Can physical therapists deliver a pain coping skills program? An examination of training processes and outcomes

A Mind-Body Intervention to Improve Physical Activity for Patients with Chronic Hip-Related Pain: Protocol for a Mixed Methods Study

BACKGROUND

Pain and dysfunction persist for most patients following hip-related pain treatment. Additionally, individuals with hip-related pain are typically less physically active than individuals without hip pain, despite evidence that regular physical activity reduces chronic musculoskeletal pain. Poor psychological health is common in patients with hip-related pain and further reinforces low physical activity. Mind-body interventions can improve psychological health and activity levels but have yet to be integrated to provide comprehensive, psychologically informed care for patients with hip-related pain. Thus, we are using the NCCIH intervention development framework to develop Helping Improve PSychological Health (HIPS), a novel, multimodal mind-body intervention to improve physical activity for individuals with hip-related pain and poor psychological health.

METHODS

We will recruit physical therapists (N = 20) and patients with hip-related pain (N = 20) to participate in 60 min qualitative interviews (focus groups with therapists; one-on-one interviews with patients). Using these data, we will develop the initial HIPS intervention and provider training materials. One physical therapist will be trained to deliver the HIPS intervention to five participants in an open pilot trial. Participants will attend six 30 min HIPS intervention sessions. We will collect quantitative data on satisfaction, improvement, and physical activity, alongside qualitative exit interviews with participants and the physical therapist in order to refine the HIPS intervention and provider training materials.

RESULTS

This study has been approved by the MGB IRB. We aim to develop and test the initial feasibility of the HIPS intervention in an open pilot trial. The findings from this project will inform a subsequent feasibility RCT.

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.

The effects of telehealth-delivered mindfulness meditation, cognitive therapy, and behavioral activation for chronic low back pain: a randomized clinical trial

BACKGROUND

Chronic low back pain (CLBP) is a significant problem affecting millions of people worldwide. Three widely implemented psychological techniques used for CLBP management are cognitive therapy (CT), mindfulness meditation (MM), and behavioral activation (BA). This study aimed to evaluate the relative immediate (pre- to post-treatment) and longer term (pre-treatment to 3- and 6-month follow-ups) effects of group, videoconference-delivered CT, BA, and MM for CLBP.

METHODS

This is a secondary analysis of a three-arm, randomized clinical trial comparing the effects of three active treatments-CT, BA, and MM-with no inert control condition. Participants were N = 302 adults with CLBP, who were randomized to condition. The primary outcome was pain interference, and other secondary outcomes were also examined. The primary study end-point was post-treatment. Intent-to-treat analyses were undertaken for each time point, with the means of the changes in outcomes compared among the three groups using an analysis of variance (ANOVA). Effect sizes and confidence intervals are also reported.

RESULTS

Medium-to-large effect size reductions in pain interference were found within BA, CT, and MM (ds from - .71 to - 1.00), with gains maintained at both follow-up time points. Effect sizes were generally small to medium for secondary outcomes for all three conditions (ds from - .20 to - .71). No significant between-group differences in means or changes in outcomes were found at any time point, except for change in sleep disturbance from pre- to post-treatment, improving more in BA than MM (d =  - .49).

CONCLUSIONS

The findings from this trial, one of the largest telehealth trials of psychological treatments to date, critically determined that group, videoconference-delivered CT, BA, and MM are effective for CLBP and can be implemented in clinical practice to improve treatment access. The pattern of results demonstrated similar improvements across treatments and outcome domains, with effect sizes consistent with those observed in prior research testing in-person delivered and multi-modal psychological pain treatments. Thus, internet treatment delivery represents a tool to scale up access to evidence-based chronic pain treatments and to overcome widespread disparities in healthcare.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03687762.

Understanding the Role of Therapist Quality in Accounting for Heterogeneity of Patient Outcomes in Psychosocial Chronic Pain Treatments

A variety of evidence-based psychosocial treatments now exist for chronic pain. However, on average, effect sizes have tended to be modest and there is a high degree of heterogeneity in treatment response. In this focus article, we explore the potential role that therapist quality in delivering treatment may have in accounting for a degree of this variability in outcome. Therapist quality refers to the skillful delivery of treatment, harnessing both specific and common therapeutic factors during sessions. While recognized as important to assess and report in clinical trials by some reporting guidelines, few randomized controlled trials evaluating psychosocial treatments for chronic pain have reported on therapist factors. We reviewed the clinical trials included in three systematic reviews and meta-analyses of trials of cognitive-behavioral therapy (mainly), mindfulness-based interventions, and acceptance and commitment therapy. We found that of the 134 trials included, only nine assessed and reported therapist quality indicators, with a variety of procedures used. This is concerning as without knowledge of the quality in which treatments are delivered, the estimates of effect sizes reported may be misrepresented. We contextualize this finding by drawing on the broader psychotherapy literature which has shown that more skillful, effective therapists demonstrated ten times better patient response rates. Examination of the characteristics associated with these more effective therapists tends to indicate that skillful engagement of common factors in therapy sessions represents a distinguishing feature. We conclude by providing recommendations for assessing and reporting on therapist quality within clinical trials evaluating psychosocial treatments for chronic pain. PERSPECTIVE: Therapist quality in the delivery of psychosocial treatments for chronic pain has rarely been assessed in clinical trials. We propose that therapist quality indicators are an under-studied mechanism that potentially contributes to the heterogeneity of treatment outcomes. We provide recommendations for assessing and reporting on therapist quality in future trials.

