Chronic pain can cause substantial disability and adversely affect quality of life among people living with HIV (PLHIV).1–4 Pain management has become a treatment priority in HIV care and in recent reports estimate chronic pain to affect between 39% and 85% of PLHIV compared with only 11.2% of the general population.5 , 6 Despite outstanding advances in antiretroviral (ART) treatment and life expectancy for PLHIV, there are gaps in reach regarding the etiology, pathophysiology, and successful mitigation of pain in this patient population.7 Prescription opioid misuse appears to be more common among PLHIV, likely due to complex comorbidities of HIV itself, histories of substance abuse, and/or mental health challenges, making alternative methods of pain control even more essential in this population.8 , 9 As in the general population, opiate analgesics are not indicated for long-term use among PLHIV. While chronic opioid therapy is common among PLHIV, it remains poorly studied; even when PLHIV receive pharmaceutical pain treatment, they are still likely to persistently report high levels of pain, suggesting that current strategies to manage pain among PLHIV are inadequate.10 , 11
While physical therapy (PT) is widely used as a safe, cost-effective, nonpharmacologic alternative for chronic pain management in the general population, there is a paucity of research in the area of PT as chronic pain mitigation and opioid use outcomes.12–14 Recent studies encouragingly point to the use of PT for chronic pain management among PLHIV, and it is essential to further investigate specific PT interventions and multidisciplinary collaboration to address the intersection of HIV, chronic pain, and opioid use.15 , 16
The patient was a 64-year-old, virologically stable, HIV-positive man enrolled at the Grady Health System Infectious Disease Program (IDP) at the Ponce de Leon Center, a multidisciplinary HIV clinic in Atlanta, Georgia. The patient was diagnosed with HIV in 2005, 12 years prior to this report. At the time of this study, the patient was on the ART regimen of Prestiza (darunavir), Norvir (ritonavir), and Epivir (lamivudine). The patient's viral load remained undetectable throughout the intervention period, and his CD4 count ranged from 369 to 313 cells/mm3. Aside from HIV, the patient's medical history was significant for controlled hypertension, controlled diabetes mellitus, and a history of fungal sinusitis, which requires him to be on long-term antibiotics. The patient had stable food and housing and lived alone in an apartment. He reported positive social support from a sibling and 2 close friends; however, he reported periods of loneliness and depression. He was followed by a mental health counselor at the Ponce Center for intermittent depression and psychological support.
The patient was referred to PT for chronic pain secondary to a 15-year history of bilateral lower extremity distal sensory polyneuropathy, as well as 5-year history of chronic lower back pain. The patient had lumbar spine magnetic resonance imaging on the same week as the initial evaluation, which revealed L3/L4 disc bulge without spinal canal narrowing, L3/L4 left neural foraminal narrowing, and multilevel mild degenerative joint disease.
The patient signed an informed consent form to voluntarily be the subject of this case report after guided ethical information was provided. The CARE checklist (see Supplemental Digital Content 1, available at: http://links.lww.com/REHABONC/A13) was closely adhered to in the writing of this case report. The patient expressed readiness to decrease opioid use and understood that the goal of the intervention was to both decrease pain and wean opioids.
The patient received all medical care—including PT—at the Ponce Center, which is the largest, most comprehensive ambulatory outpatient HIV/AIDS facilities in the nation with an enrollment of nearly 6000 individuals, all with a history of AIDS. Nearly 90% of enrolled patients pertain to ethnic or racial minority groups, 42% are uninsured, and 64% are below 100% of Federal Poverty Level. The clinic is located at an identified HIV cluster in Atlanta, and more than 70% of HIV-positive individuals residing in Atlanta live within 2 miles of the clinic.17 Physical therapy has been available on a weekly basis at the IDP since 2014. The PT treatment room has an adjustable treatment table, a blood pressure monitor, a pulse oximeter, and PT equipment such as varying levels of resistive exercise band, therapeutic tape, and prefabricated orthoses.
