Chronic Pain Rehabilitation: A Tri-Dimensional Approach

Join Dr. Snell from QLI as he discusses chronic pain rehabilitation. Topics include an overview of how pain works, how chronic pain develops, the difference between acute pain and chronic pain, and how to treat chronic pain.

Speakers: Trisha Funk, Tim Benak, Dr. Snell

Video Transcription

Introduction

Tim Benak – 00:00

All right. Good morning, everyone. Thanks for joining us today. Today we’re going to be doing Chronic Pain Rehabilitation: A Tri-Dimensional Approach with Dr. Snell.

But before we begin, I brought Trisha Funk into Studio Q today. She’s one of our admissions liaisons. So anytime there’s someone who is looking at QLI, she’s out and about and visiting with them doing an assessment to make sure that they are appropriate for our program. And I just brought her in to talk briefly about that we’re still up and we’re still taking referrals and what that looks like, and if you have any questions to reach out to her, but I’ll let her just quickly hop on the mic here.

Trisha Funk – 00:38

Yeah, just wanted to stop by and say hello to everyone and good morning. I’m just reaching out to our folks and reminding them that we still are taking new admins still offering our intensive rehabilitation program to injured workers.

The referral process has not changed. So please reach out to any one of us. Phone, email, we are still here. Certainly the evaluation process and the logistics of an admission have changed, doing more things virtually and certainly have some precautions in place to keep everyone safe.

Tim Benak – 01:13

So I think that’s a big thing. And that’s why I want to bring you in. I know everything the landscape has shifted a little bit over the last 30 to 60 days. And we just want to let everyone know, let our partners know that we’re still here and taking the necessary precautions to make sure that we’re we’re able to serve those injured workers out there.

Trisha Funk – 01:28

Yeah. So absolutely. You know, and things are continually changing, but we are trying to stay ahead of it and looking forward to continuing to serve folks.

Tim Benak – 01:35

Definitely. And I’m going to go ahead and put Trisha his contact information into the chat. If you have any questions, feel free to reach out to her. Thanks, Tricia.

And now we’ll go ahead and get started with the presentation. We’ve got 472 of you on right now. That’s a record for us, Dr. Snell, that’s wonderful. You know, even in person we were out and about, we were talking about the adventures we’ve gone on across this country giving presentations. I think that’s the most we’ve ever had in one room. We’ve got everyone situated at home. They’re all social distancing. So right in front of the computer ready to learn a little bit.

So for the for the ones that this is a webinar that you’ve attended. You’ll recognize this voice for others. Just a quick little introduction, Dr. Snell, you’ve been here for coming up on 22 years and you’re a director of neuro psychology and psychology.

Dr. Snell – 02:36

In the psychology department, relatively small department. There are four doctoral level providers within that department and our research coordinator as well. I absolutely love what I do. This is a wonderful place to work and I think it’s what has kept me here.

Tim Benak – 02:52

Well, we’re lucky to have you here. Definitely a collaborative approach between all the teams here and Dr. Snell will talk about that a little bit in this presentation today. So before taking too much of his time, I’m gonna go ahead and pass it off to him.

Dr. Snell – 03:08

So thank you very much, everyone, for joining us today. Interesting times we have right now I think as we’re going through this process, just the whole pandemic, all of the Zoom meetings that we’re now attending everything that we’re doing remotely, I think you know, after the fact you’re going to ask, what did you learn through this process?

I think one thing we’ve learned is to keep at least half of the office clean, so that your background looks nice. We’ve also had the opportunity to meet a lot of our co workers’ pets and children through this process. So that’s interesting as well.

I do anticipate as we go through this presentation today, there are going to be some questions Tim’s going to monitor that on chat. And if we are not able to address your question live throughout this presentation, we will get to a response by way of email. So please ask any questions that you have.

So we’re going to jump right into this.

What is Pain?

Pain is an unpleasant but a relatively complex and fascinating system that’s both effective and essential. It’s a protective mechanism that is crucial to our survival.

Pain is your body’s alarm system alerting your brain that there is danger or whether that’s actual or potential tissue damage.

All pain experiences are normal, no matter how crazy this might seem. It is perception and we’re going to talk about this in a great deal of detail.

The soldier may have been wounded in a firefight but continues tending to the mission not even aware of, not feeling pain in that moment.

Compare that to stubbing your toe on a footstool in the kitchen as I did earlier this week. Suddenly, the rest of the world just kind of fades into the background and nothing is more important than the throbbing toe that you feel.

So for some, for example, looking at a syringe when you’re about to get an injection, that heightens the expectation, anticipation of the pain that you expect to feel, as opposed to looking away or being distracted.

That expectation and anticipation is actually a component of your perception, it affects your experience of pain. Pain affects how we move, how we think, how we act, and all of those responses are the brains way of ensuring our safety, it protects us, it helps our injuries heal.

But it’s the potential of danger that it’s important to emphasize. The emotional circuits in your brain influence your expectation, which affects the pain that you perceive. And as we talked about, that anticipation can influence your choices, which over time can limit your actions. And although it’s not your intent, the result of that can result in increased perception of pain.

So to rephrase, it’s your brain that decides if pain is the best response in a particular situation. Interestingly enough, that also means that if no problem exists in your body, tissue, nerves or immune system, it’ll still hurt if the brain thinks there is danger.

Pain Facts

The information here is obtained from facts and figures website hosted by the American Academy of pain medicine, as well as from the CDC. The number of individuals experiencing pain at any given time and for more than 24 hours, is fairly substantial.

Chronic Pain actually affects around 100 million Americans, the CDC reports an incidence rate between 11 and 40%, depending on definitions.

