioning places patients at the heart of the process’.130 The present study thus illustrates the potential value of qualitative research in articulating the patient voice for both clinical practice and policy.

The model supports an embodied, non-dualistic approach that may be useful for other chronic conditions. It also suggests possibilities that might help patients to move forward alongside their pain, namely an integrated relationship with the painful body; redefining a positive sense of self now and in the future; communicating, rather than hiding, pain; knowing that I am not the only one with chronic pain; regaining a sense of reciprocity and social participation; recognising the limitations of the medical model; and being empowered to experiment and change the way I do things. Further research comparing the experience of chronic MSK pain with other chronic conditions might help to more fully understand and improve patients’ experience of chronic illness. In addition to this, studies were not identified that specifically considered the impact of age or gender on the experience of pain. Finally, research to explore the impact of qualitative research on practitioners and policy makers would help to maximise its usefulness for improving health care.

Acknowledgments

We thank the authors of the primary qualitative studies included and the patients who told their stories. The full report of the study from which this paper is drawn is available online at http://www.journalslibrary.nihr.ac.uk/hsdr/volume-1/issue-12

Appendix 1. Characteristics of included studies

Author and year	Age range, years	Condition	Source of participants	Country	Number included	Males	Data collection	Methodology^b
Aegler 2009, 71	29–61	MSK	PMP	Switzerland	8	3	Semi-structured interview	Thematic analysis
Afrell 2007, 72	30–72	MSK	PC, PMP, pain clinic	Sweden	20	7	Semi-structured interview	Phenomenology
Allegretti 2010, 77	28–72	MSK (CBP)	PC	US	23	12	Semi-structured interview	Thematic analysis
Arnold 2008, 97	31–72	FM	Rheumatology	US	48	0	FG	Grounded theory
Bair 2009, 61	27–84	MSK	RCT	US	18	7	FG	Thematic analysis
Campbell 2007, 78	34–78	MSK (CBP)	PMP	UK	16	NK	FG	Thematic analysis
Campbell 2008, 62	36–66	MSK	Non-service users	UK	12	3	Interviews	Thematic analysis
Cook 2000, 79	22–63	MSK (CBP)	Back pain rehab	UK	7	3	Semi-structured interview	Thematic analysis
Coole 2010^a, 90	22–58	MSK (CBP)	Back pain rehab	UK	25	12	Semi-structured interview	Thematic analysis
Coole 2010^a, 88	22–58	MSK (CBP)	Back pain rehab	UK	25	12	Semi-structured interview	Thematic analysis
Coole 2010^a, 89	22–58	MSK (CBP)	Back pain rehab	UK	25	12	Semi-structured interview	Thematic analysis
Cooper 2008^a, 81	18–65	MSK (CBP)	PT	UK	25	5	Semi-structured interview	Framework analysis
Cooper 2009^a, 80	18–65	MSK (CBP)	PT	UK	25	5	Semi-structured interview	Framework analysis
Crowe 2010^a, 83	25–80	MSK (CBP)	Adverts and PT	New Zealand	64	33	Semi-structured interview	Thematic analysis
Crowe 2010^a, 82	25–80	MSK (CBP)	Adverts	UK	64	33	Semi-structured interview	Thematic analysis
Cunningham 2006, 98	30–70	FM	University	Canada	8	1	Semi-structured interview	Thematic analysis
