Patient education in Pain Management

Introduction

Pain is a complex, multi-faceted perceptual experience that demands an explanation. As a sufferer, an inability to make sense of the often worrying and persisting uncertainties of pain, forces many to retreat from life’s pleasures. As a clinician, it is therefore vital to ensure a collaborative facilitation of meaning in those who live with pain. Educational skills are merely assumed in both practice & research. [1] In many disciplines, pain education accounts for less than 1% of undergraduate programme hours within the United Kingdom. [2]

Patient education has been defined as, "any set of planned activities designed to improve a patient's health behaviours, health status, or both." [3] These activities aim to facilitate the patient's knowledge base in order to help them make sense of their pain and guide them towards effective, ongoing self-management.

To facilitate an understanding of pain’s complexities and the importance of self-determined, sustained self-management, we must first develop facilitatory skills.  Facilitation can be defined as, “A technique by which one person makes something easier for others.” [4]. Helping & enabling are central to meaningful facilitation. Yet, the desire for practice-based educators to ensure efficient and effective learning “often leads to concentration on what they are doing rather than what the learner is doing.” [5] The following image shows a summary of different methods of pain education that are used by healthcare professionals and their advantages and disadvantages:

Delivery Method Advantages Disadvantages

Verbal 1:1 

Moseley (2005)

Patient centred

Questions answered

Expense

Time consuming

Limited recall

Audiovisual DVD

Oliveira (2006)


Cheap

Mass production

Impersonal

Limited engagement

Booklets/Pamphlets 

Burton et al., (2007)

Mass education 

Cheap

Boring 

Low compliance 

May change behaviours 

Mass communication

Expensive 

Generalisation

Email

Lorig (2002)

Quick

Personal

Tech limitations

Spam issues

Internet

Morr (2010) 

Easy, free

Interactive

Tech limitations

Competing for attention

Joint Models

Louw et al., (2012)

Visual 

Realistic

Biomedical 

Fear/threat nocebo inducing

[3]. Even though patient education has been viewed and practised as a preventive strategy majorly, it includes all the information about the disease/disorder/condition the patient is concerned with. Education is a vital part of rehabilitation from pain; a process which requires the acquisition of new knowledge and skills. This requires the ability to concentrate, undertsand and process information. The information must also be retained, retrieved, integrated and used in a meaningful way. [6]

When including patient education as part of a pain management programme, there are certain topics which should be covered to address the areas patients often have concerns or misunderstandings about. These topics include: the anatomy and physiology of the affected part(s), the multi-faceted nature of persistent pain, the difference between acute and chronic pain, triggers and flare up management, fear avoidance and pacing, the role of exercise, the role of physiotherapy and other treatments/interventions, realistic expectations about a diagnosis and cure, and goal setting. [7] 

Factors which will affect patient education include physiological, psychological, sociocultural and environmental. In Pain Management, the patient is enabled to understand pain mechanisms in order to reconceptualise their pain experience. Pain is "a multiple system output activitated by the brain based on perceived threat." [8]. Therapeutic neuroscience education aims to help people make sense of their pain and reconceptualise their understanding of the outdated and unhelpful societial view of pain being lniked to harm or damage. For example, many patients believe that degeneration is a disease and needs to be cured. The primary goal of patient education should be to facilitate understanding that degeneration is not a disease but a normal aging process and has to be treated with that view. 


Need[9]

Cost containment studies show that educating patients results in significant savings. Educated patients maintain better health and have fewer complications; as a result, they require fewer hospitalizations, emergency department visits, and clinic and physician visits.  As the growth of health care continues to outpace inflation in many countries around the world, health policy makers have increasingly focused their attention on cost containment. Managed care has a major focus on reducing the supply of services. There is increasing attention to lowering health care costs through primary prevention efforts.</span>There is evidence to support patient education not just in general pain management but in specific pain conditions. A meta-analysis of patient education for migraine sufferers showed that education led to decreased disability, increased quality of life, and decreased frequency of migraine in the intermediate term. [10] For neck pain and whiplash disorders structured patient education has some benefit (albeit small) when combined with physiotherapy. [11]

