Role of the Physical Therapist at Pain Treatment Centers

Role of the Physical Therapist at Pain Treatment Centers A Survey CLARICE M. DOLIBER A nationwide survey of pain treatment centers was conducted for the purpose of investigating the role of the physical therapist at the centers. The majority of centers employing a physical therapist treated both inpatients and outpatients. Cervical and low back pain were the most common types of pain. The treatments most commonly used were an individualized exercise program, relaxation training, transcutaneous electrical nerve stimulation, and instruction in body mechanics. The majority of therapists attended staff meetings once a week, were responsible for teaching classes related to physical therapy, and were involved in some type of patient follow-up. Almost half of the therapists were engaged in pain research and clinical education. Key Words: Multi-Institutional systems, Pain, Physical therapy. Chronic pain, defined as a problem of several months duration that has not been responsive to conventional medical therapies, is a complex malady that can affect every aspect of a person's life. The chronic pain patient often ends up in a vicious cycle that can lead to several surgical procedures, lowered self-esteem, depression, disability, discomfort, and expense. 1, Physical therapists and other health professionals have tried many approaches for treating chronic pain. These approaches include nerve blocks, cordotomies, dorsal column stimulators, exercise, massage, cold, heat, relaxation, transcutaneous electrical nerve stimulation (TENS), biofeedback, pharmacology, psychotherapy, and operant and behavioral conditioning. Despite these various treatments, many people continue to suffer unrelenting pain. 3 The concept of a multidisciplinary team approach to the treatment of chronic pain was first implemented in the years after World War II. 4 Since that time, hundreds of pain treatment cen Ms. Doliber was a student at Sargent College of Allied Health Professions, Boston University, Boston, MA 01, when this article was written. She is now Staff Physical Therapist, Braintree Hospital, Braintree, MA 0184 (USA). This study was completed in partial fulfillment of the requirements for the degree of Master of Science in Physical Therapy. This project was supported by funding from the Dudley Allen Sargent Research Fund. This article was submitted January 14, 1983; was with the author for revision 3 weeks; and was accepted January, 1984. ters have been developed in the United States. Recent publications have professed the success, measured by patient surveys, of these pain treatment centers in chronic pain treatment., Delineation of the role of the physical therapist at pain centers would provide information to physical therapists for establishing professional guidelines for chronic pain treatment. The purpose of this study was to describe the role of the physical therapist at pain treatment centers in the United States. METHOD I used a nationally distributed mail questionnaire to investigate the role of physical therapists at 3 pain treatment centers in the United States. The pain treatment centers were all those listed in the Pain Clinic Directory, which was developed and published in 1979 by the American Society of Anesthesiologists' Committee on Pain Therapy. States were grouped according to the geographical locations delineated by the United States Department of Public Health. A physical therapist at each pain treatment center was asked to complete the questionnaire. I included a director's feedback postcard with the questionnaire should a physical therapist not be a member of the staff. The postcard included a question about why a physical therapist was not on the staff and provided space for comments. The first two sections of the questionnaire requested information about the characteristics of the inpatient and outpatient services of the pain treatment center. These sections included questions on the number of patients treated; the status of the center as inpatient, outpatient, or both; the average number of treatments or length of stay; and space allotted to the center. The third section of the questionnaire obtained information about the services and staffing of the pain treatment center. Questions concerned the types of patients treated; orientation of the center as comprehensive, specific modality, or pain syndrome; staffing; autonomity of the center or subordinate to what department; selection of appropriate treatment by the physical therapist or prescribed treatment by a physician; types of treatment used; and adjuncts to treatment such as behavior modification, team approach, and family, community, and patient education. The fourth section of the questionnaire asked if the pain treatment center was currently conducting research, whether the physical therapists were involved in this research, and if the physical therapists were currently conducting their own research. The fifth section inquired if the pain treatment center was currently providing clinical education to physical therapy students or if the center planned to do so in the future. The final section of the questionnaire asked if the center performed patient follow-up, if the physical therapists were involved in the follow-up, and how long after dis- Volume 4 / Number, June 1984 90

