Photo Credit: mi-viri
Dr. Kaelee Brockway and Dr. Shakeel Ahmed discuss the overlooked benefits of referring patients with COPD experiencing pain to physical therapy.
Pain management in patients with chronic obstructive pulmonary disease (COPD) presents unique challenges. In a review published in Respiratory Medicine, Kaelee Brockway, PT, DPT, EDD, and Shakeel Ahmed, PT, PhD, examined clinical practice guidelines for this patient population and found that many pain management recommendations are inconsistent with current evidence and best practices.
In light of these gaps, Physician’s Weekly (PW) spoke with Dr. Ahmed and Dr. Brockway about how clinicians can improve pain recognition and management in their patients with COPD.
PW: What are some challenges when managing pain in patients with COPD?
Dr. Brockway: The biggest challenge we face, as physical therapists, is that we tend to get to these patients too late in the game. We don’t get the chance to prevent this pain from ever becoming an issue for them. We don’t get a chance to be the primary providers that address pain in people who have COPD.
As physical therapists, we manage four major systems: the musculoskeletal, the neuromuscular, the cardiovascular and pulmonary, and the integumentary systems. The cardiovascular and pulmonary systems represent about 25% of our practice, and we are usually excited to be one of the first to help manage pain in people with chronic diseases. It just so rarely happens.
Dr. Ahmed: To add to that, the major problem or complaint that patients with COPD show up with at a clinic is not pain. It’s breathlessness. Breathlessness supersedes any other complaint they might have. That could be one of the reasons why we see few of these patients being treated for pain.
Why do you think there is variability in pain management recommendations across COPD guidelines?
Dr. Brockway: Clinicians see patients with COPD and pain differently. Our article pointed out that pain can be part of the COPD diagnosis in and of itself. All the coughing can produce musculoskeletal and bodily pain, but patients can also have chronic or acute pain not related to their COPD.
Often, clinicians who are gatekeepers tend to have a narrower view of the patient. Physical therapists don’t always get to have access and see patients holistically for their COPD, pain, chronic disease, and all their other comorbidities and determine whether their pain is related to COPD.
Dr. Ahmed: When a patient with COPD walks in, clinicians anticipate a typical set of concerns, often including symptoms like breathlessness, fatigue, difficulty climbing stairs, or needing help with daily tasks. While pain is sometimes mentioned, the focus initially tends to be on managing these primary symptoms, with pain management addressed as part of the overall care plan.
Dr. Brockway: The one common thread across all the recommendations we reviewed was that everyone included in their patient population had trouble with activity tolerance. We are the primary providers who address activity tolerance, so you would think that referral to physical or occupational therapy would be at the top of the list for what these patients need most. Unfortunately, we don’t see that in practice.
Which pain management approaches are most recommended for patients with COPD? Are they effective?
Dr. Brockway: Opioids are, unfortunately, still most recommended right now. Opioids are the number one recommendation, even though it is completely against the Department of Health and Human Services’ Management of Chronic Pain clinical practice guideline. Opioids are not supposed to be a first-line treatment for pain. We don’t need to perpetuate the opioid epidemic, and we also don’t need all these medications to be out in the world.
I’m not saying we don’t need to treat the pain. We absolutely do. But the Department of Health and Human Services recommendations say that we should consider more conservative measures first before we opt for opioids, surgery, and other pain treatments.
Regarding COPD, only one country in the whole list of clinical practice guidelines used non-pharmacological conservative management first: Spain. Providers in Spain used massage exercises, breathing techniques, and other conservative interventions for their patients with COPD who had pain, and they had equal success as everybody else without opioids.
Dr. Ahmed: While opioids can be a treatment option, they should not be considered the primary approach. It is essential to consider the potential effects of opioids on respiratory function, as these medications can suppress breathing if the dosage is not carefully managed even in individuals without underlying respiratory issues. Patients with COPD already experience compromised breathing, which could be further impacted by opioid use. In severe or refractory cases, opioids may be considered if other treatments are ineffective, but they should not be the first line of treatment.
Dr. Brockway: As physical therapists, we’re not primarily involved with the prescription of medications. We help and work with prescribers on managing the medication profile and what is in the patient’s best interest. But we are not the primary prescribers. We acknowledge there are roles for opioids and that they also can reduce cough, which could be very useful.
But from a physical therapist’s perspective, we don’t want to reduce cough in people who have COPD. We want to manage cough because cough is important for clearing the airways. If we constantly suppress someone’s cough, they will be at a higher risk for pneumonia and other side effects. We would rather use opioids sparingly to help people manage cough when they need to sleep, have doctor’s appointments to travel to, or need to be talking a lot—times when patients can’t be coughing and managing their disease. But opioids are not supposed to be a long-term solution.
How can clinicians use non-pharmacological interventions for pain management?