Meaning-centered pain coping skills training for patients with metastatic cancer: Protocol for a randomized controlled efficacy trial

BACKGROUND

Many patients with advanced cancer describe pain as a debilitating symptom that greatly interferes with daily activities and enjoyment of life. Psychosocial interventions can improve cancer-related pain but rarely address spiritual concerns (e.g., loss of meaning, peace), which can influence the pain experience for those facing life-threatening illness. To address these needs, we systematically developed and pilot tested a novel psychosocial intervention called Meaning-Centered Pain Coping Skills Training (MCPC). In this randomized controlled trial, we aim to determine MCPC's efficacy for reducing pain interference (primary outcome) and improving secondary outcomes. We will also estimate MCPC's cost-effectiveness.

METHOD/DESIGN

Patients (target N = 210) with advanced solid tumor malignancies (Stage IV) and clinically-elevated pain interference will be enrolled and block randomized with equal allocation to MCPC + enhanced usual care or enhanced usual care alone. MCPC's four, videoconferenced, 45-60 min weekly sessions will be individually delivered by trained study therapists. Primary (pain interference) and secondary (pain severity, anxiety and depressive symptoms, pain self-efficacy, social support, spiritual well-being) patient-reported outcomes will be assessed at baseline, and 8-weeks (primary endpoint) and 12-weeks after baseline.

CONCLUSION

Our MCPC intervention is the first to systematically address the biopsychosocial-spiritual aspects of pain in patients with advanced cancer. If MCPC demonstrates efficacy, next steps will involve hybrid efficacy-effectiveness and implementation work to broaden access to this brief, manualized, remotely-delivered intervention, with the goal of reducing suffering in patients with life-threatening illness.

Current evidence does not support the routine use of cognitive behavioural therapy in total knee arthroplasty: A systematic review

Background

There is a significant dissatisfaction rate in patients undergoing total knee arthroplasty (TKA), and poor mental health in patients is increasingly recognized as a major contributor to dissatisfaction. The aim was to review the effectiveness of cognitive behavioural therapy (CBT) in improving pain and functional outcomes of patients undergoing TKA and highlight important aspects that may be crucial for improvement.

Methods

A systematic search was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were included if they were randomized control trials that included patients undergoing unilateral or bilateral TKA, with CBT as an intervention compared against usual care, and reported outcomes in pain, knee function and any psychological outcomes as measured.

Results

Eight RCTs were selected which included 683 participants. The timings of CBT delivery, profiles of therapists, and outcome measures reported varied across the studies. Overall, 3 studies reported significant improvement in pain outcomes, 3 studies reported significant improvement in functional outcomes and 5 studies reported significant improvements in psychological outcomes.

Conclusion

Current evidence does not support the efficacy of CBT as current literature is too heterogenous. Further studies with homogenous CBT methods are required to further ascertain the true relationship between CBT and postoperative outcomes of TKA. Future studies should consider the points set out in this review, such as the importance of revisiting CBTskills, providing individualized therapy, having a supervisory team to support the fidelity of interventions, and identifying which group of patients would best benefit from CBT.

Willingness to use nonpharmacologic treatments for musculoskeletal pain in the emergency department: a cross-sectional study

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Patients in emergency department with musculoskeletal pain report high willingness to try nonpharmacologic treatments, and health care provider encouragement correlated with greater nonpharmacologic treatment use.

Objectives:

Pain is an individual experience that should incorporate patient-centered care. This study seeks to incorporate patient perspectives toward expanding nonpharmacologic treatment options for pain from the emergency department (ED).

Methods:

In this cross-sectional study of adult patients in ED with musculoskeletal neck, back, or extremity pain, patient-reported outcomes were collected including willingness to try and prior use of various nonpharmacologic pain treatments, sociodemographics, clinical characteristics, functional outcomes, psychological distress, and nonmusculoskeletal symptoms. Least absolute shrinkage and selection operator regression identified variables associated with (1) willingness to try and (2) having previously tried nonpharmacologic treatments.

Results:

Responses were analyzed from 206 adults, with a mean age of 45.4 (SD 16.4) years. The majority (90.3%) of patients in ED were willing to try at least one form of nonpharmacologic pain treatment, with 70.4%, 81.6%, and 70.9% willing to try respective subcategories of active (eg, exercise), passive (eg, heat), and psychosocial (eg, prayer) modalities. Only 56.3% of patients had previously tried any, with 35.0%, 52.4%, and 41.3% having tried active, passive, and psychosocial modalities, respectively. Patient-level factors associated with willingness included pain in upper back, more severe pain-related symptoms, and functional impairments. The factor most consistently associated with treatment use was health care provider encouragement to do so.

