Group physical therapy improves outcomes for patients on an inpatient psychiatric pain service

Abstract

Background

While physical therapists have provided group physical therapy interventions for patients admitted to inpatient psychiatric pain service lines, to date, it has not been assessed whether the patients’ outcomes of pain and function have improved during their stay. Thus, our aim is to evaluate how group physical therapy, as part of an inpatient psychiatric rehabilitation team, impacts outcomes for patients receiving chronic pain treatment services.

Methods

Data was retrospectively retrieved from patients who received group physical therapy during their inpatient psychiatric pain admission. At evaluation and discharge, PROMIS Pain Interference Scale tracked pain, while AM-PAC Basic Mobility Outpatient Short Form measured functional mobility. Paired samples statistics were used to evaluate outcomes.

Results

Over a 6-month period, 25 patients (average age 40.28 +/− 15.93 years) received group physical therapy. All patients had the treatment diagnosis of chronic pain. The null hypothesis, that there was no difference between evaluation and discharge scores, was rejected for both the PROMIS Pain Interference Scale t (25) = 3.82, two-tailed p < .001 and the AM-PAC Mobility Score t (25) = −2.24, two-tailed p = .03.

Conclusions

Group physical therapy, as part of an inpatient psychiatric pain management team, assists with improving patient outcomes of pain and mobility.

Introduction

Chronic pain, or pain lasting longer than 3 months after acute injury has resolved, may present with broad symptomologies, and stem from a variety of etiologies.^1–3 Chronic pain impacts a wide range of ages, and can be experienced regardless of race and/or gender ³ (although prevalence of chronic pain is higher in females^1,3 older adults, individuals with lower socioeconomic status, and those who self-report as non-Caucasian). ³ Globally, 20% of individuals experience chronic pain, which creates financial burden via decreasing productivity and/or preventing participation in occupation based activities. ¹ Chronic back pain, for example, has been found to cost the United States 12.2–90.6 billion dollars in lost productivity annually. ⁴ Likewise, the economic burden of chronic pain is more costly to the healthcare system than cancer and cardiovascular disease combined. ¹ Additionally, chronic pain has been found to be linked to higher rates of suicidal ideation in individuals with major depressive disorder. ⁵ Fortunately, chronic pain can be managed successfully by psychiatric pain services, both in inpatient and outpatient facilities. ⁶

Individuals admitted to inpatient psychiatric pain management services may present with higher levels of impairments due to their pain, which may limit functional mobility, and/or impact reports of self-harm or harm to others. These patients may also have co-morbidities, including psychiatric issues, due to the prolonged nature of their pain; for example, depression and/or anxiety, or they may have had psychiatric health conditions prior to the onset of pain, making the pain more challenging to manage. Inpatient chronic pain programs often involve a large multidisciplinary team. This team may include, but is not limited to, psychiatrists, nurses, social workers, occupational therapists, and physical therapists (PTs). Each team member manages different aspects of the patient’s care, depending on their scope of practice. Psychiatrists may manage medications and provide behavioral interventions targeted at both the psychiatric health condition and pain management, nurses provide immediate bedside care, social workers create safe discharge plans, and occupational therapists design psychological treatments and strategies around safe coping mechanisms and methods to complete activities of daily living. PTs have a unique role with this patient population; PTs create treatment plans to promote patient return to functional mobility, improve self-efficacy, and decrease catastrophizing. ⁷ The use of multidisciplinary teams in pain management have been shown to be both patient and cost effective. ⁸ Additionally, the use of the multidisciplinary team approach aids in the implementation of the biopsychosocial model to pain management, as each team member addresses the reason for pain from a different angle: distress, trauma, interpersonal factors, patient expectations, coping skills. Each team member collaboratively promotes the management and maintenance of these chronic pain conditions. ²

