Good afternoon, everyone. Hi. My name is Justin Yang, and we're going to start this session now. Everybody just got back from lunch, so we're going to try to keep it—I know you guys are in full coma at this point—we're going to try to keep it as engaging as we can. So, welcome to this session, Targeted Rewiring, How Innovative Evidence-Based Behavioral Medicine Treatments Change Chronic Pain Management. So, I am Justin, and I'm the Associate Program Director for the Harvard Occupational Medicine Residency Program. I'm also Assistant Professor of Medicine at Boston University, and I am board-certified in Internal Medicine, Occupational Medicine, and Addiction Medicine as well. I'm going to pass it on to Kristen for her to introduce herself. All right. Thank you. Good afternoon. My name is Kristen Slater. I'm a Clinical Assistant Professor at Stanford in the Pain Management Department, and I'm working as a pain psychologist there. Hi. I'm Dr. Michael Spertus, and I wear a few different hats, mostly at the VA. As a physician in whole health, which I'll be discussing today, and in pain medicine particularly, non-pharmacologic approaches to pain, and also the Chief Clinician Well-Being Officer there, and I am an Assistant Professor at the University of Miami Miller School of Medicine, and have a small private practice where I focus on behavioral and lifestyle medicine. Thank you. And before we start, there's some disclosures. And before that, the handouts are in your swap card, so the app. So you can look at the handouts and follow along as well. Disclosures. I am the founder of Connexus Health, the Medical Director for Apply VR and Pelago as well, and also do some phase three clinical trials. None of the disclosed entities have financially sponsored, guided, or reviewed the content of this session. All views are expressed here on my own, and not directly from Harvard or Boston University. Dr. Slater does not have any financial disclosures, and Dr. Spertus has no financial disclosures, but all of the views are expressed on his own, and not directly related to his institution, including the Department of Veteran Affairs. All right, so as I mentioned, this is going to be an interactive session, so we're using Slido. If you can take out your phone and capture the QR code. There's two parts to the Slido app. On the left-hand side of your browser, you can put in your questions. So there's a Q&A section. At any point of the time during the presentation, if you have any questions, feel free to put them into the Q&A section. It's all going to pop up at the end, and we'll answer your questions at the end. And then on the right-hand side of the browser tab, that's where you're going to be putting in your answers to the questions that we're asking throughout the session here. All right, the first question, this is a question that you can type into the Slido browser. What is your current toolbox for treating chronic back pain? There's no right or wrong answers here. Anything that you can think of, you can put in multiple answers. You can put in Advil. You can put in, yes, I see one that's saying PT right now. As long as you don't put in, you know, thoughts and prayers or water, that's not really going to help. Mindfulness, great. Okay, not opiate. Love that one. CBD medications, exercise, good exercise. Okay, PT, massage, mats, exercises, pain meds, sleep hygiene, mindfulness, breathing techniques, education. That's a really good answer. EAP provider training, pain management, pain medication, pain management specialist. We've got some up here. That's great. Explain pain techniques. That's actually a great one as well. Sometimes it's just about, you know, what pain is. Specialized physio program, activity awareness, PT NSAIDs, PT resistance training. Okay, so I think that these are all great answers, and I think the answer is from everyone to sort of, like, there's a main thing that we're seeing here. So not opiates, which is great. PT, NSAIDs. Those are, like, the majority of people that are answering what they have in their toolbox. And this is the reason why we're here, is that there's actually other things that we can use and that we can put in our toolbox, which is the pain psychology and the pain rehab portion for chronic back pain, or for chronic pain of any kind, actually. So, you know, the first question is, you know, why do we need a chronic pain program, right? That's sort of why we're here. We all know that we're sort of in a pain and opiate crisis. This is, and I had another session back on Sunday about substance use disorder in the workforce, and this is similar to the slides that I used in that session as well, so that we have had so many issues with opiates. We're now in the fourth wave of the opiate crisis, which is essentially synthetic opiates, such as fentanyl, that's mixed with stimulants. Before that, we had the third wave, which is synthetic opiates, fentanyl, flooding our street, and then before that, we have heroin, which when, you know, when prescription opiates, they were not really available anymore after the DEA crackdown in the early 2000s, and people start resorting to street recreational drugs. I know this started with the first wave, which is, as we know, the over-prescribing of opiates back in the late 90s and the early 2000s. So with that, you know, I want to ask Dr. Spertus of your thoughts on, you know, what do you see at the VA in terms of pain and what's the difference, if there is any, between the VA population and the general population? Thanks, Dr. Yang. So looking at this slide here, we can see the prevalence, what is the state of chronic pain, and it does differ by status, and to