The patient's PT goals were as follows: (1) to be able to perform functional activities such as walking and housecleaning for more than 30 minutes without needing to rest; (2) to be able to stand long enough to cook himself nutritional meals; (3) to sleep through the night (≥7 hours) without awakening from pain; and (4) to gain independent pain management skills for home.
CLINICAL FINDINGS AND DIAGNOSTIC ASSESSMENT
The patient reported that Vicodin (hydrocodone bitartrate and acetaminophen), a prescribed opioid analgesic, was the only entity that decreased his pain. He had never tried PT for pain management previously and was reluctant to decrease his Vicodin dosage for fear of pain becoming unremitting and unbearable. At the time of initial evaluation, the patient was setting his alarm clock for 5:00 AM, at which time he would take 1 Vicodin tablet to prevent the pain from developing. He would then go back to sleep for 2 hours, with the purpose that he would awaken later without pain. He would then take another Vicodin at 12:00 noon, and again at 8:00 PM.
Initial PT examination revealed no impairments in range of motion or strength in the trunk and extremities. The patient's chief complaints were inability to sleep through the night secondary to lower extremity pain and inability to do any type of physical activity for more than 30 minutes without rest breaks secondary to pain. The patient's reported significant distress from his lower extremity pain (average 10/10 on the Numerical Rating Scale) and slight (average 3/10) lower back pain. Within the year preceding the PT intervention, the patient had been prescribed Lyrica (pregabalin) for his neuropathic pain; however, he could not tolerate the side effects and ceased use.
At the time of the PT encounter, the patient had a prescription for Vicodin twice a day (90 pills per month), taking 3 tablets per day for the past year. Vicodin is an oral opiate tablet comprising hydrocodone bitartrate and acetaminophen, USP 5 mg/300 mg. At 3 tablets per day, the patient was taking 15 mg of hydrocodone—or 15 morphine milliequivalents (MME)—per day. Morphine milligram equivalents are used to equate different types of opioids into one standard value, allowing for comparisons and risk evaluations. It is widely recognized that daily opioid dosages close to or greater than 100 MME per day are associated with significant risks of overdose or misuse.18 While standards currently do not exist for what constitutes “significant” opioid decrease, it is clinically accepted that a decrease of 25% in MME over time is considered a safe and successful tapering.19
After the initial evaluation, the patient participated in a 24-session PT intervention that comprised weekly visits including manual therapy, progressive\resistive exercise components, home exercise program (HEP), and self-pain management. The intervention comprised weekly visits (with some weeks off due to patient or therapist conflicts and/or holidays) over a 7-month period. The patient reported completing HEP at least 6 days per week once or twice daily. The patient had blood pressure and heart rate taken at the beginning of each treatment session; vital signs were stable at each visit (Table 1).
The timeline for opioid use and pain reports is elaborated in Table 2; however, further detail is warranted to fully describe the patient's opioid weaning process. Upon initial evaluation, the patient was taking 3 Vicodin tablets per day. By session 5, he agreed to decrease Vicodin dose to 2×per day by cutting out the 5:00 AM dose. By treatment 10, patient reported that he was able to distract himself from pain by watching television, walking around his neighborhood, and performing light housework. By this time, he reported that he could delay opioid use by 2 to 3 hours after using the transcutaneous electrical nerve stimulation (TENS) unit. At 2 points during the intervention period, the patient agreed to try eliminating Vicodin completely. However, upon trialing this, the patient experienced significant, distressing lower extremity pain that prevented him from sleeping through the night. This also increased his anxiety and overall distress levels.
Patient education focused on nonpharmacological chronic pain management. The first step of this was to encourage patient to cease taking the analgesic as a preventative measure—in other words, to stop taking it in anticipation of pain, when he was not currently experiencing pain. By ceasing to set his alarm for 5:00 AM and allowing himself to wake up naturally, he was able to observe that he actually did not awaken in pain, therefore, did not need to take this early morning dose. After this, he agreed to delay opioid use until after he had attempted the TENS unit, his stretching program, and diaphragmatic breathing. Upon initial evaluation, we discussed the difference between “taking pills away” versus “not needing the pills as much.” With this framework, the patient understood that the focus of PT was to address chronic pain management as opposed to solely focusing on opioid weaning. It also empowered the patient to know that he was an equal partner—with his needs at the forefront—of his opiate weaning process. The patient agreed to only use Vicodin as a “last resort” after if TENS/exercise/breathing techniques were ineffective.