TABLE 1 Geographical Distribution of Respondents Region New England New York Middle Atlantic South Great Lakes Southwest Midwest Rocky Mountain Pacific Coast Northwest of Centers Mailed To 34 38 0 8 4 Postcards Returned 4 11 1 1 30.8 9.4 8.9 7.3 3.7 19. 8. 1 Questionnaires Returned 3 8 17 3 3.0.9 1.8 3.3 8.3 3 30.9 7 1 17 14 39 18 4 Total Returned 3.8 3.3 44.7 3..0 9. 9. TOTAL 3 7 7 147 charge patient follow-up was done. For this question, I gave respondents several choices, ranging from up to one month to over two years. A question about the criteria used to determine the success of treatment was included in this section. Eight criteria were listed and respondents were instructed to check all of those used. Throughout the questionnaire, space was provided for comments. Two registered physical therapists and several senior physical therapy students reviewed the questionnaire to establish its validity. RESULTS Total Response I constructed frequency tables for all items on the questionnaire. Of the 3 surveys mailed, 7 (7.4) questionnaires and 7 (8.) director's feedback postcards were returned for a total response of 147 (.9). The total response rate from each of the public health regions ranged from 3.3 to 9. percent (Tab. 1). The response rate for the questionnaires from each of the public health regions ranged from.9 to 0 percent. Forty-six (3.9) of re- TABLE Questionnaire Response of Relative Frequency of Types of Pain Treated Pain Type Frequently Occasionally of Total Respondents (N = 7) Rarely Never TOTALS a Cervical pain Low back pain Headache Nerve root injury Myofascial syndromes Causalgic syndromes Arthritis Central pain syndrome Peripheral nerve injury Bursitis Carpal tunnel syndrome Orofacial pain Phantom limb pain Stump pain Cancer pain Spinal cord injury Visceral pain Thalamic syndrome Post-herpetic neuralgia Traumatic pain Reflex sympathetic dystrophy Postsurgical pain Learned pain Psychosomatic pain Abdominal pain Ankylosing spondylitis 81.9.7 8.3 0.8 4.8 41.7 40.3 37. 34.7 33.3 30. 7.8 0.8 7.8 33.3 30. 3.1 4.8 37. 98.7 94. 9.9 9.8 93. 90.3 9.8 91. 94.4 91. 93. 9.8 94.4 94. 90.3 a Totals do not equal 0 percent because of values not reported by respondents. 90 PHYSICAL THERAPY

RESEARCH spondents to the questionnaire were from centers that treated both inpatients and outpatients, 11 (1.3) from centers that treated inpatients only, and 1 (0.8) from centers that treated outpatients only. The response rate from the director's feedback postcard from each of the regions ranged from percent to 3.7 percent. Director's Feedback Of the respondents who returned director's feedback postcards, 38.7 percent did not check any of the three reasons why a physical therapist was not employed but did include comments. Most of these comments stated that if physical therapy was necessary, patients were referred to a physical therapist outside the facility. Almost 3 percent of the respondents who returned director's feedback postcards indicated that physical therapy would be valuable for the patients they treated, but that their budget did not allow for a physical therapist; 1.3 percent indicated that physical therapy was not necessary for the patients they treated; and.3 percent indicated that they were currently in the process of hiring a physical therapist. Questionnaire Response Characteristics of inpatient and outpatient service. The most common responses on the questionnaire describing inpatient service were the following: 1) between 1 and beds (9.); ) 80 to 0 percent of beds occupied (.); 3) average length of stay between 1 and 30 days (3.4); and 4) self-contained on its own ward (77.3). The most common responses describing outpatient service were the following: 1) between one and five patients treated a day and ) an average of less than physical therapy treatment sessions for each patient (37.9) over a period of one to four weeks (3.). Services and staffing. Eighty-five percent of the respondents considered the pain center to be comprehensive. The remainder indicated that the center was either modality-oriented, that is using only certain modalities for pain treatment or syndrome-oriented, that is treating only certain pain syndromes. Forty-nine percent of the respondents worked full-time at the pain center, 33.3 percent rotated through the pain center and other departments, and 17.4 percent acted as consultants. Most of the respondents () indicated that the pain center formed its own department. Of those who were part of another department, 44.1 percent were part of physical or rehabilitation medicine and 3.3 percent were part of anesthesiology. The remainder were in the departments of neurology, psychiatry, neurosurgery, behavioral medicine, and psychobiology. The most common types of pain rated as frequently, or occasionally treated at the pain treatment centers were cervical pain, low back pain, headache, nerve root injury, and myofascial syndromes (Tab. ). The majority (3.9) of physical therapists indicated that physical therapy treatments were prescribed by a physician. The treatments most commonly used by physical therapists were an individualized exercise program, relaxation training, TENS, instruction in body mechanics, and biofeedback (Tab. 3). Ninety percent of the therapists indicated that behavior modification was a part of treatment. At least percent of the physical therapists generally met family members of patients, believed that family education was, at least, moderately a part of their role, and were TABLE 3 Questionnaire Response of Relative Frequency of Types of Treatments Used Treatment Frequently Occasionally of Total Respondents (N = 7) Rarely Never TOTALS a Individualized exercise program Relaxation training TENS Instruction in body mechanics Biofeedback Group exercise Mobilization Hot packs Cold packs Deep muscle massage Ice massage Whirlpool Manipulation Therapeutic pool Paraffin Acutherapy Electrical nerve stimulation Gait training Traction Ultrasound Education in kinesiology Aerobic conditioning Leisure counseling Electrical muscle stimulation 81.9 9.4.3 7.0.4 0.8.4 7.8.4 1.3 8.3 4.8 98. 97. 98. 93.0 91. 87. 90. 90. 8.1 87. 43.0 a Totals do not equal 0 percent because of values not reported by respondents. Volume 4 / Number, June 1984 907