point out, though, even just for the overall population in the U.S., it's quite high. It's at least 20% in most of the prevalence studies that have been done, which is really pretty high, results in disability, results in loss of function, and results in dollars, of course. And here we can see, too, looking at the veterans compared to non-veterans, a couple of different things. So overall, pain prevalence is higher in the veteran population, hovers around 28 some studies to actually showing over 30% prevalence. So really quite a bit higher. And in particular, there's an age difference, so that the chronic pain begins younger in the veterans, which is no surprise, given enlistment ages. And it does tend to actually even out with the older age. So I think, you know, for us occupational health specialists, there is a need for non-opiates, a non-pharm approach to the public-sensitive, safety-sensitive positions that we have, you know, including those that's regulated by the DOT and, you know, in the aerospace industry and whatnot. So it's important for us to actually know what are the toolbox that we have and what are the resources that we have as well when it comes to treating chronic pain. So I'm going to switch gear a little bit to talking about the neuroscience behind pain. So I think it's important for us to actually understand how our brain communicates between pain and emotion and mental health in order for us to know how to treat the patient. So I'm going to ask Dr. Stahir to go into a little bit of just letting us know what chronic pain and the neuroscience behind what pain is about. So I'll actually take the definition first and then Dr. Slater will go into some of the neuroscience here. So chronic pain, the biggest thing is that it's complex. And this is why the model that we're going to be talking about is different, why this chronic pain program, so to speak, is needed and why it's multidisciplinary by nature. Because what we've been doing up to this point hasn't worked and it's led to the crises that we have, both in terms of prevalence of pain and the use of opioids and other things that are just not helpful. So the, interestingly, the International Association for the Study of Pain, IASP, the task force reconvened for the first time since 1979 and they actually changed their definition. But even their old definition, an important feature of it, so they define it as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. So that's really important because it's not just the anatomical, it's not just the physical. And that was even going back to 1979 where pain is processed, mostly in the brain, in the nervous system. The difference is that it was previously described, the definition had the or described in terms of such damage. Now they added this piece of or resembling that associated with actual or potential tissue damage. The point being here is that, you know, sometimes there is this stigma of pain that happens. You know, oh, this is in your head, so to speak. All pain that is experienced is real pain. And that is a really important point to get across. If they are suffering, they have the pain there. And that has to do with what we're going to talk about next, with how pain is processed. Thank you. Yeah, the part of that definition that I really want to highlight that's interesting is that pain is both a sensory and emotional experience. The emotional experience of pain is built into the definition of pain. And yet a lot of times, especially in our western culture, in the western world, we tend to really focus on just treating the sensory aspect of pain, at least initially. And we're really doing our patients a disservice when we do that because we're only treating half of the definition of pain. And it's really important that we treat the full definition of pain, including the emotional experience piece. And not only does the medical definition of pain outline this for us, but when you all have chronic pain patients that you are working with, they tell you this suffering piece as well, right? Like, you hear this in their narrative. When they're coming in and they're sitting in your office, you know, if you ask them, like, tell me how you're doing. What is it like to have this pain? They will use descriptors. Like, it's awful. It's depressing. They will tell you things like, I can't sleep. They'll tell you things like, I can't work. I can't do the things that I used to do, right? So you really hear the suffering component of pain when you're just interacting with someone with chronic pain. And it's so important that we are not only acknowledging that, but treating that part. And actually, when we break down and look at what's going on with global pain, look at the neuroscience of it, it's very interesting. So we see that there is actually a separate pain pathway that accounts for the suffering aspect of pain. So we see this separate, you know, kind of pain neuro tag in the medial aspects of pain, the medial pathway. And why that's important is because it's interesting to acknowledge that these three different pathways are separable. We can divide them out and know that there's a difference. So how do we know this? We used to see this initially kind of by accident when people that had brain injuries. So people would have a lot of pain, and then they would maybe have a damage to their brain, and they would come in, and they would have a lot of tissue damage, but emotionally they were kind of flat. They weren't expressing a lot of the same emotional aspects that we typically see in pain, the suffering part. So I thought that's interesting, what's going on here, right? And then when we break it down, we