June 6, 2022

Taking Aim at Pain: Class Offers Coping Strategies for Spine Surgery Recovery

Clinician-led online behavioral pain management class aims to transform standard of care


It’s estimated that 10% to 40% of lumbar spine surgery patients experience persistent postsurgical pain, which leads to emotional distress and impaired quality of life while also increasing healthcare costs. In response, Cleveland Clinic’s Center for Spine Health is offering a perioperative behavioral pain management class for spine surgery patients to mitigate persistent postsurgical pain.


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“We are making a cultural shift, prioritizing behavioral pain care and reducing the stigma of psychological interventions,” says Sara Davin, PsyD, MPH, a psychologist in the Center for Spine Health. “Just like patients with diabetes go to a diabetes self-management class or patients with obesity go to nutrition classes, patients with pain can attend a class to learn how to manage it.”

The two-hour clinician-led class, called TREK for Surgical Success, is based on Stanford University’s Empowered Relief™ self-management intervention.

“Empowered Relief was developed by Beth Darnall, PhD, to improve access to behavioral pain management across the board and provide a low-burden intervention that teaches the most essential skills for managing pain, understanding that pain is both sensory and emotional,” explains Dr. Davin.

Clinical pathway for perioperative optimization

Several Cleveland Clinic caregivers are trained and certified in the intervention, including psychologists, nurses and nurse practitioners. Since 2018, the health system has adopted the program for various patient populations, most recently for those who will undergo spine surgery.

Cleveland Clinic has created a pathway to operationalize Empowered Relief as standard of care for spine surgery patients. The clinical pathway focuses on education of providers and patients, efficient clinical implementation and continuous improvement of the intervention’s integration into standard of care.


“Few people are actually making it part of standard of care, and we’re aware of no other academic medical center that’s using it for spine surgery,” says Dr. Davin.

The Center for Spine Health offers its online group class to patients before or after surgery to help them establish a plan for long-term pain relief. Participants are taught and practice skills for pain relief, including relaxation exercises. They also complete a survey to identify unhelpful pain thoughts and then practice reframing those thoughts.

“It’s designed as a one-and-done single session so patients can apply the skills on their own,” says Dr. Davin. “We tell patients to practice the skills before and after surgery. Then if they need additional help — such as a one-on-one coaching session — we can do that.”

Study points to program benefits

As part of a quality improvement project, the Center for Spine Health analyzed participation rates and patient satisfaction with the TREK for Surgical Success class to determine whether it improved patient-reported outcomes, specifically pain interference and pain catastrophizing.

The analysis revealed a 61.5% engagement rate among the 78 patients scheduled for TREK for Surgical Success between July and March 2022. Those who completed the post-class survey reported high satisfaction with the class, with 46.7% of respondents answering 10/10 to the question, “How likely are you to use the skills and information you learned?”


A detailed examination of the class and results of the study were recently published in Frontiers in Pain Research. Dr. Davin and colleagues plan to continue monitoring patients and examining long-term outcomes, focusing on use of the skills taught in the class, opioid use, pain levels and overall function.

Tips for integrating the class into standard of care

Dr. Davin offers advice for others who would like to make behavioral pain management standard of care and adopt a pathway for Empowered Relief in specific patient populations:

  • Get executive buy-in. “We have multidisciplinary support starting with our leadership, including Michael Steinmetz, MD, Director of the Center for Spine Health,” she says.
  • Create clinical champions. Cleveland Clinic assigned physician and nurse champions to educate clinicians in their areas about the online class, enhance clinical engagement and serve as key stakeholders to identify problems in the system.
  • Engage Empowered Relief instructors. Clinicians can become certified to teach the classes, or clinician instructors can be found worldwide on the program’s website.
  • Educate clinicians. Providers need to understand not only the importance of behavioral pain management and how the class works, but also how to present the information to patients. “Messaging about the program needs to be constant and consistent across the enterprise,” says Dr. Davin.
  • Make it easy for providers. “The class shouldn’t be a burden on nurses and physicians,” she says. “Try to integrate it into everything else patients do during the surgical period.” This may require additions to the electronic medical record and creation of marketing and supplemental materials.

“We believe behavioral pain care is essential to help people preparing for and recovering from surgery,” Dr. Davin concludes. “From a broader standpoint, we know that pain costs us so much in terms of healthcare and lost productivity. By sharing this best practice with the public, we hope to make a bigger impact on a huge public health problem.”

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