Conclusions:

Patients in ED report high willingness to try nonpharmacologic treatments for pain. Higher pain severity and interference may indicate greater willingness, while health care provider encouragement correlated with treatment use. These findings may inform future strategies to increase the introduction of nonpharmacologic treatments from the ED.

From Fear to Safety: A Roadmap to Recovery From Musculoskeletal Pain

Contemporary conceptualizations of pain emphasize its protective function. The meaning assigned to pain drives cognitive, emotional, and behavioral responses. When pain is threatening and a person lacks control over their pain experience, it can become distressing, self-perpetuating, and disabling. Although the pathway to disability is well established, the pathway to recovery is less researched and understood. This Perspective draws on recent data on the lived experience of people with pain-related fear to discuss both fear and safety-learning processes and their implications for recovery for people living with pain. Recovery is here defined as achievement of control over pain as well as improvement in functional capacity and quality of life. Based on the common-sense model, this Perspective proposes a framework utilizing Cognitive Functional Therapy to promote safety learning. A process is described in which experiential learning combined with "sense making" disrupts a person's unhelpful cognitive representation and behavioral and emotional response to pain, leading them on a journey to recovery. This framework incorporates principles of inhibitory processing that are fundamental to pain-related fear and safety learning.

Implementation of Psychologically Informed Physical Therapy for Low Back Pain: Where Do We Stand, Where Do We Go?

Low back pain continues to be a leading cause of disability and cost throughout the world. Evidence-based guidelines recommend use of non-pharmacological interventions to address decreases in physical function due to low back pain. Psychologically informed physical therapy (PIPT) is one way to effectively and efficiently address the need for non-pharmacological approaches. However, adoption of psychologically informed practice (PiP) by physical therapists has shown mixed results due to implementation challenges. In this perspective, we discuss the current state of PIPT training and implementation. We also propose a conceptual roadmap for future implementation needs related to increasing delivery of PIPT-informed approaches.

Training of Physical Therapists to Deliver Individualized Biopsychosocial Interventions to Treat Musculoskeletal Pain Conditions: A Scoping Review

OBJECTIVE

Current guidelines recommend management of musculoskeletal pain conditions from a biopsychosocial approach; however, biopsychosocial interventions delivered by physical therapists vary considerably in effectiveness. It is unknown whether the differences are explained by the intervention itself, the training and/or competency of physical therapists delivering the intervention, or fidelity of the intervention. The aim was to investigate and map the training, competency assessments, and fidelity checking of individualized biopsychosocial interventions delivered by physical therapists to treat musculoskeletal pain conditions.

METHODS

A scoping review methodology was employed, using Arksey and O'Malley's framework. Seven electronic databases were searched between January and March 2019, with a bridge search completed in January 2020. Full-text peer-reviewed articles, with an individualized biopsychosocial intervention were considered, and 35 studies were included.

RESULTS

Reporting overall was sparse and highly variable. There was a broad spectrum of training. More sophisticated training involved workshops combining didactic and experiential learning over longer durations with supervision and feedback. Less sophisticated training was brief, involving lectures or seminars, with no supervision or feedback. Competency assessments and fidelity testing were underperformed.

CONCLUSIONS

Training in some interventions might not have facilitated the implementation of skills or techniques to enable the paradigm shift and behavior change required for physical therapists to effectively deliver a biopsychosocial intervention. Lack of competency assessments and fidelity checking could have impacted the methodological quality of biopsychosocial interventions.

IMPACT

This study highlighted problematic reporting, training, assessment of competency, and fidelity checking of physical therapist-delivered individualized biopsychosocial interventions. Findings here highlight why previous interventions could have shown small effect sizes and point to areas for improvement in future interventions. These findings can help inform future research and facilitate more widespread implementation of physical therapist-delivered biopsychosocial interventions for people with musculoskeletal pain and thereby improve their quality of life.

Psychologically informed physical therapy for musculoskeletal pain: current approaches, implications, and future directions from recent randomized trials

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Randomized trials have examined the efficacy of psychologically informed physical therapy methods including graded activity or graded exposure, cognitive-behavioral-based physical therapy, acceptance and commitment-based physical therapy, and internet-based psychological programs compared to traditional physical therapy approaches for musculoskeletal pain. Summary findings suggest that psychologically informed physical therapy is a promising care model; however, more convincing evidence is needed to support widespread adoption, especially in light of clinician training demands.

Psychologically informed physical therapy (PIPT) blends psychological strategies within a physical therapist's treatment approach for the prevention and management of chronic musculoskeletal pain. Several randomized trials have been conducted examining the efficacy of PIPT compared to standard physical therapy on important patient-reported outcomes of disability, physical function, and pain. In this review, we examine recent trials published since 2012 to describe current PIPT methods, discuss implications from findings, and offer future directions. Twenty-two studies, representing 18 trials, were identified. The studied PIPT interventions included (1) graded activity or graded exposure (n = 6), (2) cognitive-behavioral-based physical therapy (n = 9), (3) acceptance and commitment-based physical therapy (n = 1), and (4) internet-based psychological programs with physical therapy (n = 2). Consistent with prior reviews, graded activity is not superior to other forms of physical activity or exercise. In a few recent studies, cognitive-behavioral-based physical therapy had short-term efficacy when compared to a program of standardized exercise. There is a need to further examine approaches integrating alternative strategies including acceptance-based therapies (ie, acceptance and commitment therapy or mindfulness) or internet-based cognitive-behavioral programs within physical therapy. Although PIPT remains a promising care model, more convincing evidence is needed to support widespread adoption, especially in light of training demands and implementation challenges.

