Chronic Pain Interventions for the Clinician

Background

In my first semester of physical therapy school, an orthopedic resident casually introduced me to pain neuroscience. In the following weeks, I hounded him and physical therapy faculty for more research. Serendipitously, my first clinical was at the Durham VA which was heavily populated with chronic pain cases. My compassion for and love of this topic motivated endless hours of study. I wanted to be able to serve well and provide hope to a population that is often hopeless. My exposure and interest grew and, by the time third year arrived, I was firmly aware that my research and capstone would be in the realm of pain neuroscience. Under the guidance of my mentor, Dr. Tawny Kross PT, DPT TSE, and my advisor, Dr. Deborah Givens, PT, PhD, DPT, I put my exuberance to use and completed a semester of research and clinical experience. While implementing a pain neuroscience education protocol at the VA, I was able to see patients and grow in my clinical judgment. Continuing with this trend, I chose to create educational VoiceThreads for the physical therapy orthopedic residents at UNC. Focusing on interventions, I presented three that have moderate to strong evidence for alleviating chronic pain.¹ 

Project Overview and Purpose

Chronic pain is highly prevalent and often misunderstood. Though the literature varies widely, estimates of chronic pain’s prevalence range from 15-64%, with some studies citing that 25.3 million adults in the US experience chronic pain daily.^2,3  Clinicians typically feel helpless or frustrated when a patient seems resistant to treatment and does not improve. Indeed, recent surveys indicate that this frustration could be linked to a statistic that states that as many as 44% of rehabilitation professionals experience burnout and have high rates of depression (12%).⁴  Horrifically, the latest statistics reveal that the hopelessness experienced by patients with chronic pain have led to death by accidental opioid overdose, which has surpassed motor vehicle accidents. Indeed, every 11-30 minutes, someone dies of an overdose.⁵ The need for effective treatment of persisting pain has never been more imperative.

Rehabilitation of prolonged pain becomes more about addressing nerve sensitivity than tissue damage. Proven methods are structured around delivery of pain neuroscience education in an effort to decrease the threat associated with pain by increasing a patient’s understanding of physiology.² Graded physical activity is also designed to reintroduce feared movements while incorporating the innumerable benefits of exercise.⁶ Research has also shown that the best interventions can be ineffective without a strong therapeutic alliance.^7–9  Improving the therapeutic alliance between a physical therapist and a patient leads to a significant reduction in the intensity and disability associated with chronic pain.^7–9 These interventions are cornerstone practices that should be familiar to clinicians working with patients in pain.

Statement of Need

In the typical physical therapy program, the curriculum touches on treating patients with chronic pain, but the brevity of such lectures is inadequate for developing confidence in treatment of such a population. In the orthopedic residency curriculum at UNC, students spend two weeks on such topics. However, Dr. Givens expressed the need for education on specific interventions to guide their clinical practice. Such interventions would be firmly based on the latest evidence and be practical for implementation into the clinic. Working with her to narrow my focus and define the project, I proposed three intervention-focused presentations to facilitate residents’ learning and competency. By name, the interventions are neuroscience education, graded physical activity, and therapeutic alliance.

Products

In preparation for this capstone, I completed an independent research experience. I implemented a practice guideline for pain neuroscience education at the Durham VA clinic for patients with chronic low back pain. I also composed a case study of an individual patient. Additionally, I completed a critically appraised topic (CAT) in Evidence Based Practice II on the clinical questions: “For male patients ages 50-60 with chronic low back pain characterized by central sensitization, is hypnosis in combination with typical physical therapy interventions compared to therapy alone more effective in reducing perception of pain (via numerical pain rating or other pain scale)?” This research set much of the groundwork for creating educational modules. For this capstone, I created three VoiceThreads that are guidelines for treatment of chronic pain patients. The topics included: pain neuroscience education, graded physical activity, and therapeutic alliance.

Evaluation

I crave feedback and constructive criticism and was able to receive such input at multiple points in the capstone development. Last year, Dr. Kross introduced the idea of seeing patients at the Durham VA and helped me develop it into an independent study along with Dr. Givens and other physical therapy faculty. Dr. Kross provided ongoing feedback in the clinic and was a sounding board when I felt stuck in patient treatments. Dr. Givens met with me numerous times over the school year, sculpting the capstone products to ensure I was meeting defined needs. I received feedback on rough drafts from her and  Dr. Kross on the relevancy and efficacy of the material. At its completion, my committee, advisor, and the orthopedic residents gave me feedback about the material. For the residents, I created a Qualtrics survey which established that the objectives were well defined, the module was appropriately difficult while enriching, the material was organized and communicated clearly, and the lectures were informative. The residents considered the materials to be helpful for clinical practice and practical for use. The averages were “agree” on a scale of “strongly disagree” to “strongly agree.” In addition to sought-out feedback, several clinicians that received my work through affiliations contacted me and informed me they would keep the material “handy” for relevant patient cases. I am so thankful to receive critique from those whom I respect and whom have vast clinical and research experience. It has been an honor to work under my committee and advisor.

