Circling back to supported self-management

I’ve been writing a bit about supported self-management over the last few months. Partly because it’s topical given that medications and exercise offer very small reductions in pain and disability, and people do have lives outside of swallowing a pill and doing 3×10 reps! And partly because it is what we end up doing. It is the bulk of what people living with pain use to have lives.

Self-management refers to a broad range of strategies people with pain use in their daily lives to help them live well. I’m aware of the multiple definitions that exist for self-management, and that the level of agreement isn’t great – and of course, throughout my discussion I always consider self-management to be supported. Supported by relationships with health professionals, friends and family, and within healthcare systems. Or perhaps not so much the latter.

Drawing on Nicholas & Blyth’s commentary from 2016 (because it’s pretty good), the key elements of self-management are:

• being actively involved in daily actions to manage the effects of pain
• knowing about pain and the options for managing pain
• monitoring signs and symptoms and responding to these
• collaborating with health professionals and others to develop ways of living around pain

From my perspective, some of the things that seem to be important in self-management are:

• Knowing how to set limits on demands/obligations from others. This is important because, whether we like it or not, pain does limit how much we can do. I’m not certain this is always considered, especially when I hear of people with pain being asked to do far more than I am expected to do. It is reasonable for people with pain to say no! Being able to say no shouldn’t come with a host of negative consequences like ‘you’re being noncompliant’, or ‘you’re not trying hard enough’, or ‘you’re just using our pain as an excuse to get out of things.’ Unfortunately, for those with an accident insurance claim, the consequences of saying no can be pretty harsh.
• Knowing how to adapt, adjust, tweak or vary anything being suggested. This includes mindfulness, exercise, medications, pacing… And this one is a doozy because there are some very shouty people who think that their way to [insert strategy here] is The Way. If we had agreement we’d all be seeing good results, right? We don’t, and we see so many different ways of doing [insert strategy here] that I think we can be pretty confident that there is no One Way to do any of them. Contextual sensitivity is needed. What this means is being able to adapt, adjust, tweak or vary the things to suit the purpose and the context. “How it functions in this context” is likely more important than “what it looks like in a healthcare context”.
• Being able to feel the effect. To know what it feels like, and use this as the guide for action. No I don’t mean only the short-term effects (resting does feel great at times) but over the longer term. Asking: Does this [insert strategy here] give more options, allow me to move towards the things that matter, adapt and adjust over time? Helping someone feel what it feels like so they can use that ‘body knowledge’ in any context probably means less talking from the therapist, and more guiding to notice and reflect. Now that’s a set of skills many therapists have never been taught, particularly movement therapists.

I’ve written before about the way ‘the social’ is often ignored in a ‘biopsychosocial’ approach to pain. The factors that fall into the social are the very ones those of us living with chronic pain most have to deal with. The social impacts on how much we’re listened to by health professionals and others, whether we can say no without harsh consequences, how OK it is to adapt, adjust, tweak or vary how we do anything (including the things clinicians suggest), how much notice we take of our own body (because we’re often being talked at, taking our attention away from what we’re actually experiencing), and even on whether we can get to have a decent sleep (I am that person sneaking away from a social event and snuggling down in my bed at 9.30pm!).

Social factors also popularise what’s on offer, how much these things cost, who is able to offer them, and whether they fit in our lifestyle. Our gender, age, ethnicity, cultural background, religion, socio-economic status, education, the type of work we do – all of these are social. And they make an extraordinary difference to how we can employ self-management. A study by Webster et al., (2022) examined what people with chronic pain do in their health work in the context of having difficulty making ends meet.They found there is work in managing chronic pain alongside poverty and subsistence, trying to legitimise their needs (and themselves), attempting to adhere to biomedical models (even when it is clear that social contextual factors are hugely contributing), and navigating multiple diagnoses. The authors call this ‘chronic struggle’ – a term that resonates with my experiences listening to people with chronic pain as a clinician. The experiences they describe are ‘the social’ – and clinicians, we need to listen.

If you’re working in a supermarket job, you can’t just stop the queue of people at the checkout to go do a stretch and pace yourself. The skills needed to make that happen are in those three self-management skills: to safely say no, to be able to adapt (etc), and to use how it feels to guide actions. The social aspects of doing self-management take grit, confidence, great communication skills, and quite a lot of personal power. And for many people with chronic pain, being assertive and taking control over what is expected from you is high risk.

