How do you establish who will do well with pain management?


ResearchBlogging.org
Some people just won’t do well with pain management.  In just the same way as a surgeon selects good candidates for surgery, so people need to be selected for self management.  Although there is some truth that getting even a little pain management is good for everyone, the cost of doing so in staff energy and the effect on other participants can make it a very unrewarding task.

How do you work out who is in and who is out?

I’ve used a ‘readiness for change’ model, following Prochaska and diClemente’s ‘stages of change’ approach for some time now.  This uses the idea that if we work with people at their level of readiness, we’ll reduce resistance to our efforts, and we can target our approach to suit.

The problem with this lies in trying to establish just what they’re ready for – there’s a huge difference in approach needed for someone who is contemplating beginning to exercise but is precontemplating returning to work!  Self management is no simple behaviour change choice, it’s a whole series of changes in most areas of a person’s life.

Another approach is a ‘stepped care’ approach, where everyone gets the same initial management, and as their recovery progresses (or not as the case may be), new and more intensive initiatives are introduced.  So everyone who fronts to a primary care clinicians gets ‘reassurance and advice to gradually return to normal activity’ for an acute low back pain.  If the person isn’t making adequate progress after four to six weeks, he or she might get a more in-depth assessment and targeted input from maybe a physiotherapist or occupational therapist, or a referral to a brief, functionally-oriented reactivation programme.  If this still doesn’t produce recovery and return to function, a more intensive approach with psychological or psychosocial input can be introduced until, after a long time, the Big Guns of an interdisciplinary pain management programme get brought out.

Recently there have been some interesting studies looking at more detail at the characteristics of those who seem to do well despite experiencing chronic pain, versus those who don’t do so well.  Some unsurprising results in some instances, with Foster, Thomas, Bishop, Dunn & Main (2009) finding ‘Patients’ perceptions that the problem will last well into the future, that many symptoms are related to their back problem, their weak beliefs about personal controllability and low confidence in their own ability to perform normal activities despite the pain‘ predicted disablity at six months – and somewhat surprisingly, found that fear avoidance, depression and catastrophising didn’t predict so well.

This is truly interesting, because it demonstrates that the factors that are identified in people later in the life of their pain may not be the same as those in the earlier stages.  It’s also interesting because once again, it’s patient’s perception of the effect of the problem, and their sense of helplessness and lack of control that predict disability. Perception is reality.  (I say this, because self efficacy has been found to be such an important indicator of whether someone returns to work – if they think they can, they probably will; if they think they can’t, they probably won’t)

Foster, Thomas, Bishop, Dunn & Main point out that this finding suggests that two models related to health are implicated: the self-regulatory model and the self-efficacy model.  In both, where an individual views their situation as helpless, and a future with pain and problems is inevitable, the person begins to become passive, inactive, doesn’t engage in coping behaviours, and doesn’t follow advice to remain active despite pain.

In another recent paper by McCracken and Zhao-O’Brien(2010), a concept of psychological flexibility, or the ability to accept and experience negative emotions, was found to be related to wellbeing and disability in people with chronic pain.  Their paper suggests ‘when people with chronic pain are willing to have undesirable psychological experiences without attempting to control them, they may function better and suffer less. General acceptance may have a unique role to play in the disability and suffering of chronic pain beyond similar processes such as acceptance of pain or mindfulness.’

This is another aspect of how an individual presents that might be important to identify when deciding who is ready for and will benefit from developing self management skills.

The problem is that it’s precisely those people who are not psychologically flexible, who lack effective self-regulation and have low self-efficacy, and who are not ‘contemplating’ self management who really need the input!  The next step is to identify how to help people move towards psychological flexibility and self regulation and self efficacy, probably through using a ‘stages of change’ manner where resistance is rolled with, and our approach is tailored to help people look at their situation and see how it’s not helping them to move towards what they want.  That is our mission.  Next thing is world peace!

If someone is not ready for self management – is it worth pushing this concept onto them, or is it better to ‘contain’ costs and put the effort into someone who is ready and can do well? This is an ethical judgement, but just as a surgeon chooses good candidates for surgery, maybe we need to choose good candidates for pain management.  And then be prepared to look at new and different ways for people who are not, because they’re the ones who are suffering and costing us, our economy and our health systems.

Foster, N., Thomas, E., Bishop, A., Dunn, K., & Main, C. (2009). Distinctiveness of psychological obstacles to recovery in low back pain patients in primary care Pain DOI: 10.1016/j.pain.2009.11.002
McCracken, L., & Zhao-O’Brien, J. (2010). General psychological acceptance and chronic pain: There is more to accept than the pain itself European Journal of Pain, 14 (2), 170-175 DOI: 10.1016/j.ejpain.2009.03.004

7 comments

  1. Wow, what a powerful post! I love that you are raising the question.
    My personal experience tells me that if we do not address the chronic pain trail of debris, it is tough to move ahead. There are so many psychological/emotional issues that stem from the pain experience that also need intervention and healing.
    By continuing to identify the obstacles perhaps we closer to an answer.
    Thanks for moving the discussion forward.
    Mary
    bluestarmoon.wordpress.com

    1. Hi Mary
      Thanks so much for the compliment! I agree that we need to start early to help people at risk for chronicity, and after a case conference yesterday where we discussed three people who weren’t coping with the self management concept I was left wondering just how we start to build momentum without also building resistance – respecting individual choices while avoiding risking therapist burnout!
      Like I said – if we can achieve this, world peace might be easy!
      Do you have thoughts about how we can do this?

