As the COVID-19 pandemic sweeps around the globe, shuttering schools and businesses, pain clinics and therapists’ offices have closed, too. As a result, people with chronic pain swiftly lost access to their usual care, necessitating a rapid shift to telehealth interventions. For chronic pain, these can range from a phone or video chat with a provider, to remote support group meetings, to mobile apps designed to help patients self-manage their pain condition.
In response to this rapidly changing environment, a group of pain researchers and clinicians have published a topical review in the May 2020 issue of PAIN, bringing some guidance on remote pain care for providers. In the review, they consider the public health consequences of COVID-19 for people with chronic pain, as well as the implications of the halt of usual pain care. The article also outlines the available options for remote care and the evidence supporting those therapies. The article is freely available and includes a video and slide decks in three languages (English, Spanish, and Mandarin).
Christopher Eccleston, a pain psychologist and researcher at the University of Bath, UK, headed the team that authored the review.
“The paper’s focus is on the front-line, immediate effect of closing pain clinics’ doors. We tried to use the language of, ‘Keep your doors open, or at least keep your doors ajar.’ It was pragmatically about trying to get good advice to people who need it immediately,” said Eccleston.
Tonya Palermo, a pediatric pain researcher at the University of Washington, Seattle, US, and a co-author of the review, said that the pandemic opened the way for telehealth overnight after years of efforts to move in that direction.
“We’ve known for many years that access to pain care is very limited across populations, so there’s been a really big push for several decades to try and come up with remote approaches, using both the Internet and mobile apps. Patients and families are often struggling to find appropriate care that’s evidence-based at home, so this provides a flexible opportunity,” according to Palermo.
Patients “very happy to be seen this way”
Some providers might be hesitant to use telehealth interventions simply because the clinicians are unfamiliar with these approaches, Palermo said.
“We wanted to provide guidance to providers who maybe had never explored it before to think about telehealth. We saw it as an opportunity – telehealth approaches can continue to serve patients by addressing limited in-person access to care – but we also recognize that lack of familiarity will make some providers hesitant and really unsure of how best to approach care of patients at this time.”
Providers are being pleasantly surprised by the effectiveness of remote care, Palermo added. “They’ve realized that, wow, they can still accomplish a lot, and I think they’re encouraged by the receptivity of patients. Patients are very happy to be seen this way. So for some who are new to this area and worry they can’t provide an adequate visit, I think they can be reassured that in fact they certainly can.”
Kat Gloor is one such patient happy with her remote care for chronic pain. “I feel guilty about this, but I feel better than ever,” she said. Gloor, who oversees annual giving for a small liberal arts college, has lived with trigeminal neuralgia since 2015, and she developed complex regional pain syndrome (CRPS) after breaking her elbow last year.
Before the pandemic, she was seeing a physical therapist twice per week, but has now moved to online therapy. Gloor, who lives in rural Ohio, appreciates getting her care from home and doesn’t miss the hour-long drive to her appointments. “It’s much nicer to wait on your couch than in a waiting room,” she added. And, with remote care, Gloor also took the opportunity to see different physiotherapists based in totally different places – one in Chicago and one in the UK.
Remote care options are particularly necessary during quarantine, Palermo said.
“At this time when parents are home with kids, there’s a real limited ability to go to an appointment for a variety of reasons.” But patients have long wanted the option, explained Palermo. “We’ve learned over the past decade in our research that, for patients, the convenience of being able to receive care at home is something that they desire. They want access to high-quality care, and they often don’t have it in their own communities, so this fits a need they’ve always had.”
That’s true for Gloor, who also plans to explore online options for a support group. “I was desperately looking for support groups in my area, but there aren’t any.”
Not all approaches to pain care are available for remote delivery, of course. Massage therapy, water-based exercise therapy, and steroid injections are just a few examples of interventions requiring in-person treatment that are currently unavailable.
Telehealth can’t entirely replace in-person care, even for behavioral therapies, said Beth Darnall, a psychologist at Stanford University School of Medicine in Palo Alto, US, who was not an author of the review.
“It’s important to recognize that there’s real value in our in-person treatments, where we are accessing the in-person dynamics, making eye contact, shaking hands, saying their name, greeting family, showing caring and support, and being welcoming,” Darnall said. “These can all fundamentally alter one’s emotional state, one’s sense of belonging and connecting to the therapist. The challenge is how to preserve the magic of this in-person treatment as we transition to online delivery platforms.”
