Self-Management Interventions for Chronic Pain

Abstract

SUMMARYIndividuals living with chronic pain face daily challenges of managing symptoms, modifying roles and responsibilities, and coping with the negative emotional consequences of pain. Self-management interventions teach a variety of strategies to meet these challenges and build participants‘ self-efficacy for their use. These interventions have been delivered in individual, group and online formats for a variety of different pain conditions. The evidence supports the efficacy of self-management interventions in improving pain, mental health and health-related quality of life outcomes. Acceptance of the chronic nature of their pain is a necessary step before individuals are ready to self-manage. Clinicians can play a critical role in supporting self-management through answering questions, providing advice, addressing barriers and facilitators, and encouraging self-management efforts.

Practice Points

▪	Self-management interventions (SMIs) teach the skills required for day-to-day management of chronic pain conditions and may be based on the Stanford model, acceptance and commitment therapy, or cognitive–behavioral therapy.
▪	SMIs target self-efficacy and include peer role modeling, practicing skills, feedback and support, and/or addressing emotions.
▪	SMIs delivered in group sessions include the benefit(s) of the group dynamic while being cost effective, and online interventions can be used to reach immobile or rural groups.
▪	SMIs are effective in reducing pain and improving mental health and health-related quality of life in chronic pain groups.
▪	SMIs combined with antidepressant pharmacotherapy are more effective in reducing depression than either modality alone.
▪	Individuals must accept the chronic nature of their pain before they are ready to listen to self-management teaching.
▪	Self-management teaching needs to be tailored to individual functional abilities, include regular support and encouragement, and be consistent between clinicians.
▪	Individuals encounter both barriers to, and facilitators of, self-management that need to be first assessed and then addressed by either healthcare providers or SMIs to help individuals succeed.
▪	The Pain Stages of Change Questionnaire can be a useful tool to help identify who is ready to self-manage their pain.

Chronic pain presents a worldwide challenge due to its high prevalence and cost. Recent international prevalence studies suggest that 11–45% of community-dwelling individuals report chronic pain often experienced at multiple body sites [1–8]. Chronic pain is associated with psychosocial distress and physical disability [9], and multiple interventions are often needed to achieve significant pain relief [10]. When compared with other devastating conditions such as cancer, chronic pain results in significantly worse health-related quality of life and healthcare costs [11,12].

Chronic pain, like all chronic conditions, requires day-to-day management by the affected individual. Lorig and Holman, leaders in the field for the past three decades, have delineated the key tasks involved in the self-management of a chronic condition to enhance quality of life. These tasks include managing medical interventions 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; and dealing with the emotional consequences of a chronic condition. Daily challenges will be different for each individual and may change over time, thus transferable skills such as problem solving, decision-making, resource identification and communication skills for partnering with HCPs are invaluable [13].

Self-management also requires the ability to appraise one‘s situation and resources, and decide on a course of action [13]. 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; and working on improving one‘s emotional state [14]. Since self-management interventions (SMIs) target self-efficacy at least one, and most often a combination, of the above four efficacy-enhancing strategies are included.

This article reviews the evidence for SMIs in chronic pain groups. SMI studies were included if: published in 2007 or more recently; participants reported pain for a minimum of 3 months; details of the intervention were included; and the interventions met Lorig and Holman‘s definition of self-management. An intervention was considered to meet Lorig and Holman‘s definition if it: taught a pain management skill; targeted self-efficacy through one of the previously mentioned strategies; and involved participants in pain management goals [13]. All studies addressing the clinician‘s role were also included. As the focus of SMIs is equipping individuals with self-efficacy and not on teaching specific exercises, a discussion of exercise approaches is a separate topic for review.

