Objectives Chronic Self-Management Support with Science Education and Exercise Jordan Miller, PT, PhD Post-Doctoral Fellow, McGill University Assistant Professor, School of Rehabilitation Therapy, Queen s University Chair, Science Division, Canadian Physiotherapy Association November 16, 2016 Background Review the evidence on: self-management individualized exercise pain science education Evidence on chronic pain self-management support with pain science education and exercise (COMMENCE) Give an example of what COMMENCE looks like Discussion and questions The context: The challenge of chronic pain in primary care Chronic pain is often associated with reduced abilities Usual care for chronic pain includes medication, but no exercise or physical activity recommendations Narcotics alone only provide small changes in function for people with chronic pain Exercise and self-management may be approaches that can help improve function either along-side medications or as stand-alone strategies Somerville 2008, Ashworth 2013, Glynn 2010, van Oostrom 2014 What is self-management? Self-management: The taking of responsibility for one's own behavior and well-being Self-management support: the systematic provision of education and supportive interventions by health care staff [or others] to increase patients skills and confidence in managing their health problems Self-management includes having the confidence to deal with medical management, role management, and emotional management of their conditions Institute of Medicine, 2003 1
Why do we need self-management support? - People living with pain have to self-manage their conditions. They face management decisions every day. - How do I get through my housework? - What should I eat? - Should I exercise today? - What do I do when I am feeling stressed or angry or depressed? - Who is the best health care provider to see when I have a certain health concern? What does the evidence say? Self-management support for chronic diseases (generally): - Knowledge: moderate to large increases - Self-efficacy: small to moderate increases - Depression: negligible to moderate effects - : negligible to small effects - Function: negligible to moderate effects - The health care system is not prepared for the growing challenge of dealing with chronic pain - We need to support the daily management decisions of people living with pain, so that health care providers are available when people need them Nolte and Osborne. Qual Life Res 2013; 22(7):1805-16. What does the evidence say? What does the evidence say? Self-management support for osteoarthritis Low quality evidence suggests that in comparison to an attention-control, self-management support results in: - no difference in self-efficacy - a statistically significant, but not clinically meaningful change in pain - no significant difference in function *Other systematic reviews have suggested small effects in self-efficacy and function Kroon et al. Cochrane Database of Systematic Reviews, 2014. Self-management support for chronic low back pain: - Small reductions in pain - Small reductions in disability Du S et al. Patient Educ Couns 2016 [ahead of print]. 2
What does the evidence say? What programs are already available? Summary: - Self-management interventions are diverse, as are the effect size estimates in the literature - There does seem to be some consistent reports of improved knowledge and self-efficacy - Results on function seem to be small to negligible Chronic Disease Self-Management Programs (Stanford Model) - Living a healthy life with chronic conditions - Arthritis self-management program - Chronic pain self-management program http://patienteducation.stanford.edu/programs/cdsmp.html What does this type of self-management look like? What does this type of self-management look like? Format 2.5 hours, once/week, 6 weeks Facilitated by two trained leaders, at least one of which is a non-health professional with a chronic disease Content 1) Dealing with frustration, fatigue, pain and isolation 2) General exercise recommendations for strength, flexibility, and endurance 3) Medication use 4) Communicating effectively 5) Nutrition 6) Decision making 7) Evaluating new treatments. http://patienteducation.stanford.edu/programs/cdsmp.html http://patienteducation.stanford.edu/programs/cdsmp.html 3