In addition to the multidisciplinary team approach, inpatient psychiatric pain services provide care in both individual and group environments. Individual sessions allow patients to receive one-to-one specifically tailored care, using outcome measures to evaluate and track progress. While these individualized treatment sessions and assessments are important for precision-based medicine, they lack the impact of socialization on pain behaviors. Thus, group interventions are aimed at targeting coping and pain management in an open environmental setting. ⁹

Systematic reviews have shown that a variety of exercise interventions can be successfully implemented for chronic pain, both in group and individual settings. ¹⁰ Additionally, it is known that performing exercises in a group can add motivation and positively impact performance. ¹¹ While PTs have been providing group physical therapy interventions for patients admitted to the inpatient psychiatric pain service, to date, no one has assessed whether the patients’ outcomes of pain and function have improved during their stay. Thus, our aim is to assess quality improvement to see if PT group intervention, in conjunction with multidisciplinary standard of care, improves patient outcomes for patients admitted to inpatient psychiatric pain service lines. We hypothesize that the inclusion of group PT interventions will improve patient outcomes.

Methods

Participants

Participants were included if they received group PT during their admission to an adult inpatient psychiatric pain service. Participants who did not receive group PT were excluded. Data was retrospectively extracted from the Epic © Clarity patient medical records database by a business analytics and data program manager and uploaded directly to a secure desktop for data analysis, as per the Johns Hopkins Medicine Institutional Review Board protocol (IRB00385015) and in accordance with the Declaration of the World Medical Association. Given the retrospective nature of the study design, the Institutional Review Board approved a waiver of consent. A G*Power a priori power analysis was performed with the effect size from prior literature, ¹¹ which determined 16 participants were needed, power = 0.80, two-tailed α ≤ 0.05.

Psychiatric pain service

The Johns Hopkins Pain Treatment Program is housed within the Johns Hopkins Hospital, in an urban setting, with patients of diverse socioeconomic demographics. The Pain Treatment Program is a multidisciplinary approach to support patients with chronic pain. The inpatient program focuses on individuals who have become restricted in aspects of daily living, despite pursuing previous pain relief options, with the primary mission to increase the functional ability of each patient. Adults who have a diagnosis of chronic pain for at least 6 months and are medically stable, are voluntarily admitted to the inpatient unit for treatment. Often, patients have additional co-morbidities which accompany chronic pain, such as depression, anxiety, insomnia, and fatigue. During their admission, patients receive a multidisciplinary approach to treatment led by the psychiatry team, with involvement from multiple pain services and specialties: interventional pain, physical medicine and rehabilitation, physical therapy, occupational therapy, nutrition, social work, case management, and medical/surgical consults as needed.

Outcomes

As standard of care, during evaluations and discharges PTs administer the PROMIS Pain Interference Scale to evaluate pain, and the AM-PAC Mobility to measure functional mobility.

PROMIS Pain Interference Scale: The PROMIS Pain Interference Scale is a self-reported, non-disease specific instrument that measures the role of pain on a person’s life. This includes how much pain impacts social, cognitive, emotional, physical, and recreational activities, as well as sleep and quality of life. ¹² This measure was selected to assess the impact of pain related distress on the individual’s life.

AM-PAC Basic Mobility Outpatient Short Form: The Boston University AM-PAC Basic Mobility Outpatient Short Form is an 18-question self-reported form used to gain understanding of patients’ insight of their functional capabilities. Questions are asked in the format of “How much difficulty do you currently have…” for functional tasks such as transfers, ambulation, and balance. Higher scores indicate more independence. ¹³ This measure was selected to assess the impact of pain on the individual’s functional mobility.

Of note, individuals were admitted to the Pain Treatment Program if they had a diagnosis of chronic pain. Currently, minimally important differences and minimally clinically important differences have yet to be established for patients with chronic pain from varying etiologies for these outcome measures; emphasis has been focused primarily on low back pain and fractures.^14–16

Physical therapy treatment

While admitted to the inpatient psychiatric pain service, patients who are deemed appropriate for PT by the treating psychiatrist attend daily group PT sessions. Group sessions are offered twice daily for 1 h. Groups are performed off the psychiatric unit in a rehabilitation gym; thus, attendance was limited to six patients per group for safety during transport to the group location. One PT creates and implements treatment sessions specific to the patient needs. Additionally, one rehabilitation technician attends all sessions to aid with safety and to assist patients to/from the restroom if needed during group sessions.

