Table 2 Components and Defining Elements of the PEERC Intervention

Patient Engagement

The engagement approach uses motivational interviewing (a method that works on facilitating and engaging intrinsic motivation within the client in order to change behavior) and elicitation of thoughts and beliefs about the patient’s targeted expectations. The physical therapist uses behavioral interviewing methods to elicit information on thoughts, feelings, and behavior related to pain. The interaction focuses on the patients’ pain, how pain influences their lives, and their thoughts and beliefs about pain.

Education

The health coach emphasizes that pain is a complex, multidimensional experience that is affected by thoughts, feelings and behaviors as well as the important role that self-management plays in treatment. Educational methods are informed by the literature on health literacy and use simple diagrams and charts from a provided booklet to help patients understand the equivocal results of conservative and non-conservative interventions. The health coach also familiarizes patients with the current most recommended strategies for care, including any potential harms, a timeline of expectancy and recurrence rates.

Cognitive Restructuring

Cognitive restructuring involves learning how: (1) to recognize thoughts that are distorted, unrealistic and/or self-defeating; (2) to replace these thoughts with more rational, realistic, adaptive thinking [26]; and (3) to engage in behavioral activation assignments designed to reinforce more adaptive thinking. Home based strategies such as behaviorally testing negative thoughts via behavioral activation exercises (e.g. engaging in an activity the patient is capable of, but has been avoiding because of fear of pain) are assigned. A number of CBT methods are employed, including discussion of how thoughts, feelings, and actions affect and are affected by pain, and a review of prior session content and practices. The patient is encouraged to identify activities that the user tends to avoid, leading to discussions of how to change activities and the development of an individual plan to increase the fit between daily activities and personal goals.