Abstract
Context:
Individuals with persistent pain-related disability have lower self-efficacy, which impacts daily function and health.
Aim:
To explore self-efficacy among individuals with persistent pain who were part of a dyad (caregiver and care-recipient) who completed the Merging Yoga and self-management Skills intervention (MY-Skills).
Methods:
Participants completed MY-Skills, an 8-week group, dyadic-based self-management and yoga program. Self-efficacy outcomes were collected using the Chronic Pain Self-Efficacy Scale; PROMIS® Self-Efficacy for Managing Daily Activities; and PROMIS® Self-Efficacy for Managing Symptoms.
Results:
Eight participants completed the study (50.23±14.77 years old, 77% female, (69%) with pain >10 years). Self-efficacy improved across all measures and domains, with significant improvement for physical function self-efficacy (38.97±19.45 vs. 59.10±18.60, p=.004).
Conclusions:
MY-Skills improved self-efficacy to varying degrees, which may contribute to participants’ confidence in performing activities. Further research is needed to examine dyadic outcomes among caregivers and care-recipients.
Keywords: self-efficacy, self-management, yoga, persistent/chronic pain, dyad
Introduction
Persistent, or chronic, pain is a pervasive and debilitating condition that impedes daily functioning, including self-care, interpersonal relationships, and work for an estimated 39 million people in the United States [1]. Persistent pain is self-reported pain that lasts longer than the expected healing period, or over three months. Persistent pain and subsequent disruption of daily activities impairs health, well-being, and quality of life (QoL) [2]. People with greater pain-related disability (the interference of pain with daily activities) report lower self-efficacy. Self-efficacy is the perceived ability to assert control over one’s self and the environment [3]. Greater self-efficacy is associated with reduced pain-related disability, less pain severity, and improved mood [4]. Importantly, individuals with greater self-efficacy report better overall health and QoL.
Self-management education and complementary approaches, such as yoga, meditation, and relaxation are beneficial strategies to address persistent pain. Yoga improves the mind-body connection, reduces pain, and improves self-competence among individuals with persistent pain [1, 5, 6]. However, researchers examining the effects of yoga on self-efficacy among individuals with pain conditions report mixed results [2, 5–7]. For example, yoga may contribute to increased feelings of capability and confidence; however, yoga intervention alone may not substantially improve self-efficacy. Self-management interventions incorporate education to improve health-management and performance of daily activities and roles by emphasizing skills to adapt to changing needs [8]. Elbers et al. found that self-management programs, particularly group self-management, increased self-efficacy for individuals with musculoskeletal pain [9].
The experience of pain involves more than the biological response; it is influenced and interpreted through psychosocial factors, including interactions with caregivers and others [10]. Thus, dyadic relationships (interactions between two people, often a caregiver and care-recipient) should be addressed and examined [10]. Dyadic interventions address a condition as well as the needs and health of both members and the relationship. In a review of dyadic studies, Li and Loke [10] noted that members of the dyad have a “reciprocal influence” on each other that affects QoL, mental health, emotional coping, role adjustment, and self-efficacy. Dyadic interventions for partners managing chronic conditions have demonstrated significant improvement in perceived competence and self-efficacy among caregivers and care-recipients. In a study by Keefe et al., dyadic participants (knee arthritis) were more likely to have improved coping, pain control, physical fitness, and psychological disability than individuals participating without their partners [11].
Interventions combining yoga and self-management strategies appear to be feasible and beneficial for individuals managing chronic conditions [12]. However, to our knowledge, no studies have been published addressing the impact of a merged yoga and pain-specific self-management intervention on self-efficacy among dyads with persistent pain. Therefore, the purpose of this study was to explore if individuals with persistent pain in dyadic relationships improve self-efficacy after completing the Merging Yoga and self-management Skills (MY-Skills) intervention.
Methods
A quasi-experimental design was used to study the impact of MY-Skills on self-efficacy for individuals with persistent pain in a dyadic relationship.
