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