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


Pain Manag Nurs. 2017;18(5):295-308. 

In This Article


This study was approved for ethical compliance by the Queen's University and Affiliated Teaching Hospitals Research Ethics Board.

Participants and Pain Screening Tools

This study was part of a larger, cross-sectional survey of 8,000 randomly selected Canadians (VanDenKerkhof et al., 2015). The survey was conducted between 2011 and 2012, and telephone book listings were used to identify potential participants who were then mailed a questionnaire with a cover letter explaining the study and inviting them to participate. Study participation was considered evidence of informed consent. From the 1,505 respondents, 695 reported chronic pain. An additional 15 individuals with chronic pain volunteered for the study (e.g., family members of participants who heard about the survey) and were included to increase the total sample size. This resulted in a sample of 710 participants for the current analysis. All participants in the current analysis answered positively to the following questions used to screen for chronic pain: "Are you currently troubled by pain or discomfort, either all the time or on and off?" and "Have you had this pain or discomfort for more than 3 months?" (Torrance et al., 2006, Wong and Fielding, 2011). CPNC was classified using the Self-Report Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale (SLANSS) (Bennett, 2001, Bennett et al., 2005). The seven items on the SLANSS screen for symptoms typical of neuropathic pain (e.g., altered sensation) and include two self-assessment items testing for allodynia and altered pain threshold. Scores of 12 or higher out of a possible 24 were considered to indicate the presence of CPNC as per recommendations for use (Bennett, 2001, Bennett et al., 2005). Further detail on the survey methodology is available elsewhere (VanDenKerkhof et al., 2015).

An additional analysis was conducted using a more stringent method of grouping participants with possible neuropathic pain that included both a SLANSS score ≥ 12 and a pain diagnosis, suggesting a probable or possible neuropathic condition (Treede et al., 2008). Diagnoses considered probably or possibly neuropathic included accidents with nerve damage, amputations, shingles, surgeries, back problems, diabetes, and cancers.

Sociodemographic characteristics included in this analysis were sex, age, marital status, education, household income, and ethnicity.

Barriers and Facilitators

Potential barriers and facilitators were identified through reviewing qualitative and quantitative research on chronic pain self-management as well as chronic disease self-management models. The most commonly identified items were (1) self-efficacy (Hill-Briggs, 2003, Jensen et al., 2003, Hadjistavropoulos and Shymkiw, 2007, Ryan and Sawin, 2009, Strong et al., 2002, Suter et al., 2008); (2) depression (Bair et al., 2009, Hadjistavropoulos and Shymkiw, 2007, Krein et al., 2005, Suter et al., 2008); (3) social support (Bair et al., 2009, Grey et al., 2006, Hill-Briggs, 2003, Ryan and Sawin, 2009); (4) relationship with health care provider(s) (Bair et al., 2009, Cooper et al., 2009, Grey et al., 2006, Hill-Briggs, 2003, Matthias et al., 2010, Ryan and Sawin, 2009, Suter et al., 2008); (5) pain intensity (Grey et al., 2006, Hadjistavropoulos and Shymkiw, 2007, Krein et al., 2005, Ryan and Sawin, 2009); (6) fear of exacerbating pain (Bair et al., 2009, Hill-Briggs, 2003, Suter et al., 2008); (7) access to health resources (Grey et al., 2006, Ryan and Sawin, 2009); and (8) health literacy (Ryan and Sawin, 2009, Suter et al., 2008). To explore whether these barriers and facilitators reflect the current experience of individuals with chronic pain, respondents were asked to select from a list which item(s) made it easier or harder for them to manage their pain. An "other" category was also provided. Respondents then completed brief instruments capturing the five most commonly identified barriers and facilitators (items 1–5).