High Impact chronic pain in 2016, which is most recent data by the CDC reported was around 8% of US adults.

Both chronic and high impact chronic pain were noted to be more prevalent among adults living in poverty. Adults with less than high school education are adults with public health insurance.

The bigger piece is the impact on the quality of life. Around two thirds of individuals with chronic pain import. They talk about the impact of that pain of their overall enjoyment of life. Over three quarters of patients surveyed reported feeling depressed, and anxiety and depression is much more common in a population that is sustained trauma of any kind.

About 70% report difficulty concentrating. So it is not just emotional, that is cognitive as well as the emotional and physical reaction.

Around 86% of individuals with chronic pain report an inability to sleep well. And we know that sleep, nutrition, physical exercise, these are all crucial to maintaining our health, our physical health, our cognitive health, and our emotional health.

So these are all things that become cyclical in nature, when an individual is experiencing this in a chronic condition.

Acute vs. Chronic Pain

Let’s look briefly at the distinction between acute and chronic pain is are frequently treated the same, but they are really very different and they warrant very different treatment approaches.

An orthopedic injury can be anything from an overuse injury, like tennis elbow, to a torn ligament, like an ACL tear, or even a broken bone or a sprain or a bulging disc in your back. That would be an acute issue.

Chronic pain, on the other hand is not the result of actual tissue damage or injury. As all the tissues are healed at the point. This can be hard for a patient to understand because they feel pain in that limb or that part of their body.

You know that with a stroke, it is the brain that is not sending a signal because of that loss of neural tissue. And so the limb is not moving. But it’s not because there’s anything wrong with the limb, it’s because the brain itself is not sending the signal. Even if your arm is perfectly intact, there’s no muscle activation  because the part of the brain that sends that signal is not firing.

The other side of that coin is the pain receptors in the brain. If they are firing, then you perceive pain, even if the distal receptors of the affected part of the body are not sending signals. It’s an issue of perception.

When it comes to dealing with pain, we have a lot of different tools in the toolbox. And the key to effective and efficient treatment is using the right tool for the job.

You know, they say if you only have a hammer, the world becomes a nail. Well, historically, pain has been treated with opiates and narcotic pain medication. And if that becomes the default and get used over and over again, even when it’s not working, it can actually make the problem worse.

Chronic Pain doesn’t respond well to pain medications or other interventions such as injections ablations or stimulators. Especially in the long term. And the main reason for this is that pain is a subjective experience.

As pointed out by mills and others in their 2019 article on the epidemiology and associated factors and population based studies of chronic pain, Chronic Pain is something that persists beyond normal tissue healing time, and in the absence of other factors is generally taken to be about three months in length.

There are many risk factors for chronic pain, including socio demographic, psychological, clinical, and biological factors. The authors went on to state that chronic pain is a separate condition in its own right, not merely an accompanying symptom of other ailments. And, like most diseases, it often arises from a series or combination of multiple events.

Even if there is a solitary precipitating event in the genesis of chronic pain, such as a specific injury that occurs, there remains a series of factors that affect the duration, the intensity, and the effects of chronic pain. Those effects are physical, psychological, social, and emotional.

Health related behaviors and their outcomes are the most important modifiable risk factors. I’m gonna say that again, modifiable risk factors in the genesis duration and impact of chronic pain.

For the remainder of this presentation, we’re going to talk about how pain works, how chronic pain develops, and how to treat chronic pain.

Pain Physiology

Now, it all starts with a neuron. And this is a simplified picture of a pathway. At one end of the neuron, there are receptors that can be found pretty much everywhere in your body and muscles, ligaments and tendons. The only place you don’t have receptors are throughout the brain tissue itself, and some areas of cartilage in your body.

This is a representation, simplification of the receptors because they are very specialized and they respond only to a certain type of stimulation.

You have mechanical receptors that respond to pinch or pressure, for example. You have temperature receptors that respond to temperature changes or perception of temperature.

Then you also have chemical receptors that respond to chemical compounds such as allergens, or lactic acid, for example.

Now, it’s interesting to note that none of these receptors are specifically dedicated to pain perception and there is no separate pain pathway.

Substantial work and physiology over the years hypothesized the role of pain receptors. And what that work demonstrated was that the perception of pain, known as nociception, reflects threshold levels of signal.

In other words, from a mechanical receptor standpoint, a soft stimulation, you perceive as touch more of a stimulation you receive as a squeeze or pressure. Even more the brain willing interpret his pain, it’s a gate mechanism type of perception.

It’s also interesting that the same amount of pressure applied by you is less likely to be interpreted as pain than pressure, same mechanical amount of pressure provided by an external source.

If you grab the tip of your finger and squeeze it as hard as you can, if you feel a lot of pressure, but you don’t really have the same perception of pain as if I grab your finger and pinch it really hard. That probably felt like pain.

So it is interesting, it’s the same reason that you can’t tickle yourself because your brain is perceiving whether that is under your control or not.

A message gets sent to the spinal cord by these receptors and chemicals are released, which can only attach to specific receptors in the secondary neuron or nerve fiber. This is how these cells communicate.

And like a key and a lock, if they fit, they open that gateway, and the danger message gets passed on to the brain.

If the brain decides that what is happening is not a big deal. And again, that’s why if you pinch your own finger, it does not feel as painful as if an external mechanical force is applying that same force. If your brain decides that what’s happening is not a big deal, it will send down inhibiting chemicals.

In the graphic above, it’s a little heart shaped chemical of happy hormones. And this can include things like endogenous opiates, your body has an opiate system that it utilizes to restrict the amount of information coming up. Seratonin as well. These in turn, activate different sensors and thereby limit danger messages that are able to get through.

