Recently I ran an online survey on this blog asking the question ‘Should self management include:’ and then I listed a number of options such as ‘injection therapy’, ‘medications’, ‘intermittent hands-on therapy’, ‘intermittent hands-off therapy’ and so on. My thoughts were that while the term ‘self-management’ is bandied about a lot, there isn’t really a consensus on what self-management should look like.
I was right. The three most popular choices were:
– having intermittent hands-on therapy as needed – 31%
– nonmedical coping strategies with no ongoing contact with a self-management therapist – 26%
– regular hands-off reviews with a self-management therapist – 26%
Following quite closely behind these two were:
– regular reviews with a medical specialist – 9%
– having regular oral medication – 7%
– receiving regular injections/blocks – 0%
Now the limitations of online surveys like this are well-known and accepted, but I did think it was interesting that two of the main options used in our Pain Management Centre – regular reviews with a medical specialist and having regular oral medications were not particularly strongly endorsed. And no-one in the three months this survey was up endorsed having regular injections or block, and yet in our Centre this is a common and strongly supported option by many of the medical staff.
Taking a look at the most frequently endorsed options, these to me are probably the two key choices for someone with ongoing pain – either intermittent hands-on therapy during flare-ups, or managing pain essentially without any hands-on input at all, half and half with contact or not.
Well – this result flies in the face of some of the most keenly argued reasons for encouraging self-management. To have hands-on therapy on an intermittent basis hasn’t been shown to make any practical difference in terms of function. And the evidence is quite strong that to have hands-on treatment leaves the person dependent on someone else to ‘fix’ the problem, that seeking treatment is associated with distress and at least some of the relief experienced with hands-on therapy at this time is about reducing that distress simply by ‘taking action’, and that by doing this the use of self-management strategies is eroded especially during set-backs.
Of course, the idea that reducing use of health care resources and thus the cost of chronic conditions hasn’t gone from the consciousness of health managers and funders, and so they encourage the ‘hands-off’ approach. Which leads me to the paper I’ve referred to today – what do patients think about ongoing use of self-management strategies, and what are the implications for physiotherapists, occupational therapists and others – and how do we influence patients to carry on with them (oh and does adhering to self-management long after treatment make any difference to health and disability anyway?).
A study not so long ago by Curran and colleagues found that a year after completing a comprehensive pain management programme, few participants carried on with the strategies they’d been developing during the programme. Strangely enough, their outcomes remained quite high despite abandoning those activities. At the time I wrote about this paper I suggested that ‘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’.
Maybe part of our work as therapists is to help people believe that they can live well. And that’s all.
Moore & Jull, in their editorial suggest that maybe physiotherapists shouldn’t be held to account if patients choose not to use self management strategies. It’s not really the physiotherapists’ fault, they argue, ‘should physiotherapists or other clinicians be held responsible for poor outcomes in the longer term if patients do not adhere, conform or comply with suggested self-management strategies?’
Moore & Jull also suggest that the ways in which outcome measurements are taken, typically for research at completion of a programme, at three months, six months, one year and maybe 18 months – two years, may not be appropriate for nonmedical input.
I’m not so inclined to agree with either of these views. So I’ll put my cards on the table. To me, self-management involves me as a patient learning as much as possible about how I can manage my health problem, using as many strategies as I can that avoid leaving me in the hands of health providers. So I err on the side of learning skills. Something I know about learning skills and changing habits is that it takes a while to make a change, and longer to maintain it!
Depending on how I put a self-management approach to a patient, it’s possible to put someone off the idea in a ‘take it or leave it’ fashion; or to work with the person to explore what’s important to them and identify whether they’re ready to engage with it or not. Motivational interviewing approaches have been used with success even with people who are being ‘obliged’ to attend self-management! It’s my job to work alongside the patient to help define what they want from therapy, and how important my approach is. So while I may not be able to ‘make’ someone choose self-management, at the very least I can try to ensure they have the choice to begin a programme…or not.
It is our responsibility as health providers to work with the person – and change our communication to work with them, not the other way around. After all, we’re trained in being health providers – none of us are ‘trained’ to be patients, at least not formally. So, should we be held accountable for the amount of engagement our patients have with what we offer them? Oh yes – to a point. I’d hope a selection process for treatment would ensure that people who don’t want self-management are not obliged to have it.
The second point that outcome measurement shouldn’t be carried out in the same way as for other medical processes – I really can’t agree with this either. Surely our outcomes need to be retained after treatment – and why wouldn’t it be helpful to know whether what we do is having an effect one or two years later? Of course, if you’re using pain intensity as a key outcome measure, and you fail to acknowledge the recurring nature of painful conditions, then it’s likely that some of the people ‘fail’ your input. But it’s never quite that simple: if we measure function, engagement with life, goals achievement, distress, beliefs and so on, even if the person isn’t ‘doing the exercises’, or the relaxation, or the planning that we showed them, hopefully we will still see something positive – or maybe we need to think again about how we discharge patients from treatment.
Like I said, changing habits is hard. I saw a man yesterday about 8 months since I last saw him. He’s successfully returned to work, but he’d had a flare-up after Christmas and wanted to go over his set-back plan. You could say he’s a ‘failure’ because his pain has persisted, and he’s coming back for treatment. I’d say he’s a success because he’s recognised that learning to do things differently and being able to review what went well and what needs refining is a life-long process – and he wanted some help.
Let’s spend some time discussing, researching and learning to help people self-manage – it’s an incredibly important topic, and one that needs far more debate and definition than it’s had to date.
Moore, A., & Jull, G. (2010). Capitalising on effective treatment strategies for low back pain – How do we bridge the self-management gap? Manual Therapy, 15 (2), 133-134 DOI: 10.1016/j.math.2010.01.007