Providers' roles in enhancing patients' adherence to pain self management

ABSTRACT

Practice guidelines and empirical research related to pain management encourage clinicians to take active roles in providing education about self management and promoting adoption of a self-management approach. The purpose of the study was to review the relevant literature, summarize aspects of the patient–provider interaction that influence patient engagement in self management for chronic pain, and outline practice recommendations in this area. Review of the literature on aspects of the patient–provider interaction that promote engagement in pain self-management was used. Findings are synthesized into recommendations for providers. Patients benefit from a biopsychosocial and patient-centered approach. Patients are more likely to fully disclose when providers respond empathically, which can improve conceptualization and treatment. Patient education and motivation play important roles in engaging patients in self management. Self management is influenced in part by the patient–provider communication process. Suggestions for communication strategies to facilitate patient engagement in self-management techniques, including empathic discussion of barriers and motivation enhancement, are provided.

Pain is one of the most common presenting problems in medical settings [1], and the majority of pain treatment tends to be carried out in the primary care context [2]. Pain that persists beyond 3 months and that does not remit with typical treatments for acute pain, such as rest, non-steroidal anti-inflammatory drugs, and heat or ice, is considered chronic pain. It is estimated that more than 100 million Americans have chronic pain [3], and prevalence in other countries varies from about 10–50 % of the general population [4]. Not only is chronic pain a prevalent health issue but it also significantly impacts quality of life [5–8] and the costs of care, and lost productivity are estimated to total almost $635 billion each year [3].

Pain guidelines have recommended self-management strategies in the treatment of chronic pain [9, 10]. Self management differs from other treatments such as surgery and medication in that it emphasizes the patient's own control over his/her pain experience rather than relying on external factors to treat pain symptoms. At its most rudimentary level, self management consists of basic methods such as distraction, physical activity, and ice or heat to manage pain. Many patients use these practices on their own or are able to easily implement them after receiving reassurance and encouragement from their providers. Other patients may benefit from additional self-management techniques, such as those emphasized in cognitive–behavioral treatment for chronic pain, that aim to modify the thoughts and behaviors that contribute to the maintenance and exacerbation of pain. Such self-management skills include time-based pacing, relaxation, stress management, and identifying and modifying catastrophic thinking related to pain; these techniques have been shown to be effective in a number of studies [11–15]. Self-management techniques are consistent with the biopsychosocial model of chronic pain. In contrast to the biomedical model's focus on pain resulting from an underlying physiological or structural process (e.g., tissue damage), the biopsychosocial model also emphasizes the contributions of psychological and social factors to the development and maintenance of chronic pain, such as depressed mood or avoidance of physical activity due to fear of pain exacerbation [16].

Many individuals with pain likely successfully implement basic self-management strategies, such as distraction or physical activity, on their own and, therefore, do not seek pain management services. Studies of resource utilization have not found a strong relationship between pain severity and help seeking. In contrast, other factors, such as lack of social support and poor physical functioning, are reliable predictors of help seeking among individuals with chronic pain [17, 18]. This suggests that those who seek care from providers may have fewer coping resources or are more concerned about potential causes and implications of pain. Patients' expectations for treatment usually include treatments that will provide fast relief and not require significant lifestyle changes, such as medications. In response to these expectancies, providers may feel pressured to explain the cause of pain and provide a medical intervention to distressed patients rather than first emphasizing self management, which may in turn further reinforce patient concern and reliance on medical intervention for pain management.

Motivating patients to engage in programs that teach self-management depends largely on the communication process and the quality of the patient–provider interaction. A comprehensive review of the literature on the role of the physician–patient relationship demonstrated that the quality of the patient–provider interaction predicts patient outcomes, including patient adherence to treatment recommendations, participation in the decision-making process, and satisfaction with the encounter and overall treatment, as well as some primary medical outcomes [19]. Improved provider communication has also been associated with improved self care of diabetes [20] and some physiologic measures such as improved blood pressure [21]. Providers play important roles in providing patients with information about self management and in enhancing motivation and self efficacy for engaging in self-management techniques.

There are three primary aims of this review. First, we will review what is known about patient-centered pain care and communication processes that facilitate patient self management. Second, we will discuss two specific goals of that interaction, namely, (1) to educate patients about chronic pain and self-management strategies and (2) to enhance motivation and self efficacy for pain self-management. Third, we will outline recommendations regarding patient–provider communication and strategies for facilitating patient engagement in self-management.

