Active Self MAnagement?

Paul McCambridgeCreator of self management online tool “the pain.clinic”N.e. director of large online health and fitness platformsDirector at “back to roots”Future reseearch wprk Working on research papers with kclup&running community mental health scheme

…..and plenty more….2

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Active self management is the new kale!!

BUt what the heck is it?

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All major guidelines

Lancet 2018Nice National low back pain pathwayAmerican college of physiciansAmerican pain society/british pain society

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“Pain self management has NOT been clearly defined in the pain literature and there is

confusion between many studies due to different definitions of this term

(Nicholas&Blyth 2016)

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For something so significant, was it a major part of our education?

Bps - very critical of self management and pain education across all health professions

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Supervisor Clinicians and interns

SUPERVISORS

“Almost all clinicians stated that they did not attend a specific course on SMS”“There is a lack of a comprehensive SMS course”“They needed to gain the skills required to use SMS, especially communications skills”

BIGGEST BARRIER - LACK OF TIME

INTERNS

“Most interns stated that they lacked to skills to use SMS efficiently and were not trained on SMS” “The interns referred to the need for training courses to gain skills required to use SMS”

BIGGEST BARRIER - LACK OF TIME

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Intern points Of Further Interest

“Interns believed that focussing on SMS and active care may result in losing patients”

“Intern also believed that using SMS would increase the duration of their treatments, thus seeing less patients”

“Regarding Internship program requirements, the interns stated that the use of SMS was NOT a program requirement

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Clinician points of further interest

Half were excited and half were anxious about utilising SMS, one clinician felt TERRIFIED of having self-management guidelines.

Clear desire for more education and understanding of the topic.

This matches current evidence amongst many healthcare professions (See Notes)

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No consistent support for specific self-management strategies across all individuals

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Effectiveness of self-management of low back pain:Systematic review with meta analysis

“There is moderate-quality evidence that self-management has small effects on pain and disability in people with LBP. Although effective when compared to minimal clinical intervention, we are unsure if self-management provides worthwhile effects in the management of LBP. This result challenges the endorsement of self-management in treatment guidelines” (Oliveira et al 2012) *note to paul study analysis*

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So what do we know?

- Consistent theme that the patient is expected to play an active role in their own management

- They identify their own treatment goals and work on achieving these goals

- Strongest evidence in pain self management comes from structured multi-disciplinary programs

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THE MISNOMER??

THERE IS GOOD EVIDENCE THAT WHILE A LARGE PROPORTION OF PEOPLE WITH CHRONIC PAIN ARE CAPABLE OF EMPLOYING THEIR OWN PAIN SELF HELP MANAGEMENT STRATEGIES, MANY REQUIRE AND WANT HELP IN ACQUIRING THESE SKILLS.

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IRONICALLY SELF MANAGEMENT IS A PARTNERSHIP

Dr Yu Fu “Patient-Professional partnership is the key to the success of self management”. (2018)

This partnership concept is supported in multiples papers, especially THE WORK Kate Lorig (2002), Julie Barlow (2009) and mARRIANNE Matthias (2010,2018)

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“Whats the Matter?”What Matters to You?

“For a partnership to be implemented and for health professionals to value patients as partners, patients’ expertise and experiences must be recognized as a complementary contribution to their treatment” (Pomey, Ghadiri, Karazivan, Fernandez, & Clavel, 2015)

What matters to you? As opposed to what’s the matter with you? (Barry & Edgman-Levitan, 2012)

Barry, M. J., & Edgman-Levitan, S. (2012). Shared decision making—The pinnacle of patient-centered care.The NewEngland Journal of Medicine,366, 780–781. doi:10.1056/NEJMp1109283

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Patient self management is healthy for US!

The authors (Matthias 2010) concluded that clinicians need support, both instrumental and emotional, around the care of individuals with chronic pain. In addition, they concluded that enhancing patient-centered communication and empathy, as well as focusing on shared decision-making, hold promise for alleviating the strain on clinicians.