Improving Study Conduct and Data Quality in Clinical Trials of Chronic Pain Treatments: IMMPACT Recommendations

The estimated probability of progressing from phase 3 analgesic clinical trials to regulatory approval is approximately 57%, suggesting that a considerable number of treatments with phase 2 trial results deemed sufficiently successful to progress to phase 3 do not yield positive phase 3 results. Deficiencies in the quality of clinical trial conduct could account for some of this failure. An Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials meeting was convened to identify potential areas for improvement in trial conduct in order to improve assay sensitivity (ie, ability of trials to detect a true treatment effect). We present recommendations based on presentations and discussions at the meeting, literature reviews, and iterative revisions of this article. The recommendations relate to the following areas: 1) study design (ie, to promote feasibility), 2) site selection and staff training, 3) participant selection and training, 4) treatment adherence, 5) data collection, and 6) data and study monitoring. Implementation of these recommendations may improve the quality of clinical trial data and thus the validity and assay sensitivity of clinical trials. Future research regarding the effects of these strategies will help identify the most efficient use of resources for conducting high quality clinical trials. PERSPECTIVE: Every effort should be made to optimize the quality of clinical trial data. This manuscript discusses considerations to improve conduct of pain clinical trials based on research in multiple medical fields and the expert consensus of pain researchers and stakeholders from academia, regulatory agencies, and industry.

The KOMPACT-P study: Knee Osteoarthritis Management with Physiotherapy informed by Acceptance and Commitment Therapy-Pilot study protocol

INTRODUCTION

Incidence of total knee arthroplasty (TKA) is projected to rise 276% in 2030, and psychological distress affects up to 42% of people with knee osteoarthritis undergoing TKA, with demonstrated detrimental effects on postoperative outcomes. Few studies have assessed psychological treatment in people awaiting TKA, and these have been psychologist-delivered treatments. No evidence exists regarding psychologically-informed interventions delivered by health professionals currently embedded in TKA clinical pathways. The primary aim of this pilot study is to explore the safety, acceptability and feasibility of the Knee Osteoarthritis Management with Physiotherapy informed by Acceptance and Commitment Therapy (KOMPACT) approach in people awaiting TKA.

METHODS AND ANALYSIS

51 community-dwelling adults scheduled for a primary TKA at two hospitals will be recruited to this pilot, mixed-methods, prospective randomised controlled trial with assessor blinding. Participants will be randomised in a 1:2 ratio to either usual care (education class) or usual care plus KOMPACT (2 hours 20 min of preoperative physiotherapy informed by Acceptance and Commitment Therapy). Our primary outcome measures are safety (length of stay, complications and psychological health after KOMPACT), acceptability (treatment credibility and qualitative data) and feasibility (recruitment, retention and intervention fidelity) of the KOMPACT approach. Secondary outcomes include health service outcomes, patient-reported physical and psychological outcomes, and physical performance measures. Quantitative data collection was conducted at baseline, 1-2 weeks before TKA, 6 weeks after TKA and 6 months after TKA. Qualitative data collection is 1-2 weeks before TKA. Data analysis will take a quantitative-led approach with triangulation after thematic analysis of the qualitative data.

ETHICS AND DISSEMINATION

This study has full ethics approval (HREC/18/WMEAD/440). Results from this study will be published in peer-reviewed journals and presented at local and international conferences.

TRIAL REGISTRATION NUMBER

Australia New Zealand Clinical Trials Registry (ACTRN12618001867280p).

Comparing the Usability and Acceptability of Wearable Sensors Among Older Irish Adults in a Real-World Context: Observational Study

BACKGROUND

Wearable devices are valuable assessment tools for patient outcomes in contexts such as clinical trials. To be successfully deployed, however, participants must be willing to wear them. Another concern is that usability studies are rarely published, often fail to test devices beyond 24 hours, and need to be repeated frequently to ensure that contemporary devices are assessed.

OBJECTIVE

This study aimed to compare multiple wearable sensors in a real-world context to establish their usability within an older adult (>50 years) population.

METHODS

Eight older adults wore seven devices for a minimum of 1 week each: Actigraph GT9x, Actibelt, Actiwatch, Biovotion, Hexoskin, Mc10 Biostamp_RC, and Wavelet. Usability was established through mixed methods using semistructured interviews and three questionnaires, namely, the Intrinsic Motivation Inventory (IMI), the System Usability Scale (SUS), and an acceptability questionnaire. Quantitative data were reported descriptively and qualitative data were analyzed using deductive content analysis. Data were then integrated using triangulation.

