Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Expert Patient Programmes: disappointing for patients and clinicians
- Amanda C de C Williams (30 June 2007)
|
|
|||
|
Amanda C de C Williams, Reader in Clinical Health Psychology University College London
Send response to journal:
|
The review by Griffiths and colleagues of Expert Patient Programmes, and the questions they raise about the failure to produce the promised benefits, is very welcome, as is their recommendation that EPPs not be regarded as a panacea for all chronic problems. Widespread enthusiasm for greater empowerment of patients seems to have blinded proponents of EPPs to the variable quality of studies in the USA, the most cited of which recruited from the community people who were already relatively well adjusted to their health problems but hoping to build on that adjustment: they were not ‘patients’. Self-management is not a treatment but a goal of many treatments currently provided in the NHS, under the rubric of rehabilitation or not, like most psychological therapies. Equating self-management with lay-led programmes implies that all such rehabilitation maintains patients in a dependent relationship. Pain management programmes, which the Griffiths et al review did not include, have been shown by several systematic reviews and meta-analyses to produce substantial and lasting gains in physical, psychological and behavioural domains (Morley et al. 1999, Van Tulder et al. 2000, Guzman et al. 2001), and individual studies among those show reductions in health care use following treatment. People with persistent pain who attend these programmes are by definition the minority for whom conventional treatments have not worked. Successive treatment failures are deeply distressing for the patient, raising the possibility of harm from further failures. Treatment initiatives for these patients should therefore be based on robust evidence, such as exists for a range of rehabilitative behavioural change programmes available in the NHS. It is unethical to substitute a treatment which has been so poorly evaluated, and where trials are so far unable to support the claimed benefits. Further, specific and authoritative education for patients about the causes of pain and therefore about what they can safely attempt, despite worries about exacerbating the problem, may underpin reactivation (Moseley et al. 2004). Providing only instruction in behaviour change short-changes patients on this opportunity, and likely renders any behaviour change as short-lived as the reassurance on which it is based. Amanda C de C Williams PhD CPsychol Reader in Clinical Health Psychology, UCL Guzmán J, Esmail R, Karjalainen K, Irvin E, Bombardier C. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001;322:511-516. Morley S, Eccleston C, Williams A. Systematic review and metaanalysis of randomised controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 1999;80:1-13. Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clinical Journal of Pain 2004;20:324-330. Van Tulder MW, Ostelo R, Vlaeyen JWS, Linton SJ, Morley SJ, Assendelft WJ. Behavioral treatment of for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group. Spine 2000;25:2688 -2699. Competing interests: None declared |
|||