As a modern health practitioner, do you feel comfortable treating patients with pain? As someone who suffers from chronic pain, are you content with your present treatment plan? As modern pain practitioners, how can we make a difference and improve the care we provide? 

In 2011, the Institute of Medicine (IOM) released a report stating that 100 million Americans live with ongoing pain. Of these 100 million, approximately 20 million suffer from high-impact chronic pain. (1) Further, about 83% of people with high-impact chronic pain could not work for a living, and one-third had difficulty with self-care activities, such as washing themselves and getting dressed. (2) High-impact chronic pain is a relatively recent term used to describe people who have pain that persists for 3 months or more and is accompanied by at least one major activity restriction. It is debilitating.

The U.S. Department of Labor Bureau of Labor Statistics states that there are approximately a half-million practicing psychologists and mental health providers in the US. (3) Of these professionals:

• Over one-third have little or no training in pain science or pain education.
• Over half (55%) don’t feel confident treating patients with physical pain. (4)

As a consequence of its pervasiveness, demoralizing impact, and notable cost to society (hundreds of billions of dollars annually), chronic pain is a public health crisis.

Here is a Quick Guide on How a Physical Therapist Can Promote Health and Wellness for pain.

Why The Biomedical Model Isn’t Enough

The American Academy of Pain Medicine Board of Directors responded to the IOM’s report by establishing the AAPM Pain Psychology Task Force in 2015. The task force assessed for “pain psychology services, resources, and training in key stakeholder constituencies across the United States.” (4) This assessment was the first of its kind in the U.S. and the data it yielded allowed researchers to draw important conclusions, in terms of establishing some direction and a trajectory for how to reduce the number of people suffering from chronic pain.  

The needs assessment revealed the following:

• 90% of psychologists and therapists are interested in learning more about pain psychology.
• Poor reimbursement for psychological services is a primary barrier to high-quality pain care.
• Improved integration of pain education into the training of health-care professionals is needed.

In 2017, just six years after chronic pain among Americans reached the level of “public health crisis,” the U.S. Department of Health and Human Services declared a national public health emergency—the United States opioid epidemic. The unprecedented number of people abusing prescription pain relievers included in this epidemic suggests that not only has the biomedical treatment of persistent pain proven unsuccessful but in many cases, it’s been lethal.

Are Physicians Prepared to Treat Pain?

Although the number of people with chronic pain is substantial, studies reveal a gap in pain education. Research from 2011 showed that many U.S. medical school curriculums include no courses on pain education, and many other curriculums allot fewer than 5 hours in 4 years of medical training. (5) Thus, not surprisingly, roughly one-third of post-residency physicians responded that they feel “somewhat unprepared” or “very unprepared” to treat pain. (6) The same 2011 report legitimately called for increased pain education and training for cross-disciplinary health providers who treat individuals with pain, including psychologists.

Are Psychologists Prepared to Treat Pain?

A 2016 study published in Pain Medicine revealed (4):

• More than one-quarter of health psychology programs do not address pain education in the curricula.
• One-third of programs dedicate 0–4 hours of coursework on pain education. 
• 40% dedicate 5–10 hours to pain education.
• 28% dedicate 11 or more hours to pain education.
• Directors of graduate psychology programs were unanimous in wanting more training in pain education!

What is Pain Psychology?

We have a chronic pain epidemic, a gap in pain science research, and pain education.

Pain psychology has emerged in response to this trifecta, and the concept is well supported. The treatment modality aims to empower people who are living with pain, by adding a trained psychologist to the patient’s healthcare team. According to the American Psychological Association, “Two decades of studies now confirm the value of psychological interventions in reducing self-reported pain, pain-related interference, depression, and disability, while increasing health-related quality of life.” (7)

A pain psychologist is a licensed psychologist with a Ph.D. or a PsyD in clinical psychology and has completed an APA-accredited post-doctoral fellowship that specializes in chronic pain. They offer patients pain management skills, as well as coping strategies, goal-setting exercises, and other techniques that geared toward helping clients lead a full and rewarding life. A pain psychologist works with patients to offer tools and strategies for managing pain, encourages positive lifestyle change, and stress management tools.

Research has shown an interest and willingness to provide education in this field for therapists and other healthcare providers. It inspires hope for a transformation in psychology that will include and emphasize pain science education.

