DR. RAKEL: At least in my experience of working with patients, that can be quite a powerful combination. I always ask why the pain has a tendency to reoccur after they get temporary relief from an adjustment, a massage, acupuncture treatment, or an epidural injection. It seems like part of the reason that the pain might come back is that we’re not addressing some of the other emotional aspects that may perpetuate that dysfunction.
DR. SCHUBINER: As I mentioned earlier, it’s been shown that emotional factors can cause significant muscle spasm, which can then, of course, create malalignments. So, treating the malalignment is important, but it is often necessary to identify the root cause. Studies have shown that patients with low back pain undergo a process known as “central sensitization,”21 as do patients with fibromyalgia.
When we look carefully at the new research on central sensitization, we’re beginning to realize that chronic pain is primarily a disorder of the brain, and not a disorder of the body.
DR. RAKEL: Our patients have visited Dr. King and Dr. Schubiner and are doing quite well, but they need to learn how to become empowered to understand what they can do to maintain this benefit over time. Dr. Kurisu, this is an area that interests you, and you have expertise in working to empower the patient and to work with some of our other colleagues to recondition the body and strengthen it to increase support. There’s been excellent research on yoga therapy for this as well as physical therapy.22–25
How can we sustain these benefits over time?
DR. KURISU: Well, one of the main questions I always get from patients is the question, “What can I do to prevent this from occurring? What are some of the things I can do at home?” From a primary care perspective for a provider examining a patient with low back pain, I believe that physical therapists or some manual therapists are some of the more underutilized people and referral sources that we have.
What I have done in my practice is to establish a very close network of people that I refer to: physical therapists, yoga therapists, massage therapists, etc. I also perform osteopathic manipulation. It is important for a provider to know all the therapists at a personal level to know what type of styles and techniques of therapy they will offer. It is important to remember that not all physical therapy is the same. Any provider should become educated about what type of exercises should be done for what specific condition. It’s one of those things that patients ask about when you demonstrate an exercise to them and you’re showing them how to do it.
Physical therapists excel at this because they have a lot of time to spend with the patient, while educating the patient about their condition. They also give the patients handouts listing different exercises and stretches for the patient to perform at home. I tend to call these handouts “homework.” I always tell the patient that the main trick is that you MUST do your homework because all of the research shows that you show improvement when you actually invest time and energy into your recovery.
Most of the patients that I’ve seen, and ones that I’ve talked to, enjoy the hands-on therapy. They enjoy the one-on-one attention they get from a provider who performs manual therapy. They enjoy that aspect a lot more than just taking a medicine that’s prescribed to them. So, I tell all my family medicine colleagues to try to think of writing a prescription for manual therapy (OMT, physical therapy, or chiropractic) instead of a prescription for medication or other interventions.
Therefore, if the prescription for physical therapy runs out, they might need a refill. Then, exactly as all providers do for medications, one can write a refill for that prescription of physical therapy. The physical aspect of chronic low back pain is just one part of the picture.
The emotional aspect is another part. We have a whole network of people to refer to in the mind/body area—psychologists, psychiatrists, and mind/body therapists—to help these patients deal with the chronicity of their pain. In addition, we attempt to empower ourselves as physicians to become more involved in the patient’s care plan. Too often, we see physicians treating low back pain with either just medications or physical therapy. However, you might not see the patient again for 6 to 8 weeks, and so much can happen in that time.
The sports medicine doctors do this very well, and they can actually write out a care plan for the patient. This goes along with the European guidelines for prevention of low back pain.26 These guidelines were released in 2004, and they group populations into 3 different groups. I’ve used a modified version of that. So, the first group is the general population dealing with low back pain, which includes the need for psychological therapy, physical therapy, and exercises and stretches.
The second group is of workers, because some people are hurt on the job and they need a specific guideline for when to go back to work and some sort of limitations that they have to maintain at work. The third group is school-age children, but I expand on this to include athletes as well. Many athletes really want a plan of action for when they can get back to a certain level in their sport. Patients can then take this plan with them and take it to their coaches.
There is a lot of one-on-one intervention that goes on when patients are dealing with a chronic injury or chronic pain. I would recommend you always make sure that you’re extending out to that network of people that you refer to. I have weekly conversations with the psychologists as well as the physical therapist that we refer patients to, to make sure that we’re all on the same page and no one’s giving overlapping advice on any treatment.
DR. RAKEL: I’ve heard from each of you about the importance of some key areas. Number one is the relationship, as Dr. Kurisu said—the quarterback, who is someone to help guide and create a plan to communicate among these different professionals to make sure we’re not overlapping treatment.
Also, it is important to match the patient to the therapy that they feel will work best for them. We’re not going to send everybody to a yoga therapist. I might not send everybody to physical therapists. If we can best match the patient’s belief system to the most appropriate team member, we will likely get a better clinical response.
Dr. Kurisu, you said it’s important when you get to know them so you can best make that match. Everybody talked about time. Let me mention the importance of laying on hands and then using the art of manual therapy to help reduce that pain and discomfort while also addressing the importance of the emotions and how internalized negative emotions might exacerbate or even trigger muscle spasm.
DR. SCHUBINER: One very important thing that I learned from you, Dr. Rakel, is that often, the majority of the therapeutic benefit results from the doctor-patient relationship. The most important ability a clinician has is the ability to listen, to take time with the patient, and to create an agreement between the doctor and the patient on defining the problem and deciding on the best form of therapy. So, I think you’re absolutely right in emphasizing that point.
DR. RAKEL: I think people get disgruntled when they perceive that they’re seeing silos of care that are just focused on a procedure or an imaging study that sees them as an object. I think everybody’s concerned about that. So I’m just going to encourage a little freedom. Any other areas that anybody wants to talk about before we finish?
DR. SCHUBINER: The other major mainstream medical approach to chronic pain comes from treatment in specialized pain clinics. Pain clinics initially arose in this country due to the widespread undertreatment of pain for people with severe pain often caused by cancer and other structural processes. The data that I’ve seen from pain programs do not typically show actual pain reduction, but rather improved coping with pain. However, I think we have shown that you can achieve significant reductions in pain. That process can only occur when we promote self-care on the part of the patient.
We have all been talking about this aspect of care. It’s promoting what the patient can do for themselves. If chronic pain is a condition of the brain, we have to help patients activate the parts of their mind, brain, and spirit that lead to healing. Healing consists of not only healing the back, but also working to heal the whole person. When we think about healing the whole person, we’re helping people to define their meaning and purpose in life. We’re promoting a deep social connection and encouraging people to align with their true selves.
DR. RAKEL: I think that’s an exciting point that you made very well, Dr. Schubiner. If I was to open a new low back pain clinic, we can change our intention from naming it the Chronic Low Back Pain Clinic to the Myofascial Health and Resiliency Clinic. That simple intention changes everything and helps the patient believe that they can get better.
DR. KING: I always appreciate it when a patient says that the work that I’ve done gives them hope. They have hope that they can get well. As soon as I hear a patient say that, I know that we’ve activated this part of their being that they need to utilize for their eventual resolution as to how “well” they can get. So, I experience an idea of what we do when giving the patient hope.