Less Exercise and More Drugs: How a Low-Income Population Manages Chronic Pain

Barriers and facilitators for physical activity in people living with chronic pain: a systematic review and combined analysis

ABSTRACT

Chronic pain is a prevalent and complex health issue associated with physical, emotional, and social consequences. Management of pain is multifactorial and challenging; however, physical activity (PA) has consistently been shown to be beneficial. Despite this, PA levels among people with chronic pain are low. This study aimed to identify facilitators and barriers to PA among adults with chronic pain and analyse these using the structure of a validated behaviour change model: the capability, opportunity, and motivation behaviour change model (COM-B). We performed a systematic review of 6 databases and subsequent combined analysis including peer-reviewed primary research published in English up to November 15, 2023. Search terms consisted of 3 components: pain, PA, and facilitators/barriers. Quality appraisal of studies was conducted using appropriate tools. The systematic search yielded 40 eligible studies with a total of 2164 participants. The studies represented various chronic pain conditions, locations, and study designs. The key barriers to engagement in PA were the impact of pain severity, comorbidities, lack of knowledge about PA benefits, and time constraints. Key facilitators were a personalised approach, social support, and awareness of the benefits. The findings were categorised according to the COM-B model, allowing for the identification of modifiable factors. Person-centred approaches, education, and accessible environments were identified as important aspects to consider for successful PA promotion among people with chronic pain. Utilising the factors identified in the COM-B model is crucial for successful future interventions to increasing PA uptake and adherence in this population.

Telehealth delivery of physical therapist-led interventions for persons with chronic low back pain in underserved communities: lessons from pragmatic clinical trials

In this perspective, we present our experience developing and conducting two pragmatic clinical trials investigating physical therapist-led telehealth strategies for persons with chronic low back pain. Both trials, the BeatPain Utah and AIM-Back trials, are part of pragmatic clinical trial collaboratories and are being conducted with persons from communities that experience pain management disparities. Practice guidelines recommend nonpharmacologic care, and advise against opioid therapy, for the primary care management of persons with chronic low back pain. Gaps between these recommendations and actual practice patterns are pervasive, particularly for persons from racial or ethnic minoritized communities, those with fewer economic resources, and those living in rural areas including Veterans. Access barriers to evidence-based nonpharmacologic care, which is often provided by physical therapists, have contributed to these evidence-practice gaps. Telehealth delivery has created new opportunities to overcome access barriers for nonpharmacologic pain care. As a relatively new delivery mode however, telehealth delivery of physical therapy comes with additional challenges related to technology, intervention adaptations and cultural competence. The purpose of this article is to describe the challenges encountered when implementing telehealth physical therapy programs for persons with chronic low back pain in historically underserved communities. We also discuss strategies developed to overcome barriers in an effort to improve access to telehealth physical therapy and reduce pain management disparities. Inclusion of diverse and under-represented communities in pragmatic clinical trials is a critical consideration for improving disparities, but the unique circumstances present in these communities must be considered when developing implementation strategies.

Consumer Perceptions of Home-Based Percussive Massage Therapy for Musculoskeletal Concerns: Inductive Thematic Qualitative Analysis

BACKGROUND

Musculoskeletal pain is a prevalent concern among diverse populations, from the average individual to the elite athlete. Handheld percussive massage therapy devices like massage guns have gained much popularity in both medical and athletic settings. Its application has been prominently recognized in injury prevention and rehabilitation. The expansion of the market to provide handheld percussive therapy devices with varying features and price points has encouraged professional and novice use. While percussive therapy holds similarities to more studied therapeutic modalities, like vibration therapy and soft tissue mobilization, there is limited evidence-based information on the indications and contraindications.

OBJECTIVE

This study aims to use a qualitative analysis of consumer perceptions to understand the perceived therapeutic potential of percussive massage therapy as a home-based intervention for musculoskeletal concerns of everyday users and elite athletes. Additionally, we aim to gain insight on valuable characteristics supporting its therapeutic potential as well as pertinent limitations.

METHODS

The TOLOCO massage gun (TOLOCO) was identified as the best-selling percussive massage therapy device on Amazon. We performed an inductive thematic qualitative analysis on the top 100 positive comments and the top 100 critical comments of the device between June 2020 and April 2023 to determine 4 relevant themes.

