Dr. Steven George explains how PTs can treat those who have had musculoskeletal pain during COVID-19

Chronic pain is not a new problem in the United States. It is one of the most common reasons for seeking medical care and has been linked to anxiety and depression, poor health and reduced quality of life and, as seen in the news, a dependence on opioid prescriptions.

However, this is the first time in recent history that those managing pain are doing so through a pandemic. As mounting research points to the effectiveness of conservative care, physical therapy has asserted a central role in both preventing and managing long-term musculoskeletal pain. How can physical therapists best support patients during a time when postponed treatment puts musculoskeletal patients at a higher risk of delayed recovery and chronic pain?

To learn more, we sat down with MedRisk International Scientific Advisory Board (ISAB) member Steven Z. George, PT, PhD, FAPTA, from Duke University’s School of Medicine. He is the Laszlo Ormandy Distinguished Professor in Orthopaedic Surgery and also serves as Director of Musculoskeletal and Surgical Sciences for the Duke Clinical Research Institute and Vice Chair of Research for the Department of Orthopaedic Surgery.

The Psychosocial Factors of Pain

Helping injured workers manage musculoskeletal pain is a primary focus for physical therapists, but according to Dr. George, effective treatment often encompasses more than addressing physical symptoms. An emerging topic of PT research is how beliefs and emotions impact the pain experience.

Especially in the case of an on-the-job injury, psychosocial factors, which include pain-related fears, perceived injustice, and fear of reinjury, can prevent a patient from being active in their rehabilitation. This can then significantly impact recovery. According to Dr. George, pain catastrophizing (another psychosocial factor), which is associated with pessimism and helplessness, can lead to poor outcomes in musculoskeletal injury. Depression and anxiety, whether specific to the injury or a general trait, can also affect potential for recovery.

“We have 25 years of literature where researchers were looking for one particular factor that posed the most risk to recovery – a ‘ring to the rule them all,’” he added. “But what we have found is there’s not just one, and it’s not even just about the number of factors that are elevated. They compound. So, this needs to be considered as a cumulative risk model.”

This research is supported by the use of screening tools, such as the STarT Back Screening Tool, the Optimal Screening for Prediction of Referral and Outcome tools, or the Örebro Musculoskeletal Pain Questionnaire (ÖMPQ) MedRisk uses to assess for psychosocial factors, in a rehabilitation patient.

It is not uncommon for patients to exhibit 1 or 2 psychosocial factors, but when this number increases, there is a higher risk of delayed recovery. Although it’s too early to say, it’s reasonable to expect to see more of these boxes being checked by workers’ comp patients in 2020 and 2021.

“Everyone talks about the second wave of COVID-19, but we are also concerned about the second wave of pain management. As treatment resumes, it may be harder to change negative beliefs and fears related to work injury. And when you think about catastrophizing, this pandemic is also a ‘hand that’s been dealt’ to us all,” Dr. George said.

As hospitals have postponed surgeries and PT treatment has been delayed, many patients have not had the same level of access to nonpharmacologic pain management options, such as PT, during the pandemic. These factors, combined with the psychological impact of such a profound event, will likely equate to a different experience of pain – and likewise, a different course of treatment – for these patients moving forward.

Psychologically Informed Physical Therapy

How should PTs adapt their approach to delivering treatment as the country continues to fight coronavirus? The answer includes implementing safety precautions, like masks and disinfecting, to mitigate the spread of the virus – and more. Many clinicians are embracing the principles of psychologically informed practice, as it bridges the gap between standard PT practice, based on biomedical tenets, and a more cognitive-behavioral approach, derived from principles of mental health treatment. (Click here to learn more about related research from MedRisk ISAB member Dr. Chris Main.) The main goal is to identify psychosocial signs, or “yellow flags,” that may affect treatment outcomes. 

Using screening tools like those mentioned above, PTs then adapt standard treatments to incorporate, for example, deep breathing exercises, mental imagery and progressive muscle relaxation, to ease the pain associated distress and improve outcomes.

One way to prompt a discussion about the patient’s pain experience is through motivational interviewing, a counseling technique that helps patients resolve ambivalent feelings and insecurities and find internal motivations to change their behavior. In taking this personalized approach, PTs can also open the door to exploring the relationship between fear and movement. A behavioral approach to exercise is one of the hallmarks of psychologically informed practice.

“If a patient stops an exercise and says it hurts, the PT needs to understand whether they are stopping because they are experiencing injury or because they are experiencing pain,” Dr. George said. “Not all pain is bad; successful rehab involves working through some of the pain. That’s how the system adapts.”

Psychologically informed physical therapy encourages PTs to incorporate “gentle pushback” to lead patients to a place where they see the value of stretching themselves to do 10 minutes of exercise while bearing some discomfort, rather than stopping at 5. This approach is all predicated on the assumption that the exercises being prescribed by the PT are not harmful.

These types of conversations during therapy also encourage patients to take an active part in their recovery, which Dr. George believes is particularly important to treating today’s PT patients. Self-management is a part of all treatment guidelines, but as the use of telerehabilitation rises, PTs must reassure patients that their participation is part of a team-based approach.

“You don’t want the patient to take it as ‘It’s all on you. It’s more ‘We are going to work on finding techniques that work for you, together,” he said.

Conclusion

During these uncertain times, patients may start treatment later than planned or in a different method than expected (i.e., telerehabilitation). However, PT remains one of the most valuable methods for preventing or managing long-term musculoskeletal pain.

Conservative care, particularly immediately after injury, has been shown to be effective and to have a protective effect against opioid use, but even patients who may have been given a short-term pharmacologic treatment can see beneficial effects through physical therapy. The entire care team, including the patient, needs to be involved in developing a long-term treatment plan of which physical therapy may be a part.

No matter the patient’s circumstances, clinicians should assume that the pandemic has had an impact on their recovery and, like so many aspects of pandemic life, treatment will require adaption to be most effective.

“Whether the patient’s injury is physically affected by COVID-19 or not, we should be sensitive to just how stressful it must have been to be in pain during this time,” Dr. George said. “Let the patient state that simple fact without the PT feeling like it needs to be fixed. Be open to recognizing [the pandemic] as something that has made this recovery much, much harder and allow that to be a part of treatment.”