Woodstock and Area Community Health Centre Developing a new self-management program for people living with pain Offer multidisciplinary health care for people who have traditionally faced barriers accessing health care Focus on the health of the community Priority populations: Mental health challenges Addiction Poverty Isolated seniors No health insurance Woodstock and Area Community Health Centre WACHC recognized a need for improved care for people living with persistent pain Clients felt health care options like physiotherapy or multidisciplinary pain programs were inaccessible The health care team felt the need to offer services outside of medication and advice They reached out to our research team to help develop and evaluate a new treatment option Why did you not use an existing program? Can we target function with a different self-management approach? Health professional led vs. peer led Individualized goal-oriented exercise neurophysiology education Behavioural strategies 4
Developing a new self-management program for people living with pain Known in the research community as: Chronic Self-Management Support with Science Education and Exercise (COMMENCE) Known in the clinical community as: Living better with pain Program overview 2 times/week over 6 weeks Once per week = group setting, once per week = individualized Emphasis is on gradual increases in activity while controlling symptoms Individualized exercise Cognitive behavioural principles Self-management support Science Education Science Education education that emphasizes cognitive-behavioural or neurophysiological aspects of pain demonstrates improvements in: Disability Self-efficacy Negative pain cognitions Science may make activity and exercise approaches more effective Louw A et al. Arch Phys Med Rehabil 2011; 92:2042-56. Burton AK et al. Spine 1999; 24:2484-91. Linton SJ and Andersson T. Spine 2000; 25: 2825-31. Symonds TL et al. Spine 1995; 20:2738-45. Pairing pain science education with selfmanagement and exercise A better understanding of pain and why self-management strategies or exercise work may increase conviction and/or confidence for change An understanding of the relationships between stress, thoughts, and pain can be empowering and lead to effective self-management decisions 5
Cognitive behavioural principles Cognitive behavioural principles Progressive goal setting an important way for participants and provider to collaborate on a plan increases motivation and adherence an important component in both self-management and exercise interventions Graded exposure - strategy aimed at reducing fear of movement or activity by gradual exposure to the feared activity in a context which does not evoke a great deal of fear. - This approach has been shown to reduce pain related fear and disability Locke and Latham. American Psychologist 2002; 57(9): 705-17 Bodenheimer T et al. J Amer Med Assoc 2002;288:2469 75. Stewart MJ et al. 2007; 128:59-68. de Jong JR et al. J 2008;9:1123 34. de Jong JR et al. Clin J 2005;21:9 17 Vlaeyen JW et al. Behav. Res Ther. 2001; 39(2):151-66. Vlaeyen JW et al. Res Manag. 2002; 7(3):144-153. George SZ et al. Spine. 2003;28:2551 60. Cognitive behavioral principles Cognitive behavioural principles Graded activity Graded activity exercise approaches demonstrate improvements in pain and function with varied chronic pain conditions Attention is provided to the effects of increases in activity on biological, psychological, and social factors associated with pain and related disability. Activity planning/scheduling: Most people with chronic pain understand exercise is beneficial and many set goals of increasing participation There is a gap between motivation to increase activity levels and participation in increased activity. Activity planning helps participant plan for how they will implement an activity and forms a log to monitor success of the implementation plan Lindstrom I et al. Phys Ther. 1992;72:279 290. Pengel LH et al. Ann Intern Med. 2007;146:787 796. Kay TM et al. Cochrane Database Syst Rev 2012; 8: CD004250. Latimer AE et al. Rehabilitation Psychology 2006; 51: 273 280. LuszczynskaA. Social Science & Medicine 2006; 62: 900-8. Luszczynska A et al. Health Psychology, 26, 507 512 Milne S et al.. British Journal of Health Psychology, 7, 163 184. 6
