Original Article Self-Management and Self-Management Support on Functional Ablement in Chronic Low Back Pain ---

-

From the Department of Physiological Nursing, School of Nursing, University of Nevada, Las Vegas, Nevada. Address correspondence to Jennifer Kawi, PhD, MSN, APN, FNP-BC, School of Nursing, University of Nevada, 4505 Maryland Parkway, Las Vegas, NV 89154-3018. E-mail: jennifer. [email protected] Received November 20, 2011; Revised April 24, 2012; Accepted May 6, 2012. 1524-9042/$36.00 Ó 2014 by the American Society for Pain Management Nursing doi:10.1016/j.pmn.2012.05.001

Jennifer Kawi, PhD, MSN, APN, FNP-BC

ABSTRACT:

This study examined self-management (SM), self-management support (SMS), and functional ablement in chronic low back pain (CLBP) patients and the role of SM in explaining the relationship of SMS to functional ablement. The pervasiveness of CLBP is alarming in today’s health care. Although the literature is beginning to explicate the impact of SM and SMS in other chronic illnesses, these are yet to be clarified in CLBP. The adapted chronic care model guided this study. A nonexperimental, cross-sectional, descriptive design with mediation analysis was used. Through convenience sampling, 110 participants were recruited from two pain centers that used similar multimodal pain management practices. Although the findings showed lack of mediation, it was found that SM and SMS were strongly correlated. Furthermore, overall health was found to be a significant covariate to the functional ablement of CLBP patients. This study assists in advancing knowledge and contributing toward understanding SM, SMS, and functional ablement in CLBP. It is important to engage patients and health care providers in SM and SMS. More exploration is necessary to assess the influences of SM and SMS in CLBP outcomes toward improving the complex care of these patients. Ó 2014 by the American Society for Pain Management Nursing The pervasiveness of low back pain is alarming in today’s health care clinic environments. The National Institute of Arthritis and Musculoskeletal and Skin Diseases (2009) states that 25% of adults in the United States experience at least one day of back pain in a 3-month period. Consequently, 28% of adults with low back pain suffer from limitations in functional ability and/or disability (National Center for Health Statistics, 2006). Low back pain is the most common reason for a clinic visit, with 12%-15% seeing their health care providers yearly because of this problem (American Academy of Orthopedic Surgeons, 2008). In effect, many of these adults suffer from chronic low back pain (CLBP), defined as pain persisting in the low back area for >3 months (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2009). Health care costs related to CLBP range from $12.2 to $90.6 Pain Management Nursing, Vol 15, No 1 (March), 2014: pp 41-50

42

billion annually (Haldeman & Dagenais, 2008). In other chronic illnesses, studies on self-management (SM) and self-management support (SMS) have shown some success in decreasing health care costs and improving outcomes, including positive health-directed behaviors, more symptom-free days, and better quality of life (Pearson, Mattke, Shaw, Ridgely, & Wiseman, 2007). However, there remains limited understanding on SM and SMS as they relate to patients with CLBP. CLBP patients’ SM experience frequently includes coping with pain of varying intensity (Crowe, Whitehead, Jo Gagan, Baxter, & Panckhurst, 2010). The concept of SM includes demonstration of tasks and skills with self-efficacy so that patients can make decisions and engage in behaviors to adequately manage their chronic illness (Lorig & Holman, 2003). This is an important factor in achieving functional ablement, defined as personal capability in response to environmental demand, derived from the seminal work of Verbrugge and Jette (1994) on the process of disability. In addition, because patients make choices in activating their SM (Hibbard, Stockard, Mahoney, & Tusler, 2004), and health care providers influence patient activation through supporting patients in their SM (Wagner, Austin, Davis, Hindmarsh, Schaefer, & Bonomi, et al., 2001), it is timely to examine SM and SMS in CLBP patients, especially in potentially influencing a key outcome of functional ablement. The view of humans as being capable is in juxtaposition to the negative connotation suggested by the terms disability and disablement. For the present research study, the positive outcome examined was termed ‘‘functional ablement,’’ a perspective that challenges the limited views of capacity and optimizes the opportunity for SM. A philosophic perspective of optimism was offered, recognizing that in the presence of CLBP, there is a potential to maximize functional ability. Thus, this study’s purposes were to examine SM and SMS in CLBP and the role of SM in explaining the relationship of SMS to functional ablement through a nonexperimental, cross-sectional, descriptive design using the mediation approach.

