Emotional distress is a common but seldom addressed aspect of chronic pain, a growing health problem that affects millions of Americans. Reduced mobility, limitations in daily activities, dependence on opioids , anxiety and depression, and poor perceived health or reduced quality of life are among the most frequent issues faced by people with chronic pain (1). The elderly population is the most affected, and due to mobility restrictions, the one with the greatest need for home-based physical therapy (2). There is a concerning lack of research, however, about what strategies are better suited to treat chronic pain in the home care setting.
Given the overreliance on opioids and the severe side-effects they cause -especially in older adults taking several prescription drugs-, a shift from analgesic medications toward non-pharmacological interventions for chronic pain management and treatment has been promoted by public health systems worldwide (3, 4). Physical Therapy is commonly prescribed to chronic pain, but the practice has traditionally focused on improving physical function, while neglecting the cognitive and emotional components of the chronic pain experience.
Check out my blog HOW TO INTEGRATE PSYCHOLOGICAL AND BEHAVIORAL APPROACHES INTO PHYSICAL THERAPIST TREATMENT OF CHRONIC PAINPhysical Therapy is commonly prescribed to chronic pain, but the practice has traditionally focused on improving physical function, while neglecting the cognitive and emotional components of the chronic pain experience. Click To Tweet
A CBT-Based Home Care Protocol for Chronic Pain in Older Adults
A 2017 study published in the Journal of the American Geriatrics Society describes the results of a pain self-management protocol delivered by physical therapists (PTs) for older adults with activity-limiting pain that were receiving home care. This was a cluster randomized, pragmatic trial – a study in which groups of subjects are randomized to different treatment arms, to assess the effectiveness of a treatment or intervention in a real-world health scenario that reflects routine clinical practice (5).
The study included 588 home care patients, 55 years of age or older, admitted with orders for physical therapy, endorsed activity-limiting pain, and reported pain scores of ≥3 on a 0–10 scale.
A total of 17 rehabilitation teams (each one comprising at least 15 PTs) from the Visiting Nurse Service of New York, a not-for profit home health agency, were randomized to deliver either usual care (UC; 8 teams) or UC plus a Cognitive-Behavioral Pain Self-Management (CBPSM) protocol (9 teams).
Intervention Training: PTs on the 9 intervention teams participated in 2 half-day training sessions scheduled 3 weeks apart to learn how to deliver a CBPSM protocol that combines pain self-management and exercise approaches for use in senior centers. This protocol was previously tested in a pilot single-arm study that demonstrated preliminary efficacy in reducing pain and pain-related disability among older adults with chronic low-back pain (6). Program adaptation, feasibility, and acceptability were also reported in previous studies (7, 8). A total of 285 participants received care from a PT randomized to the intervention group. PTs provided patients with a booklet to reinforce the CBPSM content and ask them to review it between treatment sessions, and to remind them to practice all newly and previously learned techniques between sessions. PTs were not aware that they were participating in a clinical trial; instead, they were told that the training was part of a quality improvement initiative sanctioned by the home care agency to improve pain outcomes among agency patients.
Usual Care: Following an initial, comprehensive assessment of patients’ physical and psychological functioning, home environment, and use of or need for assistive devices, the PT home health was defined with the treating physician in terms of therapy goals, frequency and duration of treatment, identification of any equipment to be ordered, and a discharge plan. Individualized exercise programs aimed at increasing strength, reducing fall risk, and improving range of motion, gait and/or transfer ability, balance or coordination, and activity of daily living (ADL) functioning were then established. A total of 303 patients received care from a PT in one of the 8 UC groups.
Patients in both groups received an average of 8 PT home visits (typically 2 per week), and study outcomes were assessed by research assistants blinded to participants’ group status both before (baseline) and 60-days following enrollment.
Primary outcomes included:
- Pain-related disability, measured using the Roland-Morris Disability Questionnaire, which evaluates the impact of pain on patients’ function on the day of the interview
- Pain intensity over the past week, measured through the Brief Pain Inventory
- Gait speed, determined by measuring the time it took patients to walk 10 feet at usual pace
- Functional status, assessed as the ability of patients to complete by themselves or with assistance 7 instrumental and 7 basic ADLs.
