An Expanded View of Self-Management: Patients' Perceptions of Education and Support in an Intervention for Chronic Musculoskeletal Pain

Exploring the effect of wound related pain on psychological stress, inflammatory response, and wound healing

AIMS AND OBJECTIVES

The relationship between pain and poor healing is intricate, potentially mediated by psychological stress and aberrations in inflammatory response. The purpose of this study was to examine the biopsychosocial model of pain by assessing the relationships between pain, stress, inflammation and healing in people with chronic wounds.

DESIGN

This was a 4-week prospective observational study to explore the relationship of pain, stress, inflammation and wound healing in a convenience sample of patients with chronic wounds in a chronic care hospital in Canada.

METHODS

Only subjects over 18 with chronic wounds were recruited into the study. Chronic wounds were defined by the duration of wounds for more than 4 weeks of various aetiologies including wounds caused by pressure injuries, venous disease, arterial insufficiency, surgery or trauma and diabetic neuropathy. Participants were evaluated for pain by responding to the Brief Pain Inventory-Short Form, the McGill Pain Questionnaire-Short Form and the Leeds Assessment of Neuropathic Symptoms and Signs scale. Stress was measured by the Perceived Stress Scale (PSS). All wounds were assessed with the Pressure Ulcer Scale for Healing tool. The levels of matrix metalloproteinases were analysis by obtaining wound fluid from all participants.

RESULTS

A total of 32 individuals with chronic wounds participated in the study. Correlation analysis indicated pain severity was positively and significantly related to pain interference, McGill Pain Questionnaire scores, neuropathic pain and matrix metalloproteinase levels. Logistic regression was used to determine the predictors for high or low perceived stress. The only significant variable that contributed to the stress levels was BPI-I. Results suggested that participants who experienced higher levels of pain interference also had an increased odds to report high level of stress by 1.6 times controlling for all other factor in the model.

CONCLUSION

Pain is a complex biopsychosocial phenomenon affecting quality of life in people with chronic wounds. Results of this study identified a significant relationship between pain, stress and wound healing.

How Chronic Pain Patients' and Physicians' Communication Influences Patients' Uncertainty: A Pre- and Post-Consultation Study

Chronic pain is a health problem that is difficult to diagnose, treat, and manage, partly owing to uncertainty surrounding ambiguous causes, few treatment options, and frequent misunderstandings in clinical encounters. Pairing uncertainty management theory with medical communication competence, we predicted that both physicians and patients are influential to patients' uncertainty appraisals and uncertainty management. We collected pre- and post-consultation data from 200 patients with chronic neck and spine/back pain and their physicians. Patients' reports of their physician's communication were a consistent predictor of their post-consultation uncertainty outcomes. Physicians' reports of both their own and patients' communication competence were associated with patients' positive uncertainty appraisals. Physicians' reports of patients' communication competence were also associated with reductions in patients' uncertainty. Findings illustrate how both interactants' perceptions of communication competence-how they view their own (for physicians) and the other's-are associated with patients' post-consultation outcomes.

Patient motivators to use opioids for acute pain after emergency care

Introduction

Patients are stakeholders in their own pain management. Factors motivating individuals to seek or use opioids therapeutically for treatment of acute pain are not well characterized but could be targeted to reduce incident iatrogenic opioid use disorder (OUD). Emergency departments (EDs) commonly encounter patients in acute pain for whom decisions regarding opioid therapy are required. Decision-making is necessarily challenged in episodic, unscheduled care settings given time pressure, limited information, and lack of pre-existing patient provider relationship. Patients may decline to take prescribed opioids or conversely seek opioids from other providers or non-medical sources.

Methods

Using a framework analysis approach, we qualitatively analyzed transcripts from 29 patients after discharge from an ED visit for acute pain at a large, urban, academic hospital in the midwestern United States to describe motivating factors influencing patient decisions regarding opioid use for acute pain. A semi-structured interview guide framed participant discussion in either a focus group or interview transcribed and analyzed with conventional content analysis.

Results

Four major themes emerged from our analysis including a) pain management literacy, b) control preferences, c) risk tolerance, and d) cues to action.

Discussion

Our findings suggest targets for future intervention development and a framework to guide the engagement of patients as stakeholders in their own acute pain management.

"The Pain Doesn't Have to Control You." A Qualitative Evaluation of Three Pain Clinics Teaching Nonopioid Pain Management Strategies

PURPOSE

To explore factors related to effectiveness of nonpharmacological treatment for opioid-dependent patients suffering with chronic pain.

APPROACH

A qualitative study incorporating individual interviews and focus group interviews.

SETTING

3 rural Oregon nonopioid pain management clinics.

INTERVENTION

A 10-week nonpharmacological educational program incorporating cognitive-behavioral therapy, movement therapy, mindfulness, and other skills.

PARTICIPANTS AND METHODS

Across sites, we conducted 9 individual interviews with clinic staff and 3 focus group interviews with 34 patients who had participated in the course. Thematic analysis was used to identify themes within and across respondent groups.