The social is about participation, if you’re going to use ICF (WHO – ICF). Participation is all about being able to do the things – in ICF-speak it’s “… involvement in a life situation… Participation restrictions are problems an individual may experience in involvement in life situations.” and goes on to say “…Because the current environment brings in a societal context, performance as recorded by this qualifier can also be understood as “involvement in a life situation” or “the lived experience” of people in the actual context in which they live.”

Self-management, because it is about daily life, is inevitably about participating in life situations. It’s up to health professionals to learn about a person’s real daily life contexts to make sure that what is suggested as ‘self-management’ can actually be done, and to help people with pain develop those three skills I’ve suggested at the very least. And for all of us to push back on attempts to limit our ability to do those without kickbacks.

Nicholas, M. K., & Blyth, F. M. (2016). Are self-management strategies effective in chronic pain treatment? Pain Management, 6(1), 75-75–88. https://doi.org/https://doi.org/10.2217/pmt.15.57

Webster, F., Connoy, L., Sud, A., Rice, K., Katz, J., Pinto, A. D., Upshur, R., & Dale, C. (2022). Chronic Struggle: An Institutional Ethnography of Chronic Pain and Marginalization. J Pain. https://doi.org/10.1016/j.jpain.2022.10.004

Self-management skills we don’t often discuss

I’m back from my summer break (I’m in Aotearoa/New Zealand – we shut down over Christmas/New Year just like the US and UK do over July/August!), and I want to begin with a cracker of a topic: medication management!

Now I am not a prescriber. I don’t hold any ability to write prescriptions of any kind, not even exercise ;-). Yet most of the people I’ve seen in clinical practice have started their journey living with pain by being prescribed medications.

All medications have side effects, true effects (well… maybe), adverse effects, and the human factor: taking them in the way that optimises the pharmacodynamics of the drug. It’s this last part that can sometimes be omitted by prescribers. Or at least, that’s my take after listening to hundreds of people over my clinical career.

What do I mean? Well, all drugs have a kind of ‘release profile’ as the active ingredients are metabolised (broken down) in the body. Most drugs will be released gradually into the system, peak after a certain time, and then gradually reduce in concentration until there’s no active ingredients (metabolites) left. There’s a difference between what we feel (the effects we experience) and how long the metabolites remain present – people using cannabis, for example, will know that the effects of euphoria/calm/sedation/relaxation wear off reasonably quickly, but the metabolites hang around in the fatty tissues for months (Lucas, Galettis & Schneider, 2018). Alcohol is metabolised at a fairly predictable rate, but the experience of being intoxicated differs for each person depending on their tolerance, the food present in their belly, fatigue, gender and so on (Greaves, Poole, & Brabete, 2022).

When prescribing a drug, the prescriber usually holds some assumptions about how it’s going to be used. Most medications are intended to be taken regularly at the same time of day every day – the prescriber should take into account things like any sedating effects, any other side effects, and the effect the person and prescriber are looking for. But people do some weird stuff with medications and may not take them in the way the prescriber thought they would.

Why do some people not take a pill at the same time every day? Well, some groups of people don’t find it easy to hold to a schedule – people with ADHD, people working shiftwork, people who have kids (especially newborns!). Some people think of pain medications as a bit like optionally taking paracetamol (acetaminophen) - take it as needed, no worries if you don’t take it all the time. This is OK for acute (short-term) pain, where you’re pretty confident the pain will reduce over time, but not so good for chronic pain where the pain is present to a greater or lesser extent for months. And some drugs given for chronic pain need to be taken consistently to get the effect you’re looking for. Some people might worry that medications used routinely could lead to dependence or tolerance. Dependence is about physiological adaptation to the presence of a drug leading to a ‘withdrawal’ effect if the drug isn’t present. Tolerance is the process of the body adapting to the presence of a drug and needing more and more to get the same effect. There’s no doubt that both of these processes can occur in some an analgesics (pain relief), particularly opioids, and careful prescribing and taking the medications as they are intended to be taken is critical.

