Can Low Back Pain Be Tamed at the Population Level?

For a person with chronic low back pain, a spine surgeon’s office is not the ideal point of entry to the healthcare system. Neither is a spine imaging suite or the office of a pain specialist with a predilection to prescribe opioids. But those are places where far too many Americans with persistent back pain have surfaced at early stages of their disease in recent years. The result has been needless numbers of mutilating spine surgeries, premature imaging studies and avoidable opioid addictions — all without improved patient outcomes to show for it.

As detailed in a recent post on this blog, Cleveland Clinic’s Neurological Institute has devised an unprecedented pilot population health initiative for chronic low back pain aimed at helping patients recover and become active again. The initiative, which launched in August 2016, promotes functional outcomes rather than procedure-based care and focuses on rehabilitation, relying primarily on a combination of physical therapy and behavioral medicine. It targets patients at high risk for extended disability.

“If we do a better job with people at risk for prolonged disability — if we treat them a bit differently — maybe they won’t keep cycling through the system like they have been,” says Mary Stilphen, PT, DPT, Senior Director of Rehabilitation and Sports Therapy at Cleveland Clinic.

A collaboration of PTs, pain psychologists, physiatrists

The program’s name, Back On Trek, alludes 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 physical therapists (PTs), behavioral medicine specialists and physiatrists treat participants in the 12-week pilot program at Cleveland Clinic’s Lutheran Hospital on Cleveland’s west side.

“Literature supports a collaborative approach,” explains Stilphen. “If we combine cognitive behavioral therapy and physical therapy and focus on educating our patients about the neuroscience and neurophysiology behind their pain, we may achieve a better outcome.”

Multiple entry points

Eligible patients have typically experienced several months of chronic spine pain and screen negative for red flags suggestive of a possible medically dangerous pathology, as specified by the Cleveland Clinic Spine Care Path.

Patients who meet those criteria may self-refer to the program through the telephone contact center or be referred by a Cleveland Clinic physiatrist or medical spine physician. Additionally, patients may access the program through an initial assessment by a PT at any of Cleveland Clinic’s 47 outpatient therapy locations. At that assessment, PTs use the Keele STarT Back Screening Tool; if the tool indicates a high risk for prolonged disability, the patient may be referred to the program.

Referred patients meet first with a behavioral medicine clinician with specialized expertise in pain to gain an understanding of the biopsychosocial contributors to their pain, which helps the team focus interventions appropriately.

“This program identifies patients who are likely to have psychosocial stressors, which can certainly impact recovery,” says Ian Stephens, PT, DPT, OCS, Physical Therapy Clinical Rehab Manager at Cleveland Clinic. “It puts them in the setting to best address those issues and enables us to adjust our approach as indicated.”

The role of physical therapy

The program has two key components: individual therapy sessions and group conditioning sessions.

Individual therapy sessions involve meeting once a week with a PT who provides conventional interventions, such as manual therapy and corrective exercise, as well as offering pain neuroscience education.

“The physical therapy management strategy relies heavily on patient education,” says Stephens. “The goal is to reduce fear of pain by helping patients understand more about pain. Fear of pain is often more disabling than actually experiencing pain. That knowledge brings empowerment, as patients learn strategies to better manage or control their pain.” Pain neuroscience education is the primary strategy used by PTs to reduce fear of movement.

During the group sessions, four to six participants meet for aerobic conditioning — twice weekly early at the beginning, then once a week. Each patient is given a goal and positive feedback when it’s achieved. Patients also have weekly group sessions with a behavioral medicine specialist. “We’re hopeful the group dynamic will prove to support and motivate patients,” says Stephens.

Physicians add support to the program, reinforcing the messages from the PTs and behavioral medicine specialists. “Some patients tend to do better when they know there’s a collaborative team overseeing their care,” Stilphen explains. All team members meet weekly to discuss patients’ progress.

Educating the educators

Three to four outpatient PTs who specialize in treating people with spine pain are partaking in the pilot program. They will receive ongoing education on the cognitive behavioral approach to treating patients with chronic pain and on methods for talking to patients about the neuroscience of spine pain.

“Education needs to be delivered in a way that patients can process, so we’re using images, metaphors and stories instead of anatomical models and medical jargon,” says Stephens. “But providing this kind of education may not be a skill set that every PT has. It requires refinement, like anything else a PT offers when managing patients.”

To that end, core training based on the textbook Therapeutic Neuroscience Education: Teaching Patients About Pain is offered to the program’s PTs, physiatrists and other participating clinicians so they speak the same language — and hopefully improve patient outcomes.

“We know our low back pain patients get better with therapy, but those at high risk for disability don’t typically get to the same level as somebody at low risk,” says Stilphen. “We want to see if we can make an impact on the high-risk group and get them back to a manageable baseline.”