SELF-MANAGEMENT CHRONIC PAIN PROGRAMS
Rae Marie Gleason
People living with fibromyalgia and other chronic pain illnesses face daily challenges of managing their symptoms, modifying roles and responsibilities, and coping with the negative emotional consequences of pain. One of the most difficult problems is the sense of losing control of one’s life.
Pain not only impacts the physical dimension it also impacts the person’s ability to make plans for the next day, take part in children’s activities or share in the social aspects of life. A goal of self-management interventions is to help people regain an element of control; in other words, to learn how to keep pain from dictating how a person lives their life. There are a variety of self-management interventions that teach strategies to meet these challenges and build participants’ self-efficacy for their use. Interventions can be delivered in individual, group and online formats for a variety of different pain conditions. Supporting evidence shows the benefit of self-management techniques in improving pain, mental health and health-related quality of life outcomes.
Acceptance of the chronic nature of a person’s pain is necessary before individuals are ready to self-manage. Clinicians play a critical role in supporting self-management through answering questions, providing advice, addressing barriers and facilitators, and encouraging their patient’s self-management efforts.
Chronic pain, like all chronic conditions such as diabetes, requires day-to-day management by the affected individual. Experts in self-management have delineated the key tasks involved in the self-management of a chronic condition to enhance quality of life. The tasks include:
- Managing medical treatments such as using medication appropriately and building partnerships with their healthcare providers (HCPs)
- Using cognitive and behavioral strategies to manage symptoms
- Modifying family, social and work roles, and responsibilities to maintain some normalcy in life
- Dealing with the emotional consequences of a chronic condition
Daily challenges will be different for each individual and may change over time including invaluable, transferable skills such as problem solving, decision-making, resource identification, and communication skills for partnering with HCPs.
The ability to evaluate one’s situation and resources, and then decide a course of action, is required for any self-management program to be successful. This ability is called self-efficacy in social cognitive theory and can be enhanced by:
- Practicing and mastering a task or skill
- Observing peers modeling the skill
- Receiving reinforcement feedback and support
- Working to improve one’s emotional state
Self-management interventions (SMIs) target at least one, and most often a combination, of the above four improvement strategies.
There are three SMI models most commonly cited for their positive outcomes for people with chronic conditions.
1. The Stanford Chronic Disease Self-Management program aims to provide individuals with a toolkit of knowledge and skills for managing pain and the physical, social and emotional consequences. It is typically provided in a community setting and facilitated by a healthcare professional and community volunteer with a chronic pain condition or, more recently, by two trained lay leaders.
2. The second type of SMI, Acceptance and Commitment Therapy, focuses on helping individuals change behaviors motivated by fear of pain to a desire to engage in valued activities despite pain.
3. Cognitive–Behavioral Therapy (CBT) principles have been used to develop or supplement a pre-existing SMI. CBT seeks to help individuals identify the relationships between their thoughts, emotions and behaviors while encouraging positive self-management behaviors. It is delivered in a clinical setting by a trained individual, typically a clinical psychologist or cognitive–behavioral therapist.
Following is a table of SMI interventions that helps explain the three different programs and their regimens.
|Overview of common self-management interventions.
||Typical mode and length
|Stanford Model(includes Chronic PainSelf-ManagementProgram, Arthritis
Self-Management Programand Chronic Angina
|Self-management principles/responsibilitiesGoalsetting and action plans
Pain management tools (e.g., use of medications and multiplecognitive strategies)
Physical activity and exerciseHealthy eating
Dealingwith difficultemotionsand depressionFatigue and sleep
Working with your healthcare provider
$1§ 6 weeks with 2 h of groupsessions per week (total:12h)
$1§ 6 weeks with 1–2 h online perweek tocover all 25 sessions(total:6–12h)
Workbook provided for group andonline sessions
|Acceptance andcommitment therapy
||Principlesof the pain–avoidance–suffering cycle
Identifying values/valued activities, and gradually increasingexposure tovalue-directed behavior (instead of pain-directedbehavior)
Cognitive defusion (identifying and observing negative thoughtswithout acting on them, and distancing oneself from them) Mindfulness
Accepting and being willing to engage with pain
Committing toaction and identifying obstacles to desired action Planning for future action and obstacles
$1§ 3–4 weeks of 6.5 h perday for5 days of each week
$1§ 8 weeks of 1.5 h sessions perweek
Workbook with telephonesupport ± one individual session:
$1§ 6 weeks of scheduled workbookexercises with one telephone callper week
||Cognitiverestructuring (e.g., identifyingand evaluatingcatastrophicthinking and constructing realistic alternatives)
Identifying and restructuring pain avoidancebeliefs and behaviorsBehavioral activation (e.g., pacing and activity scheduling)
Understandingbiopsychosocial influencesof paingoal setting
Lifestyle changes (e.g.,exercise)
Self-regulatory skills (e.g., progressive muscle relaxation andbreathing exercises)
Pain management skills (e.g., attention diversion and stress-copingskills)
Relapse prevention strategies
$1§ 5–12 weeks with 1.5–2 h sessionsper week
$1§ 6–25 weeks with twoto25 sessions
$1§ 4–8 weeks with one or moremodules per week
|†Reflects cognitive–behavioural therapy asit has been modified in the currentliteraturetoinclude elements ofself-managementand self-efficacy.
Table from Self-management interventions for chronic pain published in Pain Management - Future Medicine, July 2013.