When considering the need for patient-centred care, it is essential that we ask a fundemental question when educating people about pain: What do patients want? In a recent met-analysis, Yelland (2011) discovered that patients are seeking the following:

  • Pain relief
  • Functional improvement (work return)
  • Acquired knowledge
  • Believed/Listened to (social legitimisation)
  • Accurate diagnosis (clearly & confidently explained)
  • A positive shift in attitude

In addition, Gifford (2014) suggests that people in pain want to know five things:

  1. What's wrong with me?
  2. How long is it going to take to get better?
  3. Is there anything I can do to help myself?
  4. Is there anything that you can do to help me?
  5. How much will it cost?

Therapeutic neuroscience education (TNE) should aim to address all of the above factors by facilitating a meaningful understanding of the contemporary evidence base related to pain neuroscience. This must be delivered with empathy and compassion for the person's lived pain experience.

However, despite our desire for patient centred care, Eccleston & Crombez (2007) argue that the delivery of contemporary helathcare all too often fails to live up to the needs of people in pain.  Rather than facilitating a helpful reframing of pain, which guides patients towards acceptance and self-efficacy, Eccleston & Crombez (2007) highlight the repeated and escalating perseverance loop of short-term, problem solving behaviours that many patients continue to experience. "Pain is an ideal habitat for worry to flourish." (Eccleston & Crombez, 2007). Unfortuantely, without an adequate and meaningful understanding of pain, many patient's worries continue to grow.      

Factors affecting Patient Education 

  1. Inadequate assessment of pain. Assessment of the patient's symptoms should be person centred and should follow the biopsychosocial approach. [12] In order to effectively assess pain and begin managing and educating patients, it is essential for clinicians to relinquish some of their "authority" and empower the patient to become engaged and proactive.
  1. Inadequate understanding of how patient perceives his/her pain. Understanding what a patient believes about the causes or consequences of pain will allow the clinician to better inform the patient and correct any misinformation. However clinicians must approach these conversations with respect in order to earn the patient's trust.[12] Examples of perceptions of pain common among cancer patients include: a fear of addiction to medications, concerns about side effects, discussing pain will distract the doctor from curing the disease, pain is an indication of the progress of the disease. [13] 
  2. Variations/ differences in the information received. { For example, a patient with knee pain is confused whether to do or avoid activities like cycling and walking due to the differences in the information provided even among health care providers}. Education and pain management will be less successful if information varies among clinicians, and if the care pathway is disjointed with poor communication among team members. There is no clear consensus on the ideal mode, personnel, intensity, or content of delivery. Content of patient education should address aspects of the condition that the patient may have little knowledge about. Some of these aspects will include: decreased understanding of the various therapies, poor understanding of the disease and the  consequences of poor compliance, poor understanding of clinic visits, and poor understanding of medication dosage/regimens.[14] 
  3. Life style
  4. Cultural barriers. The format and content of patient education material should be appropriate and culturally sensitive for the target audience; with consideration for language, beliefs, experiences and values.[15] Factors such as literacy, age group, and socio-economic status will impact on how well patients will learn from the materials provided. If patients do not understand the information provided then they will nto be able to self-care effectively. 

Requirement 

The following are important in patient education for pain management[16]:

  1. Recognise the impact of, and evidence for, the use of therapeutic neuroscience education and self-management as a critical part of pain management.
  2. Design and apply appropriate educational strategies based on educational science.
  3. Identify the range of educational opportunities available across therapeutic domains (eg, injury, disease, medical and post surgical intervention) with consideration of age, culture and gender.
  4. Consider the scope and evidence for/against various contemporary therapeutic educational styles (e.g. biomedical, psychological, neuroscience) and models (e.g stages of change theory) and service delivery modes including face to face, web-based, group education.
  5. Identify key variables which may impact on knowledge outcomes for the patient (eg self efficacy, health literacy, co-morbidities, culture), the clinician (eg health professional's pain-related beliefs), the message (e.g. use of multimedia), and the context (e.g. insurance limitations; risk reduction; injury prevention)