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Step 1 - Build the relationship with effective communication

Research has found that feeling believed and having pain acknowledged by clinicians was very important to pain patients and promoted more listening, validation, and managing expectations can have a remarkable impact on helping patients effective coping behaviors.

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*Lewandowski W, Good M, Draucker CB. Changes in the meaning of pain with the use of guided imagery. Pain Manag Nurs. 2005;6(2):58-67. *McCracken L. Psychology and chronic pain. Anaesth Intensive Care. 2007;9(2):55-58.

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Communicating about Chronic Pain:Instructions for Clinicians

Communicating about Chronic Pain: Instructions for Clinicians1. Listening and Showing Empathy (Time and Personal Experience?)2. Admitting they do not have all the answers but explains how a patient can benefit from

referrals3. Giving patients an explanation of their diagnosis beyond the label of “chronic pain”,

explaining why imaging may or may not be needed.

Patient Perspectives on Communication with Primary Care Physicians about Chronic Low Back Pain (Sarah Evers et al 2017)

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A good partnership improves results

Working collaboratively with patients on goals can increase compliance and adherence to these goals!

Every partnership is tailored and unique - POS Story!

Coppack RJ, Kristensen J, Karageorghis CI. Use of a goal setting intervention to increase adherence to low back pain rehabilitation: a randomized controlled trial. Clin Rehabil. 2012;26(11):1032-1042.

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STEP 1 Build the relationship

Step 2 Empower the patient

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How to empower patients? (Discuss paper)

- Goal Setting- Action Planning- Knowledge (Only when combined with above)

How to empower patients : A systematic review and meta analysis (Werbrouck et al 2018)

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We can start this individualization before you even meet

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Make a plan!- A clear agreed upon treatment plan with concrete tasks to accomplish

between appointments will assist patients with pain in moving forward in adopting a self-management mindset. Homework and accountability.

- Setting functional goals can encourage movement toward improving quality of life despite the pain.

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Kent Stuber preliminary work- Lowest pacit scores were on goal setting and follow up coordination- This was also seen in the interview data

- “No, I’ve never actually actively done it (goal setting) with her (the chiropractor)”

Stuber, KJ et al (2018) A pilot study assessing patient-centred care in patients with chronic health conditions attending chiropractic practice. Complementary therapies in medicine

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Fear-Avoidance Behaviors (FAB) and Impact on Self-Management of PainInterestingly, it may not only be patients with pain who have fear-avoidance beliefs. A systematic review found that there is strong evidence that health care providers’ beliefs about back pain are associated with the beliefs of their patients. Further, they found moderate evidence that health practitioners with elevated fear avoidance beliefs are more likely to advise patients to limit work and physical activity, less likely to adhere to treatment guidelines, have more sick leave prescriptions. (Ben Darlow 2012) *Where knowledge is important!

Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. Eur J Pain. 2012;16(1):3-17.

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The challenge of self-efficacy

Provide Positive Feedback (Powerful if done by clinician!)Involve Significant Others (such as a spouse or family members to encourage self management behaviors outside of the clinician’s office)Discuss realistic and attainable goals (SMART)Discuss self-management of flare-ups in advance (Flare up Tool-Kit)Create/utilize multiple opportunities (How can you create these?)

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Calming the system down

Active vs Passive

Active coping strategies Active coping strategies are associated with better outcomes and might include regular exercise, maintaining daily activities, ignoring pain sensations (when appropriate), developing adaptive thinking (i.e., decreasing catastrophizing, fear-avoidance beliefs and increasing pain self-efficacy beliefs), or practicing relaxation exercises and guided imagery. Passive coping strategies are associated with poorer outcomes. (seeking someone else who can do something to make the pain go away and fix me “external locus”) and avoiding activity.

