Welcome back to the Healing Pain Podcast with Anne Söderlund, PT, PhD
On this episode, we’re discussing patient adherence to treatment as a foundational aspect of pain management. The evidence-based and research in this era tell us that high levels of adherence to things like physical activity or perhaps an exercise program are highly correlated with positive health outcomes, but what about when a patient does not adhere to the agreed-upon treatment plan? Do we know how to increase patient adherence? Do we know how to promote the maintenance of pain self-management behaviors? Joining me to discuss adherence to and the maintenance of self-management behaviors in people with musculoskeletal pain is Dr. Anne Söderlund. Anne is a Professor of Physiotherapy in Sweden with a special interest in behavioral medicine.
Her research area is on prevention, treatment and evaluation of health problems from a behavioral medicine perspective embedded within a physiotherapy framework. This includes a strong focus on an individual’s behavior, behavior change, and the ability for functioning in everyday life at different ages. On this episode, we discuss the important topic of helping patients adhere to exercise programs and other self-management techniques for the treatment of chronic pain. As a leader in this area, it has some great research with regard to physiotherapy and behavior change. She’s definitely someone’s work I recommend that you follow. Without further ado, let’s begin and let’s meet Dr. Anne Söderlund.
Watch the episode here:
How To Promote Self-Management Strategies To Reduce Pain And Improve Function With Anne Söderlund, PT, PhD
Anne, welcome to the show. It’s great to have you here.
Thank you. It’s great to be here.
I’m excited to talk about your paper. Whenever I have someone who’s done a good quality piece of research, I like to mention the paper. I recommend everyone to read it. I want to start out with that. The name of the paper that you wrote is Adherence to and the Maintenance of Self-Management Behaviour in Older People with Musculoskeletal Pain: A Scoping Review and Theoretical Models. It’s in the Journal of Clinical Medicine 2021. When I came across the paper, I was excited because first of all, I loved theoretical models. It helps people think about what they’re doing and put things in better frameworks for all of us, reflect on our own practice and say, “There are things I’m doing within this model and I could do better or start to insert within this model.” The whole paper is in the context of pain self-management. Pain self-management in and of itself is a big topic. Based on your paper and your experience, how do you define pain self-management and what does that include?
There are a lot of definitions for this one pain self-management or self-management in general. We needed to decide for one definition. When I was clinically active, what I thought the self-management would include and did include. It’s the borrowed definition I used to be used in our paper. It did well to us. It is about the ability to manage the symptoms, different parts of treatments, physical and psychological consequences, and lifestyle changes that the chronic condition demands to people. It is also monitoring the condition to see by yourself. “What I am doing with myself? What are the good things and the bad things I am doing with myself?” It’s also the effects of both cognitive and emotional responses. What are bought off to the self-management? It is quite a lot and the whole that I got into my opinion. Definitions suits as well in this paper.
It’s a very encompassing definition. There’s a lot under the hood there with regards to pain self-management. As a therapist, as I was reading that and reflecting on it, it also gave me a little bit of pause and say, “Someone who is living with pain and someone who’s managing pain has a lot that they have to consider in their life with regard to managing the condition and potentially overcoming the condition.” It’s interesting when I see it in this light that there’s a lot here that we have to start to look at and piece apart as clinicians and researchers to help people. The study had two aims. I’d like to briefly tell us what those two aims were. Tell us why this paper was important for you to start to delve into with regard to research.
We have been talking about adherence and maintenance in pain context but also in other context in physiotherapy in particular and generally too. Since 1970s or something, it’s so huge for many years. There is nearly nothing that happened during these years. We have been just talking about it. Advancing knowledge in this area hasn’t been great at all. We wanted to show the caps in research and maybe stimulate researchers to go and study further these concepts but also clinicians, specifically the second aim, which was about to reframe some models about this. We plan to have components that people could recognize and use in clinical work. These components are not so complicated. As clinicians or as a researcher, we are not thinking about this. We’re like, “It will be okay. We have a treatment package and we will do this with the patient.” The patient will follow the routine, which is not happening.