Exercise Exercise Individualized exercise: - Individualized exercises in this program are very goaloriented - Focus is on gaining the functional abilities to be able to participate in specific life roles identified by the participant as important - Individualized exercise approaches have been supported in the literature for people with chronic pain Aerobic exercise Aerobic exercise can result in positive physiological changes to the nervous system, motor system, endocrine system, and immune system. Evidence suggests regular aerobic exercise can improve function and mood May contribute to confidence in the ability to gradually progress other activities Meiworm L et al. Clin Reheumatol. 2000;19:253 7. Hoffman MD et al. Arch Phys Med Rehabil. 2004;85:1183 7. Hoffman M and Hoffman D. Curr Headache Rep. 2007;11:93 7. Is COMMENCE is effective at improving function? Future directions Clinicians need to understand that people with chronic pain and multimorbidity experience barriers to attendance Future research should investigate barriers to attendance and participation and ways to overcome them Miller, 2016 Miller, 2015 7
Potential barriers Potential barriers Personal factors - Financial difficulties - Competing life priorities - Difficulty achieving desired changes - Depression and low motivation - Mobility restrictions - Learning difficulties System factors - Lack of self-management supports available - Conflicting advice - Access challenges - Time of day, transportation, poor communication Schoenberg NE et al. Qualitative Health Research 2011; 21(5):601-11. Bodenheimer and Abramowitz (2010). Helping patients help themselves: how to implement selfmanagement support. Oakland, CA; California Healthcare Foundation Mead H et al. Patient Education and Counseling 2010; 79:69-76. Hitchcock NP et al. Journal of General Internal Medicince 2007; 22(Suppl3):419-24. Schoenberg NE et al. Qualitative Health Research 2011; 21(5):601-11. Bodenheimer and Abramowitz (2010). Helping patients help themselves: how to implement self-management support. Oakland, CA; California Healthcare Foundation Mead H et al. Patient Education and Counseling 2010; 79:69-76. Hitchcock NP et al. Journal of General Internal Medicince 2007; 22(Suppl3):419-24. Example: June What does this program look like? Linking pain education, cognitive behavioural principles, exercise, and self management - Low back and knee pain for 10 years - Difficulty going up and down stairs - Difficulty walking more than 10 minutes 8
DANGER! 2016-11-22 THOUGHTS EMOTIONS BRAIN Education THOUGHTS EMOTIONS BRAIN Education STRESSES STRESSES TISSUE DANGER! + - SPINAL CORD PROTECTION - - Muscle spasm - Weakness - Run away - Lay down/freeze - Release hormones TISSUE DANGER! + - SPINAL CORD PROTECTION - - Muscle spasm - Weakness - Run away - Lay down/freeze - Release hormones THOUGHTS EMOTIONS BRAIN Education TISSUE STRESSES DANGER! + - SPINAL CORD PROTECTION - - Muscle spasm - Weakness - Run away - Lay down/freeze - Release hormones What happens if we aim here? Flare-up 9
Flare-up Flare-up What happens if we aim here? What happens if we aim here? Future Future TT TT TT TT Flare Flare Flare Flare 10
Future TT TT Flare Flare Exercise #1 Frequent movement that doesn t make your pain worse Exercise #2 Work to the alarm without flaring up Do a little bit, frequently Flare-up Aim here 11
Flare-up Aim here Goal setting and graded activity plan Set goals Decide an activity that you would like to do more of Set a short-term (within the next 6 weeks) and longterm (longer than 3 months) goal for that activity Make sure it is SMART Specific Measurable Action oriented Realistic Time-bound Goal setting and graded activity plan Short term goal: walk 15 minutes daily within 6 weeks. Long-term goal: walk 30 minutes daily within 4 months Goal setting and graded activity plan Graded activity plan. Week: Activity: walking 1 10 minutes 2 11 minutes 3 12 minutes 4 13 minutes 5 14 minutes 6 15 minutes 7 16.5 minutes 8 18 minutes 9 20 minutes 10 22 minutes 11 24 minutes 12 26 minutes 13 28 minutes 14 30 minutes 12
Results I am living with pain, how do I use this information? June reached her goal of walking 30 minutes per day within 4 months She is having no difficulty going up stairs, although she still has to place two feet on each step on the way down Consider signing up for a self-management program in your area If you feel like you need extra support for the changes in physical activity and exercise, consider seeing a physiotherapist to support these changes If you feel like you need extra pain science I am a health care provider working with people living with pain, how do I use this information? THANK YOU! Be aware of self-management programs in your area If your client or patient has a function or participation goal, consider the importance of: Individualized, goal oriented exercise science education Strategies to support behaviour change Questions: millerjd@mcmaster.ca 13