Throughout the intervention period, the patient's physician and physical therapist had frequent, detailed communication to discuss the patient's progress, typically every 1 to 2 weeks initially and then whenever the patient decreased his opioid use (ie, from 2 to 1 tablet). These phone conversations frequently occurred as part of the patient's PT sessions, which allowed for open communication about goals, progress, and challenges in pain reduction and opioid weaning. With this up-to-date knowledge of the patient's pain management and daily opioid use, the patient's physician decreased the patient's monthly opioid prescription as the patient's pain decreased.
FOLLOW-UP AND OUTCOMES
Outcomes were measured in patient report of pain on the Numerical Rating Scale, opioid use/MME, and functional goals met. Subjective information was gathered verbally at each session, and opioid prescriptions were confirmed through the patient's physician and electronic medical charts. While the patient's pain reports did decrease throughout the intervention, there were noteworthy fluctuations that speak to the complex components of chronic pain.
During the December holiday season (sessions 14-15), the patient reported increased feelings of depression and loneliness, which he attributed to feeling of isolation from his family and friends, and melancholy that he frequently felt during that time of year. During this time, his pain scores increased and he was hesitant to decrease his opioid use from 2 to 1 pill per day. Given that this was a finite period of time (2-3 weeks of the holiday season) and that the patient was feeling significant emotional distress, the physical therapist and the physician agreed that keeping the patient on the same dose was appropriate and that the weaning schedule could be continued after the holidays. The physical therapist provided emotional support and discussed ways for the patient to stay busy during the holiday season, as well as ideas for engaging in pleasurable activities. The patient's physician also contacted the patient during this time via telephone to check in, providing further emotional support and encouragement. The physician, the physical therapist, and the patient were all in agreement that the patient should speak with his mental health counselor during this time, which the patient reported to be helpful and effective in allowing him to process his feelings of sadness and loneliness. The patient had an established relationship with this counselor and had used mental health counseling sessions within the past year previous to this episode.
At the end of the 24-session intervention, the patient reported no pain (0/10). He reported that he was able to do daily tasks such as housecleaning and shopping in addition to walking around his neighborhood for 30 minutes without fatigue or pain. The patient ceased to report pain after session 18 of the intervention and from that point onward, he reported 0/10 pain on the Numerical Rating Scale. The patient showed clinically meaningful reduction in pain on the 11-point Numerical Rating Scale, which is defined by a decreased of 2 points or a 30% decrease on a 0- to 10-point numerical scale.18 The patient was well beyond the clinically meaningful definition, as he had an 11-point—a 100% decrease—in pain.
The patient decreased his opioid analgesic use from 3 tablets per day (15 mg hydrocodone/15 MME) to ½ tablet per day before bedtime (2.5 mg hydrocodone/2.5 MME), an 83.3% decrease in MME. This is well above the recognized marker for “safe and successful tapering” of 25% decrease in MME. While (at the time of this writing) the patient had not fully eliminated opioid analgesia for pain management, he felt that taking ½ tablet of Vicodin at bedtime eliminated his pain at night. Because his pain increased with inactivity, this low dose allowed him a full night of restful sleep.