There are two aims in this paper. The first aim was to study the adherence and maintenance of these pain self-management programs. The second was to basically create these theoretical models for adherence and how that relates to behavior and behavior change, which is so important. As physiotherapists, even though we’ve been focused on behavior change since the beginning, the language around behavior change hasn’t entered our stratosphere probably until the last years. Why is behavior change so important for a physical therapist to consider? Why is it important within the context of this pain self-management approach?
I believe it is about everything we do. There are some treatment methods that we manually do with the patient and to the patient that the patients are not supposed to do back home but in every patient’s treatment program, there are things that the patients should continue back home. Many times as older people, more in that case, they need to do it for the rest of their lives. For example, you can’t stop exercising or stopped being physically active. You need to do it for the rest of your life. What should we do to support these changes?
It is about behavioral change. Even with those two cases, we give the patient something called Transcutaneous Nerve Stimulation latent apparatus. They are supposed to use it back home. That is also a behavior change. If they are not doing, they are not getting the effect. If they are doing it, they are getting the effect. It is about to meet patients in the behavior change circle. It is very good that we have started to use this vocabulary in the PT area and also acknowledge that this is what we do and this is what we should do. It is no complicated thing. It is not only psychologists who should do that.
That was very apparent as I’ve read your paper. It’s another one of the reasons why I wanted to reach out to you. There’s an aspect. We’re a little bit responsible for it as physical therapists. There’s maybe a stigma attached to it, so to speak. When people look at us, they look at us like, “We instruct on exercise. That’s all we do as physical.” The primary thing we do is instruct on exercise. No matter who we’re talking about, whether it’s a personal trainer, a yoga instructor, a Pilates instructor or a licensed physical therapist, there’s a lot that is underlying exercise instruction, specifically therapeutic exercise instruction when you’re working with populations of people with chronic disease and chronic pain. I believe your work lends a lot of support to that. Within that pain self-management realm, we’re not just prescribing exercise. We’re working on cognitive behavioral change with regard to the promotion of physical activity, which is a different conversation.
We shouldn’t forget that instruction is one type of behavior change strategy. We need the instruction. We need to show what to do or how to do it. That is part of it but we should not stop there. There is so much more to cave or to help people to support the change. It is fun when you see that, “I got the keys to the person in front of me. He or she understands what we are doing together.” It’s very exciting to use these components for behavior change instructions.
It’s important for us to talk about the words adherence and maintenance because that’s the crux of this research. Describe to us what adherence means and what maintenance means with regard to pain self-management.
Several years ago, we were using only the word compliance. Compliance is something that the therapist says that the patient must do. There is no agreement. Adherence is a more patient-centered way to get an agreement of what to do, how to do it, and how to reach the goals the patient had. There are situations where we should use them to compliance. It is when you are using opioids. You need to adhere or comply with the prescription. You should not take less or more. That is compliance. We have no treatment parts that we could demand compliance from the patient adherence, which is a personal centric way to get an agreement, how to start, what to do, and where is to call.
With maintenance, these two are quite together. You don’t get maintenance without adherence. Maintenance is a difficult concept, especially in the physical activity area or exercise area where we know that the patients should keep on doing. That is maintenance. With study, they are measuring the effect of disability or range of motion in longer term in some months then they call it maintenance. That is not maintenance for me. It is sustained effects but it doesn’t say what the patient is doing. The maintenance of the self-management behavior is different but it is very difficult to define when we do reach the maintenance in years.
I want to bring this point back. We’ve been talking about exercise and physical activity a lot. This paper is broader. When we’re talking about pain self-management, it’s not just the physical. It’s also the psychological and cognitive-behavioral lifestyle as well as the environmental and social aspects of that entire pain self-management program. As a metaphor, it’s a lot. You broke these down into maintenance of behavior and adherence to behavior. You have these models. Can you tell us the three parts of these models because both have three parts that are similar?
