Physical Therapists’ Use of Cognitive-Behavioral Therapy for Older Adults With Chronic Pain: A Nationwide Survey
This article has been cited by other articles in PMC.
Chronic pain is a highly prevalent and often disabling condition among older adults.1–3 Prior research has demonstrated strong associations between chronic pain and substantial morbidity, including depression and functional disability,4–8 as well as increased health care utilization.9–11 Given the prevalence of chronic pain, its impact on health, and its costs, which approach $100 billion annually,12 chronic pain represents a public health issue of major importance.13–15
The most commonly administered treatment for chronic pain is analgesic medication (eg, acetaminophen, nonsteroidal anti-inflammatory drugs, opioids).16,17 Analgesic medications also constitute the most frequently endorsed treatment by older patients.16,18 Although many older people derive benefits from analgesic medications, the costs and side effects associated with many of these drugs and the potential for drug-drug interactions pose significant limitations to this treatment approach.19–21 In addition, many older adults continue to report substantial pain despite regular use of analgesic medications.16 These limitations have led to a call for effective nonpharmacological interventions to manage chronic pain.22
Aside from physical therapy, other nonpharmacological approaches to pain management include cognitive-behavioral therapy (CBT), hypnosis, and individual psychotherapy.23,24 Of particular interest in the present study is the use of CBT because this treatment approach has demonstrated efficacy for a wide range of chronic pain disorders.25–28 Cognitive-behavioral therapy is an intervention that seeks to enhance patients’ control over pain using diverse psychological techniques.29 Underlying this therapy is the notion that a person's beliefs, attitudes, and behaviors play a central role in determining his or her overall experience of pain.23,30
Standard CBT pain protocols seek to: (1) teach patients specific cognitive and behavioral skills to better manage pain; (2) inform patients regarding the effects that specific cognitions (thoughts, beliefs, attitudes), emotions (fear of pain), and behaviors (activity avoidance due to fear of pain) can have on pain; and (3) emphasize the primary role that patients can play in controlling their own pain as well as adaptations to pain. Cognitive-behavioral therapy has proven efficacy for reducing pain and disability levels among middle-aged people with diverse chronic pain disorders.25–28 Prior research also has demonstrated that older adults can benefit from a CBT program directed toward pain management.29,31,32 Although numerous efficacy studies have demonstrated the benefits of this particular therapy, few older adults use CBT techniques for managing pain.25,33
In a recent study of older primary care patients with chronic pain, only 4% reported using cognitive methods for managing pain,34 and a non–clinic-based study of older adults with chronic pain showed that only 3% cited the use of cognitive methods for managing pain.16 Access to psychological treatments such as CBT often is gained through multidisciplinary pain management programs. However, older patients are less frequently referred to this type of program,35 leaving them with less access to these interventions. These data, coupled with the findings of a recent study showing that older adults with chronic pain are highly receptive to trying cognitive methods as a means of managing pain,34 provide additional support for efforts to teach CBT techniques to people with chronic pain in conventional health care settings.
We propose that CBT is consistent with physical therapy intervention in that both promote adoption of self-management strategies and use some similar techniques such as graded activity pacing and relaxation training. Other CBT techniques used by physical therapists include cognitive restructuring to identify counterproductive thought patterns36,37 as well as the use of imagery to enhance goal achievement.38–41Instructing patients with chronic pain in the use of specific coping skills such as these may help to reduce activity avoidance associated with chronic pain and may enhance exercise program adherence and functional recovery.42
Given the under-referral of older adults to multidisciplinary programs,35 the importance of integrating psychological treatments for pain management into standard care,43 and the concordance of physical therapy and CBT philosophies, it seems important to investigate the potential for incorporating CBT into physical therapy for the treatment of older adults with chronic pain. Accordingly, the primary purpose of this study was to identify the extent to which physical therapists currently use CBT techniques when treating older patients with chronic pain and ascertain their interest in, and barriers to, incorporating CBT into their treatments. We also sought to determine the specific types of more-conventional physical therapy interventions used in the treatment of this patient population. Finally, in related analyses, we sought to determine whether specific participant characteristics (eg, years in practice, practice setting) were independently associated with level of interest in CBT.
