Tapping Behavioral Medicine to Remake Chronic Back Pain Care

Pilot program promotes pain rehab over early interventions

For many patients with chronic low back pain, expert education in how to put their pain in perspective and effectively manage it is far more useful in the long run than a spine surgery, a nerve block or an opioid prescription.

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That principle is at the heart of a large-scale pilot population health initiative launched by Cleveland Clinic’s Neurological Institute in August 2016 to help patients with chronic low back pain recover and become active again.

The pilot program, detailed in this recent Consult QD post, promotes functional outcomes rather than procedure-based care and focuses on rehabilitation, relying chiefly on a combination of physical therapy and behavioral medicine interventions for pain. The aim is to remake the management of chronic low back pain by reversing recent trends toward overreliance on premature imaging, spine surgery and inappropriate opioid use and starting patients off with thoughtful, targeted use of conservative therapies.

RELATED: Is Chronic Back Pain Syndrome a Spine Problem?

Pairing behavioral medicine with physical therapy

The program’s name, Back On Trek, is a nod to its mission of Transforming, Restoring and Empowering patients — as well as providing them Knowledge. Achieving this goal requires a multidisciplinary approach. A team of behavioral medicine specialists, physical therapists (PTs) and physiatrists treat participants in the 12-week pilot program at Cleveland Clinic’s Lutheran Hospital on Cleveland’s west side.

“Collaboration is important because pain is a multifaceted experience,” says Sara Davin, PsyD, MPH, a psychologist in the Department of Psychiatry and Psychology and the Center for Neurological Restoration’s Chronic Pain Rehabilitation Program. “We can really only treat chronic pain if we have the expertise of all disciplines When you gather around the table with different specialists, it’s powerful. It’s like putting a puzzle together.”

The program’s frontline providers are PTs and behavioral medicine specialists in pain. “We know that conservative treatments are sometimes not used early on in individuals with chronic low back pain,” says Dr. Davin. “So behavioral medicine will work with physical therapy to assess and treat each patient who enters the program, as well as provide group education.”

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Who’s a candidate?

Eligible patients have typically experienced several months of chronic back pain and screen negative for red flags suggestive of a possible medically dangerous pathology. Individuals meeting these criteria may self-refer to the program by phone or be referred by a physiatrist or medical spine physician. Or they may access the program through an initial assessment at one of Cleveland Clinic’s 47 outpatient therapy locations, where PTs determine if a patient is at high risk for prolonged disability and is a program candidate.

Essential role for biopsychosocial assessment

At that point, one of two behavioral medicine clinicians with specialized expertise in pain — Dr. Davin or a colleague — meet with the patient and perform a biopsychosocial assessment. “We’re not just dealing with pain,” explains Dr. Davin. “In this and many other conditions, we know that psychosocial variables are often better predictors of outcome than is the actual pathology or disease. This is where behavioral medicine comes in.”

The initial behavioral medicine appointment includes a battery of assessments looking at the patient’s history of pain, psychological status, social relationships and work status.

“We want to discern anything that might be relevant, either to helping the patient or to erecting barriers to progress in his or her individual situation,” says Dr. Davin. In particular, the behavioral medicine pain specialist will try to uncover fear and avoidance issues using the Fear-Avoidance Beliefs Questionnaire (FABQ), which measures fear of pain and resulting avoidance of physical activity.

Strength in numbers

Patients also participate in an eight-week group therapy session. “Individuals with pain often feel isolated or misunderstood,” notes Dr. Davin. “To connect with others going through the same thing, see their progress, and listen to their challenges and successes seems to be a big agent of change.”

The 90-minute sessions, held once a week, combine education, cognitive behavioral therapy, relaxation training and mindfulness meditation. The basic neurobiology of pain is an early focus. “Patients need to know what causes their pain — not only from a medical and biological standpoint, but also the psychological and social factors,” explains Dr. Davin. “I try to empower patients and help them realize they can actually make a difference in what’s going on in their brain and what they feel in their body.”

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Most sessions include six to 12 participants, although an initial orientation also includes family members. “Involving the family is important,” Dr. Davin points out. “Family and other social support is predictive of better outcomes once patients complete the program.”

Talking the same language

Simultaneous with the group therapy sessions, patients participate in individual physical therapy and group aerobic conditioning sessions, as detailed in this related post. Physicians add support to the program, reinforcing messages from the PTs and behavioral medicine specialists.

Much work has gone into ensuring that all providers work together and send a consistent message to patients. “We don’t want to be three separate disciplines,” notes Dr. Davin. “We want to be united.” To that end, core training based on the textbook Therapeutic Neuroscience Education: Teaching Patients About Pain is offered to all participating clinicians so they speak the same language — with the goal of improving patient outcomes.

“We want to help people before they get to the level of severe, disabling chronic pain,” says Dr. Davin. “Early intervention and prevention can make a difference in the patient’s health and quality of life while also avoiding unnecessary treatments and costs associated with getting help late in the game.”