So as the message comes through the spinal cord, different areas of the brain become activated. And this is a little bit of a busy slide here. But it’s also representative of the fact that pain is a very busy and complex signal.

So what happens here is that information comes in through the spinal column. And it goes to the sensory area of the brain, the sensory cortex, which is represented by the number five there.

But there are numerous parts of the brain that are interacting with each other, including some important ones, such as number four, and number six, you see in the midbrain there.

The hippocampus, which is involved with memory, spatial cognition, and fear conditioning, and the amygdala, which is also associated with emotional memory and fear conditioning, these are the two that when you look at the needle on the end of that syringe coming toward your arm, have you anticipate and expect the pain, which worsens it. So that is the perceptual aspect that is involved.

Movement as well and motor planning is involved.

It’s All About the Context

Now it is perception. And this is a little interesting slide that I threw in here just to show you that perception involves how your brain expects to see things. Now within the figure that you see above, what I want you to do is pay particular attention to this center top piece, this center side piece, and this piece that is sitting on the on the floor of the figure.

The interesting thing of it is that all three of those are exactly the same color. But your brain does not perceive them as such, the one that appears to be in shade appears to be kind of orange. Now I’m going to manipulate the figure and slide a piece of it up and let you see that those are exactly the same color. Isn’t that bizarre?

It is because your brain is used to seeing things in shadow and is able to perceive the colors accurately. But not.

What you do is your brain is used to seeing things in a certain way. And you can trick the eye and us the brain.

So whatever your brain perceives, interestingly enough, is the experience. And what I want to illustrate with this is that the way in which the brain perceives an object or a situation may be very different from what’s actually going on. But whatever your brain perceives, is your experience of reality.

With experience, such as the manipulation of that figure that I just did to align those squares, you can change your perception to match a different reality. And in large part, that perceptual change that I just showed you, is analogous to the process of starting to treat chronic pain in changing a person’s perceptions to better match a true reality.

How Does Acute Pain Become Chronic?

So if it’s a matter of context, let’s talk about the underlying physiology that’s inaction. How does acute pain become chronic? It doesn’t happen overnight, but it is a gradual adaptation. As I said earlier, that is typically defined by at least three months of lack of resolution of that perception of pain.

Generally speaking, the brain becomes more sensitized, and therefore more protected. This happens at every level of the pathway. And there are physiological changes that take place at the level of neuron there are input changes.

Typically an individual who is experiencing pain, I’m going to use as an example, my left hand, if I have chronic pain in my left hand, I am likely to decrease the use of activity and sensory input from the joints that are indicating threat and injury.

The brain responds to that by basically dialing up the volume. So if you’re sending less of a normal signal to the brain, by protecting and not using that part of your body, the brain actually produces more receptors to try and get a signal that it is used to getting that basically results in increased sensitivity, to touch to temperature or to chemical triggers.

This is one of the ways in which complex regional pain syndrome or CRPS develops over time is this cycle of increased receptors and increased sensitivity.

At the level of the spinal column, with the increase in receptors in the periphery, there are now more messages coming in and the message is more easily getting through. There more receptors on the secondary neuron. The brain is actually being told that there’s more danger to the tissue than there actually is.

In terms of pain as a perception based on a gating mechanism, a stronger signal is more likely to be interpreted as pain. So it makes sense that a stronger signal being sent is going to result in increased sensitivity and a greater likelihood that the information received by the brain is going to be interpreted as a harmful danger signal.

At the level of the brain, with repetitive input, continued pain, in the same areas of the brain getting activated over and over this route becomes a default network. So when a signal comes in from that part of the body, the brain is primed to react to that as pain to activate all of those centers that communicate with each other in the brain.

Even though the acute pain is now gone, the brain is still running that network. Another example of this, I’m sure that you have all heard about at one time or another is something called phantom pain that occurs often after a traumatic amputation.

An individual no longer has the left foot because of that below knee amputation. But they feel that left foot, they feel pain, they feel cramping and the muscles that are no longer there.

It’s because that part of the brain that receives that signal is still capable of running that network in the absence of a signal coming in.

We call this the dark side of neuroplasticity, the brain adapts and whatever the brain does, a lot of the brain gets better at. We actually have something within the brains functioning that we refer to as automaticity. That is the neuroplasticity of doing something over and over again until it becomes such a routine that you don’t think about it when you’re doing it.

Try brushing your teeth when with your non dominant hand and you’ll see neuroplasticity and how that action makes things that you do routinely automatic so that you don’t have to pay attention to them or think about them.

But the dark side of that is with pain comes more pain, the system gets better at producing it. That’s also why pain medications nerve ablation stimulators in such are not as effective in the long term as they are in the short term. They are ideal for short term change. But if the brain has adapted in a chronic pain situation, they will not affect.

Aside from the continuous activation of this network, there are other changes that happen within the brain as well.

This is a visual representation of the areas of cortex of the brain that are dedicated to various body parts more of your brain from a sensory standpoint is dedicated to your mouth, lips, tongues fingertips than they are to your trunk, and the middle of your body.

As an area becomes hyper sensitized, adjacent areas within that brain tissue can also become more sensitized, can become easier to trigger. We call this smudging it’s an overlapping of different parts and functions.

The body can do that from a motor standpoint as well. If you lose a couple of your fingers to amputation, the brain will actually remap the motor signals that used to go from an area to those fingers to the adjacent areas. So it operates in both directions. But from a sensory standpoint, this is a relatively good hypothesis for why CRPS acts in the way it does that spreading of sensitization.

Some loss of specificity of movement, for example, can also make a body part more difficult to move.