Overview of SMIs

▪ Intervention types

A wide variety of SMI programs are described in recent studies. Although some authors specify no basis for their intervention protocols, three models are frequently cited as being used or adapted to develop interventions (Table 1). First, the Stanford model of patient self-management aims to provide individuals with a toolkit of knowledge and skills for managing pain and the physical, social and emotional consequences. It is typically delivered 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 [201]. The second type of SMI, acceptance and commitment therapy, aims to help individuals change behaviors that are motivated by fear of pain to those motivated by a desire to engage in valued activities despite pain [15]. This SMI is generally delivered in a clinical setting by a clinical psychologist or an interdisciplinary team consisting of psychologists, nurses and occupational and physical therapists. Third, cognitive–behavioral therapy principles have been used to develop or supplement a pre-existing SMI. Cognitive–behavioral therapy seeks to help individuals identify the relationships between their thoughts, emotions and behaviors and encourage positive self-management behaviors [202]. It is delivered in a clinical setting by a trained individual, typically a clinical psychologist or cognitive–behavioral therapist [202]. The details of each SMI may or may not be tailored to meet specific needs of different chronic pain groups. For example, both unmodified [16,17] and modified [18–20] acceptance and commitment therapy interventions have been tested and found to be effective in pain groups reporting high levels of pain distress, disability and/or interference.

▪ Format

SMIs are delivered using various formats, settings and facilitators to reach a target pain population (Box 1). Group sessions are the most common format, and are frequently cited as a strategic decision whereby the group dynamic is used to encourage problem solving [17,21–32] and role modeling [25,33]. Hurley et al. tested a SMI in individuals with chronic knee pain that included both educational topics similar to the Stanford model and an exercise component. Using a randomized cluster design, 418 participants were assigned to usual care, or SMIs were delivered in individual or group sessions. When all groups were compared 6 months after completing the intervention, participants receiving the SMI sessions in either format reported significantly improved physical function, health-related quality of life, pain, anxiety and self-efficacy [23]. Group sessions were less expensive to deliver [34], and there may be added benefits from group processes (e.g., social interaction), validation from other group members and the structure and routine of group meetings [35].

▪ Setting

Hospital and clinic locations are the most common settings for SMIs. Less formal setting options include community locations such as seniors centers, which may improve accessibility [27,36]. Rarely, SMIs have been delivered by a facilitator in an individual‘s home when limited mobility presents a significant challenge [37,38]. Telephone- and internet-based interventions have been developed and tested more recently, and allow participants to select their own setting and timing (Box 1)[16,36,39–51].

▪ Facilitator

SMIs are delivered by multidisciplinary HCPs or by trained lay leaders in the case of standardized interventions. Most SMIs are delivered by at least two facilitators, whose roles may differ depending on their area of expertise. In group and individual sessions, facilitator roles may include educating (e.g., differences between acute and chronic pain) [52], instructing in skills (e.g., correct low back posture) [53], leading brainstorming and problem-solving discussions to help individuals reach their goals [22] and role-playing scenarios (e.g., communicating with family/primary care physician) [54]. In SMIs delivered online or via telephone, facilitator roles include designing online content [55], providing feedback on discussion or journal posts [44], problem solving with an individual [39] and reviewing previously taught skills (Box 1)[56].

▪ Participants

SMIs have been tested in individuals across the lifespan living with varying conditions and levels of pain and disability. SMIs are most often delivered to adults aged 18 years or older who are able to attend sessions in community or clinical settings; however, SMIs are also commonly designed for, and offered to, groups of adults aged 50 years and older. Chronic pain of all types, back pain and arthritis are the most commonly studied conditions (Box 1). Since pain occurs in a social context, partners and/or parents are often invited to attend at least one session or participate in a specially designed partner/parent intervention [25,56–59]. Participants were recruited from pain clinics [26,33,43,52,60–62], rehabilitation facilities [19–20,57,63], primary care [17,22,23,31,34,39,46,64–70] and community centers [21,27,28,35,53,71] representing various levels of health status and access to healthcare services.

Evidence for SMIs

▪ Feasibility

SMI feasibility studies have focused on acceptability and utility of new delivery modes, and measures of cost–effectiveness have been included in other SMI studies. Costs and healthcare use were included in one pragmatic randomized controlled trial [24] and one cohort study [33] with those participating in the intervention having lower pain management costs (e.g., fewer follow-up appointments). Recipients of SMIs report decreased use of analgesics [64,65,72], hospitalizations [73], visits to emergency rooms and other medical/health consultations [28,72,74,75], and overall self-reported healthcare use [19,20,76] compared with pre-SMI use or usual care group.

