Barriers and Facilitators to Chronic Pain Self-Mana

Qualitative Study of Primary Care Patients with C

Musculoskeletal Pain and Depression

Matthew J. Bair MD MS Matthew J. Bair, MD

, MS

VA HSR&D Center of Excellence for 

Implementing Evidence Based Practice, a

R tif egens

t

r

i

e

f I tit t I Instit

u

te, Inc

Assistant Professor of Medicine, IU Scho

of Medicine, Indiana

polis

1
Co-authors

yM i S M tthi PhD Marianne S. Matthias, PhDyKathryn A. Nyland, BSyMonica A. Huffman, BSyDaWana L. Stubbs, MDyKurt Kroenke MD Kurt Kroenke, MD,yTeresa M. Damush, PhD

Bair MJ, Matthias MS, Nyland KA, Huffman MA, Stubbs DL, Kroenke K, Damush 

2

Facilitators to Chronic Pain Self-Management: A Qualitative Study of Primary CarComorbid Musculoskeletal Pain and Depression. Pain Medicine 2009;10:1280-90
Funding Sources:

yHSR&D C D l HSR&D Career Deve

lopme

Award (Bair)

, IU Roybal Cent

Grant (Bair), and NIMH GranR01 MH071268 (Kroenke) 

3
Disclosures:

yNo relevant financial relationshi
Background

y P i t f 20% f ll li i i 

P

a

i

n accoun

t

s for 20% 

of 

all 

cli

n

i

c

v

i

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y Anal

g p p 

esics = 12% of all 

prescri

ptions 

y $100 billion dollars/yr in health care y Excessive surgery (e.g., back pain)y Leading cause of work loss & disabiliy Leading reason for alternative medic
Self-Management De

yThe ability to manage the symptom

treatment, physical and psychosociaconsequences and life-style changes inherent in living with a chronic con

6

Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-managem

for people with chronic conditions: A review. Patient Educ Couns 20
Self-management for 

yDamush et al. showed enhancing 

patient self-management skills d d i it d i decreased pain severity and impfunctional status

DamushTM,Weinberger M, Perkins SM, et al. The long-term effects of a sel

7

g g

program for inner-city primary care patients with acute low back pain. Arch 2003;163:2632–8.
Self-management for pa

yNewman et al. found “strong eviden

clinical trials that self-management programs are effective for both low pain and osteoarthritis

Newman S Steed L Mulligan K Self-management interventions for ch

8

Newman S, Steed L, Mulligan K. Self management interventions for chLancet 2004; 364:1523–37.
Pain self-management progr

yArthritis Self-Management Prog

yTrains both professionals and l

l d ea

ders

yStandardized program for pati

with chronic pain

9

Lorig K, Gonzalez VM, Laurent DD, Morgan L, Laris BA. Arthritis selfprogram variations: Three studies. Arthritis Care Res1998;11:448–54
Premise of PSMP

yTeach skills that patients can use to 

manage their pain on their own and encourage participation with providdeciding their treatment plan

10

Lorig KR, Holman H. Self-management education: History, definition, oumechanisms. Ann Behav Med 2003;26:1–7.
Potential Challenge

yPatients who have depression—

yPresent in 30% to 50% w/ ch

pa

i

n

yMay interfere w/ self-manag

of 

pain

B i MJ R bi RL 

K W K k K D i d i bi

11

B

air MJ, R

obinson RL, Katon

W, Kroen

k

e K. Depression and pain comorbi

review. Arch Intern Med 2003;163:2433–45.
Gap in Literature

yLittle research on pain selfmanagement among patients wi

medi l d hi t i b

dical and psychi

a

t

r

i

c comorb

yChallenges patients face, particu

when pain is accompanied by depression?

12
Study Objective

yTo identify barriers and facilit

self-management of chronic musculoskeletal pain among pwith comorbid pain and depre

13
Study Design

yA qualitative study of focus gr

14
Participants (N = 18)

yRecruited after participation in 

clinical trial

15
Stepped Care for Affective Disor

and Musculoskeletal Pain (SCAMy To determine if a stepped-care app

improves:

y Both pain and depression outcoy In primary care patients

Kroenke K, Bair M, Damush T, et al. Care forAffective Disorders and MuPain (SCAMP) study: Design and practical implications of an interventio

16

pain and depression.Gen Hosp Psychiatry 2007;29:506–17
SCAMP Trial Design

PAIN an

d DEPRESSION

Usua

Stepped Care

Step 1: Optimized antidepressant therapy

Step 2: Pain self-management program

Assessments at baseline, 1, 3, 6, and 12 

17
Pain Self Pain Self-Management Prog

Management Prog

(6 sessions over 12 weeks)

y Education Education – pain; vocabulary; red flag

pain; vocabulary; red flag

y Id if i / dif i f d b li 

Identifying /modifying fears and belie

yGoal-setting and problem setting and problem-solvingy Exercise Exercise – strengthening; aerobic; etc

strengthening; aerobic; etc

yRelaxation; deep Relaxation; deep-breathing; breathing;yH dli i fl Handling pain flare-upsyWorking py with clinicians and em with clinicians and employe

18
SCAMP Study Findin

y Substantial improvements in depre

severi d i i ity, response, response, and rem

iss

ion ra

y Moderate benefits in pain severity 

disability

Kroenke K, Bair MJ, Damush TM, Wu J, Hoke S, Sutherland JM, Tu W. Op

Antidepressant Therapy and Pain Sel

f-Management in Primary Care Patients 

19

Musculoskeletal Pain and Depression: A Randomized Controlled Trial. JAMA 2110
Rationale

yTo complement the quantitative 

from SCAMP

yH l l i d l i 

Help explain reasons underlying intervention effect 

yWhy y particular aspects may have 

worked and did not work

20
Focus Group Protocol

yStratified by gender and clinic si

vs University)

y3 6 i i i d 3 to 6 pat

ients part

i

c

ipate

d

yExperienced moderatorySemi-structured 

questions 

21
Data collection

y Same moderator facilitated all four focuy 2 note-takersy Sessions were both audio