THEORETICAL ORIENTATION The chronic care model (Wagner et al., 2001), the theoretic orientation for this research study, was developed through a multidisciplinary group of experts with support from the Robert Wood Johnson Foundation to improve chronic illness care. This model specifies that when health care teams are prepared and proactive (demonstrating SMS) and patients are activated (engaged in SM), then patient outcomes improve. The model suggests the mediating function

Kawi

of SM guiding this research. In other words, when health care providers establish a working partnership with patients (SMS), then SM is facilitated, resulting in favorable patient outcomes.

RESEARCH QUESTIONS 1. What is the (a) level of SM, (b) amount of perceived SMS, (c) mental health state, (d) functional ablement score, and (e) mean pain intensity in CLBP patients? 2. Does SM mediate the relationship of perceived SMS to functional ablement in patients with CLBP?

REVIEW OF RELATED LITERATURE Several studies have related SM to chronic illnesses and chronic pain. However, only a few retrieved empirical studies focus on CLBP. Those few authors evaluated patient SM experiences, verbalized multiple failed treatment approaches, and acknowledged poor adherence to advice and performance of SM strategies (Cooper, Smith, & Hancock, 2009; Liddle, Baxter, & Gracey, 2007; Townley, Papaleontiou, Amanfo, Henderson, Pillemer, Beissner, & Reid, et al., 2010). Typical outcome measures were improved disability or function and pain level (Chiauzzi, Pujol, Wood, Bond, Black, Yiu, & Zacharoff, et al., 2010; Coudeyre, Givron, Vanbiervliet, Benaim, Herisson, Pelissier, & Poiraudeau, et al., 2006; May, 2010; Schulz, Rubinell, & Hartung, 2007; Sokunbi, Cross, Watt, & Moore, 2010). However, some research studies (Escolar-Reina et al., 2009; Haas et al., 2005) noted contrasting findings on CLBP outcomes from SM strategies, although the need for SMS toward enhancing SM was reinforced (Zufferey & Schulz, 2009). There was considerably less empirical research on SMS for CLBP. Crowe, Whitehead, Jo Gagan, Baxter, & Panckhurst, et al. (2010) conducted a study evaluating common patient SM strategies (medications, exercise, and heat application) and provider SMS roles (exercise, prescribing medications). In a randomized controlled trial, the use of advice with exercise was an effective SMS strategy in improving pain, function, and disability with support emphasized as an essential facilitator to SM (Liddle, Gracey, & Baxter, 2007). In another randomized controlled trial, supervised individualized exercise regimen and SM techniques enhanced adherence to exercise (Jordan, Holden, Mason, & Foster, 2010). In the area of chronic pain in general, Blyth, March, Nicholas, and Cousins (2005) highlighted the importance of using appropriate SM strategies in improving pain-related disability and decreasing use of health services. Accordingly, active strategies (i.e., exercise) decreased pain-related disability, whereas passive

