A Self-Management Perspective
 
U pper Grand Family Health Team has been instrumental in developing a chronic pain program. Community stakeholders identified that more than 20 percent of our patient population suffered from chronic pain issues. The summer of 2008, six interprofessional members of the family health team were trained in the delivery of the Stanford self-management program. The main focus of the chronic pain program is to improve the quality of life in patients with chronic pain by promoting self-management in their own community. The chronic pain self-management group meets weekly for 2.5 hours for a total of six sessions. The Stanford model was chosen for this program, as it is the gold standard, developed, tested, evaluated and uses validated tools. The program helps patients gain self-confidence and control symptoms by building skills, sharing experiences and group support.
The Upper Grand Chronic pain self management group is inter professionally led by nurses, a nurse practitioner, mental health therapist, social worker, dietitian and pharmacist. Referral to the program is both interprofessionally or self-driven. Any chronic pain patient may be referred such as those with arthritis, fibromyalgia, injury, neuropathy, etc. During the program if needed any patient may be referred for a personal consultation with any of the professionals at the Upper Grand Family Health Team.
The program adheres to the Five A’s: assess, advise, assist, agree and arrange. Content of the program includes: self-help principles, debunking myths, differences between chronic and acute pain, balancing rest and activity, exercise, range of motion, pain management relaxation, depression, nutrition, evaluating non traditional treatments problem solving, communication skills, medications, fatigue, and action planning/feedback. Each of the six-week group sessions covers a variety of topics, each week building on the previous. Exercise, problem solving and action planning/feedback are three key components that are discussed in all of the six group sessions. The pain and symptom cycle is discussed to help patients identify how their symptom(s) can lead to a down ward spiral of pain. The self-management toolbox includes a variety of tools/approaches a patient can uses to interrupt the pain and symptom cycle and improve their quality of life. Patients have commented on many benefits from trying different tools and being made aware of resources. They especially find the support they receive from each other in a group setting very beneficial. A pre and post evaluation is done measuring knowledge, symptoms, physical activity level, communication and emotional wellbeing. Participant’s comments include: “The past few weeks have changed my life for the best, I feel much better at times”. A group like this has been needed for a long time, thank goodness it’s here now” The key messages are: chronic pain self management keeps the patient at the centre of care, encourages autonomy and empowers patients to take ownership, equates to a best practice medical/behavioural and role/emotional management model, is part of multi-dimensional care of a patient with chronic pain and Chronic Pain Self Management is a cost effective community-based strategy.
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shelley lillie
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laurie barnhardt
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the wagner model
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on this topic
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Health Council of Canada
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The second initiative for the chronic pain program that was implemented was a chronic pain comprehensive assessment. After visiting chronic pain clinics and training we adopted the train-the-trainer model and 4 of the team members are trained to administer the comprehensive assessment. The assessment contains several tools that are self-reporting by the patient. The brief pain inventory (BPI) and the pain disability index (PDI) measures the degree of disruption to the patient’s life by chronic pain. The higher the interference score, the more that the patients pain interferes with function and contributes to his/her disability. Some patients may require an assessment by a PT/OT to assess their limitations and recommend aids to living. All patients can benefit from recommendations for graded exercise, beginning at whatever level they are currently functioning at and gradually increasing the duration and intensity. By repeating the BPI Interference Scale in the future, you will have a more objective assessment of functional improvement with treatment. We also assess for a neuropathic pain component with the DN4 tool. The hospital anxiety and depression scale (HADS) is used to identify undiagnosed anxiety or depression. A patient’s suffering and quality of life will be adversely affected by significant anxiety and/or depression. Patients with high scores on the HADS may benefit from a mental health referral. The pain catastrophizing scale is used. A patient with a high PCS score likely has a significant element of pain-related anxiety and pain avoidance behavior contributing to his/her disability and may benefit from a referral for cognitive-behavioral treatment. These patients may confuse the difference between “hurt” and “harm” and need education and encouragement to participate in activities to improve fitness. Patients are asked to provide a complete history of their work and sleep habits as both of theses components can affect their ability to cope with chronic pain.Patients then summarize their current and previous treatments.
Patients are met with and the information they have provided is summarized with them and shared with the physician. Several tools are used to assess risk of addiction: CAGE screening, smoking history and opioid risk assessment. The patients are then asked to sign the opioid prescribing agreement. The team provides recommendations to the patient and physician from the comprehensive pain assessment. It clearly identifies any outstanding chronic pain issues and patient’s goals.
Both the chronic pain self-management group and the comprehensive chronic pain assessment have met our program goal of improving the quality of life in patients with chronic pain. Self-management allows patients to define their goals and support positive lifestyle changes. Comprehensive assessments provide a complete chronic pain picture that is used by both the patient and physician to refine treatment plans.
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