Nonpharmacologic Interventions Help Address Pain Management in COPD

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Dr. Brockway reviews nonpharmacological interventions, such as physical therapy, for pain management in COPD.

Physician’s Weekly (PW) spoke with Kaelee Brockway, PT, DPT, EdD, to understand how the incorporation of palliative care principles into COPD management involves recognizing the importance of non-pharmacological interventions, such as physical therapy, for pain management, emphasizing collaboration among healthcare providers to reduce variability in treatment recommendations, and ensuring timely referrals to appropriate providers.

PW: How should providers incorporate palliative care principles into managing pain for patients with COPD?

Dr. Brockway: Palliative care is disease management. We’ve talked about different ways that physical therapists can help with disease management when it comes to the impairments that result from COPD, but physical therapists are capable of other parts of disease management in palliative care. COPD often doesn’t just come by itself. It tends to come with other conditions like kidney issues, hypertension, and heart failure. Those are all things that we provide palliative care for.

The clinical practice guidelines we reviewed that referred patients to palliative care, which was then left undefined, looked at palliative care as a separate service. But the patients who have chronic diseases, and especially those who have multiple chronic diseases, go to enough doctor’s appointments as it is; they don’t need another service. As crucial as palliative care is, it can be provided by different healthcare providers. So our point is that these people don’t need more doctor’s appointments; they need to get to the people who can provide them the most bang for their buck and the most service for their time. If we can manage their pain, we can manage their activity limitations, we can manage their aerobic capacity impairments, and we can manage their cough. Sending these folks to physical therapy can give them much service for their time.

How do you view the role of nonpharmacologic interventions in managing pain for patients with COPD?

A clinical practice guideline from Spain was the only one that specifically brought up nonpharmacologic interventions. It talked about using things like massage, relaxation techniques, and breathing interventions. These are things that physical therapists provide. Although we don’t provide massage specifically, that’s what massage therapists do. We work on soft tissue problems and help people with those, which is common in folks with COPD. The structural changes accompanying the disease of COPD, such as the structural changes to the chest, result in a lot of muscular impairment that impairs breathing.

As physical therapists, muscles are at the center of our practice. We work on them all the time in this population, but one clinical practice guideline also recommended cough management or suppression.

From a physical therapist’s perspective, we don’t want to suppress cough—that isn’t the goal for patients with COPD. We don’t want them to stop coughing; coughing is how they clear their airways, and if we’re not clearing their airways, we’re going to end up with more significant problems like pneumonia or another COPD exacerbation that’s going to land them in the hospital.

The physical therapist’s perspective on cough is that we need that cough to be effective in clearing the airways, which also takes muscular effort to get behind that cough. It needs to do its job when we need it to do its job so that these folks are not coughing all day long, tearing up their airways, causing bleeding in their soft tissues, and lots of pain and discomfort that go along with that in addition to whatever other pain or discomfort they already have. So that’s what we want to do from that nonpharmacological perspective, especially for pain, is to prevent the pain from starting in the first place by managing cough, not suppressing it, and then treating the pain that’s already there with the potential interventions that we have in our toolbox.

What changes do you think should be implemented in the approach to pain management for patients with COPD?

I think we need to get people to the correct providers to manage their pain. This article was published in Respiratory Medicine and not in a physical therapist journal because physical therapists already know what we do to treat pain. We don’t need to know more about that. We’ve got that down. The people who need to know are the referrers.

Healthcare providers need to know what everyone else is doing for the referral process and how they can help these people manage this pain.

The United States Department of Health and Human Services clinical practice guidelines for pain management emphasize the importance of non-pharmacological and non-invasive conservative care. The most recent US Surgeon General, Dr. Adams, also noted that physical therapists are the front line of non-pharmacological and non-invasive pain management.

For those who have these conditions, they need to go to therapists first for pain management. Physical therapists are direct-access care providers in every state in this country. They are completely capable of screening on a medical basis for people who do not belong in our clinic and can go to any other care provider to get the care that they need. Therapists are happy to get them there and facilitate those referrals.

It’s a team approach. It’s not unidirectional. It’s not just the physicians who make the referrals, it’s also therapists who get patients to them when needed and manage the care as a team.

In Part 1, Dr. Brockway explained how, through optimizing pain management strategies, physicians can better support patients with COPD in their journey towards improved health.