RESULTS

Results demonstrated that no device was considered optimal as all scored below average in the SUS (median, IQR; min-max=57.5, 12.5; 47.5-63.8). Hexoskin was the lowest scored device based on the IMI (3.6; 3.4-4.5), while Biovotion, Actibelt, and Mc10 Biostamp_RC achieved the highest median results on the acceptability questionnaire (3.6 on a 6-point Likert scale). Qualitatively, participants were willing to accept less comfort, less device discretion, and high charging burdens if the devices were perceived as useful, namely through the provision of feedback for the user. Participants agreed that the purpose of use is a key enabler for long-term compliance. These views were particularly noted by those not currently wearing an activity-tracking device. Participants believed that wrist-worn sensors were the most versatile and easy to use, and therefore, the most suitable for long-term use. In particular, Actiwatch and Wavelet stood out for their comfort. The convergence of quantitative and qualitative data was demonstrated in the study.

CONCLUSIONS

Based on the results, the following context-specific recommendations can be made: (1) researchers should consider their device selection in relation to both individual and environmental factors, and not simply the primary outcome of the research study; (2) if researchers do not wish their participants to have access to feedback from the devices, then a simple, wrist-worn device that acts as a watch is preferable; (3) if feedback is allowed, then it should be made available to help participants remain engaged; this is likely to apply only to people without cognitive impairments; (4) battery life of 1 week should be considered as a necessary feature to enhance data capture; (5) researchers should consider providing additional information about the purpose of devices to participants to support their continued use.

Development of a Comprehensive, Nonsurgical Joint Health Program for People With Osteoarthritis: A Case Report

BACKGROUND AND PURPOSE

Existing osteoarthritis (OA) care models often fall short in addressing the many biological, psychological, social, and behavioral characteristics that contribute to disability. As US health care shifts towards value-based payment, there is an increasing need to develop and test scalable, cost-effective, and multi-modal OA care models. This administrative case report will describe the development and pilot of a new, value-based comprehensive care model for OA.

CASE DESCRIPTION

The Joint Health Program (JHP) is a physical therapist-led conservative care model for individuals with hip and knee OA. In the JHP, physical therapists with specialized training in cognitive behavioral-theory based strategy function as the central care provider (ie, the primary osteoarthritis provider) who delivers evidence-based, psychologically informed interventions and coordinates care within a multi-disciplinary network of dietitians, behavioral health specialists, and orthopedic providers. The JHP is focused on enhancing patient engagement, shared decision making, self-management and multi-modal patient interaction, and long-term follow-up.

OUTCOMES

A value-based, comprehensive care program for OA led by physical therapists demonstrated feasibility and acceptability within a large, academic health care system, which has led to its early growth. Barriers to development and integration of the program were addressed through effective collaboration among health care providers, program and health system administrators, and executive leadership.

DISCUSSION

The JHP serves as a model for future physical therapist-led, value-based care models that could be developed in other health care systems for OA and other chronic conditions. Future work will identify characteristics that predict program response and compare the effectiveness of this program to existing models of care.

Determining Brain Mechanisms that Underpin Analgesia Induced by the Use of Pain Coping Skills

Objective

Cognitive behavioral therapies decrease pain and improve mood and function in people with osteoarthritis. This study assessed the effects of coping strategies on the central processing of knee pain in people with osteoarthritis of the knees.

Methods

Mechanical pressure was applied to exacerbate knee pain in 28 people with osteoarthritis of the knee. Reports of pain intensity and functional magnetic resonance imaging measures of pain-related brain activity were recorded with and without the concurrent use of pain coping skills.

Results

Coping skills led to a significant reduction in pain report (Coping = 2.64 ± 0.17, Not Coping = 3.28 ± 0.15, P < 0.001). These strategies were associated with increased activation in pain modulatory regions of the brain (medial prefrontal and rostral anterior cingulate cortices, Pcorrected < 0.05) and decreased pain-related activation in regions that process noxious input (midcingulate cortex, supplementary motor area, secondary somatosensory cortex, and anterior parietal lobule, Pcorrected < 0.05). The magnitude of the decrease in pain report during the use of pain coping strategies was found to be proportional to the decrease in pain-related activation in brain regions that code the aversive/emotional dimension of pain (anterior insula, inferior frontal gyrus, orbitofrontal cortex, Pcorrected < 0.05) but did not differ between groups with and without training in coping skills. However, training in coping skills reduced the extent to which brain responses to noxious input were influenced by anxiety.

Conclusions

The results of this study support previous reports of pain modulation by cognitive pain coping strategies and contribute to the current understanding of how analgesia associated with the use of pain coping strategies is represented in the brain.

Targeted interventions to prevent transitioning from acute to chronic low back pain in high-risk patients: development and delivery of a pragmatic training course of psychologically informed physical therapy for the TARGET trial

BACKGROUND

Low back pain (LBP) is a public health concern because it is highly prevalent and the leading cause of disability worldwide. Psychologically informed physical therapy (PIPT) is a secondary prevention approach that first aims to identify individuals at high risk for transitioning to chronicity and then provides tailored treatment to reduce that risk. Training models that are feasible to implement with acceptable training quality are needed to improve scalability for widespread implementation of PIPT. This manuscript describes the PIPT training program that was developed for training physical therapists providing PIPT in the TARGET trial.

