Chronic Musculoskeletal Pain Psychological Strategies for Rehabilitation in an Interdisciplinary Setting Judith R. Gale, PT, MA Coordinator of Physical Therapy Services The University of Alaba'T/U1, at Birmingham Pain Treatment Center
Frank A. Brotherton, PhD Assistant Professor and Director of Psychological Services The University of Alaba'T/U1, at Birmingha,m Pain Treatment Center
Gail M. Jensen, PT, PhD Associate Professor and Director of the Post-Professional Program Division of Physical Therapy School of Health Related Professions The University of Alaba'T/U1, at Birmingham
Acute and chronic pain affects from one-third to one-half of all Americans each year. I .2 The costs are staggering, not only in terms of health care services, but also in terms of lost productivity, medications, and compensation. It has been estimated that national expenditures for pain management can reach $85 to $90 billion each year. 1 Between 550 and 700 million workdays are lost annually because of chronic pain at an estimated cost of $55 to $60 billion. 1.3 Because of the complexity of the chronic pain patient and the need to address multiple aspects of health care with many patients, multidisciplinary and interdisciplinary pain control clinics have become more common in the past several years. 4 It is generally recognized that many complex problems may be more successfully resolved when more than one discipline is involved in the treatment process. At the simplest and least integrated level, this practice is applied when a patient seeks the advice of var-
ious specialists before making a decision regarding treatment. This practice is applied more haphazardly when the patient is referred from one specialist to another. In a multidisciplinary approach, specialists from different disciplines apply their independent knowledge and techniques to the problem. This may occur sequentially or simultaneously. The key feature of the multidisciplinary approach is that the contributions are independent and lack integration. There is little or no communication among disciplines. The interdisciplinary approach to patient assessment and treatment involves close interaction among the various specialists and yields a result that is interactive. s Ideally, each specialist is at least minimally knowledgeable of the others' fields. By its nature, the interdisciplinary approach requires communication and cooperation among disciplines. Each team member must be aware of what the others are doing. Each must support the others' treatment regimens and techniques. The interdisciplinary approach is best carried out simultaneously rather than sequentially. Physical therapy and psychology are integral parts of most interdisciplinary pain treatment centers. Chronic musculoskeletal pain and dysfunction is a frequent cause of visits to physical therapists. Many people with physical illnesses have some degree of psychological distress as well. 6- 8 Frequently, the person with physical and psychological symptoms will seek the help of a medical health practitioner, such as a physician or physical therapist, before seeking psychological services. This may be because the physical symptoms are more easily recognized, and may also
30
WaR K / WINTER 1991
be due, in part, to the fact that seeking medical services is more socially acceptable than seeking help from a psychologist. Physical therapists therefore should have knowledge of some of the psychological complications that may influence treatment outcomes. 9 Physicial therapy curricula are required to provide at least an introduction into the psychosocial aspects of illness behavior. Although the American Physical Therapy Association provides basic guidelines for these requirements through its accreditation process, the course offerings by individual physical therapy programs are varied in terms of content and depth.lO Although physical therapists work with patients with chronic musculoskeletal pain, they often have little insight into the psychological factors that effect treatment outcomes or into the behavioral aspects of treatment. Poor results from treatment in terms of decreased pain, increased function, and return to work may, in part, be due to physical therapists' lack of insight into the use and application of psychological theory in their practice. This article will present two contrasting patient cases that include psychology and physical therapy in the treatment of chronic pain. The application of psychological strategies to physical therapy will be explored.
CASE 1 NB was a 40-year-old female with a 10-year history of severe headaches when initially seen at the Pain Treatment Center. Her headaches were throbbing in nature, occurred at least once per week, and were associated with nausea and photophobia. The headaches began at the base of the occiput and radiated to the right temple. Occasionally she could prevent the headaches from becoming severe with the use of muscle relaxants and nonsteroidal anti-inflammatory drugs. Frequently, however, they became incapacitating, requiring that she lie in bed until they passed, usually within 24 hours. She was unemployed at the time of her initial evaluation. She found it difficult to hold down a full-
time job as the headaches often prevented her from completing her workday. Medical diagnostic workup was essentially negative, although she was found to have malocclusion (a posterior open bite), resulting in right temporomandibular joint (TMJ) stress. A splint was used to reduce this stress and resulted in a slight decrease in the frequency of the headaches. A series of greater occipital nerve infiltrations with local anesthetic also provided slight relieE Her headaches remained quite debilitating despite these measures and the trial of multiple analgesics and anti-inflammatory agents. Evaluation by the physical therapist revealed a 25% limitation in lateral flexion of the cervical spine, both actively and passively. There was tenderness elicited with grade IV unilateral posterior-anterior (P-A) movement of the facets at C3/4 and C4/5 on the right with moderate stiffuess noted. There was associated tenderness with palpation of the right paracervical musculature, with increased tension in the right upper trapezius muscle. Resisted cervical rotation and lateral flexion were painful. TMJ examination was remarkable only for slight restriction in lateral excursion to the left. She was neurologically intact. Physical therapy diagnosis was cervical facet dysfunction and muscular tension as contributory factors to the headaches. Psychological evaluation indicated a clinical profile notable for reported stress regarding financial worries associated with unemployment, diminished self-esteem, and the presence of domineering, critical parents. The Minnesota Multiphasic Personality Inventory (MMPI) suggested subclinical and nonclinical indications of inhibition of anger, introversion, social maladjustment, and high standards ofconduct. The Beck Depression Inventory (BDI)ll results were consistent with those of the MMPI, suggesting absence of depression. The Multidimensional Health Locus of Control Scale (MHLC)12 indicated she was likely to attribute status of her health to chance, although self and powerful others also contribute to her health status. Psychological diagnosis was that psychological factors affected physicial condition. Prognosis relative to pain treatment was good.
