Patient Education and Counseling 98 (2015) 677–680
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short Communication
A prospective evaluation of the Chronic Pain Self-Management Programme in a Danish population of chronic pain patients Mimi Mehlsen a,*, Lea Heegaard b, Lisbeth Frostholm c a
Department of Psychology and Behavioural Sciences, Aarhus University, Denmark The Danish Committee for Health Education, Denmark c Research Clinic for Functional Disorders, Aarhus University Hospital, Denmark b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 September 2014 Received in revised form 7 January 2015 Accepted 10 January 2015
Objective: This study evaluates the feasibility and changes in pain, pain cognition, and distress during a patient education course and a 5-month follow-up period. The Chronic Pain Self-Management Programme (CPSMP) is a lay-led patient education consisting of six manualized sessions. Methods: A Danish adaptation of the CPSMP was tested in four municipalities. The sample consisted of 74 women and 13 men between 26 and 80 years with a long pain history (+10 years). Participants completed questionnaires before the CPSMP, immediately after and 5 months after the program. Results: The study showed that the Danish version of the CPSMP was feasible. The sample was heterogeneous with respect to age, education, duration and causes of pain but all participants reported serious pain and most experienced high levels of distress and disability. Participants evaluated the CPSMP as satisfying and more than 75% would recommend the program to other patients. Participants showed significant improvements on pain, disability, catastrophizing, depression, anxiety, and health worry, and changes were stable through the follow-up period. Conclusion: A consistent pattern of stable improvements in pain, pain cognition and distress was observed but the scope of changes was modest. Practice implications: The Danish version of the CPSMP is feasible. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Chronic pain Self-management Patient education Lay-led CPSMP
1. Background Chronic pain is pain which persists beyond normal tissue healing time, which is defined as 3 months [1]. The estimated prevalence of chronic pain in the European Union is 27% [2] with human costs such as a reduced quality of life [3], and an increased risk of developing common mental disorders [4]. Waiting lists for specialized pain clinics are often long with deterioration in health as an unacceptable consequence [5]. Therefore, low cost interventions have great individual and societal relevance. The Chronic Pain Self-Management Programme (CPSMP) is a patient education program targeting chronic pain patients [6]. The content of the CPSMP is similar to the Arthritis Self-Management Program, which has demonstrated efficacy in improving pain, selfefficacy, health behaviors and health care utilization in arthritis patients [7], but the CPSMP is adapted for various idiopathic
* Corresponding author at: Department of Psychology and Behavioural Sciences, Aarhus University, Denmark. Tel.: +45 87165874. E-mail address: [email protected] (M. Mehlsen). http://dx.doi.org/10.1016/j.pec.2015.01.008 0738-3991/ß 2015 Elsevier Ireland Ltd. All rights reserved.
chronic pain conditions [6]. The teaching methods used in the CPSMP are based on increasing participants’ self-efficacy, i.e. their belief in their own ability to set goals and implement behavioral changes, to reach their goals [8]. The program intends a high degree of participant involvement using the support of the group to strengthen participants’ self-efficacy. The program is not aimed at symptom-directed treatment of pain, rather the intention is to optimize pain management and to support rehabilitation and treatment processes [9]. In the first study on the effects of CPSMP in 110 participants with idiopathic pain, LeFort [6] found that participants reported less pain, less dependency on others, improved mental health, increased activity and satisfaction with their lives 3 months after end of treatment compared to a wait-list control. In the only other study of 256 older pain patients, improvements were found 6 and 12 months after a similar intervention, but there were no differences in effect when compared to patients receiving written material only [10]. In the present study we wished to examine the feasibility of a Danish version of the Canadian– American CPSMP measuring pre- to post intervention changes in relevant outcome measures.
678
M. Mehlsen et al. / Patient Education and Counseling 98 (2015) 677–680
2. Methods
3. Results
2.1. Recruitment
3.1. Sample
Data for the present study was obtained from a pilot test in four municipalities of the adapted Danish version of the Chronic Pain Self-Management Program. Participants were eligible if they were 18+ years, spoke Danish, had pain lasting more than 3 months, rated their pain intensity >5 on a 10-point scale. Pain should not be caused by conditions of primary concern to the participant, e.g. cancer in acute stage or pregnancy, and participants with substance abuse, psychiatric or physical disease that would disturb participation in the course were excluded. Questionnaires were collected 2–14 days before the course started (T1), 1–3 weeks after the course (T2), and 5–6 months after the course started (T3).
One-hundred eligible citizens were included in the program. Of these, 87 answered the baseline questionnaire, 69 returned the first follow-up questionnaire immediately after the course and 73 the second follow-up questionnaire. The participants were 26 to 80 years old, had suffered from chronic pain between 0 and 45 years. More than one cause of pain was reported by 48% and 5% marked 4–5 causes of pain. The most frequent causes of pain were tear/ work injury, diseases, and accidents, 16% reported the cause of their chronic pain to be unknown (Table 1).
