Managing the Complexities of Chronic Back Pain

Podcast Transcript

Dr. Alex Rae- Grant:  Neuro Pathways, a Cleveland Clinic Podcast for medical professionals, exploring the latest research discoveries and clinical advances in the fields of neurology and neurosurgery. Welcome to another episode of Neuro Pathways. I'm your host, Alex Rae- Grant, neurologist in Cleveland Clinics Neurological Institute. Together we are exploring the latest to neurological advances. Today we're talking with Drs. Sarah Davin and Kush Goyal about managing the complexities of chronic back pain. Dr. Davin is a pain psychologist and the director of the Center for Comprehensive Pain Recovery at Cleveland Clinics Neurological Institute. Dr. Goyal is a physical medicine and rehabilitation interventionalist and physician leader. He is also a champion of the Back on TREK chronic back pain program in Cleveland Clinic's Neurological Institute. Sarah and Kush, welcome to Neuro Pathways.

Dr. Kush Goyal: Thanks for having us.

Dr. Sarah Davin:   Yes, thanks. Glad to be here.

Dr. Alex Rae- Grant:  So let's start with some easy questions for you both. Where are you from and how did your careers lead you to Cleveland clinic? Sarah.

Dr. Sarah Davin:  I am born and raised in Indiana and I came to Cleveland Clinic with a very specific purpose. I actually did my fellowship here in chronic pain psychology when I got my doctorate in psychology. I knew pretty quickly that I wanted to work with individuals with chronic pain and there's very few fellowships in the country that deliver pain psychology training. So that's how I ended up here and I stayed.

Dr. Alex Rae- Grant:  And Kush.

Dr. Kush Goyal:  I am a native East-sider of Cleveland, so I went to high school here. I did some college and residency in the Midwest, came back for a fellowship also like Sarah and kind of stayed on staff after fellowship in the spine center.

Dr. Alex Rae- Grant:  But just to get this clear, you do treat people from the West Side, right?

Dr. Kush Goyal:  I treat people from all over the country, even some people abroad.

Dr. Alex Rae- Grant:  Very good. Okay. It's estimated there are at least four of five people in the U.S. will suffer from back pain at some time in their lives. That's quite a significant statistic and places a significant burden on the nation. On a previous Neuro Pathways episode with Mike Steinmetz, we discussed innovative surgical treatment options for back pain patients. Kush, can you share with us how medical management is evolving for the chronic back pain patient?

Dr. Kush Goyal:   Yeah, in our medical spine department, the technical advances have not been as great as the surgical technical advances. However, we've had great progress in terms of a multidisciplinary treatment for chronic back pain. We've began to focus more on, again, a multidisciplinary approach to treating back pain, not just focusing on procedures and surgery but actually integrating other members into the team as far as physical therapists, as well as our behavioral medicine specialists.

Dr.  Alex Rae- Grant:  All right, so if I was referring a patient to your program, how would I explain pain psychology and what you guys do?

Dr. Sarah Davin:  That's a really important question. I think it's important to message this as not a psychological condition. That somebody like me is a behavioral specialist that can help them understand how to utilize their own mind and make that a tool that will help them experience less pain. So typically pain psychology, the treatments we offer are based in cognitive behavioral therapy for pain, which is a very specific treatment approach for individuals that have pain. And we really focus on the connection between one's thinking or mindset and interpretation of their pain, which can include fearful thoughts or catastrophic thoughts about pain and how it impacts their emotions. And then their behavioral coping decisions.

We work with folks on learning how to pace activities and to also find ways to calm their nervous system so that their pain processing center is less active and over time they can experience less pain. And with some patients you will see that quite quickly. Once they learn how to regulate their stress, they will say, "Wow, my pain has gone down." And so I think those are some really important sort of selling and messaging points. When you're referring to somebody like myself.

Dr. Alex Rae- Grant:  Do you want to tell us a bit about how someone would come into the program and be evaluated by your multidisciplinary team? I mean, how does that actually look?

Dr. Kush Goyal: Yeah, there are several ways they can get into our programs. We do have some form of an open access into our chronic back pain programs. Some patients can enter in via primary care referral, a physical therapy referral or direct referrals from the spine center or a pain management.

Dr. Alex Rae- Grant:  Do you want to talk a little bit about how we currently approached the chronic pain as an organization? For example, maybe some of the pathway approach that we have been using recently?

