PORTLAND—A lot of health care providers involved in the care of patients with HIV/AIDS think physical therapists (PTs) have a very narrow role to play in chronic pain when in actuality, "we have a very big footprint," says Michael DeArman, DPT, Fellow of the American Association of Orthopedic Manual Therapists.
In his session, "Physical therapy alternatives for people living with HIV and persistent pain," he reviewed how his role in the care of patients with HIV has evolved over the years. He explained that the emphasis in physical therapy used to be on exercises that would help to maintain lean body mass, because it was a predictor of survivability and helped patients avoid opportunistic infections.
After that, the role of the PT focused largely on helping patients deal with the adverse effects of medications. DeArman explained that back in the days of azathioprine (AZT), for example, many patients developed peripheral neuropathy, lipodystrophy, and low cervical fat deposition leading to neck pain. PTs also helped patients deal with the complications of surviving with HIV, including the effects of meningitis and stroke. "But we don't see much of that anymore because the medications are so much better,” DeArman said. “That's not the profile for HIV anymore."
But now patients are dealing with chronic pain
DeArman reported that 80% to 90% of people with HIV/AIDS have chronic pain for at least 2 months, if not much longer. He said, "PT can be an alternative to opioids," and explained that his efforts are twofold. "Graded activity to slowly build peoples' ability to do aerobic exercise is a really good way to manage pain,” he said, “but the other half of it is a lot of counseling and education, talking about how pain works and doesn't work, and how what you're told and what you believe and experience and your expectations can affect the experience of pain and the level of pain at any given moment."
He remarked that now about 60% of this professional time is devoted to the counseling and educational aspects of pain and 40% to movement and exercise: "It's not really the kind of therapist I trained to be, and it's not what most people think of as physical therapy work, but it's falling in our lap."
He said that as a society, we rely heavily on more formal counseling by psychotherapists and counselors, for example, to manage depression and anxiety, but that few others in the medical realm are picking up the slack when it comes to pain education for patients with HIV.
Tools for talking
DeArman discussed some of the tools and techniques he uses when talking to patients about their pain, such as motivational interviewing and assessing readiness for change. He uses the Fear-Avoidance Beliefs Questionnaire (FABQ) to uncover how a patient's fear-avoidance beliefs about physical activity may be affecting their pain. He also assesses levels of catastrophization, or how seriously a patient interprets a physical symptom; a high level correlates with greater pain states. Similarly, those with low self-efficacy—feelings about how well you can control your destiny and situations—are more likely to experience chronic pain states than those with high self-efficacy.
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