After coming up with some of the content and structure for a programme, and discussing the need for a stable clinical team with effective skills in group-based CBT and an applied behavioural focus, today I thought I’d add in something about selecting, assessing and follow-up that’s required.
I get absolutely frustrated with reading and hearing about interventions that are either not required to furnish, or don’t consider outcomes – both psychometric questionnaire results (thought to indicate change in the ‘real world’) and real world outcomes. The art of making sure that what we do makes a difference, and knowing how to do this well seems to be quite lost on many clinicians and it really frustrates me. I’d find it professionally unsatisfying if I carried out an intervention and never had a clue as to whether it made a difference long after I’d finished seeing the person, so I can’t understand why so many clinicians (a) don’t measure outcomes (b) measure them poorly either through inadequate pre-treatment measures, inappropriate timing of post-treatment measures, or using irrelevant measures (c) measure outcomes using only psychometric questionnaires, or unidimensional measures.
I’ve mentioned outcomes first because part of selecting people for a programme is about taking baseline measures so that you know where you’re starting from, and you can ensure the programme is appropriate for the person’s needs. Selection also includes identifying the person’s readiness to move towards self managing pain, because if someone’s not ready they can become resistant (just think of all the ways people avoid doing what they don’t want to do! And include yourself), become ‘innoculated’ against the concepts (‘tried that, it didn’t work’), and influence group process negatively.
Just as a surgeon selects people for surgery after careful assessment, and declines surgery for people who are unlikely to benefit from it, so we need to be similarly selective in pain management. Pain management programmes are not ‘the last resort’ after everything has failed, they are a positive step forward for people who need to and want to take over the management of their own situation. Like any other self management programme like alcohol and drug rehabilitation, until the person is ready to do what will be very difficult and life-long, it’s unlikely they’ll benefit.
Every participant for a pain management programme needs to be comprehensively, and recently, assessed from a biopsychosocial perspective. Medical issues need to be managed before programmes commence, and the person needs to be reassured that they are safe to begin to do things again – and I’m afraid, this almost always needs to be reassurance from a doctor. Psychsocial issues influencing the person need to be identified – note the word psychosocial. Without considering the social it’s unlikely the situational and contextual factors that often constrain behaviour change, including things like litigation, family, case management issues and work issues. These factors influence beliefs, attitudes, behaviours and emotions and it’s critical that the person is seen as one person within a whole network of others.
When screening to establish readiness for pain management, other factors to consider are concurrent activities like vocational management, other investigations and pending treatments, evne things like holidays and training. Some of the other areas that might make it difficult for someone to participate are communication style, cognitive functioning, learning style, fatigue, activity level, and needs that don’t ‘fit’ with the majority of the programme participants and content or structure.
I’ll post a screening semi-structured interview later today, that I’ve used to help identify whether a participant is ready and appropriate for a group pain management programme.
All participants need to have some baseline measurements taken before a programme. In fact, there should be one set at comprehensive assessment, and a second set before a programme, another set at completion of the programme, then at least two, but preferably three times after – I think 1, 4 and 9 months later, or thereabouts. As time progresses, the intervening variables confound outcomes, and the number of respondents also drops, so it can be a challenge to obtain enough responses and for them to reflect programme changes over time.
What to measure and how? I’ll leave that for another day, suffice to say that questionnaire results are not enough. Not that they’re unimportant, because they are – but until they have had predictive validity established within the community in which your patients live, they may not reflect much useful information. Real world actions are far more valid, but are much more difficult to measure accurately – on the other hand, I think I’d like a valid measure that actually measures something important and useful, than to measure something irrelevant but do so incredibly accurately. Otherwise we could all give participants a blood test for glucose levels and be done with it!
References? Loads and loads of ’em. Where do I start?
The first and probably most comprehensive reference is either of the two editions of Pain Management: Practical applications of the biopsychosocial perspective in clinical and occupational settings by Main, Sullivan & Watson. The first edition was by Main & Spanswick, it’s a Churchill Livingstone publication under the Elsivier imprint. The first edition contains almost a ‘recipe’ for how to run this type of programme, while the second edition contains more conceptual material but provides excellent information to support clinical practice.
Fordyce, W E (1976). Behavioral methods for chronic pain and illness. CV Mosby, St Louis, MS.
Turk, D, Meichenbaum, D, Genest, M. (1983). Pain and behavioral medicine: a cognitive-behavioural perspective. The Guilford Press, New York.
Loeser, J., Sullivan, M. (1995). Disability in the chronic low back pain patient may be iatrogenic. Pain Forum, 4: 114-121
Main, C., Parker, H. (1989). The evaluation and outcome of pain management programmes for chronic low back pain. In Roland, M., Jenner, J. (Eds.) Back pain: New approaches to rehabilitation and education. Manchester University Press, Manchester, pp 129-156.
Keefe, F., & van Horn, Y. (1993). Cognitive-behavioral treatment of rheumatoid arthritis pain maintaining treatment gains Arthritis Care & Research, 6 (4), 213-222 DOI: 10.1002/art.1790060408