responsible for formally teaching patients' classes related to physical therapy. Most (7.) of the respondents indicated that community education was part of their role. In addition to physical therapy, the most commonly reported disciplines represented at pain treatment centers were occupational therapy, biofeedback, social work, nursing, psychology, and medicine (Tab. 4). Sixty percent of the therapists indicated that the center staff met once a week to discuss patient care and believed that these meetings were extremely important to the continuity and efficacy of patient care. Research and clinical education. The majority (8.1) of physical therapists indicated that the pain treatment center was currently conducting research. Forty-five percent of the therapists indicated they were involved in research at the pain center, and.4 percent indicated that they were currently conducting research independently. The majority () of the therapists did not provide clinical education for physical therapy students. Of the therapists who did not provide this service, 40 TABLE 4 Questionnaire Response on Staffing Discipline Physical therapy Medicine Psychology Biofeedback Nursing Social work Occupational therapy Psychiatry Vocational rehabilitation Recreational therapy Movement therapy Art therapy Anesthesiology Dietary Pharmacy Family therapy Corrective therapy Physician's assistant Hypnotherapy Patient-insurance liaison Clergy Relaxation therapy Physical therapy assistant Dentistry Acupuncture percent planned to begin a clinical education program in the near future. Follow-up study and evaluation of treatment success. Most (87.) of the respondents indicated that follow-up study was performed by the center after the patient was discharged, and 70.8 percent of all respondents were involved in this process. The length of time after discharge that patients were contacted for follow-up ranged from one month to over two years with the majority (1.) of centers following patients for at least six months. The two most common criteria used for determining a treatment's success were the patient's increased activity level (0) and decreased pain behavior (9). criteria used by therapists were increased range of motion or strength (), decreased drug intake (88.9), improvement of self-concept (8.1), return to employment (83.3), and increased interaction with peers (70.8). DISCUSSION Most of the responses indicated that the pain treatment centers surveyed had similar characteristics and followed pro a (N = 7) 7 4 7 3 43 4 34 31 3 1 11 30 () TOTAL 88.9 79. 73. 8.3 47. 1.3 41.7 a Number of respondents indicating that at least one member of the discipline was employed at the pain treatment center. grams similar to those that have been documented in the literature. The average length of stay for patients in inpatient centers was between 1 and 30 days. Various studies have reported average lengths of stay of three to six weeks, 4 three weeks, and four to six weeks. 7 Aronoff et al reported that the majority of patients at pain treatment centers had back-related pain. 8 My results are consistent with this finding. Most of the respondents indicated they were from comprehensive pain treatment centers, at which a variety of disciplines were represented. Berns, 7 Aronoff et al, 8 and Seres and Newman 9 reported that a similar variety of disciplines were represented at the comprehensive pain treatment centers with which they were affiliated. These results show a high incidence in the use of an individualized exercise program, relaxation training, TENS, instruction in body mechanics, and biofeedback. Several authors have reported that physical therapists at their pain treatment centers use similar treatments. 7,9, The majority of physical therapists were responsible for teaching classes related to physical therapy to patients. This responsibility is consistent with the large percentage of therapists who reported that instruction in body mechanics and relaxation training were included in their treatment programs for the patient with chronic pain. Several authors have reported that posture and body mechanics were taught in group sessions at their pain treatment centers. 7,9-11 I found it interesting that 90 percent of the physical therapists used behavior modification as an adjunct to the treatment of the patient with chronic pain. Aronoff and Wilson state that for some pain sufferers "pain is used in place of needed social skills and removes many burdensome responsibilities." 11 Reinforcement of healthy, socially appropriate behavior often reduces the patient's pain behavior and increases constructive activities. 11 Newman et al and Aronoff and Wilson 11 believed that the involvement of the spouse and other family members was important in the treatment of the patient with chronic pain. The majority of physical therapists who responded to my questionnaire generally met patients' families and believed that family education was at least moderately a part of their role. Family education about chronic pain is an im- 908 PHYSICAL THERAPY