My coauthor and I were talking a lot about how should do we these models. We start from the beginning. We think all by ourselves, and the whole thing. We had been doing research since 1970s in these areas. There should be something to start with. In several years, I have been interested in some of the cases at work. She’s a psychologist in London, college and university. This is her model. It is a lot than only what is happening between two persons. How should I support my patient and individual here? It is large. They call it COM Model.
The ingredients are capability, motivation and opportunity. I could see them in these areas, how to model adherence and maintenance, but then we decided to do it from this point of view. You were talking about the environment. There is an environmental aspect in this. It shows to our clinicians and research that don’t forget that one. There is some motivation. There is capability, which is the personal thing with your skills and what you have. It affects motivation but also the environment affects motivation. You shouldn’t forget to admire the environmental parts of this.
That COM you mentioned is Capability, Opportunity and Motivation. With capability, opportunity and motivation, both applied to the maintenance of behavior as well as to the adherence of behavior with regard to that pain self-management. I want to talk about those a little bit as well because there are some interesting points in each of those. If we’re looking at adherence to behavior under that capability section, one of the first things you have there is education, which is important because in the world of physical therapy, pain education is a hot topic. It’s been a hot topic for years. It will continue to build in some way. It’s not a pain neuroscience education necessarily. What I like about this is it’s much broader. Can you talk about the broader perspective of education with regard to that capability construct there?
We should see it as a product because there are so many buts in this pain self-management and in people’s lives who has the condition. We need to talk about pain condition, what it is, health perceptions, what do people think about their health, and what is affecting their health. It’s not only the knee problem. It’s most probably many things. In the beliefs, what do I believe where my problems are coming from? Whose fault is it, if you can say so? Also, the literacy, what do they know about anatomy? These are more educational things in what we have always been doing in pain area. It’s also treatment knowledge and skill. What is the level of the patients? It is quite a complex part too.
The one part of that whole education category that jumps out at me is literacy. I’m on show 230 or something like that. Every time I engage with an expert like yourself, I always think, “We’re going to use some high-level terms. That’s okay.” I always tried somewhere during these interviews to break down what we were saying so that it’s simple, approachable and easy for people. As professionals with masters, doctorates, licenses and continue education, we have a lot of information in our head but the ability for us to meet that person with their literacy level is so important.
Even within the realm of pain neuroscience education, one of the biggest flaws I see is pain neuroscience itself is quite complicated. Unless you’re able to eloquently distill that down in a way that’s simple, it might not be effective the way we read about it and the research, the way we hear about it in courses and things like that. Literacy under the education is so important. If we jumped down to the motivation aspect of it, there are some things that are very common to physical therapists and other professionals, goal setting, self-monitoring, coping with and benefiting from lapses. The coping with that was interesting but the benefiting from lapses, what did you mean by that in that part?
What did you learn when you lost yourself in the old behavior? I should not have a large adult to bake. I should have taken a little bit less doing it before I get so much more tense, some headache, or something. It is learning when you are calling down to the previous behavior. It’s also when it is explicitly said that it’s a part of the coping that you are learning for your downhills. It is also for the patient. I am allowed to do a mistake. It is not catastrophic when I stopped exercising or doing whatever it is during 1 week or 2 weeks. Maybe I could seek if I have flu or something. This is something that is expected. It is very human thing to fall down. As we know from smoking, for example, this is the same thing.
When we talk about that adherence, sometimes people identify it as compliance but knowing that if you prescribe an exercise program, a certain dietary approach or a meditation program for your patient, you can rest assure that they’re going to be days where they don’t do it. That’s okay to normalize it for them. From that, there’s some kind of learning that happens. It may be, “You didn’t meditate this week. What have you noticed that’s changed? Has sleep gotten worse?”
Before you decided that you are not going to do it, what happened before? What happened afterwards? What are your thoughts about this? Discuss the lapse. You need to discuss it. It’s just not that go and learn by yourself. We need to stimulate the learning from lapses.