Chronic Musculoskeletal Pain
Ms. B participated in the multidisciplinary pain treatment program once a week for eight weeks. Physical therapy centered on mobilization of the cervical spine and decreasing tension in the paracervical musculature through massage, stretching, and soft tissue mobilization. This patient progressed well, with decreased muscular tension and full cervical range of motion maintained from week to week. She was seen briefly in individual psychotherapy to explore coping mechanisms to reduce the effects of the stressors in her life. She attended the pain education and stress management groups with emphasis on relaxation techniques. In addition, the psychologist and the physical therapist worked with the patient to decrease tension in the right upper trapezius through biofeedback. Again, she was able to maintain decreased muscle tension from session to session. Her attendance and participation in the pain control program were regular and consistent. She was compliant and reported good control of the headaches through self-management techniques. Although she continued to have occasional mild headaches, her severe headaches resolved and she was able to return to work full time three weeks into the program.
CASE 2 KS, a 22-year-old-female, was first seen at the Pain Treatment Center four months after a motor vehicle accident. Her symptoms included constant soreness in the neck, head, and face with intermittent sharp, stabbing pain. She complained of headaches and weakness in the upper extremities. She also had had chronic right TMJ pain for several years, which significantly increased after her accident. She had never held a steady job but was working occasionally at the time of her evaluation. Prior to coming to the Pain Treatment Center, she had been evaluated by an oral/maxillary surgeon who suspected a disc subluxation in the right TMJ and consequently prescribed a repositioning splint that the patient wore 24 hours per day. An orthopedic workup, which included x-rays of the cervical spine, was
31
negative. She had been treated with multiple analgesics and anti-inflammatory drugs. In addition, she had been seen by a physical therapist and was treated with massage, modalities, mobilization, and exercise for three months with minimal relief Physical therapy evaluation demonstrated full active and passive cervical range of motion, with pain reported throughout the movements in all planes actively. All resisted cervical tests were painful. No neurological deficits were noted. TMJ assessment revealed full painful active range of motion with reciprocal click on the right with depression-elevation. All resisted TMJ tests were painful on the right. The right TMJ was hypermobile and painful with distraction and distraction-protrusion. Tenderness was reported with palpation of all the muscles of mastication and the paracervical musculature, with increased tension noted in the upper trapezii, sternocleidomastoids, and masseters bilaterally. Physical therapy diagnosis was hypermobility of the right TMJ and spasm of the cervical and masticatory muscles. Evaluation by the psychologist revealed a clinical profile of severe depression and anxiety. In addition, results of the MMPI suggested unpredictable, inconsistent, and irresponsible behavior as well as severe social maladjustment and insecurity. Results of the BDI were consistent with those of the MMPI in suggesting severe depression comprising both somatic and cognitiveaffective symptoms. The MHLC indicated she was likely to attribute the status of her health to external rather than internal factors. Psychological diagnosis was psychological factors affecting physical condition and probable personality disorder (borderline and/or antisocial). Very poor response to treatment was predicted. Long-term psyschotherapy was recommended. Ms. S was seen at the Pain Treatment Center for ten months and received multidisciplinary treatment. Medical interventions included antiinflammatory and antidepressant drugs, cervical nerve blocks, and trigger point injections. Physical therapy treatment was intensive and concentrated on decreasing muscular tension and muscle re-education. Multiple physical
32
W 0 R K / WINTER 1991
therapy approaches were utilized without longterm effect. The patient was seen individually by the psychologist to address her depression and antisocial behaviors. She also attended the pain education and stress management groups but did not complete the series. Her attendance and participation in the entire pain treatment program were sporadic and she frequently missed appointments. She reported little pain relief, yet continued to return for treatment even when confronted with her lack of cooperation and consequent lack of progress. At the conclusion of treatment, she was not working, nor was she seeking employment.