Dr. Kush Goyal: Yeah. The Cleveland Clinic Center for Spine Health has developed a few different care paths for acute, subacute and chronic back pain and they are all treated somewhat differently, but we'll focus on chronic back pain for right now, which we define as having back pain three months or greater in duration. Often these patients have had back pain frequently for several years and some have had episodes of pain that have resolved but also recurred several times a year and have lasted many years. That puts them at a loss of function.

Dr. Alex Rae- Grant:  Sarah is as the director of the Center for Comprehensive Pain Recovery, you lead a cross functional team of specialists who work together to manage the complexity of chronic pain. Can you tell us the type of patients you see and the role of the team members in their treatment?

Dr. Sarah Davin:  Within our center, we see any person that has had chronic pain, so as Kush mentioned, that's three months or more of pain. It could be anywhere in the body and going back to the multidisciplinary approach, that's really the only way that this works because we know that pain is such a complex whole person problem really. And so that's why it's great to have a team of specialists within our center. We have physician leaders who are trained in pain as well as in psychiatry and addiction. We have advanced nurse practitioners that have specializations in treating chronic pain and addiction and depression and anxiety, which often co-occur with having any sort of persistent pain.

We have multiple behavioral specialists who have specific training and pain, and this is important to note because pain is different than really any other sort of health condition. And so to really know these patients and to understand how to educate them and treat them as an entire person. You have to have an understanding of the science behind pain and then the application of the behavioral principles that we use. We also work very closely with physical and occupational therapists. They're literally right down the hall from us, so it's great because we can walk patients down there. Coordinate appointments and talk as a team about how each patient is doing and progressing and meeting their goals. And really as a team, our primary goal is to help enhance patient's function, how they are participating in life. Pain reduction is part of the goals, but the primary, the first target is getting people moving and doing activities that perhaps they have not been doing because of pain.

Dr. Alex Rae- Grant:  I understand you guys bring in pain psychology early in the treatment and intervention. Can you talk a bit about how that happened?

Dr. Sarah Davin:  This is the area I get really excited about because there's a lot of research coming out about the value of pain psychology or behavioral intervention early on in the course of pain. So that it does not become extremely disabling and go on and on and on. There's some research coming out of Stanford that has really led the way in this and showing that early and brief intervention can decrease the risk of pain after surgery. It can decrease what we call pain catastrophizing, which is essentially a negative pain mindset.

And these things are all really closely linked to using more healthcare, having more disability associated with pain. And so when I see patients and I tell them that just by one session maybe two. Meeting with me or somebody like me, they can gain skills that can help them. They get excited as well. And so it's a way to make pain psychology scalable and more accessible to more people as well as not to overly burden the patient with saying, "Okay, you're going to have to see me every week for 12 weeks to get any kind of benefit."

Dr. Alex Rae- Grant:  So let me ask you guys a bit of a different question, but what I think about when I'm treating my chronic population of MS patients, what does success look like? How do you guys decide your programs have been successful?

Dr. Kush Goyal: Yeah, I think I have a unique perspective of seeing patients before they'd join a chronic pain program. Oftentimes, in the middle of the program as well as after. So some of those are some our most gratifying appointments in my entire practice. So patients will come back and I usually ask them a very simple questions. What do you like about the program? What was surprising, what was unexpected and what would you recommend we change?

And one of the first things they usually say is, "I wish I knew about this program before. It really changed the way I thought about pain and how I experience it. It gave me different ways of understanding of how to deal with pain or how to live with it and not really suffer from it but actually live with it." So most of them are really happy. They can come to a place like Cleveland Clinic, where we have a multidisciplinary approach to chronic pain, which is often very different from how they were treated before they entered into our center.

Dr. Alex Rae- Grant:  Are you expecting all the pain to go away?

Dr. Kush Goyal: So we tell patients there's different forms of pain. There's, you know, discomfort or stretched. There's a pain that gets aggravated by certain mechanical activities. But ultimately a lot of the pain gets amplified by how much you think about it, focus on it. Some patients even obsess about it. So we teach them that the minds focus on pain can actually amplify how much a patient experiences. And we really educate them on ways of learning to live with the pain, but not focused on it so much. And that surprisingly and very effectively helps them improve their function.

Dr. Alex Rae- Grant: So I would think one of the goals would be to have them functioning more either at home or hopefully work. I mean, is that something that you guys focus on, on the program and that-

Dr. Sarah Davin:  Definitely function, but function means a lot of different things.