  2. It hurts to see folks in pain situations not realizing the part they can play. I think for too long they were convinced that a pill or surgery would make things better.
    Sometimes I feel that the support someone has at home can determine their level of participation and recovery. I see many folks whose families do not even recognize the battle patients face or how important therapy is to recovery. We can deliver meals for folks, wish we could have traveling caring counselors who could visit someone in their environment to validate the fact that this is as essential as eating.
    For youngins, they can always blog about it and feel they have support. My youngest daugher has: http://yeskneecan.com/about/
    Myself, a counselor and a massage therapist got a chronic pain support group going for awhile. It was great to see the sharing and validating that occurred.
    some thoughts,
    Mary

  3. Mary, you’ve identified important needs, foremost–validating the pain. The “stepped-care approach”, therefore, is a terrible misfortune for the patient. Why wait for “If the person isn’t making adequate progress after four to six weeks…a more intensive approach with psychological or psychosocial input can be introduced”. A traveling (or an on site) caring counselor, as you suggested, is a must, especially if that person has personal experience. I would love the opportunity to be in this field.

    As a 58 year old with T4-L2 spinal fusion (with extensive nerve damage) since 1964, I manage extremely well. What has helped all these years is consistent exercise, vegetarian (with some fish) diet, stress reduction through meditation or yoga or simple mindfulness, changing positions often, power napping or bed rest as needed, and frequent albeit short massages. Good social relationships can not be overrated. Pain comes in waves, fear and stress make it worse. Minimizing or eliminating pain medication as soon as possible is helpful. When I need to take something (rarely), a third or half a vicodin suffices.

    All the best to you and your colleagues.
    Respectfully,
    Sue Doherty

    1. Hi Sue
      Thanks for taking the time to put your view across, it’s great to have your personal experience to draw on.
      I guess the points I’d like to make is that most people with acute (short-term) pain, particularly low back pain, don’t experience long-term pain and disability, so to put enormous resources in to everyone in the short-term is over-doing it for some, and probably leaves people who need long-term input without enough input.

      Validating that the pain is real, not imaginary, not a sign of mental ill health, not a sign of ‘not coping’, and needs effective management should be top priority for all health providers in all settings. A stepped care approach doesn’t necessarily lead to people’s experiences not being ‘validated’, because IMHO empathy and respect should be the first step for every provider.

      Not everyone needs therapy, counselling or even physiotherapy or help to get moving again – but for those who do, this should be provided as early as possible. Research suggests that getting moving again within days of the onset of acute low back pain is the best management, and some people are helped by seeing a physiotherapist who can coach them through and increase their confidence to do so.

      Social support can work both ways – sometimes it helps, sometimes it hinders recovery, depending on the person and the others in the social environment. I’m really wary of the tendency for a ‘pity party’ to develop where the time is spent bemoaning ill health (of any type) and not constructively looking to accept and move onward. And this is my personal experience with depression over 25-odd years, and chronic pain for longer! While affirmation that ‘this is horrid and no-one enjoys feeling sore’ is nice, for a time, it can lead to a never-ending failure to appreciate what already IS good, and away from starting to do things that are good and valued in life.

      I don’t recommend using specific medications for pain, partly because every medication has side effects, and partly because so often medications don’t help. I do affirm using activity (whether it’s exercise or simply things like gardening doesn’t matter!), managing stress (not always by minimising it, but dealing with it effectively), using relaxation and other forms of self regulation, setting goals and doing them bit by bit, but probably most of all, not allowing the pain to dictate what I do. It’s hard work, and as I pointed out in this article, not everyone is ready for this, nor is suited to this – but it does mean that I can be flexible, I can accept the bad and the good, and I can generally have good things in my life, including good relationships. What more do we want really?
      Thanks to both of you for your contributions!

  4. Gday. Great post. This is a really tricky issue for all of us – researchers and clinicians and those who are both. Nice up-to-date citations mixed with personal strategies – well done! We are currently trying to find the tool or combination of tools that can most quickly give us this sort of idea and the Foster paper sounds like a good place to go. Again, great contribution.

    1. Thanks for the compliment Lorimer! I know this is almost a holy grail for pain clinicians, and so many variables to take into account. It really is a dilemma as to whether to ‘pick the low hanging fruit’ (ie people who are showing signs of being ready to self manage) but these people don’t cost as much in human and economic terms as people who are much less ready to self manage. One of the reasons my own research is looking at people who are naturally resilient is that I think we can learn much from these people, and we know next to nothing about them simply because they don’t present for treatment. Let’s keep going with learning to identify ‘risk factors’ or ‘obstacles’ to recovery, but let’s also learn to identify the strengths people bring to their situation.
      cheers
      Bronnie

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