2.2. Procedure Participants were invited to participate in the CPSMP by local professionals in health care and social work. After receiving information about the evaluation, they completed the baseline questionnaire. The CPSMP consisted of six 2.5 h weekly workshops focusing on how to manage pain in daily life. Two trained workshop leaders facilitated the workshops in groups of 8–16 chronic pain patients. At least one of the workshop leaders suffered from a long term pain condition. After the last session, follow-up questionnaires were mailed to all participants with a postage prepaid envelope (T2 and T3). Written reminders were sent after 2 weeks and after 4 weeks participants were contacted by phone. 2.3. Questionnaires At baseline questions about socio-demographic parameters, pain duration and cause were answered. Pain was measured by the VAS and the Present Pain Intensity index from the McGill Pain Questionnaire [11]. Physical disability was measured by the 23-item Modified Roland-Morris Disability Questionnaire [12–14]. Pain catastrophizing was measured by the 13-item Pain Catastrophizing Scale [15]. Pain-related Self-efficacy was measured by a 5-item modified version of Arthritis Selfefficacy Scale [16]. The Common Mental Disorders Questionnaire [17] included four subscales assessing: depression, anxiety, physical symptoms, and illness worry. To evaluate the program, 13 questions were constructed regarding satisfaction, and relations to workshop leaders and other participants. 2.4. Statistical method Missing data in psychometric scales were handled at item level. If more than half the items on any given scale were completed, missing scores were replaced by the mean of the completed items [18]. Changes in pain, disability, catastrophizing, self-efficacy and distress were tested by repeated measures ANOVAs. A reliable change index (RCI) was calculated to evaluate statistical reliable change in each participant [19]. The RCI is a function of the standard deviation of the measure and its reliability: SE = SD1(H(1 rxx). When the applied reliability parameter (r) is a test–retest correlation based on data from a comparable sample, it introduces a historical control. For outcomes where test–retest coefficients were available, we calculated the RCI. Percentages of participants displaying reliable change were estimated. Clinical significance of change was evaluated by comparison with published cutoff values. Percentages exceeding clinical cutoffs before and after intervention were estimated.
Table 1 Sample characteristics at baseline. Variable
N
Age Mean (SD)
52.0 (12.4)
Gender Women Men
74 (85%) 13 (15%)
Living alone Marital status Not married Married/partner Divorced Widowed
31 (36%)
Children in household
25 (29%)
Education None/unskilled Skilled Short (
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short Communication
A prospective evaluation of the Chronic Pain Self-Management Programme in a Danish population of chronic pain patients Mimi Mehlsen a,*, Lea Heegaard b, Lisbeth Frostholm c a
Department of Psychology and Behavioural Sciences, Aarhus University, Denmark The Danish Committee for Health Education, Denmark c Research Clinic for Functional Disorders, Aarhus University Hospital, Denmark b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 9 September 2014 Received in revised form 7 January 2015 Accepted 10 January 2015
Objective: This study evaluates the feasibility and changes in pain, pain cognition, and distress during a patient education course and a 5-month follow-up period. The Chronic Pain Self-Management Programme (CPSMP) is a lay-led patient education consisting of six manualized sessions. Methods: A Danish adaptation of the CPSMP was tested in four municipalities. The sample consisted of 74 women and 13 men between 26 and 80 years with a long pain history (+10 years). Participants completed questionnaires before the CPSMP, immediately after and 5 months after the program. Results: The study showed that the Danish version of the CPSMP was feasible. The sample was heterogeneous with respect to age, education, duration and causes of pain but all participants reported serious pain and most experienced high levels of distress and disability. Participants evaluated the CPSMP as satisfying and more than 75% would recommend the program to other patients. Participants showed significant improvements on pain, disability, catastrophizing, depression, anxiety, and health worry, and changes were stable through the follow-up period. Conclusion: A consistent pattern of stable improvements in pain, pain cognition and distress was observed but the scope of changes was modest. Practice implications: The Danish version of the CPSMP is feasible. ß 2015 Elsevier Ireland Ltd. All rights reserved.
Keywords: Chronic pain Self-management Patient education Lay-led CPSMP
1. Background Chronic pain is pain which persists beyond normal tissue healing time, which is defined as 3 months [1]. The estimated prevalence of chronic pain in the European Union is 27% [2] with human costs such as a reduced quality of life [3], and an increased risk of developing common mental disorders [4]. Waiting lists for specialized pain clinics are often long with deterioration in health as an unacceptable consequence [5]. Therefore, low cost interventions have great individual and societal relevance. The Chronic Pain Self-Management Programme (CPSMP) is a patient education program targeting chronic pain patients [6]. The content of the CPSMP is similar to the Arthritis Self-Management Program, which has demonstrated efficacy in improving pain, selfefficacy, health behaviors and health care utilization in arthritis patients [7], but the CPSMP is adapted for various idiopathic
* Corresponding author at: Department of Psychology and Behavioural Sciences, Aarhus University, Denmark. Tel.: +45 87165874. E-mail address: [email protected] (M. Mehlsen). http://dx.doi.org/10.1016/j.pec.2015.01.008 0738-3991/ß 2015 Elsevier Ireland Ltd. All rights reserved.