THE PATIENT–PROVIDER RELATIONSHIP

The evolution of the patient–provider relationship

Over the past 30 years, the nature of the patient–provider relationship and decision-making process has changed greatly. Only several decades ago, physicians tended to serve a largely paternalistic role in treatment decision making [22, 23]. As the medical field advanced and developed additional treatment options (thus necessitating decision-making among available treatment options) and patients became more informed about their own healthcare [23], the emphasis shifted from physician paternalism to shared decision making. This involves the provider presenting risks and benefits of available treatment options and the patient articulating his/her values and goals, with this process eventuating in a mutually agreed-upon decision. Collaborative treatment and decision-making approaches have been promoted by the Institute of Medicine [24] and the American College of Physicians with the American Pain Society [10].

There now appears to be a relatively normal distribution of patient-centeredness. Whereas some physicians continue to have a paternalistic style of care, and others are primarily patient-centered, most fall somewhere in between these two extremes [25, 26]. However, these findings tend to reflect physician self-report of shared decision making, and observational data indicate that many physicians make minimal efforts to actually foster patient decision making in day-to-day practice [27]. Research on patient attitudes shows that, although patients often vary in the degree to which they want to participate in medical encounters, most patients prefer physicians who are patient, attentive, integrative, cooperative, patient-centered, informative, and empathetic [25, 28, 29].

Patient-centered pain care

Collaborative management and patient-centered communication are especially important in chronic conditions such as pain. Optimal provider–patient communication about chronic pain is important for several reasons: (1) there are numerous treatments for chronic pain that vary significantly in their invasiveness, effectiveness, and possible complications, and there is ambiguity regarding what constitutes the best treatment for a given patient; (2) patients often report concerns related to providers' views of the legitimacy of their pain complaints, which may affect disclosure and engagement [30–34]; and (3) engaging patients in self management is often essential to achieving adequate symptom relief and improving quality of life [11–15, 35–37]. Collaboration often begins by identifying problems and shared goals. Communication is crucial during this early stage because providers and patients often hold different views and assumptions. Providers often focus on diagnosis, treatment adherence, and overall effectiveness. Conversely, patients more often focus on emotional distress, functional impairment, and maintaining their quality of life [38, 39], all factors which are addressed in the self-management approach to chronic pain.

The working alliance and patient outcomes

The provider–patient working alliance is defined as a strong and positive bond between provider and patient that is associated with working collaboratively to achieve mutually agreed-upon goals. The working alliance is considered to be one of the most important aspects of patient-centered care [40, 41]. Although the concept of the working alliance originated in mental health research, the quality of the provider–patient relationship has a significant impact on patient outcomes in medical settings as well. A stronger provider–patient alliance has been associated with patient agreement with treatment recommendations, greater self efficacy, and increased physician empathy, and is a significant predictor of patient satisfaction and adherence to treatment recommendations [42, 43].

Specific aspects of the provider–patient encounter appear to predict satisfaction and adherence among patients with chronic pain [44, 45]. Patients who report receiving clear information about pain and treatment are more likely to be satisfied both with the care they received and the improvement in their symptoms, and, in turn, are also more likely to be adherent to treatment recommendations [44]. In a review paper, Street and colleagues [46] examined underlying proximal and intermediate variables linking the provider–patient communication process to health outcomes. In their model, aspects of the communication process, such as information exchange, empathic and reassuring responses from the provider, and the quality of the provider–patient relationship, can all affect proximal outcomes such as patient understanding, trust, and motivation. These proximal outcomes in turn affect intermediate outcomes such as knowledge of self-management skills and treatment adherence, which contribute to positive health outcomes [46]. Indeed, studies have shown that responding to patient questions, reducing patient health-related distress, establishing a stronger working alliance, responding empathically, and supporting patient autonomy and self efficacy [40, 46–52] are associated with improved patient adherence to self management.