DISCUSSION These two cases demonstrate completely different outcomes in terms of pain relief and return to work. While KS was not able to comply with and benefit from the pain treatment program, NB was able to successfully complete it and to return to work. There are several factors in the cases that may serve to explain the different outcomes. Physical therapy evaluation revealed a muscular tension component to the headaches in both cases. In the case of NB, there was also a cervical facet dysfunction. KS's symptoms were complicated by TMJ dysfunction, perceptions of muscular weakness, and other vague symptoms. While NB tolerated treatment well and reported relief with each session, KS was quite often aggravated by attempts to alleviate her pain, even when treated palliatively. Physical therapy intervention in the second case was completely unsuccessful. The psychological profiles of the two women were quite different. In the case of NB, stress and diminished self-esteem were factors contributing to hC!-r perception of pain. The results of psychological testing predicted good outcome relative to pain treatment. The second case, KS, presented a much more involved clinical profile. She was seen as severely depressed and anxious. Psychological test results predicted very poor response to treatment. From the outset, then, the differences between these two cases
were evident. Psychological intervention before initiation of treatment by other disciplines may have provided better outcome in the second case, as the patient's depression and anxiety may have precluded successful results. Use of some psychological strategies by the physical therapist might have encouraged better compliance with the program and, therefore, a more favorable outcome. Another factor that should be considered is the two women's work histories. While NB had worked regularly until the headaches forced her to quit, KS had never worked full-time. This reflects very different premorbid functional levels. In terms of case management, these two women were treated somewhat differently. Although both patients received individual psychological intervention and physical therapy treatment, only in the first case did the physical therapist and the psychologist work together to enhance the treatment outcome. In the second case, interaction between disciplines was infrequent. It is possible that with more open communication regarding difficult patients, a better end result might be achieved. There is much controversy surrounding factors that predict response to pain control programs and the approaches for successfully returning the chronic pain patient to work. Predictive scales have yielded conflicting results. 13-15 There is disagreement around theories that compensation or pending litigation adversely effect treatment outcomes. 16-19 In the cases presented here, results of psychological testing did predict eventual outcome in terms of response to pain treatment. These results may serve as guidelines, rather than as prognosticators. If, for example, a patient had poor response predicted, this might be an indication that progress should be reviewed three or four weeks into the pain treatment program. That review could look at participation, compliance, and progress in terms of successful achievements of goals. If a patient were found to have a poor prognosis to pain treatment, poor participation, and poor compliance, this review might encourage a timely decision to curtail unsuccessful treatments and direct efforts along another path.
Chronic Musculoskeletal Pain
RECOMMENDATIONS TO INCREASE THERAPY COMPLIANCE In today's world of specialization in health care, it has become increasingly difficult for practitioners to acquire knowledge and skills outside their own disciplines. The interdisciplinary approach to complex patient cases, however, requires the specialist to cross disciplines to some extent. Each must communicate effectively with the others on the team and each must be somewhat knowledgeable of the others' fields in order to achieve maximum benefit for the patient. This section will address some fundamental psychological techniques and principles that may be useful for the physical therapist. These principles and techniques are drawn primarily from the field of behavior therapy but may be applied in any field that involves interpersonal influence. They go beyond the traditional approach to behavior therapy which involves the simple application of concrete positive and negative reinforcers. Perhaps they are best considered persuasive interaction skills. In many ways, the most fundamental of these techniques is based on shaping. Shaping refers to changing behavior by beginning with the present behavior and gradually, over time, requiring closer and closer approximations to the desired behavior. 2o The therapist must adapt the task to the individual patient and assess where the patient is at each step. If, for example, the goal is for the patient to walk two miles per day, we begin with his or her present distance of two blocks per day. Walking two blocks might be sufficient for the first week of the program, with the distance thereafter increasing 10%-20% each week. By using the present status as a starting point, we ensure initial success with the program. This initial success is motivationally more important than rapid progress toward the goal. Rate ofchange can be adjusted individually following the initial success to achieve optimal progress toward the target behavior. The key elements of shaping are starting with the patient's present status and gradual change. Each small step toward the target behavior must be reinforced. This may be ac-
33
complished in several ways. Praise and encouragement are important, but are often delayed since the physical therapist may not see the patient on a daily basis. More immediate and more effective reinforcement is likely to come from involvement of family members and from the patient charting his or her daily progress. In the case of the second study patient, KS, shaping might have been used to facilitate compliance by starting her on an exercise program that included only activities that she was already doing. From there, the physical therapist could have gradually increased her program. The patient might have been asked to keep a log of her activities as one form of reinforcement. Another useful technique to ensure compliance with the treatment regimen is matching, which may be considered a variant of shaping. Matching or tailoring involves determining and then matching the patient's style of doing things. 20,21 For example, a previously athletic individual is more likely to be compliant with a program of exercise that has a conceptual link to his or her preferred sport. The exercises should be designed and explained in terms relevant to the patient's former life-style. Another way of using this technique is to have the patient participate in setting treatment goals in terms of his or her priorities. An appropriate starting point might be to ask, "What enjoyable things could you do in the past that you would like to be able to do now?" Such an approach avoids patient resistance to change by initially matching the patient's behavior and style. Matching might have been used by the physical therapist with the second patient case to increase motivation and interest in the treatment regimen. Her input into the treatment goals might have stimulated interest in sticking with the program in order to reach those goals. Relating the exercises to previous activities might have proved more successful than asking the patient to comply with a program with which she had no interest or input. Behavior therapists are well aware that for many individuals, the most powerful reinforcers are social reinforcers controlled by family members. The recent emergence and growth
34
W 0 R K / WINTER 1991
of specialization in family therapy is largely based on the theory that individual behavior does not exist in isolation or only in interaction with the external physical environment. Individual behavior occurs in interdependent, cybernetic relationships with the behaviors of other people, most notably other family members. Behavior is a function of contingencies, the most numerous and strongest of which are mediated through family interactions. Changes in individual behavior, then, must involve changes in family interaction. Such changes are best accomplished by direct involvement of the family in the treatment process. As demonstrated in the Stanford Family Focus Project, awareness of family dynamics can provide the physical therapist valuable directives for ensuring the ultimate success of treatment regimes. 22 Family influence may impede or facilitate therapeutic change. Close family members who are not supportive of a treatment regimen can have a negative influence on the patient's participation in the program. The patient spends a relatively short period of time with the therapist compared to that spent with the family. It would be advantageous, then, to include the family in the treatment process. Involvement could be formal, by having the family assist with an exercise program, or informal, by having them observe instruction in exercises and explanation of the treatment rationale. A "tough" approach to the chronic pain patient is usually unwise. These patients are often very fearful of pain, and any treatment that
involves more than minor temporary increases in discomfort will be strongly resisted. The pain patient's typical aversion to active forms of treatment and preference for passive modalities probably reflect this anxiety-driven avoidance of activity. If the patient complains of increased pain with treatment, it is better to modify the program than to ignore the complaints. This is especially true in the outpatient setting where the patient is easily able to resist participation. Early success will do much to assure continued compliance, while early failure will decrease motivation. These fundamental psychotherapy techniques and principles are a sample of those that may be used by other disciplines to facilitate change. These are easily acquired skills that do not require extensive theoretical background or training in psychology.