Dr. Alex Rae- Grant:  Mm-hmm (affirmative)

Dr. Sarah Davin:  You ask what does success look like? And I'm thinking about patients coming back and telling me that they went on a trip somewhere with their family and they're smiling when they talk about it, except instead of being preoccupied with the trip being completely ruined by their pain. We focus on getting back to activities that they have stopped doing because of pain. And I think ultimately experiencing joy and happiness. And I teach patients that these are really the antidote to pain and can impact their pain processing systems.

So they may not immediately feel 100% less pain. But if they continue to do this over time, what you see is that patients are more engaged in life and have a variety of life experiences. And then over time they're talking less about their pain, and they're oftentimes feeling less physical discomfort.

Dr. Kush Goyal: Yeah. And then we really love when they say, "Actually, I have started to apply for another job and now I'm back to work, or I decided to join the workforce."

Dr. Alex Rae- Grant:  So tell us a little more about programs that you're offering, even ones in a pilot phase. Can we go into that a bit?

Dr. Sarah Davin:   Sure. So we have two what we call Functional Restoration Programs. These are for folks that have chronic pain. The first is the Back on TREK program, which we mentioned that Dr. Goyal is very involved in and this is for folks that have three months or more of back pain and involves physical therapy, behavioral optimization and bringing in spine specialists as needed. Then we also have an intensive outpatient program for pain. It's called the Chronic Pain Neuro Rehabilitation Program. And this is for those very complex individuals with any sort of chronic pain condition that has become very disabling. That requires more intensive care and that's a Monday through Thursday day program for four weeks.

So those are our primary functional restoration programs. We also have some exciting new pilot programs that we are offering through the center for comprehensive pain recovery, the first of which is a perioperative optimization clinic that we are collaborating with the Center for Spine health for. So the idea here is to identify patients prior to surgery that have certain risk factors that we can target very quickly. And so we will make it more likely that their surgical outcome will be a favorable one.

Along with that, we are offering a single session pain psychology class, and this is based off of the research out of Stanford. They have found that this class, when people sit through it post-surgery, they are quicker to reducing opioids and they have better overall outcomes. And then we are also doing a research project around that particular single session pain psychology class, offering it in person and also a digitized version for patients that are having lumbar laminectomy.

Dr. Alex Rae- Grant:  So I know that a lot of clinicians do see chronic pain patients in their practice of neurology or general internal medicine practice. So any advice you'd share with them in terms of how they are dealing with that population in ways they could do it in a little more optimal way.

Dr. Kush Goyal:    Yeah, and I've learned a lot over the course of probably the last five or six years. I work in Center for Spine Health and meeting a lot of colleagues that taught me how to really understand a patient's pain. But really you have to listen to the patient. So first, you don't want to be narrow-minded about just treating patients the way you are specifically trained to do. You also want to learn that what other options are available. For me, I didn't really understand initially how much their stress or they're coexisting psychiatric illnesses can play a role in their pain.

As I started to understand that in the last few years, I started to understand that and be able to explain to patients that, does your stress or does your anxiety tend to increase your pain or affect your pain? And I started to understand that patients who have coexisting biopsychosocial problems tend to again amplify their back pain or focus on it a lot. So as, I understood that I could start to explain to them that we actually have a great team that can help them with their problem. Beyond just the typical treatments of injections or surgery.

Dr. Sarah Davin:    I would also say believe in the power of early intervention. Oftentimes I think that we get in the mindset of not doing anything until we see something really bad. Or we know for sure that this patient is in a high degree of suffering. And if you can take even one or two minutes to explain to the patient what's going on, they really have a need to know and to understand. And then referring to a team like ours who can help to teach them and to educate them and to arm them with some skills and tools to self-manage their pain. And to lessen the likelihood of chronic disabling pain.

Dr. Alex Rae- Grant:  Well, Sarah and Kush, thank you so much for joining us today. We really appreciate your time and insights.

Dr. Sarah Davin:  Thanks for having me.

Dr. Kush Goyal: It was fun. Thank you.

Dr. Alex Rae- Grant:  This concludes this episode of our Neuro Pathways Podcast. You can find additional podcast episodes on our website, clevelandclinic.org/neuropodcast. Subscribe to the Neuro Pathways Podcasts on iTunes, Google Play, Spotify, SoundCloud, or wherever you get your podcasts. And don't forget, you can access real-time updates from experts in Cleveland Clinics, Neurological Institute on our consult QD website, consultqd.clevelandclinic.org/neuro or follow us on Twitter at CleClinicMD. All one word that's at C-L-E, ClinicMD on Twitter. Thank you for listening. Please join us again soon.