Carrying on with self-management strategies doesn’t make a difference


Continuing in the vein of yesterday’s post where I discussed a study showing no additional benefit from adding graded exposure or graded activity to treatment by classification, today I want to discuss a recent finding showing that all the hard work put into helping people develop and use self management may not make a difference to their recovery in the end.  It’s this study (doi:10.1016/j.ejpain.2008.06.009) by Charlotte Curran, Amanda C. de C. Williams, and Henry W.W. Potts – Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain

What?! Shock and panic around the world! Pain management skills are not used!

The whole basis of self management lies with the idea that people develop practical skills they can use in the ‘real world’ so that when they experience pain, they have a range of strategies that improves their ability to cope.  So if they’re not actually using these skills after six months, what on earth are we doing all this treatment for?

Well, here are some of my thoughts.

First of all, cognitive behavioural approaches to pain management are predicated on the belief that people are able to develop ways of coping with their pain that move them from feeling trapped and helpless to being able to move forward. By reconceptualising their pain experience as something that they can live alongside, they can begin to develop new ways of viewing themselves – perhaps not as ‘life as it used to be’, but more like ‘life as it is for the future’.  I guess this could be something along the lines of acceptance (and yes, you know I’ve written about this before – here is an example of one of the pieces of research, and here is a book using the ACT approach), but I wonder if there is something more.

A couple of words have become popular in my neck of the woods – demoralisation is one of them, and optimism is another.

People become demoralised (rather than depressed) when they try and try and try again to ‘find a cure’ or ‘get a fix’, but don’t seem to be getting very far.  Some people become cynical, pessimistic and frustrated, while others simply seem to be passive and take whatever comes their way.  They don’t look much beyond this week, next month and tonight’s sleep.  Future goals? Forget it.  Sometimes this demoralisation remains even after going through a pain management programme where they meet other people, realise they’re not alone – but don’t seem to be able to generate that spark of ‘maybe life can be different and it’s my job to make it so’.

People who do seem to get a sense of optimism start to look toward the future.  When they go through almost any procedure or programme, they start to look beyond tonight’s sleep, tomorrow’s fatigue, and next week’s struggle, and somehow compare life now with life when they were at their worst.  Things are looking up.

I wonder whether it’s this new attitude of possibility, the momentum gained from making small changes that show the person they are moving again, and a new view of themselves as someone more than their pain – but perhaps quite a different ‘someone’ than the person who existed before they had their pain.

Is it this that people gain from being part of a pain management programme?

We’ve known for ages that the ingredients inside the ‘black box’ of cognitive behavioural pain management approaches are unknown.  We don’t know whether a pinch of exposure therapy, a cup of exercise and a bucket of self regulation training is any better than a handful of cognitive therapy, a tablespoon of operant conditioning and a shake of social learning.  And it seems that identifying what works for whom and when is an incredibly elusive goal – more so if we start to think that what we’re measuring isn’t actually what makes the difference!

We do know that pain intensity alone doesn’t directly predict disability (although it may have an influence).  We also know that doing some sort of activity helps (although we don’t know exactly what kind of activity).  Having better sleep seems to be good for people, and knowing that other people are going through similar things and doing OK also seems to be good.  Acceptance has a place, as does the ability to self regulate (not just relaxation, but goal-setting too).

What a wealth of things to research – really practical research!  I’m looking forward to the future – are you?

doi:10.1016/j.ejpain.2008.09.013

Editorial: On adherence to self-management strategies, Michael K. Nicholas, 2008, European Journal of Pain

7 comments

  1. Which I guess begs the question, why use individualised interventions for chronic pain patients (1:1 physio, psychology etc)?
    The pain management service I work within pays scant regard to the group approach, reflected in the numbers attending, the support for staff involved and the budget for the programme itself.
    I suggest the 1:1’s are easier and more comfortable for patients and clinicians alike, but if we are unable to determine who is most likely to benefit from which intervention (a dash of everything) then the group process is where the evidence lies and the emphasis should be placed.

    I accept that some patients may require assistance with mood for example, before engaging. But how can we judge that the person ‘doesn’t need PT or psych input’ if we are not even confident that the things we are assessing are appropriate.

    I’m also keenly aware (really need to work on my referencing) that previous failed interventions lead to an increased likelihood that subsequent interventions will also fail (anticipation, learned response etc) so feel its really important that the group intervention (whilst time-demanding, staff draining and intense) is considered for a much broader slice of the chronic pain population. Perhaps we still (deep, deep down!) think that WE are going to be the individual clinician who is going to make the difference? Our desire to heal is deeply engrained.

    Would be interested to hear from other clinicians involved in group interventions and their comparison with 1:1 interventions.

  2. We have both group and individualised programmes for people with chronic pain. I prefer groups myself, although I do see the need for some individualised input for some aspects (eg where there is sexual assault, PTSD etc).
    In fact, I really enjoy groupwork, and I think it’s both cost-effective and ensures that people with chronic pain learn not just through ‘advice’ from someone like me, but also from watching other people with chronic pain learn and do things differently (social cognitive model).

  3. Is the cost-effectiveness of the programme accepted? Purely from a subjective perspective it seems to demand a lot clinicians time, for a relatively small number of patients.
    Is there much research in the effectiveness of group size? Presumably if you could get (for example) 20 people engaged in one ‘group’ your cost efficiency (and therefore attractiveness to management) would be far greater than smaller, more intimate groups.

  4. Currently it is accepted in NZ, and although I can see the external view that it’s a lot of input for a limited number of people, it’s probably more cost effective than some of the alternatives (e.g. one patient to one therapist two or three times a week for the duration of a 12 week programme).
    We’ve found that for optimal group interaction, the size of the group needs to be around 8 maximum. More than that and it’s too easy for someone to slide out from participating, less than that and many of the dynamics of social cognitive theory start to slip.
    Turk and Okifuji write a review of the cost effectiveness of MDP’s a couple of years back – they compared it with surgery, compensation for time off work, and individualised programmes, and suggested it continues to be cost effective.

  5. Thanks, sounds very interesting. I imagine information on group size is transferable from other therapy groups re: contribution and ability to hide.

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