Chronic Musculoskeletal Pain Management: Integrating Mental Health and Behavioral Interventions

Chronic pain affects roughly 1 in 5 Americans. Nearly 10% of people experience high-impact, extreme pain that substantially restricts their daily activities. Yet, despite its prevalence, our healthcare system often struggles to provide effective, long-lasting pain solutions. It is ironic that for something so common, we as a healthcare industry are often surprisingly ineffective at addressing it.

As a physician specializing in non-surgical MSK management and a clinical leader of an MSK value-based care specialty solution, I’ve witnessed vast inconsistencies in addressing high-impact and ongoing MSK pain.

However, what I have seen is that when treating each patient’s pain holistically, considering all physical, behavioral and psychological factors, we can achieve greater results. To achieve these outcomes, we need a fundamental reframing of how we approach MSK disorders and the pain they cause.

All MSK Pain Is Different

Understanding that each patient’s MSK pain is unique underscores the importance of tailored approaches. Yet, many primary care physicians (PCPs) need more resources, time, and training to manage the complex and highly variable causes of MSK pain effectively. Many are unfamiliar with – or have no professional relationships with – every type of specialist who can help a patient with an MSK-related issue.

My specialty, Physical Medicine and Rehabilitation (PM&R), is a perfect case in point. Often referred to as rehabilitation medicine, physicians in this specialty treat a wide variety of medical conditions, including those affecting the musculoskeletal and nervous systems. Many PM&R physicians subspecialize in areas including sports medicine, pain medicine, spinal cord injury medicine, and neuromuscular medicine.

Physical therapy is another. Many in the healthcare system are unaware of the breadth of interventions a physical therapist may utilize to assist patients with MSK issues.  

The Behavioral Health Component

Meanwhile, no matter the MSK-related medical specialty or subspecialty, a patient’s mental health significantly affects their chronic pain management and the types of behavioral health interventions that can help patients.

Any physician can recount stories of two patients with identical MSK disorders and physical attributes but who report widely different levels of pain. Quite frequently, it’s due to the myriad psychological factors that affect how a person experiences their chronic pain. 

TailorCare developed two approaches that can help.

First, we help patients identify a tolerable pain level that allows them to engage in their activities of daily living. This ensures patients have appropriate expectations for treatment. We compassionately help patients build realistic expectations for their pain, even as we’re working tirelessly to address underlying causes. We support them in managing their pain so they can continue engaging in the activities they love.

Second, TailorCare uses a behavioral health screening tool – the PHQ-2 and 9 to screen for depressive symptoms. This objective and validated screening tool enables our clinical navigators, licensed physical therapists, to better understand behavioral health factors that often impact chronic pain and help guide patients into CBT interventions when appropriate.

In addition to referring patients to a specialist for medical intervention, healthcare providers can consider therapeutic interventions with a multidisciplinary approach to address the myriad of contributing factors to pain. These approaches include interventions such as mindfulness meditation, reiki, pilates, or non-strenuous yoga, all of which have evidence to alleviate pain.

The Hardest Cases

In some of our most challenging cases, patients in extreme pain have also suffered past physical, sexual or emotional trauma. Such circumstances can contribute to increased pain catastrophizing or negative thought patterns that magnify the threat of pain. Importantly, pain catastrophizing symptoms can be addressed through cognitive behavioral therapy (CBT), making it even more critical to evaluate the mental health of patients with MSK pain.

How can physicians understand when a patient is appropriate for CBT and the non-traditional treatments described above?

They should consider three questions. 

• What practitioners might also help the patient find relief? 
• Is there a mental health component that is exacerbating the patient’s pain that behavioral health support can address? 
• How can I incorporate a tailored, multidisciplinary pain management approach for my patient’s needs?

Together, we have the tools to revolutionize how we treat chronic pain. It’s time we apply them.