RESULTS

The 4 themes identified upon qualitative analysis were pain management, versatility, accessibility, and safety and user education. Consumer reviews indicated use for this percussive therapy device in adolescents, adults, and older people across a spectrum of activity levels. Consumers reported the therapeutic potential of percussive massage therapy in managing wide-ranging musculoskeletal concerns like acute pain, chronic pain, nonsurgical injury rehabilitation, postsurgical injury rehabilitation, and injury prevention. Consumers highlighted the versatility of the device to address person-specific needs as a key feature in supporting its perceived therapeutic benefits. Additionally, consumers frequently commented on the affordability and availability of this device to increase accessibility to home-based care. Some critical reviews emphasized a concern for the quality of the device itself. However, this concern did not translate to the overall modality of percussive massage therapy. Of note, despite strong approval for its therapeutic potential, consumer reviews lacked evidence-based insights on appropriate usage.

CONCLUSIONS

Home-based percussive massage therapy holds value with its perceived efficacy in pain management for acute and chronic conditions, as well as in injury prevention and rehabilitation. As a low-cost and readily available device for everyday users and high-performing athletes, percussive massage therapy works toward establishing increased health care accessibility and optimizing health care usage. This home-based intervention can serve to reduce the significant personal and economic burden of prevalent musculoskeletal concerns. However, the limited scientific research on percussive massage therapy raises concerns about the lack of evidence-based care and indicates the need for future studies.

Dosage of Physical Activity to Avoid Impairment of Activities Due to Pain: Analysis of Population-based Conditional Processes

BACKGROUND

Physical activity's established health benefits include pain control, yet there is no consensus on the required dosage according to the literature.

AIM

To test the influence of exercise on perceived health in patients whose daily activities are limited due to pain. Besides, analyze the possible moderating effect of age and find a formula for exercise dosage based on the perceived level of health.

METHODS

Cross-sectional study based on the 2017 Spanish National Health Survey with 4,123 participants reporting activity limitations in their daily activities due to pain. The International Physical Activity Questionnaire (short version) was used to calculate energy expenditure. Data included age, sex, leisure-time physical activity, sitting time, pain-related impairments, pain medication, and perceived health. Mediation regression analysis was conducted using the SPSS PROCESS 4.0 macro.

RESULTS

Results indicate a decline in perceived health with age. The relationship between exercise (energy expenditure) and perceived health was highly significant (d=-0.224, p<0.001). Age moderated the association between pain and energy expenditure up to 75.61 years (0.1568, p=0.05) and between energy expenditure and perceived health up to 75.74 years (-0.289, p=0.05), but this effect diminished afterwards. A formula was developed to estimate energy expenditure based on the desired level of health.

CONCLUSIONS

The perception of health in people who are limited in their daily activities due to pain (moderate to very much) is mediated by the amount of physical activity they perform. Besides, this perception is moderated by age, up to 76 years.

BeatPain Utah: study protocol for a pragmatic randomised trial examining telehealth strategies to provide non-pharmacologic pain care for persons with chronic low back pain receiving care in federally qualified health centers

INTRODUCTION

Although evidence-based guidelines recommend non-pharmacologic treatments as first-line care for chronic low back pain (LBP), uptake has been limited, particularly in rural, low-income and ethnically diverse communities. The BeatPain study will evaluate the implementation and compare the effectiveness of two strategies to provide non-pharmacologic treatment for chronic LBP. The study will use telehealth to overcome access barriers for persons receiving care in federally qualified health centres (FQHCs) in the state of Utah.