Method
Sample
The membership directory of the American Physical Therapy Association (APTA) served as the sampling roster for this study. Names were randomly chosen from the Orthopaedics and Geriatrics sections, with 14,891 and 4,401 listed members, respectively, in approximately equal numbers to reach the target goal of 150 participants. These sections were selected for sampling due to their relevance to the diagnosis (chronic pain) and population (older adults) of interest. Participants were selected from all 50 states, proportionate to the number of section members in each state. Eligibility criteria included a valid mailing address, a telephone number, and current practice with the patient population of interest. The target sample of 150 was selected for practical purposes based on the resources available for data collection. Because this study was predominantly descriptive in nature and no prior research addresses this area of practice (there are no data on the variance of the outcome variable), no formal power calculations were carried out. The sample of 150 was judged to be of sufficient size to gain an understanding of physical therapists’ current use of CBT and to ascertain their overall interest in and barriers to using CBT techniques.
Prospective participants first were contacted by letter, informing them as to the nature of the study. We then placed telephone calls to prospective participants 2 weeks, on average, after each letter was mailed. Verbal consent for participation was obtained at the time of the call.
Thirty-eight physical therapists could not be contacted because of an incorrect telephone number or mailing address, and 25 therapists were ineligible (the most common reasons were retirement and not being involved in the care of older adults or patients with chronic pain). Of the 173 eligible physical therapists contacted, 21 declined to participate and 152 (88%) completed the survey. All 50 states were represented in the sample, and all participants answered every question in the survey instrument.
Instrument Development
The telephone survey instrument (Appendix) was designed by a multidisciplinary team comprising a physical therapist, 2 physicians, and 1 health psychologist with expertise in pain management. Collectively, the team has more than 40 years of experience delivering nonpharmacologic pain therapies to older adults. The initial draft of the survey instrument was reviewed by 2 physical therapists outside the research team, each with more than 15 years of physical therapy experience. Both worked in outpatient orthopedic settings, 1 as a manager. The second reviewer also worked in home health. The therapists were asked to review the draft survey instrument to ensure that the list of potential physical therapy interventions was sufficiently inclusive, recommend items for exclusion, consider whether the items were worded clearly, and identify potential barriers to implementation. In addition, student physical therapists were asked to read the survey instrument aloud to another student and to time the interview. Based on therapist input and length of interviews, items regarding physical therapy interventions were consolidated, wording was altered, and 2 new barriers to CBT were incorporated. After these revisions, the therapists reviewed the instrument again to ensure that their concerns were addressed and to review changes made due to input of the other reviewer.
The main section of the survey instrument was designed to determine how frequently physical therapists used CBT interventions for treatment of older patients with chronic pain and the frequency of use of other physical therapy interventions for this patient population. The list of CBT interventions included in the instrument was drawn from a comprehensive review of the literature regarding CBT for pain management in older adults.29,32,44 Based on research team and physical therapist input, those CBT interventions deemed most unrelated to physical therapist practice were deleted from the survey (ie, anger management, sleep habits). To determine the other types of treatments used in the care of this population, a list of potential interventions was generated by the research team and reviewed by outside physical therapists, then cross-checked with theGuide for Physical Therapist Practice45 to ensure representation from major categories of interventions. Because the focus of the study was on chronic pain management, no integumentary interventions were included. Furthermore, items related to the use of devices and equipment were excluded from the survey instrument in an effort to focus on treatments associated with pain management, rather than other pathologies or impairments. In keeping with the telephone survey format, the research team determined that the instrument needed to be brief and, therefore, limited the interventions surveyed to broad categories (eg, physical agents), rather than specific techniques (eg, cold packs, ultrasound).
The final version of the survey instrument queried respondents regarding their frequency of use of 14 interventions: physical agents, electrotherapy, exercises to increase joint stability, exercises to increase joint mobility, general conditioning exercises, soft tissue techniques, joint mobilization or manipulation, injury prevention education, relaxation, distraction, visualization and imagery, cognitive restructuring, pleasurable activity scheduling, and activity pacing. Response choices were: “always” (80% or more of the time), “frequently” (between 50% and 79% of the time), “sometimes” (between 25% and 49% of the time), and “rarely” (less than 25% of the time).
The next portion of the survey instrument addressed the extent of therapists’ interest in 5 interventions classified as CBT (relaxation, distraction, visualization and imagery, cognitive restructuring, and activity pacing and pleasurable activity scheduling). Respondents were asked to indicate their level of interest in the 5 techniques using the following response categories: “not interested,” “interested,” “very interested,” or “already using technique.”