RESEARCH portant component in the treatment of the patient with chronic pain because any change in the patient's behavior influences and is influenced by his family. The majority of physical therapists from my study met with other staff at least once a week to discuss patient care and believed that these meetings were extremely important to the continuity and efficacy of patient care. Seres and Newman believed that biweekly staff conferences were an integral part of their pain treatment program. 9 Aronoff and Wilson proposed that staff "need to meet periodically to continually collaborate their specialized approaches in a coordinated manner.'' 11 The criteria selected by the respondents for determining treatment success were similar to those reported by Maruta et al who used modification of attitude, reduction of pain-related medication, and improvement of physical function as criteria for evaluating improvement. 1 The majority of respondents indicated that patients were contacted for follow-up for at least months after discharge from the program. Cairns et al reported follow-up intervals of 1, 3,, and 1 months, whereas Seres and Newman 9 reported follow-up only to 3 months after discharge. An accurate follow-up program is necessary to determine how long after discharge patients maintain advances gained at the pain treatment center and what factors influence this improvement. Berns 7 and Newman et al reported the formation of self-help groups consisting of former patients to reinforce the gains made at the pain treatment center. Whether the centers I studied had such groups is not known because this area was not investigated in the questionnaire. The study had some limitations. The Pain Clinic Directory was compiled by the American Society of Anesthesiologists through the use of a questionnaire sent to its membership and that of the International Association for the Study of Pain. The use of the Pain Clinic Directory limited the study to involvement of those pain treatment centers whose directors were members of one of these associations. Because the directory was compiled in 1979, any pain treatment centers that have developed since then were not included in the study. Some information not requested in the questionnaire might have assisted in interpreting the results. For example, the length of stay for an inpatient unit and the number of treatments given by an outpatient unit may have been limited by the failure of third-party payers to cover a longer stay or more treatments and, thus, may not have reflected the center's opinion about the optimal length of stay. I did not investigate the factor of funding in the questionnaire. Additionally, questions about the types of assessment used by physical therapists at pain treatment centers or specific questions regarding research were not included. I can suggest a number of additional studies. For example, criteria for admission, cost, and third-party reimbursement could be explored. The role of the physical therapist in the treatment of patients with chronic pain in hospital physical therapy departments and private practice could also be studied. CONCLUSIONS This study provided an overview of the role of physical therapists at pain treatment centers. In general, the physical therapists who responded to this survey 1) belonged to a multidisciplinary team that met once weekly to discuss patient care; ) primarily used an individualized exercise program, relaxation training, TENS, instruction in body mechanics, and biofeedback to treat patients with chronic pain; and 3) used behavior modification and family education as adjuncts to the treatment of the patient with chronic pain. Documentation of this role and the rationale for some of the treatment approaches used by physical therapists at pain treatment centers may assist other physical therapists to establish a treatment approach for patients with chronic pain. REFERENCES 1. Chapman CR: Psychological aspects of pain patient treatment. Arch Surg 11:77-77, 1977. Gorsky BH: Chronic pain: A management plan based on experiences in a pain clinic. Postgrad Med :147-14,1979 3. Painter JR, Seres JL, Newman Rl: Assessing benefits of the pain center: Why some patients regress. Pain 8:1-1,1980 4. Hudson JS, Pratt TH: Pain clinics: Their value to the general practitioner. South Med J 7:84-847,1979. Ignelzi RJ, Sternbach RA, Timmermans G: The pain ward follow-up analyses. Pain 3:77-80, 1977. Newman Rl, Seres JL, Yospe LP, et al: Multidisciplinary treatment of chronic pain: Longterm follow-up of low back pain patients. Pain 4:83-9,1978 7. Berns J: Team approach to chronic pain. Health Soc Work 3():18-19,1978 8. Aronoff GM, Wilson RR, Sample SS: Treating chronic pain: The team appproach. Nursing Care :1-7,1978 9. Seres JL, Newman Rl: Results of treatment of chronic low back pain at the Portland Pain Center. J Neurosurg 4:3-3,197. Crue BL, Pinsky JJ, Agnew DC, et al: What is a pain center? Bull Los Angeles Neurol Soc 41(4):-17,197 11. Aronoff GM, Wilson RR: How to teach your patients to control chronic pain. Behavioral Medicine 1(7):9-3,1978 1. Maruta T, Swanson DW, Swenson WM: Chronic pain: Which patients may a pain management program help? Pain 7:31-39,1979. Cairns D, Thomas L, Mooney V, et al: A comprehensive treatment approach to chronic low back pain. Pain :301-308,197 Volume 4 / Number, June 1984 909