The acceptability of group and individual self-management sessions has been largely established in prior research. Current studies have focused on whether individuals perceive SMIs delivered in an online format to be useful, acceptable and satisfactory. Moderate-to-high ratings of acceptability, usefulness and satisfaction with online formats have been reported in teenagers aged 11–17 years [48,55] and adults aged 55 years or older [36]. There were only two studies where the online delivery of a SMI was either not well accepted in a small group of adults, or felt to be too labor intensive when a lot of time using a handheld device was needed to complete online journals and questions [44,51]. Generally, researchers reported lower adherence to programs with significant required time (e.g., attendance of both affected individuals and partners [58]) and minimal contact with peers and/or HCPs (Box 1)[16].

▪ Pain, health-related quality of life & mental health

Pain is the most commonly measured outcome of SMIs, and is generally measured as pain intensity, pain disability and/or pain interference. In reviewed studies that included one of these pain outcomes, statistically significant immediate (e.g., measured at the end of intervention) [18,22,33,42,47,53,56,57,59–61,72,77–86] and sustained improvements (e.g., typically measured 3–12 months after the intervention ends) were reported [18,20,22,23,28,29,39,45,48,52,55,56,59,60,62,65,71,72,74,77,81,83,85–89]. Effect sizes for reduced pain intensity and interference fall between d = 0.27 and d = 0.50 [48,55,59,74], with pain intensity ratings decreasing by 1–3 points/mm on an 11-point visual analog or numeric rating scale [39,48,87,90]. Improvements in pain were noted immediately following the intervention and in the following months and years. An improvement immediately following the intervention did not predict whether improvement would be reported in the following months and years (e.g., groups with no immediate pain improvement reported improved pain at later follow-up), which suggests multiple processes underlying these improvements.

Measures of mental health are the second most common outcome of SMI research, including catastrophizing, depression and anxiety. Participants of SMIs consistently report less catastrophizing [31,41,42,47,49,51,61,64,65,76,81,82,89–91] and anxiety [16–18,23,43,49,53,57,59,62,65,82,83,92–94] than preintervention or usual care group levels immediately following the intervention. This improvement was generally sustained in the following months to years; however, unlike pain there were no delayed gains in either catastrophizing or anxiety. This supports the work of Curran and colleagues who identified post-treatment improvement as the best indicator of long-term improvements in mood, self-efficacy and catastrophizing [95].

The evidence for SMIs decreasing depression is mixed with both significant [17–20,42,43,48,52,53,57–59,62,64–66,72–76,80,91,92,94,96] and null results reported [16,21,23,24,31,38,49,57,60,61,64,65,83,84,89,95,97]. Individuals with depression are potentially less likely to be ready to self-manage their pain, and have higher levels of pretreatment pain intensity and disability [81,95]. Despite these challenges, having comorbid depression does not mean that an individual will not experience positive outcomes from a SMI. Glombiewski et al. screened participants for depression prior to their starting of a SMI. Having pretreatment depression did not predict post-treatment variation in pain intensity scores [80]. In interventions combining self-management and antidepressant pharmacotherapy, participants receiving the combined therapies reported significantly better mental health outcomes than those receiving usual care, just self-management or just pharmacotherapy [66,82]. These findings suggest that maximum improvements in depression may require both self-management and aggressive antidepressant therapies.

The evidence for the role of SMIs in improving health-related quality of life is also relatively consistent both immediately after and in the months following the delivery of a SMI [16,17,23,25,30,32,33,41,46,47,56,63,72,79,86,87,97]. This improvement has been reported in both mental and physical domains of health-related quality of life, but is more common in physical domains. All long-term improvements in health-related quality of life were preceded by a short-term gain, thus the processes by which health-related quality of life can be improved through SMIs occur during the delivery phase.