CONCLUSION In this article we have presented two patient cases and have attempted to explain the differences in treatment outcomes. The use of psychological theory in physical therapy has been explored. Whether the patient care setting is multidisciplinary, interdisciplinary, or specialized, successful treatment involves communication. The health care professional must have open interaction with other disciplines, the patient, and the family in order to achieve maximum benefit for the patient.
REFERENCES 1. Bonica JJ: Preface. In Ng L (ed): New Approaches to Treatment of Chronic Pain: A Review of Multidisciplinary Pain Clinics and Pain Centers. Washington DC: US Government Printing Office, 1981. 2. Ng L: A perspective on chronic pain: Treatment and research. In Ng L (ed): New Approaches to Treatment of Chronic Pain: A Review of Multidisciplinary Pain Clinics and Pain Centers, Washington DC: US Government Printing Office, 1981, pp 1-11. 3. Sternbach RA: Survey of pain in the United
States: The Nuprin pain report. ClinJ Pain 1986; 2:49-53. 4. Dickerson CC: Pain centers: A survey and analysis of past, present and future functioning. In Tollison CD (ed): Handbook of Chronic Pain Management. Baltimore: Williams & Watkins, 1989, pp 664-678. 5. Turk DC, Stieg RL: Chronic pain: The necessity of interdisciplinary communication. Clin ] Pain 1987; 3:163-167. 6. Davis H, Kenyon P: Psychology: Its relevance
Chronic Musculoskeletal Pain
35
to the practice of physiotherapy. Physiother 1981; 67:67-69.
surgical treatment. Arch Physical Med and Rehab 1983; 64:560-563.
7. Lee pw, Chow Sp, Lieh-Mak F, et al: Psychosocial factors influencing outcome in patients with low-back pain. Spine 1989; 14:838-842.
16. Leavitt F, Garron DC, McNeill, TW, et al: Organic status, psychological disturbance, and pain report characteristics in low back-pain patients on compensation. Spine 1982; 7:398402.
8. French S: Pain: Some psychological and sociological aspects. Physiother 1989; 75:255-260. 9. Schunk C: Psychological causes. In Scully RM, Barnes ML (eds): Physical Therapy. Philadelphia: Lippincott, 1989, pp 313-318. 10. Guccione A, DeMont M: Interpersonal skills: Education in entry-level physical therapy programs. Physical Ther 1987; 67:388-393. 11. Beck AT, Ward CH, Mendelsohn M, et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561-571. 12. Wallston BS, Wallston KA, Kaplan GD, et al: Development and validation of the health locus of control (HLC) scale. J Consult and Clin Psychology 1976; 44:580-585. 13. Maruta T, Swanson DW, Swenson WM: Chronic pain: Which patients may a painmanagement program help? Pain 1979; 7:321-329. 14. Aronoff GM, Evans WO: The prediction of treatment outcome at a multidisciplinary pain center. Pain 1982; 14:67-73. 15. Turner JA, RobinsonJ, McCreary CP: Chronic low back pain: Predicting response to non-
17. Mendelson G: Compensation, pain complaints, and psychological disturbance. Pain 1984; 20: 169-1 77. 18. Taylor Wp, Stern WR, Kubiszyn TW: Predicing patients' perceptions ofresponse to treatment for low back pain. Spine 1984; 9:313316. 19. Dworkin RH, Handlin DS, Richlin DM, et al: Unraveling the effects of compensation, litigation, and employment on treatment response in chronic pain. Pain 1985; 23:49-59. 20. DiMatteo MR, DiNicola DD: Achieving Patient Compliance: The Psychology of the Medical Practitioner's Role. New York: Pergamon, 1982, pp 224-236. 21. Lorish C, Parker J, Brown S: Effective patient education: A quasi-experiment comparing an individual strategy with a routinized strategy. Arthritis and Rheumatism 1985; 28: 1289-1297. 22. Sasano EM, Shepard KF, Bell JE, et al: The family in physical therapy. Physical Ther 1977; 57:153-159.
