Table 1 Nonpharmacological approaches for pain levels and symptoms of depression in people with osteoarthritis (31 interventions from 23 studies).

Aerobic exercise only (4 interventions from 4 studies)

 *Cheung et al. 2017, USA⁷⁰, Community and home

A low-impact aerobic and strengthening exercise program that involved 15 min of mild aerobic exercise for a full-body warm-up, 30 min of strengthening exercises (isometric and isotonic exercises, i.e. without/with moving the joints). Participants were also asked to practice the aerobic portion 15–30 min/day and the strengthening portion 30 min/day on non-consecutive days at home. The program was progressive in nature

8 weeks: One weekly 45-min group session with 2–4 days per week home practice sessions

Three-armed RCT (Aerobic strengthening, hatha yoga & control)

Raters were blinded

No post-intervention follow-up

Pain levels:

WOMAC

d = 0.00

Depression:

HADS

d =  − 0.12

13

 *French et al. 2013, Dublin⁷¹, Academic teaching hospitals

Exercise therapy (ET) sessions were administered by a senior grade or clinical specialist physiotherapist. They included flexibility and strengthening exercises delivered using a semi-structured protocol. The protocol provided guidance on exercise prescription and progression but could be tailored to individual patient physical assessment findings. Strengthening focused on low-load exercise, commencing in non-weight-bearing positions, and progressing to functional positions. The key target muscles were the gluteal muscles. A daily home exercise program supplemented the clinic-based treatment. Participants were also encouraged to undertake aerobic exercise, such as walking, cycling, or swimming for at least 30 min, 5 days a week, and were given written and verbal information on the principles of aerobic conditioning, such as pacing, gradually progressing intensity and time of exercise, and incorporating exercise into daily life

8 weeks: One 30-min session per week (8 sessions in total)

Three-armed RCT (exercise therapy, ET with adjunctive manual therapy, control)

Raters were blinded

No post-intervention follow-up

Pain levels not reported

Depression:

HADS

d = 0.16

15

 *Kuntz et al. 2018, Canada³⁴, University setting

The traditional exercise (TE) intervention reflected the current gold standard of strengthening exercise for knee OA. The program emphasized knee strengthening but also involved an aerobic warm-up, balance exercises, and stretching. TE was designed and supervised by kinesiologists and physical therapists and took place at a physical activity center. The sessions involved a ten-minute warm-up performed on a treadmill or cycle ergometer. Then, lower extremity strengthening was performed on pneumatically resisted exercise machines. Exercises included all major muscle groups of the lower extremity. The quadriceps were targeted at every session. Participants also completed balancing activities and static stretching. There was a progressive increase in the number of sets and resistance during strengthening exercises over the course of the intervention

12 weeks: 1-h, 3 times a week (36 sessions in total)

Three-armed RCT (Traditional exercise, bio-mechanically-based yoga & control)

Raters were blinded

No post intervention follow-up

Pain levels:

KOOS

d = 0.75

Depression:

CESD

d =  − 0.09

13

 Lin et al. 2020, Taiwan⁷², Hospital clinic

The active video games treatment involved using a computerised system called “Hot Plus” (Supreme Investment Co., Taipei). Two sessions were selected that required participants to move their trunk and lower limbs as fast as possible to tread on the step-sensing pad placed on the floor to complete on-screen tasks. The first session was ‘‘Whack-a-mole,’’ which required the player to stump moles into the holes when virtual moles appeared. It had 3 different levels. More and faster moles appeared simultaneously at higher difficulty levels. The second session was ‘‘Archery,’’ which required the player to step on the sensing pad to shoot an arrow when virtual dynamic targets appeared on the screen. This task also had 3 difficulty levels. Faster and smaller shooting targets appeared on the screen at higher difficulty levels

4 weeks: 20 min, 3 times a week (12 sessions in total)

Two-armed RCT (active video games versus traditional therapeutic exercise

Raters were blinded

One- and three-months post intervention follow-up

Pain levels:

WOMAC

d = 0.05

Depression:

HADS

d =  − 0.03

12

Movement meditation (7 interventions from 6 studies)

 *Cheung et al. 2017, USA⁷⁰, Community and home

The hatha yoga program was designed by a group of expert yoga teachers. Sessions included poses in the seated, supine, prone, and standing positions; breathing exercises; and relaxation/mindfulness training. Key yoga poses included “easy” seated pose, reclining bound angle, half locust variation, head to knee pose, warrior I and II, tree pose variation, bridge, reclining hamstring stretch with hip opener with strap, reclining twist and relaxation pose. A progressive series of poses with props such as yoga mats, blocks, straps, blankets, and chairs were used, and poses were modified when needed based on the participant’s physical abilities to increase confidence and the ability to remain in the pose and receive the benefits. Each yoga class consisted of 8–10 yoga poses with 2–3 new variable poses introduced at each session. A registered yoga instructor who was experienced in working with older adults with functional limitations taught the classes

8 weekly 45-min group classes with 2–4 days per week home practice sessions

Three-armed RCT (Hatha yoga, aerobic strengthening & control)

Raters were blinded

No post-intervention follow-up

Pain levels:

WOMAC

d = 0.51

Depression:

HADS

d = -0.32

13

 *Fransen et al. 2007, Australia²⁷, Community

Tai chi sessions were facilitated by four different Tai Chi instructors trained in a special program for arthritis designed by the study author Paul Lam. This program is a modification of 24 forms from the Sun style of Tai Chi and includes a preliminary 10-min warm-up session. Participants were able to purchase, if they desired, a Tai Chi video to assist with home practice

12 weeks: 1-h, 2 times a week (24 sessions in total)

Three-armed RCT (Tai chi, hydrotherapy, waiting-list control)

Raters were blinded

6-month post intervention follow-up

Pain levels:

WOMAC

d = 0.52

Depression:

DASS-21

d = 0.21

14

 *Kuntz et al. 2018, Canada³⁴, University setting

The biomechanically based yoga exercise program was led by a certified, trained yoga instructor and consisted of alignment-based postures that activate the lower limb musculature while maintaining a low knee abduction movement. The selected weight-bearing, static poses were performed barefoot and included squats and lunges with varying foot, trunk, and arm positioning. Careful attention was given to ideal alignment of the leg throughout the exercises. The classes began with a body-awareness exercise performed in supine followed by the strengthening postures and concluded with a closing deliberate relaxation exercise performed in supine. Exercise difficulty was progressively increased

12 weeks: 1-h, 3 times a week (36 sessions in total)

Three-armed RCT (Traditional exercise, bio-mechanically-based yoga & control)

Raters were blinded

No post intervention follow-up

Pain levels:

KOOS

d = 0.99

Depression: CESD

d = 0.51

13

 Moonaz et al. 2015, Canada³⁵, Hospital affiliated fitness centres

The yoga program was designed by a registered yoga therapist (SM) with input from Johns Hopkins Arthritis Center faculty. Two yoga therapists with 10 + years of experience taught classes. Each class began with questions/comments (5 min), breathing exercises and chanting (5 min), warm-up and moving sequence (surya namaskara; 15 min), and isometric poses (asanas) (20 min) to increase strength, flexibility and balance. Classes ended with deep relaxation (sivasana; 10 min), a closing chant, and meditation (5 min). See supplemental file for sample class and modifications. Poses included gentle forward bends, backbends, twists, balances, standing, sitting, and lying poses, and were modified for individual at the discretion of the teacher and/or participant. Complexity of poses and intensity was standardized to allow gradual progression

8 weeks: 1-h, 2 times a week (16 sessions in total)

Two-armed RCT (yoga versus wait-list control)

Raters were blinded

9-month post intervention follow-up

Pain levels:

SF-36 (pain component)

d = 0.62

Depression:

CESD

d = 0.84

13

 *Park et al. 2016, USA⁷³, Community centres

English linguistically tailored yoga program. Sit ‘N’ Fit Chair Yoga, designed for older adults with OA, is performed while sitting in a chair with arms, for easy access and standing. The chair is used for support for the standing poses. The intervention was developed by a research team of health care providers with a yoga teacher who has taught yoga for more than 15 years and is certified by the International Yoga Alliance. The yoga intervention consists of four components while using the support of a chair: breath of life (10 min), body proper (20 min), warrior in the body (5 min), and mind–body connection (10 min)

8 weeks: Two 45-min sessions per week (16 sessions in total)

Four-armed RCT (chair yoga—English, chair yoga – Spanish, English/Spanish control: health education program)

Raters were blinded

One- and three-month post-intervention follow-up

Pain levels:

WOMAC

d = 0.19

Depression:

EDD-V1

d = 0.12

12

 *Park et al. 2016, USA⁷³, Community centres

Spanish linguistically tailored yoga program. Sit ‘N’ Fit Chair Yoga, designed for older adults with OA, is performed while sitting in a chair with arms, for easy access and standing. The chair is used for support for the standing poses. The intervention was developed by a research team of health care providers with a yoga teacher who has taught yoga for more than 15 years and is certified by the International Yoga Alliance. The yoga intervention consists of four components while using the support of a chair: breath of life (10 min), body proper (20 min), warrior in the body (5 min), and mind–body connection (10 min)

8 weeks: 45-min, 2 times a week (16 sessions in total)

Four-armed RCT (chair yoga – Spanish, chair yoga – English, English/Spanish control: health education program)

Raters were blinded

One- and three-month post-intervention follow-up

Pain levels:

WOMAC

d = 0.83

Depression:

EDD-V1

d = 0.43

12

 Zhang et al. 2022, China⁷⁴, Hospital

Traditional Chinese Yijinjing Qigong exercise provided by professional instructors. Each session included a 5-min warm-up and cool-down period and a 30-min practice. Phase 1 (weeks 1–2) focused on fundamental principles, movement techniques, safety precautions. Phase 2 (weeks 3–4) focused on learning/practicing forms/associated movements. Phase 3 (weeks 5–12) involved completion of the family exercise plan, review video/homework materials

12 weeks: 40 min, 2 times a week (24 sessions in total)

Two-armed RCT (qigong, stretching control)

Raters were blinded (single-blinded)

One- and three-month post intervention follow-up

Pain levels:

WOMAC

d = 0.42

Depression:

BDI

d = 2.57

14

Multimodal (10 interventions from 8 studies)

 *Ahn and Ham 2020, South Korea⁷⁵, Community

Experimental group 1 – Program outlined below with muscle strengthening plus stretching

Health education and counselling combined with exercise classes based on the Interaction Model of Client Health Behaviour. The intervention involves 8 sessions and promotes cognitive-affective-behavioural skills including education and counselling on the disease characteristics and treatment options, encouraging self-responsibility, strengthening self-efficacy, self-monitoring, positive reinforcement, and emotional support regarding pain control, medication adherence, depression, and diet. Communication skills training was also provided to promote the client-professional interaction. Trained community health nurse practitioners led the intervention

Duration not clear: 8 sessions (4 individual and 4 group), individual home visits were 30–60 min and group community sessions were 60–90 min

Three-armed RCT (multimodal approach with muscle strengthening plus stretching, multimodal approach with muscle strengthening plus walking, control)

Raters were blinded

No post intervention follow-up

Pain levels:

WOMAC

d = 0.66

Depression:

CESD

d = 0.07

13

 *Ahn and Ham 2020, South Korea⁷⁵, Community

Experimental group 2 – Program outlined above with muscle strengthening plus walking

Duration not clear: 8 sessions (4 individual and 4 group), individual home visits were 30–60 min and group community sessions were 60–90 min