HCPs‘ role in self-management

▪ Self-management advice

HCPs can support self-management by providing self-management advice and encouragement for those who are ready. Individuals with chronic low back pain have reported that, as a necessary first step in learning to self-manage, they had to make an internal shift to realize that their active participation was necessary for relief of pain (e.g., physical therapy only helped if they performed their homework between visits). This shift helped them see themselves, rather than a clinician, as the agent of relief, and to view relief as a long-term practice rather than an immediate cure [98].

Helping individuals make this shift in focus from cure to active self-management was a key approach used by HCPs of multidisciplinary pain clinics when biomedical interventions had failed to provide relief [99]. Facilitating this shift involved educating patients/clients about the ‘chronic‘ nature of their pain, emphasizing self-management as a therapy similar to traditional biomedical treatments, sharing pain management plans with patients/clients and shifting the perception of HCPs from one of medical intervention to one of skills education (e.g., stretches and relaxation) [99].

Once focused on management, individuals report being ready to hear self-management messages [98]. When interviewed, patients with chronic pain reported that self-management messages were most helpful when they were consistent between HCPs [100], individualized for their level of function [98], and supported with ongoing reassurance and encouragement [98].

A discrepancy may exist between how HCPs and those living with chronic pain perceive the role of HCPs. When HCPs were asked to describe their role in supporting self-management for patients with chronic low back pain, they included encouraging exercise, prescribing analgesics, providing sickness certificates and referring to specialists [101]. Conversely, individuals with chronic spinal cord pain identified family physicians as the person to whom they address their management questions, although most reported that he/she was not able to answer them. Question topics included both traditional medical and alternative pain management therapies, pain causes, future expectations, how other people with similar conditions manage and how to access information on their condition [102].

▪ Identifying & targeting self-management barriers & facilitators

Using qualitative interviews, individuals have been asked to describe barriers and facilitators of chronic pain self-management (Box 2). Some barriers could be targeted directly; for example, an individual who is doing fairly well self-managing, but reports a lack of family support may be encouraged to attend a support group or referred to a SMI that encourages family participation. Other barriers may highlight the need for referral to a SMI (e.g., an individual who feels that his/her current self-management strategies are ineffective). Still other barriers may be permanent, but addressed through a SMI or self-management advice tailored to specific needs (e.g., modified exercises for individuals with spinal cord injuries).

Other personal or situational factors may present opportunities for clinicians to build on the individual‘s resources (Box 2). Some of these factors may be addressed easily by HCPs, such as reinforcing the evidence [103] and encouraging self-management activities [104]. Other facilitators of self-management may be optimized through a SMI, such as receiving support from peers [105] and learning a variety of new skills [104].

Selecting individuals for successful SMI

Following participation in a SMI, specific qualities have been identified which seem to predict, mediate or be associated with improved outcomes (Table 2). Similar to the findings of qualitative research, acceptance of the chronic nature of pain and willingness to take an active role in management were identified. These qualities can be used to recognize which individuals are likely to benefit from a SMI.

The Pain Stages of Change Questionnaire has also been used to assess readiness to self-manage [106]. This tool is based on the transtheoretical model of change and stages theory and categorizes individuals into one of four stages: precontemplation, contemplation (combined with the preparation stage from the model), action and maintenance [106]. Individuals in the precontemplation stage look to HCPs to manage and relieve their pain [106] and may have high levels of psychological distress, low self-efficacy and fear of movement [107]. These individuals are unlikely to be ready to engage in active self-management [108]. Those in the contemplation stage have just started to consider involvement in pain management, but may not have the necessary skills [106]. Individuals in this stage may benefit from a SMI where they can gain the knowledge, skills and self-efficacy to get started. In the action stage, individuals are learning and using self-management skills, and may turn to HCPs or SMIs to reinforce and teach new skills [106,108]. Individuals in this stage tend to have low levels of psychological distress, low fear of movement and high levels of self-efficacy [107]. Finally, individuals in the management stage use self-management strategies that they find useful and express confidence in their ability to manage future pain [106]. There is evidence to support the benefit of SMIs, resources and support from HCPs for individuals in the contemplation and action stages of self-management [63,109], thus assessing stage of change may help identify who will benefit from a SMI.

