En blogg om muskelskjelettplager

How to get people with persistent pain moving

written by Daniel Major, PhD-student and member of the Musculoskeletal Health research group at Oslo and Akershus University College of Applied Sciences 

Movement seems to be one of the few interventions most physiotherapists and other health care providers seems to agree that will most likely be helpful for patients with persistent pain. The last few years there have been written great articles about the potential of movement (or exercises) when treating patients with persistent pain, but how do we get people moving? I do not think I have the definite answer, but I will try to explore some of the literature regarding exercise adherence and provide a brief summary of the strategy I use when trying to get people with persistent pain moving without constant supervision. Exercise adherence seems to be viewed by many therapists as the patients’ responsibility, but to increase exercise adherence I believe we need to take some of the responsibility and facilitate the behaviour change. I believe we need to have comprehensive knowledge about the barriers and facilitators, and learn to incorporate strategies that have the potential of facilitating people with persistent pain to adhere to exercise/movement/physical activity in the long-term.

A Cochrane review concluded that there was moderate evidence to suggest that self-management programmes and the inclusion of interventions based on cognitive and/or behavioural principles could help some groups of people with persistent musculoskeletal pain improve exercise adherence [1]. However, only 18 of the 42 RCTs showed that their interventions successfully enhanced adherence to exercise or physical activity in people with persistent musculoskeletal pain [1]. Incorporating specific adherence enhancing strategies within an exercise programme, including education and behavioural techniques such as positive reinforcement, goal setting, and use of an exercise contract, may be beneficial in increasing exercise adherence for people with persistent musculoskeletal pain [1]. A recent clinical update from Booth et al., [2] wrote “A better understanding of strategies to improve treatment adherence such as goal setting, self‐monitoring and professional feedback is required.”

Everybody knows we should prescribe exercises, but should we start talking more about strategies to increase adherence? Everybody knows that movement is good, but how do we get people with persistent pain moving?

Barriers to exercise adherence and possible strategies to overcome these

We have all heard why people do not exercise. Lack of time, lack of motivation, lack of energy, and that exercise cause pain are some of them [3, 4]. We need to find strategies that can be used to challenge and change these barriers to exercise adherence [3]. We need to define barriers for long-term adherence to exercises (problem definition), suggest solutions to overcome these barriers (generation of possible solutions) and based on shared decision-making we should make action plans that the person in front of you feels confident they will be able to do (solution implementation) [5]. Some examples: If a person says, he/her does not have the time to exercise. We should consider identifying available time slots in their weekly routine. We could also consider incorporating exercise into daily routines. We could recommend walking/bicycling instead of driving to work. If lack of motivation is a barrier, we could discuss the benefits of exercise, and set short- and long-term goals that are tailored to the patient to hopefully increase motivation. To make the exercise program less boring, we could tailor the exercise program to the patient’s personal preferences. If lack of energy to exercise is a barrier, we could discuss that regular exercise will increase energy over the longer term and can improve sleep quality. If pain is a barrier, we could reassure by saying that pain is often felt when people with persistent pain exercise and that this is normal and safe, and that this does not mean that exercise is harmful.

A strategy to increase adherence to exercise/physical activity

Lorig and Holman have provided five core self-management skills which I find very helpful when trying to get people moving: Problem solving, decision making, resource utilization, forming of a patient/health care provider partnership, and taking action [5]. I will try to operationalize how our research group work with these skills when trying to increase adherence to self-managed exercises in our coming Ad-Shoulder trial.

Fig 1: Core self-management skills

Problem solving

During the first session with the physiotherapist the focus will be on actively involve the participant in how to keep a good performance level of exercises or how to improve their ability to exercise. The barriers for a long-term adherence to exercises will be defined (problem definition), concrete solutions to overcome these barriers will be suggested (generation of possible solutions), and a brief set of maximum three exercises (because of higher odds of adherence [6]) for the coming week will be agreed upon (solution implementation).

Decision making

During the second session the decision making process will be the main focus. The experiences from the first week will be used to go into a more thorough discussion around how to implement a behaviour in line with adherence to shoulder exercises. For example, the physiotherapist might consider that the participant needs more knowledge in order to meet the goal of long-term adherence to shoulder exercises. This can be related to topics such as how to deal with pain during or after the exercises, what is the optimal dosage of exercises/physical activity, and/or how to deal with pain catastrophizing related to exercises and physical activities. The topic can also be how to organize the daily life in order to prioritize the shoulder exercises.

Example: If pain is experienced whilst exercising the participant will be told that as a rule of thumb it should be no worse upon cessation and should be returned to the pre-exercise level after 24 hours. The participant will also be encouraged to judge what is manageable/acceptable. If the participant experiences unmanageable pain during or after the exercise sessions, they will be advised to cut back on the exercise dosage and try to find a comfortable exercise level, stick to this for 1 or 2 weeks, and add to it by 10 to 20% every 7 to 14 days.

Resource utilization

This skill is related to teaching people how to use resources. Self-management includes helping people seek these out from many sources. For this specific study, we will encourage the participant to identify beneficial resources in their local environment, such as a local gym where they can exercise. Information resources about pain will also be utilized.

Forming of a patient/health care provider partnership

The forming of a participant/physiotherapist partnership will include shared goal setting based on patients’ personal preferences by using the Patient Specific Function Scale [7], and collaborative problem solving. To strengthen the patient-therapist interaction we will allow patients to tell their story, provide emotional support, chat with the patient in a friendly manner and to motivate and show encouragement [8].

