Not a day for hanging out the washing

Self management – a very vexing definition


ResearchBlogging.org
Self management is one of those terms that is used to describe the aim of cognitive behavioural programmes for chronic pain. It’s even in my description of this blog! At the same time, it’s difficult to arrive at a definition of self management that “everyone” agrees upon.

Self management can mean helping people to be “actively involved in their health care and to provide a variety of creative and individualized strategies to deal with their health problem in their daily life and ultimately to live as normally as possible despite their symptoms” (Zuffery & Schulz, 2009) – but the Devil is in the details!

What exactly does being “actively involved” mean?  Can it mean accessing treatments like massage, injections, acupuncture “as needed”? Or does it mean exclusively managing pain without recourse to so-called “passive” treatments?  And what are the implications of either of these two options (and yes, shades in between)?

Let’s take the most extreme option, that of having a chronic pain problem like fibromyalgia where there is no definitive treatment and no structural deficit that can be “fixed”, and learning to manage this problem without accessing any treatments.  Self management, in this case, might mean:

  • knowing as much about the diagnosis and underlying neurobiology as possible;
  • being “health literate” and able to negotiate through health care systems;
  • knowing how to select the appropriate coping strategy or strategies to achieve a specific goal; and
  • maintaining a healthy and active lifestyle, with full participation in occupations, activities and roles within the family and community

Alternatively, at the other end of the spectrum, for someone with a recurrent structural change (say low back pain that responds to medial branch blocks), self management might look like:

  • knowing as much about the diagnosis and underlying neurobiology as possible;
  • recognising the “early warning signs” indicating that either a flare-up is happening, or the medical procedure is starting to ‘wear off”;
  • being “health literate” and knowing how to access this help as needed;
  • knowing how to select the appropriate coping strategy or strategies to achieve a specific goal;
  • maintaining participation in occupations, activities and roles within the family and community, while living a healthy life

There’s not a lot of difference between the two – one doesn’t access treatment, the other does.  However – and here’s my take on self management – there is a great deal of difference in terms of managing fluctuations in pain, and in the focus on symptoms.

One of the predictors of coping well with a chronic health problem is self efficacy.  Self efficacy is confidence that you can manage a situation yourself.  At least within North American and possibly a majority of New Zealanders, self efficacy is influenced by having an internal locus of control – this means recognising that the efforts the person does make a difference, rather than expecting or hoping that someone or something outside of themself will be effective. (There are differences in cultural expectancies, hence localising my description).

Typically, it seems that people who can make a difference to their own health through their own efforts, feel more confident to manage fluctuations in pain – which, it has to be said, occur with all chronically painful conditions.  Those that are hoping for something to “take the pain away”, or who try to rid themselves of the pain through avoiding activities when they’re sore, or increasing their medication intake or access treatments to reduce their pain, seem to be less confident to weather these fluctuations, and can become distressed when their efforts don’t work, or their pain doesn’t settle, or they’re asked to do things even when they’re sore.

Where’s the evidence for this? Well, Blyth and colleagues carried out a very large study of non-treatment-seeking people in Australia who had chronic pain.  Their findings showed that “use of active strategies was associated with lower levels of disability, less distress, less reliance on medication, and less use of formal health care” – although combinations of what we might call “passive” coping such as rest and heat/cold were often used with active coping strategies such as exercise, changing position and so on.

Now I’m not comfortable with classifying various strategies as passive=bad, active=good.  I think it’s more complex than that because my taking on coping and self management is that we don’t use strategies without some sort of goal in mind.  That goal might be to reduce distress so the kids don’t see Mum crying; it might be to remain standing so Dad can watch the rugby; it could be to keep going so the housework gets done; or it might be to be productive at work. I think we need to be cautious about simplistic classifications unless we also take into account the end goal, or the “what is important to the person” aspect of the coping strategy.

I have a sneaking suspicion, though, that it’s not so much the skills used in the process of living everyday life that promotes self management and self efficacy – I think it may be an “attitude”.  In other words, it’s not what you do, but the way that you do it (or the spirit that you do it in).

My rationale for this is the growing evidence that greater pain acceptance is associated with less distress and disability (see for example, Wright, Wren, Somers, et al; 2011).  They looked at pain acceptance and hope and optimism in a group of obese patients with musculoskeletal pain.  Using the Chronic Pain Acceptance Questionnaire which divides pain acceptance into  pain willingness (or how willing a person is to experience increases in pain during the pursuit of something important), and activity engagement (or how involved in everyday living a person is). They found that “pain acceptance remained a significant predictor of psychological distress and pain disability” even after controlling for optimism, demographic, and medical variables.

This is important stuff – along with the strategies, which have always been the focus of pain management, these attitudinal changes seem to be important in self managing pain.  Now: how do we influence this attitude?

One final question: do people who have greater pain acceptance also need health literacy skills to manage the tendency of our health systems to want to offer a fix or a cure to people with chronic health problems? Because while our views have mainly about the person with pain and what he or she does, I don’t think we’re nearly as aware of, nor focus on, the influence of social forces like family, healthcare system, community attitudes and so on.  More on this later folks!