Conclusion & future perspective

Chronic pain is difficult to manage. Even with multiple treatment modalities and maximally tolerated doses of the best pharmacologic agents, pain intensity is often reduced by only 26–38% [10,110], thus individuals are increasingly relying on SMIs to manage their pain. This paper includes a review of research on current approaches to SMIs, as defined by Lorig and Holman [13] and published in the past 5 years, when a critical mass of research in this field began to emerge. The results suggest that SMIs can reduce both the physical and psychosocial burden on affected individuals while reducing healthcare use. Although research participants may be different from the average individual with chronic pain, these results include participants from various sectors of care and they support the need for HCPs to explore whether SMIs are an appropriate addition to their current chronic pain care.

HCPs play an important role in realizing these positive effects. To actualize this role, HCPs may require additional training in how to collaborate with their patients/clients in setting health goals and decision-making, and tailoring SMIs to individual barriers, facilitators and needs. The role of personality factors and traits as barriers to self-management have been identified in the literature; however, they were not addressed in the studies included in this review.

Some of the current self-management barriers may be eliminated through the use of online SMIs. Self-management websites provide a cost-effective means of reaching individuals in their own homes, thus eliminating issues of mobility, transportation and rural access. In addition, online material allows individuals to tailor interventions by providing opportunities for them to select topics of interest, reread sections and continue to receive self-management support outside of a specific number of sessions.

The shift in focus from cure to management has been repeatedly identified as a critical step in learning to self-manage. Further work is needed to understand how to help individuals accept the chronic nature of their pain. Evaluating readiness to self-manage may help with identifying who is appropriate for referral to a SMI; however, more work is needed in developing tools for this purpose.

Table 1. Overview of common self-management interventions.

Intervention	Common topics	Typical mode and length	Ref.
Stanford Model (includes Chronic Pain Self-Management Program, Arthritis Self-Management Program and Chronic Angina Self-Management Program)	Self-management principles/responsibilities Goal setting and action plans Pain management tools (e.g., use of medications and multiple cognitive strategies) Problem solving Physical activity and exercise Healthy eating Dealing with difficult emotions and depression Fatigue and sleep Working with your healthcare provider	Group sessions: ▪ 6 weeks with 2 h of group sessions per week (total: 12 h) Online: ▪ 6 weeks with 1–2 h online per week to cover all 25 sessions (total: 6–12 h) Workbook provided for group and online sessions	[201]
Acceptance and commitment therapy	Principles of the pain–avoidance–suffering cycle Identifying values/valued activities, and gradually increasing exposure to value-directed behavior (instead of pain-directed behavior) Cognitive defusion (identifying and observing negative thoughts without acting on them, and distancing oneself from them) Mindfulness Accepting and being willing to engage with pain Committing to action and identifying obstacles to desired action Planning for future action and obstacles	Group sessions: ▪ 3–4 weeks of 6.5 h per day for 5 days of each week ▪ 8 weeks of 1.5 h sessions per week Workbook with telephone support ± one individual session: ▪ 6 weeks of scheduled workbook exercises with one telephone call per week	[15]
Modified cognitive–behavioral therapy^†	Cognitive restructuring (e.g., identifying and evaluating catastrophic thinking and constructing realistic alternatives) Identifying and restructuring pain avoidance beliefs and behaviors Behavioral activation (e.g., pacing and activity scheduling) Understanding biopsychosocial influences of pain goal setting Lifestyle changes (e.g., exercise) Self-regulatory skills (e.g., progressive muscle relaxation and breathing exercises) Pain management skills (e.g., attention diversion and stress-coping skills) Relapse prevention strategies	Group sessions: ▪ 5–12 weeks with 1.5–2 h sessions per week Individual sessions: ▪ 6–25 weeks with two to 25 sessions Online: ▪ 4–8 weeks with one or more modules per week	[202]

† Reflects cognitive–behavioural therapy as it has been modified in the current literature to include elements of self-management and self-efficacy.

