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Ep. 105 - LiveWell Talk On...Pain Psychology (Dr. Benjamin Tallman)

episode 105

Ep. 105 - LiveWell Talk On...Pain Psychology

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Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guests: Dr. Benjamin Tallman, health psychologist, St. Luke's Physical Medicine and Rehab

***This episode was recorded prior to the COVID-19 pandemic. Aspects of the Pain Psychology Program described in this podcast may currently be altered for the safety of our patients and team members.***

Dr. Arnold:
This is LiveWell talk on pain psychology. I'm Dr. Dustin Arnold, chief medical officer at Unity Point Health-St. Luke's Hospital. Pain. It is an all too familiar problem and most common reason that a person sees a physician. Unfortunately, treating pain isn't always straightforward. You've likely heard of medical treatment options such as medication, surgery, physical therapy and more. However, psychological treatments are also an important part of pain management and often isn't on the top of the mind of clinicians nor patients. Here to tell us more about pain psychology and its key role in pain management is Dr. Benjamin Tolman, licensed psychologist for St. Luke's Hospital, physical medicine and rehabilitation department. Welcome.

Dr. Tallman:
Thanks for having me today. I appreciate being here.

Dr. Arnold:
To start it off, let's talk about acute and chronic pain and how you see those two in relation to pain psychology. And then we'll go into what is pain psychology.

Dr. Tallman:
A lot of acute pain we deal with on the inpatient basis and using more techniques like self-regulation exercises, things like guided imagery, clinical hypnosis to manage some of those acute symptoms. Whereas chronic pain is a much different animal. So there are many different, what we consider biocycle social factors that can impact pain. So relationship patterns, how we think, our thinking patterns, behavioral patterns in any number of things that can influence and impact pain. So when we think about chronic pain, we're really looking at a multitude of factors that could be impacting somebody's experience of pain. So it's really quite a bit different from acute pain.

Dr. Arnold:
And a patient could have acute and chronic pain. They might have chronic debilitating pain and then have a broken hip on top of that. So, let's just talk about the pain psychology program. I know you've started it and you should be proud of that. I'm certainly proud of your accomplishments. But tell us, just give us the basic structure of the program, how it works up on PMNR and throughout the hospital.

Dr. Tallman:
Yeah, so patients are initially referred from their provider, in many cases a primary care provider, but essentially any provider could refer a patient to us with any type of pain related concern. And we don't turn anybody away. They can have any different types of pain, musculoskeletal pain. They can have neuropathic pain and a variety of pain conditions, whether it's fibromyalgia to arthritis. Patients first come to a CAR pain empowerment group. This is a two hour group that really provides information about what pain psychology is. We again give them information about the biocycle social model, other factors that are influencing their pain and then other cognitive behavioral techniques that they can use to manage their pain. So it's really an introduction, getting folks excited, but also giving them some information about pain psychology as most patients have never heard of pain psychology. Oftentimes when patients are referred to our program, I think there's tremendous stigma still with patients going to a psychologist. So initially they think we're going to say that their pain is all in their head. We never challenge anybody's pain. If somebody is coming to our program, we certainly believe that they're in pain and we want to help them become more functional. That's really the goal of our program, certainly we'd love to see reduced pain levels, but our goal is really to increase functioning, increase independence and get people doing things you know that they haven't done for a very long time. Oftentimes people with with chronic pain concerns get away from things that are enjoyable. They stopped going to, you know, their granddaughter or grandson's basketball game.

Dr. Tallman:
They stop engaging with other activities in life that they enjoy. They're not hanging out with friends or family members so we could look at and help people understand how to take back control of their life. So folks come to an initial two hour pain empowerment group. And after they've made it through that group, if they're interested, then they really get into the meat of the program, which is an eight session cognitive behavioral therapy group for patients with pain. Each group lasts an hour and a half, so over a two month period. And patients learn a number of different types of skills related to pain management. How thinking patterns influence pain, how behavioral patterns influence pain, and then a whole range of different types of self regulation exercises, some of which I've already mentioned; clinical hypnosis, biofeedback, and even virtual reality for pain management. So once patients get through that cognitive behavioral therapy group and they graduate, you know, we recognize that people still may need some additional support. So they're then eligible for a support group for up to a year. We call this our monthly maintenance group. So not everybody needs support each month. So we might have somebody come one month and then maybe they don't come for three or four months. But it's still a way that they can hone their skills, refresh their skills, and then tell success stories.

