Self-management at the core of back pain care: 10 key points for clinicians

Key Points

1. Clinicians can increase the skills of patients for self-management of back pain.
2. Clinical support of self-management leads to improved use and distribution of health care resources.
3. Organizations need protocols that allow patients to self-manage and support self-efficacy.

BACKGROUND & OBJECTIVE

Persistent low back pain (LBP) is a devastating global problem that is not being fixed through clinical intervention alone. The literature supports promoting self-management of LBP for social, physical, and emotional challenges at home and in the community (1,2). It isn’t sufficient to focus on just clinical treatment.

The authors of this paper aimed to set out points for clinicians to address in addition to traditional treatment that enable patients to better self-manage their pain for optimal function.

Persistent low back pain is a devastating global problem that is not being fixed through clinical intervention alone.

Health care practitioners have an ethical obligation to put their patient first, and that includes the promotion of self-management.

METHODS

• This paper was a commentary to establish recommended self-management instruction in the clinical setting.
• The authors defined the terms to delineate the difference between self-care, self-management, self-efficacy, and symptom management.
  • Self-care: actions done daily for health including bathing, sleep hygiene, nutrition, and exercise.
  • Self-management: the individual’s ability to manage their symptoms, treatment, and the consequences of their choices. This is supported by the health care professional, not led by them.
  • Symptom management: actions by the patient or the clinician to address the LBP.
  • Self-efficacy: this is a core belief that your actions will make a substantial difference and that they are under your control.

RESULTS

Key points for promoting self-management

Planning:

• Value based goals for direction of care. Use patient specific functional goals.
• Shared decision making with clear understanding of the options for care and the evidence or cost/benefit of each choice.
• Identify the stage of readiness to change and work at the current level while supporting movement to self-management.

Delivery:

• Make sense of the symptoms through education and evidence.
• Teach skills for problem solving and management.
• Set patients up for success with proper grading of treatment and home programs.
• Continue to provide tools for self-management.

Evaluation:

• Patient specific functional goals and consistent revisiting of those goals.
• Assess patients understanding of their back pain.
• Continued support of patients as they manage their pain, check the actions and plans and help with adjusting them as needed to increase success.

LIMITATIONS

The authors point out the organizational constraints that may make promoting self-management problematic. These include financial considerations (there is no money to be made for people treating their own flares), managing expectations that pain will completely and permanently resolve, and to reduce dependency on clinical intervention.

CLINICAL IMPLICATIONS

To promote self-management as part of a baseline approach to treating LBP, clinicians must have good communication skills and organizational support. Organizational support is critical as the financial incentive is to see people more often instead of teaching people self-care and self-management techniques for their pain. This promotion of self-management is a philosophical alignment that is in opposition to maximizing profits (as profits are the driving motivation for many health care and hospital practices). Clinicians who teach patients to self-manage may face negative consequences from their clinical directors, corporate financial officers, or clinic owners.

It comes down to a question of benefit to the patient or to the finances of the organization. Health care practitioners have an ethical obligation to put their patient first, and that includes the promotion of self-management. Clinicians are in an optimal environment to focus on patient specific functional goals and guide the treatment based on those goals. We have the ability to focus on teaching the skills for improved self-management of health including pain, nutrition, sleep quality, exercise intensity and frequency, social interactions, and the purposeful pursuit of pleasure.

+STUDY REFERENCE

Kongsted A, Ris I, Kjaer P, Hartvigsen J (2021) Self-management at the core of back pain care: 10 key points for clinicians. Brazilian Journal of Physical Therapy, 25(4), 396–406.

SUPPORTING REFERENCE

1. Huber M, Knottnerus JA, Green L, et al. How should we define health? BMJ. 2011;343:d4163.
2. Buchbinder R, Underwood M, Hartvigsen J, Maher CG. The Lan- cet Series call to action to reduce low value care for low back pain: an update. Pain. 2020;161(Suppl 1):S57S64
3. Hutting, N. et al. (2022) “Person-centered care for musculoskeletal pain: Putting principles into practice,” Musculoskeletal Science and Practice, 62, p. 102663.