Self-management has become a popular term for behavioral interventions as well as for healthful behaviors. This is especially true for the management of chronic conditions. This article offers a short history of self-management. It presents three self-management tasks—medical management, role management, and emotional management—and six self-management skills—problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning, and self-tailoring. In addition, the article presents evidence of the effectiveness of self-management interventions and posits a possible mechanism, self-efficacy, through which these interventions work. In conclusion the article discusses problems and solutions for integrating self-management education into the mainstream health care systems.

Self-management education: history, definition, outcomes, and mechanisms.

Self-management approaches for people with chronic conditions: a review.

Pain is an unpleasant sensory and emotional experience. 1 Pain is a complex phenomenon derived from sensory stimuli or neurologic injury and modified by individual memory, expectations, and emotions. 2 Pain is usually associated with injury or a pathophysiologic process that causes an uncomfortable experience and is usually described in such terms. Although there are no objective biologic markers of pain, an individual’s description and selfreport usually provides accurate, reliable, and sufficient evidence for the presence and intensity of pain. 3 Persistent pain can be defined as a painful experience that continues for a prolonged period of time that may or may not be associated with a recognizable disease process. The terms persistent and chronic are often used interchangeably in the medical literature. Unfortunately for many elderly persons, chronic pain has become a label associated with negative images and stereotypes often associated with longstanding psychiatric problems, futility in treatment, malingering, or drug-seeking behavior. The term persistent pain may foster a more positive attitude by patients and professionals for the many effective treatments that are available to help alleviate suffering. 4 The clinical manifestations of persistent pain are commonly multifactorial. Because of the complex interplay among these factors across several domains (physiologic, psychologic, and social), discriminating which factors are most important for the purpose of treatment can be very challenging. Further complicating this task is the fact that pain expression and hence the importance of specific factors commonly vary, not only across individuals but also over time in one individual. Elderly persons have been defined by demographers, insurers, and employers as those aged 65 years and over. In healthcare discussions, the elderly persons often described are those who are most frail, with health and disability problems typically encountered in the older population. By age 75 many persons exhibit some frailty and chronic illness. In the population above age 75, morbidity, mortality, and social problems rise rapidly, resulting in substantial strains on the healthcare system and societal safety nets. This group represents the fastest growing segment of the total population. 5 The greatest challenges in geriatric medicine are represented by the oldest, sickest, and most frail patients with multiple medical problems and few social supports. The guideline panel focused its attention on this group as it prepared this update. Persistent pain is common in older people. 6 A Louis Harris telephone survey found that one in five older Americans (18%) are taking analgesic medications regularly (several times a week or more), and 63% of those had taken prescription pain medications for more than 6 months. 7 Older people are more likely to suffer from arthritis, bone and joint disorders, back problems, and other chronic conditions. This survey also found that 45% of patients who take pain medications regularly had seen three or more doctors for pain in the past 5 years, 79% of whom were primary care physicians. Previous studies have suggested that 25% to 50% of community-dwelling older people suffer important pain problems. 6,8,9 Pain is also common among nursing home residents. 10,11 It has been estimated that 45% to 80% of them have substantial pain that is undertreated. Studies of both the community-dwelling and nursing home populations have found that older people commonly have several sources of pain, which is not surprising, as older patients commonly have multiple medical problems. A high prevalence of dementia, sensory impairments, and disability in this population make assessment and management more difficult. The consequences of persistent pain among older people are numerous. Depression, anxiety, decreased socialization, sleep disturbance, impaired ambulation, and increased healthcare utilization and costs have all been found to be associated with the presence of pain in older people. Although less thoroughly described, many other conditions are known to be worsened potentially by the presence of pain, including gait disturbances, slow rehabilitation, and adverse effects from multiple drug prescriptions. 12 Psychosocial factors affect and are affected by pain in older patients. It has been shown that older adults with good coping strategies have significantly lower pain and This guideline was developed and written under the auspices of the American Geriatrics Society (AGS) Panel on Persistent Pain in Older Persons and approved by the AGS Board of Directors on April 8, 2002.

The management of persistent pain in older persons.

http://www.faculty.umb.edu/pjt/epi/oakes04.pdf

The (mis)estimation of neighborhood effects: causal inference for a practicable social epidemiology.

For both clinical and economic reasons, the increasing number of persons living with chronic conditions represents a public health issue of growing importance. Emphasizing patient responsibility, and acting in concert with the provider community, self-management represents a promising strategy for treating chronic conditions—moving beyond education to teaching individuals to actively identify challenges and solve problems associated with their illness. Self-management also shows potential as an effective paradigm across the prevention spectrum (primary, secondary, and tertiary) by establishing a pattern for health early in life and providing strategies for mitigating illness and managing it in later life. We suggest ways to advance research methods and practical applications of self-management as steps in its future development and implementation.

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[Self-management: a comprehensive approach to management of chronic conditions].

Although chronic pain is a frequent cause of suffering and disability and is costly to society, there continues to be limited access to specialty pain clinic services. Hence, there is a need for cost-effective, accessible interventions that will help people find ways to better manage this difficult problem. This randomized controlled trial examined the effect of a low-cost, community-based, nurse-delivered, group psychoeducation program entitled the Chronic Pain Self-Management Program (CPSMP). It has a standard protocol that was modified from the successful Arthritis Self-Management Program (ASMP). One hundred and ten individuals with mixed idiopathic chronic pain conditions were enrolled in the study (75% female; mean age 40 years; mean chronicity 6 years) and were randomly assigned to one of two conditions: the 12-h (CPSMP) intervention group, or the 3-month wait-list control group. Self-report measures of pain-related and other quality of life variables as well as two hypothesized mediating variables were collected pre-treatment and 3 months later by assessors blind to group allocation. One hundred and two subjects completed the study. Results of intention-to-treat analysis indicated that the treatment group made significant short-term improvements in pain, dependency, vitality, aspects of role functioning, life satisfaction and in self-efficacy and resourcefulness as compared to the wait-list control group. Because it has a standard protocol, this intervention has the potential to be reliably delivered at low cost in varied urban and rural community settings and hence be more widely accessible to a greater number of people suffering from chronic pain than is currently the case with more specialized pain clinic services. Based on the results of this study, further research evaluating the long-term impact and potential cost savings to the individual and to the health care system is warranted.

Katherine M Rowat

Papers

Randomized controlled trial of a community-based psychoeducation program for the self-management of chronic pain