Again, the upside of this is that the system is highly plastic, if it can adapt to a negative situation, it could also adapt to a more positive situation. Anything that changes the brain’s perception of danger will make the system less sensitive and will change the perception of pain.

As you can see, this is an extremely complex process that happens in the brain. These changes don’t happen overnight, and they’re not going to be reversed overnight.

With a hyper sensitization of the brain system as well as the emotional connections that are associated with this, I hope you see that it’s becoming more clear that medical interventions and physical procedures will only have a limited effect on chronic pain. Again, it’s why it is chronic in nature.

What Does the Research Say?

I don’t have to spend as much time on this one as I used to because this is changing. And this is encouraging that this is changing. The prescribing guidelines published by the CDC in 2016. clearly state that the conditions which result in long term opiate usage should be carefully monitored. You should use the lowest effective dosing for acute pain and you should avoid extended use.

Fortunately, this slide reflects guidelines that are now being seen in clinical practice much quicker than is typical.

These guidelines just came out about four years ago and they’ve been adopted relatively quickly secondary to massive information campaigns and a focus on changing what has become an identified as an epidemic.

In 2018, there were just over 67,000 drug overdose deaths, which was actually declined from 2017 by about 4000 or so.

This decline was a drop that has been increasing drop in a rate that’s been increasing over many, many years since 1999 to 2017. There has been a gradual year by year increase in the number of overdose drug deaths.

The rate of drug overdose associated with synthetic opiates really peaked within the last few years between 2013 and 2018. The synthetic opiates, things like fentanyl, fentanyl analogues, Tramadol, they increase dramatically from one person per 100,000 in standard population in 2013, to almost 10 per 100,000 in 2018. That is a 10 fold increase in a span of five years.

And that’s why opiate abuse, opiate overdoses, that’s why you had a massive amount of information, coverage from the media, government focus and labeling this as a health crisis at an epidemic level.

Changes have been accelerated normally, to go from research to practice takes about 17 years. It’s a long time between research findings and implementing that as a practice change. We’ve actually seen in a relatively short span of time, this change start to be adopted and thankful that it is.

It’s not something that is completely adopted by all providers. At this point, there are still misuses of narcotic pain medication, you see that certainly within chronic pain population, but that is changing over time, and quickly.

Surgical interventions, they tend to have relatively short term responses spinal cord stimulators show significant evidence for the efficacy of failed back surgery syndrome and moderate evidence for high frequency stimulation. But it is a transient process.

There is a meta analysis by Kumar and other researchers that looked at the positive results reported at 12 months. About 81% of the cases after implantation of a spinal cord stimulator. 81% reported improvement at 12 months, and that sounds like a fantastic result.

On the other hand, if you look at those same individuals at 24 months, the primary outcome of pain relief was now reported by only 37% of those individuals, it changes dramatically year by year. And so it is not a permanent fix.

And again, the reason for that is the brain is running that pain network. And so regardless of what’s going on in the body, or at a spinal level, if the brain is telling you that you’re perceiving pain, you’re going to perceive pain.

Pain Leads to Suffering

So pain is involved from the standpoint of perception of an unpleasant stimulus or the perception of danger or damage within the body. But from that pain, comes something that we call suffering. The anticipation of pain leads to disuse, of the affected body part, deconditioning that accompanies the general decrease of activity of the level that an individual normally exposes themselves to.

Within the Butler and Mosley book Explain Pain they differentiate between what they call clean pain and dirty pain.

They define clean pain as the actual perception of pain, what you are feeling the reality in your brain of what you are perceiving. They define dirty pain as the suffering that accompanies that perception. The lifestyle changes the loss, the grief.

You can’t directly control, clean pain. That is a gradual process of change, but you do have direct control over the suffering aspects.

To address that, we often ask the question, what have you lost as a result of this pain? What are the things that you want to do that you don’t do because of pain? That’s the suffering that results not just from the experience of pain, but from the anticipation of pain, from the planning that’s involved in avoiding pain, from avoiding situations where pain may be a part.

That’s a very interesting aspect because struggling with pain is the best single predictor of the majority of things that people want to change when it comes to chronic pain.

People who struggle with pain, people who suffer as a result, people who are fighting against the pain itself that is the best single predictors of worse pain, of lower levels of activity because of the avoidance.

The expectation of suffering leads to disuse. And from a physical standpoint, protection of that affected body part, results in that increased sensitivity. The brain responds to the lack of sensory input by increasing sensitivity. It becomes a vicious cycle.

So many things that are a part of keeping us healthy, both emotionally, emotionally and physically get pushed aside, because of the suffering aspects of pain.

I mean, I’ve had patients that have said, I don’t go to the store, because I know that I will be wiped out for two or three days. If I do that.

Well, if you don’t engage in any physical activity, yes, engaging in any physical activity is going to be harder and harder, more deconditioning occurs.

So how do you begin to reverse this series of factors that results in what we call chronic pain?

Well, one is the same gradual process of physiological strengthening that involves pushing yourself towards a physical goal. If you want to run marathons, you can’t just go out and run a marathon tomorrow, you gradually have to build up your strength and endurance to do that. And I guarantee you that that process is going to result in pain and you’re going to feel sore.

That process though, is toward a specific goal. And little by little you build up that strength. People who can run marathons aren’t these magical warriors who were born with this ability they have, over time, built that muscle up that’s necessary.

Shifting Focus

From the Butler and Mosley example, in talking with patients about chronic pain, I also have used one of the analogies that they have in their book, which is to talk about the fact that chronic pain by very definition doesn’t go away. It’s dirty. It’s unhelpful, and it leads to suffering.