RESULTS

Analysis revealed 4 primary themes: program goals; program benefits; characteristics of patients who benefit from the program; coordination of clinic experiences with other care. Several primary findings can be highlighted. The clinics focused on improving patients' quality of life, while opioid use reduction was a potential secondary benefit, driven by patients. Major program benefits included enhanced pain self-management skills, patients' greater assertiveness in communications with healthcare providers, and, in numerous cases, opioid use reduction. Participants were unanimous that predisposition toward active self-management of one's pain was an essential factor for positive outcomes. Patients reported considerable variability in providers' understanding of their clinic participation.

CONCLUSION

Nonpharmacological approaches for treating chronic pain can be effective for many patients. Clinics teaching these approaches should be more fully integrated into the healthcare system.

Common reported barriers and facilitators for self-management in adults with chronic musculoskeletal pain: A systematic review of qualitative studies

BACKGROUND

Self-management strategies are considered a necessary component of chronic musculoskeletal pain management to address ongoing symptoms and challenges. However uptake of self-management can be impeded by a number of factors.

OBJECTIVES

The aim of this study was to explore common impeding and facilitating factors of self-management strategies from the patient perspective.

METHODS

An electronic search was performed between 2009 to May 2020 for the following databases: MEDLINE, AMED, PsychINFO, Cochrane Library, PubMed, CINAHL, PEDro, and Google Scholar. The search terms included peer-reviewed qualitative or mixed-method studies investigating the perspective of chronic musculoskeletal pain patients in regards to the use of self-management strategies. Study rigor and bias was assessed using the CASP (Critical Appraisal Skills Programme) questionnaire specific to qualitative studies. Qualitative data was coded using a three-stage thematic synthesis process. Confidence in findings was assessed using CERQual (The Confidence in the Evidence from Review of Qualitative Research).

RESULTS

Twenty-seven studies were included with 487 participants. Six major themes were identified and divided into external and internal influencing factors. The external influencing factors were made up of the following three themes: health care practitioner role, supportive environment, accessibility. While the three internal influencing themes were: physical factors, knowledge and understanding, and psychological factors.

CONCLUSION

Learning to self-manage for patients in chronic pain required ongoing support either from healthcare practitioners or from social circles. To further assist the self-management process practitioners can improve self-efficacy through increasing patient knowledge of chronic pain, utilising goal setting and finding ways an individual can access ongoing support, either from the practitioner or through group programs.

The Impact of Reassurance on Musculoskeletal (MSK) Pain: A Qualitative Review

BACKGROUND

The reassurance provided during patient-therapist interactions is significantly associated with psychosocial outcomes, including fear and increased confidence. Currently, there are no available reviews that discuss the impact of reassurance for patients with musculoskeletal (MSK) pain. The aim of the present review was to qualitatively synthesize themes around reassurance mechanisms, and the impact during the interaction between patients with MSK pain and therapists. A systematic search strategy was undertaken. Studies were included if they were qualitative or mixed methods studies, examining the patient-therapist consultation, in any MSK clinical setting, with any health care professional, for adult patients with acute to chronic MSK pain. A thematic synthesis was conducted and supported by a particular assessment using CERQual.

RESULTS

Twenty-four studies were included (451 patients). Certain themes that related to both positive and negative outcomes of reassurance were identified as well as themes that illustrate the mechanisms causative of the outcomes. Using CerQual, we identified the most supported outcomes.

CONCLUSIONS

Effective reassurance includes affectionate interactions such as therapeutic relationship building and interpersonal skills, an individualized patient-centered approach, education and the provision of self-management strategies. It should be noted that some interactions that use pathoanatomic models led patients to misinterpret the information provided, this created feelings of fear.

Exploring the relationships among social support, patient activation, and pain-related outcomes

OBJECTIVE

Social support has been linked to more effective pain adaptation. The relationship between social support and other relevant constructs is less well-understood. Chief among these is patient activation, which has robust links to effective self-management, yet has not been well-studied in chronic pain. We sought to better understand these relationships in an effort to inform future intervention strategies for patients with chronic pain.

METHODS

Using baseline data from a clinical trial with patients with chronic pain (N = 213), we analyzed the relationships among perceived social support and patient activation, depression, anxiety, general health perceptions, pain centrality, pain catastrophizing, and pain intensity and interference. Multiple linear regression was used to examine the effect of social support on outcomes. Patient activation was explored as a mediator of the effect of social support on outcomes.

RESULTS

Social support was significantly associated with all outcomes except pain. Social support explained the greatest variance in patient activation (squared semi-partial correlation =0.081), followed by depression (0.073) and general health perceptions (0.072). Patient activation was not found to be a significant mediator of the effect of social support on pain-related outcomes.

CONCLUSIONS

Findings provide insight into the roles of patient activation and social support in chronic pain management. Although patient activation did not mediate the relationship between social support and outcomes, this study is an important step toward gaining a more complete understanding of constructs thought to be related to pain self-management and points to the need to advance theory in this area to guide future research. Such work is needed to optimize interventions for patients with chronic pain.