There’s the idea that the therapist has to jump in and get them right back on track, so to speak. That’s so important.
The patient feels like, “My therapist didn’t like this.” It is not about liking but we should not show anything about accepting or non-accepting the lapses. We should take it as normal. It is part of the course.
Finally, under the opportunity to category under this adherence to behavior, you have behavior prompting factors external to the person. You have booster sessions with problem-solving discussions. Tell us what you mean by a booster session. Where does that come in within this entire pain self-management adherence behavior aspect?
Since we are human, we are getting tired for doing daily the same thing, whether it is exercise, taking a walk or something. We also know from studies that behavior change takes time. Three months is nothing. Most probably something between 6 months and 1 year is where the change is happening. It’s sticking to me. The post-assessment is for checking. When I was clinically active, I used it. When you feel that you’re leveling out somehow, you call me. They seldom call you. In quite many cases, say you have a treatment period of 2 months. In 3, 4, 5 months, you need to have a short call, have a Zoom meeting or meet the patient at the clinic to buffer up how is it going. Why it’s going so and so? Why isn’t it going so and so? What are your calls? What is your next call in this area for yourself? It’s reminding about things.
Potentially when the behavior changes were after, it begins to settle on around 6 months to 1 year. I would say that’s true. It also makes me think about the way our entire healthcare system is set up both on inpatient and outpatient basis where people come in. If you’re inpatient, then you’re in an inpatient rehab program for every day for, let’s say 6 weeks or 4 weeks. If you’re outpatient, it’s twice a week for probably a similar amount of time. That might not be the best use of our time. It might not be time-intensive enough for the change that we’re after. When you say that, to me I wonder, are we just wasting money?
We are wasting money. It’s also from the point of view that we have individuals here. I don’t function the same way as you do, so I need a different kind of rehabilitation period than you do. Maybe for me, it’s once a week or every second week. For another person who is down and needs support on several areas, it’s once a day during some weeks. Still, when these weeks are hour, then relieve the patient. Get along. Do what you’re told to do. It’s not good. No wonder they are back again.
That ties in well with those booster sessions because we’re saying, “Here’s the behavior change we need. Here’s probably how long it takes.” You can potentially create a different type of program for this particular patient. Keep in mind that they probably need some kind of support as that time from you starts to lengthen. Don’t just forget about the person. Give them the opportunity to re-contact you but also as professionals, we should re-contact people more and say, “How’s it going? How are you doing?” We’ll move over to the maintenance of behavior, which was the second part. You have the physical as well as the psychological knowledge and skills needed to engage in a target behavior activity. Under that, you have identifying high-risk situations for relapse. We have relapse come into the situation here. Tell us what you meant by identifying high-risk situations for relapse.
It means to discuss with the patient what the patient thinks when he or she stops doing that behavior, we have been agreed or should be done to get better health. Often these discussions are not so easy for the patients, so we need to help them. We know that when the patient has a fever, then it pulls down. That is high-risk situation when you can tell. If the family is not well-functioning, if there are bad days in the family, those are very risky situations to lead the call. There has to be a plan on what are these. What should I do when these situations come along? That is also the same thing as in that year relapse. It is important that we let the patient, the individual know that it is normal. You are a normal person. There is nothing to worry about but it needs to be taken care by a blank.
If I’m hearing you correctly, it’s starting a different conversation with regard to the therapeutic relationship in that regard. Instead of someone coming to you and expecting that you have something or can do something to cure their pain, so to speak, it’s more like, “I’m here to facilitate your own self-management with regard to the physical, the psychological, the lifestyle and the environmental part of it. As we’re starting to look at that, I’m going to help you identify barriers that might come up that could potentially be high risk for you or parts of your life that could be high risk, where it’s hard for you to either engage in that self-management or to continue with that self-management the way that’s needed.” Even in that whole section right there, I don’t think most people come to us thinking, “I’m going to learn about pain self-management.” They come to us thinking, “This person has the solution to my problem.”