METHODS AND ANALYSIS

BeatPain Utah is a pragmatic randomised clinical trial with a hybrid type I design investigating different strategies to provide non-pharmacologic care for adults with chronic LBP seen in Utah FQHCs. The intervention strategies include a brief pain consult (BPC) and telehealth physical therapy (PT) component provided using either an adaptive or sequenced delivery strategy across two 12-week treatment phases. Interventions are provided via telehealth by centrally located physical therapists. The sequenced delivery strategy provides the BPC, followed by telehealth PT in the first 12 weeks for all patients. The adaptive strategy uses a stepped care approach and provides the BPC in the first 12 weeks and telehealth PT to patients who are non-responders to the BPC component. We will recruit 500 English-speaking or Spanish-speaking participants who will be individually randomised with 1:1 allocation. The primary outcome is the Pain, Enjoyment and General Activity measure of pain impact with secondary outcomes including the additional pain assessment domains specified by the National Institutes (NIH) of Health Helping to End Addiction Long Initiative and implementation measures. Analyses of primary and secondary measures of effectiveness will be performed under longitudinal mixed effect models across assessments at baseline, and at 12, 26 and 52 weeks follow-ups.

ETHICS AND DISSEMINATION

Ethics approval for the study was obtained from the University of Utah Institutional Review Board. On completion, study data will be made available in compliance with NIH data sharing policies.

TRIAL REGISTRATION NUMBER

NCT04923334.

Association of nonpharmacologic chronic pain management with function in a low-income population: Evidence from a survey of a sample of Latinos from five states

BACKGROUND

Low-income minority populations often confront barriers to professional nonpharmacologic management of chronic pain and, without this care, may have poorer daily function.

OBJECTIVE

To examine the association of professional nonpharmacologic chronic pain management in the past year categorized as physical interventions or mind-body interventions with current functional status.

DESIGN

Online, population-based survey.

SETTING

Community-dwelling Latinos from five southwestern states (California, Texas, Arizona, Nevada, and New Mexico).

PARTICIPANTS

The survey was offered to all Latino online panel members aged 35 to 75 years in 5 states (N = 1007). With weights, this sample represented 11,016,135 persons. Of 516 respondents (51%), 486 (94%) had valid surveys and, of these, 102 members (21%) had chronic noncancer pain. With weights, they represented 1,140,170 persons with chronic pain.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Daily impairment in mobility and in activities of daily living (ADLs).

RESULTS

Of the weighted sample, 37.2% reported daily impairment in mobility and 29.4% in ADLs. Professional physical interventions for chronic pain were received by 41.2% and mind-body interventions received by 33.4% but usually with physical interventions. Adjusted odds ratios (AOR) of daily mobility impairment for respondents who used physical interventions with mind-body interventions or alone were both less than 0.10 (p < .01) versus none. Only professional physical intervention was associated with decreased odds for daily impairment in ADLs (AOR = 0.07; 95% confidence interval = 0.01 to 0.94; p = .045).

CONCLUSIONS

In a weighted sample of Latinos with chronic pain, professional physical interventions reduced the likelihood of daily impairment in mobility and ADLs.

Depression predicts chronic pain interference in racially diverse, income-disadvantaged patients

BACKGROUND

Chronic pain is one of the most common reasons adults seek medical care in the US, with prevalence estimates ranging from 11% to 40%. Mindfulness meditation has been associated with significant improvements in pain, depression, physical and mental health, sleep, and overall quality of life. Group medical visits are increasingly common and are effective at treating myriad illnesses, including chronic pain. Integrative Medical Group Visits (IMGV) combine mindfulness techniques, evidence based integrative medicine, and medical group visits and can be used as adjuncts to medications, particularly in diverse underserved populations with limited access to non-pharmacological therapies.

OBJECTIVE AND DESIGN

The objective of the present study was to use a blended analytical approach of machine learning and regression analyses to evaluate the potential relationship between depression and chronic pain in data from a randomized clinical trial of IMGV in diverse, income disadvantaged patients suffering from chronic pain and depression.

METHODS

The analytical approach used machine learning to assess the predictive relationship between depression and pain and identify and select key mediators, which were then assessed with regression analyses. It was hypothesized that depression would predict the pain outcomes of average pain, pain severity, and pain interference.

RESULTS

Our analyses identified and characterized a predictive relationship between depression and chronic pain interference. This prediction was mediated by high perceived stress, low pain self-efficacy, and poor sleep quality, potential targets for attenuating the adverse effects of depression on functional outcomes.

CONCLUSIONS

In the context of the associated clinical trial and similar interventions, these insights may inform future treatment optimization, targeting, and application efforts in racialized, income disadvantaged populations, demographics often neglected in studies of chronic pain.