Tune into this podcast with Dr. Beth Darnall, Ph.D. to learn more about pain psychology.

The Emerging Neuroscience of Pain Psychology

In 1973, the International Association for the Study of Pain (IASP) defined pain as an experience comprised of both sensory and emotional dimensions. This posits psychology (that is, the science and study of the mind, including thoughts and feelings) is integral to the experience of both acute and chronic pain treatment. (8)

A growing body of research supports the importance of psychosocial factors in improving the quality of life for people with chronic pain and has contributed to the biopsychosocial model as a  comprehensive framework for pain management. Now is the time to move forward and put the research into motion.

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Psychologically Informed Care

Principles of psychology and pain psychology can be infused into provider evaluation and treatment as well as multidisciplinary pain care and transdisciplinary pain care. Psychologically informed physical therapy is one example that addresses both the physical and psychosocial factors, by integrating basic principles of psychology into conventional physical therapy treatments. (9) These include cognitive-behavioral techniques such as relaxation training, cognitive restructuring for catastrophizing, fear-avoidance behaviors and pain beliefs, sleep education, coping skills, activity planning, and pacing and pleasant activities. Physical therapists are now expected to recognize pain associated with psychosocial distress (yellow flags) and to modify their treatment approach accordingly. A gap exists between learning how to identify pain associated psychosocial distress in patients, training resources and competence to apply treatment required to effectively manage pain. Physical therapists and other pain practitioners are embracing the psychosocial component by providing the opportunity for:

1. pain education on how to screen for psychological risk factors at the initial evaluation and assessment. (10)
2. training in the foundational principles of cognitive behavioral therapies such as CBT, ACT, mindfulness, MBSR, and motivational interviewing which have been shown to be effective in treating many chronic musculoskeletal conditions. (11)
3. refinement of psychologically informed treatment approaches and integration into daily practice to decrease the likelihood that patients will encounter continued disability due to musculoskeletal pain.

Other practitioners in pain care and pain management are well positioned to fill this gap and provide psychologically informed care including occupational therapists, pain management nurses, chiropractors, pain physicians, and nutritionists. Since primary care providers (GPs and nurse practitioners) are often the gatekeepers to care, pain education and psychologically informed care is essential and will provide them with the skills to identify psychological risk factors (“yellow flags”) in patients with chronic pain and refer to the appropriate practitioner.

With the awareness of the data surrounding chronic pain and opioid abuse, what can modern pain practitioners do to encourage the momentum while pain education guidelines, certification outlines, and curricula adjustments are being made to accommodate pain science?  

What are your thoughts?

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REFERENCES:

1. Centers for Disease Control and Prevention. Prevalence of chronic pain and high-impact chronic pain among adults – the United States, 2016. Morbidity and Mortality Weekly Report. Available at:      https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm?s_cid=mm6736a2_w

1. National Center for Complementary and Integrative Health. Prevalence and profile of high-impact chronic pain. Available at:  https://nccih.nih.gov/research/results/spotlight/Prevalence-Profile-High-Impact-Chronic-Pain
2. U.S. Department of Labor, Bureau of Labor Statistics. Available at: http://www.bls.gov/
3. Darnall BD, Scheman J, Davin S, et al. Pain psychology: a global needs assessment and national call to action. Pain Medicine 2016;17:250-63.
4. Mezei L, Murinson B, Johns Hopkins Pain Curriculum Development. Pain education in North American medical schools. J Pain 2011;12(12):1199-208.
5. Johnson M, Collett B, Castro-Lopes JM. The challenges of pain management in primary care: a pan-European survey. J Pain Res 2013;6:393-401.
6. American Psychological Association. Pain, pain go away. Available at: http://www.apa.org/research/action/pain.aspx.
7. IASP Task Force on Taxonomy. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. Seattle: IASP Press; 1994.
8. Keefe FJ, Main CJ, George SZ. Advancing psychologically informed practice for patients with persistent musculoskeletal pain: promise, pitfalls, and solutions. Physical Therapy 2018;98:398–407.
9. Shelley BM, Katzman JG, Comerci JD Jr, et al. ECHO Pain curriculum: balancing mandated continuing education with the needs of rural health care practitioners. J Contin Educ Health Prof 2017;37(3):190-4.
10. Sturgeon JA. Psychological therapies for the management of chronic pain. Psychology Research and Behavior Management 2014;7:115-24.