And if you try and solve a problem that is unsolvable, you get stuck in a game of tug of war. If you try to change something you cannot change. That’s by definition, impossible. If you don’t like to get wet, you’re not going to be able to control whether or not it rains. But you can control whether or not you take an umbrella with you when you go, or whether you plan something on a day that it’s going to rain or it’s not going to rain. You can only control certain aspects.

And so it’s identifying what things can you control? And what can you not control. So if you are in this tug of war with this dirty pain experience, the only thing that you can control is whether or not you are directly fighting against the pain itself.

So acknowledging that that monster is there, but not letting that drive your choices.

What are the things that you value in life? What would you do if you didn’t have this pain? Is that a thing that you value? That’s important enough that you would do it even if you have pain?

That’s one of the questions I have often asked folks in evaluating their appropriateness for an inpatient chronic pain program.

If you could do the thing that you say is most important to you, and feel exactly the same amount of pain that you feel when you’re not doing that thing, would you do it? And the answer, of course, is, well, yes, if it’s going to be the same amount of pain either way. I’d rather do something that has sense of meaning to me. I want to go out and throw a ball with my son in the yard, I have the same amount of pain doing that, as I do sitting in the lounger in the dark basement that I’m in, then I would much rather be a good father and go do that thing.

So we know that once individuals start making these changes, engaging in living a valued based existence, the result is increased physical activity, a decreased sensation and sensitivity of pain, a decreased perception of pain and more importantly, an increase in feelings of quality of life and control.

The Solution to Chronic Pain

Now, I said earlier, that the researchers have defined chronic pain as a biopsychosocial, it is involved in more than just the physiology of pain. Diopsychosocial described pain and disability as a complex and dynamic interaction among the physiological aspects, the psychological aspects and the social aspects that can perpetuate or even worsen each other, resulting in chronic pain syndromes.

A multidisciplinary versus interdisciplinary comparison is in talking about what works, how do you address this as a problem?

Multidisciplinary

Multidisciplinary is relatively easy to achieve. It’s getting a diverse group of providers under one roof or within one system. It’s getting that group together in one location, you got a little bit ease of access, but they’re still each autonomous entities operating in their own little silos.

Interdisciplinary

Interdisciplinary on the other hand, is a lot harder to pull off because it involves having those providers actually collaborate, working together. The patients benefit from the combined expertise.

Interdisciplinary treatment often isn’t easily achieved in most settings. And one reason is because of third party billing. I mean, that’s a traditional way that most hospitals are set up, each of your clinicians are billing for the time that they spend with the patient.

Now, I’m lucky enough to work in an environment where that is not an issue when QLI was first set up, it was with an agreement with the state of Nebraska and state Medicaid dollars, and it was set up with a per diem reimbursement rate, which meant that for a patient that we’re working with on an inpatient setting, we get a flat rate per day for that individual.

That allows two different therapists to be working with a patient at the same time without having to flip a coin to decide who gets to build for this hour. So it does give you the latitude not only for your clinicians to be working together toward the same goal, but to actually physically in the moment be working together.

I really think that particularly for chronic pain, we need to rethink the heuristic for how we put together a program in order for it to be effective. We need to adapt our understanding and our thinking about pain, and how to treat it.

From a practical standpoint, by way of example, if I’m working with a client who has anxiety over transfers, I can work with that individual individually as you normally would in hospital setting to work on anxiety reduction on different techniques on different strategies that they can do. And the PT that’s going to be working with them on doing the actual physical transfers.

Instead of being siloed and each of us working independently, we can also work together. I can work with the patient on reducing their anxiety while the physical therapist is actually working with them doing the transfers.

And so it opens up opportunities that you might not otherwise have. Now, again, a holistic treatment program is what’s going to be most effective for treating chronic pain because you have to treat all of it at the same time. You have to treat the biological aspect, you have to treat the psychological aspects and you have to treat the social aspects.

Again, I I’m very fortunate to be in an environment where this organization has been doing that for 30 years with other diagnoses. And there’s strong evidence for that interdisciplinary approach not just on improving functioning, but treating the person not treating a diagnosis.

QLI is certainly not the only treatment facility that understands that and implements this holistic approach. And I would certainly encourage you to look for that in any program where you want a successful treatment for chronic pain. Successful programs understand this and they pay attention to all aspects of the person.

Now I want to throw in just a little bit to you know, QLI did not start out being a chronic pain treatment facility. And quite frankly, it is not the majority of what we do. We typically limit the number of chronic pain clients that we’re working with at any given time because of the intensity of such programs.

Historically QLI started out working with individuals diagnosed with traumatic brain injury. That was the majority of our initial clientele.

Over time, we adapted that holistic treatment approach to other populations and spinal cord injury and stroke, in particular. We were approached by case managers and adjusters saying that this model is what is most needed in treating the most severe and intractable cases of chronic pain. Would you consider taking this client and seeing what you can do?

That’s how we got started in chronic pain. That’s how we developed a chronic pain program. We were approached by catastrophic health care carriers and clinical managers that understood that this holistic approach is a key to treatment. And it convinced us to develop a program based on QLI’s tri dimensional approach.

Tri-Dimensional Rehabilitation

Tri-Dimensional Rehab is a treatment model that was put in place from day one at QLI and it involves the application first off of medical care, what type of medical care is needed to keep somebody healthy and safe.

You can think of it as Maslow’s hierarchy. And that’s the base of the pyramid. If that is on hold, everything else is going to have to wait until you get somebody healthy enough to engage and participate.

The next level of the pyramid is providing the teaching and repetition routines that are critical to neuroplasticity. We know that what the brain does, a lot of it gets better at.

