Linda Rogers of San Antonio loves caring for children, including her own grandchildren. This summer in her home, she is watching and cooking for six youths ranging in age from 1 to 12. She has little time to be bogged down with aches and pains.
Rogers, 51, has coped with chronic pain from neuropathy, gout and rheumatoid arthritis for 10 years. A couple of years ago, she was approached about participating in a six-month chronic pain self-management program developed by a team at UT Health San Antonio and The University of Texas at San Antonio (UTSA).
Rogers and other patients with chronic non-cancer pain were studied in a clinical trial. Study participants were randomized to receive the program in two settings: monthly one-on-one clinic meetings with a community health worker trained as a chronic pain health educator, or group lectures presented by physicians and other health care providers at a local library.
At the end of the program, participants in both arms of the study showed a clinically significant improvement in the primary outcome measure, which was the time it takes to perform a five times sit-to-stand test. Faster performance on this test is associated with a lower likelihood of future falls and disability.
A strategy for life
“The program gave me long-lasting tools to manage my pain,” Rogers said. “It’s an innovative way to keep off medication.”
She is doing morning stretching to relieve muscle tightness and evening stretching to sleep better. As she cooks, she is doing knee bends, lifting one leg four times and then the other leg four times. “It helps work out the kinks,” she said. She is also practicing breathing exercises.
The “Living Better Beyond Pain/Vivir Mejor Más Allá del Dolor” self-management program is being studied as an affordable and practical resource to help primary care clinics serve chronic pain patients through non-drug approaches, said Barbara J. Turner, M.D., M.S.Ed., M.A., MACP. The program explores diet, sleep, goal-setting, mindfulness and meditation, and physical activities such as stretching, walking and gentle muscle strengthening.
Dr. Turner, professor of medicine in the Joe R. & Teresa Lozano Long School of Medicine at UT Health San Antonio, is lead author of a study that evaluated whether program participants such as Rogers would improve in how well they function. Results were published this May in the Journal of General Internal Medicine.
Patients received instruction in two settings
The study enrolled participants 35 to 70 years of age with chronic pain who had been treated with at least two months of opioids (narcotics) in the past year. Patients were from two primary care clinics and one HIV clinic in San Antonio that serve mainly low-income community members. More than three-quarters of the participants were Hispanic, and approximately half were women.
In this trial, 53 participants were randomized to meet one-on-one with a community health worker in a primary care clinic and 58 participants were randomized to attend group lectures at two San Antonio public libraries, Memorial and Collins Gardens. Both groups received the same half-hour presentations on a broad array of topics that can help manage pain and increase the ability to be active. This included understanding pain, goal setting, stretching, mindfulness, sleep, self-massage and eating.
“We did not offer a non-intervention arm of the study, because clinic directors wanted to help their disabled patients, and we know that lack of education does not help patients with chronic pain,” Dr. Turner said.
Improvement on sit-to-stand test
Measurements of the five times sit-to-stand test were recorded at the start of the study, at three months follow-up and at six months.
In the beginning, the 111 participants averaged 22.6 seconds to sit and stand five times, which indicates significant disability. After three months of the chronic pain self-management program, participants completed the exercise on average four seconds faster, which is a clinically important improvement.
“These are people who are very disabled, so the improvement was really remarkable,” Dr. Turner said. “We came up with an exercise program that is very feasible for this population.”
Several other functional measures were evaluated as secondary endpoints including better performance on a measure of mental function and a measure of overall physical function.
Effect of pain on performance
“The sit-to-stand test and other assessments are useful ways to quantify what people can do and also quantify where function is compromised,” said study co-author Maureen Simmonds, Ph.D., PT, professor of physical therapy in the School of Health Professions at UT Health San Antonio.
Dr. Simmonds in 1998 developed the Simmonds Performance Battery, a collection of tests that quantify, for example, the effect of health conditions, pain and aging on performance.
“When people improve, we are able to show that, to measure it,” she said.
Overcoming fear of pain
In the program, patients with chronic pain learn to separate themselves from the fear that often accompanies their pain, Dr. Simmonds noted.
“Most people understand acute pain is tied to tissue injury,” she said. “The assumption is that a little bit of pain is associated with a small injury, and if the pain increases in intensity, it must mean something more severe is happening. However, although acute pain may be associated with tissue injury, this is NOT the case with chronic pain. Worries about persistent pain and what it may mean become scary and threatening.
“This program explains that if we get going, and don’t wait for the pain to disappear totally, it will diminish as we get moving,” Dr. Simmonds said.
Primary care ramifications
The study confirmed that a community health worker who is trained in the curriculum can effectively extend a primary care team’s outreach to patients with chronic pain, Dr. Turner said.
“Chronic pain self-management training is an obvious missing component of routine primary care, but it has not been delivered in a way that could be affordably implemented,” Dr. Turner said.
Primary care practices could offer the program to chronic pain patients much as they currently offer diabetes self-management programs to diabetic patients. The ramifications are clear.
“We have this huge national opioid crisis, and we aren’t talking enough about, after we cut down on prescribing drugs, what can we offer people,” Dr. Turner said. “Not a second drug, believe me. It’s not going to work.
“This program, offered in the primary care setting, is meant to fill that gap.”
In the end, a better life
“The program taught me that medication is only a supplement to help with pain,” Rogers said. “If you can use other methods, it’s better than getting hooked on medication. The main idea of the program was for us to manage pain to have a better quality of life.”
Dr. Turner is the former founding director and Dr. Simmonds is a scholar with the Research to Advance Community Health (ReACH) Center at UT Health San Antonio. Zenong Yin, Ph.D., professor of health and kinesiology at UTSA; Yuanyuan Liang, Ph.D., professor at the University of Maryland School of Medicine; and Natalie Rodriguez of ReACH collaborated on the study.
About UT Health San Antonio
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