Table 2. Factors predicting or associated with positive outcomes of self-management intervention.

Factors	Predictors/correlates/mediators/moderators of positive outcomes
Demographic	Non-Caucasian ethnicity [111] Older age [112]
Health status	Pain intensity [113,114] Fewer comorbid conditions [112] Physical activity [115]
Mental health	High baseline levels of pain-related anxiety [111] Catastrophizing [113] Optimism [112]
Pain and management beliefs	High self-efficacy [96,108,115–117] Sense of internal control over pain [96] High perceived importance of self-management behavior [117,118] High acceptance of chronic pain and perceived ability to manage it [113,119] Pain beliefs [120] Stage of change/readiness to change (contemplation, action or maintenance stage as per the Pain Stages of Change Questionnaire) [106,117,118,121]
Current self-management skills	Use of self-management strategies prior to intervention [114] High level of mastery in skills related to care of condition [112]
Healthcare provider‘s actions	Giving information on the effectiveness of self-management strategies and illness, and clarifying doubts and questions during clinical encounters [114] Receiving loss-based messaging of self-management behaviors (e.g., “if you don‘t perform self-management behaviour X you may experience the following negative consequences…”) [108] High satisfaction with information provided by primary care physician [96]

Box 1. Overview of self-management intervention organization and delivery.

Formats

▪	Group sessions
▪	Individual sessions
▪	Telephone calls and/or self-study toolkits
▪	Online website
▪	Combinations (e.g., initial individual session followed by telephone calls)

Noncompletion & withdrawals

▪	Percentage in group or individual sessions ranges from 0 to 58% (average percentage reported: 21%)
▪	Percentage in online sessions ranges from 0 to 26% (average percentage reported: 16%)
▪	Percentage in self-study toolkits ranges from 30 to 54% (average percentage reported: 42%)

Settings

▪	Hospital/clinic
▪	Community center
▪	Home (individual, online or telephone formats)

Facilitators

▪	Clinical psychologists
▪	Physical and occupational therapists
▪	Nurses and nurse practitioners
▪	Physicians
▪	Students or others trained in cognitive–behavioural therapy
▪	Social workers
▪	Fitness instructors
▪	Trained community volunteers living with the targeted chronic pain condition
▪	Combinations of professionals or a professional teamed with a trained volunteer

Participants

▪	Aged 8–89 years
▪	Pain present for a minimum of 3 months
▪	Unknown, moderate or high levels of daily pain-related disability, interference and/or anxiety
▪	Mild-to-severe pain intensity
▪	Pain conditions: general chronic pain, back pain, osteoarthritis, rheumatoid arthritis, hemophilia, noncardiac chest and angina pain, tempromandibular joint dysfunction pain, fibromyalgia syndrome, chronic widespread pain, headaches, irritable bowel syndrome and spinal cord injury pain

Box 2. Barriers and facilitators of self-management.

Barriers

▪	Lack of support from family and friends [104]
▪	Limited physical resources [104]
▪	Depression [104]
▪	Ineffectiveness of pain management strategies [104]
▪	Time limitations and competing life priorities [104]
▪	Activity avoidance due to fear of pain exacerbation [104]
▪	Lack of tailoring of strategies to personal needs [104]
▪	Inability to maintain use of strategies outside of an intervention study [104]
▪	Physical limitations [104]
▪	Difficult patient–physician interactions [104]

Facilitators

▪	Encouragement from healthcare providers [104]
▪	Treated depression [104]
▪	Supportive family and friends [104]
▪	Having a variety of self-management strategies to use [104]
▪	Social support from individuals with the same condition [105]
▪	Flexibility in self-management program scheduling [103]
▪	Tailoring of self-management program to level of disability [103]
▪	Hearing concrete evidence supporting the effectiveness of self-management strategies [103]

Financial & competing interests disclosure

The authors would like to thank the Canadian Pain Society for providing funding through the Trainee Research Interchange Program that supported collaboration on this paper. S LeFort carries out leader training for the Chronic Pain Self-Management Program and is paid for her time by Stanford University. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.