Perspectives of patients with chronic pain about a pain science education video

Purpose: Patients have responded in variable ways to pain science education about the psychosocial correlates of pain. To improve the effectiveness of pain education approaches, this study qualitatively explored participants' perceptions of and responses to pain science education.Methods: We conducted a qualitative content analysis of interviews with fifteen, adult patients (73.3% female) who had recently attended a first visit to a chronic pain clinic and watched a pain science educational video.Results: Participants thought it was important to improve their and healthcare providers' understanding of their pain. They viewed the video favorably, learned information from it, and thought it could feasibly facilitate communication with their healthcare providers, but, for many participants, the video either did not answer their questions and/or raised more questions. Participants' responses to the video included negative and positive emotions and were influenced by their need for confirmation that their pain was real and personal relevance of the pain science content.Conclusion: Study results support the feasibility and value of delivering pain science education via video and increase our understanding of patients' perceptions of and responses to pain science education. The video's triggering of emotional responses warrants additional research.

Management of chronic musculoskeletal pain in veterans: a systematic review

Background and aim of the work.

Veterans are military with health problems due to military conditions. The improved body armor and operational conditions has reduced the number of deaths, but increased the number of veterans with severe injuries, affected by musculoskeletal pain and associated syndromes, such as post-traumatic stress disorder. Multimodal approaches are considered in USA the gold standard for the treatment of these problems, while in Europe and Italy the data are unknown. The aim of this review was to describe and summarize multimodal therapeutic approaches that apply to the veteran population for chronic musculoskeletal pain and relate syndromes management.

Methods.

A comprehensive systematic review of the literature on Cochrane Library, PubMed, CINAHL e PsycINFO databases was conducted, from 2001 to 2020.

Results.

228 papers have been found, 134 were selected after the first screening. 24 quantitative studies were included in the review, all from USA. Different multimodal interventions with different kind of treatment types emerged. The analyzed studies’ sample size was 11 million (mean age = 57.67 years; SD=±11.94). The multimodal approaches showed a significant improvement in all outcomes (pain reduction and control, opioid therapy reduction, psychosocial outcomes) compared to traditional therapy.

Conclusions.

Multimodal therapeutic approaches seem to guarantee a good management chronic musculoskeletal pain and related mental disorders, and the reduction and control to opioid use. Military nurses emerged as professionals who have a central role in this approach. European and Italian authorities should consider veterans, in order to assess their expected increase in the future. (www.actabiomedica.it)

Peer Support for Self-Management of Chronic Pain: the Evaluation of a Peer Coach-Led Intervention to Improve Pain Symptoms (ECLIPSE) Trial

BACKGROUND

Pain self-management is an effective, evidence-based treatment for chronic pain. Peer support, in which patients serve as coaches for other patients, has been effective in other chronic conditions and is a potentially promising approach to implementing pain self-management programs using fewer clinical resources.

OBJECTIVE

To test a peer coach-delivered pain self-management program for chronic pain.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Veterans with chronic musculoskeletal pain.

INTERVENTION

Intervention patients were assigned a trained peer coach for 6 months. Coaches, who were volunteers, were asked to contact their assigned patients, either by phone or in person, twice per month. Coaches and patients were given an intervention manual to guide sessions. The control group was offered a 2-hour pain self-management class.

MAIN MEASURES

The primary outcome was total pain, assessed by the Brief Pain Inventory (BPI). Secondary outcomes were anxiety, depression, pain catastrophizing, self-efficacy, social support, patient activation, health-related quality of life, and healthcare utilization. Outcomes were measured at baseline, 6 months, and 9 months.

KEY RESULTS

Two hundred fifteen patients enrolled (120 intervention, 95 control). Adherence to intervention protocol was low, with only 13% of patients reporting having at least the recommended 12 peer coach meetings over the 6-month intervention. BPI total decreased from baseline to 6 months and baseline to 9 months in both groups. At 9 months, this change was statistically significant (intervention, - 0.40, p = 0.018; control, - 0.47, p = 0.006). There was not a statistically significant difference between groups on BPI at either time point. No secondary outcomes improved significantly in either group after adjusting for multiple comparisons.

CONCLUSIONS

Patients randomized to peer support did not differ from control patients on primary and secondary outcomes. Other peer support models that do not rely on volunteers might be more effective.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02380690.

Patients' Experiences with Telecare for Chronic Pain and Mood Symptoms: A Qualitative Study

OBJECTIVE

Pain, anxiety, and depression commonly co-occur, can have reciprocal effects, and are associated with substantial disability and health care costs. However, few interventions target treatment of pain and mood disorders as a whole. The Comprehensive vs. Assisted Management of Mood and Pain Symptoms (CAMMPS) trial was a randomized trial comparing two pragmatic telecare interventions, a high- vs low-resource approach to pain and anxiety/depression treatment. The purpose of the current study is to better understand patients' perspectives on both intervention approaches, including intervention components, delivery, patient experiences, and patient outcomes.