Participants
Individuals were recruited via the community and a local pain clinic. Participants identified as being in a dyadic relationship (or “dyad”) comprised of a care-recipient and caregiver, and both had to meet the pain inclusion criterion (≥ score 5 on the Brief Pain Inventory (BPI)). See Table 1 for complete inclusion and exclusion criteria. The university Institutional Review Board approved the study. All participants provided written consent.
Table 1.
Inclusion and Exclusion Criteria
| Inclusion Criteria | Exclusion Criteria |
|---|---|
|
| |
| • At least 18 years old | • Significant cardiovascular disease (class 3 or 4 congestive heart failure or myocardial infarction within the past 3 months) |
| • English-speaking | |
| • Reporting chronic/persistent musculoskeletal pain for at least 3 months | |
| • Stroke or transient ischemic attack within the past 6 months | |
| • Able to stand with or without an assistive device | |
| • Receiving/planning to receive cancer treatment within 6 months | |
| • Living in a private home within the community. (The care-recipient did not have to reside with the caregiver.) | |
| • Alzheimer’s disease or dementia diagnosis | |
| • Expectation of death within 12 months | |
| • Part of a care-recipient and caregiver dyad | • Currently undergoing rehabilitation for chronic/persistent pain |
| • Reported sedentary lifestyle (no more than 30 minutes of organized physical activity twice per week) | |
| • Undergoing drug or alcohol treatment | |
| • Currently participating in an exercise study | |
| • Reported moderate pain (BPI ≥ 5) | |
| • Clearance for physical activity as indicated by the PAR-Q+ or physician approval | • Completed self-management education for chronic/persistent pain in the previous year |
| • Caregivers must identify as the primary caregiver for the care-recipient and performed those duties for at least the previous 6 months | |
BPI = Brief Pain Inventory; Mini Mental = Short Mini Mental Status Exam; PAR-Q+ = Physical Activity Readiness Questionnaire Plus
Intervention
Dyads participated in the MY-Skills program twice weekly for eight weeks. Standardized sessions included 45 minutes of group self-management and one hour of guided yoga (Table 2). Trained clinicians delivered the self-management intervention, including: problem-solving, action planning, coping, and effective communication. A yoga therapist delivered the progressive yoga protocol and provided modifications as necessary.
Table 2.
Self-Management Content and Yoga Mantra by Session
| Session | Theme | Self-Management Content | Yoga Mantra |
|---|---|---|---|
|
| |||
| 1 | Taking Care of You | Introduction to MY-Skills, yoga, and self-management | “I am here for my care.” |
| 2 | Taking Care of Us | Community resources and the influences of partnership | “We are here for our care.” |
| 3 | Pain 101 | Overview of pain, triggers, and meaningful activities | “I will help myself.” |
| 4 | Pain as a Pair | Factors influencing pain as a pair | “We will help each other.” |
| 5 | Motivation and Pain | Motivators when experiencing pain | “I am capable.” |
| 6 | Body Mechanics | Body mechanics tips with different activities and corrections | “We are capable.” |
| 7 | Stress Management | Stress management and strategies | “Breathe in quiet, breathe out calm.” |
| 8 | Dealing with Difficult Emotions | Identify difficult emotions and identify adaptive strategies | “Breathe in quiet, breathe out calm.” |
| 9 | Communication as a Pair | Assessing communication and tips | “I am strong, together we are stronger.” |
| 10 | Communication with your Medical Team | Communicating your pain, preparing for visits, practicing communication | “I am strong, together we are stronger.” |
| 11 | Fatigue and Pain | Fatigue and pain, exercise and yoga as strategies | “I will work with my energy.” |
| 12 | Activity Modification | Activity log, tips, and strategies | “We will work with our energy.” |
| 13 | Healthy Eating and Pain | Food choices to help with pain | “I choose health.” |
| 14 | Yoga and Pain | Yoga basics, compare to other forms of physical activity | “We choose health.” |
| 15 | Applying Skills and Forming Habits | Applying skills and forming habits at home and in the community | “I can help myself.” |
| 16 | Summary and Long-Term Action Planning | Program summary, long-term action planning | “We can help each other.” |
Data Collection and Analysis
Trained, masked research assistants collected baseline demographic data and pain characteristics (Table 3). Self-efficacy outcome measures were completed at baseline and eight-weeks. The Chronic Pain Self-Efficacy Scale (CPSS) measures the perception of self-efficacy in individuals with pain across three domains: pain management, physical function, and coping with symptoms [13]. The CPSS is considered reliable and valid, increased scores indicate greater self-efficacy [13]. The PROMIS® Self-Efficacy for Managing Daily Activities Short Form 4a (SE-Daily Activities) measures the self-reported belief in one’s ability to perform daily activities. The PROMIS Self-Efficacy for Managing Symptoms Short Form 4a (SE-Symptoms) measures self-confidence related to controlling symptoms and preventing symptom interference in areas of life. Both scales are considered reliable and valid [14]. Increased scoring suggests greater self-efficacy.
