Promoting Chronic Pain Self-Management Education

Self-management is the first rung of the ladder in pain care—followed by primary care, with specialty care and pain centers most appropriately used for the most complex problems (4, 7, 17). Individuals with chronic pain live the majority of their lives outside the health-care system at home with their families. It is in this context that they manage the consequences of their pain condition on their lives every day (2). According to Lorig et al. (8), successfully managing the daily problems arising from a condition like chronic pain is an educational process that requires mastering a set of key tasks including:

• Building partnerships with health-care providers
• Using active cognitive and behavioral strategies to maximize function and reduce pain and other symptoms
• Modifying family, social, and work responsibilities as needed to maintain important relationships and meaningful life roles
• Dealing with the emotional ups and downs of living with a chronic pain condition
• Maintaining and/or building a healthy lifestyle that features stress management, regular exercise, healthy eating, and sound sleep habits
• Using appropriate resources and managing decisions for interventions such as medication use, surgical procedures, and complementary therapies

As one pain patient put it: “I had to relearn how to live” (4).

The educational processes of successful self-management programs are typically grounded in social, cognitive, and behavioral theories, targeting improved confidence to achieve optimal functioning, acceptance of limitations, as well as more positive ways of thinking, feeling, and behaving (11). The application of self-efficacy theory, for example, has been well established. Beyond conveying educational content, the targeting of self-efficacy involves enhancing individuals’ capacity to organize and integrate cognitive, social, and behavioral skills in order to manage chronic conditions on a daily basis. 

To operationalize self-efficacy principles, self-management programs improve patients’ confidence to achieve optimal health by providing opportunities for

• Skills mastery—practicing self-management techniques in a supportive environment
• Modeling—learning positive health behaviors from facilitators and peers
• Reinterpretation of symptoms—examination of illness-related beliefs that may lead to maladaptive behaviors (e.g., sedentary behavior as a means to avoid continued pain)
• Social persuasion—support and encouragement from like-minded peers (11)

What are chronic pain self-management interventions? 

Without information, support, and education, mastering self-management tasks is often a lengthy and frustrating process of trial and error that can take considerable time. The purpose of chronic pain self-management education is to speed up trial-and-error learning by providing evidence-based information and, most importantly, a supportive environment that fosters the acquisition of such self-management skills as problem solving, decision making, using appropriate resources, and taking action for change (1, 9).  

While a wide variety of self-management programs exist, a review of chronic pain self-management intervention studies published since 2007 (10) found that most interventions can be classified under three broad categories: 

1. The Stanford model that aims to provide a tool kit of knowledge and skills for managing pain and its physical, social, and emotional consequences (7, 12, 16)
2. Acceptance and commitment therapy with a focus on changing behaviors that are motivated by fear of pain to those motivated by a willingness to reengage in valued activities despite pain (5, 19)
3. Cognitive-behavioral therapy using principles to help identify the relationships between thoughts, emotions, and behaviors and encourage positive self-management behaviors (3, 14, 18)

While the overwhelming majority of trials report that self-management interventions play a role in reducing the physical and psychosocial burden of chronic pain, there is also evidence of a lack of effect, which may be related to facilitator skill level, the heterogeneity of pain conditions in study samples, and other methodological issues (10, 13). A key feature of all successful self-management interventions is building people’s confidence or self-efficacy to manage pain and its impact on their lives (6, 10).  

Resources and Strategies 

The following actions are recommended to increase educators’ awareness and promotion of chronic pain self-management education. These actions include:

• Enhancing training of health professionals and persons with pain on chronic pain self-management principles and communication skills (2, 4, 10, 20)
• Providing information about chronic pain self-management programs 
• Ensuring access to programs to all who can benefit regardless of income or place of residence

This will necessitate new models of delivery such as using social media, better collaboration between community-based programs and services and primary health-care providers in order to enhance appropriate and timely referral, and stabilizing funding for both community-based and primary care self-management education (1, 4, 15). Regardless of approach, it is essential to:

• Tailor evidence-based educational materials and programs to be appropriate across ages, pain conditions and disabilities, cultures, and literacy levels (1, 4, 10)
• Continue to refine self-management interventions to target self-efficacy enhancing strategies
• Conduct more research in patient readiness for self-management interventions and the best combination of therapies (e.g., anti-depression medication, structured exercise, etc.) with self-management interventions (10). 