DESIGN

Qualitative, semistructured interviews.

SETTING

A Veterans Affairs Medical Center.

SUBJECTS

Twenty-five patients were purposefully sampled from both study arms.

METHODS

Patients were interviewed about their experiences with pain and mood treatment, perceived benefits and changes, and experiences with the intervention model to which they were randomized. The constant comparison method guided analysis.

RESULTS

Pain was more important than mood for most participants. Participants described developing increased awareness of their symptoms, including connecting pain and mood, which enabled better management. Participants in the high-resource intervention described the added value of the study nurse in their symptom management.

CONCLUSIONS

Patients in a telecare intervention for chronic pain and mood symptoms learned to connect pain and mood and be more aware of their symptoms, enabling more effective symptom management. Patients in the high-resource intervention described the added benefits of a nurse who provided informational and motivational support. Implications for tradeoffs between resource intensity and patient outcomes are discussed.

Managing Chronic Pain in an Opioid Crisis: What Is the Role of Shared Decision-Making?

Shared decision-making (SDM) is a widely-advocated practice that has been linked to improved patient adherence, satisfaction, and clinical outcomes. SDM is a process in which patients and providers share information, express opinions, and build consensus toward a treatment decision. Chronic pain and its treatment present unique challenges for SDM, especially in the current environment in which opioids are viewed as harmful and a national opioid crisis has been declared. The purpose of this qualitative study is to understand treatment decision-making with patients taking opioids for chronic pain. Ninety-five clinic visits and 31 interviews with patients and primary care providers (PCPs) were analyzed using the constant comparison method. Results revealed that 1) PCPs desire patient participation in treatment decisions, but with caveats where opioids are concerned; 2) Disagreements about opioids, including perceptions of lack of listening, presented challenges to SDM; and 3) PCPs described engaging in persuasion or negotiation to convince patients to try alternatives to opioids, or appeasing patients requesting opioids with very small amounts in an effort to maintain the patient-provider relationship. Results are discussed through the lens of Charles, Gafni, and Whelan's SDM model, and implications of the role of the patient-provider relationship in SDM and chronic pain treatment are discussed.

Patterns and Perceptions of Self-Management for Osteoarthritis Pain in African American Older Adults

OBJECTIVE

To explore and describe older African Americans' patterns and perceptions of managing chronic osteoarthritis pain.

METHODS

A convergent parallel mixed-methods design incorporating cross-sectional surveys and individual, semistructured interviews.

SETTING

One hundred ten African Americans (≥50 years of age) with clinical osteoarthritis (OA) or provider-diagnosed OA from communities in northern Louisiana were enrolled.

RESULTS

Although frequency varied depending on the severity of pain, older African Americans actively used an average of seven to eight self-management strategies over the course of a month to control pain. The average number of self-management strategies between high and low education and literacy groups was not statistically different, but higher-educated adults used approximately one additional strategy than those with high school or less. To achieve pain relief, African Americans relied on 10 self-management strategies that were inexpensive, easy to use and access, and generally perceived as helpful: over-the-counter (OTC) topicals, thermal modalities, land-based exercise, spiritual activities, OTC and prescribed analgesics, orthotic and assistive devices, joint injections, rest, and massage and vitamins.

CONCLUSIONS

This is one of the first studies to quantitatively and qualitatively investigate the self-management of chronic OA pain in an older African American population that happened to be a predominantly higher-educated and health-literate sample. Findings indicate that Southern-dwelling African Americans are highly engaged in a range of different self-management strategies, many of which are self-initiated. Although still an important component of chronic pain self-management, spirituality was used by less than half of African Americans, but use of oral nonsteroidal anti-inflammatory drugs and opioids was relatively high.

Exploring peer coaches' outcomes: Findings from a clinical trial of patients with chronic pain

OBJECTIVE

Although peer coaching can help patients manage chronic conditions, few studies have evaluated the effects of peer coaching on coaches, and no studies have systematically examined these effects in the context of chronic pain coaching.

METHODS

Peer coach outcomes were assessed as part of a randomized trial of peer coaching for chronic pain. In this exploratory analysis, linear mixed models were used to evaluate changes in peer coaches' pain and related outcomes from baseline to 6 and 9 months. The Šidák method was used to account for multiple comparisons.

RESULTS

Peer coaches (N = 55) experienced statistically significant increases in anxiety and pain catastrophizing from baseline to 6 months, which were no longer significant after adjustment. All other changes were not statistically significant.

CONCLUSIONS

Despite prior studies suggesting that peer coaches benefit from serving as a coach, the current study failed to support that conclusion.

PRACTICE IMPLICATIONS

Peer coaching remains a promising model, with high potential for implementation, for a number of chronic conditions requiring self-management. However, to maximize the benefits of such interventions, it is essential to monitor both those being coached and the coaches themselves, and not to assume that serving as a coach is inherently beneficial.

