Pilot Program

Addressing the Needs of Patients With Chronic Pain

Fed Pract. 2018 February;35(2):43-49

References

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Participants and Intervention

Program participants were patients with a chronic pain diagnosis who enrolled in the interdisciplinary pain team OPGP between April 2016 and April 2017. Most patients were referred by their PCPs due to chronic low back, neck, joint or neuropathic pain, although many presented with multiple pain areas. The onset of pain often was a result of a service-related injury or overuse, or the etiology was unknown.

A board-certified pain physician, licensed clinical psychologist, 2 licensed PTs, and a clinical pharmacist led the OPGP sessions. The program was composed of 3-hour-long sessions held weekly for 8 consecutive weeks. Each week, a member of the team covered a specific topic (Table 1).

The team psychologist provided a CBT approach for managing chronic pain, which included an introduction to a proactive model of coping with chronic pain; cognitive restructuring and ways to promote healthy thinking; relaxation techniques and mindfulness; and strategies to improve communication with family and providers related to chronic pain. Other team members presented information from their discipline.

These sessions focused on the importance of exercise, movement, and physical therapy; appropriate use of medications for managing chronic pain; pacing activities and body mechanics; and the medical approach to managing chronic pain. In addition to didactic presentations, interaction and therapeutic dialogue was encouraged among patients. The education portion of each weekly session lasted about 90 minutes, including a short break. Then, following another short break, patients proceeded to the physical therapy area and engaged in an individualized, monitored exercise program, conducted by the team PTs. Patients also were issued pedometers and encouraged to track their steps each day. Education in improving posture and body mechanics was a key component of the exercise portion of the program so patients could resume their normal daily activities and regain enjoyment in their life. Pain outcomemeasures were collected at admission and immediately before discharge.

Medication management also was an important part of the program for some patients and included tapering off opioids and other drugs and implementing trials of adjuvant pain medications shown to help chronic pain. For some patients, this medication management continued after the patient completed the program.

Measures

The Pain Outcome Questionnaire (POQ) is a 19-item, self-report measure of pain treatment outcomes. Pain rating, mobility, activities of daily living, vitality, negative effect, and fear are the functioning domains evaluated, and the subscale scores are added to produce a total score. The POQ was developed from samples of veterans undergoing inpatient or outpatient pain treatment at VA facilities. For each of the subscales and the total score, higher values indicate poorer outcomes. In normative outpatient VA samples, a total score of 71 is at the 25th percentile, and 120 is at the 75th percentile. The POQ has been shown to have good reliability and validity among veterans in an outpatient setting.²⁵

The Pain Catastrophizing Scale (PCS) is a 13-item scale designed to measure various levels of pain catastrophizing.²⁶ Each item is rated on a 5-point Likert-type scale, from 0 (not at all) to 4 (all the time). The PCS consists of 3 subscale domains: rumination, 4 items; magnification, 3 items; and helplessness, 6 items. Responses to all items also can be added to produce a total score from 0 to 52, with higher scores indicating a higher level of catastrophic thinking related to pain. This project evaluated both the total score and the 3 subscale scores.

The Pain Self-Efficacy Questionnaire (PSEQ) is a 10-item questionnaire that assesses confidence in an individual’s ability to cope or to perform activities despite the pain.²⁷ The PSEQ covers a range of functions, including household chores, socializing, work, as well as coping with pain without medications. Each question has a 7-point Likert scale response: 0 = not at all confident, and 7 = completely confident, to produce a total score from 0 to 60. Higher scores indicate stronger pain self-efficacy, which has been shown to be associated with return to work and maintenance of functional gains.

The Patient Health Questionnaire-4 (PHQ-4) is a 4-item instrument used to screen for depression and anxiety in outpatient medical settings.²² Patients indicate how often they have been bothered by certain problems on a 4-point Likert scale, from 0 (not at all) to 3 (nearly every day). The PHQ-4 provides a total score (0-12) with scores of 6 to 8 indicating moderate and 9 to 12 indicating severe psychological distress; 2 subscale scores, 1 for anxiety (2 questions) and 1 for depression (2 questions). For this analysis, the total PHQ-4 score has been dichotomized with 1 indicating a score in the moderate or severe range vs 0 for a score of mild or no psychological distress. Likewise, each of the subscale scores have been dichotomized with 1 indicating a score of 3 or greater, which is considered a positive screen.

The 6-minute walk test (6MWT) measures the distance (in feet) an individual can walk over a total of 6 minutes on a hard, flat surface.²⁸ Even though the individual can walk at a self-selected pace and rest if needed during the test, the goal is for the patient to walk as far as possible over the course of 6 minutes. The 6MWT provides information regarding functional capacity, response to therapy, and prognosis across a range of chronic conditions, including pain.