Then again, she said, “as wonderful as in-person care can be, there’s necessarily a gap in treatment access; it can be days or even months after getting a referral before anyone can act on that. That’s what I love about technology: It can fill these gaps and provide rapid access to care. It will never fully replace in-person care for all, but it can greatly enhance our traditional systems.”
Another challenge for some people is mastering the technology. Carrington Reid, a geriatrician at Weill Cornell Medicine, New York City, US, and a review author, said his patients’ average age is about 85.
“The challenge is that not all older people have online access or feel comfortable using technology. Maybe one in five have the technological skills to use a video link, but the majority don’t,” Reid said.
Breaking barriers overnight
There is at least one additional bright side to the difficult challenge that the pandemic has created for traditional pain care.
“One silver lining of all this is that hospitals had been really pretty resistant to teletherapy, until this pandemic happened, and now everyone’s embracing it,” said Robert Jamison, a psychologist and researcher at Brigham and Women’s Hospital and Harvard Medical School, Boston, US, who was not an author on the new review. “The coronavirus pandemic pretty much forced the issue a bit, so in some ways it’s an experiment to figure out how it works.”
Eccleston agreed. “This pandemic has immediately taken away attitudinal barriers and institutional barriers,” he said. “When this pandemic hit, it almost felt like those barriers went away overnight. It wasn’t, ‘I’m not sure we can do this.’ It was, ‘Let’s get this done!’ And I think we have to capitalize on that.”
“In a very short time, we broke down a lot of the barriers,” agreed Palermo.
Those barriers included concerns about security and privacy, and also issues related to licensing of healthcare providers, insurance, and reimbursement. Previously, certain technologies were “deemed not secure enough to be used by healthcare professionals,” Palermo said, “but we’ve also broken down some of the barriers for psychologists to practice across state lines, which has been a decades-long struggle. Providers are really being pushed right now to figure out a solution, so I’m hopeful that these solutions will be maintained in the future.”
“In countries with insurance-based healthcare systems,” Eccleston added, “they’re still having trouble with billing and knowing how to suddenly change how they get the money flowing. In the past, that was seen as a reason not to do something, but now it’s a reason to say, ‘let’s fix that.’”
Limited yet promising evidence
So patients are keen on telehealth, and as the barriers have come down quickly, providers are now much more readily using this approach. But how strong is the evidence for telehealth?
“This review points out that there is an evidence base” in support of telehealth care for chronic pain, said Reid. “It’s not as strong as we’d like, but it’s better than nothing. It certainly provides strong support for more research to figure out how to harness technology as a way to deliver interventions, monitor outcomes, and assess pain and symptoms over time.”
While the evidence base is limited, it does suggest that remote care can be similarly effective for pain management as in-person care.
For example, Jamison had previously evaluated the effectiveness of remote versus in-person group cognitive behavioral therapy for chronic pain management. He found that “both groups did just about equally well, and there were some definite benefits for people in the remote session,” such as obviating the need to travel to a clinic and affording patients more freedom to care for family at home. “There was also slightly less dropout, so there’s an argument for more compliance,” Jamison added.
Some patients, like Gloor, even report that they had a better experience online than in person, because they received more one-on-one attention.
“What I value more than anything is knowledge and conversation. In a regular 10- to 15-minute appointment, there’s no time for that,” Gloor said.
Palermo said the evidence that does exist in support of remote pain care puts providers in a better position than those in some other areas of medicine.
“We’re fortunate to have had some evidence base already developed for remotely delivered treatments, so we at least were positioned to be able to fairly rapidly make some recommendations on how to move forward,” she said.
Continuity of care
Importantly, the review considered the downsides of simply not treating people with chronic pain during the pandemic.
“At some level, there’s this fantasy amongst some health planners that if you ignore chronic pain problems, the patients will go away,” Eccleston said. “What we’re trying to say as clearly as possible is that spontaneous recovery is extraordinarily rare. People simply don’t just get better if you don’t do anything about it – in fact they get worse.”
Providing remote care makes financial and medical sense, too, said Jamison, particularly at a time when telehealth may be the only treatment option.
“Working with people early on helps for chronic pain care in general. If you take two people and match them pretty closely, one with minimal pain and the other with severe pain, the one with severe pain is three times more expensive to treat. There’s an argument that if you can treat it early, you’ll save money and reduce overall healthcare utilization.”
