Evaluation of a non‐pharmacological interdisciplinary pain rehabilitation and functional restoration program for chronic pain in veterans

Abstract

Objective To conduct a quality improvement evaluation of the Empower Veterans Program (EVP), an interdisciplinary pain rehabilitation/functional restoration program option for functional restoration for high‐impact chronic pain, offered in a large metro‐area Veterans Health Administration (VHA) system. Data Sources VHA Corporate Data Warehouse electronic medical record data for patients treated by EVP between 2015 and 2019. Evaluation Design This retrospective design first compared EVP patients considered engaged or not engaged in completing treatment in terms of demographic characteristics and post‐treatment changes in clinical measures related to opioid use and mental health. We then compared mortality risk between matched groups of treated and untreated patients with chronic pain and concurrent opioid prescriptions using propensity score matching and Cox proportional hazards methods. “Treated” in the matched groups was defined as any level of EVP participation (i.e., both engaged and not engaged). Data Collection/Extraction Methods We first identified 1053 EVP patients with 1 year of pre‐and post‐treatment follow‐time and determined their engagement level. From those with chronic pain and prescription opioids, we matched 237 EVP patients to 375 untreated patients. Principal Findings Engaged patients (57.4% of treated patients), were somewhat older than the non‐engaged (mean age 57.1 vs. 53.7, Cohen's D = 0.30), and achieved lower mean PHQ9 depression scores in the post‐treatment year (9.2 vs. 10.6, Cohen's D = 0.20). Participation in EVP was associated with a 65% lower mortality risk among Veterans with chronic pain and opioid use when compared to the untreated patients: (HR: 0.35, 95% CI: 0.17, 0.75). Conclusions EVP was associated with a large reduction in mortality risk for Veterans with both chronic pain and opioid use. This result could inform the decision process in a VA station or region when considering providing or expanding access to an interdisciplinary rehabilitation/functional restoration program for chronic pain.

Remotely Delivered Psychologically Informed Mindful Movement Physical Therapy for Pain Care: A Framework for Operationalization

“…This paper offers a PiPT framework for mindful movement that is evidence-based, theory-driven, and has real-world implementation with positive outcomes for an integrated approach to interdisciplinary pain care. 63,65,68 With both national and international physical therapy organizations advocating for the role of PTs to support a biopsychosocial approach and integrating mental health, 37 This program also demonstrates a successful translation to this approach for pain care to remote delivery. This shift to remote delivery created the opportunity to optimize active learning strategies including interoceptive skills-building, and use of MI to support self-efficacy to trust and restore a sense of safety in the body and explore adaptations for safe movement.…”

“…This paper offers a PiPT framework for mindful movement that is evidence-based, theory-driven, and has real-world implementation with positive outcomes for an integrated approach to interdisciplinary pain care. 63,65,68 With both national and international physical therapy organizations advocating for the role of PTs to support a biopsychosocial approach and integrating mental health, 37 this framework can support the development of best practices for PiPT. This paper offers insight into how to integrate ACT, mindfulness, MI, and PNE through an emphasis on interoceptive, body-based learning to optimize self-efficacy for movement.…”

“…27 Improvements have also been noted for acceptance (activity engagement despite pain, willingness to experience pain), depression, anxiety, sleep disturbance, mindfulness (nonreactivity to negative thoughts and emotions, observing their experiences), fatigue, adoption of healthy self-care, greater positivity and empowerment to participate in life, changing medication use, and reduction in total mortality among veterans with chronic pain and opioid use. [62][63][64][65]…”

Integrated pain care models and the importance of aligning stakeholder values

“…The clinical outcomes, 3,13,27,43 cost-effectiveness, 17 and the process for accrediting interdisciplinary pain care facilities 24,27 have been established. 3,13,17,27,43 However, widespread deployment has been limited, in part, by the model framework which does not fully account for the payer vector. 8,29,36 For example, in a prospective study of adults receiving interdisciplinary care for chronic pain, clinical outcomes were adversely affected by the lack of insurance benefits for physical therapy services.…”

“…8,35 Patients are generally expected to participate a highly structured treatment protocol spanning multiple weeks. The clinical outcomes, 3,13,27,43 cost-effectiveness, 17 and the process for accrediting interdisciplinary pain care facilities 24,27 have been established. 3,13,17,27,43 However, widespread deployment has been limited, in part, by the model framework which does not fully account for the payer vector.…”