Photo Credit: Sudok1

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

Patients with COPD often experience pain, yet current clinical practice guidelines (CPGs) lack comprehensive recommendations for managing it, according to a study published online in Respiratory Medicine. Kaelee Brockway, PT, DPT, EdD, and her colleague reviewed 32 CPGs. Of those, 24 mentioned pain, and of those, only 13 provided recommendations for its treatment.

Common suggestions included opioids, pharmacologic management, and further medical assessment. However, recommendations varied widely and did not consistently align with the latest evidence. Some guidelines also mentioned palliative care, treating cough, and nonpharmacologic interventions like massage and relaxation techniques.

According to Dr. Brockway, it is imperative for physicians to recognize the importance of addressing pain in COPD patients, whether it’s directly related to the disease or not. There’s a need to standardize pain management practices and reduce variability in treatment approaches. Referrals should be made to healthcare providers who can effectively manage pain and improve the quality of life for COPD patients.

Physician’s Weekly (PW) spoke with Dr. Brockway to better understand how optimizing pain management strategies can help physicians better support COPD patients in their journey toward improved health and well-being.

PW: How do you approach pain management in patients with COPD?

Dr. Brockway: We try to take an individualized approach to people’s pain when it comes to COPD. Pain can take two major forms—It can be because of their COPD or because of the treatment for their COPD. There are specific drugs given to people who have COPD that cause muscle spasms, which result in pain. Sometimes it is about managing and treating within what we’re capable of.

COPD comes with pain in and of itself. Some of these patients are coughing so hard that they tear up their airways; they can even cause their own internal fractures of their ribs or their spine.

A lot of these clinical practice guidelines don’t look at pain holistically, and they don’t look at people who have COPD holistically because they don’t recognize that people who have COPD can have pain from other things. They may have osteoarthritis and knee or back pain that has nothing to do with their COPD, but that creates the frame through which they do everything else.

It doesn’t matter where the pain is coming from, we try to address it to the individual needs of that person.

Were you aware of variability in pain management recommendations for COPD patients?

We were going through the literature and finding that no one was talking about pain. From a physical therapist’s perspective, it was hard to understand because we know these people have pain for various reasons. We were not aware that we may be one of the only providers looking at pain in this population from a holistic perspective. We make assumptions that healthcare providers know what other healthcare providers do, but that’s not the case. Physicians creating practice guidelines are looking at what physicians do, and that’s exactly what they should be doing.

However, that is the purpose of creating a physical therapist-specific practice guideline—we are looking at the management of that condition from the perspective of what a physical therapist can do. Treat pain in this population is a huge component of the disease management process for us. Now, of course, we do many of the other components of disease management for people who have COPD, like cough management, making coughs more effective so people don’t have to cough all day long, clearing airways, managing secretions, and then really just getting back to normal activity. Then the number one deficit in people with COPD is poor aerobic capacity and poor activity tolerance.

Our goal is to get these people back to moving effectively and efficiently regardless of whether that means moving through their house to get to the bathroom, moving to their doctor’s appointment, or even moving oxygen in and out of their lungs or blood from their heart to their lungs to the muscles in their body they need to use. We manage that part.

What are your thoughts on recommending opioids for this patient population?

We absolutely acknowledge that opioids may have a place. Opioids aren’t just used to manage pain in this population; they’re also used to manage cough. We’ve been using opioids to manage cough for a long time, but we also know that there are other ways to manage cough that don’t come with the risks and side effects that opioids bring, like constipation and central sensitization of pain. Those are things that we end up having to treat because opioids are present, which we wouldn’t then have to treat if they weren’t. There are nonpharmacologic ways to manage cough. That’s part of what we do as physical therapists, and there are also pharmacologic ways to manage cough that don’t bring along all those adverse effects.

While we acknowledge that they can serve a purpose and play a role, we really want to emphasize that there are other and probably better ways to manage cough in this population. The US Department of Health and Human Services pain management guidelines agree with that.

In Part 2, Dr. Brockway discusses nonpharmacologic interventions to help address pain management in patients with COPD.