Losing access to treatment during the pandemic could be especially harmful, said Palermo.
“We wanted to push providers to think about the negative consequences of halting care right now. Not only do we worry about the negative consequences of pain being untreated, but we also know that during this time, a lot of psychological symptoms are going to emerge that either weren’t there before or are going to intensify during this period of isolation and extreme disruption in routine,” said Palermo.
Darnall agreed. “In this time, people are under vastly more stress and distress, and they have reduced access to care at a time they need it more than ever. So there’s an ethical imperative to supply access to care for people with chronic pain. The imperative is on healthcare systems to flex so we meet the needs of a population in their heightened time of need.”
That added stress could worsen pain, said Reid. “Stress levels are uniformly higher, the uncertainty adds to it, and that invariably makes pain worse; with negative emotions, pain levels go up.”
Self-management: rewards and challenges
The sudden move to telehealth has forced pain care to rely more on self-management by patients – a move that, ironically, has long been recommended by experts but had not yet been realized.
“This really reprioritizes the kind of strategies we use,” Palermo said. “Self-management has now been elevated to a higher priority than in the past. That’s very different from the way care has been previously offered. We can appropriately help patients understand that there are many things they can do to help their pain condition and provide access to these tools.”
Aside from the issues of security and privacy, the risks of remote care are low, but the motivation and self-discipline needed to self-manage pain also pose a challenge, Palermo said.
“The treatments themselves are fairly low risk; they’re mostly behavioral interventions. But I think another risk is that they rely on self-motivation. These are tools that a person needs to engage with, and it can be challenging to sustain that. That’s where a clinician can play a really important role in holding a patient accountable, setting assignments or goals, and connecting with the patient around how self-management interventions are working,” according to Palermo.
Gloor can identify with the challenge of self-reliance.
“Personally, I find it can be hard to get through the exercises in an empty room, so I connected with some other patients in the UK, and we chat while doing the exercises,” according to Gloor. On the other hand, she said, “In a strange way, I feel an increase in my own self-efficacy. There’s an opportunity to feel like I’m participating more fully in my health. I feel more empowered now.”
A permanent shift?
Both researchers and patients hope that the sudden shift to remote care won’t simply be reversed when the pandemic has ebbed.
“What we’re starting to see now is that this goes much further” than simply providing care during the crisis, Eccleston said. “People are shifting priorities. There’s a positive message here: Let’s not just ramp back down as if nothing changed when the immediate pressure subsides. We also need to prepare for a backlash against telehealth and telemedicine. It may be inevitable to see a return of excess caution when telehealth is a choice, not an imperative. We need to learn and take what’s good from this natural experiment.”
That might include devising new uses for technology in pain care, Eccleston added. “The real prize here is not our current solutions. Right now we’re just thinking of how to replace face-to-face care with technological alternatives, but really the future question is how to personalize treatments by using technology and communication more effectively.”
That effort will include getting patient input, as well as stretching the use of new technology. “We want to make use of this technology – and it exists. For example, we can employ remote assessment using face processing, body posture assessment, and non-verbal utterances. We can look at the quality of consultations and investigate what improves those episodes of care. And we could even explore links with other existing databases for primary research, such as genetic information. And we are currently building virtual reality environments, which can provide a rich context for therapy delivery. The possibilities abound,” Eccleston said.
“It’s a real tragedy, and there’s economic fallout,” Jamison said of the pandemic, “but there is a silver lining in being able to understand how eHealth will be utilized. We’re going to learn a lot. It’s going to be part of the future for sure. A lot more therapy is probably going to go on this way; this is the new normal.”
Will behavioral interventions and self-management techniques in fact take a bigger role in pain management after the pandemic?
Reid says that patients will “vote with their feet once they can get back to the clinic for a steroid injection, and we’ll see whether this natural experiment will lead to a fundamental change in preference that people want to use to manage pain. A silver lining could be that people, by necessity, have to gain skills in technology, which will push those who historically have not learned to use the tools to use them, become less fearful of them, and more willing to view them as positives.”
As for Gloor, “I really do hope that things shift,” she said, “and that it’s not something that we go back to,” referring to the pre-pandemic way of managing pain. “As a rural patient, I find remote care very helpful.”
Does she think that shift will happen? “A girl can dream.”
Stephani Sutherland, PhD, is a neuroscientist and freelance journalist in Southern California. Follow her on Twitter @SutherlandPhD