I have never met a patient who comes with an idea that he or she has the solution for the problem. If it is, it is from the internet. “I read about this and about this kind of therapy. It’s always that somebody is giving to the patient.” The attitude from the patients does not help us to get the right path. We need to facilitate the right path from the patients so that we are getting them on-board on their thinking.
One of the things with regard to values-based living, values-based activity and values-based goal setting that I spent a lot of time on with patients is, “You have everything you need inside of you to negotiate through this period of recovery. I’m going to help you facilitate that process in a way that’s smoother and more efficient.” That takes a while for people to come to terms with that. There’s nothing outside of me that is missing. Everything I have is within this person is going to help me with that entire process. I look at it like when babies first begin to walk, we don’t tell them you’re going to put your foot down and then separate.
They just begin walking. It’s part of a developmental process. They have everything they need inside them. Somehow, it’s there. We come over them. Maybe we hold their waist or grab their hands. We help facilitate them as they become stronger, bounce better, then move on to being independent. I look at pain the same way with people. I believe that is a healthier way for people to start to approach pain self-management and all the various aspects here. That jumps us down to the motivation aspect, which is that self-efficacy for problem-solving both handling barriers and relapse. Relapse keeps coming up here, which is great but the self-efficacy part is so important for people.
I love the concept of self-efficacy. It’s a positive thing. I try to put it in everywhere. Research has shown us that if you believe in your capability to do something, then you are much more likely to do it if you do not believe yourself having the capability. Most of the term problem solving as well as self-efficacy is so situation-specific. They can do the exercise and physical activity very well and have a high self-efficacy with those but not maybe in problem-solving. That needs to be one part of the teaching or discussion with the patient. Identify when the patient solves a problem. For example, when the patient went off if you are discussing relapses in which situations, if there is a risk, “What did you do? What is your plan to do them?” They come up with a good plan, then they have solved the problem before the problem exists. They get the highest self-efficacy when the problem comes on their way.
I was excited to see that in there because I know it’s a big mediator of change with regards to pain. I like that it’s in that paper and that entire theoretical framework you have. Pain self-management is a big topic. This is a scoping review. It’s a systematic review but a little bit different. You spent a lot of time going through literature. What did you find was missing? You hope to see certain aspects but there was missing from the literature.
I wanted to see more studies about self-management, especially for all the people. Also, I believed that I would find much more ingredients in the treatment packages that were targeted for adherence or maintenance. It was so poor. I was like, “This can’t be happening.” I was doing several searches. It respects on the case.
We don’t have a lot of research out there on pain self-management itself, which is so fascinating to me. That’s not used to be me.
Much as we are using self-management than as a treatment strategy. It’s working quite well. People are not taking care of the adherence part or the maintenance part. I don’t understand how therapists and researchers think that people are continuing when they are not doing anything for that part.
We could have wonderful studies that it’s a six-week intervention and then we follow them up to month three, which is what most studies are like. It may or may not have a control group. That’s in here or there basically but after that, we have no idea what’s happening.
We leave it. In fact, there’s moral unethical.
Talk to me about that. Why would that be? That’s for you as a researcher to say that it is really powerful. Why is that an unethical challenge within the literature?
There are things that you can do to increase further adherence after the study if you are talking about studies and also the maintenance of behavior change. There are components strategies that you can have in your package from the beginning, which will keep the patient or the person totally in other kind of platform to keep it that way but it should be. It is unethical to let it be.
I believe this entire show that I have worked on for many years is a public service announcement basically for both practitioners and people living with pain but more and more, I realized that effective pain management and effective pain self-management is a human right that in many ways is missing from everything we’re doing. When you say the word ethics to me and as I read research, it all starts out with 1 out of 3 people struggle with chronic pain globally. Twenty-five percent of any country struggle with pain globally. Pain is physical and emotional, that’s all great. What are we doing with it? If we’re spending all this money on a six-week intervention, we only follow people to three months and then we forget about them. We let them out into the world. We don’t follow up or provide them with support or as you call those booster sessions in your paper. We don’t follow them into the environment, in the context of their life and see if this works. Most of our research studies are in very controlled environments, in an academic setting, which is not real life. Not only just me but everyone who’s reading this, where is our money going toward? How is it effective? Is it effective?