Frank A. Brotherton, PhD Assistant Professor and Director of Psychological Services The University of Alaba'T/U1, at Birmingha,m Pain Treatment Center
Gail M. Jensen, PT, PhD Associate Professor and Director of the Post-Professional Program Division of Physical Therapy School of Health Related Professions The University of Alaba'T/U1, at Birmingham
Acute and chronic pain affects from one-third to one-half of all Americans each year. I .2 The costs are staggering, not only in terms of health care services, but also in terms of lost productivity, medications, and compensation. It has been estimated that national expenditures for pain management can reach $85 to $90 billion each year. 1 Between 550 and 700 million workdays are lost annually because of chronic pain at an estimated cost of $55 to $60 billion. 1.3 Because of the complexity of the chronic pain patient and the need to address multiple aspects of health care with many patients, multidisciplinary and interdisciplinary pain control clinics have become more common in the past several years. 4 It is generally recognized that many complex problems may be more successfully resolved when more than one discipline is involved in the treatment process. At the simplest and least integrated level, this practice is applied when a patient seeks the advice of var-
ious specialists before making a decision regarding treatment. This practice is applied more haphazardly when the patient is referred from one specialist to another. In a multidisciplinary approach, specialists from different disciplines apply their independent knowledge and techniques to the problem. This may occur sequentially or simultaneously. The key feature of the multidisciplinary approach is that the contributions are independent and lack integration. There is little or no communication among disciplines. The interdisciplinary approach to patient assessment and treatment involves close interaction among the various specialists and yields a result that is interactive. s Ideally, each specialist is at least minimally knowledgeable of the others' fields. By its nature, the interdisciplinary approach requires communication and cooperation among disciplines. Each team member must be aware of what the others are doing. Each must support the others' treatment regimens and techniques. The interdisciplinary approach is best carried out simultaneously rather than sequentially. Physical therapy and psychology are integral parts of most interdisciplinary pain treatment centers. Chronic musculoskeletal pain and dysfunction is a frequent cause of visits to physical therapists. Many people with physical illnesses have some degree of psychological distress as well. 6- 8 Frequently, the person with physical and psychological symptoms will seek the help of a medical health practitioner, such as a physician or physical therapist, before seeking psychological services. This may be because the physical symptoms are more easily recognized, and may also
30
WaR K / WINTER 1991
be due, in part, to the fact that seeking medical services is more socially acceptable than seeking help from a psychologist. Physical therapists therefore should have knowledge of some of the psychological complications that may influence treatment outcomes. 9 Physicial therapy curricula are required to provide at least an introduction into the psychosocial aspects of illness behavior. Although the American Physical Therapy Association provides basic guidelines for these requirements through its accreditation process, the course offerings by individual physical therapy programs are varied in terms of content and depth.lO Although physical therapists work with patients with chronic musculoskeletal pain, they often have little insight into the psychological factors that effect treatment outcomes or into the behavioral aspects of treatment. Poor results from treatment in terms of decreased pain, increased function, and return to work may, in part, be due to physical therapists' lack of insight into the use and application of psychological theory in their practice. This article will present two contrasting patient cases that include psychology and physical therapy in the treatment of chronic pain. The application of psychological strategies to physical therapy will be explored.
CASE 1 NB was a 40-year-old female with a 10-year history of severe headaches when initially seen at the Pain Treatment Center. Her headaches were throbbing in nature, occurred at least once per week, and were associated with nausea and photophobia. The headaches began at the base of the occiput and radiated to the right temple. Occasionally she could prevent the headaches from becoming severe with the use of muscle relaxants and nonsteroidal anti-inflammatory drugs. Frequently, however, they became incapacitating, requiring that she lie in bed until they passed, usually within 24 hours. She was unemployed at the time of her initial evaluation. She found it difficult to hold down a full-
time job as the headaches often prevented her from completing her workday. Medical diagnostic workup was essentially negative, although she was found to have malocclusion (a posterior open bite), resulting in right temporomandibular joint (TMJ) stress. A splint was used to reduce this stress and resulted in a slight decrease in the frequency of the headaches. A series of greater occipital nerve infiltrations with local anesthetic also provided slight relieE Her headaches remained quite debilitating despite these measures and the trial of multiple analgesics and anti-inflammatory agents. Evaluation by the physical therapist revealed a 25% limitation in lateral flexion of the cervical spine, both actively and passively. There was tenderness elicited with grade IV unilateral posterior-anterior (P-A) movement of the facets at C3/4 and C4/5 on the right with moderate stiffuess noted. There was associated tenderness with palpation of the right paracervical musculature, with increased tension in the right upper trapezius muscle. Resisted cervical rotation and lateral flexion were painful. TMJ examination was remarkable only for slight restriction in lateral excursion to the left. She was neurologically intact. Physical therapy diagnosis was cervical facet dysfunction and muscular tension as contributory factors to the headaches. Psychological evaluation indicated a clinical profile notable for reported stress regarding financial worries associated with unemployment, diminished self-esteem, and the presence of domineering, critical parents. The Minnesota Multiphasic Personality Inventory (MMPI) suggested subclinical and nonclinical indications of inhibition of anger, introversion, social maladjustment, and high standards ofconduct. The Beck Depression Inventory (BDI)ll results were consistent with those of the MMPI, suggesting absence of depression. The Multidimensional Health Locus of Control Scale (MHLC)12 indicated she was likely to attribute status of her health to chance, although self and powerful others also contribute to her health status. Psychological diagnosis was that psychological factors affected physicial condition. Prognosis relative to pain treatment was good.