Sometimes the side effects of a medication can be almost as useful as the active ingredient. A case in point is the sedating effect of tricyclic antidepressants. For someone with persistent pain, sleep can be something we’d dream of if only we could get some sleep! So, knowing how long it takes before feeling the sedative effects of a tricyclic antidepressant, and how long that sedation can last, can be used thoughtfully to decide the best time to take a dose. For example, some tricyclic antidepressants begin to give that sedating feeling about two hours after taking the dose – and that sedated feeling remains for around 12 hours. Taking this kind of drug ‘at bedtime’, or when you want to get into bed to fall asleep, might mean you have a hangover effect because most of us don’t have the luxury of a 12 hour sleep! But taking it a couple of hours earlier, or around 12 hours before you want to get up, might mean you fall asleep more easily and wake up without the hangover. Checking with your prescriber or your pharmacist-dispenser to work out the best time to take a drug is really helpful to optimise both the side effects and minimise the negatives.

Medications are an important part of pain management for some people. The hit rate for getting the gold standard ‘50% reduction in pain’ is pretty low, and for many people there is no medication to touch the sides of pain (see Katz et al., 2015 for a nice discussion about NNT; and Patel & Dickenson, 2021 for info on just how poorly individual drugs work. They advocate for ‘multimodal’ prescribing, but unless this is done very carefully I’m not 100% convinced, and the evidence for this approach is, as they say, scant). I’m one of these people who find nothing I’ve tried has reduced my pain at all. So the effectiveness of any medication depends a lot on you and how your body metabolises the medication. I wish you all the very best if you are one of those who gets a good response to medications – hoorah!

What should you do if you’re thinking about using medications as part of your pain self-management?

Be prepared to try a few out, because it is always a trial in YOU and YOUR experience with a medication that matters.

Give the medications a decent trial – two weeks at the recommended dose, noting all the effects of the drug on you, your pain, your ability to think straight, your sleep, and your ability to do the things you want and need to do in life. This might mean using a diary to record the dose, the time you took it, bedtime, wake time, and then any medication effects you notice.

Most important, make sure the medication has a positive effect on your ability to do things. If you have so much sleepiness with a drug that you can’t do things, it might reduce your pain, but does it do much for YOU?

ALWAYS WORK WITH YOUR PRESCRIBER! Prescribers are responsible for what they write down on the prescription, and for ensuring the benefits outweigh any harms. They should know how the drug is thought to work, and the effects, side effects, pharmacodynamics and interactions with other drugs and substances you are using. Prescribers need to recognise that in pain relief, YOUR experience is YOUR experience. There are good reasons why some medications don’t help some kinds of pains (the ‘analgesic ladder’ was developed for cancer pain, not for chronic pain. Many types of chronic pain don’t respond to opioids – fibromyalgia being one of them).

Ask questions about the medication you’re prescribed. Ask about how long it takes to kick in, how long it will hang around in your system, why you need to take it at a certain time, and what you can expect as side effects. Ask if you need to take it with food, or on an empty stomach. Ask if you should avoid things like grapefruit juice (it can interfere with processing some meds). Ask what the therapeutic dose is, and how to build to that dose. Also ask how to reduce the dose if you don’t like the effects. If your prescriber is too busy to answer these questions, ask your pharmacist-dispenser (they know SO much about drugs!).

In the end, only YOU can tell whether it’s worth it. And it is OK to stop taking a drug if it’s not doing anything for you – just do with with the support of your prescriber. Clinicians, if you’re not a prescriber, get familiar with the current prescribing practices, understand the drugs and their presumed effects, become aware of the side effects and be ready to listen to the person and recommend they see their prescriber or pharmacist-dispenser for a detailed conversation about timing and managing meds long-term.

Greaves, L., Poole, N., & Brabete, A. C. (2022). Sex, gender, and alcohol use: implications for women and low-risk drinking guidelines. International journal of environmental research and public health, 19(8), 4523.

Katz, N., Paillard, F. C., & Van Inwegen, R. (2015). A review of the use of the number needed to treat to evaluate the efficacy of analgesics. J Pain, 16(2), 116-123. https://doi.org/10.1016/j.jpain.2014.08.005

Lucas, C. J., Galettis, P., & Schneider, J. (2018). The pharmacokinetics and the pharmacodynamics of cannabinoids. British journal of clinical pharmacology, 84(11), 2477-2482.

Ryan Patel & Anthony H Dickenson(2022)Neuropharmacological basis for multimodal analgesia in chronic pain,Postgraduate Medicine,134:3,245-259,DOI: 10.1080/00325481.2021.1985351

Do clinicians know how to help people develop pain self management?

In recent posts I’ve been discussing pain self management and why it’s not only necessary, but inevitable for people living with pain. Today I turn my gaze to health professionals, and the skills needed to support developing self management – because it’s not the same as ‘telling’, or ‘educating’, or even ‘advising’.

