Management of pain induced by exercise and mobilization during physical therapy programs: views of patients and care providers

No pain, no gain? Children with cerebral palsy and their experience with physiotherapy

OBJECTIVES

Recent studies have shown that physiotherapy can induce pain in children and young adults with cerebral palsy (CP). There is a lack of knowledge of children's pain experiences during therapy sessions and the specific causes of pain. The main objective of this study was to better understand the experience of children and young adults with CP during physiotherapy sessions and to analyse the coping strategies used by children and therapists.

METHODS

Qualitative study with focus groups. Eighteen children/young adults with CP who experienced pain during physiotherapy were interviewed, using focus groups as a source of data collection in a phenomenological perspective. Data collection and analysis were consecutive to ensure that the data saturation point was reached. The transcripts were coded manually using thematic analysis. First, interesting features of the verbatim were coded, then codes were collated into potential themes and then the themes were checked to ensure they worked in relation to the coded extracts. Multiple coding was performed by 3 different researchers, and results were merged at each step.

RESULTS

This study confirmed that among the 18 children interviewed (mean [SD] age 13.17 [4.02] years, 10 girls), physiotherapy, particularly stretching, induced pain. Participants reported that the experience of pain led to a dislike of physiotherapy, although some believed that the pain was necessary to show that the treatment was effective. The use of distraction techniques and the relationship with the physiotherapist were key elements associated with the perception and experience of pain.

CONCLUSIONS

This study confirmed that patients with CP experience pain during physiotherapy. Stretching seems to be the main source of pain. Beliefs and practices regarding the concept of pain show that physiotherapists need training in this field.

Comparison of Downstream Health Care Utilization, Costs, and Long-Term Opioid Use: Physical Therapist Management Versus Opioid Therapy Management After Arthroscopic Hip Surgery

BACKGROUND

Physical therapy and opioid prescriptions are common after hip surgery, but are sometimes delayed or not used.

OBJECTIVE

The objective of this study was to compare downstream health care utilization and opioid use following hip surgery for different patterns of physical therapy and prescription opioids.

DESIGN

The design of this study was an observational cohort.

METHODS

Health care utilization was abstracted from the Military Health System Data Repository for patients who were 18 to 50 years old and were undergoing arthroscopic hip surgery between 2004 and 2013. Patients were grouped into those receiving an isolated treatment (only opioids or only physical therapy) and those receiving both treatments on the basis of timing (opioid first or physical therapy first). Outcomes included overall health care visits and costs, hip-related visits and costs, additional surgeries, and opioid prescriptions.

RESULTS

Of 1870 total patients, 76.8% (n = 1437) received physical therapy, 71.6% (n = 1339) received prescription opioids, and 1073 (56.1%) received both physical therapy and opioids. Because 24 patients received both opioids and physical therapy on the same day, they were eventually removed the final timing-of-care analysis. Adjusted hip-related mean costs were the same in both groups receiving isolated treatments (${\$}$11,628 vs ${\$}$11,579), but the group receiving only physical therapy had significantly lower overall total health care mean costs (${\$}$18,185 vs ${\$}$23,842) and fewer patients requiring another hip surgery. For patients receiving both treatments, mean hip-related downstream costs were significantly higher in the group receiving opioids first than in the group receiving physical therapy first (${\$}$18,806 vs ${\$}$16,955) and resulted in greater opioid use (7.83 vs 4.14 prescriptions), greater total days' supply of opioids (90.17 vs 44.30 days), and a higher percentage of patients with chronic opioid use (69.5% vs 53.2%).

LIMITATIONS

Claims data were limited by the accuracy of coding, and observational data limit inferences of causality.

CONCLUSIONS

Physical therapy first was associated with lower hip-related downstream costs and lower opioid use than opioids first; physical therapy instead of opioids was associated with less total downstream health care utilization. These results need to be validated in prospective controlled trials.

Home-based cycling program tailored to older people with lumbar spinal stenosis: Barriers and facilitators

BACKGROUND

Lumbar-flexion-based endurance training, namely cycling, could be effective in reducing pain and improving function and health-related quality of life in older people with chronic low back pain.

OBJECTIVES

To assess barriers and facilitators to home-based cycling in older patients with lumbar spinal stenosis (LSS).

METHODS

We conducted a retrospective mixed-method study. Patients≥50 years old followed up for LSS from November 2015 to June 2016 in a French tertiary care center were screened. The intervention consisted of a single supervised session followed by home-based sessions of cycling, with dose (number of sessions and duration, distance and power per session) self-determined by patient preference. The primary outcome was assessed by a qualitative approach using semi-structured interviews at baseline and 3 months and was the identification of barriers and facilitators to the intervention. Secondary outcomes were assessed by a quantitative approach and were adherence monitored by a USB stick connected to the bicycle, burden of treatment assessed by the Exercise Therapy Burden Questionnaire (ETBQ) and clinical efficacy assessed by change in lumbar pain, radicular pain, disability, spine-specific activity limitation and maximum walking distance at 3 months.