Dr. Arnold:
You talked about the stigma of psychology. I really think to some level we've worked very hard on reducing the stigma of mental health and now we've replaced that too, with a stigma attached to chronic pain and chronic opioid use. It's interesting how those two have almost flipped as far as something that labels a patient that is not an enjoyable label. It can be and it starts with release of just intrinsic bias prior to seeing those patients, which that I have to do redirect myself when I'm dealing with those patients. Because nobody wants to be chronic pain patient with chronic opioids, period. They just, they don't. And we can talk about the opioid epidemic and the fact that, you know, pain used to be the fifth vital sign. We're as healthcare providers, we're responsible for a significant portion of the opioid epidemic.

Dr. Tallman:
Absolutely. And I think, you know, there's been lots in the news about the opioid epidemic and really I think it stems from, you know, our culture and how we help people manage their health. You know, typically patients come to their physician and they're looking for ways to be able to manage their pain, if that's what it is or their acute illness. And historically we've relied on usually biomedical interventions, medications, and our culture has gotten accustomed to going to providers, looking for medications to be able to manage symptoms. So it's a very reactionary process. We typically wait until people are sick to get them healthy instead of the opposite, which is, how can we be proactive? Give patients a set of skills or techniques that they can use to manage their health ahead of time. So you know, we could mitigate some of the negative health things that might come up before they arise. I think the same thing is with pain as well.

Dr. Arnold:
Correct. I also have, as you know you've heard me say this, nobody goes to rehab halfway to rock bottom. You know once it's broken is when people look for a solution and not preventing it from breaking. That's just, that's just human nature that will not change. I think we need to have some clarity, some clarification. The goal of the pain psychology program is not to get people off opioids. It is to improve their life, correct?

Dr. Tallman:
That is correct. You know as a licensed psychologist, I don't prescribe medications. I leave that up to my physician colleagues and certainly there's a lot of patients that come to our program and they want to get off those medications because of some of the negative side effects. But no, the goal is not to come to our program to get off medications. You know, quite frankly, the goal is not even to reduce pain. Now, many people that do come to our program, once they've learned some of these skills, they're using some of the cognitive behavioral interventions, their pain levels do decrease. But what we really see are these peripheral effects of our program. You know, when we look over, I just did an outcomes report for the last 18 months of patients that went through our cognitive behavioral therapy group. We see a nice 29% decrease in depressive symptoms, 27% decrease in anxiety symptoms. I think one of the ones that's most impressive is patients are reporting a significant improvement in their functional ability. Their day to day things, they're moving more, they're getting out and about. And we see some improvement in pain related scores. But again, we're seeing the big improvements in function. That's really the goal of the program. So sometimes we have to educate folks. Ideally, if I could take patients pain away, I absolutely would, but many times that's not realistic. If somebody had pain, chronic pain for 15 or 20 years and they've had several failed surgeries and they've done other things, the likelihood of us taking their pain away is pretty small. So you know, a realistic goal might be maybe reducing their pain, but it might be increasing function. So I think we have a tendency as a medical culture to really focus on treating symptoms. Which is good. In the case of chronic pain, that can be difficult. Whereas if our focus says if we increase function, people have better outcomes and again we've really seen that from the good outcomes of our program. We haven't had anybody yet in the last 18 months that's gone through our program, that's completed it and hasn't had some type of positive indicator on a health related quality of life measure. So you know I'm also a research scientist. So we look at the data, we want to make sure that what we're doing is actually working. And so far people are getting better from an anxiety and depression standpoint, but also becoming better from a functional standpoint. So we're very pleased with our outcomes. So what we're doing is working.

Dr. Arnold:
I think people listening like myself can understand biofeedback and self hypnosis and redirection therapy. Virtual reality, how does that play into it? That's something new and a new phenomenon. And just how does that work? What are the mechanics of that?