TRIAL REGISTRATION

NCT from clinicaltrials.gov: 02262377.

Applying the NIA Health Disparities Research Framework to Identify Needs and Opportunities in Chronic Musculoskeletal Pain Research

Disparities in the experience of chronic musculoskeletal pain in the United States stem from a confluence of a broad array of factors. Organized within the National Institute on Aging Health Disparity Research Framework, a literature review was completed to evaluate what is known and what is needed to move chronic musculoskeletal pain research forward specific to disproportionately affected populations. Peer-reviewed studies published in English, on human adults, from 2000 to 2019, and conducted in the United States were extracted from PubMed and Web of Science. Articles were reviewed for key words that focused on underrepresented ethnic/race groups with chronic musculoskeletal pain applying health factor terms identified in the NIAHealth Disparity Research Framework four levels of analysis: 1) environmental, 2) sociocultural, 3) behavioral, and 4) biological. A total of 52 articles met inclusion criteria. There were limited publications specific to underrepresented ethnic/race groups with chronic musculoskeletal pain across all levels with particular research gaps under sociocultural and biological categories. Current limitations in evidence may be supplemented by a foundation of findings specific to the broader topic of "chronic pain" which provides guidance for future investigations. Study designs including a focus on protective factors and multiple levels of analyses would be particularly meritorious. PERSPECTIVE: Chronic musculoskeletal pain unequally burdens underrepresented ethnic/race groups. In order to move research forward and to systematically investigate the complex array of factors contributing toward health disparities, an organized approach is necessary. Applying the NIA Health Disparities Research Framework, an overview of the current state of evidence specific to chronic musculoskeletal pain and underrepresented ethnic/race groups is provided with future directions identified.

Chronic Pain Self-Management Program for Low-Income Patients: Themes from a Qualitative Inquiry

OBJECTIVE

To examine factors influencing initial engagement, ongoing participation, learned behaviors, and subjective functional outcomes after a trial of the Living Better Beyond Pain (LBBP) chronic pain self-management program.

DESIGN

Qualitative study using the Grounded Theory approach.

SETTING

Two 60-minute focus groups and phone interviews in May 2017.

SUBJECTS

Focus groups with 18 participants who completed LBBP and six-month measures; telephone interviews with 17 participants who stopped attending.

METHODS

Study coordinators randomly selected program completers for focus groups and conducted phone interviews with noncompleters. Inductive thematic analysis was used to identify patterns in semantic content with a recursive process applied to focus group transcripts and interview transcriptions to codify into themes. Themes were categorized according to the Theory of Planned Behavior.

RESULTS

Focus group and telephone interview participants were primarily Hispanic and unemployed. Attitudes fostering participation in LBBP included dissatisfaction with the status quo, need to reduce pain medication, and lack of training and knowledge about chronic pain. Positive social norms from meeting others with chronic pain and support from the LBBP team encouraged attendance and adoption of behaviors. Transportation, pain, and competing activities were barriers, whereas adapting activities for the disabled was a facilitator. Maintaining behaviors and activities at home was challenging but ultimately rewarding due to improvement in daily function with less pain medication.

CONCLUSIONS

This qualitative study complements quantitative results showing clinically significant improvements in function after the LBBP program by adding practical insights into ways to increase participation and outcomes. Participants strongly endorsed the need for chronic pain self-management training.

Pain Relief after Surgical Decompression of the Distal Brachial Plexus

Background  Brachial plexopathy causes pain and loss of function in the affected extremity. Entrapment of the brachial plexus terminal branches within the surrounding connective tissue, or medial brachial fascial compartment, may manifest in debilitating symptoms. Open fasciotomy and external neurolysis of the neurovascular bundle in the medial brachial fascial compartment were performed as a surgical treatment for pain and functional decline in the upper extremity. The aim of this study was to evaluate pain outcomes after surgery in patients diagnosed with brachial plexopathy.

Methods  We identified 21 patients who met inclusion criteria. Documents dated between 2005 and 2019 were reviewed from electronic medical records. Chart review was conducted to collect data on visual analog scale (VAS) for pain, Semmes-Weinstein monofilament test (SWMT), and Medical Research Council (MRC) scale for muscle strength. Pre- and postoperative data was obtained. A paired sample t -test was used to determine statistical significance of pain outcomes.