Resource Text

English: LeFort SM, Webster L, Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M. Living a healthy life with chronic pain. Boulder, CO:  Bull Publishing; 2015. http://www.bullpub.com/

Spanish: LeFort SM, Webster L, Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M. Vivir una vida sana con dolor cronico. Boulder, CO:  Bull Publishing; 2016.

REFERENCES

1. Aloha Kohut SA, Stinson JN, Ruskin D, Forgeron P, Harris L, van Wyk M, Luca S, Campbell F. iPeer2Peer program: a pilot feasibility study in adolescents with chronic pain. Pain 2016; 157: 1146-1155.
2. Blyth FM, March LM, Nicholas MK, Cousins MJ. Self-management of chronic pain: a population-based study. Pain 2005; 113: 285-292.
3. Guidelines for Pain Management Programmes for Adults. British Pain Society 2013. https://www.britishpainsociety.org/static/uploads/resources/files/pmp2013_main_FINAL_v6.pdf.

4. Institute of Medicine of the National Academies (IOM). Committee on Advancing Pain Research and Education. Relieving pain in America: a blueprint for transforming prevention, care, education and research. Washington, D.C.: National Academies Press; 2011.
5. Johnston M, Foster M, Shennan J, Starkey N, Johnson A.  The effectiveness of an acceptance and commitment therapy self-help intervention for chronic pain.  Clinical Journal of Pain 2010; 26: 393-402. 
6. Keefe FJ, Somers TJ, Maitre, LM.  Psychologic interventions and lifestyle modifications for arthritis pain management. Rheumatic Disease Clinics of North America 2008; 34(2): 351-368.
7. LeFort SM, Webster L, Lorig K, Holman H, Sobel D, Laurent D, Gonzalez V, Minor M. Living a healthy life with chronic pain. Boulder, CO:  Bull Publishing; 2015.
8. Lorig KR, Bodenheimer T, Holman H et al. Patient self-management of chronic disease in primary care. JAMA 2002; 288: 2469-2475.
9. Lorig KR, Holman HR. Self-management education: history, definition, outcomes and mechanisms. Ann Behav Med 2003; 26: 1-7.
10. Mann EG, LeFort SM, van Den Kerkhof EG. Self-management interventions for chronic pain. Pain Manage 2013; 3: 211-222.
11. McGillion M, LeFort S, Stinson J. Chronic Pain Self-Management. In: Rashiq S, Schopflocher D, Taenzer P (Eds). Chronic pain: a health policy perspective (pp. 167-176). Wiley-VCH Verlag. Weinheim Germany. 2008. 
12. McGillion M, Watt-Watson J, Stevens B, LeFort S, Coyte P, Graham A. Randomized controlled trial of a psychoeducation program for the self-management of chronic cardiac pain. JPSM 2008; 36:126-140.
13. Mehlsen M, Hegaard L, Ornbol E, Jensen JS, Fink P, Frostholm L. The effect of a lay-led, group-based self-management program for patients with chronic pain: a randomized controlled trial of the Danish version of the chronic Pain Self-Management Programme. Pain 2017;158: 1437-1445. 
14. Newton-John T, Geddes J. The non-specifc effects of group-based cognitive-behavioural treatment of chronic pain. Chronic Illness 2008;4:199-208.
15. Ory MG, Lee Smith M, Patton Kulinski K, Lorig K, Zenker W.  Self-management at the tipping point: reaching 100,000 Americans with evidence-based programs. Journal of the American Geriatric Society 2013; 61: 821-823.
16. Osborne RH, Wilson T, Lorig KR, McColl GJ. Does self-management lead to sustainable healh benefits in people with arthritis?  A 2-year transition study of 452 Australians. J Rheumatology 2007; 35: 1112-1117.
17. Smith BH, Elliott AM. Active self-management of chronic pain in the community 2005; 113: 249-250.