METHODS

The PIPT training program was developed, tested, and modified using an iterative process. Content development consisted of stakeholder engagement, beta testing, modification of training, and confirmation of final course objectives. Methods of delivery consisted of a website that included brief online educational modules followed by a live 8-h workshop that included video-based mock case scenarios and case-based role playing. Attitudes, beliefs, and confidence in implementing PIPT principles were assessed before and immediately after training to measure training quality and impact.

RESULTS

Early stakeholder engagement and beta testing indicated the need for increased emphasis on experiential learning opportunities and patient-centered communication training. Booster training varied extensively across TARGET sites with involvement of 'clinician champions' providing brief follow-up sessions identified as best practice. Favorable post-training changes in physical therapist attitudes and beliefs toward biopsychosocial treatment orientation and increased confidence in implementing PIPT principles were observed.

CONCLUSIONS

PIPT training for provider participation in the TARGET trial was feasible to deliver. Course content was acceptable to physical therapists and resulted in improved beliefs and confidence in applying PIPT skills during clinical practice. Ongoing consultation and site-based continuing education were methods by which specific TARGET sites maintained or augmented PIPT skill training; however, implementing ongoing training was challenging in general. Due to the pragmatic nature of the TARGET trial, it was not possible to directly measure the effect of PIPT training on treatment fidelity, which was a limitation of our approach.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02647658 . Registered on 6 January 2016.

Implementation of person-centred practice principles and behaviour change techniques after a 2-day training workshop: A nested case study involving physiotherapists

OBJECTIVES

The aims of the present study were to determine how well physiotherapists implemented person-centred practice principles and behaviour change techniques after a workshop, and to evaluate whether self-audit of performance differed from audits of an experienced training facilitator.

METHODS

Eight physiotherapists each completed a 2-day workshop followed by two telephone consultations with four patients with knee osteoarthritis. The training facilitator audited audio-recordings of all consultations, and therapists self-audited 50% of consultations using a tool comprising: (a) 10 person-centred practice principles rated on a numerical rating scale of 0 (need to work on this) to 10 (doing really well); and (b) seven behaviour change techniques rated with an ordinal scale (using this technique effectively; need to improve skill level; or need to learn how to apply this technique).

RESULTS

Physiotherapists showed "moderate" fidelity to person-centred principles, with mean scores between 5 and 7 out of 10. For behaviour change techniques, the training facilitator believed that physiotherapists were using three of seven techniques "effectively" during most consultations and "needed to improve skill levels" with most other techniques. Physiotherapists scored themselves significantly lower than the training facilitator for two of 10 person-centred principles, and tended to rate their skills using behaviour change techniques less favourably.

CONCLUSIONS

Physiotherapists performed moderately well when implementing person-centred practice principles and behaviour change techniques immediately after training, but had room for improvement, particularly for skills relating to providing management options and changing thinking habits. Physiotherapists' self-ratings of performance generally did not differ from expert ratings; however, they underestimated their ability to implement some principles and techniques.

Physiotherapists' Adoption of a Theory-Based Skills Training Program in Guiding People with Rheumatoid Arthritis to Health-Enhancing Physical Activity

Purpose

To describe physiotherapists’ (PTs’) adoption of a theory-based skills training program preparing them to guide people with rheumatoid arthritis (RA) to health-enhancing physical activity (HEPA) within a 1-year intervention trial.

Method

This was a longitudinal case study. Ten female PTs (age 25–59), delivering the HEPA intervention, participated. Data were collected on five occasions over a 19-month period: once before the training course, once after 4 course days, twice during the HEPA intervention and once after the HEPA intervention. Knowledge on about physical activity (score 0–6) and behavior change techniques (BCTs) (score 0–18), fear-avoidance beliefs (score 8–48) and self-efficacy to guide behavior change (score 9–54) were assessed with a questionnaire. Structured logbooks were used to register PTs’ self-reported guiding behavior. Criteria for PTs’ adherence to the protocol were pre-set.

Results

PTs’ knowledge on about BCTs and their self-efficacy increased significantly (p < 0.05) from median 9 to 13 and from median 38 to 46.5, respectively. Knowledge on about physical activity was high and fear-avoidance beliefs were low before the education (median 6 and 13.5, respectively) and did not change over time. Two out of ten PTs fulfilled the pre-set criteria for adherence throughout the intervention.

Conclusion

The results suggest that a theory-based skills training program improves PTs’ knowledge on about behavior change techniques and their self-efficacy to guide people with RA to HEPA. PTs’ adherence to the protocol was not complete but the clinical relevance of the adherence criteria need to be validated against observed PT behavior and patient outcomes.

Physiotherapist-delivered Stress Inoculation Training for acute whiplash-associated disorders: A qualitative study of perceptions and experiences

BACKGROUND

Formally trained and accredited physiotherapists delivered Stress Inoculation Training (SIT) integrated with guideline-based physiotherapy management to individuals with acute whiplash associated disorders (WAD) as part of a randomised controlled trial. The delivery of SIT by physiotherapists is new.

OBJECTIVES

To investigate physiotherapists' perspectives on delivering SIT as part of the trial and in routine practice.

DESIGN

Qualitative descriptive.