Potential barriers to implementation of CBT into physical therapist practice were generated by the research team based on their clinical experience and a review of the literature, with additional barriers identified by the outside therapists. A list of 6 potential barriers was identified, and an option to identify “other” barriers was included. Statements were worded as facts (eg, “the techniques are not part of physical therapist practice”), and respondents were asked to indicate whether each statement was true or not true.
Items related to demographic characteristics of respondents included percentage of practice focused on patients 65 years or older with chronic pain, years of physical therapist practice, racial or ethnic group, sex, hours per week in patient care, highest academic degree, practice setting, size of practice community (ie, large metropolitan area, small city, suburban, or rural), and any specialist certification.
Data Analysis
Descriptive statistics (frequency for categorical data, mean and standard deviation for continuous data) were computed to address the primary purpose of identifying the extent to which physical therapists currently use CBT techniques and other physical therapy interventions and ascertaining their interest in using CBT treatments and barriers to using CBT.
The secondary purpose of the analysis was to determine whether particular therapist characteristics were associated with interest in CBT. A composite variable indicating overall “interest” in CBT was created by summing participants’ answers to each of the 5 items assessing interest in CBT techniques: “not interested” was coded as 1, “interested” as 2, “very interested” as 3, and “already using technique” as 4. Scores for each participant could range from a low of 5 (no interest) to 20 (maximal interest). The variable shows good normal characteristics in a normal probability plot. Skewness is less than twice the standard error of skewness, and kurtosis is less than twice the standard error of kurtosis, so problems do not exist on either account at a conventional level of significance.
Nine independent variables were included in the statistical models a priori based on the research team's subject-area knowledge. These variables were practice setting (outpatient, hospital, home care, or skilled nursing facility), percentage of patients with pain (≤50%, >50%), highest degree (Bachelor's or certificate versus Master's or higher), practice location (large metropolitan, small city, suburban, or rural), part-time or full-time practice (<35 hours per week versus ≥35 hours per week), race or ethnicity (non-Hispanic Caucasian versus other), sex, APTA section (Orthopaedics versus Geriatrics), and years in practice (0–5 years, 6–15 years, >15 years). All 9 variables are categorical and were included as classification factors in the models. An examination of 2-way and 3-way interactions was carried out, focusing on the variables significant or within range of significance in a main effects model. A final model was specified that included the percentage of patients with pain, degree, interaction between these 2 variables, and the main effects for the other 7 variables. A number of other models were examined to verify that the final model presented in this report correctly represented the results. These other models included a mixed model in which the individual components of the composite variable were levels of a repeated-measures classification factor (CBT domain), and therapists were included in the model as levels of a random classification factor.
Statistical analysis was by general linear model methods. Analyses were carried out with SAS 9.1 software.*
Results
Descriptive Results of Study Sample
Table 1 shows that most participants were white (84%), worked full time (65%), had practiced physical therapy for more than 15 years (55%), and were currently employed in the outpatient setting (57%). Approximately 1 in 4 participants reported that more than 50% of their patients were older adults who report chronic pain as a major complaint.
Sample Characteristics
Frequency of Use of Physical Therapy and CBT Interventions
The proportion of participants who reported use of physical therapy interventions when treating older patients with chronic pain is shown in Table 2. The vast majority (≥91%) reported that they frequently or always used active exercise in their plan of care for these patients, including general exercises, joint mobility, and stability exercises, and 90% included prevention education. Almost 70% of the participants reported that they frequently or always used physical agents (eg, heat, cold), whereas joint mobilization or manipulation was frequently or always used by only 42%.
Frequency (%) of Use for Each Intervention (N=152)
With respect to CBT techniques, 81% of the sample reported that they either frequently or always used activity pacing when treating older patients with chronic pain, and 39% said they frequently or always addressed pleasurable activity scheduling. Infrequently used CBT techniques included cognitive restructuring (77%=rarely or never used), relaxation training (84%), and use of visual imagery or distraction (88%).
Therapists’ Interest in CBT Techniques
The Figure shows the relative proportions of the sample who reported current use of CBT techniques in their treatment of older patients with chronic pain, interest in incorporating the techniques in their respective practices, or no interest. A substantial majority indicated interest in incorporating each of the techniques.