18.Thorn BE, Day MA, Burns J et al. Randomized controlled trial of group cognitive behavioural therapy compared with a pain education control for low-literacy rural people with chronic pain. Pain 2011;152: 2710-2720.

19. Volwes, KE, McCracken L, O’Brien JZ. M. Acceptance and value-based action in chronic pain: a three-year follow-up analysis of treatment effectiveness and process. Behav. Res. Ther 2011;49:748-755. 
20. Yank V, Laurent D, Plant K, Lorig K. Web-based self-management support training for health professionals. Patient Education and Counseling 2013; 90: 29-37.

RESOURCES

1. Bair MJ, Matthias MS, Nyland KA et al. Barriers and facilitators to chronic pain self-management: a qualitative study of primary care patients with comorbid musculoskeletal pain and depression. Pain Med 2009; 10: 1280-1290. 
2. Dear BF, Gandy M, Karin E, Ricciardi T, Fogliati VJ, McDonald S, Staples LG, Nicholson Perry K, Sharpe L, Nicholas MK, Titov N. The pain course: an RCT comparing a remote-delivered chronic pain management program when provided online and workbook formats. PAIN 2017;158(7):1289-1301.
3. Forman J.  A nation in pain.  Healing our biggest health problem. New York, N. Y.: Oxford University Press; 2014.
4. Hadjistavropoulos T, Hadjistavropoulos HD. (Eds.). Pain management for older adults. A self-help guide. Seattle, WA: IASP Press; 2008. (Note: new edition in press)
5. Institute of Medicine of the National Academies (IOM). Committee on Advancing Pain Research and Education. Relieving pain in America: a blueprint for transforming prevention, care, education and research. Washington, D.C.: National Academies Press; 2011. (Note: Especially Chapter 4).
6. Lorig KR, Holman HR. Self-management education: history, definition, outcomes and mechanisms. Ann Behav Med 2003; 26: 1-7. (Note: Provides a comprehensive overview of self-management).
7. Mann EG, LeFort SM, van Den Kerkhof EG. Self-management interventions for chronic pain. Pain Manage 2013; 3: 211-222. (Note: Provides a recent overview of studies on self-management published since 2007).
8. McGillion M, Watt-Watson J, Stevens B, LeFort S, Coyte P, Graham A. Randomized controlled trial of a psychoeducation program for the self-management of chronic cardiac pain. J PSM 2008; 36():126-140.
9. Palermo TM, Wilson AC, Peters M, Lewandowski A, Somhegyi H. Randomized controlled trial of an internet-delivered family cognitive-behavioural therapy intervention for children and adolescents with chronic pain. Pain 2009; 146 (1-2): 205-213. (Note: Highlights a new approach to addressing self-management in pediatric groups involving the family unit).
10. Thorn BE, Day MA, Burns J et al. Randomized controlled trial of group cognitive behavioural therapy compared with a pain education control for low-literacy rural people with chronic pain. Pain 2011; 152; 2710 2720. (Note: Describes how self-management interventions can be tailored to meet the needs of unique groups).

AUTHORS

Sandra LeFort, MN, PhD
Professor Emeritus, School of Nursing
Memorial University of Newfoundland
St. John’s, Newfoundland and Labrador, Canada

Michael McGillion, RN, PhD
Associate Professor and Assistant Dean, Research
Heart and Stroke Foundation/Michael G. DeGroote Endowed Chair in Cardiovascular Nursing Research
Scientist, Population Health Research Institute
International Visiting Professor of Cardiovascular Nursing
Faculty of Health and Life Sciences, Coventry University
School of Nursing, Faculty of Health Sciences
McMaster University
Hamilton, Ontario, Canada

REVIEWERS

Gill Furze, RN, PhD
Professor Emeritus
Faculty of Health and Life Sciences
Coventry University
Coventry, UK

Sigridur Zoëga, RN, PhD
Assistant Professor and Clinical Nurse Specialist
University of Iceland and Landspítali – University Hospital
Reykjavík, Iceland