Firstly, let’s check out what people with pain want in self management. Lim and colleagues (2019) conducted a systematic review examining studies identifying ‘health information needs’ of people with low back pain. I put that title in quotes because my initial response is “Is health information what people want?” or is this about what clinicians think people want? Anyhow from 41 studies (mostly qualitative) they found that people had a “…desire for a diagnosis, potentially contributing to expectations for and overuse of imaging. People with low back pain expressed a strong desire for clear, consistent and personalised information on prognosis, treatment options and self-management strategies, related to healthcare and occupational issues.” All well and good – until you poke a little more deeply and find that ‘Most participants wanted to learn specific exercises that they could perform to manage their LBP’ – and that was about all these authors extracted about self management from all these studies. The context of these studies were typically primary care or physiotherapy/musculoskeletal clinician settings, lending credibility to my thoughts that the contexts in which people expect treatment to ‘fix’ the problem may not be the most appropriate for developing self management skills.

Kongsted, Ris, Kjaer and Hartvigsen (2021) discuss ten points clinicians need to consider when supporting people to develop self management strategies, and place their approach within the model developed by Richard and Shea (2011). This model consists of three concentric circles of ‘self-care’ or healthy lifestyle behaviours, ‘self-management’ or managing the actual or potential impact of disease, ‘symptom management’ or actions to reduce symptoms, and healthcare advice, diagnosis and treatment. They embed their recommendations to clinicians within a cycle of planning, delivery and evaluation, with the core constructs being person-centredness, problem solving, and adjusting goals after evaluating the impact. Nice stuff. They include some helpful messaging about current clinical practice and how these can be turned into self management support – things like ensuring outcomes are ascribed to the person’s own actions rather than clinician’s hands or special exercises. Read the whole article as it’s very practical.

The critical elements in pain self management, in my ever so humble opinion, are that they need to fit into a person’s daily life and become second nature. There need to be many different ways to do the things a person needs (many strategies!), and the person needs to be able to select the appropriate strategy/ies to meet their own goals and priorities in that context. (For more on this, read about the Extended Evolutionary Meta-Model in an earlier post of mine – I argue we need to teach flexibility, resilience and meta-cognition as part of supported self management).

Now clinicians don’t, as a general rule, get a lot of training in how to be person-centred, to trust in the values and decisions people themselves make, to let go of the things they learned in school (and still learn in CPD). In short, learning how to coach or facilitate rather than tell. We graduate with a pretty clear professional identity, knowing that we’re recipients and disseminators of special knowledge not granted everyone and as a result, pretty keen to strut our stuff to anyone who hangs around long enough! The thing is, though, that our ‘special knowledge’ is typically full of assumptions and values that may not get questioned.

Kerns et al (2022) detail ‘psychologically’ guided core competencies for self management based on the IASP interprofessional curriculum for pain clinicians. Again I put ‘psychologically’ in quotes because while they can certainly be considered psychological, doing so can make these skills seem more complex than they need to be. They are, instead, a shift in attitude towards the person living with pain.

The four main areas are:

1. Pain is multidimensional and because of this, people and their experience of pain need to be respected with reassurance and empathy. Using active listening and motivational interviewing, clinicians are asked to promote the outcome of reducing pain interference rather than just pain intensity. Overall, clinicians are asked to support self-efficacy and optimism.

2. Pain assessment is more than biomedical and includes strengths, vulnerability, barriers and facilitators to engaging in things that matter (they call them goals, but I hate that term, and especially the SMART acronym!), while also evaluating what increases and reduces pain and pain interference.

3. Pain management is about person-centred self management where the person and the clinician develop a shared plan for achieving what matters (including subgoals, timelines), and use a decision-balance approach to evaluating the good/not-so-good in both short and long-term of any treatment/therapy options. General good health practices, disease management where that’s needed, and the use of medications should also be included.

4. The clinical and social context are incorporated so that relationships between the person and their clinical team are core. Issues like previous trauma, mental health problems, and other health problems are included – and care is coordinated and integrated (yeah, right). Looking at community resources, social determinants of health, racism and sexism and ableism and all the isms need to be looked at, along with family.

All really good stuff. Again, what’s missing to me is the process of developing flexibility and context sensitivity, along with embedding these practices in the routines, habits and life contexts of the person, not just now – but for the future.