can see this. If you want to go to the next slide. So the reason it's important to understand this is when we look at this idea of network science, right, it shows us that if we're just kind of attacking pain, this global, you know, this global summation of pain randomly, we're not going to do a whole lot, right? We're not going to make a big difference. But when we have a very targeted attack plan and we are addressing each of these pathways and really honing in on treatments for each of these pathways, that's when we see a difference. That's when we see an opportunity to really dissolve this global pain pathway. And Dr. Spurlus, do you have something to add? Yeah, and just to jump in on that too, one of the really interesting features of this is that this has been talked about in some of the Eastern philosophies, in particular Buddhist psychology and philosophy for years and years. And they refer to it as this concept of the two arrows. The first arrow being the physical injury, and the second arrow, it's when you have the pain experience, it's like having another arrow, and that's what actually creates the suffering. And so now we have the neuroscience that is actually backing this up. Thank you. So with all that definition and understanding of the neuroscience behind it, Dr. Slater, I'm wondering if you could talk a little bit about what exactly our topic is today, the target rewiring portion of it. And some of you guys might also have heard of the word neuroplasticity, or maybe not. So can you talk a little bit about what that means? Absolutely. So when we're talking about targeting the suffering part of pain, what we're really getting into is there are evidence-based approaches that the whole kind of outcome goal of those approaches is to target the suffering aspect of pain. And we'll be talking about what those are more specifically here in a bit. The neuroplasticity piece refers to the idea that our brains are shapeable, they're malleable, we can change the pathways in our brains until the day we die. And when it comes to pain, unfortunately, our kind of natural, innate response to pain isn't all that helpful. We have a fight-or-flight response to pain initially, which elevates our nervous system activity, which feeds into this pain cycle. So pain itself activates the fight-or-flight system. Things like stress, suffering, anxiety, thinking about pain, worrying about our future with pain, those all activate the same part of the nervous system. It's the sympathetic nervous system. And neuroplasticity refers to this idea of knowing that information, we can work, and we have to be deliberate about this, but we can work to rewire the nervous system so it gets out of that constant fight-or-flight state. And that's what a lot of the treatments that we have in behavioral medicine are designed to do. That's very helpful to understand. Dr. Spertus, anything to add there? We're good? Okay. All right, so before we go into the next topic, which is sort of the meat of our discussion today, what are some evidence-based pain psychology treatments that you know of? Feel free to either shout out your answer or type it into Slido. Meditation. Meditation? Okay, good. Biofeedback. Biofeedback? Okay. Anybody else? Or are you guys just typing? Hypnosis? Who said that? Great. That's a great answer. CBT. I was waiting for that one. And, okay, a lot of people answered CBT. Anything else? Any other thoughts? Coaching? Okay. I think, thinking back into, like, my residency training, if we get to actually talk about chronic pain treatment, we sort of just go through it in terms of just saying, oh, there's CBT, and that's the option. So we don't really talk about chronic pain in our specialty. And even in the curriculum, it's not really discussed. So that's what I always say when somebody asks me, like, what toolbox or what tool do you have for chronic pain? CBT is the one. But really, what does CBT mean? And what really is CBT? And what are some other evidence-based pain psychology treatments that we can use for chronic pain? And that's sort of the main discussion that we are going to have today. So these are some of the treatments, evidence-based pain psychology treatments that we have. You know, I think I want to start by asking our two experts here, what exactly is CBT? We say that for literally every single thing that we can think of in medicine. But what is it exactly when it comes to treatment for pain? Has anyone not heard of CBT? Okay. So cognitive behavioral therapy, it is what we consider the gold standard of treatment for a number of different mental health conditions, but also for chronic pain. Cognitive, so that's the thought process part, right? So in cognitive behavioral therapy, we are helping people identify thought processes that are very normal, right, and potentially unhelpful when it comes to pain. So thoughts like, this is never going to end, my life is over, I won't be able to do anything anymore, those types of things. So thinking back to the neuroscience of pain, all of those thoughts, just thinking those things, right, rumination about those thoughts, you can almost feel your body getting more activated when those thoughts are going on, right? Again, anything that activates the nervous system is going to activate pain because pain is part of the nervous system. So we work with folks to help them in CBT. The strategy is to help them to restructure, so to notice thoughts that are unhelpful and then to come up with more advantageous, more helpful thoughts. The behavioral piece of CBT is numerous. So we work with folks on different behaviors that we know can also exacerbate pain, things like sleep that are