Barriers and Facilitators to Supporting Patient Self-Management

Welcome back to SpineIQ’s Back Blog! Last week, we discussed practical tips that clinicians can incorporate into their practice to help encourage self-management. This week we will discuss barriers and facilitators to supporting patient self-management to give our patients the best chance at success!¹

Facilitators to self-management:  The positives that will make a difference

One of the important aspects of self-management from a psychological perspective is helping patients differentiate between the pain they are experiencing and the core of who they are.^2,9 Clinicians can encourage this behavior by changing the conversation from “struggling with pain” to “coping with pain.”¹⁰ Terminology and “Self-Talk” are critically important factors in coping.  Patients report that education which facilitates their understanding of the multifactorial nature of pain can change their beliefs from a purely biomedical idea of pain to a better understanding that they are not their condition.¹¹ Trying different education and interventions that result in a positive experience (e.g., Cognitive Behavioral Therapy) helps patients feel encouraged to self-reflect and change their view of how pain impacts their life.¹²

Additionally, feeling empowered to regain control of their life is a powerful facilitator for self-management.¹³ Clinicians can encourage patient empowerment through active listening and providing a safe space for patients to feel heard and validated. Including friends and family who are able to believe, understand, and encourage the patient outside of your clinic is also important.¹⁴

Finally, building a strong partnership with the patient helps them feel more comfortable about opening up about what therapeutic goals are most critical. This partnership is commonly referred to as therapeutic alliance and it is a crucial facilitator to being able to foster trust, encouragement, and maintenance of self-management in patients. ¹⁵ Telling the patient what to do will provide them with the “HOW”, helping them better understand their condition will provide the “WHY”.

Barriers to self-management: The Negative realistic challenges.

The amount of time and effort that some self-management interventions take is seen as a barrier for self-managing.^2,3 This barrier is increased if patients are looking for a “quick fix” rather than trying to understand complex multifactorial, biopsychosocial beliefs about their pain.⁴ Patients that have symptoms of depression and anxiety may find the amount of time and effort required to be a bigger barrier compared to those without mental health symptom,⁵ providing another reason why it is imperative to screen for these common co-morbidities.

Patients report that when clinicians offer poor explanations, conflicting explanations,  or fail to listen it creates barriers to self-management.^6,7 These barriers are compounded when patients do not feel that clinicians understand their specific context and give general advice without thought of collaborating with the patient, their context, and environment.⁸

Summary:

It is important that clinicians are aware that building a good therapeutic alliance by listening, understanding, believing, and including the patient in decisions is crucial to overcome common barriers to self-management. Patients also report that the time and effort needed to engage in self-management activities as a barrier. Clinicians can help overcome these barriers by listening carefully to the patient at the onset of their care and asking them how much time they can commit to such efforts. Different strategies (e.g., exercise and self-reflection) can be achieved within a small amount of time or broken up during the day to fit into busy schedules. Finally, it is important that clinicians are aware of their patient’s context and environment and include friends/family if the patient feels this would be helpful. The most important thing for clinicians to keep in mind is that patients want to be heard, encouraged, and considered partners in their care.

Stay tuned for next month’s BackBlog series, where we plan to discuss key studies that all spine care professionals need to know!

References:

1. Devan H, Hale L, Hempel D, Saipe B, Perry MA. What Works and Does Not Work in a Self-Management Intervention for People With Chronic Pain? Qualitative Systematic Review and Meta-Synthesis. Phys Ther. 2018;98(5):381-397. doi:10.1093/ptj/pzy029
2. Andersen LN, Kohberg M, Herborg LG, Søgaard K, Roessler KK. “Here we’re all in the same boat”–a qualitative study of group based rehabilitation for sick-listed citizens with chronic pain. Scand J Psychol. 2014;55(4):333-342. doi:10.1111/sjop.12121
3. Andrews NE, Strong J, Meredith PJ, Gordon K, Bagraith KS. “It’s very hard to change yourself”: an exploration of overactivity in people with chronic pain using interpretative phenomenological analysis. Pain. 2015;156(7):1215-1231. doi:10.1097/j.pain.0000000000000161
4. Oosterhof B, Dekker JHM, Sloots M, Bartels E a. C, Dekker J. Success or failure of chronic pain rehabilitation: the importance of good interaction – a qualitative study under patients and professionals. Disabil Rehabil. 2014;36(22):1903-1910. doi:10.3109/09638288.2014.881566
5. 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 Malden Mass. 2009;10(7):1280-1290. doi:10.1111/j.1526-4637.2009.00707.x
6. Bunzli S, McEvoy S, Dankaerts W, O’Sullivan P, O’Sullivan K. Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain. Phys Ther. 2016;96(9):1397-1407. doi:10.2522/ptj.20140570
7. Buijs PC, Lambeek LC, Koppenrade V, Hooftman WE, Anema JR. Can workers with chronic back pain shift from pain elimination to function restore at work? Qualitative evaluation of an innovative work related multidisciplinary programme. J Back Musculoskelet Rehabil. 2009;22(2):65-73. doi:10.3233/BMR-2009-0215
8. Caiata Zufferey M, Schulz PJ. Self-management of chronic low back pain: an exploration of the impact of a patient-centered website. Patient Educ Couns. 2009;77(1):27-32. doi:10.1016/j.pec.2009.01.016
9. Barlow J, Turner A, Swaby L, Gilchrist M, Wright C, Doherty M. An 8-yr follow-up of arthritis self-management programme participants. Rheumatol Oxf Engl. 2009;48(2):128-133. doi:10.1093/rheumatology/ken429
10. Toye F, Barker K. ’I can’t see any reason for stopping doing anything, but I might have to do it differently’–restoring hope to patients with persistent non-specific low back pain–a qualitative study. Disabil Rehabil. 2012;34(11):894-903. doi:10.3109/09638288.2011.626483
11. Hainsworth J, Barlow J. Volunteers’ experiences of becoming arthritis self-management lay leaders: “It’s almost as if I’ve stopped aging and started to get younger!” Arthritis Rheum. 2001;45(4):378-383. doi:10.1002/1529-0131(200108)45:4<378::AID-ART351>3.0.CO;2-T
12. Hållstam A, Stålnacke BM, Svensen C, Löfgren M. “Change is possible”: Patients’ experience of a multimodal chronic pain rehabilitation programme. J Rehabil Med. 2015;47(3):242-248. doi:10.2340/16501977-1926
13. Morgan M, Cousins S, Middleton L, Warriner-Gallyer G, Ridsdale L. Patients’ experiences of a behavioural intervention for migraine headache: a qualitative study. J Headache Pain. 2015;17:16. doi:10.1186/s10194-016-0601-5
14. Goldthorpe J, Peters S, Lovell K, McGowan L, Aggarwal V. “I just wanted someone to tell me it wasn’t all in my mind and do something for me”: Qualitative exploration of acceptability of a CBT based intervention to manage chronic orofacial pain. Br Dent J. 2016;220(9):459-463. doi:10.1038/sj.bdj.2016.332
15. Howarth M, Warne T, Haigh C. Pain from the inside: understanding the theoretical underpinning of person-centered care delivered by pain teams. Pain Manag Nurs Off J Am Soc Pain Manag Nurses. 2014;15(1):340-348. doi:10.1016/j.pmn.2012.12.008