Chronic Pain Self Management Program

CPSMP CSMPs developed at Stanford University using the principles of self-management and self-efficacy (Dr. K. Lorig) CPSMP developed by Dr. Sandra LeFort (Nurse – McGill University) The Arthritis society offers the same 6 week program but is Arthritis based For those that can’t commit to 6 weeks, the Arthritis society also offers a 1 day workshop which covers almost the same content Contact CCAC for further info on their Chronic disease program

Overview Foundational points of CSMPs – focus on self-efficacy theory (Stanford University Approach) Demonstrate how these processes have been incorporated in the pain program Overview of the 6-week program Evidence – is this worth our time? Referral process Every FHT has physicians, nurse practitioners and nurses. Other providers can include: social workers. dietitians, pharmacists, addictions counselors, psychologists, chiropodists, etc.

Definition of Self-Management The individual’s ability to manage the symptoms, treatment, physical and social consequences and lifestyle changes inherent in living with a chronic condition.

Basic Self-Management Prinicples Willing to learn and take responsibility for daily management their chronic pain Tasks (take care of own health, complete normal activities, manage their emotions) Focus on taking some responsibility for managing their health

5 Core Self-Management Skills Problem Solving Decision Making Use Resources Partnership with HCPs Take action for change

What is Self-Management Education? Programs based on adult learning principles, that provide patients with the 5 core skills to live an active and meaningful life. Maintain a wellness focus to improve QOL Come to terms with their “new self”

CPSMP Early Origins Provide patients with behaviour change strategies (exercise, nutrition, etc.) → lead to active self management Early studies – found no differences in outcomes (despite exercising more, eating better, etc.) Change approach using self-efficacy theory

Self-Efficacy Developed Albert Bandura (Stanford) The exercise of human agency through people’s beliefs in their capabilities to produce desired effects in their actions Need to believe you can attain the goal!

Theory of Self-Efficacy Not as simple as knowing what to do Must believe in your ability to organize and integrate cognitive / social / behavioural skills to achieve control over everyday circumstances

Four Key Components of Self-Efficacy Skills mastery – opportunity to practice in a supportive environment Modelling – peers … “if they can do it … I can do it” Re-interpretation of symptoms – cognitive re-framing; examination of illness related beliefs Social persuasion – gentle encouragement by peers / family / friends / HCPs (action plan)

CPSMP A standardized, Community-based education program (adapted CDSMP) Based on the self-management & self-efficacy theory Runs for 2.5 hrs per week for 6 weeks (10-16 participants and two facilitators) 2.5 hrs but a break is offered, and suggest participants to bring pillows/back support, or stand and move around to keep comfortable We only have a few Living a Healthy Life books so they are able to borrow them for a week at a time Confidentiality in the group, except in suicidal or threatening situations

CPSMP Content Self-management (concept) What is chronic pain Pacing (balancing activity / rest) Exercise Using your mind Dealing with difficult emotions depression

CPSMP Content Con’t Fatigue Medications Communication – family / HCPs Evaluating non-traditional treatments Weekly contracts / problem solving steps

Strategies Used in all Stanford Self-Management Programs Mini-lectures (information sharing) Self-reflection (how chronic pain affects their lives) Quiz (common myths) Brainstorming Weekly action plans (process of attaining short term goals) Feedback Group problem solving Mid week phone call

CPSMP Model Content may change – but process must be consistent: Action plans (weekly, acheivable) Feedback (action plans) Modelling - for each other Reinterpreting symptoms / changing beliefs (cognitive re-framing) Persuasion – seeing peers succeed in class / facilitator encourage to “do a bit more”

LeFort et al. Pain 1998; 74(2-3): 297-306. Evidence 2 RCTs funded by Health Canada & Canadian Institutes for Health and Research (CIHR) 110 patients with mixed idiopathic chronic pain 75% female (mean age 40y, ~ 6 year hx pain) Randomized to intervention or 3-month wait list control group Self report measures of pain & QOL indicators LeFort et al. Pain 1998; 74(2-3): 297-306.

