Learning to manage pain using self management strategies ain’t easy – as we know, changing habits and doing things differently is not something any of us do without a bit of effort. It’s especially difficult when life in general is full of challenges, but so much more so when pain is the problem,you have a mood disorder that saps your energy and when other people (even health professionals!) challenge your decision to manage pain independently. There are even some researchers who would say that using self management strategies is not all that important – after all, after about a year, many people don’t use any of the new skills, but still feel differently about pain anyway (Curran, Williams and Potts, 2009).
The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) project is a “randomized clinical trial designed to test the effectiveness of a stepped-care approach to deliver a combined medication and behavioral intervention for primary care patients with chronic musculoskeletal pain and depression.” The programme included 12 weeks of antidepressant medication ‘therapy’ followed by six sessions of pain self-management delivered over a further 12 weeks, and was delivered in primary care. The model used was a ‘social cognitive’ one, which essentially aims to enhance self efficacy and social support, and the definition of self management was “the ability to manage the symptoms, treatment, physical and psychosocial consequences and life-style changes inherent in living with a chronic condition.”
The study itself has been discussed in many publications, so I don’t want to review that aspect, but instead look at this paper which, using a qualitative approach, examines “the challenges patients face, particularly when pain is accompanied by depression, in learning and applying self management skills.” And not only look at obstacles, but also facilitators or factors that enhance using these skills.
Focus groups consisting of people who had completed the programme and who were willing to be involved in follow-up discussions, met and the following questions used to guide discussion:
- What difficulties (if any) has your pain caused in your life?
- Can you share with us some of the challenges you have faced in managing (coping with, dealing with) your pain?
- What about some of the successes you have had in managing your pain better?
- Think of some of the ways or strategies the SCAMP Pain Study taught you to better deal with (manage) your pain.
- Which of these strategies did you find particularly helpful to better manage your pain?
- Why did you find these helpful (relieve pain, improve activity, or both)?
- How did they help?
- Which of these strategies did you not find helpful?
- What were some of the challenges that you faced in using these strategies to better manage your pain?
- Do you think stress or mood problems (such as depression) made using these strategies more difficult?
- What are some things that made these strategies easy to use regularly?
- Has anyone learned other ways to manage/deal with your pain that we have not discussed today?
- Let’s say that this discussion was going to be shared with your doctors with the goal to help them better treat your pain, what would you like to tell them?
(I think these make great questions to ask anyone who has completed a pain management programme, maybe at a six month review!)
What did they find?
Barriers to using self management included – pain, over-reliance on medications, the effect of low mood, inadequate tailoring of coping strategies to the individual, fear of activity and that pain reduction didn’t occur with some of the strategies – amongst a few others.
Facilitators to using self management included – mood improvement, supportive family and friends, support groups, support from nurse care managers (who were responsible for delivering this programme), social comparison (I’m not as badly off as …), being proactive – and others.
The paper discusses each of these factors in a little more detail, but I’m curious about some of the comments. While it seems that the material delivered looks like much of what almost every self management for pain programme delivers, I wonder how much attention was paid to the cognitive therapy component – identifying and challenging thoughts and beliefs about pain and activity.
Things like “the exercise isn’t suitable for everyone (walking)”, or “I’d love to do it (go walking) but the pain gets in the way” suggests to me that it would be helpful to really work with people as they implement exercise (for example) to challenge the belief that pain needs to stop activity. At least in the programme I work on, by titrating the activity level, working with small goals and helping people learn how to increase activity, and using effective self talk to challenge the reasoning behind the beliefs about pain, people seem to begin to let pain interfere less with what they want to do. Recently one person returning for the six week followup said ‘My pain isn’t any different, but I feel differently about it’ – this person said he found himself chasing an animal down the road when he would never have thought this possible before the programme!
I was curious about the indication that over-using medication was problematic – it’s something we’ve discussed within our team, along with the prn use of medications and use of other passive modalities like acupuncture, or injection procedures. Our thoughts have been that it tends to reduce the confidence people have in their own coping skills because it’s so much ‘easier’ to use medication than to use these other skills. It seems that in this study at least, their medical providers reinforced the use of medications for pain relief rather than endorsing the use of self management. I have wondered long and hard about this, because it seems that the medical model is so pervasive it’s very difficult for biomedical clinicians to ‘change tack’ to support nonpharmacological strategies. I don’t know what the answer is!
In terms of facilitators, it’s great to see that participants in this programme found that improved mood helped them keep on with self management. While I can understand the hesitation some clinicians have about over-treating depression (“he’s depressed because he’s got pain – reduce the pain and he won’t be depressed any more, simple!”) the debilitating effects of low mood can erode the will to persist with difficult actions. Not to mention making life more miserable than it needs to be with pain.
The rest of the facilitators were mainly social support – now I’m not sure whether this is because of the social model used in this programme, but it’s a really important finding. Why? Well I observed a couple of days ago that the ‘social’ part of the biopsychosocial model sometimes looks like it’s been lost. As well, it’s really difficult to get family members and others to attend pain management, and one of my recent patients said ‘but this pain is my problem, not my partners, so why would he get involved?’ But no one is a island, and social support to help maintain newly formed habits is really important. People can make or break self management! So an important finding was that practice nurses (nurse managers) were thought to be a vital part of maintaining self management. Maybe that link between delivering a service and the family health centre is one we need to strengthen.
A final comment about support groups – while these can be great, they can also be ugly. It depends so much on the focus of the group – whether it’s on living well or commiserating about hardship. If it’s the former I think (don’t have any data on this though!) it’s probably a very positive part of living with pain. If it’s about a pity party or maintaining an identity as a ‘disabled person’ then maybe it’s less helpful. And if it’s on a self-destruct path (and I’ve seen this happen), it can be very unhelpful indeed.
Obstacles and facilitators: something to look at more in the future. Along with defining what self management looks like for each individual – because there is no single recipe for everyone!
Curran, C., Williams, A. C. d. C., & Potts, H. W. W. (2009). Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13(2), 178-188.
Bair, M., Matthias, M., Nyland, K., Huffman, M., Stubbs, D., Kroenke, K., & Damush, T. (2009). Barriers and Facilitators to Chronic Pain Self-Management: A Qualitative Study of Primary Care Patients with Comorbid Musculoskeletal Pain and Depression Pain Medicine, 10 (7), 1280-1290 DOI: 10.1111/j.1526-4637.2009.00707.x