Discussion
chronic pain, pain
CHRONIC PAIN, SECONDARY, EVENTS
Our study examined the effect of PEERC, an intervention designed to improve expectations of PT, on patient report of having had surgery, or being scheduled for surgery (primary outcome). In this manner, PEERC is a novel form of psychologically informed physical therapy as it was not designed to directly address pain associated distress. Our secondary aim was to evaluate the impact of PEERC on expectations and satisfaction with PT outcome, pain, and function. We did not find differences between PT only and PT + PEERC in our primary outcome at six months follow up, nor did we identify between group differences for any of the secondary outcomes included in this trial.There are several potential reasons we did not detect differences between PT and PT + PEERC. Firstly, similar to many studies performed in the 2020 to 2022 timeframe [Third, we used an A versus A + B design to measure the effectiveness of the addition of the PEERC intervention. In theory, this design allows the investigators to understand better the true, isolated ‘effect’ of the “add-on” intervention [The hallmark of the PEERC intervention is the targeting of maladaptive cognitions and provision of compensatory pain management strategies for those with ongoing pain in order to improve patient expectations for treatment. Our pain catastrophizing (PCS) baseline measures were low for the PT arm (10.24; SD = 9.44) and even lower in the PT + PEERC arm (7.89; SD = 6.73). It has been suggested that pain catastrophizing scores of 30 or greater are considered clinically relevant level of catastrophizing in populations with chronic pain [Considered as a whole, the baseline characteristics of our study population suggest there may have been a “mismatch” between the patients we recruited and the goals of PEERC. That is, a majority of the study sample (70%) told us at baseline that they were not interested in having surgery and already had reasonably high expectations of PT care delivered by physical therapists. Simply stated, there is chance that the PEERC intervention is potentially beneficial, but the study was conducted with a population who is not as likely to need or benefit from it.We noticed a number of intriguing issues during implementation of the PEERC health coaching. Although PEERC included six visits, over a six-week timeframe, with phone calls serving as the medium, it was clear that in multiple occasions, patients did not participate in the PEERC health visits at the level that we had hoped. Despite requests to dedicate time to the full session (as outlined in the daily fidelity sheets), there were several times in which PEERC calls occurred during inopportune times; 1) while the patient was driving a car, 2) attending or coaching their youth’s sporting events, 3) while at work, 4) while cooking dinner, or 5) during other activities in which they multi-tasked the cognitive behavioral strategies of the PEERC with other daily activities. There were multiple occasions where a lack of preparedness from the patient was evidenced in the PEERC homework activities. This may be related to our selection of a phone to interact with the PEERC group. Although the use of phone allows broader accessibility, in situations such as cognitive behavioral based approaches, where non-verbal cues relationship building between patient and provider are known to enhance treatment, video may be a better alternative [