Self-Management Can Work in Chronic Pain Care

Adults with chronic pain experienced positive changes in their daily lives after participating in a self-management intervention in a primary care setting, based on data from a small qualiative study involving 17 individuals.¹

Current guidance for the management of chronic pain includes individualized and multidisciplinary strategies, wrote Ragnhild Hestmann, assistant professor in the department of health and nursing at the Norwegian University of Science and Technology, Trondheim, and colleagues.

“Interventions with a multidisciplinary approach are often delivered to groups of people in different settings and consist of several components that interact with each other,” the team noted in their paper, published in BMC Health Services Research. However, data on the effects of interventions delivered in a group primary care setting are lacking.

Pain Intervention Study Methods

Hestmann et al reported on data from 17 adults with chronic pain who agreed to be interviewed after participating in one of two interventions for pain management in a primary care setting.¹

The interventions took place in a Healthy Life Centre, a primary care setting in Norway. Participants were randomized to the pain self-management intervention or a group-based outdoor physical activity program that also served as a control group. Participants were interviewed 3 months after completing the interventions.

The pain management intervention course consisted of 2.5-hour weekly sessions for 6 weeks, and combined lectures, discussions, movement exercises, and “homework” assignments to practice self-management strategies. The interventions were designed to encourage changes in the participants’ attitudes in thinking about pain and emphasized sharing experiences.

Participants ranged in age from 32 to 74 years; 13 were women and 4 were men. Of these, 10 individuals reported pain with a duration of at least 10 years, and the majority reported musculoskeletal pain, as well as back pain, fibromyalgia, osteoarthritis, rheumatism, and osteoporosis.

Self-Management and Group Interventions Both Led to Improvements

Overall, participants in both the physical activity and the self-management groups reported improved self-management of pain as a result of the interventions.

“Their experiences of meeting others in the same situation, having the opportunity to share experiences, and belonging to a group were emphasized as important,” the researchers wrote. Participants in both groups reported that physical activity was an important part of pain management in their everyday lives.

In addition, several participants in the self-management course reported that the intervention gave them practical strategies to manage their pain management day to day. Specific techniques included relaxation, stretching, breathing, and elements of CBT.

One of the strengths of the study by Hestmann et al was the qualitative aspect, according to Corey B. Simon, DPT, PhD, senior fellow at the Center for Aging & Human Development at Duke University, Durham, NC.

He highlighted three take-home points for clinician:

1. “Regardless of treatment, patients felt empowered to self-manage their pain condition. They learned new strategies to think, feel, cope with their pain positively; which in turn, creates positive behavior such as activity engagement.”

2. “Group-based interventions can be a very powerful tool in pain management. At the same time, the study points out that not every patient liked group-based interventions, which is why personalized care is paramount.”

3. “Patients liked physical activity because it helped to manage their pain. This is a major victory in self-management; if clinicians can get patients to understand and buy into the power of physical activity despite feeling pain, they are more likely to self-manage and experience positive outcomes.”

Chronic Pain Management Challenges in Primary Care

In terms of how clinicians can use this information, Dr. Simon provided some strategies, starting with understanding the challenges at stake.

Rising Patient Populations

“Healthcare workers, including primary care clinicians, are fighting a losing battle against the chronic pain epidemic,” according to Dr. Simon.

Recent CDC data suggest that more than 50 million adults in the United States experience chronic pain, and these numbers are worse than they were 5 years ago.² “In other words, current healthcare strategies have failed to make a dent in chronic pain,” said Dr. Simon.

The CDC report also found that more than 17 million individuals experience high-impact chronic pain or pain that restricts daily activity, which increases the risk for morbidity and mortality. The prevalence of chronic pain will likely continue to increase as the population ages, and this will continue to challenge a healthcare system that is unable to treat chronic pain, he noted.

Legacy of a Biomedical Approach

“The silver lining is that we already possess strategies for combatting chronic pain and its influence on daily physical activity,” noted Dr. Simon. “The first hurdle for clinicians is to abandon a biomedical mindset (that pain corresponds to a peripheral injury) in favor of a ‘biopsychosocial’ mindset,” he said.

While pain can involve bone, discs, nerves, tendons, and other specific areas, “we now understand that the intensity, impact, and recovery from acute pain (or in the case of chronic pain, non-recovery) depends upon a multitude of biological, psychological, cognitive, social, and cultural factors that are individual to the patient and best served by a clinician who understands the multifactorial nature of pain,” Dr. Simon added.

See, for instance, the ACR’s guidance on integrated care for rheumatoid arthritis.

Reliance on Drugs

A second challenge is for clinicians to avoid over-reliance on pharmacologic and surgical interventions, especially as a first line of defense, said Dr. Simon. A growing body of evidence suggests that nonpharmacological interventions are at least as effective as drugs or surgery to manage chronic pain, he said.

Psychologically informed interventions include CBT, acceptance and commitment therapy (ACT), or mindfulness-based stress reduction (MBSR), said Dr. Simon – all of which can be initiated in primary care settings. “Self-management is often the end-goal of these interventions: to progress the patient towards autonomy in understanding factors which exacerbate their pain, such as stress or over-activity, and to give them tools to modify their lifestyle in a way that maximizes function and quality of life,” he noted.

Overcoming Barriers to Self-Management of Pain

Patient Buy-In

One potential barrier to self-management of chronic pain in a primary care setting is patient buy-in, Dr. Simon said. “At first glance, buy-in may seem out of our control, and it certainly can be,” he noted. Determinants of buy-in to self-management include patients’ acceptance of previous biomedical clinical advice, their perceptions about the source of their pain, and the yearning for a ‘quick fix’ on account of life stressors,” he said.

More on adherence strategies.

Therapeutic Relationship

The power of communication in psychologically informed interventions is often underestimated, said Dr. Simon.

“Simply communicating at the initial encounter is inadequate. Using motivational interviewing skills one time is inadequate. Communication must be woven through every clinical encounter and build upon the patient’s thoughts, feelings, and experiences.”

Multiple studies have shown the importance of communication in fostering therapeutic alliance between clinician and patient and positive outcomes, but some clinicians possess ineffective communication skills and may lack confidence in their ability to communicate with patients, he said.

Dr. Simon and colleagues recently published a pair of articles to guide clinicians in understanding and utilizing effective communication in patients with pain.^3,4

Time Restrictions

Time is also a barrier that can restrict even effective communication skills, Dr. Simon added. “If a clinician lacks time to communicate with patients, communication can’t be effective,” he said.

“The good news is that self-management is achievable if both primary care and secondary or specialty care are aligned in good communication,” said Dr. Simon. “If the patient hears the same message that empowers them to take an active role in their care, then they are more likely to do so. Also, many specialty clinicians – including psychologists and physical therapists – have the time and expertise to guide patients organically towards self-management,” he said.

Conclusion

Looking ahead, Dr. Simon agreed with the researchers’ conclusions that more work is needed in other geographic locations and in different primary care models.

Also, “it is important to gauge the thoughts and feelings of primary care clinicians in addition to patients,” Dr. Simon emphasized. “Therapeutic alliance is a very powerful thing, and if the clinician is not on the same page as the patient, then self-management will be difficult to facilitate,” he said.

“Finally, it is important to consider self-management in the context of multiple health conditions. Many patients with chronic pain live with medical comorbidities such as cardiovascular disease or diabetes,” he noted. In the United States, primary care clinicians must manage all health conditions, and prioritize those with the highest risk, so future research also must consider the feasibility of facilitating self-management in the presence of other conditions, he added.

Disclosure: The study¹ was supported in part by The Research Council of Norway.