Results  Pain severity in the affected arm was significantly reduced after surgery (pre: 6.4 ± 2.5; post: 2.0 ± 2.5; p  < 0.01). Additionally, there was an increased response to SWMT after the procedure. More patients achieved an MRC rating score ≥3 and ≥4 in elbow flexion after surgery. This may be indicative of improved sensory and motor function.

Conclusion  Open fasciotomy and external neurolysis at the medial brachial fascial compartment is an effective treatment for pain when nerve continuity is preserved. These benefits were evident in patients with a prolonged duration elapsed since injury onset.

Sociocultural factors influencing physiotherapy management in culturally and linguistically diverse people with persistent pain: a scoping review

BACKGROUND

People with persistent pain from culturally and linguistically diverse (CALD) communities experience significant health inequities.

OBJECTIVE

To synthesise the sociocultural factors influencing pain management between CALD patients with persistent pain and physiotherapists treating CALD patients.

DATA SOURCES

Major electronic databases MEDLINE, AMED, Scopus, Web of Science, PsycINFO and Google Scholar were searched until July 2018.

STUDY SELECTION

Studies were included if they explored clinical interactions between physiotherapists and patients with persistent pain from diverse ethnocultural backgrounds.

STUDY APPRAISAL

The methodological quality of qualitative and quantitative studies were assessed using the Critical Appraisal Skills Programme (CASP) Checklist and Mixed Methods Appraisal Tool (MMAT) respectively.

SYNTHESIS METHOD

A thematic synthesis approach was used to extract the common themes.

RESULTS

Sixteen articles from 16 studies were included. Eleven studies were qualitative and five studies were quantitative. Ten explored patients' perspectives, four explored physiotherapists' perspectives, and two explored both. Key factors included: (a) language competence; (b) active vs passive coping strategies; (c) gendered influences; (d) cultural-spiritual beliefs, illness perceptions and expression of pain; (e) treatment satisfaction and; (f) barriers to access.

CONCLUSION

Discordant perspectives on causation, pain management approaches, and patient autonomy in management are evident between CALD patients and physiotherapists. Such discordance potentially create stress in the therapeutic alliance and undermines the efficacy of pain management interventions. To mitigate such barriers, it is crucial to foster cultural competence in physiotherapy and equip physiotherapists with opportunities to maximise their sociocultural awareness, knowledge and skill practising physiotherapy in cultural plural societies.

Experiences, barriers, and facilitators to participating in physical activity and exercise in adults living with chronic pain: a qualitative study

PURPOSE

To explore experiences, barriers, and facilitators to participating in physical activity and exercise in adults living with chronic pain.

MATERIALS AND METHODS

An interpretive description qualitative study using semi-structured interviews was conducted. Participants included adults living with chronic pain (pain >3 months in duration). Transcripts were analyzed using thematic analysis.

RESULTS

Sixteen participants (five men; 11 women) with a median age of 53 years (range: 28-87) were interviewed. Three major themes related to physical activity and exercise in adults living with chronic pain were conceptualized by the researchers: the challenge of staying active (decreased activity levels, discomfort during physical activity, and uncertain and fluctuating abilities); diverse factors influence participation (pain, fatigue, perceived risks, beliefs about physical activity, competing demands, social support, motivation, other health conditions, and access to supports for physical activity or exercise); and perceived outcomes (pain management, functional improvements, social participation, mental health, and overall well-being).

CONCLUSIONS

Participating in physical activity and exercise was a challenge for adults living with chronic pain, whereby participation was influenced by multiple factors. Rehabilitation providers should aim to reduce modifiable barriers to physical activity and exercise for adults living with chronic pain, with the goal of improving health outcomes for this population.Implications for rehabilitationDespite the perceived benefits, participation in physical activity and exercise is a challenge for adults living with chronic pain.Diverse factors can influence participation in physical activity and exercise from the perspective of adults living with chronic pain.Rehabilitation providers should aim to reduce modifiable barriers to physical activity and exercise for adults living with chronic pain.Results can be used to inform future person-oriented physical activity and exercise interventions for adults living with chronic pain.