Table 3.
Demographics and Pain Characteristics
| All Participants (n=13*) | |
|---|---|
|
| |
| Age, years | 50.23±14.77 |
| Gender | Female: 10 (77%) |
| Male: 3 (23%) | |
| Race | White: 12 (92%) |
| Black: 1 (8%) | |
| Part of a couple (no) | 8 (62%) |
| Education (some college) | 9 (69%) |
| Time since pain started, > 10 years | 9 (69%) |
| Are you limited in any activities because of physical, mental or emotional problems? (yes) | 7 (54%) |
One care-recipient replaced their caregiver during the study, and baseline data were collected for both caregivers.
While the program was designed to therapeutically benefit dyads, the data were not examined at the dyadic level. Data were normally distributed; paired t-tests were completed, significant was set at .05. The percent change was calculated for each variable. SPSS® Statistics Version 26.0 was used.
Results
Baseline demographics and pain characteristics were collected for 13 participants (Table 3). The average participant age was 50.23 years old, nine participants (69%) reported having pain for more than ten years, and 54% reported limitations in activities. Eight participants completed the intervention, which is a 61.5% completion rate. Drop out was related to a vehicle accident, change in dyadic relationship, and no longer being interested in the study. Others were lost to follow up. Mean attendance for all participants was 10.63 ± 3.46 yoga sessions and 10.75 ± 2.92 self-management sessions out of a possible 16 sessions over the 8-weeks intervention.
Participants demonstrated a 51.7% increase in self-efficacy related to CPSS-physical which was a statistically significant improvement (p=.004). CPSS-total increased 19.4% and CPSS-coping improved 22.8%, but neither score rose to the level of significance. Mean outcomes increased slightly for CPSS-management, SE-Daily Activities, and SE-Symptoms, but no statistically significant change was found (Table 4).
Table 4.
Self-Efficacy Scores for All Participants (caregivers and care-recipients) n=8
| Baseline | 8-weeks | p | Percent change | |
|---|---|---|---|---|
|
| ||||
| CPSS-total | 48.51±18.92 | 57.92±16.58 | .128 | +19.4% |
| CPSS-management | 51.50±23.98 | 53.63±23.15 | .574 | +4.1% |
| CPSS-physical | 38.97±19.45 | 59.10±18.60 | .004 | +51.7% |
| CPSS-coping | 50.23±17.97 | 61.70±16.83 | .207 | +22.8% |
| SE-Daily Activities | 13.63±1.41 | 14.34±3.20 | .451 | +5.2% |
| SE-Symptoms | 12.75±3.20 | 13.00±3.16 | .815 | +2.0% |
CPSS = Chronic Pain Self-Efficacy Scale; CPSS-total = CPSS total score for all domains; CPSS-management = CPSS pain management domain; CPSS-physical = CPSS physical function domain; CPSS-coping = CPSS coping with symptoms domain; SE-Daily Activities = PROMIS Self-Efficacy for Managing Daily Activities Short Form 4a; SE-Symptoms = PROMIS Self-Efficacy for Managing Symptoms
Discussion and Conclusion
Discussion
After the MY-Skills intervention, participants demonstrated improved efficacy in performing daily activities and fulfilling their life roles, particularly related to physical function. The trend toward improved self-efficacy following MY-Skills was demonstrated in similar research combining yoga and self-management for other chronic conditions. Schmid et al. [5] reported significantly increased self-efficacy for individuals with persistent pain participating in a biweekly yoga-only study. Schmid et al. [12] also found a significant increase in balance self-efficacy following a study involving yoga plus elements of self-management education for managing fall risk with chronic stroke. The MY-Skills participants reported significant improvement in CPSS-physical scores but indicated nominal increases in SE-Daily Activities scores. The CPSS-physical scale includes items related to social access not included in other measures, which possibly is more sensitive to changes in self-efficacy. Participants demonstrated a greater improvement in scores for CPSS-coping, suggesting that MY-Skills possibly influenced self-efficacy in coping skills more than managing symptoms.