So if you want to teach a skill, you practice it. If you’ve ever taken on something that you didn’t know how to do and you’ve learned how to do it, and you’ve learned how to do it well, you did that by doing it over and over and over again, oftentimes with a mentor or with a coach.

As a clinician, that’s our job, we are coaches, to get people to put in the practice and repetition for what they need to get more independent, and increase their abilities.

And then the tip of the pyramid is an aspect of rehab, I think that often gets ignored or at least minimized. But it’s crucial in developing the trust and relationships that support the level of engagement that you need in this difficult and frustrating process to get the repetition that you want.

If you have a sense of purpose with a task, it doesn’t mean that the task is fun, or easy. There are a lot of things we do throughout our days or weeks that we wouldn’t categorize as fun or easy, but we choose to do them because they serve a purpose in our life, in our job, or in our responsibilities to those that we care about.

That repetition of those things that aren’t necessarily fun, or enjoyable. If it serves a greater purpose in our life, we are more likely to do it and we’re more likely to do it independently. I’m not going to do it because somebody says I have to I do it because I want to. And that is a huge piece when it comes to the difficult things that we are asking people to do.

I’ll speak a little bit more to the aspects of acceptance in terms of what that means in the context of rehab in a couple of minutes. But the bottom line here is fostering acceptance, instilling hope and restoring a sense of anticipation of pleasure.

If you can put that in place, that is the capstone of this tri dimensional rehabilitation model. It’s an integration of those things that are motivations and passions within an individual’s life, integrating those within their rehab program. That’s where it gets really complicated, because you can’t just take a program off the shelf, because people are different, their motivations or passions are all unique to them.

Integrating that within their program is going to be a very individualized process. That means you can’t manualize this. Because the spark or passion is different for every person. Again, you can’t take it off the shelf, you can’t use a workbook or a generalized approach, it’s not going to be as effective for targeting that person.

So if you’re focused on the physiology and component skills as you are in an emergent situation, in an acute situation, that’s exactly what you want. You don’t want your cardiologist winging it when it comes to doing your procedure.

On the other hand, the further out you get from injury, the more complex it becomes to individualize that program. Because you have to look at that person’s life, their passions, their dreams, and their values.

The Role of Corporate Culture

I’m not going to spend a lot of time on this. But I do want to remind you that the environment in which those services are provided is important.

There’s a tremendous amount of research out there that supports the fact that exposure to positive influences, a positive environment and a conscious attention to positive aspects and expectations are associated with decreased stress, improved mood, and direct improvement in measures of cognitive and physical functioning.

In the midst of the current COVID-19 health concerns, there’s a general kind of umbrella of general stress that we all seem to be under. We know through extensive empirical data, the role that stress plays in compromising our attention, our ability to concentrate, our cognitive levels, as well as the physiological effect of increased cortisol levels.

If you’re under stress, you have higher cortisol levels, which directly compromises your immune system. And this is a time where you need to work on actively relaxation, being able to back that down, because you want your immune system as healthy as it can be right now.

So being emotionally healthy is a contributing factor to our cognitive and physical health. And in any organization, maintaining a positive culture within the organization has a direct effect on your efficacy.

And from a mercenary standpoint, it’s cheaper, you keep good staff, you don’t have to constantly retrain.

Cognitive Behavioral Therapy

Now I’m going to say something here that might be offensive. And that is psychology is an important part of this. Now, you might not be surprised to hear psychologists say that, but the data actually supports it. It’s not just my opinion.

You need to differentiate what you think about when you hear psychology and what that means. When you think about these really difficult cases, they oftentimes have a lot of emotional problems and chronic issues. This does not equal mental illness. But we do need to look at and treat the aspects of the psychological pieces that are supportive and are contributing here.

Now the definition of pain is a negative sensory and emotional experience. That definition recognizes that along with pain comes an emotional response, how you think and react to that.

People naturally respond to a negative experience by attempting to escape it. Pain typically signals harm or threat. It’s something that everybody wants to avoid. Your body is naturally attuned to avoid things that cause damage to it.

But sometimes people try to escape pain by retreating to bed becoming sedentary. Avoiding things this fear avoidance might seem like a good idea on the surface, but that sedentary lifestyle actually worsens pain over time, it leads to deconditioning, contributes to depression. So helping people address this in the bigger picture.

Cognitive behavioral therapy, or CBT, as it’s commonly called, is the aspect of psychological therapy that has the strongest amount of research support, from the standpoint of treatment of chronic pain.

It is supported as an evidence based therapy within the APA within the AMA, within other medical bodies. It’s the only approach that is listed as applicable to all types of pain because it’s an interdisciplinary treatment approach. It allows us to intervene at multiple points in levels using multiple disciplines. It is a supportive and therapeutic process.

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy is one of the third wave cognitive behavioral therapies that is particularly applicable to the treatment of chronic pain. It’s called ACT, Acceptance and Commitment Therapy.

ACT is an approach that’s based on solid and sound scientific foundation of cognitive behavioral therapy, and it’s been demonstrated to be successful in treating patients with chronic pain.

It’s a mindfulness based approach and awareness of the connection between your thoughts and your emotions and your perceptions, the role that your mind plays in affecting your decisions.

It also involves commitment, moving toward valued goals, committing to act in a manner that advances the values in your life. It is an evidence based practice that is accepted by multiple organizations and shows the strongest scientific evidence based research data for effectiveness with chronic pain population.

The goal of this therapeutic approach is to increase your psychological flexibility, and there are many interconnected aspects.

Contact, we live so much of our lives thinking about an anxious about the future worrying or dwelling in the past. In doing so you’re devoting less time to what’s actually happening here and now. That’s the mindfulness aspect of ACT.