kind of surprising. So we work on sleep hygiene. We know that there's a very direct correlation between sleep and pain. If people are sleeping better, their pain is better. In fact, poor sleep the night before is the number one determinant of pain severity the next day. So we work on things like sleep. We work on things like relaxation, diaphragmatic breathing, how to lower nervous system activity that way, how to pace themselves during the day so they're not pushing and crashing and flaring up for three days. There are a number of different behavioral, like what can they do to help themselves? What am I missing? I think that covers it pretty well. The only thing that I would add here is, you know, just to Dr. Yang's point too, when I was in training, it was that really CBT was interchangeable with just therapy overall. And it was, you know, CBT for everything. But what does that really mean? And so knowing what it actually involves entails what's happening is really helpful when we're thinking about what are the options in the toolbox. And knowing that CBT itself is a specific tool to actually help with this process. And all of these treatments, which we'll be going through in some detail more, you know, they're listed as psychological treatments. I really like to think of them as mind-body approaches. Because, yes, we're using the doorway in as through the psychological piece. But we're ultimately having outcomes, as we showed, in the body, in the nervous system, and even on heart rate and other areas as well. Thank you. So, and by the way, there's a lot of companies that have made apps for CBT contents for pain. So we can talk about that a little bit in details when it comes to like the innovation options that we have these days as well. I want to go into a little bit detail on Empowered Relief, because this program was designed by your colleague, right, at Stanford, Dr. Beth Darnell, which she's also very involved in the ACOM Back Pain Treatment Guideline as well. So, Dr. Saylor, could you talk a little bit about Empowered Relief? Because I think Empowered Relief is something that is easily that the patients can do. And, you know, we can refer to patients who do as well. So just can you talk to us a little bit about it? Absolutely. So Empowered Relief is a unique intervention. It is based in CBT. However, traditional CBT, as I just described it, is typically delivered by a pain psychologist or a mental health provider that specializes in pain or health psychology. It is typically eight to 12 sessions, being about two hours per session. And it's getting more so to be in the app format and online format. However, a lot of times it is in person and it's at places like large academic medical centers, where we know that is not accessible or realistic for a lot of our folks with pain to have access to that kind of treatment. It's, you know, if you also think about some of the barriers of pain, even just things like knowing how they're going to feel and having it be predictable to show up to an appointment eight weeks in a row or navigating a parking lot or driving, things like that. So Dr. Darnell developed a one-time class, which makes it unique. So this is a two-hour, one-time intervention that is delivered primarily online. We have delivered it in person, but it is through the internet, which means we can see. I've taught Empowered Relief classes with 150 people before. So really the key behind Empowered Relief is accessibility, both with its duration of being truncated into one time, that people are usually able to commit to that, and its delivery of being online. But it does go over evidence-based concepts. A very important part of CBT, I forgot to mention, was this pain neuroscience education piece. So helping people understand what's going on in their bodies with pain. So Empowered Relief goes over that piece of it, as well as it introduces three evidence-based skills and strategies for people, and they are able to come up with a personalized plan by the end of this two-hour intervention. So they have tools in their toolkit to help themselves with pain. Interestingly, this has been studied in not only the low back population, but a number of different chronic pain conditions, as well. Dr. Darnall put her Empowered Relief class head-to-head against a more traditional eight-week CBT course, and she is very open in saying she was a little surprised to find out that the one-time Empowered Relief class was non-inferior to the traditional eight-session CBT course, as far as outcomes, meaning that people had changes in their pain interference. They were doing more, pain intensity was less, they were not catastrophizing as much. That's that unhelpful thought process about pain. They felt better about being able to handle pain themselves, and actually other things, like their sleep was better, depression and anxiety, fatigue went down. So a number of different advantageous outcomes with a very brief intervention, which makes this a very helpful approach. Another thing that's unique about this is that you do not have to be a mental health provider or pain psychologist to deliver this class. There are, you can be anyone working in the chronic pain space, you do a two-day certification course, and you are good to go for delivering Empowered Relief. So right now it's out in about 27 different countries, over 10,000 patients have received Empowered Relief at this point, so it's all about accessibility. That sounds really, really amazing. So it sounds like, in a nutshell, you're putting eight weeks of CBD into that two hours, and it's virtually, so you're democratizing that accessibility to a CBD program that just wasn't