- and video

-rec

y Audio-tapes were professionally transcry Sessions were 2 hoursy Moderator and note-takers met to discu

impressions

22
Data analysis

y

1st read of transcripts independe

yCreated a preliminary list of sa

quotes

yPreliminary list of themes yDevelo

p gp ment of a

greed u

pon co

yMAX.QDA 2007 software

23
Participant Recruitme

yAll patients who completed the 12-

SCAMP trial intervention were elig

yClose

-out survey participants were 

out survey

, participants were 

they were interested

y Participants received $40 for their t

travel expenses

24
Setting

yVeteran Affairs () 

VA and Unive

primary care clinics

25
Participants

y11 from Universit

y, 7 from VA

yAge 27 to 84 years old (M = 54y61% womeny72% hit d 22% bl k 72% 

whit

e and 22% blac

k

26
Participants

y101 ti t l t d th 12 101 patient comp

l

e

t

ed th

e 12-m

trial

y52 randomly contactedy18 refused and14 could not be 

sch d l d h

e

d

u

l

ed or were no-s

hows

yAll 18 participants had complete

self-management program

27
Broad themes

y12 unique barriersy10 unique facilitators ySelf-management practices used 

participants 

28
B i t i lf Barr

iers t

o pa

i

n selfmanag t emen

t

29
Pain is disabling and interfer

with self-management y “A lot of those things I love to do, b

do. Like, I love to walk. I use to walevening; and, now, I evening; and, now, I m like, it takes 

’m like, it takes 

forever to go down three blocks and 

30
Patients fear the

y will hurt m

with exercise and physical acy“There have been times I have be

pain, and I don’t want to exercisdon

’t t t d h ti 

t want t

o end up hurting my

31
PCPs prescribe medications 

only modality to relieve painy “M

y j pp 

 doctor 

just wants to 

push 

presc

after prescription, and I didn’t want th i I t d t fi it S k th

e pa

in, I wan

t

ed t

o fi

x it. So, you k

the different techniques, like the relexercise, working, and gardening, an. I didn . I didn t want to take a whole bun

’t want to take a whole bun

medicine”

32
Dep g

ression and Stress Nega

Affect Self-Managementy“Well, I mean, when you are depre

you just don’t want to do nothing. want to I just want to lay there want to . . . I just want to lay there wallow in my pity.”

y“And down in the hole was where 

were focusing on how bad you hurwere focusing on how bad you hurfelt like you were the only one wit

33
Other barriers

ySome strategies don’t work o

not tailored

yL k f i l t Lack 

of soc

i

al suppor

t

yNot having the timeyLack of self-disci

pline

yLimited financial resources

34
F ilit t t i l

Facilit

a

tors t

o pa

i

n sel

manag t emen

t

35
Re e o dep ess o sy pto s 

lief of depression symptoms 

patients with pain self-managemy“The depression went away and 

able to do more.”

y“Ok f h “Okay, so once you got out of th

depression, you were able to, stathink about strategies to help yopain.”

36
H i g th S t f O

Hav

i

ng th

e Support 

of O

y“It makes a world of difference . 

Nothing works better than supp

y“ h ( ) “

s

h

e (nurse care manager) can g

back on track back on track and provide posi

” and provide 

“posi

reinforcement.”

37
Other facilitators

ySocial comparisonyBeing a proactive patientyPositive thinkingyHaving different options for self

mana

gemen

t

38
Discussion

y Identified patient perceived barriers and facilitato

self-management 

y Barriers:

y Disabling effects of painy How PCPs use medications as the sole modality foy Negative effects of depression and stressy Fear that exercise and activity exacerbates painy Lack of efficacy of some self-management practicey Lack of social support

39
Discussion

y Facilitators

yTreatment and relief of depression symyHaving supportyComparing one Comparing one s pain with that of oth

’s pain with that of oth

yBeing a proactive patient, having ayPositive attitud d e an using positive 

thinking/affirmations

yHaving a menu of options

40
Limitations

yPossible we did not capture poss

perspectives on what makes selfmanagement l diffi 

t more or less difficu

yPossibility of self-selection bias

41
Implications

y Identifying barriers and Identifying barriers and needs is helpful in the d

“needs

” is helpful in the d

and implementation of successful self-managemefo pat e ts w t c o c ess (G asgow) r pat

i

e

nts w

i

t

h chr

onic illness (G

lasgow)

y Providers should be aware of what interferes with 

patients engage in these activities

y Effective treatment of depression should be a goa

optimize outcomes from self-management interv

y Interventions need to be developed to equip prov

brief yet tailored self brief, yet tailored self-management tips

42
Implications

yM difi ti th t b tt dd M

odifications th

at b

etter

addres

barriers and facilitators may be n

yCross-cutting relevance of patie

managemen

t

Ch d h J M SC M ji W l M li Ch i di 

43

Ch

o

dos

h

J, Morton SC, M

ojica

W, et

al. Metaanalysis: Chronic disease 

management programs for older adults. Ann Intern Med 2005;143:42
Conclusions

yF t t di h ld id F

u

ture

s

t

udies

s

hould conside

to capitalize on the facilitatoridentified while at the same taddressing the barriers to paimanagement

44
Thank you

Matthew Bair@va gov Matthew.Bair@va.gov

45