Chronic Musculoskeletal Pain
Ms. B participated in the multidisciplinary pain treatment program once a week for eight weeks. Physical therapy centered on mobilization of the cervical spine and decreasing tension in the paracervical musculature through massage, stretching, and soft tissue mobilization. This patient progressed well, with decreased muscular tension and full cervical range of motion maintained from week to week. She was seen briefly in individual psychotherapy to explore coping mechanisms to reduce the effects of the stressors in her life. She attended the pain education and stress management groups with emphasis on relaxation techniques. In addition, the psychologist and the physical therapist worked with the patient to decrease tension in the right upper trapezius through biofeedback. Again, she was able to maintain decreased muscle tension from session to session. Her attendance and participation in the pain control program were regular and consistent. She was compliant and reported good control of the headaches through self-management techniques. Although she continued to have occasional mild headaches, her severe headaches resolved and she was able to return to work full time three weeks into the program.
CASE 2 KS, a 22-year-old-female, was first seen at the Pain Treatment Center four months after a motor vehicle accident. Her symptoms included constant soreness in the neck, head, and face with intermittent sharp, stabbing pain. She complained of headaches and weakness in the upper extremities. She also had had chronic right TMJ pain for several years, which significantly increased after her accident. She had never held a steady job but was working occasionally at the time of her evaluation. Prior to coming to the Pain Treatment Center, she had been evaluated by an oral/maxillary surgeon who suspected a disc subluxation in the right TMJ and consequently prescribed a repositioning splint that the patient wore 24 hours per day. An orthopedic workup, which included x-rays of the cervical spine, was
31
negative. She had been treated with multiple analgesics and anti-inflammatory drugs. In addition, she had been seen by a physical therapist and was treated with massage, modalities, mobilization, and exercise for three months with minimal relief Physical therapy evaluation demonstrated full active and passive cervical range of motion, with pain reported throughout the movements in all planes actively. All resisted cervical tests were painful. No neurological deficits were noted. TMJ assessment revealed full painful active range of motion with reciprocal click on the right with depression-elevation. All resisted TMJ tests were painful on the right. The right TMJ was hypermobile and painful with distraction and distraction-protrusion. Tenderness was reported with palpation of all the muscles of mastication and the paracervical musculature, with increased tension noted in the upper trapezii, sternocleidomastoids, and masseters bilaterally. Physical therapy diagnosis was hypermobility of the right TMJ and spasm of the cervical and masticatory muscles. Evaluation by the psychologist revealed a clinical profile of severe depression and anxiety. In addition, results of the MMPI suggested unpredictable, inconsistent, and irresponsible behavior as well as severe social maladjustment and insecurity. Results of the BDI were consistent with those of the MMPI in suggesting severe depression comprising both somatic and cognitiveaffective symptoms. The MHLC indicated she was likely to attribute the status of her health to external rather than internal factors. Psychological diagnosis was psychological factors affecting physical condition and probable personality disorder (borderline and/or antisocial). Very poor response to treatment was predicted. Long-term psyschotherapy was recommended. Ms. S was seen at the Pain Treatment Center for ten months and received multidisciplinary treatment. Medical interventions included antiinflammatory and antidepressant drugs, cervical nerve blocks, and trigger point injections. Physical therapy treatment was intensive and concentrated on decreasing muscular tension and muscle re-education. Multiple physical
32
W 0 R K / WINTER 1991
therapy approaches were utilized without longterm effect. The patient was seen individually by the psychologist to address her depression and antisocial behaviors. She also attended the pain education and stress management groups but did not complete the series. Her attendance and participation in the entire pain treatment program were sporadic and she frequently missed appointments. She reported little pain relief, yet continued to return for treatment even when confronted with her lack of cooperation and consequent lack of progress. At the conclusion of treatment, she was not working, nor was she seeking employment.