Evaluation of a peer coach-led intervention to improve pain symptoms (ECLIPSE): Rationale, study design, methods, and sample characteristics

Chronic pain is prevalent, costly, and a leading cause of disability. Pain self-management (i.e., employing self-management strategies including behavioral modifications) is an effective, evidence-based treatment. However, implementation and delivery of a pain self-management model is challenging because of time and resources. Peer supported pain self-management offers a promising approach to implementing pain self-management programs using fewer clinical resources. Evaluation of a Peer Coach-Led Intervention for the Improvement of Pain Symptoms (ECLIPSE) is a randomized controlled trial testing effectiveness of peer coach-delivered pain self-management intervention versus controls receiving a class on pain and pain self-management. ECLIPSE is a Hybrid Type 1 study testing effectiveness while examining implementation factors. ECLIPSE enrolled 215 veterans randomly assigned to the peer coaching (N = 120) or control (N = 95) arm. The peer coaching intervention lasts 6 months, with patient-peer coach pairs instructed to talk twice per month. Coaches attend initial training, are provided a detailed training manual, and attend monthly booster sessions. Outcomes are assessed at baseline, 6 months, and 9 months. The primary outcome is overall pain (intensity and interference), measured by the Brief Pain Inventory (BPI). Secondary outcomes are self-efficacy, social support, pain catastrophizing, patient activation, health-related quality of life, and health care utilization. To maximize implementation potential of pain self-management, innovative delivery methods are needed that do not require additional resources from healthcare teams. A novel and promising approach is a peer-coaching model, in which patients who are successfully managing their pain offer information, ongoing support, and advice to other patients with pain. Clinical Trials Registration: NCT02380690.

"I Was a Little Surprised": Qualitative Insights From Patients Enrolled in a 12-Month Trial Comparing Opioids With Nonopioid Medications for Chronic Musculoskeletal Pain

Chronic musculoskeletal pain is a major public health problem. Although opioid prescribing for chronic pain has increased dramatically since the 1990s, this practice has come under scrutiny because of increases in opioid-related harms and lack of evidence for long-term effectiveness. The Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial was a pragmatic 12-month randomized trial comparing the benefits and harms of opioid versus nonopioid medications for chronic musculoskeletal pain. The current qualitative study was designed to better understand trial results by exploring patients' experiences, including perceptions of medications, experiences with the intervention, and whether expectations were met. Thirty-four participants who were purposefully sampled based on treatment group and intervention response participated in semistructured interviews. The constant comparison method guided analysis. Results revealed that participants often held strong beliefs about opioid medications, which sometimes changed during the trial as they gained experience with medications; participants described a wide variety of experiences with treatment effectiveness, regardless of study group or their response to the intervention; and participants highly valued the personalized pain care model used in SPACE.

PERSPECTIVE

SPACE trial results indicated no advantage for opioid over nonopioid medications. Qualitative findings suggest that, for both treatment groups, preexisting expectations and anticipated improvement in pain shaped experiences with and responses to medications. The personalized pain care model was described as contributing to positive outcomes in both groups.

Self-care of chronic musculoskeletal pain - experiences and attitudes of patients and health care providers

BACKGROUND

Self-care is often the first choice for people with chronic musculoskeletal pain. Self-care includes the use of non-prescription medications with no doctor's supervision, as well as the use of other modern and traditional treatment methods with no consultation of the health care provider. Self-care may have positive effects on the successful outcome of a multidisciplinary approach to treatment. The aim of this study was to investigate the experiences and attitudes of patients and health care providers to the self-care of chronic musculoskeletal pain.

METHODS

Qualitative Phenomenological study, where the data were collected by the method of an audio-taped interview in 15 patients at the outpatient clinic for pain management and in 20 health care providers involved in the treatment of those patients. The interviews were transcribed verbatim and analyzed by principles of Interpretative Thematic Analysis.

RESULTS

Topics identified in patients: a) positive aspects of self-care, b) a need for pain self-care, c) social aspects of pain self-care. Topics identified in health care providers: a) aspects of self-care, b) a need for self-care c) risks of self-care. Most of patients have positive attitude to self-care and this is the first step to pain management and to care for itself. The most frequent factors influencing decision about the self-care are heavy pain, unavailability of the doctor, long awaiting time for the therapy, or ineffectiveness of methods of conventional medicine. The health care providers believe that self-care of chronic musculoskeletal pain may be a patient's contribution to clinical treatment. However, good awareness of methods used is important in this context, to avoid adverse effects of self-care.

CONCLUSION

Patients understand the self-care of musculoskeletal pain as an individually adjusted treatment and believe in its effectiveness. Health care providers support self-care as an adjunction to clinical management only, and think that self-care of musculoskeletal pain acts as a placebo, with a short-lived effect on chronic musculoskeletal pain.

