Self-Management of Chronic Pain: Psychologically Guided Core Competencies for Providers

Introduction

Maria has significant, chronic knee pain from osteoarthritis that she feels has worsened through years of bending over and kneeling during her career as a licensed practical nurse. Nothing has successfully offered lasting relief. Medications make her feel woozy or upset her stomach. She doesn’t feel safe outside alone in her neighborhood, so she does not exercise. Maria has heard there might be other options like yoga, mindfulness, and physical therapy, but she doesn’t know how to find these services, doesn’t think she can afford them, and isn’t convinced they will work. In the meantime, Maria powers through her pain because she needs to work. She’s depressed, and pain dominates her life.

Millions of people like Maria (a fictitious patient) experience chronic pain and seek help from providers of various types. The dominant biomedical model and longstanding societal norms reinforce the idea that health problems require the attention of a health care provider who can identify the source of the problem and “do something” to eliminate it, typically via medications or surgery. However, the traditional patient–provider encounter is impractical and inefficient for managing multidimensional conditions like chronic pain. The ways individuals manage chronic pain are highly personal and not only are driven by provider-based information and interventions, but also are influenced by a lifetime of internalized views and behaviors, written or online information of variable quality, guidance from family and close social ties, and highly funded marketing efforts that reinforce biomedical approaches to health in general and pain specifically.

Self-management of chronic pain reflects intentional, active efforts to manage pain and its effects on physical and emotional function [1]. A patient’s adoption of a self-management approach for chronic pain is predicated on perceptions of self-efficacy: the belief in one’s own capacity for self-management. However, we know that pain self-management is a continuous process that requires the motivation, knowledge, and skills necessary to maintain effective physical and psychosocial function [2]. Ideally, these skills include the use of cognitive, emotional, and behavioral strategies to manage personal, family, and social roles and responsibilities and the emotional consequences of chronic pain. Ultimately, self-management of chronic pain is specific to an individual and controlled by her or him. For this reason, providers of every type must consider factors beyond provider-initiated interventions that have the potential to shape an individual’s ability to manage pain effectively and thus contribute to quality of life in the long term.

Previous work has affirmed the value of provider empathy and effective communication about the management of chronic pain and barriers that interfere with such management [3]. Successful self-management of pain thus grows from strong, dynamic, collaborative relationships between individuals with chronic pain and their health care providers—relationships that prioritize patient empowerment, activation, and self-efficacy and that can evolve over time [4]. One example of such a strategy is the Department of Veterans Affairs (VA) Stepped Care Model for Pain Management, which emphasizes general health-promoting behaviors, including nutrition and weight management, exercise and conditioning, sleep quality, engagement in meaningful activities, and family/social support [5]. The VA-based model also provides guidance for the use of patient-controlled pain-reducing activities, such as the use of ice and stretching, mindfulness-based meditation, and relaxation strategies, among other evidence-based modalities. Other resources have been developed by the American Chronic Pain Association and the Centers for Disease Control and Prevention. Clinical practice guidelines promulgated by the American College of Physicians and other entities have also specifically encouraged the use of evidence-based nonpharmacological approaches consistent with self-management of pain.

Although existing guidance emphasizes broad health-promoting behaviors as well as pain-specific approaches to patient-driven self-management of chronic pain, clinicians across disciplines are often not sufficiently aware, incentivized, or skilled to help patients learn and adopt these practices. Lack of provider training, time, and reimbursement models for self-management activities (such as health coaching) likely prevents opportunities for millions of individuals with chronic pain to learn to better self-manage their symptoms and improve their quality of life.

Self-Management of Chronic Pain: Ideal but Elusive

We are investigators from different health professions with unique clinical and scientific experiences and expertise related to chronic pain. Collectively, we are conducting pragmatic trials of nonpharmacological approaches to pain management within large, integrated health systems that serve military and veteran populations, comprising the National Institutes of Health (NIH)–Department of Defense (DOD)–Department of Veterans Affairs (VA) Pain Management Collaboratory [6]. We are well aware of the value of promoting self-management of chronic pain, as well as the challenges faced by practitioners aiming to guide patients in these activities. These challenges came into sharp relief when the rapid shift to virtual care inspired by the coronavirus disease 2019 (COVID-19) pandemic affected the delivery of evidence-based chronic pain management approaches commonly associated with in-person and hands-on care, such as physical therapy and chiropractic care [7].