The PT role on the service is to help with improving overall function. Each patient is evaluated during a one-to-one session to identify functional deficits and painful mobility. The patients then receive a customized exercise program based on their presentation. Physical therapy interventions are tailored to meet the individual’s needs. For example, a patient with back pain might spend more time working on core, hip, and back stability exercises, whereas someone with a shoulder pathology might focus on more shoulder girdle and mid-back strengthening exercises. Of note, interventions such as dry needling, soft tissue massage, and orthopedic manipulations are not performed as the goal is to improve patients’ autonomy and control over their pain management. Each patient is offered and encouraged to attend a one-hour group PT session per day to complete their activities/exercises under the care of a licensed PT. Patients’ plans of care are progressed/regressed during group sessions based on their performance. Patients are educated on how to self-pace, as well as, how to progress themselves based on pain severity. The goal of the group PT session is to progress mobility, improve independence, and foster confidence, while capitalizing on the changes that also come with medical management of the multidisciplinary team, to improve overall patient outcomes.

Statistical analysis

Given the ordinal nature of the data, non-parametric Paired Samples Statistics were performed to compare outcomes pre- and post-group PT sessions. SPSS Version 29.0.0.0 was used for statistical analyses. Statistics were performed by an individual that was blinded to both patients and interventions. α ≤ 0.05 was used for all analyses.

Results

Through retrospective analysis, from April 1st 2023 to September 30th 2023, 25 patients received group PT and completed outcome measures at evaluation and discharge. The mean age was 40.28 +/− 15.93 years. All patients had a treatment diagnosis of chronic pain. Additional demographic information on sex, gender and race was not recorded.

The null hypothesis that there was no difference between evaluation and discharge scores was rejected for both the PROMIS Pain Interference Scale t (25) = 3.82, two-tailed p < .001 and the AM-PAC Mobility Score t (25) = −2.24, two-tailed p = .03. Cohen’s d for PROMIS Pain Interference Scale was large, point estimate 0.76; whereas the point estimate for the AM-PAC Mobility Scores was close to moderate, −0.45. See Tables 1 and 2 for AM-PAC Mobility and PROMIS Pain evaluation and discharge scores.

Table 1.

AM-PAC mobility outpatient raw score evaluation and discharge. Higher scores indicate more functional mobility.

	AMPAC mobility evaluation	AMPAC mobility discharge	AMPAC mobility change
	37	46	9
	45	63	18
	61	65	4
	48	48	0
	61	61	0
	42	45	3
	56	59	3
	55	45	−10
	48	57	9
	56	50	−6
	26	49	23
	45	41	−4
	38	31	−7
	58	64	6
	47	51	4
	42	48	6
	48	48	0
	43	47	4
	43	70	27
	36	40	4
	54	53	−1
	62	63	1
	42	39	−3
	45	64	19
	37	32	−5
Mean (standard deviation)	47 (9.0)	51.2 (10.1)	4.2 (9.3)

Table 2.

PROMIS pain scores at evaluation and discharge. Lower scores indicate less pain.