Level of interest in specific cognitive-behavioral therapy interventions.
Barriers to Using CBT
The most commonly endorsed barrier to incorporating CBT techniques into practice, noted by 59% of the sample, was insufficient knowledge of the CBT modalities (Tab. 3). Fewer participants endorsed problems with reimbursement (31%), inadequate time to incorporate the techniques into practice (27%), and reluctance of patients to engage in these types of treatments (21%) as potential barriers. Of note, 21% endorsed no barriers to incorporating CBT into their practice.
Barriers to Using Cognitive-Behavioral Therapy (CBT) (N=152)
Factors Associated With Interest in CBT
A related purpose of this study was to identify factors independently associated with physical therapists’ level of interest in incorporating CBT into practice. These factors were examined using the composite interest variable as the outcome. Therapists’ mean interest in CBT techniques was 12.70 (SD=3.40).
Table 4 presents the final model. It includes each line of the analysis, raw means and least squares means for each level of each effect, and, for practice setting, single-degree of freedom tests for a priori contrasts of each of the other settings versus home care. The model R2 is .222, and the test of the 15-degree of freedom model fit had an F value of 2.59 (P=.002). Practice type was significant (P=.041), with the overall significance a result of home care having a significantly lower score on the outcome scale than each of the other 3 practice types (outpatient, hospital, and skilled nursing facility). The interaction of percentage of patients with pain and level of training was highly significant (P=.005). The least squares means in Table 1 show the pattern of the interaction. Interest in CBT was highest for physical therapists with advanced degrees and practices with lower numbers of patients with pain. None of the other variables was significant.
Association of Therapist Characteristics With Level of Interest in Cognitive-Behavioral Therapy in the Final Model (N=152)
Discussion
The results of this nationwide telephone survey demonstrate that a minority of physical therapists report using some CBT components when treating older adults with chronic pain. Notably, the techniques most related to enhancing activity levels were the most-frequently incorporated CBT treatments. Teaching patients to pace their activities and encouraging them to engage in pleasurable activities were the most commonly used interventions. These techniques may be helpful in encouraging patients to remain active and, therefore, decrease the potential for deconditioning associated with activity avoidance.
Other CBT techniques, such as distraction and imagery, were reported as being used infrequently, and the participants reported the least interest in using these strategies. Prior reports of using imagery in physical therapy focused on mental practice of motor tasks for patients with sport injuries39 or neurological diagnoses.38,40 Imagery techniques used for pain management differ in that patients assume a relaxed state and focus attention away from the pain to the mental construction of detailed scenes.
Cognitive restructuring also was used relatively infrequently, yet the participants expressed strong interest in using this strategy for patients with chronic pain. In prior studies incorporating cognitive restructuring strategies into physical therapy, the focus of the intervention was on increasing patient activity levels. Cognitive restructuring techniques were incorporated into the Strong for Life Program to enhance exercise adherence36 and into a rehabilitation program focused on increasing activity levels for patients with chronic neck pain.46 When focused on increasing activity, cognitive restructuring can be viewed as being similar to the activity pacing and pleasurable activity participation that are currently reported to be the most commonly used CBT interventions. Although we did not investigate therapists’ rationale for using particular interventions, it appears that interventions geared toward increasing movement or mobility are preferred by physical therapists over those that are more passively directed toward decreasing pain levels.
This pattern is reflected in the other physical therapy interventions addressed in the survey. Participants indicated greater use of active exercises aimed at increasing joint stability and mobility, with less-frequent use of more-passive interventions such as physical agents, joint mobilization, and electrical stimulation. These results are consistent with a prior investigation of physical therapy for older patients. Miller and colleagues47found that “therapeutic exercise” was the most frequently used intervention with older adults without regard to diagnostic classification and that physical agents and electrotherapeutic modalities were the least-frequently used. This use of active exercise is supported by research demonstrating its effectiveness in improving function and reducing pain levels for patients with chronic neck or low back pain48–51 and in decreasing pain associated with osteoarthritis.52–55 Participants reported less-frequent use of more-passive techniques such as physical agents, electrical stimulation, and manual therapy.