Wertli, MM. et al. (2014) The role of fear avoidance beliefs as a prognostic factor for outcome in patients with non specific low back pain: a systematic review.

https://www.ncbi.nlm.nih.gov/pubmed/24412032

Ramond-Roquin, A. et al. (2015) Psychological risk factors, interventions, and comorbidity in patients with non-specific low back pain in primary care: Need for

comprehensive and patient-centrered care.

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BUT……….. THE PARTNERSHIP CAN BE ONGOING!This patient-centered model focused on goal setting, seeking solutions for patients, offering flexible follow-up sessions, adopting an individualized approach, and continuous care. (WU 2018) (Also mention recent Nordic)

Maintaining long-term contact…….Patients expressed their concerns over maintaining long-term contact with health professionals after having been discharged. Regardless of treatment outcomes, future access to some forms, for example, telephone or email, of long-term relationship with health professionals in pain clinics was preferred as a resource to seek more information and reassurance

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Final Step

STEP 1 Build the relationship

Step 2 Empower the patient

Step 3 Play around (Meaningful, Fun, Patient driven creativity, changes, Individual & Social)

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Exercise - The health Unicorn

Exercise should be at the core of Self-Management (May 2016)

What is the External Validity of exercise (Ben Cormack)

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Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Jack et al. Man Ther. 2010

Medina et al. 2009. Predictive factors to adherence for home exercise program for neck and low back pain. BMC

WHO (2018) - Physical Inactivity is Pandemic and telling people to exercise more simply doesn’t work, we need new creative strategies.

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So how can we help?Participants had more bonding to the exercise program when: • Provider gave more knowledge about the problem • Promoted feedback and motivation • Reminders to exercise • Monitored their results and adherence

THEY ENJOYED IT (Angel 2018)!! (joy and passion)

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Natural History& Tissue Healing

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SensitiveNervousSystem

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Active VersusChronic Stress

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Graded ExposureTo MeaningfulTasks

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EnvelopeOf function

EXERCISE PRESCRIPTION SUCCESS RELIES UPON•Chiropractor provides education on hurt versus harm

•Chiropractor provides a reasonable & credible pain explanation

•Chiropractor and/or patient understands multidimensional nature of pain and benefits of exercise

•Chiropractor confronts maladaptive passive care expectations and gradually transitions to active care

•Manual therapy provided short term while maintaining priority of active care long term

•Trust and rapport developed

•Chiropractor helps patient set meaningful exercises based goals

•Chiropractor provides a clear explanation and purpose behind exercises

•Having exercise timeline where Chiropractor and patient look for progress.

Stilwell & Harman (2018) a focused ethnographic study exploring chiropractors’ and chiropractic patients experiences and beliefs regarding exercise adherence

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It’s not like encouraging exercise is new for us!

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It’s not like encouraging exercise is new for us

“Founded for the restoration of health to those for whom medical treatment of ordinary chiropractic adjustment and care have proved insufficient”

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PATIENT-CENTERED CARE ISN’T NEW EITHER!THE CHIROPRACTIC PROFESSION HISTORICALLY HAS CONSIDERED ITSELF TO HAVE A HOLISTIC APPROACH TO PATIENT CARE INCLUSIVE OF PHYSICAL, PSYCHO-SOCIAL, CULTURAL, SPIRITUAL AND ENVIRONMENTAL FACTORS) (jAMESON 2001,rOSNER 2016,FREEMAN 2005)

AND PRELIMINARY STUDIES SUGGEST WE ARE DOING AS WELL AS OTHERS (STUBER ET AL 2018) PATIENT ASSESSMENT OF CHRONIC ILLNESS CARE (PACIC)

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As jorge explained… make it sexy/Playful

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PATIENT EMPOWERMENT&EDUCATION (RPE-RPT)

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Patient Homework Example1) Write down any questions about today's session. Again, I don't have any specific questions, but have been reflecting on this. Just thinking about how I ensure that I still push myself that little extra bit, but make sure I'm keeping the peaks and troughs small, keeping it to small increments. It looks clear on paper, but it's all about putting it into practice.2) Thinks of 5 ways you can help calm your extra sensitive alarm system:

. Learn more about how pain works. Regular exercise - walking the dogs every morning

. Change the process - working with you and Nick on that

. Relaxation, meditation - getting back to 20 minutes mindfulness every day

. Good sleep - reading a little before I sleep and doing some breathing practice as well as alternating palm rotation stretch

. Plenty of warm ups before starting any exercises in the gym3) Fear of pain - have you noticed any tasks/exercises that you are afraid to do? Upper body training and lifting anything heavy has clearly been the concern. Now I understand more about Pain and the Brain, the fear is definitely diminishing and I am beginning to understand what to do to better manage.4) Pacing/graded exposure - write down task, think of small piece, increase the task. Now doing this with training, especially around press activity that involves shoulders. Thanks to you and Nick, I can see how changing the process and coming at it differently I can still do the workout and build up again gradually. Also applying this to other things - like gardening this week. Instead of picking up a heavy pot or compost bag myself, I ask my husband to help me carry it. So I'm not stopping lifting anything, just making sure I'm not over-doing it at present.

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ReferencesNicholas M, Blyth F. Are self-management strategies effective in chronic pain treatment? Pain Management 206;6(11):75-88

May S. Self-management of chronic low back pain and osteoarthritis. Nat Rev Rheumatol. 2010;6(4):199–209

Briggs AM, et al. Consumers’ experiences of back pain in rural Western Australia: access to information and services, and self-management

behaviours. BMC Health Serv Res. 2012;12:357

Eilayyan O, et al. Developing Theory-Informed Knowledge Translation Strategies to facilitate the Delivery of Low Back Pain Self-management support

in Clinical Practice. Quebec: McGill University; 2017.Google Scholar

Gordon K, et al. Barriers to self-management of chronic pain in primary care: a qualitative focus group study. Br J Gen Pract. 2017;67(656):e209–17.

Matthias MS, Parpart AL, Nyland KA, et al. The patient-provider relationship in chronic pain care: Providers' perspectives. Pain Med. 2010;11(11):1688-1697.

Coppack RJ, Kristensen J, Karageorghis CI. Use of a goal setting intervention to increase adherence to low back pain rehabilitation: a randomized controlled trial. Clin Rehabil. 2012;26(11):1032-1042.

Bodenheimer, T., Lorig, K., Holman, H., & Grumbach, K.(2002). Patient self-management of chronic disease in primary care.Journal of the American Medical Association,288, 2469–2475

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ReferencesBarry, M. J., & Edgman-Levitan, S. (2012). Shared decision making—The pinnacle of patient-centered care. The New England Journal of Medicine,366, 780–781. doi:10.1056/NEJMp1109283

Fu, Y et al. (2018) The Management of Chronic Back Pain in Primary Care Settings: Exploring Perceived Facilitators and Barriers to the Development of Patient–Professional Partnerships. Qualitative Health Research 28(27):104973231876822

Fu, Y et al. (2018) The association between patient-professional partnerships and self-management of chronic back pain: A mixed methods study. European Journal of Pain (United Kingdom), 22 (7), pp1229-1244.

Lewandowski W, Good M, Draucker CB. Changes in the meaning of pain with the use of guided imagery. Pain Manag Nurs. 2005;6(2):58-67.

McCracken L. Psychology and chronic pain. Anaesth Intensive Care. 2007;9(2):55-58.

Evers, S et al. Patient Perspectives on Communication with Primary Care Physicians about Chronic Low Back Pain

Coppack RJ, Kristensen J, Karageorghis CI. Use of a goal setting intervention to increase adherence to low back pain rehabilitation: a randomized controlled trial. Clin Rehabil. 2012;26(11):1032-1042.