Item 1, self-efficacy, was measured using the Pain Self-Efficacy Questionnaire (Nicholas, 1989, Nicholas, 2007). This 10-item tool asks respondents to rate their confidence in response to statements such as "I can still accomplish most of my goals in life, despite the pain." Each seven-point Likert scale is anchored with "not confident at all" and "completely confident" with scale scores ranging from 0 to 6. Scores were categorized as high (≥40/60) or low (<40/60) (Asghari & Nicholas, 2001). To allow for comparison, individual scale scores were also categorized into high (≥4/6) or low (<4/6). Testing indicates excellent internal reliability (Cronbach's α = .92) and positive correlation with other measures of self-efficacy and pain beliefs (Asghari and Nicholas, 2001, Nicholas, 2007, Tonkin, 2008).

Item 2, depression, was measured using the Patient Health Questionnaire nine-item scale (Spitzer, Kroenke, & Williams, 1999). Each item corresponds to a depression symptom listed in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, and asks respondents to indicate the frequency with which they experienced each symptom over the past 2 weeks. Response options range from "not at all" to "nearly every day" with total scores ranging from 0 to 27. Scores of 10 or higher indicate depression with a specificity and sensitivity of 88% compared with diagnosis made by a mental health professional (Kroenke et al., 2001, Kroenke et al., 2010), thus, total scores were categorized as no or mild depression (<10) and moderate to severe depression (≥10). Individual scale scores were categorized to reflect whether a symptom was experienced "not at all or several days" or "most days or nearly every day" of the past 2 weeks to reflect the fact that some symptoms of chronic pain (e.g., disturbed sleep) overlap with symptoms of depression (Cheatle, 2011).

Items 3 and 4, social support and relationship with health care provider(s), were captured with the family and friends and the physician and health care team scales of the Chronic Illness Resource Survey, respectively (Glasgow et al., 2000, Glasgow et al., 2005). Respondents were asked to rate the extent to which their family and friends encouraged them to do the tasks involved with managing their condition (Grey et al., 2006, Ryan and Sawin, 2009) and listened to what the respondents had to say about their condition (Grey et al., 2006). Four items from the physician and health care provider scale were included and asked whether their health professional(s) treated them as equal partners in care decisions, strategies, and goals (Bair et al., 2009, Hill-Briggs, 2003, Matthias et al., 2010, Ryan and Sawin, 2009); explained what they needed to do to manage their condition (Bair et al., 2009, Hill-Briggs, 2003, Ryan and Sawin, 2009); answered their questions and addressed their concerns (Bair et al., 2009, Matthias et al., 2010); and listened (Matthias et al., 2010). Items on all scales have five response options ranging from "not at all" to "a great deal," with higher scores indicating a more supportive relationship. Testing indicates acceptable reliability for the family and friends scale (Cronbach's α = .75) and excellent reliability for the physician and health care team scale (Cronbach's α = .91). Construct and predictive validity have been established by comparing scores with both validated tools and self-monitoring data (Glasgow et al., 2000, Glasgow et al., 2005). Individual items were categorized to reflect "not at all" (<3), "a moderate amount" (= 3), and "a great deal" (>3).

Item 5, pain intensity over the past week, was measured using an 11-point numeric rating scale (Dworkin et al., 2005, Dworkin et al., 2008, Haanpää et al., 2011). Scores were categorized into none or mild (0–3), moderate (4–6), and severe (7–10) pain using the recommended categories for neuropathy (Zelman, Dukes, Brandenburg, Bostrom, & Gore, 2005).

Statistical Analysis

Kurtosis and skew values were used to assess distribution of continuous variables. Age was the only normally distributed variable; therefore an independent t test was used to compare age between groups. Frequency, percent, medians, and interquartile ranges were used to compare the two pain groups on sociodemographic characteristics, barriers, and facilitators. Relative risk (RR) and 95% confidence intervals (CI) were calculated to examine the risk of reporting a given characteristic (e.g., barrier or facilitator) for those with CPNC versus those with CP. All tests were two-tailed and statistical significance was set at p < .05. Data were analyzed using SPSS Version 21.0 (IBM Corp., Armonk, NY, USA).