Despite our different clinical perspectives, however, we are remarkably well aligned on the importance of fostering patients’ capacity for self-management of chronic pain. Herein, we articulate a call to action for core competencies that are provider agnostic and grounded in evidence-based psychological principles and specific approaches that are foundational to building self-management skills, such as promoting positive behavior change and motivational interviewing [8]. We recognize that pain self-management is a higher-order construct that spans specific disciplines and interventions, and we believe that self-management competencies are akin to other critical clinical skills, such as diagnosis and intervention delivery, that should be adopted by all health care professions to better help patients manage chronic pain.

As noted, we recognize that providers might not be well prepared to help their patients acquire the knowledge, skills, and motivation to manage their pain in the long term. Hurdles include long-standing patient and provider preferences for medication-based treatment; insufficient training and resources; lack of health system algorithms for multimodal care; variable awareness of, access to, and acceptance of nonpharmacological treatments for chronic pain; and financial incentives for procedure-oriented approaches as opposed to integrated, multimodal care incorporating education, physical activity, healthy diet and sleep practices, and psychological approaches designed to support self-management of chronic pain. Moreover, for a range of reasons, many patients are either unaware of or unable to adopt evidence-based options that are available to people living with chronic pain, such as recommended behavior changes associated with positive health outcomes [9].

A critical aspect of effective self-management of chronic pain is managing behavior, which requires sustained personal effort. Patients might see a behavior like yoga as beneficial but not be well equipped, or ready, to take the necessary action. This is an essential reality for providers to recognize and address when helping patients develop pain self-management capabilities, skills, and self-efficacy. Even individuals who might initially be unprepared to contemplate behavior change can benefit from interventions designed to promote pain self-management [10], aided by a strong therapeutic alliance and a growing perception of self-efficacy [11].

Provider Core Competencies for Self-Management of Chronic Pain

The concept of core competencies for pain management is not new and has been articulated as a set of 25 skills arrayed across four domains: 1) the multidimensional nature of pain; 2) pain assessment and measurement; 3) pain management; and 4) clinical context [12]. These core competencies were developed through interprofessional consensus targeted to prelicensure requirements, but they do not explicitly address self-management strategies in detail. We believe all health care professionals involved in pain care have a responsibility to their patients to exhibit core competencies for guiding self-management of chronic pain. The details of these competencies are beyond the scope of the present commentary, but we have summarized key principles and processes in Figure 1.

Figure 1.

Patient-centered application of core competencies to support self-management of chronic pain.

The multidimensional nature of pain and pain assessment domains encourages consideration of the fact that chronic pain is multifaceted and exists along a spectrum of severity, from mild intensity and limited impact on routine functioning to high-impact chronic pain, defined as chronic pain that interferes with work and daily functioning on most days. Also important to consider are the multiple factors associated with the development and perpetuation of chronic pain (e.g., underlying pain conditions, co-occurring physical and mental health conditions, fear avoidance, pain catastrophizing, health risk behaviors). Education and motivational interviewing can support patients’ reconceptualization of chronic pain as a problem that can be self-managed, in part or in whole. These types of approaches help build a foundation for discussing current pain self-management strategies and opportunities for acquiring and practicing new approaches designed to enhance self-management capacity. Explicit attention to the clinical and social context of pain self-management includes efforts to promote integration of care and coordination across settings and providers. It is also important to address issues of equity and disparities in pain and pain care within the context of the biopsychosocial model, with recognition of experiences of racism and discrimination within and outside health care, as well as recognition of individual differences in pain coping. Providers should aim to provide equitable care overall and to identify opportunities to address inequities and injustice.

Psychologically guided self-management of pain—which includes psychological training, lifestyle modification, pain education, physical activity, and some complementary and integrative therapies—is informed by the biopsychosocial model and social cognitive theory, similar to self-management of chronic illness, and evidence suggests that it helps improve patient-centered pain outcomes [13]. Irrespective of health profession, provider core competencies built around psychologically informed pain self-management can contribute to a framework for helping patients achieve desired outcomes. Honest discussions about unique barriers and real-world challenges to changing and sustaining behaviors that contribute to important patient outcomes are critical. Example strategies include use of the Behavior Change Wheel [14] and motivational interviewing techniques, such as those employed by the VA Whole Health [15] and DOD Move to Health [16] programs, which are used to highlight actionable strategies and goals. These approaches consider the emotional, social, and psychological barriers to changing behavior, in addition to assessing whether a patient feels ready to make changes.