What skills do clinicians need to do this well? The very skills that seem to be given lip-service. The ‘soft’ skills. The communication, negotiation, listening, guided discovery and most importantly, letting go of our own agenda kind of skills that our professional training doesn’t give sufficient weight to (see Horton et al., 2022 for a recent study looking at the work we do emotionally). It really doesn’t matter if you wear a tie (or not), swear (or not), speak ‘professionally’ (or not). What does matter is that you listen, and show that you’re listening. That you develop personal self-regulation skills to manage your own emotions. That you have someone to supervise you so you can off-load and be both challenged and guided by another clinician.

Horton, A., Holman, D., & Hebson, G. (2022). Occupational and Physical Therapists’ Use of Intrapersonal and Interpersonal Emotion Regulation Strategies During Patient Interactions: A Qualitative Study. Am J Occup Ther, 76(5). https://doi.org/10.5014/ajot.2022.048199

Kerns, R. D., Burgess, D. J., Coleman, B. C., Cook, C. E., Farrokhi, S., Fritz, J. M., Goertz, C., Heapy, A., Lisi, A. J., Rhon, D. I., & Vining, R. (2022). Self-Management of Chronic Pain: Psychologically Guided Core Competencies for Providers. Pain Med, 23(11), 1815-1819. https://doi.org/10.1093/pm/pnac083

Kongsted, A., Ris, I., Kjaer, P., & Hartvigsen, J. (2021). Self-management at the core of back pain care: 10 key points for clinicians. Braz J Phys Ther, 25(4), 396-406. https://doi.org/10.1016/j.bjpt.2021.05.002

Lim, Y. Z., Chou, L., Au, R. T., Seneviwickrama, K. M. D., Cicuttini, F. M., Briggs, A. M., Sullivan, K., Urquhart, D. M., & Wluka, A. E. (2019). People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review. Journal of Physiotherapy, 65(3), 124-135. https://doi.org/10.1016/j.jphys.2019.05.010

Richard AA, Shea K. Delineation of self-care and associated concepts. J Nurs Scholarsh. 2011;43(3):255264. https://doi.org/ 10.1111/j.1547-5069.2011.01404.x.

Shhhhh! The secret we don’t talk about…

For all my writing about ACT, there are some things that ACT doesn’t directly deal with: what do people use to help them do what matters in their life? OK we do discuss actions, values, perspective-taking, mindfulness, willingness and defusion, but we don’t talk about the specifics of what people living with pain might do to live well. The skills or ways of going about daily life, using things that help people with pain do things. *Scroll to the bottom to see my totally unscientific survey for people with pain*

So for a few weeks I’m exploring self-management: this is one of those poorly-defined terms that gets tossed around SO much, so I’m defining it for my purposes so you know what I’m talking about.

Self-management strategies are all those things I do everyday that allow me to have a full life in the presence of my widespread body pain. Self-management includes the usual self-care stuff everyone needs to do like eating healthily, cleaning my body, having adequate fun and rest, sleeping well. Self-management adds those things I need to do because of my long-lasting pain – things like scanning what my pain is up to today, choosing the intensity of my life demands to suit my pain and stress tolerance, pacing (yes, even I pace myself LOL), communicating to others about my need to get up and move around, ensuring I go for a walk and do my mindfulness daily… all of those things! Some authors add symptom management to these two groups of strategies (Kongsted et al., 2021), and embed both self-management and symptom management within an interactive model including healthcare professionals. The list below comes from Nicholas & Blyth (2016) and gives an indication of the things they believe are part of self-management.

If we take a long, honest look at our musculoskeletal pain therapies, we need to be pretty humble about our success, or lack of success. While there are literally thousands of studies looking at treatments for low back pain, it is the largest contributor to years lived with disability in the world – and has been for decades (https://vizhub.healthdata.org/gbd-compare/#). Exercise therapy for chronic low back pain, recently reviewed in a Cochrane study (Hayden et al., 2021) found that while exercise therapy did reduce pain and functional limitations, the impact on daily life function didn’t meet the pre-established clinically important difference, and while pain reduced, it didn’t meet clinically important thresholds.

I’m an equal opportunity critic, so I also took a look at psychological therapies (many of which are offered by other health professionals such as occupational therapists), and found that while there were many, many studies – yet again, the results were not terribly exciting in terms of reduced pain and disability (Williams et al., 2020). Same again for pharmacological treatments for low back pain in adults: “We found no high- or moderate-certainty evidence that any investigated pharmacological intervention provided a large or medium effect on pain intensity for acute or chronic LBP compared to placebo.” (Cashin et al., 2023).