Dr. Tallman:
Yeah we're really excited. We started a virtual reality program at St. Luke's and really one of the first in the area. We have some good research to suggest that virtual reality can work really well for acute pain, pain during dressing changes, but also chronic pain. We have an idea about the mechanisms of what might be happening for virtual reality to work. Although there's still a little bit of research, we still need more well-designed research studies. But the school of thought is that you know, you experience, you feel pain in your elbow. We feel pain in our knee and our lower back or wherever it might be in our body. Pain is all processed in the brain. We have different regions of the brain that process the emotional part of pain. We have regions of the brain that process the type of pain we experience, whether it's burning, stabbing, shooting, prickling, tingling, et cetera. Areas of the brain that tell us to do something about the pain. So we think virtual reality kind of quiets down those areas of the brain that experience the effective component or the physical component of pain. And help the other areas of the brain that kind of take your attention away from those areas. So when you look at some of the research studies that look at say distraction in general, watching television as a control and a group of subjects might get virtual reality. The patients that have virtual reality have lower pain levels. So there is some type of analgesic effect that's happening. And we think it's when somebody has virtual reality on, they're fully immersed and they're in a virtual world. Whether they're on the beach or they're engaged in some type of stimulating game, the areas of the brain that are processing pain are kind of quieted down. And so far we're actually getting ready to roll out our virtual reality program on six West at St. Luke's. We've been training nurses, actually this past week, to be able to administer virtual reality headsets. And then we'll roll out our program hospital wide here probably in the next three months. So we're really excited to a rollout very new technology. Patients really like it. Our staff really like to use the headsets and I think it's going to have a very nice benefit. I think one of the biggest things with these adverse reality and these types of interventions is that they give patients more control over their health.

Dr. Tallman:
Alright, so instead of relying on somebody else, you know as a psychologist, I really want to empower patients. I really want to give them skills and tools so that they can manage their own health and their own pain. And virtual reality is one of those tools that patients can use to manage their own pain, anxiety, etc. So again, we're really excited about this new technology.

Dr. Arnold:
That is outstanding. Another exciting component that I know you've done some work on with the medical staff is approaching pain, particularly acute post-surgical pain is more as a functional, not a number on a scale of one to 10. Because if you're in pain, it's 10 to you, and if you're 10 is not my 10. So that really is becoming outdated, but talk about addressing it more from a functional standpoint.

Dr. Tallman:
Yeah. So I think sometimes there's a gap between what a provider is seeing. So if a nurse walks into a patient's room and a patient may say my pain is 10 out of 10 but then they may be up moving around in the room and functioning well. There's kind of a disconnect there, but could also be opposite. A patient might say my pain is a two, but they're not able to ambulate in the room. They're not able to participate in some of the rehabilitation activities. So when we take out the subjectiveness. The subjective, this meaning when you use a one to 10 scale, one patient's six, is completely different from another patient's six. But when we focus on function, what the patient can do, can they participate in daily activities of daily living? Are they able to get up and participate in therapies or activities? What are the things that they're actually able to do? If we can focus on function instead of the subjective piece, we can kind of cut out this disconnect that sometimes happens between providers and patients. Whereas a patient says my pain is not being controlled and the provider says, well I don't see, you don't appear to be in pain. Again, everybody's pain experience is very subjective. So I think using a functional pain scale, which is one of the tools that we're going to be using here at St. Luke's, helps put the provider and the patient on the same playing field and takes out some of that subjectiveness. And again instead of focusing on pain reduction, which certainly can be helpful, we're focusing on patients getting better, being able to do more meaningful things and increasing their function. If we're increasing function we're oftentimes also increasing their quality of life.

Dr. Arnold:
Yeah, and I think it makes the fundamental step from acknowledging pain as inevitable. Suffering, which is the functionality, is treatable and if you have your knee replaced, it's going to be painful. But you shouldn't be suffering and you should be able to function with therapy, et cetera. So I think good things are going to happen with that. How can a patient get referred to the pain psychology program? They obviously need their primary care physician to make an appointment, through the services and through the referral center. Do you see the program expanding?