Values is identifying what’s important to one’s true self and Committed Action involves setting goals according to those values and moving toward them carrying them out responsibly.

Self as Context is that aspect of you that’s unchanging, a continuity of consciousness, being able to separate yourself from your thoughts, being aware of the fact that your mind produces thoughts and you have very little control directly over what your mind throws at you.

Diffusion is learning methods to reduce your tendency to make those thoughts reality. Those images, those emotions, those memories. If they’re not happening right now, you get to decide consciously whether or not to react emotionally to that product of your mind. It’s the ability to independently observe and notice, that is just a thought.

Acceptance is allowing your thoughts and perceptions to come and go without struggling with them, acknowledging their presence, but not allowing them to drive out your action. So having a thought that would normally spin you off into worry and fear. But being able to objectively say that is just a thought. It’s not happening right now, I don’t need to react to that.

Values – Know What Matters

I want to focus a bit on a couple of aspects that are central to the treatment of chronic pain. The first is this identification of values. Values are an important aspect of a person’s belief system and it’s central to the design of a person centered approach.

Every person coming through the door has a different set of motivations, drives and values and identifying those is key to individualizing that program.

A value is an intentional quality. It’s like a compass when it comes to figuring out what direction you want to go. If you decide to go east and you have a compass to guide you, you’re traveling in a direction by intention. East is not a destination, you can’t ever get to East. East is a direction, not a destination.

Values are not destinations, they are directions. It is a quality of something you do it’s not a tangible object or item. That’s the why you do something. It’s the underlying reason for a particular goal. A goal is a tangible, measurable way point but it’s the value that drives you towards and beyond that goal.

Values involve choices, not judgments, choices. A judgment involves evaluation of alternatives, pros and cons. And depending on what you’re thinking at a given moment, you can rationalize either choice.

Do I buy a boat? Or do I not buy a boat. I come up with really good reasons on either side of that. But if I apply a value to that, not a judgment. Well, if my value is I want to be financially stable, then right now, I’m probably not going to buy a boat. So it’s making decisions on the basis of your values.

A value is a concrete and achievable event or situation or object. A goal can be completed or checked off. If you confuse goals and values, then it’s going to be difficult once that goal is achieved to know where to go next.

Values are not in the future. They’re always right now. Looking at a compass, you can see are you going east or not. So it’s being able to measure at any given point, whether or not your intent is being carried out.

There are a lot of different workbook type exercises designed to investigate and identify values, introspective exercises, such as describing how you want others to think about you to remember you when you’re no longer here.

Those can be a powerful force in identifying values, and then moving toward, How do you make plans for the committed action that is necessary.

Committed Action

The short version of committed action is do what it takes. If you have a particular value, you need to make decisions that are supportive of that particular value, taking tangible action, moving toward that goal.

Again, if it’s going out and throwing a ball with my son in the yard, then it is making choices that are based on values in that moment, acting even if those actions bring discomfort.

Again, if I want to train for a marathon, it’s going to bring discomfort to do that. But if my goal along that value of being physically healthy, is to run a marathon, then I’m going to have to do the things that are necessary, I have to do what it takes to get that done.

There are a lot of things that we’re willing to do for those that we love that aren’t fun or enjoyable, but they deepen our relationship. They provide support and caring in times when that is needed.

Specific to chronic pain, this involves acting in a way that’s consistent with the values that individual expresses what is important to them. Being able to physically interact with their world often involves pain and discomfort, more so when it’s something that they have avoided.

But with practice with repetition, with the development of routines that support that individual’s values, they’re able to support what is meaningful and purposeful to them.

Vision of Program

Vision of program is to identify what is it that drives a person, and putting that as part of what they are doing to get back to a life that is meaningful.

Again, although we feel this approach is an ideal way of addressing the multifaceted issues associated with chronic pain, an inpatient intensive rehab program is not going to be appropriate for every chronic pain case.

As a matter of fact, the vast majority of individuals who are experiencing chronic pain are going to respond appropriately to an outpatient program. But the folks that we tend to see here, as with our catastrophic brain injury or spinal cord injured diagnosed individuals tends to be those that are on the more extreme end of the spectrum. S

o our chronic pain clientele tends to be individuals that are the most severe and intractable in nature. And that higher level of intensity is necessary for some of those individuals.

We see individuals that have tried and failed in those less immersive and more traditionally medically driven approaches. But again, most individuals are going to respond to that and that is the appropriate first order of treatment.

Shifting Focus

Because this process is highly individualized, what you do in a specific case is going to depend on that person. So getting people to identify what are their natural motivations and bringing them in as part of that program.

Being able to engage them in work. It’s interesting that most of us dream about the day that we don’t have to work, when we we can retire just sit on the bank and fish. But you know, most individuals that we see have had that ability taken away by pain or injury. And getting back to work is often one of their top goals. A large part of most people’s identity, quite frankly, is what do you do? What’s your job?

So what we see is that as individuals are engaged and moving toward those valued and purposeful aspects in life, they’re effectively reprogramming their brain to be less sensitive to pain.

Working out and physical activity actively send sensation to those perceptual regions of the brain. You can recalibrate and renormalize those levels of sensitivity, the incoming signal goes from being a hyper activation with a perception of pain to a more normalized experience.

Like everything else in the brain, this process does take time and practice. It relies on excessive extensive repetition and routine for it to become more automatic. That’s neuroplasticity in a nutshell.

How Does QLI Treat Chronic Pain?

Because I’m in this environment, I want to tell you how we treat chronic pain. First off, it’s a small, cohesive and devoted interdisciplinary team. Having a dedicated smaller size team just allocated to those chronic pain patients allows for communication and decision making to occur quickly and to implement changes quickly.

