2010 Pilot Study 4

Treating Pain In Home Care: Integrating an Evidence- Based Pain into Routine Physical Therapy Practice Frailty, Palliative Needs and Outcomes of Elderly ICU Survivors

Principal Investigators: C. Murtaugh (Public Health), K Beissner (Physical Therapy), and E Bach (Public Health)

Specific Aims: Prior research has indicated that pain is highly prevalent (estimates range from 40-60%) among persons receiving home care services (1-3). Given that as many as one third of all patients who report pain-related activity limitations on admission to home care continue to report activity impairment due to pain at discharge, a strong need exists for better approaches to pain management in the home care setting. Cognitive behavior therapy (CBT), a psychological intervention focused on self-management, constitutes an evidence-based and efficacious treatment for pain (4-6) but is seldom employed in this practice setting (7). Because home health physical therapists (PTs) work with patients to restore strength and mobility and to enhance function, they are in an ideal position to integrate CBT into practice. The overall objective of this translational research project is to examine the feasibility and acceptability of incorporating CBT for pain management into physical therapy practice in a decentralized service setting. Specific aims include: 1) assessing PTs’ acceptance of instruction and integration of CBT strategies into practice; 2) determining PTs use of this evidence-based treatment after CBT training; and 3) examining patient acceptance of CBT techniques for self-management of pain.

Background and Significance: Home health care is a non-institutional, diverse health care setting that provides skilled nursing and therapy services to a high-risk population characterized by multiple chronic conditions and significant needs for both medical and self-care management.  In 2005, Medicare-Medicaid certified home health agencies discharged over 3.3 million patients, most of whom entered care from the hospital.  This study will take place in the largest Medicare-certified, non-profit home health agency in the United States, Visiting Nurse Service of New York, which has an average daily census of roughly 30,000 patients.

Design and Methods:  Study populations will include physical therapists (n=32)  and their patients (n=40) who report activity-restricting pain on admission to home care (aged 65+ years and with no cognitive impairment). Pain self-management training:  Therapists will be trained to deliver a pain self-management protocol (that employs both cognitive and behavioral techniques) previously developed by one of the investigators (K. Beissner), and modified, by obtaining direct physical therapist feedback (N=27) about the protocol, for the home care setting and patient population. Therapist training will consist of a 3.5-hour interactive session focused on instructing patients in a range of self-management techniques, with particular emphasis given to the use of techniques deemed most feasible for use in home care: e.g., progressive relaxation and guided imagery. PTs will be asked to use these particular strategies with patients meeting study criteria, and return for discussion and a booster session one month after the initial training. Primary study endpoints will include:  Evaluation of PT acceptance of the self-management program.  At the booster session, PTs will be asked to complete a survey on their comfort level using the self-management strategies, barriers to incorporating the training into home care, and its perceived effectiveness in reducing patients’ pain.  They will also be asked to give their feedback on the training sessions and provide suggestions regarding how best to translate self-management programs for use in home care.  The booster session will include a review of the CBT techniques, with particular attention to addressing provider barriers to their use in the home care setting. Evaluation of program fidelity:  After the initial training session, therapists will be asked to audiotape self-management program instruction with two patients who enroll in the study.  These audiotapes will be reviewed by two members of the research team, who will independently score the sessions on the level of adherence to the treatment protocol.   Evaluation of practice uptake:  At the booster session therapists will rate their level of confidence in delivering each component of the program and the degree to which they perceive the patient understood and benefitted from the cognitive-behavioral strategies.  Evaluation of patient acceptance of CBT:  All patients who consent to participate in the study will be contacted weekly by telephone for up to 4 weeks to determine whether they recall being instructed in pain management strategies by their therapists, whether they are using the strategies, and the helpfulness of the strategies in managing pain.  Additional questions about current pain severity and pain history also will be asked.

Next Steps: This pilot study will 1) establish the feasibility of delivering CBT to older adults receiving home care services following joint replacement, 2) determine patient and provider acceptability of CBT as a treatment for pain in home care, 3) provide information on provider-level barriers to administering this type of pain treatment, and 4) help to refine the protocol for training PTs to use CBT. Pilot data will also be used to inform the development of a randomized-controlled trial to evaluate rigorously the effectiveness of integrating CBT interventions into routine physical therapy home care services to improve late-life pain management.

References:

  1. Soldato, M., Liberoti, R., Landi, F., Finne-Sovery, H., Carpenter, I., Fialova, D., Bernabei, R., Onder, G. (2007). Non malignant daily pain and risk of disability among older adults in home care in Europe. Pain, 129:304-10.
  2. Shugarman, L.R., Buttar, A., Fries, B.E., Moore, T., Blaum, C.S. (2002) Caregiver attitudes and hospitalization risk in Michigan residents receiving home- and community- based care. J Am Geriatri Soc, 50:1079-85.
  3. Landi, F., Onder, G., Cesari, M., Gambassi, G., Steel, K., Russo, A., Lattanzio, F., Barnabei, R. (2001). Pain management in frail, community-living elderly patients. Arch Intern Med, 161:2721-24.
  4. Antall, G., Kresevic, D. (2004).  Use of Guided Imagery to Manage Pain in Elderly Orthopedic Population. Orthop Nurs, 23:335-40.
  5. Turner, J., Holtzman, S., Manci, L. (2007).  Mediators, moderators and predictors of therapeutic change in CBT for chronic pain. Pain, 127: 276-28.
  6. Morley, S., Williams, A., Hussain, S. (2008) Estimating the clinical effectiveness of CBT in the clinic: Evaluation of a CBT informed pain management programme. Pain, 137:670-680.
  7. Beissner, K., Papaleontiou, M., Olkhovskaya, Y., Reid, M.C. (2008). Physical therapy interventions for older adults with chronic pain: A national Survey of Practice Patterns. Phys Therapy Journal.