Technology-Enhanced Delivery Models to Facilitate the Implementation of Psychologically Informed Practice for Chronic Musculoskeletal Pain

Abstract

Chronic musculoskeletal pain is prevalent, challenging to treat, and often disabling. Evidence supports the role of psychological factors in pain-related outcomes, and it is now accepted that rehabilitation should combine physical and psychological approaches (ie, psychologically informed practice). This Perspective articulates a vision for technology-enhanced psychologically informed practice for chronic musculoskeletal pain, highlights relevant research evidence, discusses how technology can circumvent implementation barriers, and proposes directions for future research.

Background

Chronic musculoskeletal pain is prevalent, challenging to treat, and often disabling.¹ As mounting evidence supports the role of psychological factors in pain-related outcomes,² it is now accepted that rehabilitation should combine physical and psychological approaches (ie, psychologically informed practice [PiP]). Over the past decade, one model of PiP for chronic musculoskeletal pain has proliferated in which physical therapists are trained to blend psychological and physical interventions, known as psychologically informed physical therapy.³ This approach has generally been feasible and efficacious in clinical trials, with small but statistically significant effects on pain, physical function, and disability compared with physical therapy alone for patients with chronic musculoskeletal pain.⁴ However, pragmatic trials cite barriers to implementing psychologically informed physical therapy in real-world environments—barriers that hinder effectiveness—including physical therapist training challenges, ineffective referral procedures, and high intervention complexity.^5–7 Thus, adapting the prevailing psychologically informed physical therapy model may be necessary to advance PiP implementation.

In a recent article, Ballengee and colleagues⁸ advocated for several approaches to address PiP implementation barriers, including adoption of implementation science frameworks, hybrid effectiveness-implementation trials, and reforming physical therapist training and education. Building on these recommendations, we believe that technology can play an important role in bypassing key implementation barriers. The aims of this Perspective are to articulate a vision for technology-enhanced PiP for chronic musculoskeletal pain, highlight relevant research evidence, discuss how technology can circumvent implementation barriers, and propose directions for future research.

What Could Technology-Enhanced PiP Look Like?

Technology-enhanced PiP can be delivered via synchronous technologies, involving real-time contact with a clinician (eg, via live video, telephone) or asynchronous technologies, involving self-guided interventions (eg, mobile apps, virtual reality). Technology-enhanced PiP can also assume a hybrid format (ie, virtual psychological skills and in-person physical therapy) or a completely virtual format (ie, virtual psychological skills and physical therapy). Because more studies have tested technology-enhanced psychological interventions compared with physical therapist interventions, physical therapists can consider these models, their pros and cons, and how to apply them in PiP. Psychological interventions using synchronous technologies, such as live video, can more closely reproduce the in-clinic experience relative to asynchronous technologies. This approach may be preferred by patients who prioritize real-time interaction and a strong therapeutic relationship. Live video psychological interventions need not be delivered by physical therapists. Instead, other mental health providers specializing in pain and musculoskeletal disorders can treat patients while coordinating care with physical therapists. Compared with existing PiP models, this system more appropriately capitalizes on each provider’s expertise, which may facilitate implementation (eg, circumventing extensive PiP training). However, coordinating and integrating physical and psychological interventions between providers may be more challenging.

Mobile apps are a cost-effective and scalable solution for disseminating PiP.⁹ Push notifications can remind patients to practice skills, and “gamification” strategies, such as earning points and badges for skills practice and showing performance charts (eg, based on weekly physical activity), can further increase engagement and reduce attrition.¹⁰ These strategies should be underpinned by empirically derived behavior change principles for maximal effectiveness.¹¹ Mobile sensing technologies (eg, heart rate monitors, global positioning system, actigraphy) can also be combined with apps to deliver “just-in-time” interventions, including prompting patients to practice pain coping or relaxation skills when their heart rate reaches a certain threshold.