Secondary outcomes included:
- Depressive symptoms, assessed using the Patient Health Questionnaire depression scale PHQ-8
- Pain self-efficacy, a measure of an individual’s confidence in their ability to perform an activity or specific behavior required to achieve a goal or outcome; this was tested using the Pain Self-Efficacy Questionnaire (PSEQ)
Treatment efficacy was evaluated taking into account several demographic variables (sex, race, marital and socioeconomic status, etc.) and considering three pain types, each one affecting ~33% of patients in each group:
- Arthritis but no surgical-related pain
- Arthritis with surgical-related pain
- Other types of chronic pain
Results. Despite past evidence suggesting that better pain- and disability-related outcomes might be obtained in home care patients using a CBT-based approach, the study showed that adding the CBPSM protocol to usual care did not bring further benefit to patients. Thus, both treatments worked equally well across all demographic variables and pain categories:
- Significant and similar improvements in all primary outcomes, namely pain-related disability, pain intensity, gait speed, and functional status, were observed in both groups.
- Depressive symptoms and pain self-efficacy scores also improved significantly and to the same extent after either intervention.
- Moreover, no treatment differences were seen in subgroup analyses of sex, race/ethnicity, pain type, pain chronicity, number of pain sites, participant education level, and baseline depressive symptom or pain self-efficacy scores.
The authors point out some possible reasons as to why the CBT-based protocol failed to provide benefits beyond usual PT care. For instance, about two thirds of all patients had been recently discharged from hospital, so delivering the CBPSM protocol was arguably more difficult during the transition to home care. But the most likely reason, according to the study authors, is that PTs did not deliver the protocol as instructed. After surveying PTs’ experience with the protocol, they concluded that “therapists were comfortable delivering the protocol but did so infrequently” (9).
Insufficient time during the patient visit was cited as the most common barrier, as PTs noted that an extra 15-20 min would be necessary to implement the protocol while fully addressing the patients’ necessities. Intervention PTs also mentioned that some patients were reluctant to adopt the protocol, because they “did not think the techniques would work”, or felt that “the study materials required too much reading”. Finally, PTs reported that “not all patients were compliant with the activity journals or practiced the techniques between sessions” (9).
The authors put forward some recommendations to improve the delivery of psychologically informed approaches in future interventions:
- Monitoring and addressing (when appropriate) treatment fidelity, and providing ongoing support of providers implementing any new program. Given the complexity of the home health setting, careful planning and continued buy-in from supervisors and program staff are also needed.
- Addressing the complex medical conditions of most older home care patients. Especially for those who had been recently hospitalized, other aspects of patient care may have a higher priority than learning pain coping strategies.
- Taking into account the additional time required for staff to learn new techniques and the long-term implications of new tasks for clinical workload.
On the other hand, it is worth noting that the protocol included some elements of CBT (coping skills, relaxation training) but lacked cognitive restructuring, a critical part of standard CBT interventions. This omission in the CBPSM protocol appears to be based on conclusions from previous research, published in The Clinical Journal of Pain, that placed higher value in pain coping skills than in cognitive restructuring techniques (10).
The results of this study contrast with the findings of two clinical trials. One of these, published in Arthritis Care & Research, showed that a PT-delivered protocol combining cognitive and behavioral pain coping skills training and exercise improved physical functioning in older adults with knee osteoarthritis (11). The other, published in Pain, demonstrated significant improvement in pain distress, disability, and mood in older adults with chronic non-cancer pain who received a combined CBT and exercise protocol, compared to an exercise-only control group (12).
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Opportunities and Barriers Toward Effective PIPT Strategies
Physical therapists are in a unique position to deliver patient-centered cognitive/behavioral therapies such as CBT and Acceptance and Commitment Therapy (ACT) to reduce the physical and mental burden of pain. There are however a number of perceived barriers that are commonly cited by PTs as interfering with application of psychologically informed Physical Therapy (PIPT):
- Lack of practical skills
- Reimbursement concerns
- Perceived need to prioritize physical care
- Role clarity and individual scope of practice
- Managing the public’s expectations of the PT role
- Uncertainty about when to refer a client to a psychologist
- Lack of knowledge and understanding due to limited formal training
- Practice and consultation constraints in the form of time restrictions
- PTs may need to adhere closely to the protocol and have continuing education to sharpen their skills
To learn more about this, visit my blog WHAT DO PHYSICAL THERAPISTS THINK ABOUT PSYCHOLOGICALLY INFORMED CARE?