Wright, M., Wren, A., Somers, T., Goetz, M., Fras, A., Huh, B., Rogers, L., & Keefe, F. (2011). Pain Acceptance, Hope, and Optimism: Relationships to Pain and Adjustment in Patients With Chronic Musculoskeletal Pain The Journal of Pain DOI: 10.1016/j.jpain.2011.06.002
BLYTH, F., MARCH, L., NICHOLAS, M., & COUSINS, M. (2005). Self-management of chronic pain: a population-based study Pain, 113 (3), 285-292 DOI: 10.1016/j.pain.2004.12.004

Caiata Zufferey, M., & Schulz, P. (2009). Self-management of chronic low back pain: An exploration of the impact of a patient-centered website Patient Education and Counseling, 77 (1), 27-32 DOI: 10.1016/j.pec.2009.01.016

10 comments

    1. Thanks for posting this Gail, I hadn’t seen it! A great review, and I particularly like the continuum analysis of the various types of self management approach.
      cheers
      Bronnie

  1. Thanks for this great post! I look forward to more on the topic. I’ve started to be more aware of pain acceptance being at least a part of how a client with chronic pain will have a shift in the way they see things, at some point in the course of struggling with their pain and the various health professionals who are supposed to help. It does seem to be an important part of healing, even when pain remains.

    1. Hi Bonnie
      I totally agree – for people who have ongoing pain, it does seem that acceptance of the presence of pain reduces the sense of “life on hold” for many people, and redirects the energy that can be so often spent on looking for a cure on to more healthy and life-giving pursuits. How to help people achieve this level of acceptance is a rather more difficult question, and one I’m sure we’ll be learning more about as time goes on. In the meantime it looks like efforts to rule a line under endless new investigations and “let’s try another techno-fix” forms at least part of the process for people to move on towards greater acceptance – provided that people don’t get the impression they’re being fobbed off. And I’m not for one moment suggesting that people should give up hope of something being available at some point in the future to reduce their pain. It’s more a case of putting energy into things that bring life into life!
      cheers
      Bronnie

  2. Hi. I’m a Licensed Professional Counselor and I deal very heavily with the subject of “Coping With Chronic Pain”. I’ve just recently started my own practice in Johnson City TN. I’m not exactly new to business and psychology, but I am very new to all this online blogging stuff that I’ve began to learn since opening my practice and creating a website, so I hope it’s ok that I write a comment here on your blog.

    As I came here to WordPress.com to create an account for my practice (it was advised for me to do so by a friend who knows a thing or two about websites and blogs), I bumped into this article and enjoyed reading it very much so.

    Thanks for letting me comment, I’m still learning about all this blog tech stuff🙂

    -Doug

  3. Bronnie–I really appreciate this post and often have mini-battles at work (specifically with physicians) about passive versus active strategies for dealing with chronic/persistent pain conditions. As a Physical Therapist, the issue often circles around the notion of “maintenance care”; meaning that without the “thing” that helps the pain (insert acupuncture, chiro, PT, massage, needle-based blocks, trigger point injections, etc), the person with pain is significantly worse off. I struggle with this regularly because I have trouble defining the parameters of frequency for patients. For example, is someone really “self-managing” if they believe they need to see their chiro/PT/acupuncturist on a weekly basis in order to complete their home-based or work-based tasks? If a person gets “a full week of relief” from the manual therapy received in some professional’s office, is that a good outcome or a short-lived one? The MDs I work with often view the last scenario as a very positive outcome. “If I had a medication that would provide a week’s worth of relief, I’d prescribe it in a heartbeat.” My experience is that the folks who have the highest distress and who also seem to benefit from highly frequent “passive” modalities are also highly anxious and are fierce self-advocates. So if they are very good at asking for and receiving passive treatments, does this make them adept at self-management or just good at working the system? Respectfully.

    1. Hi Kate – that’s an excellent question. From my original stance on self-management, asking for and continuing to have hands-on treatments isn’t “self-management”, and it’s one target that used to be included in self-management programmes. I’m not sure that’s been occurring recently. Now, I don’t know. The way I approach it is to ask the person to weigh up the good and not so good of their approach – so for some the hassle of attending appointments and paying for them, and what happens when the clinician is away, and what if they need to move to another location – these are all counter to “being independent”. For another person, this doesn’t impact much on their life, they have other ways of dealing with funding and so on, and hands-on treatment is just one feature of their plan. In a publicly funded health service I’d be arguing for LESS of this kind of approach and MORE of self-reliance and not seeking hands-on treatment. In a privately funded health service I think there are market forces that make the situation far more complex. In the end, I probably err on less of the hands-on because every time a person attends one of these appointments they’re reminded (a) that they’re not “well” (b) they need help and therefore are not OK and (c) someone else has what they need. I’m not sure that’s how I’d like to live my life, after all I resent having to see a doctor for my three-monthly medication review especially when I’m well. I really don’t know, and perhaps that’s the thing – it depends so much on the values of the person experiencing pain.

  4. Reblogged this on Neil Wise Physio and commented:

    A very sage speaker at a conference once said the patient is better when they are “doing all their normal activities, back at work, off medications, not seeing other health practitioners on the side…” A good insight!

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