Three-armed RCT (multimodal approach with muscle strengthening plus walking, multimodal approach with muscle strengthening plus stretching, control)

Raters were blinded

No post intervention follow-up

Pain levels:

WOMAC

d = 0.78

Depression:

CESD

d = 0.11

13

 Barlow et al. 2000, UK⁷⁶, Community (telephone-based)

An RCT of the arthritis self-management programme (ASMP). ASMP is multicomponent and topics included: information about arthritis, an overview of self-management principles, exercise, cognitive symptom management (e.g. distraction, visualization, guided imagery), dealing with depression, nutrition, communication with family and health professionals, and contracting (setting of realistic goals during the forthcoming week). Participants report back to their group on their achievements at the weekly session. Participants are given a copy of The Arthritis Help Book (Lorig & Fries, 1995). Interactive course with group discussion, problem solving, role plays and mastery experience (trying out skills introduced)

4 months: 6 weekly 2-h sessions, delivered by pairs of lay leaders (most with arthritis)

Two-armed RCT (self-management program versus waitlist-control)

Unclear whether the raters were blinded

12-month post intervention follow-up

Pain levels:

ASE

d = 0.31

Depression:

HADS

d = 0.12

11

 *French et al. 2013, Dublin⁷¹, Academic teaching hospitals

Exercise therapy (ET) with adjunctive manual therapy (MT)

The sessions included ET (as described above) and up to 15 min of MT in line with current clinical practice at participating sites. A choice of nonmanipulative MT techniques based on pain/stiffness relations and movement restrictions of the affected hip was available, with no more than 5 MT techniques allowed during an individual session

8 weeks: One 45-min session per week (8 sessions in total)

Three-armed RCT (ET + MT, ET alone, control)

Raters were blinded

No post-intervention follow-up

Pain levels not reported

Depression:

HADS

d = 0.18

15

 Hurley et al. 2007, UK⁷⁷, Primary care providers

Rehabilitation program integrating exercise, self-management, and active coping strategies. The rehabilitation program combined discussion on specific topics regarding self-management and coping, etc., with an individualized, progressive exercise regimen. To ensure consistency in content and delivery, the same experienced physiotherapist devised, supervised, and progressed all sessions for all participants

6 weeks: Twice weekly (12 sessions in total)

Two-armed RCT (rehabilitation program, usual care)

Raters were blinded

6-month post intervention follow-up

Pain levels:

WOMAC

d = 0.29

Depression:

HADS

d = 0.16

13

 *Somers et al. 2012, USA⁷⁸, Community and clinic

Lifestyle behavioural weight management (BWM) only. Each participant was given a copy of a manual, which focused on 5 elements related to weight loss: lifestyle, exercise, attitudes, relationships, and nutrition, and contains 16 weekly sessions. The content of most of the group sessions was based on the weekly topic(s). In addition, participants received Appetite Awareness Training for 2 sessions, which emphasized the importance of attending to internal hunger and fullness cues. The overall goal of the program was a weight loss of 1–2 pounds a week achieved by gradually decreasing calorie and fat intake through permanent lifestyle changes

24 weeks: One 60-min sessions per week for first 6 months, One 60-min session every other week for the second 6 months

Four-armed RCT (PCST, BWM, PCST + BWM, standard care)

Raters were blinded

4-weeks post intervention follow-up

Pain levels:

WOMAC

d = 0.17

Depression:

AIMS (psychological subscale)

d = 0.00

14

 *Somers et al. 2012, USA⁷⁸, Community and clinic

Pain coping skills training (PCST) plus lifestyle behavioural weight management (BWM). Participants concurrently received the BWM protocol described above and the PCST protocol described under the therapeutic section of this table. During the first 12 weeks, participants attended 120 min of group sessions that first presented the BWM protocol and then the PCST protocol. During the first 12 weeks, participants also attended three 90-min supervised exercise sessions each week. During the last 12 weeks, participants attended 120 min of group sessions held every other week that first presented the BWM protocol and then the PCST protocol. All PCST + BWM groups were delivered by clinical psychologists referenced above

