Stroke QUERI Project - Self-management for Patients with Chronic Musculoskeletal Pain -- Finding what Works

Project Number XNV 87-57 funded by RR&D.
April 1, 2006 - May 30, 2007

Most patients with pain are managed in primary care. Although several guidelines regarding pain management have been published, the optimal approach is still not well understood and some treatments are controversial. The VHA clinical practice guidelines for the care of veterans with medically unexplained chronic pain calls for the provider to "empower the patient for self-management," but provides no recommendations on appropriate, efficacious interventions. In addition, pain control and self-management were two areas mentioned in the Institute of Medicine report of 20 target areas identified for quality improvement efforts.

The objective of this pilot study is to examine effective self-management strategies for chronic pain in the context of a clinical trial of primary care patients with musculoskeletal pain and depression. We will investigate which self-management strategies patients perceive to be most helpful for their pain, as well as the barriers and facilitators to adopting these strategies. We will also investigate the patients and clinical characteristics that predict adoption of pain self-management strategies by analyzing data from the "Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP)" study.

We will conduct six focus groups each comprised of 6-8 adults who have completed the intervention pain self-management program of the SCAMP study (total enrollment of 48 patients) stratified by: (a) study site (VA or IUMG) and (b) pain location (i.e. low back or hip/knee pain). Using detailed script, the moderator will lead a discussion about self-management strategies for chronic pain with study participants. After providing informed consent, participants will hear a brief purpose statement and "ground rules" for the focus groups and then the moderator will begin the discussion. Questions will be open-ended at first and include a series of probes. The questions will elicit strategies that participants found helpful (as well as not helpful) for pain relief and improvement of function. Perceived barriers and facilitators to the use of pain self-management strategies will also be elicited. Data obtained from these focus groups will include both verbal and nonverbal communications. Therefore, sessions will be audio-taped and note-takers will be present to record relevant gestures and behaviors that might contradict the spoken words. Preliminary analysis will iteratively inform subsequent focus groups, and gaps in issue coverage will be addressed explicitly as they are detected.

While pain self-management programs have proven efficacious in numerous trials for low back pain and osteoarthritis-related pain, there is no agreement about what constitutes a "successful" self-management program. Furthermore there is a critical need to determine what program components (or strategies) are of particular significance or important in terms of effectiveness. Accomplishing our aims will help inform our future studies by identifying the strategies patients perceive as most effective, provide insights on how to overcome barriers or enhanced facilitators to adopting the patient-preferred strategies, and aid clinicians in recognizing patient characteristics that predict adoption of pain self-management.