accessible for people in the past. So I think that this is definitely something that is very helpful, especially when we think about what this class would mean for our patients, that we just, we don't have the tool right now to talk about CBT, and we don't, we don't have the time in the clinic as well. So I think this is definitely something that is very helpful in just disseminating the pain knowledge. So I think the next one that, you know, I want to talk a little bit about is PRT, pain reprocessing therapy. So I think this is also something that's new and has been discussed by a lot of people. Could you tell me, Dr. Slater, if it's, if it's evidence-based, what's it about? Who started PRT, pain reprocessing therapy? Oh, interesting. Okay, so this is a newer type of therapy. It, just since about 2021, it's, and it's made quite the impact in the chronic pain behavioral health space. PRT is for a very specific type of pain. It is for a type of pain called neuroplastic pain. So neuroplastic pain is pain that does not have a strong basis in the body, meaning we, we can't explain why this person is having pain when we look at things like imaging, the, you know, the medical findings don't match what the person is presenting, the type of pain they're presenting with. As Dr. Spertus mentioned, this does not mean that their pain is, is not real. It very much is, and it can be very debilitating. However, the, the thought process here is that a lot of pain develops because it, it, our brain circuits kind of get stuck in, in going over these pain neurotags, meaning they're experiencing pain because of brain activity more so than what's going on in their body. So PRT is a treatment that addresses that type of pain specifically. It works to rewire how people think about pain. It rewires their brain circuitry so they no longer experience pain. And we don't say that lightly in the chronic pain world. When you hear about cures for chronic pain, that is very, very rare. However, PRT has been found to do just that in a number of people. So PRT was used in this really hallmark paper that came out in 2021 called the Boulder Back Pain Study. They had people with neuroplastic pain and a number of people went through PRT versus saline injection versus care as usual. Those that went through eight sessions of PRT, 66% reported no pain or being nearly pain-free after PRT sessions. So pretty remarkable. We also see brain activity that is altered when we're looking at people that go through PRT through fMRI studies. So some pretty interesting work there. That's definitely interesting. Dr. Spurt, is there anything to add here? Yeah, sure. So what's so revolutionary about PRT here as compared to some of the other things is it really was one of the first to say, you know what, we're actually going to look at not just improving the pain experience, so to speak, but actually having outcomes being pain-free. And that itself, the outcome that was being looked at, changes how we, I think, all are beginning to look at how much impact that we can have down the line and the messaging that we're giving to patients even, because it's possible to make these changes, targeted rewiring as we're talking about. And what I would say too is, you know, when we're thinking about this, because this is just another tool and there's really one main study right now that's done, more research is certainly needed. The patients that were chosen were very carefully selected, of course, but it's really eye-opening and it's really exciting in our world for this right now. Keeping in mind, though, that we're looking at different things. So something like Empowered Relief can be really good for the overall population of chronic pain, right? But that doesn't mean that some people don't need an eight-week or longer individualized session sometimes. And so there's a lot of tools in the toolbox we all want to be thinking about. It's going to be helpful for most people versus what might be helpful for this person sitting in front of me. Thank you. So I have another Slido question for you guys. The question is an easy yes or no answer. I have heard of and know about multidisciplinary pain care or pain rehab program before this presentation. You can use your Slido or I can just do a show of hands. You can just show of hands if you have heard of multidisciplinary pain rehab or pain care in the past. Okay, that's good. That's actually more than I thought. So perfect. So I want to talk a little bit about that. And Dr. Spirido, I want to ask you this question and start with you. What's the difference between multidisciplinary care versus more of a conventional approach when it comes to pain treatment? Thank you. So multidisciplinary is like it sounds. It's really looking at and partnering in a whole team to focus on chronic pain, which is very different from the standard training model of medicine that we have overall where it's very one-on-one. You go to the physician and you get something at the end, whether it's a prescription, an image, or a lab. Here, we've seen that that doesn't work in chronic pain so well. And so it's almost like a reteaching or remodeling of what is the approach that actually results in good pain care. Because it really almost requires, especially in the most complex cases, this multidisciplinary approach and rehabilitation that is not just getting a prescription, getting a lab, or having a one-time visit with a physician. Yeah, and I guess the question also is what exactly is a pain rehab program? Who's on the team, and what do you guys do together? So it really is variable. There are a lot of pain centers of excellence. For example, within the VA, we