Virtual reality is another technology with strong potential for PiP delivery.¹² Virtual reality can provide immersive and engaging audiovisual environments to facilitate pain distraction,¹³ promote healthy movement despite pain,¹⁴ and teach pain coping skills.¹⁵ Virtual reality could be used to promote at-home exercise adherence (eg, moving an injured arm to interact with virtual objects), psychological skills practice (eg, pairing deep breathing with a calming virtual environment), or both within PiP. Although a review of virtual reality intervention evidence in chronic musculoskeletal pain is beyond our scope, readers may find value in several existing reviews and commentaries.^12,16,17

What Is the Evidence for Technology-Enhanced PiP?

Although studies testing technology-enhanced PiP are scant, there is strong support in the psychotherapy and physical therapy literature for virtually delivered interventions, both clinician-led and self-guided. A robust literature supported live video/telehealth service delivery in psychotherapy prior to the COVID-19 pandemic, with studies showing equivocal retention, effectiveness, and patient satisfaction compared with in-person treatment (eg, for depression).¹⁸ Telehealth delivery of cognitive behavioral therapy and acceptance and commitment therapy for chronic pain are noninferior to in-person versions.^19,20 Research also suggests that telehealth delivery of physical therapy is feasible, is associated with similar clinical benefit as in-person physical therapy, reduces cost, and increases accessibility.²¹ Bettger and colleagues²² tested an enhanced virtual physical therapy program for patients following total knee arthroplasty, involving an avatar coach and in-home 3D biometrics with remote oversight by a clinician. The virtual physical therapy program was noninferior to traditional in-clinic or at-home physical therapy and was superior in 3-month health care cost savings. Some studies have combined telehealth delivery of cognitive behavioral therapy with physical therapy. For example, Archer and colleagues²³ tested cognitive behavioral–based physical therapy delivered via telephone for patients with chronic pain and high pain catastrophizing undergoing lumbar spine surgery. Participants receiving the intervention had greater decreases in pain and disability and greater increases in general health and physical performance compared with an educational control group at 3-month follow-up. Findings suggest that more elaborate forms of technology might not always be necessary to deliver PiP effectively.

Other studies have tested virtual self-guided/asynchronous interventions for chronic musculoskeletal pain, including psychological pain coping skills, physical therapy, or both. The optimal degree of clinician (eg, physical therapist) involvement in such self-guided interventions is a key question, which 2 notable studies have addressed. Dear and colleagues²⁴ developed and tested Pain Course, a 5-module standalone cognitive behavioral therapy–based pain-coping skills course. The original trial tested Pain Course with either regular clinician contact, optional contact, or no contact versus a waitlist control group. All 3 treatment groups demonstrated significant improvements in pain, disability, depression, and anxiety posttreatment at 3-month follow-up, and beyond. Although outcomes did not significantly differ among treatment groups, completion rates ranged from 68% to 78%, with lower completion associated with less support. Shultz and colleagues²⁵ created the Reboot Online Program, which combined an online 8-module pain-coping skills program and an online graded-exercise program. Completers reported significant improvements in various psychological/pain-related factors (eg, acceptance, catastrophizing, depression) at posttreatment through 3-month follow-up. Although program satisfaction was high, only 13 of 20 participants completed it. Together, these studies demonstrate that clinician support may facilitate full participation, particularly for virtual self-guided programs with psychological components.

How Can Technology-Enhanced PiP Circumvent Key Barriers to Implementation?