You brought up an important topic. As we look at this in a scoping review like this, you brought it out. It’s like, “We don’t know.” It’s not quite there yet. We have to do some more research. Maybe dig a little bit deeper if it’s not there but I think that’s an important part. The other part of your scope and I think this probably ties into the ethical and moral part of it is your paper focused on the elderly. Why is that important with regard to not only the paper but this topic we’re talking about?
They are not the same as elderly years ago. Elderly years ago died before elderly now. We had 65 years as our limit cutoff. Those who are 65 years, they might live 30 more years. It’s half of the 65. It’s half of their lives, which is still 1/3 left. They are not working anymore. These people should reach us and leave them, not put money in the rehabilitation of these people or not care of how their self-management should look like. The elderly as a population is increasing, which we know very well. If we are talking about economy, global economy, and national economy, we should put more money to these group of people who are somewhere near the 70 or more than that help them to help themselves in their problems. Much more of these people have chronic pain, for example, those that are under 60. We could save quite a lot of money if we were a little bit more preventive. We had a little bit more preventative actions and also self-management actions. Adherence and maintenance are as important there because of these 30 years that are left in many cases.
I believe a lot of the research that you have in here points toward helping people with longer lifespans, live healthy, and live in a more dignified manner rather than saying, we’re going to forget about them. If they come to us, we’re going to give them medication. That’s what happens with a lot of elderly people.
Some pain medication when you have a knee pain, hip pain, low back pain or whatever.
I think you’re talking about greater quality of life steps that all of us in the therapy professions know work. As we figure out these models of more effective pain self-management and how to help people maintain these behaviors, which are what we’re talking about, I think a lot of that is the future of what I see as personalized pain medicine and helping clinicians with the skills that support this rather large theoretical model that you have here. It’s been fascinating talking to you. I appreciate this paper. I want to mention the paper so people can link to it. It’s called Adherence to and the Maintenance of Self-Management Behaviour in Older People with Musculoskeletal Pain: A Scoping Review and Theoretical Models in the Journal of Clinical Medicine 2021. Tell people how they can learn more about you, how they can contact you and reach out to you.
I am in Sweden at Malardalen University. It’s in the middle of Sweden. It’s in West which is somewhere between hogskola in Stockholm. I think everybody knows hogskola in Stockholm in Sweden. My email is AnneSoderlund@MDH.se.
You have an active Twitter handle that we can tweet to you at? The Twitter handle is @AnneSode. I want to thank Professor Ann Söderlund for being with us on the show. Make sure to share this episode with your friends and family on Facebook, LinkedIn, Twitter in the university setting, pain management setting, or in a research setting for people who are interested in the topic of pain self-management. It’s a pleasure. I’ll see you next time.
- Dr. Anne Söderlund
- Adherence to and the Maintenance of Self-Management Behaviour in Older People with Musculoskeletal Pain: A Scoping Review and Theoretical Models
- Malardalen University
- @AnneSode – Twitter
About Anne Söderlund, PT, PhD
Anne Söderlund, PhD, is a professor in Physiotherapy with behavioural medicine profile at School of Health, Care and Welfare, Mälardalen University, Västerås, Sweden. She is a leader of a multidisciplinary group, BeMe-Health of 20 researchers, has a large international research network and about 100 original scientific peer-reviewed publications.
Her research area is on prevention, treatment, and evaluation of health problems from a behavioural medicine perspective in the physiotherapy framework. Her research is focused on the individual’s behaviour, behaviour change and ability for functioning in everyday life in different ages. She is an Editor-in-Chief for the European Journal of Physiotherapy.
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