This case study showed that for a 64-year-old virologically suppressed individual, a 24-session PT intervention of manual therapy, resistive exercise, and multifaceted pain management techniques had positive outcomes in both pain mitigation and decreased opioid use. While PT interventions will typically include therapeutic exercise, soft tissue mobilization, and patient education, this case is unique in the close communication and teamwork of the physician, the physical therapist, and the patient with the common goal of pain reduction and opioid weaning within the context of a multidisciplinary AIDS clinic. By having this type of open and frequent communication, the patient was able to understand that he was a key partner in the treatment team, rather than a passive recipient. The physician's expertise in opioid weaning and HIV care was essential for the physical therapist's understanding of the patient's medical and pharmacological management. In addition, the physical therapist's background in HIV-related chronic pain management allowed for a targeted intervention using PT clinical expertise (nonpharmacological pain management) specific to common HIV-related comorbidities. Finally, the involvement of the patient in decision making about his pain care plan was fundamental to his successful outcomes.
The effectiveness of this team approach was especially highlighted during the holiday season (visits 14-15) when the patient experienced emotional distress and increased perceptions of pain. The approach was ultimately successful for the following reasons: (1) It allowed the patient to freely express his feelings and increased his understanding that with emotional distress, pain perception can increase. (2) Given close communication with the physical therapist and the patient, the physician was aware and agreeable of reasons for a slight pause (2-3 week) in the opioid weaning plan. (3) The patient expressed feeling heard and supported as he worked through his feelings and understood that he had an equal role in guiding his pain management program. The patient's opioid prescription was decreased on the basis of agreement with the patient (when he felt that he could try decreasing it) and the patient's physician, who decreased the number of pills prescribed.
Another point to consider is the patient's readiness for change using the transtheoretical model/stages of change theory as a factor in his success with decreasing opioid use.20 Before the PT intervention, the patient was ready to participate in the PT program and was willing to work to decrease opioid use (preparation stage). During the PT intervention (action stage), he was keenly involved in the actions needed to decrease pain and opioid use. By the end of the intervention, he was committed to maintaining his HEP, TENS use, and decreased opioid dosage (maintenance stage). This particular patient's readiness to change should be considered when considering similar programs for patients who are still in the precontemplative or contemplative stages of readiness to change, as the intervention might not have an outcome as favorable as the patient described in this case study.
The outcomes of this case report should not be overestimated, as it explains 1 specific patient case within an extremely supportive and collaborative clinical environment. Future research is warranted to reproduce this type of study with a larger sample size. The patient in this case study was closely supervised and encouraged by a multidisciplinary team, and the physical therapist had open, frequent contact with the patient's prescribing physician. While this type of close collaboration is not readily available in many clinical settings, it is a key example of the effectiveness of multidisciplinary teamwork, with the patient as an equal partner in the pain management and opioid weaning program. One potential limitation of this study was that pain was only assessed on a weekly average, rather than examining specifics of pain fluctuations throughout the week. In a larger study, a more comprehensive pain assessment tool could be used such as the Brief Pain Inventory.
As life expectancy for PLHIV continues to increase, physical therapists will inevitably treat PLHIV for HIV-related and unrelated impairments, such as those related to the natural aging process. PLHIV are not immune to the effects of the opioid epidemic and are more likely to suffer from chronic pain than their HIV-negative counterparts. Further research is needed to explore the effectiveness of PT on management of chronic pain and opioid use in this unique patient population.
Each PT visit began with the patient being given the opportunity to express any progress and/or concerns about the PT intervention and overall pain management program. The following direct quotations were taken from the subjective portion of the patient's PT notes and give an excellent picture of his perspectives, in chronological order of treatment sessions (evaluation to last treatment):
The TENS machine is good, but ... you can't compare the pills to the (TENS) machine. The pills do help the pain more. That's just the truth.
With less pain, I have a pep in my step!
Now, I reach for the TENS instead of the Vicodin.
Before the PT, I had to take it 3×/day ... now it is ½ pill once a day before bed, and I don't feel any pain at all. I can finally sleep through the night.
I can do whatever I need to do without thinking about the pain, or worrying when the pain is going to come.
I feel like the three of us (physician, PT, and patient) are on the same level. If I have a complaint I can come out and tell you. You will accept it and believe me and give advice. You show me that it is my decision.
The author thanks Dr Vincent Marconi, MD, for consultation and clinical support for this patient's care and case report.
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