LeFort et al. Pain 1998; 74(2-3): 297-306. Evidence Con’t 102 patients completed the study Data collected pre and 3 mos post study by blinded assessors Results: significant short term improvements in pain, dependency, vitality, aspects of role functioning, life satisfaction, and self-efficacy LeFort et al. Pain 1998; 74(2-3): 297-306.

What are Patients Saying about the Program? Having their voice heard Felt that they were not alone Share with others who understand safe environment Able to take ownership of their pain Learning from others / help others Hope / direction

Principles of Self-Management Education: Active self-managers are willing to learn about and take responsibility of their daily management of chronic conditions, and are able to: Take care of overall health Carry out normal activities Manage emotional changes

Suggestions for Referrals: Chronic (> 3 to 6 months) MSK Fibromyalgia Diabetic neuropathy Whiplash injuries Persistent headaches MS

Week One Introduction- identifying common feelings Workshop overview and responsibilities Debunking myths about chronic pain Differences between acute and chronic pain Understanding the pain and symptom cycle Introducing action plans Introduce themselves and their story, this can be a very emotional but bonding time for the group What chronic pain means to me Reinforce the commitment to attend all 6 sessions as able Lots of emphasis on the pain and symptom cycle Introduction to action plans We offer to call them mid week to follow up how they are doing with these

Week Two Feedback and problem solving from the past week Introduction to physical activity and exercise Pacing-balancing activity and rest Better breathing and progressive muscle relaxation Making an action plan Start with problem solving and brain storming from the group- use problem solving steps Lots of stress placed on the importance of physical activity and breaking the P+S cycle Practice breathing exercise, dim the lights and do progressive muscle relaxation with background music Work on an action plan for next week Find a buddy, we no longer call them this week but they join a buddy system in the group

Week Three Feedback and problem solving Moving easy program Dealing with difficult emotions Using the mind: distraction Fatigue and sleep management Guided imagery relaxation Making an action plan Again with the problem solving as a group Use the CD for the exercise program A listening exercise for dealing with difficult emotions, partners report for the other Distraction- count backwards by 3’s, thinking of a flower or bird for every letter of the alphabet An exercise of thinking about your pain, time this for 30 secs, now try a distraction technique and time this for 45 secs- Ask how they felt the difference Sleep tips- lots of resources and ideas in the book, a good sharing topic Guided imagery- background music Again action plans for the week

Week Four Feedback and problem solving Moving easy program Communication skills Healthy eating Problem solving Making an action plan Again feedback and problem solving as a group Improved communication skills Canada’s food guide but lots of group interaction with their own ideas of ‘what helps their chronic pain’ Focus on problem solving skills without the team approach Again an action plan for the week

Week Five Feedback and problem solving Moving easy program Medications and chronic pain Depression Positive thinking Visualization Making an action plan Only individual issues and how they problem solved this week Information on different types of pain medications and how they work (offer RPh as needed) Talk about the difference between physical dependence and addiction Dealing with the blues and depression – group ideas of how to help with these feelings Steps towards positive thinking Visualization exercise with background music Again an action plan for the week

Week Six Feedback and problem solving Making informed treatment decisions Working with your healthcare provider Communicating about pain Moving easy program Looking back and planning for the future Making a long term action plan Evaluating treatment options out there, how to determine a legitimate suggestions vs. sales gimmick Researching on the internet and value based sites that originate from university, government or healthcare based sites Problems with healthcare organizations or providers and how to improve these- try to mend the bridge! Patients may be making more frequent appts to follow up – but hopefully the quality of these appts will be improved as well Communicating- using tools in the book, photocopy some of the pages- pain profile, describing words, the intensity scale Looking back and summarizing all the tools covered in the toolbox- using various ones to break the pain and symptom cycle Look at goals for the next 3-6 mths-how do you plan to get there, confidence levels Group persuasion is felt by seeing others succeed to do ‘a bit’ more Pull up the “What chronic pain means to me” list and ask how they feel now- list the differences – this can be enlightening to most ! Short visualization exercise to reinforce positive feelings about the progress made during the past 6 weeks Encourage members to stay in touch either with their buddy or form a contact list if they are interested. Evaluation survey to be completed

CPSMP-TVFHT Sessions are offered a few times throughout the year but as referrals come in they are placed on a waiting list for next group We also have access to other sites and their programs if evening session or other site preferred