Living Well With a Long-Term Condition: Service Users' Perspectives of a Self-Management Intervention

The outcomes of self-management interventions are commonly assessed using quantitative measurement tools, and few studies ask people with long-term conditions to explain, in their own words, what aspects of the intervention they valued. In this Grounded Theory study, a Health Trainers service in the north of England was evaluated based on interviews with eight service-users. Open, focused, and theoretical coding led to the development of a preliminary model explaining participants' experiences and perceived impact of the service. The model reflects the findings that living well with a long-term condition encompassed social connectedness, changed identities, acceptance, and self-care. Health trainers performed four related roles that were perceived to contribute to these outcomes: conceptualizer, connector, coach, and champion. The evaluation contributes a grounded theoretical understanding of a personalized self-management intervention that emphasizes the benefits of a holistic approach to enable cognitive, behavioral, emotional, and social adjustments.

Toward Patient-Centered Telerehabilitation Design: Understanding Chronic Pain Patients' Preferences for Web-Based Exercise Telerehabilitation Using a Discrete Choice Experiment

Background

Patient-centered design that addresses patients’ preferences and needs is considered an important aim for improving health care systems. At present, within the field of pain rehabilitation, patients’ preferences regarding telerehabilitation remain scarcely explored and little is known about the optimal combination between human and electronic contact from the patients’ perspective. In addition, limited evidence is available about the best way to explore patients’ preferences. Therefore, the assessment of patients’ preferences regarding telemedicine is an important step toward the design of effective patient-centered care.

Objective

To identify which telerehabilitation treatment options patients with chronic pain are most likely to accept as alternatives to conventional rehabilitation and assess which treatment attributes are most important to them.

Methods

A discrete choice experiment with 15 choice tasks, combining 6 telerehabilitation treatment characteristics, was designed. Each choice task consisted of 2 hypothetical treatment scenarios and 1 opt-out scenario. Relative attribute importance was estimated using a bivariate probit regression analysis. One hundred and thirty surveys were received, of which 104 were usable questionnaires; thus, resulting in a total of 1547 observations.

Results

Physician communication mode, the use of feedback and monitoring technology (FMT), and exercise location were key drivers of patients’ treatment preferences (P<.001). Patients were willing to accept less frequent physician consultation offered mainly through video communication, provided that they were offered FMT and some face-to-face consultation and could exercise outside their home environment at flexible exercise hours. Home-based telerehabilitation scenarios with minimal physician supervision were the least preferred. A reduction in health care premiums would make these telerehabilitation scenarios as attractive as conventional clinic-based rehabilitation.

Conclusions

“Intermediate” telerehabilitation treatments offering FMT, some face-to-face consulting, and a gym-based exercise location should be pursued as promising alternatives to conventional chronic pain rehabilitation. Further research is necessary to explore whether strategies other than health care premium reductions could also increase the value of home telerehabilitation treatment.

Veterans' pain management goals: Changes during the course of a peer-led pain self-management program

OBJECTIVE

Goal setting is a common element of self-management support programs; however, little is known about the nature of patients' goals or how goals change during pain self-management. The purpose of the current study is to explore how patients' goals and views of goal setting change over the course of a peer-led pain self-management program.

METHODS

Veterans (n=16) completing a 4-month peer-led pain self-management program completed semi-structured interviews at baseline and follow-up regarding their goals for their pain. Interviews were analyzed using immersion/crystallization.

RESULTS

Analyses revealed six themes: motivation to do something for their pain, more goal-oriented, actually setting goals, clarity of goal importance, more specific/measurable goal criteria, and more specific/measurable strategies.

CONCLUSION

The current analyses illustrate how participants' goals can evolve over the course of a peer-led pain self-management program. Specifically, increased motivation, more openness to using goals, greater clarity of goal importance, more specific and measurable goals and strategies, and the influence of the peer coach relationship were described by participants.

PRACTICE IMPLICATIONS

Pain self-management interventions should emphasize goal setting, and development of specific, measurable goals and plans. Trainings for providers should address the potential for the provider-patient relationship, particularly peer providers, to facilitate motivation and goal setting.

What do patients value about spinal manipulation and home exercise for back-related leg pain? A qualitative study within a controlled clinical trial

BACKGROUND

Patient perceptions may influence the effectiveness and utilization of healthcare interventions, particularly for complex health conditions such as sciatica or back-related leg pain (BRLP).

OBJECTIVES

To explore BRLP patients' perceptions of spinal manipulative therapy (SMT) and home exercise with advice (HEA).

DESIGN

Qualitative study in a controlled clinical trial.

METHOD

Semi-structured interviews conducted after 12 weeks of treatment asked participants about satisfaction with care and whether treatment was worthwhile. An interdisciplinary research team conducted content analysis using qualitative data analysis software to identify and summarize themes.

RESULTS

Of 192 trial participants, 174 (91%) completed interviews (66% female, age 57.0 ± 11.5 years). Participants identified interactions with providers and staff, perceived treatment effects, and information as key contributors to both their satisfaction and the worthwhile nature of treatment. HEA was liked for its convenience and ability to foster an exercise habit. SMT was liked for specific aspects of the modality (e.g. manipulation, stretching) and provider competency. Most participants reported no dislikes for SMT or HEA, but some noted the dose/time commitment for SMT and discipline of HEA as least liked aspects of the interventions.