have that. There are just also some pain centers or specialized areas, and it will vary what is offered. So that might be anesthesiology, pain physicians, and chronic pain who are doing procedures. That is still, I would say, unfortunately, most of what is happening in specialized pain care. The more multidisciplinary approach is going to involve multiple team members from different facets. Pain psychology is definitely one of the most important, I would argue, features to that. And in most of the guidelines, CBT still for chronic pain is recommended as the first-line treatment for chronic pain. It's also going to involve physical therapy, possibly exercise physio. And more and more, what we were considering how to be complementary in integrative medicine approaches are now becoming mainstreamed. So the chiropractor, the acupuncturist, the massage therapist, all of this can be involved in what is going to be an interdisciplinary capacity. And what I will say about this, too, is that there's such a spectrum about this. So you can have something like a one-off empowered relief, where it's a one-time class, and that might be really helpful for a lot of people. On the other spectrum of that, there's now up to even inpatient. This is offered at Tampa, the Tampa VA, inpatient rehabilitation for chronic pain, which involves daily opioid tapering, meetings with pain psychology, and meeting with members of the multidisciplinary team. Interesting. I kind of want to follow up on that prior question to the audience here. Raise your hand if you actually have access to a pain rehab program at your institution. Anyone? One, two, three. Okay. Okay. I have three. That's not bad. And raise your hand if you actually have worked with a pain psychologist in the past for your patient. Okay. We got a little bit more. Okay. So as we can see, there's definitely an issue with access to care right now, with the pain rehab, with the multidisciplinary pain care that we're talking about. With access, I kind of want to ask the two here, can you talk a little bit about insurance coverage? Are you finding that to be a difficulty when providing treatment to patients? Well, not the VA, of course, because VA is free for all kind of situation, but maybe Dr. Slater, can you talk about that a little bit? Yeah. So we generally don't have a lot of difficulty getting pain psychology services covered. I believe Medicare covers about 12 sessions a year of pain psychology services. So, and a lot of other insurances will cover it. A lot of times it's limited in how much they will cover varies as far as co-pays and things like that. But I will say that there are insurances that will not cover and it can be quite expensive to pay out of pocket. Another benefit of some of these shorter term interventions is that it helps with that burden. It helps with a cost burden. So insurance is covering these things in different worlds, like the workers' comp world, things like that. It definitely does require some very specific documentation and verbiage, but is possible. It just takes a little bit of legwork. And just to add to that, you know, because there's the difference between what insurance might cover versus what's actually available. And what we do often see is that there are not many pain psychologists around outside of these academic centers, by and large. Many are private pay. And it becomes very difficult to access these because they're only very, ultimately, within the country, very few large multidisciplinary centers. And because of the model that we have, you know, to reimburse multidisciplinary care with a package deal doesn't really exist as of yet. We're hoping to see changes in this the same way other things are bundled, like knee replacements, for example. So we're looking forward to some of this change in the future. Right now, it still becomes an issue. And sometimes, you know, these centers do lose money because of the type, because it's multiple specialties providing care at the end of the day. In the VA, we're able to do this a little bit more because of the model of care that we have is slightly different in the way the financials work. Yeah, and that's great. And we mentioned about Empowered Relief, and you mentioned that there's a course that people can get certified. What if, you know, the audience has patients that they think would benefit from Empowered Relief? How do they get access to that? That's a great question. So we will give you, at the very end, a QR code that has some different resources. And this will be on there. So there's an Empowered Relief website where you can go, and you can look up providers, and they will give you information as far as if they're offering classes, where they're offering classes, and where they're located. So in the Empowered Relief website, and like I said, that will be on the resources that we provide for you. And there are certain resources as well. I don't know if I'm allowed to name them, but that you can find psychologists, for example, that specialize in certain areas, including pain. Okay, that's great. And what Dr. Slater is mentioning with the resource page, you can also find that on your handout. It's at the very last page, and there's a QR code, so you can access everything that we talked about today with the resources that's associated to the different treatment modalities that we have. So anything else to say here that you want to add for the pain rehab part? I think only the specific aspects of what the whole health model is that we use within the VA. Okay, so that sort of kind of goes into the next part that we want to discuss a little bit about also is the concept of whole health. I