METHOD

Physiotherapists (n = 11) participated in semi-structured interviews. Interviews were audio-recorded, transcribed verbatim, and analysed thematically. Findings were triangulated against an audit of physiotherapists' adherence to the SIT protocol.

RESULTS

Three themes were identified: perceived value; capacity to deliver; and adaptation and implementation. Physiotherapists' saw value in SIT in that they perceived the program to have improved patient outcomes, enhanced their therapeutic alliance, and provided new skills to manage psychological contributors to WAD. Physiotherapists' capacity to deliver the program was facilitated through the development of confidence in their ability to deliver sessions, viewing SIT as falling within their current professional identity, and having confidence in their ability to manage mismatches in patients' expectations of care. All physiotherapists reported having used SIT to some extent in routine practice, by selectively delivering sessions and/or integrating the content with other management. Physiotherapists were able to deliver SIT as was intended (94.6% adherence).

CONCLUSIONS

Physiotherapists' supported adding SIT to usual management of individuals with acute WAD. Education on SIT principles is recommended during pre-professional training to facilitate future implementation.

Feasibility of Training Physical Therapists to Deliver the Theory-Based Self-Management of Osteoarthritis and Low Back Pain Through Activity and Skills (SOLAS) Intervention Within a Trial

BACKGROUND

Provider training programs are frequently underevaluated, leading to ambiguity surrounding effective intervention components.

OBJECTIVE

The purpose of this study was to assess the effectiveness of a training program in guiding physical therapists to deliver the Self-management of Osteoarthritis and Low back pain through Activity and Skills (SOLAS) group education and exercise intervention (ISRCTN49875385), using a communication style underpinned by self-determination theory (SDT).

DESIGN

This was an assessment of the intervention arm training program using quantitative methods.

METHODS

Thirteen physical therapists were trained using mixed methods to deliver the SOLAS intervention. Training was evaluated using the Kirkpatrick model: (1) Reaction-physical therapists' satisfaction with training, (2) Learning-therapists' confidence in and knowledge of the SDT-based communication strategies and intervention content and their skills in applying the strategies during training, and (3) Behavior-8 therapists were audio-recorded delivering all 6 SOLAS intervention classes (n = 48), and 2 raters independently coded 50% of recordings (n = 24) using the Health Care Climate Questionnaire (HCCQ), the Controlling Coach Behavior Scale (CCBS), and an intervention-specific measure.

RESULTS

Reaction: Physical therapists reacted well to training (median [IRQ]; min-max = 4.7; [0.5]; 3.7-5.0). Learning: Physical therapists' confidence in the SDT-based communication strategies and knowledge of some intervention content components significantly improved. Behavior: Therapists delivered the intervention in a needs-supportive manner (median HCCQ = 5.3 [1.4]; 3.9-6.0; median CCBS = 6.6 ([0.5]; 6.1-6.8; median intervention specific measure = 4.0 [1.2]; 3.2-4.9). However, "goal setting" was delivered below acceptable levels by all therapists (median 2.9 [0.9]; 2.0-4.0).

LIMITATIONS

The intervention group only was assessed as part of the process evaluation of the feasibility trial.

CONCLUSIONS

Training effectively guided physical therapists to be needs-supportive during delivery of the SOLAS intervention. Refinements were outlined to improve future similar training programs, including greater emphasis on goal setting.

Effectiveness of a physiotherapist delivered cognitive-behavioral patient education for patients who undergoes operation for total knee arthroplasty: a protocol of a randomized controlled trial

Background

Total Knee Arthroplasty (TKA) is a common and generally effective procedure performed mainly due to advanced osteoarthritis, pain, physical disability and reduced quality of life. However, approximately 20% of the patients respond poorly to the surgery and chronic pain and disability following TKA remains a major health burden for many patients. Among the most well documented and powerful psychological predictors of poor outcome following TKA is pain catastrophizing. Recent research has shown that patients with these thoughts are at higher risk of having persistent pain and lower physical function after the operation than patients with low levels of pain catastrophizing before TKA. There is high need of developing treatments aimed at improving self-management for this group of patients and the aim of this study is to investigate the effectiveness of a patient education in pain coping on physical function and pain among patients with high pain catastrophizing score before a TKA.

Methods

This study is a two-arm parallel group trial design including 56 patients with high levels of pain catastrophizing referred for total knee arthroplasty due to osteoarthritis. Patients eligible for participation will be randomized into the two arms, usual care or usual care and patient education. Usual care consists of operation and standard rehabilitation. The patient education consists of 7 individual sessions focusing on pain behavior and pain coping managed by a physiotherapist. Three before the operation and four after. Measurements will be taken at baseline before the operation and 3 and 12 months after the operation. Primary outcome will be pain after 12 months measured with VAS (Visual Analogue Scale). Secondary outcomes include physical function and activity, quality of life, pain management and psychological factors.

Discussion

Only few studies have evaluated the effectiveness of psychological interventions on patients with high levels of pain catastrophizing before the operation. This trial will provide evidence for the effectiveness of a cognitive-behavioral patient education delivered by physiotherapists and may provide better functional outcome and less pain for a vulnerable group of TKA patients. We expect that the results can provide important new knowledge to the current care recommendations.