chronic pain conditions [6]. The teaching methods used in the CPSMP are based on increasing participants’ self-efficacy, i.e. their belief in their own ability to set goals and implement behavioral changes, to reach their goals [8]. The program intends a high degree of participant involvement using the support of the group to strengthen participants’ self-efficacy. The program is not aimed at symptom-directed treatment of pain, rather the intention is to optimize pain management and to support rehabilitation and treatment processes [9]. In the first study on the effects of CPSMP in 110 participants with idiopathic pain, LeFort [6] found that participants reported less pain, less dependency on others, improved mental health, increased activity and satisfaction with their lives 3 months after end of treatment compared to a wait-list control. In the only other study of 256 older pain patients, improvements were found 6 and 12 months after a similar intervention, but there were no differences in effect when compared to patients receiving written material only [10]. In the present study we wished to examine the feasibility of a Danish version of the Canadian– American CPSMP measuring pre- to post intervention changes in relevant outcome measures.
678
M. Mehlsen et al. / Patient Education and Counseling 98 (2015) 677–680
2. Methods
3. Results
2.1. Recruitment
3.1. Sample
Data for the present study was obtained from a pilot test in four municipalities of the adapted Danish version of the Chronic Pain Self-Management Program. Participants were eligible if they were 18+ years, spoke Danish, had pain lasting more than 3 months, rated their pain intensity >5 on a 10-point scale. Pain should not be caused by conditions of primary concern to the participant, e.g. cancer in acute stage or pregnancy, and participants with substance abuse, psychiatric or physical disease that would disturb participation in the course were excluded. Questionnaires were collected 2–14 days before the course started (T1), 1–3 weeks after the course (T2), and 5–6 months after the course started (T3).
One-hundred eligible citizens were included in the program. Of these, 87 answered the baseline questionnaire, 69 returned the first follow-up questionnaire immediately after the course and 73 the second follow-up questionnaire. The participants were 26 to 80 years old, had suffered from chronic pain between 0 and 45 years. More than one cause of pain was reported by 48% and 5% marked 4–5 causes of pain. The most frequent causes of pain were tear/ work injury, diseases, and accidents, 16% reported the cause of their chronic pain to be unknown (Table 1).
2.2. Procedure Participants were invited to participate in the CPSMP by local professionals in health care and social work. After receiving information about the evaluation, they completed the baseline questionnaire. The CPSMP consisted of six 2.5 h weekly workshops focusing on how to manage pain in daily life. Two trained workshop leaders facilitated the workshops in groups of 8–16 chronic pain patients. At least one of the workshop leaders suffered from a long term pain condition. After the last session, follow-up questionnaires were mailed to all participants with a postage prepaid envelope (T2 and T3). Written reminders were sent after 2 weeks and after 4 weeks participants were contacted by phone. 2.3. Questionnaires At baseline questions about socio-demographic parameters, pain duration and cause were answered. Pain was measured by the VAS and the Present Pain Intensity index from the McGill Pain Questionnaire [11]. Physical disability was measured by the 23-item Modified Roland-Morris Disability Questionnaire [12–14]. Pain catastrophizing was measured by the 13-item Pain Catastrophizing Scale [15]. Pain-related Self-efficacy was measured by a 5-item modified version of Arthritis Selfefficacy Scale [16]. The Common Mental Disorders Questionnaire [17] included four subscales assessing: depression, anxiety, physical symptoms, and illness worry. To evaluate the program, 13 questions were constructed regarding satisfaction, and relations to workshop leaders and other participants. 2.4. Statistical method Missing data in psychometric scales were handled at item level. If more than half the items on any given scale were completed, missing scores were replaced by the mean of the completed items [18]. Changes in pain, disability, catastrophizing, self-efficacy and distress were tested by repeated measures ANOVAs. A reliable change index (RCI) was calculated to evaluate statistical reliable change in each participant [19]. The RCI is a function of the standard deviation of the measure and its reliability: SE = SD1(H(1 rxx). When the applied reliability parameter (r) is a test–retest correlation based on data from a comparable sample, it introduces a historical control. For outcomes where test–retest coefficients were available, we calculated the RCI. Percentages of participants displaying reliable change were estimated. Clinical significance of change was evaluated by comparison with published cutoff values. Percentages exceeding clinical cutoffs before and after intervention were estimated.
Table 1 Sample characteristics at baseline. Variable
N
Age Mean (SD)
52.0 (12.4)
Gender Women Men
74 (85%) 13 (15%)
Living alone Marital status Not married Married/partner Divorced Widowed
31 (36%)
Children in household
25 (29%)
Education None/unskilled Skilled Short (