Werbrouck, A et al. (2018) How to empower patients : A systematic review and meta analysis Transl Behav Med. 2018 Sep 8;8(5):660-674

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References Darlow B, Fullen BM, Dean S, Hurley DA, Baxter GD, Dowell A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: a systematic review. Eur J Pain. 2012;16(1):3-17

Rockwood K, Stadnyk K, Carver D, et al. A clinimetric evaluation of specialized geriatric care for rural dwelling, frail older people. J Am Geriatr Soc. 2000;48(9):1080-1085.

Schulman-Green DJ, Naik AD, Bradley EH, McCorkle R, Bogardus ST. Goal setting as a shared decision making strategy among clinicians and their older patients. Patient Educ Couns. 2006;63(1-2):145-151

Jensen MP, Karoly P. Control beliefs, coping efforts, and adjustment to chronic pain. J Consult Clin Psychol. 1991;59(3):431-438

Bond MR. Psychological issues in cancer and non-cancer conditions. Acta Anaesthesiol Scand. 2001;45(9):1095-1099.

Novy DM, Nelson DV, Hetzel RD, Squitieri P, Kennington M. Coping with chronic pain: Sources of intrinsic and contextual variability. J Behav Med. 1998;21(1):19-34.

Turner JA, Aaron LA. Pain-related catastrophizing: What is it? Clin J Pain. 2001;17(1):65-71.

Nicholas MK, Wilson PH, Goyen J. Comparison of cognitive-behavioral group treatment and an alternative non-psychological treatment for chronic low back pain. Pain. 1992;48(3):339-347

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References

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Jack, K et al. (2010) Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review. Man Ther.

Medina, F et al. (2009) Predictive factors to adherence for home exercise program for neck and low back pain. BMC Musculoskeletal Disorders Dec 9:10:155

Oliveira, V et al. (2012) Effectiveness of Self Management with Low Back Pain. Systematic Review with Meta Analysis. Arthritis Care Research Nov;64(11):1739-48

Medina, F et al (2009) Personal characteristics influencing patients' adherence to home exercise during chronic pain: a qualitative study. Journal of rehab medicine. Apr;41(5):347-52

Stilwell, P et al. (2017) a focused ethnographic study exploring chiropractors’ and chiropractic patients experiences and beliefs regarding exercise

adherence. Journal of the Canadian Chiropractic Association. Dec; 61(3): 219-230

Stults-Kolehmainen M, et al. (2014) Chronic psychological stress impairs recovery of muscular function and somatic sensations over a 96-hour period.

Journal of Strength and Conditioning Jul;28(7): 2007-17

Angel, S. (2018) Movement perceived as chores or a source of joy: a phenomenological-hermeneutic study of physical activity and health. International

study of qualitative studies on health and wellbeing. Volume 13, 2018 Issue 1

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ReferencesStuber, KJ et al (2018) A pilot study assessing patient-centred care in patients with chronic health conditions attending chiropractic practice. Complementary therapies in medicine

Jamison JR. Reflections on chiropractic’s patient-centered care. J Manipulative Physiol Ther. 2001;24:483–486. 26.

Rosner AL. (2016) Chiropractic identity: a neurological, professional, and political assessment. J Chiropr Humanit. 23:35–45. 27. Freeman J. Towards a

definition of holism. Br J Gen Pract. 2005;15:154–155. 28.

Cote P, Clarke J, Deguire S, et al. (2001) Chiropractors and return-to-work: the experiences of three Canadian focus groups. J Manipulative Physiol Ther.

;24:309–316.

Wertli, MM. et al. (2014) The role of fear avoidance beliefs as a prognostic factor for outcome in patients with non specifici low back pain: a systematic review.

Ramond-Roquin, A. et al. (2015) Psychological risk factors, interventions, and comorbidity in patients with non-specific low back pain in primary care: Need for

comprehensive and patient-centrered care.

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Thanks!paul@backtoroots.communitywww.backtoroots.community

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Twitter - https://twitter.com/B2Rcommunity

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