43

Self-Management and Self-Management Support

strategies (i.e., taking medications, rest) increased pain-related disability. Self-management behaviors and self-directed strategies were also noted to be strongly associated with self-efficacy, sense of well-being, and pain management (Krein, Heisler, Piette, Butchart, & Kerr, 2007; Shariff, Carter, Dow, Polley, Salinas, & Ridge, et al., 2009). In contrast, two studies conducted by Ersek et al. (2003; 2008) noted divergent findings in physical function, pain, and disability. A study conducted by Allen, Iezzoni, Huang, Huang, and Leveille (2008) using internet-based SM and SMS activities with nurses’ support increased patients’ active participation in their care, improving partnerships toward better chronic pain management. Matthias et al. (2010) highlighted the role of nurses in SMS. Nurse care managers were found to be more supporting than primary care physicians in providing SMS (Matthias, Bair, Nyland, Huffman, Stubbs, Damush, & Kroenke, et al., 2010). Furthermore, the focus on SM in chronic pain was emphasized by the Institute of Medicine (2011) in their most recent report on chronic pain. Patients are advised to adapt strategies in coping with and reducing their pain levels. Equally, health care providers need to provide effective support in assisting and sustaining patient SM. The goal is to support the patient’s functional improvement through adequate SM (Agency for Healthcare Research and Quality, 2009). In summary, current evidence-based knowledge for SM and SMS specifically in CLBP patients is lacking. Some studies show conflicting results on pain and disability, although the literature suggests the relevance of SMS in facilitating SM. It is a question whether SM explains the relationship between SMS and functional ablement.

METHODS A nonexperimental, cross-sectional, descriptive design using the mediation approach addressed the study purposes and answered the research questions. The mediation approach is based on the seminal work of Baron and Kenny (1986). A variable functions as a mediator when the following conditions are met: 1) variations in the independent variable significantly account for variations in the mediator variable and the outcome; 2) variations in the mediator significantly account for variations in the outcome; and 3) the addition of the mediator significantly decreases a previously significant relationship between the independent variable and the outcome after controlling for (1) and (2) (Fig. 1) (Baron & Kenny, 1986). For this study, SM served as a mediator if the following occurred: 1) SMS (independent variable) needed to be significantly

FIGURE 1.

-

Mediation Model.

correlated with SM and functional ablement (outcome or dependent variable); 2) SM needed to be significantly correlated with functional ablement; and 3) the significant correlation between SMS and functional ablement decreased once SM is entered in the data analysis equation. In short, the mediation approach examined whether SMS facilitated SM toward functional ablement. See Figure 1. Settings and Subjects This research study was conducted in two Nevada cities in two pain centers that used multimodal pain management. The health care providers rotate in each center and have similar pain management practices. No specific patients are seen by specific providers. Inclusion criteria were: 1) $18 years old; 2) having a doctor-diagnosed nonmalignant CLBP; and 3) able to read, write, and understand English. Given a 20% allowance in sampling for attrition or missing data, a target sample size of 110 participants was met in this study. Sampling was conducted through a nonprobability convenience method. There were no difficulties encountered during sampling. Ethical Considerations and Procedures The research study was initiated after obtaining approval from the Colorado Multiple Institutional Review Board and from the Medical Directors of both centers. Patients were asked if they were willing to participate in the research study during their clinic visits. Risks and benefits of participation were discussed privately, and all patients agreeing to participate were provided informed written consent that included authorization to use and release health information. Measures This research study required completion of two demographic surveys and four self-report instruments. The demographic surveys were in the form of a patient self-report survey and a form for the researcher to review medical records. The four study instruments were as follows: Patient Activation Measure. The Patient Activation Measure (PAM) evaluated SM elements, including knowledge, skills, and behaviors, that patients need

