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Chronic lower back pain (LBP) is a disease by itself lasting for longer than six months and involves functional impairment and disability (HSE 2011). It is commonly described as multi-factorial. Of the patients who present with LBP, 85 per cent have non-specific LBP. Non-specific LBP is defined as LBP not attributable to a recognisable, known pathology (eg, infection, tu- mour, osteoporosis, fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome) (Balague et al 2012).
LPB is the fifth most common reason for GP visits and affects 60-80 per cent of people through- out their lifetime. The global age-standardised point of prevalence of LBP (0-100 years) was estimated to be 9.4 per cent (Global Burden of Disease 2010) and was the highest in Western Europe followed by North Africa/Middle East, and lowest in the Caribbean followed by central Latin America. In Ireland it is estimated that as many as one-in-five people experience chronic or persistent pain and the most common site is the lower back (47 per cent). According to the Prime Study (Raftery et al 2012) the economic impact on chronic pain costs an estimated €4.6 billion a year, or 5 per cent of GDP and most of the burden is shared by the taxpayers. With on- going lack of awareness and improper management there could be a five-fold increase in the prevalence of LBP over a 15-year period (Pransky et al 2011).
Clinical assessment of patients with non-specific LPB is challenging as it has a large psychological component. In order to assess psychosocial factors, a colour coded Flags Framework has been conceptualised. Initially developed in relation to return to work (Kendall et al 1997), they are now used routinely in multidisciplinary assessment of such pain.
Management of such patients with non-specific cause is very difficult as there is no specific medical therapy. They fail to respond to conventional pain medications and procedures and they are dragged into a situation of hopelessness. But there is always light at the end of the tunnel. The HSE is using the ‘population health’ approach as a key part of identifying that everyone has a responsibility to promote and protect their own health and health of others. A core strategy that is widely practiced is Wagner’s Chronic Care Model, an organisational approach to caring for people with chronic disease in a primary care setting. The system is population-based and creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team. Its central strand is the role of self-manage- ment programmes (SMPs).
Self-management has been defined as “the ability to manage symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a chronic condition” (Barlow et al 2002). The goals of self-management are to enhance self-efficacy, improve knowledge and understanding about pain and mood, and to promote pacing, relaxation and coping mechanisms. Self-management aims to empower patients to make decisions on how best to manage their pain. The National Centre for Chronic Disease (2005) recognises and rec- ommends self-management in patients living with persistent pain. The UK NICE (National Insti- tute for Health and Clinical Excellence) 2016 guidelines recommend self-management programmes for non-specific LBP. SMPs complement traditional patient education in supporting them to have the best possible quality-of-life with their chronic condition. Traditional patient education programmes offer information and technical skills. SMPs include education and teach problem-solving skills.
Self-management entails: Three self-management tasks:
• Medical management. • Role management. • Emotional management.
Six self-management skills:
• Problem solving: Patients are taught basic pain solving skills.
• Decision making: Patients are given the tools to make day-to- day decisions in the manage-
ment of their pain. • Resource utilisation: Patients are taught how to find and utilise resources, eg, online support. • The formation of a patient-provider partnership: The role of
the healthcare provider is a teacher, partner and professional supervisor. The patient should be able to make informed decisions on his/her pain management and discuss with their healthcare provider.
• Goal setting and action planning: This encourages patients to actively participate in their management and to empower them to become more self-determined.
• Self-tailoring: Patients learn the principles of changing behaviour and self-management. This is tailored to each individual’s needs and is more effective than ‘one-size-fit-all’. Regardless of the chronic condition, the development of a generalised set of skills has proven to be successful in allowing patients to effectively manage their chron- ic condition on a day-to-day basis and improve health outcome.
The Chronic Pain Self-Man- agement Programme (CPSMP) is tailored towards patient educa- tion, which stems from the Stanford University self-management programme. Goal setting is a fundamental element of a suc- cessful self-management pro- gramme. The SMART (S= Specific M=Measurable A=Action oriented R=Realistic T= Timed) goals-setting acronym is recommended to help patients set effective goals. Patients attending a self-management pain programme who set goals that are attainable, realistic and timed, tend to achieve better outcomes.
St James’s SMP
The Department of Pain Medicine in St James’s Hospital, Dublin, introduced a SMP for patients with functional chronic pain conditions due to non-specific causes. It is delivered in a group set- ting by a multidisciplinary team (MDT) of experienced healthcare professionals working closely with the patients. This involves the pain consultant, clinical nurse specialists (CNSs), psychological medicine, physiotherapy, dietician, occupational therapy and mindfulness coach. The CPSMP is based on the pain tool kit, which is used by the Stanford chronic disease programme. Patients are assessed for suitability to attend the CPSMP by the pain physicians. All costs incurred by the patient on the day (lunch and parking) are covered; this is very important as most of the patients would have financial issues and this can help to increase attendances. The day is informal and encourages participation. The CNSs are available to the patients thoughout the programme to dis- cuss any issue that may arise.
A pilot study to evaluate the effectiveness of the self-management pain programme three months post-completing the programme was carried out over a three-year period (2013-2016). A total of 54 patients were enrolled in the study, of which 24.5 per cent had non-spe- cific LBP (Figure 1).
At three months, the patients were contacted by phone by an independent person. They were asked questions if they had made any positive changes in the man- agement of their pain. All patients in the pilot study had made some positive changes in the day-to-day management of their chronic pain (Table 1). All 54 patients said they were happy to have completed the programme.
The results support the effectiveness of the self-management model on non-specific LPB, which tends to be slow in progression and of long duration, and can offer patients a means to maintain or even improve their quality-of-life. Further resources and funding are required to expand the self-management pain programme for non-specific chronic pain, especially involving the lower back.
References on request