CONCLUSIONS

The quality of patient-provider interactions, perceived treatment effects, and information sharing influenced BRLP patients' satisfaction with care. Qualitative research describing patients' preferences can facilitate translation of study findings into practice and allow clinicians to tailor treatments to facilitate compliance and satisfaction with care.

Patient Perspectives on Participation in Cognitive Functional Therapy for Chronic Low Back Pain

BACKGROUND

Cognitive functional therapy (CFT) has been shown to reduce pain and disability in people with chronic low back pain.

OBJECTIVES

The purpose of this study was to investigate participants' experience of CFT by comparing participants who reported differing levels of improvement after participation in CFT, potentially yielding insight into the implementation of this approach.

DESIGN

This was a noninterventional, cross-sectional, qualitative study with an interpretive description framework.

METHODS

Individuals who had participated in CFT in 2 physical therapy settings (in Ireland and Australia) were recruited through purposive sampling based on disability outcomes postintervention (n=9), and theoretical sampling (n=5). This sampling strategy was used to capture a range of participant experiences but was not used to define the final qualitative groupings. Semistructured interviews were conducted 3 to 6 months postintervention.

RESULTS

Three groups emerged from the qualitative analysis: large improvers, small improvers, and unchanged. Two themes encapsulating the key requirements in achieving a successful outcome through CFT were identified: (1) changing pain beliefs and (2) achieving independence. Changing pain beliefs to a more biopsychosocial perspective required a strong therapeutic alliance, development of body awareness, and the experience of control over pain. Independence was achieved by large improvers through newly cultivated problem-solving skills, self-efficacy, decreased fear of pain, and improved stress coping. Residual fear and poor stress coping meant that small improvers were easily distressed and lacked independence. Those who were unchanged continued to feel defined by their pain and retained a biomedical perspective.

CONCLUSIONS

A successful outcome after CFT is dependent on instilling biopsychosocial pain beliefs and developing independence among participants. Small improvers may require ongoing support to maintain results. Further study is needed to elucidate the optimal approach for those who were unchanged.

Socio-Cultural Factors and Experience of Chronic Low Back Pain: a Spanish and Brazilian Patients' Perspective. A Qualitative Study

BACKGROUND

Low back pain (LBP) could be influenced by socio-cultural factors. Pain narratives are important to understand the influence of environment on patients with chronic LBP. There are few studies that have explored the experience of patients with chronic LBP in different socio-cultural environments. The aim of this study was to describe the experience of patients with chronic LBP in Spain and Brazil.

METHODS

A qualitative phenomenology approach was implemented. Chronic LBP patients from the University Hospital of Salamanca (Spain), and/or Federal University of São Carlos (Brazil) were included, using purposeful sampling. Data were collected from 22 Spanish and 26 Brazilian patients during in-depth interviews and using researchers' field notes and patients' personal diaries and letters. A thematic analysis was performed and the guidelines for reporting qualitative research were applied.

RESULTS

Forty-eight patients with a mean age of 50.7 years (SD: ± 13.1 years) were included in the study. The themes identified included: a) ways of perceiving and expressing pain-the participants focused constantly on their pain and anything outside it was considered secondary; b) the socio-familial environment as a modulator of pain-most participants stated that no one was able to understand the pain they were experiencing; c) religion as a modulator of pain-all Brazilian patients stated that religious belief affected the experience of pain; and d) socio-economic and educational status as a modulator of pain-the study reported that economic factors influenced the experience of pain.

CONCLUSIONS

The influences of LBP can be determined based on the how a patient defines pain. Religion can be considered as a possible mechanism for patients to manage pain and as a form of solace.

Facilitators and Barriers to Participation in a Peer Support Intervention for Veterans With Chronic Pain

OBJECTIVE

To understand facilitators and barriers to participation in a peer support intervention for self-management of chronic pain.

METHODS

After completing a pilot intervention study, peer coaches and their veteran patients took part in a qualitative, semistructured interview to explore their experiences with the intervention. Data were analyzed using an immersion/crystallization approach.

RESULTS

Three facilitators and 2 barriers to patient participation in a peer support intervention for veterans with chronic pain emerged. Facilitators were (1) having a shared identity as veterans, (2) being partnered with a person who also has chronic pain, and (3) support from the study staff. Barriers were (1) logistical challenges, and (2) challenges to motivation and engagement in the intervention.

DISCUSSION

Awareness of facilitators and barriers to participation in a peer-supported self-management program for chronic pain, as well as strategies to capitalize on facilitators and mitigate barriers, are essential for further study and ultimate clinical implementation of such a program.

Advancing the Pain Agenda in the Veteran Population

The Veterans Health Administration (VHA) provides medical care for Veterans after leaving the military. The combination of multiple deployments and battlefield exposures to physical and psychological trauma results in a higher prevalence and complexity of chronic pain in Veterans than in the general public. The VHA and the Department of Defense work together to develop a single standard of stepped pain management appropriate for all settings from moment of injury or disease onset. This article describes the education, academic detailing, and clinical programs and policies that are transforming pain care in the VHA.