De Souza 2011, 48	27–79	MSK (CBP)	Rheumatology	UK	11	5	Unstructured interview	Thematic analysis
De vries 2011, 38	31–60	FM and MSK	Adverts and FM website	Netherlands	21	9	Semi-structured interview	Thematic analysis
Dickson 2003, 70	63–80	MSK	PC	US	7	0	Interviews and observation	Thematic analysis
Dragesund 2008, 63	26–68	MSK	PT	Norway	13	5	FG	Thematic analysis
Gullacksen 2004, 99	23–55	FM and MSK	PMP	Sweden	18	0	In-depth interviews	Phenomenology
Gustaffson 2004, 100	23–59	FM and MSK	Pain management	Sweden	18	0	Semi-structured interview	Grounded theory
Hallberg 1998^a, 102	22–60	FM	Insurance hospital	Sweden	22	0	Semi-structured interview	Grounded theory
Hallberg 2000^a, 101	22–60	FM	Insurance hospital	Sweden	22	0	Semi-structured interview	Grounded theory
Harding 2005, 39	29–71	MSK	PMP	UK	15	3	In-depth interviews	Framework analysis
Hellstrom 1999, 103	32–50	FM	FM group	Sweden	10	1	In-depth interviews	Phenomenology
Holloway 2007, 91	28–62	MSK (CBP)	Pain clinic	UK	18	12	Semi-structured interview	IPA
Hunhammar 2009, 60	19–58	MSK	PC	Sweden	15	6	In-depth interviews	Grounded theory
Johansson 1996^a, 64	21–60	MSK	PC	Sweden	20	0	Semi-structured interview	Grounded theory
Johansson 1997^a, 65	21–60	MSK	PC	Sweden	20	0	Semi-structured interview	Grounded theory
Johansson 1999^a, 73	21–60	MSK	PC	Sweden	20	0	Semi-structured interview	Grounded theory
Kelley 1997, 104	50 mean	FM	PMP	US	22	0	In-depth interviews	Narrative analysis
Lachapelle 2008, 96	23–75	FM and MSK	Adverts	Canada	45	0	Ethnography and FG	Ethnography
Lempp 2009, 105	20–69	FM	Rheumatology	UK	12	1	Semi-structured interview	Thematic analysis
Liddle 2007, 84	20–65	MSK (CBP)	University	N Ireland	18	4	FG	Thematic analysis
Liedberg 2002, 106	26–64	FM	Questionnaire survey	Sweden	39	0	In-depth interviews	Thematic analysis
Lofgren 2006, 107	30–63	FM	PMP	Sweden	12	0	Diaries, FG, interviews	Grounded theory
Lundberg 2007, 68	30–64	MSK	PT	Sweden	10	5	In-depth interviews	Phenomenology
Madden 2006, 108	25–55	FM	Hospital databases	UK	17	1	Semi-structured interview	Induction/abduction
Mannerkorpi 1999, 109	29–59	FM	FM group	Sweden	11	0	In-depth interviews	Phenomenology
Mengshoel 2004, 28	37–49	FM	PMP	Norway	5	0	Semi-structured interview	Thematic analysis
Osborn 1998, 29	25–55	MSK (CBP)	Back pain rehab	UK	9	0	Semi-structured interview	IPA
Osborn 2006^a, 33	36–52	MSK (CBP)	Pain clinic	UK	6	4	Semi-structured interview	IPA
Osborn 2008, 40	36–52	MSK (CBP)	Pain clinic	UK	10	5	Semi-structured interview	IPA
Patel 2007, 66	29–62	MSK (CBP)	Benefits office	UK	38	15	Semi-structured interview	Thematic analysis
Paulson 2001^a, 110	41–56	FM	Rheumatology	Sweden	14	14	Narrative interview	Phenomenology
Paulson 2002^a, 41	41–56	FM	Rheumatology	Sweden	14	14	Narrative interview	Phenomenology
Paulson 2002^a, 111	41–56	FM	Rheumatology	Sweden	14	14	Narrative interview	Phenomenology
Raheim 2006, 112	34–51	FM	PC, PT, FM group	Norway	12	0	Life form interviews	Phenomenology
Raymond 2000, 113	38–47	FM	FM association	Canada	7	1	Semi-structured interview	Thematic analysis
Rhodes 1999, 30	25–65	MSK (CBP)	Healthcare plan	US	54	20	In-depth interviews	Thematic analysis
Sallinen 2010^a, 115	34–65	FM	PMP	Finland	20	0	Narrative interview	Thematic analysis
