What Are the Barriers and Facilitators for the Self-Management of Chronic Pain With and Without Neuropathic Characteristics?

Elizabeth G. Mann, PhD, RN; Margaret B. Harrison, PhD, RN; Sandra LeFort, PhD, RN; Elizabeth G. VanDenKerkhof, DrPH, RN

Disclosures

Pain Manag Nurs. 2017;18(5):295-308. 

In This Article

Abstract and Introduction

Abstract

Chronic pain requires affected individuals to self-manage their health. This study compared barriers and facilitators of self-management in two groups of people with chronic pain: those with and without neuropathic characteristics. A cross-sectional survey study of community-dwelling Canadians was conducted. The sample (n = 710) included randomly selected participants who reported chronic pain. The Self-Report Leeds Assessment of Neuropathic Symptoms and Signs was used to screen for neuropathic characteristics. Barriers and facilitators of self-management included self-efficacy (Pain Self-Efficacy Questionnaire), depression (Patient Health Questionnaire 9), social support and relationship with health care provider (Chronic Illness Resources Survey), and pain intensity (numeric rating scale). Participants were asked which factors they felt made pain management easier or harder. Statistical analyses included frequency, percent, relative risk (RR), and 95% confidence intervals (CI). Self-confidence to manage pain was the most commonly perceived self-management barrier/facilitator by both groups; however, participants with neuropathic characteristics (n = 188) were more likely to report low self-efficacy than those without neuropathic characteristics (n = 522) (RR = 2.1, CI = 1.62–2.72, ref = high self-efficacy). Participants with neuropathic characteristics were also more likely to screen positive for depression (RR = 2.30, CI = 1.73–3.06, ref = no/mild depression). There were no group differences in social support and relationship with health professional, but 40.8% felt they were not involved as equal partners in decision making and goal setting related to their care. Health professionals should consider collaborative decision making when seeking to support self-management abilities. Addressing low self-efficacy and depression may be especially important for supporting self-management by individuals with neuropathic characteristics.

Introduction

An estimated 3.3%-17.9% of community-dwelling adults are living with chronic pain with neuropathic characteristics (CPNC) (Bouhassira et al., 2008, Gustorff et al., 2008, Ohayon and Stingl, 2012, Smith and Torrance, 2011, Torrance et al., 2006, Toth et al., 2009). These individuals often report more intense pain (Bouhassira et al., 2008, O'Connor, 2009, Ohayon and Stingl, 2012, Torrance et al., 2006, Toth et al., 2009) with greater pain-related interference and disability (Jensen et al., 2007, McDermott et al., 2006, Ohayon and Stingl, 2012, Toth et al., 2009) and lower health-related quality of life (Jensen et al., 2007, McDermott et al., 2006, O'Connor, 2009, Smith et al., 2007, Toth et al., 2009) than those with chronic pain without neuropathic characteristics (CP). The management of CPNC is complicated, involving more frequent health care visits (Mehra et al., 2012, Torrance et al., 2007), invasive procedures (Mehra et al., 2012) and more prescription medications (Ohayon and Stingl, 2012, O'Connor, 2009, Torrance et al., 2007, Mehra et al., 2012) compared with those with CP. Despite these interventions, individuals with CPNC report less pain relief (Daniel et al., 2008, O'Connor, 2009, Ohayon and Stingl, 2012, Torrance et al., 2007); thus these individuals are living day to day with potentially poorly managed pain. Self-management has been defined as the daily activities in which one engages to manage physical health, emotional well-being, and valued life roles (e.g., performing range-of-motion exercises, reframing negative circumstances positively, problem solving how to adjust a workspace to enable work activities to continue) (Lorig & Holman, 2003). Many health care professionals are involved in pain management; however, nurses specifically play an important role in the provision of ongoing self-management support (Kawi, 2013). At present there is a paucity of evidence on the barriers and facilitators to practicing self-management for individuals with CPNC; thus there is a lack of important information to guide practitioners in supporting self-management.

Because of the inability to cure many chronic pain conditions, affected individuals must manage not only their symptoms but also the effect of these symptoms on their emotions and life roles. This is no small task because many chronically painful conditions change over time (e.g., rheumatoid arthritis), have acute exacerbations (e.g., irritable bowel syndrome), and may be complicated by new injuries, illnesses, or other life stresses (Dubin and King-VanVlack, 2010, Miller et al., 2015). Short-term interventions have been designed to teach self-management skills and to build individuals' capacity and confidence to use these skills; however, ongoing self-management support may be necessary to sustain self-management activities over time (Kawi, 2013). Integral to the provision of self-management support are health care providers who are knowledgeable and able to individualize care (Bair et al., 2009, Kawi, 2012, Liddle et al., 2009). Nurses have been identified as ideal candidates to provide this support because they are perceived as being good listeners, supportive, and encouraging (Bair et al., 2009, Matthias et al., 2010). Their educational background may emphasize the need to provide person-centered care, thus equipping them with the necessary skills and knowledge (Merritt & Boogaerts, 2014), and they may already be practicing these skills (e.g., assessing level of social support) through their provision of self-management support for other chronic conditions (Lukewich, Mann, VanDenKerkhof, & Tranmer, 2015).

Tailoring self-management support requires an understanding of an individual's context. Characteristics that have been identified as either a facilitator or a barrier of self-management include self-efficacy, mental health, access to health resources, and quality of the relationships built with health care providers (Kawi, 2013). For example, individualizing self-management support may require interventions to improve self-efficacy and mental well-being, innovative modes of delivering support to overcome access issues, and engaging strategies such as collaborative decision making. Research identifying self-management barriers and facilitators has focused largely on chronic diseases, with some preliminary work in chronic low back and musculoskeletal pain groups (Kawi, 2013).

It is currently unknown whether individuals with CPNC experience the same self-management barriers and facilitators as other pain and chronic disease groups. Qualitative research exploring the experience of living with neuropathic pain has highlighted the variety of ways by which affected individuals self-manage, and the importance of a supportive and trusting relationship with health care providers (Closs et al., 2007, Lönnstedt et al., 2011); however, barriers and facilitators have not been explored. Thus, the purpose of this study was to identify barriers and facilitators of self-management for individuals with CPNC. The study objectives were as follows: (1) to explore whether barriers and facilitators identified in the literature reflect the current experience of individuals with chronic pain, and (2) to describe and compare barriers and facilitators of self-management in individuals with CP and CPNC.

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