The origins of chronic pain are complex and include both psychosocial and physiologic components. Physicians’ Diagnostics & Rehabilitation Clinics (PDR) takes an innovative approach to rehabilitation that incorporates tenets of cognitive behavioral therapy (CBT) to address function and psychosocial barriers and ensure optimal patient outcomes.
According to the National Institute of Neurological Disorders and Stroke, approximately 80 percent of adults experience low back pain during their lifetimes and roughly 20 percent of those cases become chronic. It is with this population that PDR specializes.
For over 22 years, PDR has provided physical rehabilitation services for chronic neck and back pain. However, several years ago, the team realized that while they could treat the physiology of back pain with consistent and predictable outcomes, the psychosocial barriers presented a challenging but very real variable to patients’ recovery.
“At Physicians’ Diagnostics & Rehabilitation Clinics, our therapists are trained in identifying the psychological barriers that impede patients’ recoveries. Our goal is to help patients address inappropriate belief systems and behaviors, and give them the skills and confidence they need to address behaviors moving forward, while also meeting their physiologic needs.”
— Todd Ginkel, DC, CEO of PDR
Exploring the Root of Chronic Pain
The onset of back pain can be caused by one or more of a variety of issues, including acute injury, degenerative disc disease, sciatica and herniated discs. However, even after the physiologic cause of pain is addressed, the pain cycle continues for many patients.
Muscle weakness and other functional concerns that impact mobility contribute to lasting, chronic pain. A 2013 study published in Brain revealed distinct differences between the areas of the brain that are activated in acute and chronic pain sensations. Researchers involved in the work used functional MRI to analyze pain-related brain activity in 94 patients with acute back pain and 59 patients who’ve experienced chronic pain for more than 10 years. Results revealed that in patients with acute pain, brain activity is limited to regions associated with acute pain perception. However, in patients with chronic pain, brain activity is confined to areas of the brain that mediate emotion.
According to Todd Ginkel, DC, CEO and founder of PDR, there are psychological components to almost every patient’s chronic pain. For example, patients often present with fear avoidance because they believe physical activity will exacerbate their pain — so they stop moving and avoid activity.
“During an evaluation, I once asked a patient to bend over and touch his toes,” Dr. Ginkel says. “The patient looked at me and said, ‘I don’t bend over.’ I asked what he meant by that, and the patient responded that a physician once told him that if he bent over, the disc in his back would slip out of place. We know that isn’t true, but that is what the patient heard and now believes, so we need to address it. Otherwise, they won’t be able to complete a rigorous physical therapy program.”
Other patients may catastrophize their pain or become hypervigilant about their pain and related diagnosis. Following a diagnosis of degenerative disc disease, for example, many patients focus on the anatomic defect that they believe is causing their pain.
“They think the anatomic defect must be repaired because that’s the pain generator when, in reality, it’s not that simple,” Dr. Ginkel says. “If someone continually focuses on their pain, they reinforce those neurologic circuits, and the pain actually gets worse. It’s like riding a bike — the more you ride a bike, the better you are because it’s easy to reactivate those circuits. The same concept applies to pain.”
It is also possible for patients to believe they can work through their pain and participate in strenuous activities that stress their bodies and may potentially delay a positive outcome. These related psychosocial challenges underscore the importance of a two-pronged approach to physical rehabilitation.
A Focus on Function and Cognitive Behavioral Coaching
When patients present with acute pain, the immediate goal is to reduce inflammation and discomfort using modalities such as medication, massage and chiropractic adjustments. However, long-term management of chronic pain requires an emphasis on function, graded goal setting, and altering the way patients think about and respond to their pain.
Each patient completes a questionnaire known as the Keele STarT Back Screening Tool (KSBST) prior to beginning rehabilitation at PDR. Results are used to place the patient into a low-, medium- or high-risk category for physical and psychosocial barriers related to their spine pain. This information allows PDR’s team of spine specialists, which includes physical medicine and rehabilitation physicians as well as physical and occupational therapists, to work with patients individually and customize care based on their needs.
“Once we identify where patients are psychologically, we integrate tools, such as education about the neuroscience of pain and patient-centered goal setting, into the physical rehabilitation program,” says Jennifer Missling, PT, Director of Rehabilitation at PDR. “We want to make goal setting a collaborative process because patients are much more motivated to participate if they’re setting their own goals.”