As health care systems evolve to support self-management capacity-building activities in which health coaches, peers, and nonclinicians assume more prominent roles, pragmatic clinical trials can begin studying the effectiveness and implementation of these approaches in real-world clinical care scenarios. To that end, we recognize that, as any management approach has the potential for harm, self-management–building activities can lead to adverse effects, particularly if a strategy is not well matched to a patient. These might arise from insufficient clinical oversight, communication skills, follow-up, or understanding of providers (e.g., recommending exercise that is too vigorous) or when patients misinterpret or stray from instructions or fail to report new or progressing symptoms. To minimize potential risks, providers who help their patients engage in self-management–building activities should consider the range of recommended strategies and communicate frequently with their patients about adverse events, practicality, and level of use.

Our collective clinical experience reveals that effective evidence-based, nonpharmacological pain management approaches should include engaging patients with self-management tools. One example is the use of psychologically informed physical therapy to promote structured exercise and valued activities [17]. Others, such as acceptance and commitment therapy, mindfulness-based stress reduction, and biofeedback, are generally consistent with this perspective [13]. Although some evidence-based provider-delivered interventions (e.g., acupuncture, spinal manipulation, massage) require little or no commitment to making behavior change on the part of the patient, these clinical encounters can provide pain relief while simultaneously offering a valuable opportunity for providers to promote a more integrated and sustainable approach to chronic pain self-management. Augmenting typically passive approaches to pain management with psychologically informed pain self-management strategies within a treatment plan should form the basis of an improved standard of care.

Conclusion

We authored this commentary because, though it is widely accepted that effective self-management of chronic pain is important, empowering patients to implement it remains elusive in practice. Complicating factors include how providers are trained and reimbursement models that often favor a procedure-based approach (contributing to dependency on providers) rather than helping patients manage their pain in the long term. Through this call to action, we aim to shine a brighter light on the need to operationalize self-management strategies within health systems, which will of course require acceptance and adoption by multiple stakeholders. Consistent with well-studied theories of behavior change, through consistent application of provider core competencies for self-management of chronic pain, providers can help patients discover and address barriers and can provide support, encouragement, and reassurance. Such activities represent clinical goals focused on creating environments for patients to become the principal agents of long-term pain management success.

 

Funding sources: This project was made possible with support from Grant Number U24 AT009769 from the National Institutes of Health/National Center for Complementary and Integrative Health (NCCIH) and the Office of Behavioral and Social Sciences Research (OBSSR), in addition to support from the following UG3/UH3 cooperative agreements from the NCCIH: AT009761 (with additional support from the NIH Office of Research on Women’s Health; CG, AJL, RV), AT009763 (JMF, DIR), and from the Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense, through the Pain Management Collaboratory - Pragmatic Clinical Trials Demonstration Project Awards W81XWH-18-2-0003 (DJB) and W81XWH-18-2-0007 (SF).

Disclaimer: The view(s) expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Army, Department of the Navy, the U.S. Defense Health Agency, the Department of Defense, the Department of Veterans Affairs, NCCIH, National Institutes of Health, or the U.S. Government.

Conflicts of interest: Dr. Chad Cook receives honoraria from Pearson Education, Medbridge Education, AGENCE EBP, MAPS, and the Parker Academy. He is a stockholder of AT&T and Williams Energy. He is a research consultant for the Hawkins Foundation of the Carolinas. He is an educational consultant for the Higher Education Academy of Israel and is the Director of the Duke Center of Excellence in Manual and Manipulative Therapy (the role receives external funding).  No other authors report any potential conflicts of interest.

Disclosure: This commentary is a product of the NIH-DOD-VA Pain Management Collaboratory. For more information about the Collaboratory, visit https://painmanagementcollaboratory.org. NIH-DOD-VA Pain Management Collaboratory projects are supported by multiple U.S. government agencies and entities, including NIH’s NCCIH, National Institute of Neurological Disorders and Stroke, National Institute of Drug Abuse, National Institute of Alcohol Abuse and Alcoholism, National Institute for Child Health and Human Development, National Center for Medical Rehabilitation Research, Office of Research on Women’s Health, and the National Institute of Nursing Research; the DOD Clinical and Rehabilitative Medicine Research Program and the Military Operational Medicine Research Program; the Center for Rehabilitation Sciences Research at the Uniformed Services University of the Health Sciences; and the VA Health Services Research and Development Service of the Office of Research and Development. The contents of this commentary are solely the responsibility of the authors and do not necessarily represent the official views of the NIH, the DOD, the VA, or the U.S. Government.