In The Integrative Pain Science Institute’s blogs and podcasts Physical Therapists and other pain practitioners will find a world of information about CBT, ACT, mindfulness and other approaches consistent with PIPT, as well as qualified analyses from experts in the field.
1- Dahlhamer, J., Lucas, J., Zelaya, C., Nahin, R., Mackey, S., DeBar, L., … & Helmick, C. (2018). Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. Morbidity and Mortality Weekly Report, 67(36), 1001.
2- Ali, A., Arif, A. W., Bhan, C., Kumar, D., Malik, M. B., Sayyed, Z., … Ahmad, M. Q. (2018). Managing Chronic Pain in the Elderly: An Overview of the Recent Therapeutic Advancements. Cureus, 10(9), e3293. doi:10.7759/cureus.3293
3- Ambrose, K. R., & Golightly, Y. M. (2015). Physical exercise as non-pharmacological treatment of chronic pain: Why and when. Best practice & research. Clinical rheumatology, 29(1), 120–130. doi:10.1016/j.berh.2015.04.022
4- Lemmon, R., & Hampton, A. (2018). Nonpharmacologic treatment of chronic pain: What works?. The Journal of family practice, 67(8), 474-477.
5- Reid, M. C., Henderson, C. R., Jr, Trachtenberg, M. A., Beissner, K. L., Bach, E., Barrón, Y., … Murtaugh, C. M. (2017). Implementing a Pain Self-Management Protocol in Home Care: A Cluster-Randomized Pragmatic Trial. Journal of the American Geriatrics Society, 65(8), 1667–1675. doi:10.1111/jgs.14836
6- Beissner, K., Parker, S. J., Henderson, C. R., Jr, Pal, A., Iannone, L., & Reid, M. C. (2012). A cognitive-behavioral plus exercise intervention for older adults with chronic back pain: race/ethnicity effect?. Journal of aging and physical activity, 20(2), 246–265.
7- Beissner, K., Bach, E., Murtaugh, C., Parker, S. J., Trachtenberg, M., & Reid, M. C. (2013). Implementing a cognitive-behavioral pain self-management program in home health care, part 1: program adaptation. Journal of geriatric physical therapy (2001), 36(3), 123–129. doi:10.1519/JPT.0b013e31826ef67b
8- Bach, E., Beissner, K., Murtaugh, C., Trachtenberg, M., & Reid, M. C. (2013). Implementing a cognitive-behavioral pain self-management program in home health care, part 2: feasibility and acceptability cohort study. Journal of geriatric physical therapy (2001), 36(3), 130–137. doi:10.1519/JPT.0b013e31826ef84d
9- Beissner, K. L., Bach, E., Murtaugh, C. M., Trifilio, M., Henderson, C. R., Jr, Barrón, Y., … Reid, M. C. (2017). Translating Evidence-Based Protocols Into the Home Healthcare Setting. Home healthcare now, 35(2), 105–112. doi:10.1097/NHH.0000000000000486
10- Burns, J. W., Nielson, W. R., Jensen, M. P., Heapy, A., Czlapinski, R., & Kerns, R. D. (2015). Does change occur for the reasons we think it does? A test of specific therapeutic operations during cognitive-behavioral treatment of chronic pain. The Clinical journal of pain, 31(7), 603-611.
11- Bennell, K. L., Ahamed, Y., Jull, G., Bryant, C., Hunt, M. A., Forbes, A. B., … & Egerton, T. (2016). Physical therapist–delivered pain coping skills training and exercise for knee osteoarthritis: randomized controlled trial. Arthritis care & research, 68(5), 590-602.
12- Nicholas, M. K., Asghari, A., Blyth, F. M., Wood, B. M., Murray, R., McCabe, R., … & Overton, S. (2013). Self-management intervention for chronic pain in older adults: a randomised controlled trial. PAIN®, 154(6), 824-835.