DISCUSSION These two cases demonstrate completely different outcomes in terms of pain relief and return to work. While KS was not able to comply with and benefit from the pain treatment program, NB was able to successfully complete it and to return to work. There are several factors in the cases that may serve to explain the different outcomes. Physical therapy evaluation revealed a muscular tension component to the headaches in both cases. In the case of NB, there was also a cervical facet dysfunction. KS's symptoms were complicated by TMJ dysfunction, perceptions of muscular weakness, and other vague symptoms. While NB tolerated treatment well and reported relief with each session, KS was quite often aggravated by attempts to alleviate her pain, even when treated palliatively. Physical therapy intervention in the second case was completely unsuccessful. The psychological profiles of the two women were quite different. In the case of NB, stress and diminished self-esteem were factors contributing to hC!-r perception of pain. The results of psychological testing predicted good outcome relative to pain treatment. The second case, KS, presented a much more involved clinical profile. She was seen as severely depressed and anxious. Psychological test results predicted very poor response to treatment. From the outset, then, the differences between these two cases
were evident. Psychological intervention before initiation of treatment by other disciplines may have provided better outcome in the second case, as the patient's depression and anxiety may have precluded successful results. Use of some psychological strategies by the physical therapist might have encouraged better compliance with the program and, therefore, a more favorable outcome. Another factor that should be considered is the two women's work histories. While NB had worked regularly until the headaches forced her to quit, KS had never worked full-time. This reflects very different premorbid functional levels. In terms of case management, these two women were treated somewhat differently. Although both patients received individual psychological intervention and physical therapy treatment, only in the first case did the physical therapist and the psychologist work together to enhance the treatment outcome. In the second case, interaction between disciplines was infrequent. It is possible that with more open communication regarding difficult patients, a better end result might be achieved. There is much controversy surrounding factors that predict response to pain control programs and the approaches for successfully returning the chronic pain patient to work. Predictive scales have yielded conflicting results. 13-15 There is disagreement around theories that compensation or pending litigation adversely effect treatment outcomes. 16-19 In the cases presented here, results of psychological testing did predict eventual outcome in terms of response to pain treatment. These results may serve as guidelines, rather than as prognosticators. If, for example, a patient had poor response predicted, this might be an indication that progress should be reviewed three or four weeks into the pain treatment program. That review could look at participation, compliance, and progress in terms of successful achievements of goals. If a patient were found to have a poor prognosis to pain treatment, poor participation, and poor compliance, this review might encourage a timely decision to curtail unsuccessful treatments and direct efforts along another path.
Chronic Musculoskeletal Pain
RECOMMENDATIONS TO INCREASE THERAPY COMPLIANCE In today's world of specialization in health care, it has become increasingly difficult for practitioners to acquire knowledge and skills outside their own disciplines. The interdisciplinary approach to complex patient cases, however, requires the specialist to cross disciplines to some extent. Each must communicate effectively with the others on the team and each must be somewhat knowledgeable of the others' fields in order to achieve maximum benefit for the patient. This section will address some fundamental psychological techniques and principles that may be useful for the physical therapist. These principles and techniques are drawn primarily from the field of behavior therapy but may be applied in any field that involves interpersonal influence. They go beyond the traditional approach to behavior therapy which involves the simple application of concrete positive and negative reinforcers. Perhaps they are best considered persuasive interaction skills. In many ways, the most fundamental of these techniques is based on shaping. Shaping refers to changing behavior by beginning with the present behavior and gradually, over time, requiring closer and closer approximations to the desired behavior. 2o The therapist must adapt the task to the individual patient and assess where the patient is at each step. If, for example, the goal is for the patient to walk two miles per day, we begin with his or her present distance of two blocks per day. Walking two blocks might be sufficient for the first week of the program, with the distance thereafter increasing 10%-20% each week. By using the present status as a starting point, we ensure initial success with the program. This initial success is motivationally more important than rapid progress toward the goal. Rate ofchange can be adjusted individually following the initial success to achieve optimal progress toward the target behavior. The key elements of shaping are starting with the patient's present status and gradual change. Each small step toward the target behavior must be reinforced. This may be ac-
33
complished in several ways. Praise and encouragement are important, but are often delayed since the physical therapist may not see the patient on a daily basis. More immediate and more effective reinforcement is likely to come from involvement of family members and from the patient charting his or her daily progress. In the case of the second study patient, KS, shaping might have been used to facilitate compliance by starting her on an exercise program that included only activities that she was already doing. From there, the physical therapist could have gradually increased her program. The patient might have been asked to keep a log of her activities as one form of reinforcement. Another useful technique to ensure compliance with the treatment regimen is matching, which may be considered a variant of shaping. Matching or tailoring involves determining and then matching the patient's style of doing things. 20,21 For example, a previously athletic individual is more likely to be compliant with a program of exercise that has a conceptual link to his or her preferred sport. The exercises should be designed and explained in terms relevant to the patient's former life-style. Another way of using this technique is to have the patient participate in setting treatment goals in terms of his or her priorities. An appropriate starting point might be to ask, "What enjoyable things could you do in the past that you would like to be able to do now?" Such an approach avoids patient resistance to change by initially matching the patient's behavior and style. Matching might have been used by the physical therapist with the second patient case to increase motivation and interest in the treatment regimen. Her input into the treatment goals might have stimulated interest in sticking with the program in order to reach those goals. Relating the exercises to previous activities might have proved more successful than asking the patient to comply with a program with which she had no interest or input. Behavior therapists are well aware that for many individuals, the most powerful reinforcers are social reinforcers controlled by family members. The recent emergence and growth
34
W 0 R K / WINTER 1991
of specialization in family therapy is largely based on the theory that individual behavior does not exist in isolation or only in interaction with the external physical environment. Individual behavior occurs in interdependent, cybernetic relationships with the behaviors of other people, most notably other family members. Behavior is a function of contingencies, the most numerous and strongest of which are mediated through family interactions. Changes in individual behavior, then, must involve changes in family interaction. Such changes are best accomplished by direct involvement of the family in the treatment process. As demonstrated in the Stanford Family Focus Project, awareness of family dynamics can provide the physical therapist valuable directives for ensuring the ultimate success of treatment regimes. 22 Family influence may impede or facilitate therapeutic change. Close family members who are not supportive of a treatment regimen can have a negative influence on the patient's participation in the program. The patient spends a relatively short period of time with the therapist compared to that spent with the family. It would be advantageous, then, to include the family in the treatment process. Involvement could be formal, by having the family assist with an exercise program, or informal, by having them observe instruction in exercises and explanation of the treatment rationale. A "tough" approach to the chronic pain patient is usually unwise. These patients are often very fearful of pain, and any treatment that
involves more than minor temporary increases in discomfort will be strongly resisted. The pain patient's typical aversion to active forms of treatment and preference for passive modalities probably reflect this anxiety-driven avoidance of activity. If the patient complains of increased pain with treatment, it is better to modify the program than to ignore the complaints. This is especially true in the outpatient setting where the patient is easily able to resist participation. Early success will do much to assure continued compliance, while early failure will decrease motivation. These fundamental psychotherapy techniques and principles are a sample of those that may be used by other disciplines to facilitate change. These are easily acquired skills that do not require extensive theoretical background or training in psychology.