24 weeks: One 60-min sessions per week for first 6 months, One 60-min session every other week for the second 6 months

Four-armed RCT (PCST, BWM, PCST + BMW, standard care)

Raters were blinded

4-weeks post intervention follow-up

Pain levels:

WOMAC

d = 0.72

Depression:

AIMS (psychological subscale)

d = 0.35

14

 Tak et al. 2005, Netherlands⁷⁹, Community

'Hop with the Hip’ exercise program with strength training and lifestyle advice versus self-initiated contact with their general practitioner (usual care). The program included strength training sessions using fitness equipment under supervision of a PT, OA education from PT, guidance for a home exercise program, personal ergonomic advice (given by an OT), education on dietary aspects (given by a dietician) and participants with BMI > 30 given personal consultation. Further information was also available via a special telephone line

8 weeks: one 1-h group session per week (8 sessions in total)

Two-armed RCT (program, control)

Raters were blinded

3-months post intervention follow-up

Pain levels:

Harris Hip Score (HHS) pain subscale

d = 0.52

No depression measures

10

 Walsh et al. 2020, UK⁸⁰, Community (physio. clinic)

The Facilitating Activity and Self-management in Arthritic Pain (FASA) program is a group exercise and self-management intervention facilitated by a physiotherapist. The intervention included approximately 20–25 min of group discussion and problem-solving session (with a supporting handbook) regarding issues of self-management. Topics included activity-rest cycling, use of ice and heat for pain relief, goal setting and action plans, exercise recommendations, healthy eating and managing changes in pain. After each discussion, participants undertook approximately 30–35 min of exercise, based on stations of strengthening, aerobic and co-ordination activities. Further to the exercises, each individual completed an action plan regarding exercise/activities they aimed to achieve over the following week

6 weeks: 60-min 2 times per week (12 sessions in total)

Two-armed RCT (program, control)

Raters were blinded

6-months post intervention follow-up

Pain levels:

DI-SMFA

d = 0.13

Depression:

HADS

d = 0.07

16

 Yip et al. 2008, Hong Kong⁸¹, Hospital out-patient clinic and a Telehealth wellness centre

Modified Arthritis Self-Management Programme (ASMP: Lorig et al. 1985)⁸² with an added exercise component. Small group classes (10–15 people) were led by registered nurses trained in leading small groups and self-management principles, standard ASMP plus goal-directed exercise component relevant to the group’s lifestyle habit: stretching exercises, walking, and Tai Chi types of movement – fluid, gentle, relaxed, slow – aimed at enhancing exercise for affected joints (Yip et al. 2007)⁸³. The group practised the stretching exercise together twice each session, Tai Chi exercises were taught and reinforced for 30 min each session, intervention group were given pedometer for 3 days at baseline to reinforce walking. Routine conventional treatment prescribed by orthopaedic doctor or out-patient clinic was also provided

6 weeks: One 2-h session per week (6 sessions in total)

Two-armed RCT (ASMP, usual care)

Raters were blinded

Results are reported following 1-year post-initiation of an ongoing program

Pain levels:

ASE (pain subscale; Lorig et al. 1985)

d = 0.38

No depression measures

12

Resistance exercise only (3 interventions from 3 studies)

 Bossen et al. 2013, Netherlands⁸⁴, Community (online in people’s homes)

Web-based physical activity intervention 'Joint2Move'. The program incorporates a baseline test, goal setting, time-contingent PA objectives (i.e. on fixed time points), and text messages to promote PA. Positive reinforcement is provided of gradual PA, despite the presence of pain. The gradual increase in activities changes the perception that PA is related to pain and reinforces confidence to improve PA performance. The Join2move intervention is a fully automated web-based intervention that contains automatic functions (web-based text messaging and automatic emails) without human support

9 weeks: self-paced program in which a patient’s favourite recreational activity is gradually increased in a time-contingent way