Beware

Patients who have in-depth knowledge of their condition encounter problems when their expertise is seen as inappropriate in standard healthcare interactions, and expertise taught to patients in one branch of medicine can be considered non-compliant by those who are not specialists in that field.Although patient education can give people confidence in their own self-management skills, it cannot solve the power imbalance that remains when a generalist healthcare professional, however well meaning, blocks access to medication and supplies needed to manage chronic diseases successfully. There is a role for those involved in primary and hospital care, including those supporting and training healthcare professionals, to recognise these problems and find ways to acknowledge and respect chronic patients’ biomedical and practical expertise. [17]


Practice-based Education Skills

Recent epidemiological data brings our need to meet the challenge of persitent pain into alarmingly sharp focus. Persistent pain affects over fourteen million people in England alone. It also accounts for 4.6 million GP appointments per year. [18] By reframing pain as an epidemic, we may begin to draw useful comparisons with other epidemics. [19]

Historically, epidemics from measles to cholera have been contained through education and communication. [20] Therefore, for clinicians to adequately meet the demands of the biopsychosocial model, it is imperative that they develop their knowledge and skills as practice-based educators. Patient education forms “a significant component of modern health care.” [21] However, most clinicians have a limited educational toolkit. [22] As the pain epidemic continues to grow, we must ensure that all clinicians feel equipped to guide their patients through the complexities of therapeutic neuroscience education (TNE).

As a sufferer, an inability to make sense of the often worrying and persisting uncertainties of pain, forces many to retreat from life’s pleasures. As a clinician, it is therefore vital to ensure a collaborative facilitation of meaning in those who live with pain. Educational skills are merely assumed in both practice & research. [1] In many disciplines, pain education accounted for less than 1% of undergraduate programme hours within the United Kingdom. [23]

This persistent undervaluing of our educational role and the need for an increased awareness of facilitatory skills within healthcare places a practical dilemma at the heart of pain education. In his call for a transformative medical education system, Quintero [24] states, “In order to respond to the current needs of society, which is education’s main objective, the learning processes of physicians and their instruction must change.” In addition, Sir Ken Robinson urges us to move towards an educational system that embraces creativity and lessens the fear of failure when trying new things.  




To facilitate an understanding of pain’s complexities and the importance of self-determined, sustained self-management, we must first develop facilitatory skills. Facilitation can be defined as, “A technique by which one person makes something easier for others.” [25]. Helping & enabling are central to meaningful facilitation. Yet the desire for practice-based educators to ensure efficient and effective learning “often leads to concentration on what they are doing rather than what the learner is doing.” [26]

This traditional, copy and paste, dualistic approach to education stems from a lack of understanding regarding andragogy and a fear of losing control as an educator within learning environments. [27] The novelist, E.M. Forster provides a striking grasp of the dilemma facing contemporary pain education by suggesting, “Spoon feeding in the long run teaches us nothing but the shape of the spoon.”

Healthcare professionals need to develop three key qualities in order to meet the facilitatory demands of practice-based education [28] :

1. An ability to actively listen
2. Best use of peer-learning opportunities
3. An understanding of group dynamics

Whether healthcare professionals endeavor to facilitate a meaningful understanding of pain through either one-to-one clinical interactions or group settings, in order to engage patients in the process of TNE, we must embrace collaborative learning. [29] However, there are distinct differences between cooperation and collaboration within practice-based education. Whilst cooperation involves a superficial level of joint engagement, collaborative learning involves a wholehearted desire and active interest in collectively solving problems. [30]

