Self management – a very vexing definition

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