IMPROVING ADHERENCE BY INCREASING PATIENT KNOWLEDGE, MOTIVATION, AND SELF EFFICACY

Providers can help empower patients to develop a sense of control over their pain by providing patients with information about chronic pain and self management. A number of issues should be addressed when educating patients about chronic pain. First, a brief explanation about the differences between acute and chronic pain can help patients understand that chronic pain is a condition that will require continued management rather than an illness that can be “cured.” Second, patients should be educated about the importance of continued activity, which is perhaps the most basic yet important aspect of pain self management. A review of randomized controlled trials examining the role of advice on management of chronic low back pain showed that advice to stay active coupled with exercise was most effective for improving pain, back-specific function, and work disability [53]. Patients are also more likely to adhere to self-management strategies when provided specific information about self management and its effectiveness either verbally or through books or handouts [54, 55]. Finally, patients may benefit from education about the role of psychosocial factors in the maintenance of chronic pain. In this context, discussion of the gate control theory of pain and the cognitive–behavioral model of chronic pain may be useful. In brief, the gate control theory of pain [56] posits that a number of factors (such as mood, motivation, and cognitive focus) modulate pain perception and that pain can be altered by targeting these factors. Cognitive–behavioral treatment targets the thoughts and behaviors that maintain and/or exacerbate pain perception. Self-management tools promoted in cognitive–behavioral treatment include relaxation, activity scheduling, time-based pacing, and identifying and altering maladaptive thoughts about pain [57]. These strategies aim to reduce pain-related distress and increase functioning and overall quality of life.

It is widely acknowledged that providers often have limited time for such discussions. Nevertheless, the basics of self-management, including discussion of the biopsychosocial model of chronic pain and encouragement to continue with physical activity, can usually be completed during the course of a brief visit. Patients can be provided with handouts about the role of psychosocial factors or provided with recommendations for books or self-help manuals for pain self management. Techniques such as time-based pacing or relaxation skills can also be covered through brief education and information provision, followed by goal setting to create a plan for patients to begin implementing such techniques. Providers who have limited time to discuss such topics with patients, or who do not feel adequately trained to provide more in-depth information about these topics, may also opt to refer to other providers, such as psychologists, nurses, or physical therapists, for education and follow-up (see “Referrals to other healthcare providers” below).

Assessing and enhancing patient motivation for pain self-management

Why focus on patient motivation?

Patient motivation is especially important to successful pain self management because patients must make and maintain lifestyle changes in order for self management to be effective and for benefits to be sustained. In their review of motivation for self-management in patients with chronic pain, Jensen and colleagues [58] discuss how motivation fluctuates and is influenced both by perceived importance of change as well as self efficacy for change. Assessing and enhancing patient motivation and self efficacy supports patients' engagement in self-management. It also increases the likelihood of following up with referrals to other providers, such as psychologists or physical therapists, who can instruct the patient on self-management strategies. Becker et al. [59] showed that a low back pain intervention had stronger effects when provided in conjunction with a nurse-led motivational counseling component compared to the intervention alone or a control group that received information about pain. In addition, Habib and colleagues [60] examined the effect of an assessment and feedback intervention on attendance at pain self-management workshops. The intervention addressed patient beliefs about self management, current activity, perceived importance of self management, and perceived confidence in engaging in self management. Patients randomly assigned to receive this intervention were significantly more likely to attend pain self-management workshops than were patients in the control group who received a standard pain assessment and attention placebo. Further, studies have shown that patients who were initially hesitant about self management were less satisfied with treatment [61] and that patients' self-reported “readiness to change” predicts the likelihood of completion of a self-management program [62, 63], discussed further below.

Assessing readiness to change

Prochaska and colleagues' transtheoretical model of behavior change hypothesizes that patients vary in their stage of readiness to change behaviors (e.g., quit smoking and start exercising) and incorporates approaches to promote behavior change by enhancing motivation [58, 64]. Five stages of change have been identified: (1) precontemplation, in which the individual is not yet interested in change; (2) contemplation, in which the individual has begun contemplating change; (3) preparation, in which the individual has decided to make a change and plans to do so in the near future; (4) action, in which the individual is currently attempting change; and (5) maintenance, in which the individual continues to maintain changes.