Dr. Tallman:
I really do. We're going to be, you know, we're very grateful for the providers that have referred to our program, but what we're realizing is that I think most providers really don't know what pain psychology is and what we're trying to accomplish. When we ask our patients what providers have talked to them about, they have some idea. So one of my goals for 2020 is to do more education with providers about what is pain psychology, what are the goals of the pain psychology program, how do we help patients and how to get patients to our program. So I'm actually in the process of finishing up a mini outcomes report that we'll send all of our providers in the area with information about pain psychology and then even also some additional information about how to talk to patients about pain and how to put in referrals to our program.

Dr. Tallman:
Because again, as we've talked about, there is stigma associated with psychology and I think if there's again, more education about the type of services that we offer. Again, we're not trying to take away patient's medications. We're not going to question somebody's pain and say that it's all in their head. We want to help people have control over their pain and give them back function. So a lot of what we're going to be doing in 2020 is more education with providers. So I see our program growing. Yes, we have lots of room for growth. We just hired another psychologist that's going to be helping with our pain psychology program because we think there's going to be more expansion. So we welcome patients. Any patient with pain-related concerns and again, any type of pain condition. We really try to get in probably patients that have had the chronic pain, which is pain that they've had for three or six months. In some situations, we have had patients in our program with acute pain, well usually it was acute on chronic pain. So yeah, we would welcome more referrals. The best way to do it would be to talk with your primary care doctor. They can put in a health psychology referral or they can call a physical medicine and rehabilitation at: (319) 369-733. And they can let one of our wonderful receptionist's give them information. A receptionist can provide information about what the next steps are and how to get them, scheduled.

Dr. Arnold:
I think this is a tremendous value, Dr. Tolman. Particularly because as a clinician, I can't put a cast on pain. I can't cut out pain. All I can really do is empathize with my patient and give them pain meds. And that is not a sustainable model for addressing this. So I think this adds another arrow in the quiver of treating this complicated condition. What got you thinking about pain psychology?

Dr. Tallman:
Yeah, good question. You know, it was always interested in the health care field and the intersection between psychology and medicine. Psychology seemed to be a great fit between how the mind and body work and operate. I did some work at the University of Iowa in their spine center there and became really interested in understanding what are all the various factors that influence people's health and specifically with pain. I think also the pain patient as they're oftentimes labeled really it's a stigmatized population. And unfortunately providers oftentimes don't want to work with these types of patients because of some of the challenges that they've experienced. So, you know I think it's an underserved population. It's a population that I think is really looking for additional ways to be able to manage their pain. So it was very appealing to be able to help an underserved population Give them control, give them more skills and tools to be able to manage their pain. Also I think there's lots of really, really cool technologies right now and cutting edge evidence-based treatments to help manage pain. Things like biofeedback and use of technology like virtual reality. So for me, I like to build programs and help people by using different types of technologies to manage their pain and pain psychology seems to be a good area for me to be able to utilize those skills and to help people manage their pain and live better lives. You know in Iowa we have a significant shortage of mental health providers across our state and we have to come up with creative ways to be able to help patients manage their pain. So you know, the more we can teach providers, we can teach patients to be able to take ownership and give them skills to be able to manage pain and other mental health issues. The better off our citizens of Iowa are going to be in terms of taking responsibility and having the skills to be able to do so.

Dr. Arnold:
Yeah, I lose equally amount of sleep, what I call the pill and the pendulum where we've swung back where we we're potentially denying care to patients based upon the stigma of chronic opioid use, which that's always a concern. And sometimes the best intentions don't present with consequences that weren't thought of and you know that as well as I do. This is really great information today. Thanks so much for taking the time to talk about this. Again, this was Dr. Benjamin Tolman, psychologist with St. Luke's Hospital, physical medicine and rehabilitation department. If you have a topic you'd like to suggest for our talk on podcast, shoot us an email at stukescr@unitypoint.org. Let me encourage you, tell your family, friends, neighbors, strangers about our podcast. Until next time, be well.