By moving from more conventional, didactic teaching methods and by embracing collaborative learning activities, both practice-based educators and sufferers sense of connection is amplified. [31] [32] However, many practice settings remain implicitly unconducive to collaborative engagement. [33] When we consider the diametrically opposed seating arrangements seen within most clinic settings, it is easy to see how something so simple as where we sit in relation to our patients, can impact on our ability to facilitate a meaningful understanding of pain. Collaborative learning should involve side-by-side, close positioning, not the more traditional, dualistic stance of sitting opposite one another where the implicit, physical metaphor is one of division. [34]


Self Directed Learning

“The move to a more student-centred view of learning has required a fundamental shift in the role of the teacher. No longer is the teacher seen predominantly as a dispenser of information or walking tape recorder but rather as a facilitator or manager of the students’ learning…The more responsibility given to the student, the greater the shift in the teacher role.” Harden & Crosby (2000)

Here are ten self-directed learning skills. [30] As practice-based educators we must embrace these skills for our own development, whilst also fostering them in our patients.

  1. Ask critical questions & analyse problems;
  2. Define what needs to be learnt & be able to access relevant resources;
  3. Adopt appropriate learning strategies;
  4. Be open-minded to other points of view;
  5. Cope with ambiguity, uncertainty & change;
  6. Understand your own limitations as a learner;
  7. Observe & use experts as models for improving your own performance;
  8. Assess your own performance & make plans for improvement;
  9. Accept that facing setbacks & overcoming difficulties are essential parts of the learning process;
  10. Remain positive & self-motivating.


As practice-based educators aiming to deliver patient-centered care, it is crucial that we understand the undoubted differences between how people learn. Educators must become acquainted with each individual’s learning needs in order to optimise learning. [35] Whilst learning styles questionnaires (LSQ) provide some insight and promote discussion [36], research suggests that they don’t stand up to peer review. [37] LSQs also risk labeling learners and therefore must be viewed in context. [38]

Our ability to adapt our educational delivery and tailor meaningful pain education to individual needs is vital. This process must begin with a better understanding of interest. [39] Interest is an emotion that serves two main functions: Motivation and performance. Without an ability to actively facilitate an interest in TNE, patients will likely remain disengaged and practice-based educators will miss opportunities for sustained cognitive and behavioural change towards self-efficacy.

As practice-based educators, we must understand what lies behind the emotion of interest. “Finding something understandable is the hinge between interest and confusion.” [40] Through an appreciation of an individual learner’s coping potential and an understanding of the dynamic relationship between challenge and support [41], clinicians would feel better equipped to respond to the ever changing demands of contemporary pain education.

Daloz summerises our educational duties by suggesting, “Like guides, we walk at times ahead of our students, at times beside them, and at times we follow their lead. In sensing where to walk lies our art.” [41] Whilst there is an undoubted art to practice-based education [1], an appreciation of the theoretical models that underpin TNE and an active and continued development of facilitatory skills will enable healthcare professionals to meet the demands of contemporary pain education.


Resources

Suggested podcasts about patient education:

In this podcast specific examples and case studies of patients with complex or persistent pain are discussed,focussing upon how you may approach persistent pain patients, explain their pain, use metaphors and explanations so they understand it, and help guide them through the recovery process.  


In this podcast Dr Kieran O’Sullivan and David Pope discuss

  1. Recent research on chronic low back pain
  2. Central vs peripheral contributions to CLBP
  3. Sitting postures and behaviours, and the relationship of this to pain
  4. Is there an ideal sitting posture, and does changing sitting behaviour change CLBP?
  5. Manual therapy in CLBP
  6. Lumbar kyhposis/lordosis
  7. Physical and psychological interventions for CLBP
  8. The effect of exercise on CLBP
  9. Movement patterns and retraining in chronic pain states
  10. The challenges of talking to patients about chronic pain states


In this podcast Mike Stewart, a clinical specialist working in persistant pain, discusses the use of metaphoric expression within a framework of biopsychosocial clinical reasoning - part 1. Here is part 2[1]of the above podcast.


References

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  40. Cite error: Invalid <ref> tag; no text was provided for refs named silvia
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