Self-Assessment and Reflection

I am pleased with the outcome and products of this capstone project. I was able to improve my presentation abilities and condense a vast amount of assimilated knowledge comprehensively. One difficulty in creating an engaging and excellent presentation was the VoiceThread platform. With limited editing abilities, I was unable to format as I wanted. Despite this constraint, the presentation provided the residents with an effective resource as evidenced by their feedback. I was also able to further my knowledge and passion of pain neuroscience which can be seen by the completion of my products. This project has further developed my professional and career goals. I was able to educate physical therapists and research chronic pain treatments. Because I hope to pursue higher education and research as well as a therapeutic specialist certification and fellowship, this information has served as a base and springboard for future growth.

Initially, I was concerned that I didn’t know enough or was unable to add anything of educational value to the orthopedic residents. I was unsure of my competence or ability to educate at such a high level. However, my advisor and mentor were able to guide and affirm me—establishing that I had valuable information to share that was unfamiliar to the residents.  Developing confidence because of my research and taking to heart the feedback I received, I was able to offer my information with confidence.

Lastly, this project challenged me to create and adhere to a schedule. Because I needed the products in time for the residents’ pain module early in the spring, I was forced to work strategically. This is unlike my usual method of working sporadically. Though it was personally difficult, I have realized that this method is more consistent with professional development and more considerate while working well with a team. I am thankful for the growth.

Overall, this project allowed me to unite my passions of educating, pain neuroscience, and chronic pain treatment. It filled a need by providing specific, evidenced-based interventions for the orthopedic residents to use in their practices. The knowledge I gained not only fueled this project, but has helped set the trajectory of my career: pain research and chronic pain treatment.

Acknowledgments

I would like to say thank you to my capstone advisor Dr. Deborah Given for her indispensable support in the formation of the project and consistent guidance.

I am indebted to Dr. Tawny Kross for introducing me to chronic pain treatment, inspiring me, challenging me, and giving many hours to help me grow as a person and as a physical therapist. Your compassion for your patients and patience with me will not be forgotten.

Thank you to Dr. Jenn Cooke, PT, DPT for providing needed and helpful feedback on this capstone project and for sharing your extensive knowledge and experience with me throughout the DPT program and in this capstone project.

Thank you to the Durham VA Outpatient Orthopedic Clinic for providing a space and environment that has been imperative for my success as a student and future clinician.

Lastly, I would like to thank my family having endured endless “nerding out” rants on pain neuroscience, my patients whom shared their lives and hurts, and my classmates who have journeyed with me through three years of consistent challenges.

References:

1. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the american college of physicians. Ann. Intern. Med.2017;166(7):514-530. doi:10.7326/M16-2367.
2. Louw A, Nijs J, Puentedura EJ. A clinical perspective on a pain neuroscience education approach to manual therapy. J Man Manip Ther2017;25(3):160-168. doi:10.1080/10669817.2017.1323699.
3. Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey. J. Pain2010;11(11):1230-1239. doi:10.1016/j.jpain.2010.07.002.
4. Medscape National Physician Burnout & Depression Report 2018. Available at: https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235?faf=1. Accessed November 27, 2018.
5. www.cdc.gov/nchs/data/databriefs/db329_tables-508.pdf.
6. Louw A, Puenteduera E. Therapeutic Neuroscience Education: Teaching Patients about Pain. International Spine and Pain Institute; 2013.
7. Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J, Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys. Ther.2013;93(4):470-478. doi:10.2522/ptj.20120137.
8. Fuentes J, Armijo-Olivo S, Funabashi M, et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys. Ther.2014;94(4):477-489. doi:10.2522/ptj.20130118.
9. Taccolini Manzoni AC, Bastos de Oliveira NT, Nunes Cabral CM, Aquaroni Ricci N. The role of the therapeutic alliance on pain relief in musculoskeletal rehabilitation: A systematic review. Physiother Theory Pract2018;34(12):901-915. doi:10.1080/09593985.2018.1431343.