When to start self management for chronic pain

There’s no doubt that early self management for chronic pain is a good thing – but in our facility, we’ve always had a rather mixed feeling about introducing self management while people are still receiving medical treatment for their pain. Our experience has been that few patients are really committed to learning how to modify their lives when just around the corner there could be a procedure that will ‘fix’ the pain. So I was interested to read about this study, published last year, about a four-week programme self management programme for people who are still undergoing medical treatment.

A couple of interesting points from this study:  participants were carefully selected; the programme was brief; and participants were involved in the programme from around 5 months after they had been referred.

Firstly, participant selection.  In this group, participants were assessed using the Westhaven-Yale Multidimensional Pain Inventory.  This is a popular and robust assessment that generates three profiles – adaptive coper, interpersonally distressed, or dysfunctional.  The adaptive coper profile describes people who are relatively undistressed by their pain, who have a sense of being in control and are generally coping well.  This means they were not those people who were highly disabled by their pain at the time of their assessment.  This isn’t to say they wouldn’t develop less helpful coping strategies and beliefs over time, so they represent a group who could benefit from a self-management and ‘psycho-educational’ approach.

Secondly, the programme itself.  Most pain management programmes are reasonably intensive – they can vary from three weeks daily input, to twelve weeks with several sessions a week or less.  This programme involved four sessions, and the sessions were three hours in length.  The content appears to be very similar to what would be included in most pain management programmes, and included ‘exercise, pacing, goal setting, relaxation, education of the gate-control theory and pain pathways, activities of daily living, medication and health eating advice, posture, lifting, beds and sleeping, sleep hygiene, the influence of thought processes and communication of pain’. Along with this content, participants also had home learning activities to complete.

Finally, participants were referred by a number of different specialist groups (rheumatologists, anaesthetists, physiotherapists and nursing). They were fully screened by a team of clinicians including occupational therapy, psychology and physiotherapy. It appears there was a waiting list – so five months from receipt of referral to commencing the programme. I’m not sure about the exclusion criteria – participants were not meant to have any mental health problems yet many of them were depressed and also scored highly on anxiety.

Cutting to the results – this was a pre and post intervention design, so there was no control condition, and we can only assume that any change was influenced by the intervention. Overall function and distress changed in the directions we would hope for. In other words, it works.

What we don’t know is whether this is helpful for people who many of us would hope could manage quite well without any input. And we don’t know whether the outcomes were sustained beyond the programme time.

On the other hand, it’s a brief intervention that was provided to people during their receipt of further medical input. The brief part might excite some of the managers in health purchasing, while the medical people I know might be quite excited by the thought that self management is included at the same time as medical input. We’ve had quite vigorous debate about this in our centre – should patients be asked to wait for self management until the medical input has completed?

Before any solid conclusions can be made about this approach there must be more research. But even at this early stage, it’s interesting that the participants represent a generally more capable, less disabled and distressed group of people – they’re somewhat less likely to pursue ongoing input to reduce their pain. I would love to see this approach used as part of a stepped-care approach, so that for those individuals who do generally cope well, this is all they need. For those who need more – the ‘next level up’ or a more intense programme might be made available.

Mead, K., Theadom, A., Byron, K., & Dupont, S. (2007). Pilot study of a 4-week Pain Coping Strategies (PCS) programme for the chronic pain patient Disability & Rehabilitation, 29 (3), 199-203 DOI: 10.1080/09638280600756117


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