These findings do not surprise me. Pain is a multifactorial experience essential for our survival. Chronic or persisting pain is even more complex than acute pain because the experience lingers, defies usual treatments, is enmeshed with our socio-cultural beliefs about health and people and motivation. No wonder people living with persistent pain feel demoralised and stigmatised when few clinicians want to actually discuss the hard facts that our treatments are not very effective. We’d rather have arguments about whether the ’cause of the pain has been diagnosed’ and ‘the pendulum swinging too far.’

At the heart of this dark, bitter secret is the fear that a clinician has missed something obvious or that the treatment should have worked but one of these pesky psychosocial factors has messed up our lovely statistics.

But more importantly, failing to acknowledge just how poorly treatments fare, leaves people living with persistent weird pain in the dark like mushrooms, being fed bullsh*t.

Self-management, therefore, is what people have to do whether they’re prepared for it or not.

What exactly are those self-management strategies we need to know about?

Well, that’s another problem. We do have some fairly commonly-named strategies: exercise (or movement practices); self-regulation (relaxation, mindfulness); activity management (pacing and planning); ‘DIMs and SIMs’ (danger in me, safety in me – things that elicit feelings of being OK and safe, and things that do the opposite). But we don’t have a clear-cut, well-researched range of approaches that people with pain can check off on some kind of list. We don’t know what helps and for whom, and where and when these approaches might be useful (for a good paper looking at these, see Nicholas & Blyth, 2016).

Even more importantly, we don’t have much research showing how clinicians can help people employ these strategies in their daily life. There is a little from occupational therapy (see Lagueux et al., 2020; Pyatak et al., 2022) but in very small studies and with limited outcome data.

The gap, as I see it, is in understanding the strategies used by people living with persistent pain – and how best clinicians can help people learn them and embed them into the person’s own daily life. I suspect the research method most suited to understanding this is intensive measurement longitudinal designs, because I think it’s not just about the ‘what’ strategies people use, but almost inevitably the ‘why’ and ‘where’ they’re used.

Just for fun, have a go at this totally unscientific survey. It’s entirely anonymous, there’s nothing in it for you except curiosity, no risks and I promise to only use a screenshot if I ever talk about this in a presentation.

Cashin, A. G., Wand, B. M., O’Connell, N. E., Lee, H., Rizzo, R. R., Bagg, M. K., O’Hagan, E., Maher, C. G., Furlan, A. D., van Tulder, M. W., & McAuley, J. H. (2023). Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews, 4(4), CD013815. https://doi.org/10.1002/14651858.CD013815.pub2

Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD009790. DOI: 10.1002/14651858.CD009790.pub2. Accessed 01 October 2023.

Kongsted, A., Ris, I., Kjaer, P., & Hartvigsen, J. (2021). Self-management at the core of back pain care: 10 key points for clinicians. Braz J Phys Ther, 25(4), 396-406. https://doi.org/10.1016/j.bjpt.2021.05.002

Lagueux, É., Levasseur, M., Tousignant-Laflamme, Y., Dépelteau, A., Pagé, R., Pinard, A.-M., Lévesque, M.-H., & Masse, J. (2020). French-Canadian Adaptation of Lifestyle Redesign® for Chronic Pain Management: A Pre-Experimental Pilot Study…2020 AOTA Annual Conference & Expo. American Journal of Occupational Therapy, 74(Sup1), 1-1. https://doi.org/10.5014/ajot.2020.74S1-PO2715

Nicholas, M. K., & Blyth, F. M. (2016). Are self-management strategies effective in chronic pain treatment? Pain Management, 6(1), 75-75–88. https://doi.org/https://doi.org/10.2217/pmt.15.57

Pyatak, E. A., Carandang, K., Rice Collins, C., & Carlson, M. (2022). Optimizing Occupations, Habits, and Routines for Health and Well-Being With Lifestyle Redesign(R): A Synthesis and Scoping Review. Am J Occup Ther, 76(5). https://doi.org/10.5014/ajot.2022.049269

Williams, A. C. C., Fisher, E., Hearn, L., & Eccleston, C. (2020). Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews, 8, CD007407. https://doi.org/10.1002/14651858.CD007407.pub4