Dr. Ahmed: An important step is to refer these patients to physical therapy. Many physicians recognize the benefits of physical therapy strategies in managing pain, commonly referring patients with conditions like rotator cuff injuries or ankle sprains to physical therapists to address pain and functional limitations. This approach should also be extended to individuals with chronic respiratory diseases who experience pain as part of their symptom profile. This would be a valuable first step in ensuring that patients who currently lack access to physical therapy receive comprehensive care for pain and other symptoms.
Dr. Brockway: As far as specific interventions go, every person experiences pain differently, so treating it with one blanket intervention isn’t effective. The bonus of physical therapy is that we look at pain through an individual patient’s lens and help them manage it from various angles. We work with them alongside their pharmacological interventions to help with pain management over an entire day. There are also plenty of exercises, breathing techniques, airway clearance techniques, graded motor imagery, and neuromuscular pain management techniques that we can apply to help with pain management from the perspective of every system.
Dr. Ahmed: If somebody has COPD or any chronic respiratory disease, their physical function is significantly limited by breathlessness. As a natural response to that symptom, most of these patients avoid doing activities that make them breathless. For example, if I know that I become severely breathless if I climb one flight of stairs, my natural response to that is not to climb one flight of stairs. That activity avoidance, over time, contributes to physical deconditioning. Further, as our patients age, they become less mobile, and reduced mobility is accompanied with structural adaptations in various musculoskeletal tissues in our body, which exacerbate pain. If we manage breathlessness earlier, we can ensure that these folks remain physically active, thereby preventing physical deconditioning and maladaptations of the musculoskeletal system.
What should clinicians know about the use of palliative care in COPD?
Dr. Brockway: The Dutch COPD management guidelines showed that palliative care was the primary method of management for people with COPD and heart failure. At its core, palliative care is chronic disease management.
Physical therapists provide chronic disease management for patients with COPD by helping them manage not just the pain of their disease but also breathlessness, activity intolerance, and airway clearance. We help them with their medication administration and strengthen their breathing muscles. Patients who have trouble breathing tend to not breathe nearly as deeply. They start to use all the wrong muscles for breathing. We help them retrain their breathing to have less breathlessness, more strength, and a more effective cough.
When it comes to chronic disease management in COPD, physical therapists shine. We have many manual therapy techniques and many ways to address these deficits. Palliative care is a huge part of our role. I hope that, as a profession, we take strong ownership of this role for patients with COPD.
Dr. Ahmed: The bottom line is managing symptoms because these diseases are progressive. Patients’ physical function will decline with time and age unless significant interventions are incorporated into their treatment. Symptom management is crucial to ensure patients don’t become sedentary due to breathlessness. If I had to summarize Dr. Brockway’s wonderful description of palliative care, I think it would be breaking that vicious cycle where “breathlessness limits physical activity, leading to reduced mobility and deconditioning, which in turn exacerbates breathlessness”.
Dr. Brockway: The great thing about physical therapy is that we work in every single setting where healthcare is delivered. We’re with the patient in ICU, acute care, emergency department, skilled nursing, subacute rehab, and their home. We’re also with them in outpatient rehab or pulmonary rehab programs. We can provide palliative care at any point along the way and all points collectively. There is nothing more meaningful to patients who have trouble breathing than learning how to breathe and function better where they live.
We manage functional tasks and help patients manage their oxygen delivery. Most patients are on supplemental oxygen, and it can be a huge change in someone’s life to have to drag a tube around with them everywhere they go or carry a canister or concentrator. Those things are heavy and can be hard to carry if you’re deconditioned. We work with oxygen supply companies to make sure those delivery mechanisms are optimal for the patient, not just when they’re in their home but when they leave, too. That’s something you never really get to see if you’re not a provider in the home.
Is there anything you want to add about how we can improve pain management practices for patients with COPD?
Dr. Ahmed: Pain could be a consequence of COPD, or it could be a separate entity altogether in a patient who has COPD. I think that is something that we need to be more aware of.
Dr. Brockway: We also have a unique perspective because we see patients with pain differently. We’re used to trying to find the source of the pain and address it. Primary care physicians may not have time to dig deep into those rabbit holes. We have the time, and we’re happy to do it. We are afforded the luxury of time when it comes to our patients so we can determine whether it’s a COPD-specific symptom or a separate issue that must be treated in a completely different way.
I want providers and prescribers to know that this is something that we do. A lot of people see physical therapists as people who help with ACL reconstructions, knee replacements, and shoulder replacements, and we do all those things, but those are only 25% of the body systems that we manage. The cardiopulmonary and vascular system is 25% of our job. It is one of the primary things we do. Please send us those patients. We want to help them.
Dr. Ahmed: It’s 25%, but it’s the most important system because if you can’t breathe, nothing else matters.
