Stefan Elbers

104 Chapter 4 (2004) did not find a significant improvement on pain and disability associated with self- management interventions for patients with arthritis. This also holds for Kroon et al. (2014), who performed a systematic review and meta-analysis to assess the effectiveness of self-management programmes in patients with osteoarthritis. They concluded that self- management interventions caused small to no benefits, which is in line with the current findings. We also found two systematic reviews with contrasting findings. Du et al. (2011) studied self-management interventions for patients with chronic musculoskeletal pain and concluded that these were effective on pain intensity and disability. However, the pooled results only showed a trend in favour of self-management for patients with chronic low back pain and a statistically significant but small change in disability and pain intensity for patients with arthritis. For Du et al. (2017), the pooled comparisons (intervention vs. control) were statistically significant at all time points for patients with chronic low back pain, but the effect sizes were small (ranging from −0.20 to −0.29 for pain intensity and −0.19 to −0.28 for disability). Differences in inclusion criteria concerning the interventions could further explain the variations in outcomes. Future Directions Although the results of this study may not be surprising in light of the previous findings from systematic reviews, there is a large body of evidence that shows how psychological adjustment in the situation of a chronic disease may lead to favourable outcomes, such as improved well-being and adaptive lifestyle changes (Stanton et al., 2007; de Ridder et al., 2008; Kamper et al., 2015). Below we will discuss three ideas that may explain why generic self-management interventions are not as effective as expected and that could direct future research and intervention design. First, lasting behaviour change is a daunting challenge, which involves not only motivational factors such as self-efficacy and intention, but also automatic processes such as habit formation (Webb and Sheeran, 2006; Strack and Deutsch, 2004; Papies, 2016). For patients with enduring pain, these automatic factors may be of particular importance as they have coped with their pain often for several years, thereby allowing habitual routines to develop in response to pain perception. This could explain the marginal long-term effects because habits are difficult to modify, especially when interventions do not take these automatic behavioural processes into account (Papies, 2016). In order to successfully counter these habitual behaviours in interventions, Papies (2016) proposes a different approach with more emphasis on analysing and modifying these specific routines. This personalized approach differs from generic self-management interventions that provide one set of skills expected to benefit all patients. In order to capture the individual tailoring that is required in these interventions, we endorse the recommendation of Morley et al. (2013) to further explore the potential of single-case methodology. For example, experience sampling technology – where multiple (near) real-