Trial registration

Clinical Trials (NCT02587429). Registered 23 October 2015

Translating Evidence-Based Protocols Into the Home Healthcare Setting

Activity-limiting pain is common among older home care patients and pain management is complicated by the high prevalence of physical frailty and multimorbidity in the home care population. A comparative effectiveness study was undertaken at a large urban home care agency to examine an evidence-based pain self-management program delivered by physical therapists (PTs). This article focuses on PT training, methods implemented to reinforce content after training and to encourage uptake of the program with appropriate patients, and therapists' fidelity to the program. Seventeen physical therapy teams were included in the cluster randomized controlled trial, with 8 teams (155 PTs) assigned to a control and 9 teams (165 PTs) assigned to a treatment arm. Treatment therapists received interactive training over two sessions, with a follow-up session 6 months later. Additional support was provided via emails, e-learning materials including videos, and a therapist manual. Program fidelity was assessed by examining PT pain documentation in the agency's electronic health record. PT feedback on the program was obtained via semistructured surveys. There were no between-group differences in the number of PTs documenting program elements with the exception of instruction in the use of imagery, which was documented by a higher percentage of intervention therapists (p = 0.002). PTs felt comfortable teaching the program elements, but cited time as the biggest barrier to implementing the protocol. Possible explanations for study results suggesting limited adherence to the program protocol by intervention-group PTs include the top-down implementation strategy, competing organizational priorities, program complexity, competing patient priorities, and inadequate patient buy-in. Implications for the implementation of complex new programs in the home healthcare setting are discussed.

Physical therapists' assessments, analyses and use of behavior change techniques in initial consultations on musculoskeletal pain: direct observations in primary health care

Background

Behavioral medicine (BM) treatment is recommended to be implemented for pain management in physical therapy. Its implementation requires physical therapists (PTs), who are skilled at performing functional behavioral analyses based on physical, psychological and behavioral assessments. The purpose of the current study was to explore and describe PTs’ assessments, analyses and their use of behavioral change techniques (BCTs) in initial consultations with patients who seek primary health care due to musculoskeletal pain.

Methods

A descriptive and explorative research design was applied, using data from video recordings of 12 primary health care PTs. A deductive analysis was performed, based on a specific protocol with definitions of PTs’ assessment of physical and psychological prognostic factors (red and yellow flags, respectively), analysis of the clinical problem, and use of BCTs. An additional inductive analysis was performed to identify and describe the variation in the PTs’ clinical practice.

Results

Red and yellow flags were assessed in a majority of the cases. Analyses were mainly based on biomedical assessments and none of the PTs performed functional behavioral analyses. All of the PTs used BCTs, mainly instruction and information, to facilitate physical activity and improved posture. The four most clinically relevant cases were selected to illustrate the variation in the PTs’ clinical practice. The results are based on 12 experienced primary health care PTs in Sweden, limiting the generalizability to similar populations and settings.

Conclusion

Red and yellow flags were assessed by PTs in the current study, but their interpretation and integration of the findings in analyses and treatment were incomplete, indicating a need of further strategies to implement behavioral medicine in Swedish primary health care physical therapy.

Treatment-Based Classification System for Low Back Pain: Revision and Update

The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patient's clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent-new or recurrent-LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Association's clinical practice guidelines for low back pain.

Are self-management strategies effective in chronic pain treatment?

It has long been recognized that in the management of chronic illnesses generally, medical care alone is unlikely to be sufficient without the active contribution of the patient. This perspective has also been enunciated in numerous guidelines for the management of chronic pain. However, in the case of chronic pain at least, the nature and role of self-management have been poorly defined and, as a result, poorly understood and researched. This review considers the nature of self-management strategies for chronic pain, evidence of their effectiveness and ways in which self-management can be facilitated for those in chronic pain. A research and training agenda is proposed for where this work could go next.

Toward an evidence-based patient-provider communication in rehabilitation: linking communication elements to better rehabilitation outcomes

Background:

There is a growing interest in linking aspects of patient-provider communication to rehabilitation outcomes. However, the field lacks a conceptual understanding on: (a) ‘how’ rehabilitation outcomes can be improved by communication; and (b) through ‘which’ elements in particular. This article elaborates on the conceptual developments toward informing further practice and research.

Methods:

Existing models of communication in healthcare were adapted to rehabilitation, and its outcomes through a comprehensive literature review.

Results:

After depicting mediating mechanisms and variables (e.g. therapeutic engagement, adjustment toward disability), this article presents the ‘4 Rehab Communication Elements’ deemed likely to underpin rehabilitation outcomes. The four elements are: (a) knowing the person and building a supportive relationship; (b) effective information exchange and education; (c) shared goal-setting and action planning; and (d) fostering a more positive, yet realistic, cognitive and self-reframing.

Discussion:

This article describes an unprecedented, outcomes-oriented approach toward the design of rehabilitation communication, which has resulted in the development of a new intervention model: the ‘4 Rehab Communication Elements’. Further trials are needed to evaluate the impact of this whole intervention model on rehabilitation outcomes.