Limitations and Future Research
Additional research with a larger sample size is needed to further understand the effect of MY-Skills intervention on self-efficacy. The small sample size and location of the study contributed to demographic homogeneity; results are not generalizable to all pain populations.
The small sample size did not allow for analyses at the dyadic level, and future MY-Skills studies with larger sample sizes will allow for dyadic data analysis. Such studies might also explore confounding variables, for example, the correlation between baseline pain severity and reported self-efficacy, the relationship between care burden and self-efficacy for caregivers, or readiness for change and outcomes for care-recipients.
Conclusion
This study aimed to assess the impact of MY-Skills on self-efficacy among individuals with persistent pain in dyadic relationships. Self-efficacy is a critical component underlying individuals’ motivation to establish goals, initiate change, and persevere through challenges and setbacks [3]. Self-efficacy improved to varying degrees for MY-Skills participants, with significant increases in self-efficacy related to physical function. Increased self-efficacy in performing daily activities may reduce pain-related disability and improve quality of life; further research is needed to explore this association.
Through self-efficacy enhancing interventions like My-Skills, practitioners can support reduced pain-related disability and promote clients’ participation in daily activities [4]. MY-Skills merges the benefits of peer learning and problem-solving along with the physical, emotional, and coping benefits of yoga. Self-efficacy is a crucial element to manage chronic conditions, optimize health and well-being, and support QoL despite the pain experience. By fostering confidence in their capabilities, coping skills, and problem-solving abilities through a multi-dimensional intervention like MY-Skills, individuals with persistent pain may be better able to meet daily demands, regain a sense of control, and enhance their QoL [10].
Highlights.
Caregivers and care receivers may both have persistent pain and require interventions
Merging yoga and self-management education may impact outcomes
The MY-Skills intervention may improve self-efficacy for individuals with persistent pain
Funding:
This work was supported by the National Institutes of Health – NCCIH R34 (1R34AT009688-01), Clinicaltrials.gov, identifier # NCT03440320.
Footnotes
Conflicting Interests: None
CRediT authorship contribution statement
Charla L. Kinkel: Writing – Original Draft, Formal Analysis
Haylee Candray: Writing – Review & Editing
Arlene A. Schmid: Conceptualization, Methodology, Writing – Review & Editing, Supervision, Funding Acquisition
Christine A. Fruhauf: Conceptualization, Methodology, Writing – Review & Editing, Funding Acquisition
Karen E. Atler: Writing – Review & Editing
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Contributor Information
Charla L. Kinkel, Department of Occupational Therapy, Colorado State University.
Haylee Candray, Department of Occupational Therapy, Colorado State University.
Christine A. Fruhauf, Department of Human Development and Family Studies, Colorado State University
Karen E. Atler, Department of Occupational Therapy, Colorado State University.
Arlene A. Schmid, Department of Occupational Therapy, Colorado State University.
Data statement
The university Institutional Review Board approved the study. Participants were informed that study data would be depersonalized and remain confidential. Each participant provided informed consent for data handling. Group level data may be available upon request from the authors.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The university Institutional Review Board approved the study. Participants were informed that study data would be depersonalized and remain confidential. Each participant provided informed consent for data handling. Group level data may be available upon request from the authors.