	PROMIS evaluation	PROMIS discharge	PROMIS change
	20	16	−4
	22	26	4
	17	13	−4
	11	11	0
	23	18	−5
	25	15	−10
	15	11	−4
	21	27	6
	15	19	4
	28	21	−7
	29	22	−7
	26	21	−5
	30	30	0
	20	18	−2
	22	20	−2
	27	25	−2
	27	21	−6
	18	10	−8
	6	6	0
	30	11	−19
	28	12	−16
	16	6	−10
	6	8	2
	28	15	−13
	22	13	−9
Mean (standard deviation)	21.3 (7.0)	16.6 (6.6)	−4.7 (6.1)

Discussion

The aim of our study was to assess if group PT interventions, in conjunction with multidisciplinary standard of care, improves patient outcomes for patients admitted to inpatient psychiatric pain service lines. Our results showed that patients had improvements in both pain and function outcomes. Thackery et al., established that the PROMIS Pain Interference Scale and the AM-PAC Basic Mobility Outpatient Short From measure a similar construct, functional mobility ¹⁷ ; thus, our results align with these findings, given that both measures improved from evaluation to discharge.

In addition to improving the primary outcomes, the group PT sessions were anecdotally reported by the team to be beneficial to the patients for several other reasons. Firstly, the group PT sessions were held at a consistent time each day. This allowed for regularity, anticipation and structure to the patients’ inpatient stay. Consistency is not often realized in an inpatient setting given the multiple medical consults, tests/procedures, interventions, etc. Next, although the patients were given guidance and recommendations for their exercise interventions, the group PT sessions allowed for patient autonomy and choice, as the exercises could be completed on various pieces of equipment as selected by the patient. This gave the patients a sense of ownership and accountability over their plans of care. Similarly, as part of group PT sessions, as patients mastered their routines, therapy staff would progress the plans of care in the moment. This was reported to be beneficial as it allowed patients to receive timely positive feedback versus receiving a standard blanket approach only changed at fixed intervals. Future studies would benefit from objectively measuring staff feedback of the multidisciplinary approach.

In addition to daily group PT sessions, interdisciplinary communication was provided at regular intervals and was key to advancing patients’ multidisciplinary plans of care. Care team rounds, where all multidisciplinary staff communicated on patients’ development, often revealed a specific goal, or wish from a patient, which could then be directly integrated into group PT sessions. For example, if a patient expressed interest in mobilizing without an assistive device to their nurse, this information was communicated to the PT in care team rounds. This transfer of information allowed training exercises to be implemented into the PT plan of care to allow for balance activities, as well as strength training, to assist the patient with reaching their goal. Likewise, communication from occupational therapy about learning styles, mindfulness, or coping strategies could be integrated into a patient’s plan of care to help reinforce best habits and promote carryover.

Finally, the inpatient group PT sessions were performed in a gym located several floors below the inpatient psychiatric unit. This proximity may have provided the participants with a feeling of privilege to have the ability to leave the unit and to experience a change of scenery during their day. This, combined with the group socialization during the group PT sessions, could have contributed to the motivation to attend and participate fully in group PT sessions. As it is known, that observing other individuals participating in activities to achieve goals can be a visual reminder that encourages others to mimic those positive behaviors. ⁷ Additionally, this social exercise environment allowed new patients to adopt positive movement strategies of other patients who have been attending the group for a longer period. ⁹ In addition to the dependable implementation of the group PT sessions, other strengths of this retrospective analysis include that a consistent therapist performed the outcome measures during evaluations and discharge; thus, eliminating inter-rater inconsistencies. PT sessions provided patients with the opportunity to engage in mobility activities in a safe environment, utilize coping strategies provided by the PTs as well as other team members, and interact with peers. Future research would benefit from gathering the patients’ subjective reports on their experience with each member of the multidisciplinary team; overall, PT, in conjunction with the other members of the multidisciplinary team aided in increasing mobility and decreasing pain.

Conclusion

Over a 6-month period, 25 patients received group physical therapy as part of a multidisciplinary treatment approach for the management of chronic pain. Both the PROMIS Pain Interference Scale and the AM-PAC Basic Mobility Outpatient Short Form improved significantly from baseline evaluation to discharge. Thus, group physical therapy, as part of an inpatient psychiatric pain management team, assists with improving patient outcomes of pain and mobility and can be incorporated in chronic pain management treatment plans.

ORCID iD

Ryan Roemmich https://orcid.org/0000-0003-0797-6455

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.*