44

to manage their chronic illnesses (Hibbard et al., 2004). The PAM is a unidimensional Guttman-like measure (cumulative scale) with a 4-point Likert scale, structured developmentally in a hierarchic order with four stages. The first stage focused on beliefs about the importance of the patient’s primary role, the second included confidence and knowledge about self-care, the third involved taking action to sustain health care behaviors and prevent further problems, and the fourth (highest activation to SM) included the ability to stay on course and maintain one’s health even under stress (Hibbard et al., 2004). The PAM was conceptually validated with an original 22-item measure using the Rasch psychometric method. This method allowed the authors to determine the four hierarchic stages from the items based on levels of SM resulting infit values. Infit values ranged from 0.71 to 1.44 and outfit values from 0.80 to 1.34, indicating conformity of all of the items in the measure. Reliability was stable in those without or across different chronic conditions (0.9-0.91) and between different responses to self-rated health (0.87-0.91). To improve feasibility, the short-form 13-item PAM was created (Hibbard, Mahoney, Stockard, & Tusler, 2005). The resulting infit values were 0.92-1.05 and outfit values 0.85-1.11, indicating item conformity. Patient Assessment of Chronic Illness Care. The Patient Assessment of Chronic Illness Care (PACIC) was developed to gather information congruent with the chronic care model regarding patient’s perspectives on their chronic illness care, especially geared toward evaluating self-management support (Glasgow et al., 2005). It is a 20-item measure with a 5-point Likert scale regarding support questions on patient activation, decision support, goal setting, problem solving, and follow-up. Glasgow et al. (2005) validated the content of the measure based on a national pool of experts in chronic illness care and the chronic care model. A median subscale alpha of 0.84 (range 0.77-0.90) with 0.93 overall internal consistency was documented. The overall test-retest reliability was 0.58 (range 0.47-0.68). Oswestry Disability Index. The Oswestry Disability Index (ODI) evaluated pain-related disability or the extent to which functional level is affected by disablement specifically in low back pain patients (Fairbank & Pynsent, 2000). The ODI version 2.1a contains 10 sections with six statements each, categorized as ordinal and converted to quantitative data by summation (Fairbank & Pynsent, 2000). The sections include pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life (if applicable), social life, and traveling. The authors reported a test-retest

Kawi

reliability of r ¼ 0.83. Internal consistency published in various studies ranged from 0.71 to 0.87. Mental Health Inventory. The Mental Health Inventory (MHI) was derived from the RAND Medical Outcomes Study 36-item short-form survey developed as part of the National Health Insurance study (Veit & Ware, 1983). The MHI evaluates the positive and negative aspects of mental health state from psychologic well-being to distress with the use of a 5-item questionnaire. Questions reflecting positive affect, anxiety, and depression were included. The MHI-5 is structured with a 6-point Likert scale. The overall reliability is 0.82, ranging from 0.66 to 0.90 for the five items (Berwick et al., 1991). Data Analysis After preanalysis data screening, data analysis was performed with the use of descriptive statistics, general linear modeling, and mediation analysis. The reliability coefficients after using the measures in this study were as follows: PAM for SM, 0.91; PACIC for SMS, 0.95; ODI for functional ablement, 0.86; and MHI for mental health state, 0.80.

RESULTS The demographic surveys were summarized and presented in Tables 1 and 2. On analysis, only age differed significantly between the two centers for continuous variables, and race, education, income, and marital status differed for the categoric variables. These findings were consistent with the demographic data in both cities where each pain center was located. In general, despite these variations, no significant differences were noted in the other key variables between the two centers. For research question 1, data analysis was completed for both locations without significant differences in results between the two pain centers. For research question 2, ‘‘location’’ was added as a variable in the analyses to factor out any variance contributed by either pain center. Location was not found to be a significant variable influencing functional ablement. Research Question 1: What are the (a) level of SM, (b) amount of perceived SMS, (c) mental health state, (d) functional ablement score, and (e) mean pain intensity in CLBP patients? Mean results from the descriptive statistics are presented in Table 3. The average scores were: 60.06 out of 100 for SM (PAM), 2.6 out of 5 for SMS (PACIC), 54.72 out of 100 for mental health state (MHI), 44.48 out of 100 for functional ablement (ODI), and 2.55 out of 5 for pain intensity.

45

Self-Management and Self-Management Support

TABLE 1. Demographic Profile Pain Center 1 Variable

n

Sex Male 21 Female 37 Marital status Single 34 Currently married 17 Living with partner 6 Other 1 Hispanic, Spanish, Latin origin Yes 11 No 47 Race White/Caucasian 34 Black/African American 13 American Indian/Alaskan Native 1 Native Hawaiian/Pacific Islander 0 Asian 0 Other 10 Highest grade level completed Less than high school graduate 17 High school graduate 14 Some college or higher 27 Employment status Employed 13 Unemployed 16 Disabled, unable to work 29 Annual net household income

Self-management and self-management support on functional ablement in chronic low back pain.

This study examined self-management (SM), self-management support (SMS), and functional ablement in chronic low back pain (CLBP) patients and the role...
264KB Sizes 0 Downloads 3 Views