Technology-enhanced PiP can significantly reduce physical therapist training and clinic burden but does not negate the need for physical therapists to understand biopsychosocial determinants of chronic musculoskeletal pain. Bolstering biopsychosocial assessment training (rather than psychological intervention delivery) can help physical therapists risk-stratify patients to appropriate levels of care (eg, standard physical therapy, physical therapy plus self-guided psychological skills training, physical therapy plus live video psychotherapy), thus streamlining referral procedures. A working knowledge of evidence-based pain-coping skills remains important for physical therapists to facilitate skill acquisition. The structured and standardized nature of self-guided PiP can help physical therapists become familiar with psychological intervention components and reinforce skills using consistent language. Patient reluctance to seek psychological support is another barrier to implementation. Self-guided psychological interventions within PiP can help patients engage in treatment when they are uncomfortable meeting face to face. Framing psychological interventions as “coaching” or “education” may help reduce mental health self-stigma. Furthermore, technology-enhanced PiP may facilitate participation in postintervention booster sessions, which have been utilized in several PiP trials.²⁶ Because few studies have gathered postintervention follow-up data beyond 1 year,⁴ the long-term effects of PiP booster sessions are unclear. This gap in knowledge warrants further research.

Cost is another barrier to implementing PiP. Research by Dear and colleagues²⁷ showed that Pain Course, whether self- or clinician-guided, was highly cost-effective when clinical outcomes improved by at least 30%—primarily driven by a reduction in health care utilization. Combining online psychological programs, like Pain Course, with virtual physical therapy may further reduce health care cost. Technology can also reduce intervention complexity (another implementation barrier) by offloading psychological components to a patient-guided virtual program. However, patients are still asked to learn and integrate complex psychological skills with physical exercise. Virtual PiP programs should teach patients a minimal number of potent, evidence-based skills (eg, behavioral activation, shifting unhelpful thinking, relaxation, healthy body awareness) using simple language.

Optimizing Technology-Enhanced PiP: Where to Go From Here

To optimize technology-enhanced PiP and facilitate widespread adoption, we recommend the following future research directions. First, qualitative and mixed-methods research can reveal patients’ and providers’ preferences for (1) live versus self-guided interventions, (2) physical therapist training on how to integrate technology-enhanced PiP into practice, and (3) program language and presentation. Second, identifying best practices for psychological screening is a prerequisite for effective PiP, which should include mental health disorders and other psychosocial factors associated with chronic musculoskeletal pain (eg, pain self-efficacy, catastrophizing, avoidance behaviors).²⁸ Physical therapists may benefit from training on effectively communicating screening results to patients and the care team. Third, clinical researchers should ensure the cultural humility of technology-enhanced PiP protocols. Interventions should prioritize inclusivity of content and language that are accessible and destigmatizing. This may be achieved through focus group testing with diverse populations and other community-engaged methods (eg, community advisory boards of diverse patients and providers). Fourth, a switch to technology-enhanced PiP risks excluding patients with low socioeconomic status who lack required devices or internet access. Pragmatic testing and delivery of such interventions may require extra funds for smartphones, tablets, and data plans.

Finally, obtaining insurance reimbursement for self-guided virtual interventions (eg, apps) has proven challenging. Researchers should partner with industry stakeholders to understand optimal pathways to reimbursement, which, in the United States, may include obtaining US Food and Drug Administration approval to classify apps similar to the way drugs and devices are approved and creating or modifying Current Procedural Terminology codes for interventions in which no clinician time is necessary.²⁹ Overcoming these barriers and promoting effective technology-enhanced PiP can increase treatment value for patients living with chronic musculoskeletal pain.

Author Contributions

Concept/idea/research design: J.D. Doorley, T.A. Lentz, G.Y. Yeh, P.M. Wayne, K.R. Archer, A.-M. Vranceanu

Writing: J.D. Doorley, T.A. Lentz, G.Y. Yeh, P.M. Wayne, K.R. Archer, A.-M. Vranceanu

Fund procurement: A.-M. Vranceanu

Providing institutional liaisons: A.-M. Vranceanu

Consultation (including review of manuscript before submitting): T.A. Lentz, G.Y. Yeh, K.R. Archer

K.R. Archer and A.-M. Vranceanu are joint senior authors and contributed equally to this work.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

K.R. Archer is a PTJ Editorial Board member.

Funding

This work was supported by grants from the National Institutes of Health Fellowship in Integrative Medicine (5T32AT000051–23; K24AT009465). The funders played no role in the design, conduct, or reporting of this study.