So I and the PT need to know what each are working on and need to work together. Both needs to know what side is working on. Nutrition and PT need to know what Life Path services is doing.

It covers all hours of the day. Again, somebody is paying maybe worse at 3am. So you need to have staff that are able to respond, provide support, review, coping and compensatory strategies and help them get through those low spots in the road.

And again, I say, this level of intensive programming isn’t practical for every case. And I’m not advocating that. The program I’m talking about represents a level of intensity that’s appropriate for the most intense and intractable of cases.

But I would encourage you to seek out what resources there are that are more typical in nature, because that is going to be adequate in the vast majority of cases.

What Does a Typical Day Look Like?

For our clients our typical day, because you’ve probably want to know, what does the day look like for somebody in your program?

Well, first, you have to remember in each case, it’s going to be highly individualized and specific to that person’s goals and values. But structured formal therapies, as well as informal times, with a goal of enhancing engagement and repetition of what the client and the team are working on.

For any individual coming to us on narcotic medications, the first phase of the program is going to be tapering, coming off of narcotics.

We know by overwhelming evidence, that narcotic treatment is not an appropriate or effective treatment for chronic pain. If it was, people with chronic pain wouldn’t have chronic pain. Those medications would effectively treat it.

Based on individual goals, motivations, passions, the ultimate program ends up. And then the more important piece is how do we transition that process home?

As we see people pursuing what they’re passionate about becoming active, engaging in their own routines that give them a sense of meaning and purpose. That’s part of the process of normalizing that signal between the body and the brain, we want that to carry over, as our clients leave us.

Success isn’t measured just by the date of discharge. It’s as the person goes home and continues to progress with the tools that they’ve been given in this environment, and using them at home.

Quite frankly, it’s easy to be upbeat and positive when you are here in this environment because this is a very positive and engaging environment. It’s intensive, it’s supportive.

Being helpful with that transition home is a huge part of our program as well because it determines long term success. It’s also something that we’re really good at because we’ve been doing it a long time with brain injury and spinal cord injury.

It’s education for family and friends, not just the client and incorporate scripts for how to respond. All these routines of chronic pain that have developed over time, have responded to a certain set of circumstances. Now you have an individual who’s changed routines, and so those scripts need to change as well.

It’s real life engagement. We do that on site to the degree we can and then transition that home. It’s troubleshooting as well. We can predict some things that may come up but life has a way of surprising us. So we also need to have in our back pocket a plan B and a plan C and sometimes coming up with a plan D as well.

One huge positive that has come out of the shelter in place guidelines has been an opening up of remote therapy opportunities and processes.

Telehealth has been given a huge boost in the last couple of months and this is a way of providing ongoing support when somebody leaves your facility. This is an area of practice that qLI has been providing for a few years now. We have a specific telehealth program and that continues to expand as our providers are expanding their licenses to states across the country.

Now in most disciplines of practice, there’s a lack of national licensure and reciprocity that has traditionally been a barrier to practicing across state lines but I can see that starting to change and I think the current health environment which has necessitated more remote telehealth is probably going to help push that a little further down the road as well.

But we’re somewhat lucky here at QLI in that our telehealth services have existed for some time. So we already have clinicians that are currently licensed in a number of different states. I do hope, though, that that will open up with this process. And I’m sure that many of you are seeing a lot more telehealth and remote conferencing as a way of connecting with your clientele.

That pretty much wraps up the presentation, there are a number of references and resources here that I have put in. This Butler and Mosley book that I referenced earlier is on this particular slide as well. I highly recommend this book. This is a very good layman’s explanation of pain, as well as the process and routine for treating chronic pain and some of the ways of looking at and experiencing that.

There are also a number of resources for more recent publications as well. And I would encourage you if you have any questions, if you haven’t already asked them to please throw them our way and we will respond by way of email.

Tim Benak – 1:01:07

Yeah, so we’re gonna go ahead and we’ll get the poll question launched here. Thank you, for everyone sticking around a little bit longer. We had so much content, we just ran over a little bit, and it took a little time on the front end. So I apologize for that.

But I’ll go ahead and launch this poll question. Again, that just a reminder, if you’re looking for a CE certificate, make sure you answer this. It’s very simple. I’m just asking you guys a quick question. You know, with everyone, a lot more folks being working remote, if it’s something that you guys liked, we can offer and do a rebroadcast of some of the ones that we’ve already done this year. Pretty simple for us to put that on. So that’s actually the question.

So we did have a few, Jeff, I will send those over to you through email.

We also had 553 folks on today. So that’s, that’s a record for us. We just got to keep setting new records every time so. And I do ask for a little bit of grace on the back end of this.

With so many folks being on, there’s quite a bit of just hands on data that we have to compile and to send out your follow up email. So we typically get it out same day. I’m not saying that won’t happen. But if it doesn’t happen, you know, just a little bit of grace, it will be sent out by the end of this week for sure.

And then we had a lot of question about the PowerPoint slides, those will be attached to the follow up email. So if you answer the poll question, you’ll receive that with your CE certificate. And if you do want those, don’t ever hesitate just reach out to us.

We also will be having YouTube recordings of these. So if you are interested in that, we can send that to you as well.

Also, check us out on social media platforms. We put a lot of stories up on our on our website, Facebook, Instagram, and then next month’s webinar will actually be about limb loss about a small FTP program that we have and just kind of the the overall mindset behind our FTP program.

So Steve Kerschke will be giving that on May 20. There will be an invite coming to you guys all shortly. So thank you for joining us, and we look forward to having you join future webinars. Take care.

Categories: Chronic Pain