Physical and occupational therapy teams work with patients to achieve greater overall wellness by improving endurance and quality of movement, as well as building better sleep, nutrition and exercise habits. The team encourages patients to create functional goals that are specific, measurable, attainable, realistic and time-based (SMART). The goal for many who come to physical rehabilitation is pain elimination, but becoming pain-free is not always a realistic goal.
“What we try to do is set up SMART goals that revolve around managing instead of eliminating back pain,” Missling says. “If a patient is having a hard time ambulating the distance necessary to manage daily activities, a SMART goal might be walking a half mile to complete a shopping trip with minimal low back discomfort.”
Another key component of cognitive behavioral coaching is managing automatic thought processes. When many patients experience discomfort in their low back — even if the discomfort is the result of simple post-exercise muscle soreness — they automatically associate the discomfort with pain, and the pain with damage to their spine.
“Thoughts, behaviors and emotions are interrelated,” Missling says. “Behaviors can influence thoughts, so we change automatic thoughts through new behaviors, new experiences and knowledge. Graded exposure — for example, bending a little further each day so patients can see the activity will not hurt them — is at the heart of our cognitive behavioral coaching.”
Further addressing the mental patterns associated with patient discomfort, therapists refocus conversations on function by avoiding the word “pain” or asking patients to rate the sensation on a scale of one to 10.
The Physical Rehabilitation Protocol
To help improve spinal mobility, strength, flexibility and functionality, PDR utilizes MedX medical equipment. Using the MedX equipment, PDR physical therapists can compare an individual’s low back or neck strength to normative data for healthy people of the same gender, age and weight. Based on each patient’s individual deficits, PDR therapists develop an exercise program consisting of graded, calculated sessions of isolated exercises performed using the MedX equipment.
“The MedX machines enable patients to participate in more aggressive exercise in a safer manner than they could without the equipment,” Dr. Ginkel says. “We have the ability to focus on the lumbar or cervical spine and have patients exercise aggressively to strengthen their muscles without compromising intervertebral discs or other spinal components.”
This in-office program is complemented by a series of at-home stretching exercises that address muscle tightness. Each patient’s strength and range of motion is reassessed throughout the program, and therapists adjust the exercise regimen as they see improvement.
“MedX is a positive motivator because it allows people to objectively see where they’re starting and what their goal is,” Missling says. “Many times, patients have been to other providers who were unable to specifically measure their strength and range of motion. The ability to show patients that they have a significant loss of strength or range of motion, as well as inform them as these markers improve, is a great psychological tool.”
A typical physical rehabilitation program consists of 16 to 24 visits. Most patients come into the office no more than twice a week for eight to 12 weeks.
“What used to be an alarming sensation — because pain is a threat to the body — becomes less threatening when patients understand it and have knowledge about how it works. Through cognitive behavioral coaching, patients learn about the mind-body connection and how we perceive pain, and they discover that movement is not damaging and that if they move, they’ll feel better.”
— Jennifer Missling, PT, Director of Physicians’ Diagnostics & Rehabilitation Clinics
Measurements of Success
To assess patient outcomes, PDR therapists use a variety of tools, including patient satisfaction surveys, strength and range of motion markers measured by MedX medical equipment, and patient-specific functional scales (PSFS). The PSFS helps patients quantify whether or not they have achieved their SMART goals. In most cases, patients set no more than three SMART goals, and they rate their ability to perform the tasks associated with the goals, such as walking one mile, on a scale of zero to 10 after completing physical rehabilitation.
Patients also complete the Oswestry Low Back Pain Disability Questionnaire to assess their permanent functional disability and participate in interviews. PDR patients typically achieve better-than-average scores on the Oswestry Low Back Pain Disability Questionnaire, and when asked to rate their total recovery, patients experience 75 percent recovery on average — a significant improvement in the chronic pain population. Therapists readminister the KSBST questionnaire at the end of the program. The percentage of people who transition from high risk factor scores to medium and, eventually, to low, improves every year.
“If patients come in with high KSBST scores and leave with low scores, I have confidence that they will be able to manage their pain after they leave,” Dr. Ginkel says. “When we can convert high scores to low scores, we observe really great outcomes.”
To learn more about PDR’s approach to treating neck and back pain, visit pdrclinics.com.