Two-arm RCT (web-based intervention, wait-list control)

Raters were not blinded

Three- and 12-month post-intervention follow-up

Pain levels:

KOOS/HOOS

d = 0.19

Depression:

HADS

d = 0.13

13

 *Fransen et al. 2017, Australia²⁷, Community

Hydrotherapy sessions were facilitated by four different registered physiotherapists. The hydrotherapy program (Fransen et al.²⁷: Appendix A) was designed by the senior rheumatology physiotherapist

12 weeks: 1-h, twice a week

Three-armed RCT (Hydrotherapy, tai chi, waiting-list control)

Raters were blinded

6-month post intervention follow-up

Pain levels:

WOMAC

d = 0.71

Depression:

DASS-21

d = 0.50

14

 Taglietti et al. 2018, Brazil³⁶, Aquatic physiotherapy centre and primary health care unit

Aquatic exercise protocol in a heated pool, one-to-one sessions provided by certified physiotherapists. The water temperature was maintained at approximately 32 °C, with a depth of 1.2 m. The exercise protocol consisted of specific exercises: 5 min of warm-up with walking, patellar mobilization; stretching the leg muscles (quadriceps, gluteus, adductors and abductors of hip, triceps surae, and hamstrings); 15 min of knee and hip isometric and dynamic exercises with elastic bands (gluteus, adductors and abductors, quadriceps, hamstrings, and triceps surae); 20 min of aerobic exercises (stationary running or deep water-running); 10 min of step training and proprioceptive exercises; and 10 min of cool down with massage and relaxation

8 weeks: Two 60-min sessions per week (16 sessions in total)

Two-armed RCT (Hydrotherapy, education control)

Raters were blinded

Three-month post intervention follow-up

Pain levels:

WOMAC

d = 3.33

Depression:

GDS

d = 2.17

13

Therapeutic only (7 interventions from 7 studies)

 Allen et al. 2019, USA⁸⁵, Community (telephone-based)

Pain coping skills training for African Americans. Culturally tailored pain telephone-based coping skills training (CST) program

Coping skills training counselors provided instruction in cognitive and behavioral pain coping skills and led participants in guided rehearsals of these skills. Content included progressive muscle relaxation, mini-relaxation practices, communication with significant others about pain and coping, managing unhelpful mood, activity pacing, pleasant activities, pleasant imagery and other distraction techniques, physical activity and OA, weight management, problem solving and maintenance. Participants were asked to engage in home-based practice of the skills to enhance their application in pain-related situations. During each phone call, the counselor reviewed participants’ home practice, including successes and barriers, encouraged problem solving, and worked to set goals for application of skills. Participants were given handouts to facilitate each session, along with an audio recording to guide progressive muscle relaxation

3 months: 30–45 min sessions (11 sessions in total)

Two-armed RCT (intervention, wait-list control)

Raters were blinded

Three- and 9-months post intervention follow-up

Pain levels:

WOMAS

d = 0.17

Depression:

PHQ-8

d = 0.10

16

 Broderick et al. 2014, USA⁸⁶

Pain coping skills training delivered by nurses. Training included cognitive and behavioural skills to manage pain and enhance self-perception of pain control. Four broad coping skills were taught across ten 30–45-min sessions: relaxation response, attention diversion techniques, altering activity and rest patterns as a way of increasing physical activity, reducing negative pain-related thoughts and emotions. The training included a treatment manual and home practice

10 weeks: One 30–45 min session per week (10 sessions in total)

Two-armed RCT (intervention, usual care)

Raters were blinded

Six- and 12-months post intervention follow-up

Pain levels:

WOMAC

d = 0.22

Depression:

BDI

d = 0.17

16

 Hausmann et al. 2017, USA⁸⁷, Academic Veterans Affairs Medical Centre

Positive psychology intervention program consisting of positive psychological skill-building activities drawn from the positive psychology literature and then refined based on qualitative input from patients. Included activities to build positive psychological skills focused on gratitude, kindness, optimism, mindfulness, self-affirmation, identifying and using personal strengths reflecting on good things, and forgiveness