Although the results show a relatively low current use of CBT techniques, they provide strong evidence that therapists are interested in incorporating these techniques into practice. Only 14% and 16% of the participants were “not interested” in distraction and imagery techniques, respectively, the least popular of the CBT techniques. However, 57% were “very interested” in learning how to instruct patients in or were “already using” activity pacing and pleasurable activity scheduling, whereas 44% were similarly inclined toward the use of cognitive restructuring.
With this high level of interest in using CBT, the most commonly noted barrier to implementing these techniques into practice was lack of knowledge about the techniques. Concern regarding reimbursement was another frequently endorsed potential barrier, a concern echoed in the medical community regarding all forms of treatment,56–58 and cited here by almost 1 in 3 participants. Coupled with the concerns regarding time constraints as a factor limiting integration of CBT into physical therapist practice, research into the cost-effectiveness and efficiency of the combined treatment approach is warranted.
An additional purpose of the study was to determine whether participant characteristics were associated with level of interest in using CBT. Ascertaining level of interest could help to focus educational intervention efforts (eg, targeting groups of physical therapists most likely to incorporate CBT into practice). Of the 9 variables considered, practice setting, percentage of patients with pain, and physical therapy degree were the variables most strongly associated with interest in CBT. Respondents working in home care reported lower levels of interest in using CBT than respondents from any other practice setting. One possible explanation for this finding is that that therapists working in home care perceive greater challenges for implementing CBT than therapists working in other settings. Only one interaction was found to be significant (ie, between case load and therapist educational level). Therapists with higher academic degrees and a lower caseload of older patients with chronic pain had the highest level of interest in using CBT techniques. Although this finding is interesting, possible reasons for the observed difference remain unclear. Perhaps given the relatively lower day-to-day experience in working with older patients with chronic pain, these therapists have a lower level of comfort in their current treatment methods, thereby making them more amenable to different approaches.
While this study provides new and useful information concerning physical therapists’ level of receptivity regarding the use of CBT techniques for the treatment of older patients with chronic pain and sheds light on other techniques used by physical therapists when treating this patient population, the research has several important limitations that warrant consideration. As a telephone survey, the number of items was kept to a minimum so that the survey could be conducted in a brief time period, thereby enhancing participation. The brevity of our survey did not allow us to examine therapists’ rationale for use of some techniques over others, only their perception of how frequently they use specific treatments. We also did not gather data about the amount of time they spend using each technique, nor the emphasis placed on one treatment versus others. This type of information would be helpful in better clarifying the importance therapists place on the different techniques used. Finally, the survey focused on general approaches to treating older patients with chronic pain, regardless of the source or location of that pain. It is possible that our results might have been different had we focused on a particular disorder, such as fibromyalgia, or a specific body region, such as the lower back.
Conclusions
Physical therapists currently use some CBT interventions in the care of older patients with chronic pain, especially those interventions associated with increasing patients’ activity levels through activity pacing and counseling on scheduling pleasurable activities. Physical therapists indicate interest in incorporating CBT techniques into practice, with strongest interest in cognitive restructuring. Barriers that limit the current use of CBT include lack of knowledge in the use of the techniques, concerns with reimbursement, and treatment time constraints. Examining a wider array of physical therapy treatments, the most frequently used interventions involve active exercise, with fewer therapists reporting use of more-passive techniques such as physical agents and manual therapy. Future research into the use of CBT by physical therapists should address methods to reduce the barriers to incorporating CBT into practice and examine the effectiveness of a combined physical therapy-CBT approach to the management of chronic pain.
Notes
Dr Beissner and Dr Reid provided concept/idea/research design and fund procurement. Dr Beissner, Dr Papaleontiou, and Dr Olkhovskaya provided data collection. All authors provided writing. Dr Henderson and Dr Wigglesworth provided data analysis. Dr Hélène Larin and Dr Michael Buck provided consultation.
The Ithaca College Institutional Review Board approved the study.
This work was previously presented at the Combined Sections Meeting of the American Physical Therapy; February 6–9, 2008; Nashville, Tennessee.
This research was supported, in part, by a Summer Research Grant through the Office of the Provost, Ithaca College. This work also was supported by the John A. Hartford Foundation (Hartford Center of Excellence in Geriatric Medicine Award to Weill Cornell Medical College) and the Cornell Institute for Translational Research on Aging: An Edward R. Royball Center for Research on Translational Aging Research (P30 AG22845–01).
*SAS Institute Inc, 100 SAS Campus Dr, Cary, NC 27513-2414.
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