Sallinen 2011^a, 114	34–65	FM	PMP	Finland	20	0	Narrative interview	Thematic analysis
Sanders 2002, 34	51–91	MSK	Survey	UK	27	10	In-depth interviews	Grounded theory
Satink 2004, 76	42–70	MSK (CBP)	PMP	Netherlands	7	3	Narrative interview	Phenomenology
Schaefer 2005, 116	37–59	FM	Adverts	US	10	0	In-depth interviews	Phenomenology
Skuladottir 2011, 69	35–55	MSK	Adverts	Iceland	5	0	In-depth interviews	Grounded theory
Slade 2009^a, 86	26–64	MSK (CBP)	Adverts and university	Australia	18	2	FG	Grounded theory
Slade 2009^a, 85	26–65	MSK (CBP)	Adverts and university	Australia	18	2	FG	Grounded theory
Smith 2007^a, 31	36–52	MSK (CBP)	Pain clinic	UK	6	4	Semi-structured interview	IPA
Snelgrove 2009, 32	39–66	MSK (CBP)	Pain clinic	UK	10	3	Semi-structured interview	IPA
Soderberg 1999^a, 117	35–50	FM	Rheumatology	Sweden	14	0	In-depth interviews	Phenomenology
Soderberg 2001^a, 118	35–60	FM	Rheumatology	Sweden	25	0	In-depth interviews	Thematic analysis
Steen 2001, 67	Adults	MSK	RCT	Norway	48	NK	Semi-structured interview	Phenomenology
Strong 1994, 74	30–75	MSK (CBP)	Adverts	Australia	7	3	FG	Thematic analysis
Strong 1995, 75	30–75	MSK (CBP)	Adverts	New Zealand	15	4	FG	Thematic analysis
Sturgejacobs 2002, 42	20–57	FM	PMP	Canada	9	0	Unstructured interview	Phenomenology
Teh 2009, 87	63–86	MSK (CBP)	Pain clinic	US	15	5	In-depth interviews	Grounded theory
Toye 2010^a, 94	29–67	MSK (CBP)	PMP	UK	20	7	Semi-structured interview	Grounded theory
Toye 2012^a, 92	29–67	MSK (CBP)	PMP	UK	20	7	Semi-structured interview	Grounded theory
Toye 2012^a, 93	29–67	MSK (CBP)	PMP	UK	20	7	Semi-structured interview	Grounded theory
Undeland 2007, 119	42–67	FM	FM group	Norway	11	0	FG	Thematic analysis
Walker 1999^a, 43	28–80	MSK (CBP)	Pain clinic	UK	20	12	In-depth interviews	Phenomenology
Walker 2006^a, 95	28–80	MSK (CBP)	Pain clinic	UK	20	12	In-depth interviews	Phenomenology
Werner 2003^a, 35	26–58	MSK	PC and PMP	Norway	10	0	In-depth interviews	Phenomenology
Werner 2003, 36	31–53	MSK	PMP	Norway	6	0	In-depth interviews	Phenomenology
Werner 2004^a, 37	26–58	MSK	PC and PMP	Norway	10	0	In-depth interviews	Phenomenology

↵a More than one paper reporting experience of same group of people.
↵b The authors’ original description to define methodology was used. CBP = chronic back pain. FG = focus group. FM = fibromyalgia. IPA = interpretative phenomenological analysis. MSK = chronic musculoskeletal pain. PC = primary care. PMP = pain management programme. PT = physiotherapy. RCT = randomised controlled trial.

Notes

Funding

This project was funded by the National Institute for Health Research Health Services and Delivery Research (NIHR HS&DR) Programme (09/2001/09). Visit the HS&DR website for more information. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR programme, NIHR, NHS or the Department of Health.

Ethical approval

No ethics review was required for this study.

Provenance

Freely submitted; externally peer reviewed.

Competing interests

The authors have declared no competing interests.

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Received June 20, 2013.
Revision received August 14, 2013.
Accepted September 6, 2013.

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