RESULTS

Overall, 15 patients were included and data for 12 were analyzed at 3 months. At baseline, the mean age was 70.9 years (95% CI: 64.9-76.8) and 9/15 patients (60.0%) were women. Barriers to cycling were fear of pain and fatigue, a too large bicycle, burden of hospital follow-up and lack of time and motivation. Facilitators were clinical improvement, surveillance and ease-of-use of the bicycle. Adherence remained stable overtime. The burden of treatment was low [mean ETBQ score: 21.0 (95% confidence interval: 11.5-30.5)]. At 3 months, 7/12 patients (58.3%) self-reported clinical improvement, with reduced radicular pain and disability [mean absolute differences: -27.5 (-43.3 to -11.7), P<0.01 and -17.5 (-32.1 to -2.9), P=0.01, respectively].

CONCLUSIONS

For people with LSS, home-based cycling is a feasible intervention.

Pain patients' letters: The visit before the visit - A qualitative analysis of letters from patients referred to a tertiary pain center

BACKGROUND

Pain centers manage only selected patients, and have long waiting lists. Some patients spontaneously send letters, before the visit, and these letters represent the first contact between the patients and the pain centers. We report a study of the content and format of these letters, for a patient perspective analysis.

METHODS

During a 3 month-period, all newly referred patients to a tertiary pain center were considered. If a patient letter was provided, it was collected for analysis. Qualitative analyses including semantic and content analyses were performed to identify themes and categories.

RESULTS

Among 138 newly referred patients, 44 had sent a letter before consultation. Content analysis of 42 letters disclosed four themes: I) pain experience; II) impact of the pain problem; III) patient history; and IV) expectations. These themes could be distributed along four pain dimensions: (1) physical; (2) psycho-affective; (3) social; and (4) temporal. This first study on patient letters reveals that a bio-psychosocial model. Patients contribute actively to their trajectory, not only as healthcare seekers but also by constructing their narrative identity.

CONCLUSIONS

Patient letters constitute narrative material to be integrated into clinical analysis, alongside patient interviews, especially in pain management. Pain specialists should take account of this narrative approach to better understand the unvoiced and sometimes silent experience of pain. This may increase quality of medical care by including patient-centered data in an original method. Further studies may be valuable to analyze the possible contributions of such letters to patient management.

SIGNIFICANCE

Patients' letters constitute original narrative material to be integrated into clinical analysis, especially for pain management. Patients' letters analyses may improve the patient physician relationship, by understanding patient's perspectives, beliefs and expectations.

Kinesiophobia and physical therapy-related pain in musculoskeletal pain: A national multicenter cohort study on patients and their general physicians

INTRODUCTION

Physical therapy (PT) represents a major approach in musculoskeletal (MSK) pain. This study aimed to assess kinesiophobia, its impact and management, in patients with MSK pain treated by PT.

METHODS

A national multicenter, prospective study was conducted in France in patients with MSK pain referred to PT. Kinesiophobia was scored with the Tampa Scale of Kinesiophobia (TSK). Pain, satisfaction, analgesic intake and acceptability were assessed at the initial visit, at the 5th PT session, and at the end of PT.

RESULTS

A total of 700 consecutive outpatients with MSK pain, 54.5% female, referred to PT were recruited by 186 GPs: 501 had significant levels of kinesiophobia (TSK score>40). Patients with kinesiophobia were significantly older, with less physical activity, more pain and less acceptability. Patients from GPs presenting with kinesiophobia had both higher pain and kinesiophobia levels. After 5 PT sessions, global satisfaction was significantly higher in patients without kinesiophobia. A significant increase of PT satisfaction was observed in patients who had been given preventive analgesics before PT sessions, in 25.6% of patients. Independent predictors for specific management of PT-induced pain were: patient's kinesiophobia (OR=2.02 [1.07-3.82]), current analgesics treatment (OR=2.05 [1.16-3.63]), GP with postgraduate course on pain (OR=2.65 [1.29-5.43]), GP's independent practice (OR=1.88 [1.01-3.48]).

CONCLUSION

Kinesiophobia is frequent in patients with MSK pain, is associated to GPs' kinesiophobia and decreases satisfaction of physical therapy. Preventive analgesic treatment before PT sessions improves patients' satisfaction and should be proposed to improve MSK pain management.

Checklists to manage pain induced by exercise and mobilization (PIEM) during physical therapy programs: PIEM checklists for practitioners and physiotherapists

OBJECTIVES

Identify key informational and educational items ("messages") to provide to physicians (general practitioners and specialists) and physiotherapists for the management of pain induced by exercise and mobilization (PIEM). Develop checklists to improve this management in daily practice.

MATERIAL AND METHODS

The Delphi method for consensus-building was used to identify informational and educational messages for health professionals who deal with PIEM. Informed by the results of an extensive qualitative study, a panel of experts from 5 medical and paramedical disciplines concerned with PIEM and a representative of a patients' association were interviewed individually and iteratively in order to obtain a single, convergent opinion.