CONCLUSION In this article we have presented two patient cases and have attempted to explain the differences in treatment outcomes. The use of psychological theory in physical therapy has been explored. Whether the patient care setting is multidisciplinary, interdisciplinary, or specialized, successful treatment involves communication. The health care professional must have open interaction with other disciplines, the patient, and the family in order to achieve maximum benefit for the patient.
REFERENCES 1. Bonica JJ: Preface. In Ng L (ed): New Approaches to Treatment of Chronic Pain: A Review of Multidisciplinary Pain Clinics and Pain Centers. Washington DC: US Government Printing Office, 1981. 2. Ng L: A perspective on chronic pain: Treatment and research. In Ng L (ed): New Approaches to Treatment of Chronic Pain: A Review of Multidisciplinary Pain Clinics and Pain Centers, Washington DC: US Government Printing Office, 1981, pp 1-11. 3. Sternbach RA: Survey of pain in the United
States: The Nuprin pain report. ClinJ Pain 1986; 2:49-53. 4. Dickerson CC: Pain centers: A survey and analysis of past, present and future functioning. In Tollison CD (ed): Handbook of Chronic Pain Management. Baltimore: Williams & Watkins, 1989, pp 664-678. 5. Turk DC, Stieg RL: Chronic pain: The necessity of interdisciplinary communication. Clin ] Pain 1987; 3:163-167. 6. Davis H, Kenyon P: Psychology: Its relevance
Chronic Musculoskeletal Pain
35
to the practice of physiotherapy. Physiother 1981; 67:67-69.
surgical treatment. Arch Physical Med and Rehab 1983; 64:560-563.
7. Lee pw, Chow Sp, Lieh-Mak F, et al: Psychosocial factors influencing outcome in patients with low-back pain. Spine 1989; 14:838-842.
16. Leavitt F, Garron DC, McNeill, TW, et al: Organic status, psychological disturbance, and pain report characteristics in low back-pain patients on compensation. Spine 1982; 7:398402.
8. French S: Pain: Some psychological and sociological aspects. Physiother 1989; 75:255-260. 9. Schunk C: Psychological causes. In Scully RM, Barnes ML (eds): Physical Therapy. Philadelphia: Lippincott, 1989, pp 313-318. 10. Guccione A, DeMont M: Interpersonal skills: Education in entry-level physical therapy programs. Physical Ther 1987; 67:388-393. 11. Beck AT, Ward CH, Mendelsohn M, et al: An inventory for measuring depression. Arch Gen Psychiatry 1961; 4:561-571. 12. Wallston BS, Wallston KA, Kaplan GD, et al: Development and validation of the health locus of control (HLC) scale. J Consult and Clin Psychology 1976; 44:580-585. 13. Maruta T, Swanson DW, Swenson WM: Chronic pain: Which patients may a painmanagement program help? Pain 1979; 7:321-329. 14. Aronoff GM, Evans WO: The prediction of treatment outcome at a multidisciplinary pain center. Pain 1982; 14:67-73. 15. Turner JA, RobinsonJ, McCreary CP: Chronic low back pain: Predicting response to non-
17. Mendelson G: Compensation, pain complaints, and psychological disturbance. Pain 1984; 20: 169-1 77. 18. Taylor Wp, Stern WR, Kubiszyn TW: Predicing patients' perceptions ofresponse to treatment for low back pain. Spine 1984; 9:313316. 19. Dworkin RH, Handlin DS, Richlin DM, et al: Unraveling the effects of compensation, litigation, and employment on treatment response in chronic pain. Pain 1985; 23:49-59. 20. DiMatteo MR, DiNicola DD: Achieving Patient Compliance: The Psychology of the Medical Practitioner's Role. New York: Pergamon, 1982, pp 224-236. 21. Lorish C, Parker J, Brown S: Effective patient education: A quasi-experiment comparing an individual strategy with a routinized strategy. Arthritis and Rheumatism 1985; 28: 1289-1297. 22. Sasano EM, Shepard KF, Bell JE, et al: The family in physical therapy. Physical Ther 1977; 57:153-159.