Taking action

Taking action reflects skills that are involved in learning how to change a behaviour. An action plan for the next 1-3 weeks will be worked out, together with the patient. The action plan will contain information about the time points for exercises and/or other physical activities, the amount (number and length of sessions) and self-managed modifications of the plan. Pain intensity during the last week will be used as an indicator for progression or regression of the program. Pain which is manageable, will be allowed during and after exercises. Advice in relation to progression and regression of exercises, will be provided; this may include adjusting the volume of exercise sessions, resistance of exercises (weight), number of repetitions and/or change the type of exercises. The adjustment of the exercises program is an integrated part of the problem solving- and decision making skills.  In relation to self-management theory, the actions need to reflect something that the participant is fairly confident to accomplish. Level of confidence will be measured by asking the patient how confident they are that they will do the exercise program according to the short-term goal. The participant will score their level of confidence on a numerical rating scale from 0 (totally unconfident) to 10 (totally confident). If the answer is 7 or higher, based on self-efficacy theory, there is a good chance that the action plan will be accomplished. If the answer is less than 7, the physiotherapist will encourage to further problem solving in order to make the plan more realistic and to avoid failure.

During the last individual sessions, a long-term action plan will be developed together with the patient. In this plan, physical activities that may replace or supplement the exercise program, is discussed. This plan will strongly be tailored to the individual and the patient should be encouraged to continue an active-lifestyle in relation to physical activity involving a varied use of the upper-extremities. This plan will be evaluated in two telephone follow-up conversations, where there is room for problem solving if needed.

Joyful activities (in my opinion) that involves a varied use of the upper-extremities. Photos: Daniel H. Major and Yngve Røe

 

Hope you will give this strategy a go. It has made me more confident and strategic when trying to get people with persistent pain moving on their own and I have seen good results (level 5 evidence/”anecdata”). However, a similar intervention has yielded promising results in a Randomized Controlled Trial and has been shown to be equally as effective as usual care among patients with rotator cuff tendinopathy [9]. In the future, our research team will hopefully be able to test this self-management intervention for patients with subacromial pain/rotator cuff tendinopathy/non-specific shoulder pain in a randomised controlled trial.

References

  1. Jordan JL, Holden MA, Mason EE, Foster NE: Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev 2010(1):Cd005956.
  2. Booth J, Moseley GL, Schiltenwolf M, Cashin A, Davies M, Hübscher M: Exercise for chronic musculoskeletal pain: A biopsychosocial approach. Musculoskeletal Care 2017:n/a-n/a.
  3. Bennell KL, Dobson F, Hinman RS: Exercise in osteoarthritis: moving from prescription to adherence. Best Pract Res Clin Rheumatol 2014, 28(1):93-117.
  4. Dobson F, Bennell KL, French SD, Nicolson PJ, Klaasman RN, Holden MA, Atkins L, Hinman RS: Barriers and Facilitators to Exercise Participation in People with Hip and/or Knee Osteoarthritis: Synthesis of the Literature Using Behavior Change Theory. American journal of physical medicine & rehabilitation 2016, 95(5):372-389.
  5. Lorig KR, Holman H: Self-management education: history, definition, outcomes, and mechanisms. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine 2003, 26(1):1-7.
  6. Medina-Mirapeix F, Escolar-Reina P, Gascon-Canovas JJ, Montilla-Herrador J, Jimeno-Serrano FJ, Collins SM: Predictive factors of adherence to frequency and duration components in home exercise programs for neck and low back pain: an observational study. BMC musculoskeletal disorders 2009, 10:155.
  7. Chatman AB, Hyams SP, Neel JM, Binkley JM, Stratford PW, Schomberg A, Stabler M: The Patient-Specific Functional Scale: measurement properties in patients with knee dysfunction. Physical therapy 1997, 77(8):820-829.
  8. O’Keeffe M, Cullinane P, Hurley J, Leahy I, Bunzli S, O’Sullivan PB, O’Sullivan K: What Influences Patient-Therapist Interactions in Musculoskeletal Physical Therapy? Qualitative Systematic Review and Meta-Synthesis. Physical therapy 2016, 96(5):609-622.
  9. Littlewood C, Bateman M, Brown K, Bury J, Mawson S, May S, Walters SJ: A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: a randomised controlled trial (the SELF study). Clin Rehabil 2016, 30(7):686-696.

 

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  • Graham Yates-Osteopath

    Great article. Behavioural change is the most difficult aspect of treatment. i think one of the biggest problems is we generally work to half hour slots. In my own practice I now give 45 minutes and although financially I’m worse off, the payback is much better as you have time to breath and establish a better alliance. However I think 60-90 minutes initial treatments are realistic to go through all the stages required- listening, observing, testing, diagnosing, treatment/education, advice/behavioural change. I now take fewer notes so I can be facing and listening during the initial stage.
    I have also tried introducing stickk.com which is a website where patients make a financial commitment to their agreed goals/programme. The evidence shows sticking money on it (if you agree you did not complete your goals in a given week, your money that week goes to charity) the outcomes improve by 90-130%. It’s done on honesty, but you can post on social media and involve a referee who oversees your commitment.I road tested this myself and I have to say it did add a level of commitment (to meditate 30 mins x5 weekly) and now I am in the groove.

    • Daniel H. Major

      Thanks, Graham. Good point! I agree that behavioural change is difficult and that we need to extend our initial consultations from 30-40 min. Behavioural change and collaborative problem solving takes time and our consultations should reflect this.