Multi-dimensional approach has been shown to be effective in management of chronic pain. It usually involves a self management program along with combination of other interventions. Despite this success, a significant number of referrals fail to complete treatment or achieve improved clinical outcomes. One of the factors which may influence these outcomes is a patient’s readiness for change. One of the means of defining the readiness of patients to engage with rehabilitation and self-management is through adaptation of the stages of change trans-theoretical model (Prochaska & DiClemente 1983).
The trans-theoretical model evolved through studies examining the experiences of smokers who quit on their own with those requiring further treatment to understand why some people were capable of quitting on their own. It was determined that people quit smoking if they were ready to do so. Thus, the trans-theoretical Model focuses on the decision-making of the individual and is a model of intentional change. The TTM operates on the assumption that change in behavior, especially habitual behavior, occurs continuously through a cyclical process. But the model has been subsequently used for a large variety of health related behaviours (e.g. exercise, weight loss, mindfulness, rehabilitation programs, etc.).
There are five stages of behaviour change as defined by the trans-theoretical model:
Pre-contemplation is the stage in which people are not intending to take action in the foreseeable future, usually measured as the next 6 months. People may be in this stage because they are uninformed or under informed about the consequences of their behavior. Or they may have tried to change a number of times and become demoralized about their abilities to change. These are the clients who have be defined as de-motivated or resistant to rehabilitation programs. In actual fact, the physiotherapist needs to respond to patients in this stage with empathy and ask open-ended and non-judgmental questions. It is important to explore whether they are in pre-contemplative stage due to lack of understanding or information or whether it is because of prior poor experiences. Only through gaining this understanding can the physiotherapist address the issue and therefore influence the thought process.
Contemplation is when the patient is at the point where they may make a change in the next 6 months. The pros start to outweigh the cons, and the patient starts to think about the problem. Though still ambivalent, they may be willing to learn. However, Prochaska and Velier (1997) warned that clients may be stuck in this stage for a long time due to this ambivalence. They called it as behavioural procrastination. In context of self management, it can also represent a patient who is considering it, but still continues to seek medical cure. In such cases, they are not ready for action oriented rehabilitation programs and the physiotherapist needs to focus on education, social and emotional support to move them on to the next stage.
In the Preparation stage, the client is usually getting ready to make the change within the next month. The patient may have made at least one attempt in the past year and is setting goals and expectations for themselves. Here, the physiotherapists can provide praise for the patient’s attempts to change, assist in goal settings, discuss a plan of action, and identify potential pitfalls. These are the patients who will respond most effectively to the proposed rehabilitation and self-management programs.
Action is the stage in which people have made specific overt modifications in their life styles within the past 6 months. Since action is observable, behavior change often has been equated with action. But in the transtheoretical model, action is only one of five stages. In physiotherapy, action would equal attending appointments and adhering to both the in-clinic programs as well as any self-management advice and programs provided by the treating clinician. In this phase, patients strive to develop skills and implement the self-management program.
In most cases, patients may require to continue health related behaviours or activities beyond the operational action stage. For example, a physiotherapist may provide some hands on intervention and exercise program during the treatment (action) phase. However in order to retain the benefits and avoid replase of problems (pain or reduced range of motion), they may need to continue to adhere to the self management program agreed with the physiotherapist. This is the Maintenance phase. In this phase, patients would generally have been provided with the skills and tools to self-manage their condition, recognise the factors causing flare-ups and how to manage them. A physiotherapist would provide positive reinforcement in this stage and act as a support and fallback mechanism for advice and guidance as needed.
It is important to note that Relapse has also been defined as one of the stages in some models, however, I believe that relapse is not necessarily a stage of behaviour change, but rather a regression to one of the previous stages and therefore we need to manage the clients in regression with the same process of trying to understand what stage they have regressed to and try to move them forwards to the next stage.
From a physiotherapy perspective, it is important to understand what stage of behaviour the clients are in and rather than just pushing them to take action, we need to understand the stage, the reasons they are in that stage and through education, advice and support move them on to the next stages towards action and leading on to maintenance.
Kerns et al. adapted these stages to individuals with chronic pain in the development of the Pain Stages of Change Questionnaire (PSOCQ). They further added to the stages in which individuals in the precontemplative stage of change continue to seek a medical cure for their pain and demonstrate reliance on passive coping strategies. Additionally, individuals in the maintenance stage are thought to have more self-control and accommodation of their pain and use more active coping strategies. Kerns and colleagues suggest that cognitive therapy strategies, such as cognitive restructuring, might be more appropriate for individuals in the precontemplative and contemplative stages of change, whereas behavioral strategies requiring more active coping might be more appropriate for individuals in the action and maintenance stages of change
Evaluating pain-related predictors of patients who are in various stages of change has the potential to increase efficiency of programs with limited resources and to provide potential targets for pre-intervention depending on which stage a patient is in. For example, a patient who is in the precontemplation stage of change and is enrolled in an interdisciplinary pain program may not be ready for such an approach, which might lead to suboptimal outcomes such as poor attendance, not engaging in the components of the program, or being disruptive to other patients and/ or resistant during the program. As such, a targeted pretreatment intervention might help prepare the patient to better engage in the programming.