Patients' Perspectives on Tapering of Chronic Opioid Therapy: A Qualitative Study

OBJECTIVE : There is inadequate evidence of long-term benefit and growing evidence of the risks of chronic opioid therapy (COT). Opioid dose reduction, or opioid tapering, may reduce these risks but may also worsen pain and quality of life. Our objective was to explore patients' perspectives on opioid tapering. DESIGN : Qualitative study using in-person, semistructured interviews. SETTING AND PATIENTS : English-speaking, adult primary care patients (N = 24) in three Colorado health care systems. METHODS : Interviews were audio recorded, transcribed, and analyzed in ATLAS.ti. We used a team-based, mixed inductive and deductive approach guided by the Health Belief Model. We iteratively refined emergent themes with input from a multidisciplinary team. RESULTS : Participants had a mean age of 52 years old, were 46% male and 79% white. Six participants (25%) were on COT and not tapering, 12 (50%) were currently tapering COT, and 6 (25%) had discontinued COT. Emergent themes were organized in four domains: risks, barriers, facilitators, and benefits. Patients perceived a low risk of overdose and prioritized the more immediate risk of increased pain with opioid tapering. Barriers included a perceived lack of effectiveness of nonopioid options and fear of opioid withdrawal. Among patients with opioid tapering experience, social support and a trusted health care provider facilitated opioid tapering. These patients endorsed improved quality of life following tapering. CONCLUSIONS : Efforts to support opioid tapering should elicit patients' perceived barriers and seek to build on relationships with family, peers, and providers to facilitate tapering. Future work should identify patient-centered, feasible strategies to support tapering of COT.

Patient-professional partnerships and chronic back pain self-management: a qualitative systematic review and synthesis

Chronic back pain is common, and its self-management may be a lifelong task for many patients. While health professionals can provide a service or support for pain, only patients can actually experience it. It is likely that optimum self-management of chronic back pain may only be achieved when patients and professionals develop effective partnerships which integrate their complementary knowledge and skills. However, at present, there is no evidence to explain how such partnerships can influence patients' self-management ability. This review aimed to explore the influence of patient-professional partnerships on patients' ability to self-manage chronic back pain, and to identify key factors within these partnerships that may influence self-management. A systematic review was undertaken, aiming to retrieve relevant studies using any research method. Five databases were searched for papers published between 1980 and 2014, including Cochrane Library, CINAHL, Medline, EMBASE and PsycINFO. Eligible studies were those reporting on patients being supported by professionals to self-manage chronic back pain; patients being actively involved for self-managing chronic back pain; and the influence of patient-professional partnerships on self-management of chronic back pain. Included studies were critically appraised for quality, and findings were extracted and analysed thematically. A total of 738 studies were screened, producing 10 studies for inclusion, all of which happened to use qualitative methods. Seven themes were identified: communication, mutual understanding, roles of health professionals, information delivery, patients' involvement, individualised care and healthcare service. These themes were developed into a model suggesting how factors within patient-professional partnerships influence self-management. Review findings suggest that a partnership between patients and professionals supports patients' self-management ability, and effective communication is a fundamental factor underpinning their partnerships in care. It also calls for the development of individualised healthcare services offering self-referral or telephone consultation to patients with chronic conditions.

Nurse practitioners can effectively deliver pain coping skills training to osteoarthritis patients with chronic pain: A randomized, controlled trial

A multisite, randomized, controlled clinical effectiveness trial was conducted for osteoarthritis patients with chronic pain of the knee or hip. Adult health nurse practitioners provided a 10-session intervention, pain coping skills training (PCST), in patients' doctors' offices (N=129 patients); the control group received usual care (N=127 patients). Primary outcomes assessed at baseline, posttreatment, 6-month follow-up, and 12-month follow-up were: pain intensity, physical functioning, psychological distress, self-efficacy, catastrophizing, use of coping strategies, and quality of life. Secondary measures included fatigue, social functioning, health satisfaction, and use of pain medication. Methods favoring external validity, consistent with pragmatic, effectiveness research, were utilized. Primary ITT and secondary per-protocol analyses were conducted. Attrition was within the expected range: 11% at posttreatment and 29% at 12-month follow-up; rates did not differ between groups. Omnibus ITT analyses across all assessment points indicated significant improvement for the PCST group compared with the control group for pain intensity, physical functioning, psychological distress, use of pain coping strategies, and self-efficacy, as well as fatigue, satisfaction with health, and reduced use of pain medication. Treatment effects were robust to covariates (demographics and clinical sites). Trends in the outcomes across the assessments were examined. All outcomes, except for self-efficacy, were maintained through the 12-month follow-up; effects for self-efficacy degraded over time. Per-protocol analyses did not yield greater effect sizes. Comparisons of PCST patients who were more vs less treatment adherent suggested greater effectiveness for patients with high adherence. Results support the effectiveness of nurse practitioner delivery of PCST for chronic osteoarthritis pain.