RESULTS

Delphi consultation helped to determine 9 areas corresponding to 54 key messages of information and education for doctors and physiotherapists who deal with PIEM. These messages relate to: defining, characterizing, identifying, and evaluating PIEM; identifying factors that may cause or increase this pain; informing the patient in order to avoid misinterpretation of PIEM; preventing and treating PIEM; and dealing with it during physical therapy sessions. The method also enabled us to develop 2 synthetic instruments (checklists) - 1 for physicians and 1 for physiotherapists - to help with the management of this pain.

CONCLUSION

Consulting a panel of experts comprising different categories of actors dealing with PIEM on the basis of a thorough qualitative diagnosis in order to identify messages for a training program makes it possible to harmonize programs with the expectations of patients and the problems encountered by professionals. The formulation of this program and the institutionalization of two checklists should enable health professionals to identify, qualify, and deal more effectively with PIEM.

Care related pain in rehabilitation after orthopedic trauma: An exploratory study with qualitative data

OBJECTIVE

Care related pain (CRP) is generally under-estimated and rarely studied in rehabilitation as well as in general medecine. Beliefs about pain influence psychological distress, adjustment to pain and physical disability. In this sense, perceptions of CRP could limit recovery. This exploratory study aims to understand patients' and caregivers' subjective perceptions and beliefs about CRP.

PATIENTS AND METHODS

Questionnaires about CRP were submitted to members of the interdisciplinary team of a rehabilitation hospital and to patients with musculoskeletal complaints (cross-sectional design). Twenty patients were also individually interviewed (qualitative data). Four topics were addressed: frequency of CRP, situations and procedures causing CRP, beliefs about CRP and means used to deal with CRP.

RESULTS

Seventy-five caregivers and 50 patients replied to the questionnaire. CRP is a very common experience in rehabilitation and it is recognized by both groups. Generally, the situations causing CRP reflect the specificity of rehabilitation (mobilization…) and are similarly perceived by patients and caregivers, with patients considering them as more painful. Beliefs about CRP are clearly different from those usually associated with pain. Both groups point out the utilitarian and the inevitable character of CRP. They differ on that, that patients had a more positive view about CRP. They associate it more often with progress and see it as acceptable at least until a certain limit. They are also able to perceive the richness of means used by physiotherapists to help them coping with CRP.

CONCLUSION

Our data may suggest new keys to motivate patient to be active in rehabilitation for example in choosing carefully arguments or words which may fit theirs' beliefs about CRP, or in using various means to manage CRP. Promoting the use of relational competences with chronic pain patients and of a patient-centred approach may also be a concern in training caregivers.

Adverse events among seniors receiving spinal manipulation and exercise in a randomized clinical trial

Spinal manipulative therapy (SMT) and exercise have demonstrated effectiveness for neck pain (NP). Adverse events (AE) reporting in trials, particularly among elderly participants, is inconsistent and challenges informed clinical decision making. This paper provides a detailed report of AE experienced by elderly participants in a randomized comparative effectiveness trial of SMT and exercise for chronic NP. AE data, consistent with CONSORT recommendations, were collected on elderly participants who received 12 weeks of SMT with home exercise, supervised plus home exercise, or home exercise alone. Standardized questions were asked at each treatment; participants were additionally encouraged to report AE as they occurred. Qualitative interviews documented participants' experiences with AE. Descriptive statistics and content analysis were used to categorize and report these data. Compliance was high among the 241 randomized participants. Non-serious AE were reported by 130/194 participants. AE were reported by three times as many participants in supervised plus home exercise, and nearly twice as many as in SMT with home exercise, as in home exercise alone. The majority of AE were musculoskeletal in nature; several participants associated AE with specific exercises. One incapacitating AE occurred when a participant fell during supervised exercise session and fractured their arm. One serious adverse event of unknown relationship occurred to an individual who died from an aneurysm while at home. Eight serious, non-related AE also occurred. Musculoskeletal AE were common among elderly participants receiving SMT and exercise interventions for NP. As such, they should be expected and discussed when developing care plans.

Pain, motor function and health-related quality of life in children with cerebral palsy as reported by their physiotherapists

Background

Children and adolescents with cerebral palsy suffer from higher levels of pain than their peers without disability. The aim of this study was to explore the impact of pain on health-related quality of life and motor function in individuals with cerebral palsy as reported by health professionals.

Methods

Cross-sectional study carried out in Associations for Care of Individuals with Cerebral Palsy and Related Disabilities (ASPACE) in Balearic Islands and Castile Leon (Spain). Thirty-five physiotherapists rated pain, health-related quality of life and motor function in 91 children and adolescents with cerebral palsy [8-19y]. A semi-structured interview was used to collect demographic and clinical data according with the Study of Participation of Children with Cerebral Palsy Living in Europe (SPARCLE).

Results

Physiotherapists reported that 51% of individuals with cerebral palsy suffered from pain. Physiotherapists also perceived that pain in individuals with cerebral palsy was responsible for reductions of psychological but not physical domains of health-related quality of life. According with physiotherapists’ estimations, motor impairment scores were not correlated with pain scores in individuals with cerebral palsy, but they were significantly associated with physical and autonomy domains of health-related quality of life.

Conclusions

These findings highlighted the importance of assessing and providing interventions for pain relief in persons with cerebral palsy even at an early age.