Kerns and colleagues [65] adapted the model and developed a brief questionnaire, the Pain Stages of Change Questionnaire, to assess patients' readiness to adopt a self-management approach to chronic pain [65]. Predictive validity of the measure has been documented by demonstrating that patients who endorsed fewer items from the precontemplation scale and more items from the contemplation scale prior to participating in pain self-management treatment were more likely to complete the intervention [62]. In addition, over the course of treatment, patients were more likely to move towards the action and maintenance stages. Finally, as precontemplation scores decreased and action and maintenance scores increased, desired outcomes such as reduced pain severity, disability, and depression, and increased goal achievement tended to improve [62]. These findings have generally been supported in subsequent research employing this measure [58, 66–71].

Motivational interviewing

Patients may feel ambivalent about pain self management for a number of reasons. Even when provided with information about the ways in which self-management can improve outcomes, patients may continue to believe that medical interventions, such as medication or surgery, are necessary to achieve adequate pain relief. In addition, self-management requires continued effort on the part of the patient, so those low in self efficacy may initially find self management to be overwhelming. One way to enhance motivation for engagement in self-management is through motivational interviewing (MI). This counseling style, developed by Rollnick and Miller [72], is a collaborative and evocative method of discussing behavior change that helps patients explore and resolve ambivalence about change. There are four key principles to MI: (1) expressing empathy, which lets the patient know s/he is being heard and understood; (2) rolling with resistance, in which the provider acknowledges the inevitability of fluctuating ambivalence and refrains from confronting the patient or disputing his/her thoughts and beliefs; (3) supporting self efficacy, in which the provider elicits and reinforces statements of self efficacy from the patient; and (4) developing discrepancy by highlighting the contrast between the patient's current behavior and his/her values and goals [73].

MI has been shown to be effective in promoting change among patients with substance-abuse problems [74–77], as well as with other health behaviors, such as improving diet, diabetes management, blood pressure, and activity level [47–49, 78–80]. Although there have been few studies specifically examining the role of MI in engagement in pain self management, the results thus far appear promising [81–83]. Friedrich and colleagues found that patients receiving motivational counseling in addition to physical therapy (PT) had improved attendance, decreased disability, and decreased pain in both 4 and 12 months post-PT compared to patients receiving standard PT [81]; at 5-year follow-up, those who received motivational counseling continued to report lower pain and disability levels, as well as greater working ability [82]. Vong and colleagues [83] showed that, compared to standard PT, patients receiving PT in conjunction with MI reported significantly greater improvements on measures of general perceived health, lifting capacity, and exercise adherence. Patients also reported significantly greater improvements in the working alliance between themselves and their physical therapists, as well as greater treatment expectancy, when their physical therapists utilized MI techniques [83]. However, Basler and colleagues found no improvement in adherence to exercise recommendations among older adults with chronic back pain after a transtheoretical model-based counseling intervention [84].

Referrals to other healthcare providers

Given that physicians often have limited time with patients, patients may benefit from meeting with a nurse, social worker, or physical therapist for education and follow-up, or from a referral to a psychologist or other behavioral specialist. Patients may be hesitant if offered referrals to clinical health psychologists (who specialize in working with patients for whom coping with chronic disease and/or health behavior change are primary goals) or other mental health providers for a number of reasons. Some may have had experiences in which they felt providers indicated that their pain was “all in their head.” Others may be concerned about the social stigma of seeing a mental health provider, lack insight into how their thoughts and behavior may be exacerbating their pain, or feel rejected by their provider [85]. In order to increase the likelihood of patient acceptance of a referral, providers can first reduce stigma by providing education about the multidisciplinary model of chronic pain management, and highlight that, while many patients may not initially be aware of the model, this type of comprehensive, team-based intervention has been around for decades [86]. Providers should highlight that the mental health professional is a trusted member of an interdisciplinary team that will help the patient achieve his or her goals [87]. Early discussion of the biopsychosocial model of pain can also help patients understand psychosocial contributors to chronic pain and potentially reduce resistance if a referral is later made to a psychologist, social worker, or nurse to help address psychosocial issues that may be exacerbating pain. Further, providers can help patients clarify treatment goals (e.g., reduce pain-related distress and increase physical functioning) and discuss how mental health providers can help patients work towards those goals [87]. In keeping with the spirit of shared decision making, the discussion of a possible referral can be conducted over a series of meetings to provide patients with the opportunity to consider the referral, ask questions, and discuss their preferences [85].