6 weeks: 1 session per week (6 sessions in total)

Two-armed RCT (therapy, control)

Raters were not blinded

Three- and 6-months post intervention follow-up

Pain levels:

WOMAC

d = 1.08

Depression:

PANAS

d = 0.20

11

 Helminen et al. 2015, Finland⁸⁸, Community (groups)

Cognitive–behavioural group intervention (7 − 13 people) supervised by an experienced psychologist and a physiotherapist. Each session lasted for two hours with a 15 − 20 min break to enhance peer support and social bonding. The outline of the sessions included an introduction (15 min), lecture (knowledge and insight, max 15 min), problem solving (in pairs/teams, 15 − 20 min), skills training (15 − 20 min), homework assignments (15 min), and a résumé (feedback) of the session (15 min). A written example of a knee OA pain patient’s life was used throughout the intervention as a basis for discussion and practice in problem solving

6 weeks: One weekly 2-h session (6 sessions in total)

Two-armed RCT (therapy, control)

Raters were blinded

Three- and 12-months post intervention follow-up

Pain levels:

WOMAC

d = 0.18

Depression:

BDI

d = 0.02

15

 Lin et al. 2003, USA⁸⁹, Primary care clinics

Improving Mood-Promoting Access to Collaborative Treatment (IMPACT). Psychotherapeutic intervention using a collaborative care approach. Nurse/psychologist depression care management including psychosocial history, education, and behavioural activation, identify treatment preferences. Antidepressant medications and/or 6 to 8 sessions of psychotherapy (Problem-Solving Treatment in Primary Care). Usual care group received routinely available treatments including medication and referrals to speciality mental health services

1-year: 6–8 sessions

Two-armed RCT (therapy, usual care)

Unclear whether the raters were blinded

Three-, 6- and 12-months post intervention follow-up

Pain levels:

RAND-36 (pain subscales)

d = 0.18

Depression values not reported

14

 O’Moore et al. 2018, Australia⁹⁰, Community (online)

Internet Cognitive-Behavioural Therapy (iCBT Sadness Program). iCBT Sadness Program consists of lessons representing best practice CBT, as well as regular homework assignments and access to supplementary resources. Each lesson comprises a cartoon narrative in which a character gains mastery over symptoms of depression by learning and implementing CBT skills. Participants could submit queries via email or phone

10 weeks: 6 online sessions

Two-armed RCT (therapy, treatment as usual (TAU))

Raters were blinded

Three-months post intervention follow-up

Pain levels:

WOMAC

d = 0.28

Depression:

PHQ-9

d = 1.01

13

 *Somers et al. 2012, USA⁷⁸, Community and clinic

Pain coping skills training (PCST) only. PCST was delivered by clinical psychologists with prior PCST experience (1 to 5 years) who were systematically trained by a senior clinical psychologist who is an expert in pain coping skills training. Training included role-playing, listening to the protocol delivered on audiotape, and observation of PCST being delivered in a group format. Psychologists delivering the treatment for this protocol met for supervision weekly with the senior psychologist; audiotapes of sessions were reviewed to evaluate the concurrence between the session delivery and the intervention protocol and role-playing for the next session was conducted. Four psychologists led the PCST groups during the study. The PCST intervention was designed to 1) decrease maladaptive pain catastrophizing; and 2) enhance participants’ ability to control and decrease pain by increasing use of adaptive coping strategies (e.g. distraction, relaxation, and changing activity patterns)

24 weeks: One 60-min sessions per week for first 6 months, One 60-min session every other week for the second 6 months

Four-armed RCT (PCST, BWM, PCST + BWM, standard care)

Raters were blinded

4-weeks post intervention follow-up

Pain levels:

WOMAC

d = 0.23

Depression:

AIMS (psychological subscale)

d = -0.12

14