The role of pain in pulmonary rehabilitation: a qualitative study

Abstract

Introduction

One third of individuals with chronic obstructive pulmonary disease (COPD) report pain. To help inform a COPD-specific pain intervention, we explored the views of health care providers (HCPs) and individuals with COPD on pain during pulmonary rehabilitation (PR).

Methods

This is a qualitative study using inductive thematic analysis. Eighteen HCPs familiar with PR and 19 patients enrolled in PR participated in semi-structured interviews. Demographic data were recorded, and the patients completed the Brief Pain Inventory (Short Form).

Results

1) Interaction between pain and COPD: pain is a common experience in COPD, heightened by breathlessness and anxiety. 2) Pain interfering with PR: a) Communicating pain: HCPs rarely ask about pain and patients are reluctant to report it for fear of being removed from PR. b) PR is a short-term aggravator but long-term reliever: although pain limits exercise, concentration, and program adherence, PR may reduce pain by increasing muscle strength and improving coping. c) Advice and strategies for pain: some attention is given to pain management but this is often counterproductive, encouraging patients to cease exercise. 3) An intervention to manage pain: HCPs were enthusiastic about delivering a pain intervention within their knowledge and time constraints. Early group education was preferred.

Conclusion

A pain intervention seems warranted in PR and may improve adherence and therefore clinical benefit. A pain intervention could be provided as part of PR education with HCP training.

Keywords:

• COPD
• pain
• qualitative
• health care professions
• education
• pulmonary rehabilitation

Supplementary materials

Interview schedule – health care providers

1. Do you believe pain to be a common symptom in individuals with COPD? What do you know about pain in individuals with COPD? If yes, how do you think it affects them? Locations? Severity?

2. A recent systematic review suggests that approximately 66% of individuals with COPD have pain. Does this surprise you? Why?

3. Why do you think patients with COPD have pain? Do you think it is associated with their breathlessness?

4. Do you think participating in PR makes patients pain better or worse? Why?

5. Do you think pain affects patient’s ability to participate fully in PR? How? Please could you provide some examples?

6. Do you ask patients about their pain during their initial assessment for PR or during the program? How important do you think it is that HCPs ask about pain? Why?

7. Have any patients approached you to talk about their pain? How did you respond? Did you feel able to deal with their issues? What would have made you feel more able to offer advice/treatment?

8. Other than the exercises, do you think pain affects any other aspects of PR? How? Education/concentration? Mood/less sociable?

9. Can you describe any strategies or techniques which might help patients manage their pain whilst in PR? Education? Talking to a HCP? Specific exercises? Peer support?

10. If we were to develop a pain intervention which may consist of some education and specific exercises is this something you would be interested in delivering to individuals with COPD? If not, why not? If yes, what additional training/support would you need, if any?

11. Do you think a pain intervention could be delivered within PR or should it be delivered before or after PR? Why?

12. Should a pain intervention be delivered in a group or in one-on-one sessions? Why?

I have asked the questions I have, is there anything you would like to add about pain that we haven’t discussed?

Interview schedule – individuals with COPD

1. You said that you experience pain which is why you have been invited to take part in this interview, can you please begin by describing your pain? What makes it worse? What makes it better? Is it constant or does it fluctuate? Does it come on gradually or all of a sudden? Where is your pain? How does it affect you?

2. Do you think pain is associated with your breathing problems or is it something separate? Why? Does it get worse when you get breathless? Or does your breathlessness get worse when you are in pain?

3. Does pain affect your ability to be active and exercise? How? If not, why, how do you overcome this? Describe?

4. Do you think participating in PR makes your pain better or worse? Why?

5. Do you think your pain affects your ability to participate fully in PR? How? Please could you provide some examples?

6. Does pain affect your ability to exercise at home?

7. Has anyone in the PR program asked you about your pain? How important do you think it is for healthcare professionals to ask about your pain when you are entering this kind of program? Why?

8. Have you talked to anyone in PR about your pain? If not, why not? Health care professional and peers? How did they respond? How did that make you feel?

9. Other than the exercises, does pain affect any other aspect of PR? How? Education/concentration? Mood/less sociable?

10. Can you describe any strategies or techniques you use to try to manage your pain whilst in PR? How effective are they?

11. What do you think might help you manage your pain in PR? Education? Talking to a HCP? Specific exercises? Peer support?

12. If we were to develop a pain intervention which may consist of some education and specific exercises is that something you would be interested in participating in? If not, why not? If yes, what would you expect from the intervention? How do you think it would help you?

13. Should an intervention of this kind be delivered within PR, before or afterwards? Why?

14. Should a pain intervention be delivered in a group or in one-on-one sessions? Why?

15. Who do you think should deliver this kind of interventions? Should it be someone in the PR team or someone separate?

I have asked the questions I have, is there anything you would like to add about pain that we haven’t discussed?

Acknowledgments

This research was funded by Teesside University Research Funds (grant number 15/10/04). DB holds a Canadian research chair from Canada Research Chairs Program.

Disclosure

The authors report no conflicts of interest in this work.