DISCUSSION

Studies have demonstrated the effectiveness of pain self management, and guidelines generally suggest reassurance, information provision, and encouragement of self management (e.g., physical activity, time-based pacing, and distraction) as the initial treatment for pain. However, likelihood of patient engagement in, and continued adherence to, pain self-management is influenced by provider–patient communication. Provider behavior, including forming partnerships with patients, expressing empathy, providing information, and enhancing motivation, all facilitate patient engagement in pain self management. Based on past research, the following recommendations are made for talking to patients about pain self management:

1. Build a strong provider–patient relationship. Patients tend to be more adherent, as well as more satisfied with the interaction and treatment recommendations, when the working alliance between provider and patient is strong. Providers contribute to a positive working alliance by treating patients as valued partners in their care and engaging patients in shared decision making, which includes assessing patient goals and resources and placing particular emphasis on strategies that fit within those parameters.

2. Validate the patient's experience using patient-centered communication. Patient-centered communication has many parallels to the Rogerian person-centered therapeutic approach, which emphasizes how a clinician's authenticity, unconditional positive regard, and empathy facilitate psychotherapeutic change in a patient [88]. Many patients report not feeling understood by providers, and some report that they either withhold or emphasize certain aspects of their pain experience based on reactions they have received from providers in the past. Patient-centered communication techniques, which include exploring patient understanding, expressing support and empathy, acknowledging patient autonomy, and eliciting and responding to emotions [89], help patients feel understood by their providers. In most cases, these communication techniques can be implemented without adding time to the consultation; rather, positive changes can be made in the relationship by taking advantage of opportunities to provide empathy and support, even when these communication techniques occur only infrequently during the conversation [90].

3. Provide information on chronic pain and self-management. Early discussion of the biopsychosocial model of chronic pain and the value of multidisciplinary teams will help inform patients of the role of psychosocial factors in chronic pain and prepare patients for the possibility of future referrals to physical therapists, psychologists, or other providers. Discuss the value of self-management (for example, that it provides patients a sense of control over pain rather than solely feeling dependent on external means for pain relief) as well as the fact that it is the initial treatment of choice based on research and guidelines.

4. Utilize motivational interviewing techniques to enhance motivation and self efficacy for self management. By rolling with resistance and exploring potential benefits and barriers to adopting a self-management approach, providers can guide patients towards change while avoiding confrontation and respecting patient autonomy. Highlighting the discrepancy between a patient's values (e.g., playing with one's children) and current behavior (e.g., avoidance of activity) can elicit change talk from patient (e.g., “Maybe I can figure out a way to play with them that won't make my pain worse”). Reflecting back what the patient has said (e.g., “Sounds like you're hoping to spend more time being active with your kids”) helps the patient feel understood and reinforces statements consistent with making a change.

5. Collaboratively discuss the pros and cons of treatment delivery options of self-management, if applicable (e.g., provider recommendations, self-help/self-management workbooks, or referral to another provider).

6. Collaboratively create an action plan by setting specific, measurable, and action-oriented goals with a proposed timeline for achieving them. Because patients are used to receiving prescriptions for their medical problems, it may be helpful to emphasize that the “prescription” they are being provided is the plan for behavior change discussed during the meeting. And, just as providers often ask about medication adherence at the next appointment, set expectations that they will be asked about their behavioral goal accomplishment as well. Potential barriers and facilitators should be identified in order to develop an action plan for overcoming barriers and increasing the likelihood of adherence to recommendations for behavior change.

7. Continue the discussion of pain management during subsequent appointments. Assess patient adherence to recommended self-management strategies as well as potential barriers that may have affected adherence. If possible, problem-solve around barriers. Reinforce motivation and adherence, and if needed, return to the discussion of motivation for change.

8. Not all patients will benefit from self management alone. Patients may need to supplement self management with other treatments, such as physical therapy or medication, in order to sufficiently improve physical functioning and overall pain management. Set a timeline for discussing additional treatment options if goals are not met. Assure patients that you are not being dismissive of pain complaints but rather are first recommending a primarily self-management approach suggested by research and guidelines.

In closing, continued research in this area should be encouraged to identify methods for empowering providers to be effective in promoting patient adoption of self-management approaches to chronic pain. Incorporation of effective education and training approaches for medical providers and associated healthcare professionals that foster strong working alliances and patient-centered communication are particularly indicated.