don't have a slide for this, but raise your hand if you have heard of the concept of whole health before. Some, like 3, 4, 5, 10 maybe. Okay, so Dr. Spertus, can you tell us a little bit about what whole health is about? I would love to, since this is my daily work. And so the whole health approach is really a model, and it has been popularized by the VA, in some ways branded, but really a lot of places are now calling their approach whole health. And we've seen some of these things evolve over time, you know, previously people talked about like CAM, complementary and alternative medicine, then integrative medicine, which is really still its own area with board certification, and now the whole health model is really the buzzed terminology, I would say, that's being used. And I really like this approach, because what it does is it strips away that symptom-based reactive approach to healthcare, and really brings back the patient-provider relationship with patient-centeredness. So the person you can see is at the center, and that is the most important point, surrounded by mindful awareness, and then as we relate to pain, thinking about all of the different aspects that can affect health, well-being, and in this case, as they relate to pain. So things like moving the body, motion is lotion, finding the right pacing, starting low, going slow, the exercises, or just movement, it doesn't have to be formal exercise that work for the specific patient at hand. The surroundings, physical and emotional surroundings, is the kitchen clean enough to make healthy meals? Are they able to get outside? Personal development, which can be work-life balance, or just the balance of life. Are there more nourishing activities versus depleting activities? Food and drink, what goes into the body, food as medicine, and I think I neglected to mention our wonderful dieticians that actually come into the multidisciplinary team as well, and there's a lot of evidence based now in having anti-inflammatory type diets that can be helpful for pain also. Recharging, your battery is on low, or is it on high? Is it empty? Which is often the case when there's something like chronic pain, which can be so depleting of our internal reserves. And here is where sleep comes into play too, and I think someone mentioned on one of the areas the importance of healthy sleep, and with pain in particular, it is so important. There was a great study done, a meta-analysis, looking at fibromyalgia, actually, and insomnia, and they often overlap together, and this is because of the way, again, that it's processed, but also they happen to work with each other, and it's one of those things where they feed in to each other as well, because oftentimes it's, well, we're going to treat the pain, and then the sleep will improve, but with fibromyalgia itself and with chronic pain, there's sleep disruption overall. The pain can wake someone up, and then worsen the sleep, and it feeds into a cycle. There was a study done showing that when pain was treated with the gold standard therapy, which is cognitive behavioral therapy for insomnia, not only did the sleep improve as expected, but pain actually improved by almost 70%, and an average of 45%, which is better than most pain medications, so the importance of sleep cannot be overstated. Relationships with others, spirit and soul, what gives you that sense of meaning purpose? What can make you go outside of the pain? Because we can be some very tunnel visioned with the pain. And then finally, power of mind, which is the area that we're really focusing on today, and these targeted psychological and mind-body approaches. And I think this is the slide about the VA and VA's approach. Can you talk a little bit about that as well? Yes, and actually, can you just go back a slide, too, because that reminds me? And so often people think of this whole health approach, you can see the rest of the circle on the outer edges, too, is prevention and treatment, and then conventional and complementary approaches. So whole health is not just complementary and alternative medicine, which some people think of it as. It is one of the areas, but it's really taking into account all of the different factors that affect the person, the individuals that are sitting in front of us. And so with the next slide, this talks about how whole health can be integrated, and it's recommended in our VA guidelines, at least, to start with whole health even at the foundational step, not to wait until it gets to be chronic and severe, or where they're needing all this multidisciplinary care, because having this patient-centeredness approach, what really matters to this individual, even at the foundational step, is most important, and it happens in all phases, all steps of the care up to the tertiary pain clinic center, which is what I work in. This is definitely very interesting and helpful for us to understand what whole health is about. And I think this is also a VA model, right? This one is not VA-specific, actually. This one is from a pain management best practices task force, and the point of this slide was to show, in particular, that these are the recommended things. So it's not just medications, it's not just the interventional procedures, but this individualized multimodal, multidisciplinary approach that is really shown to be most effective. And complementary and integrative health now have come into that. Behavioral health approaches, as we've been discussing, and in particular, as I think I mentioned, that CBT for chronic pain, by this task force, was considered the first line treatment. And I'll also just add to that, you know, really the emphasis in not waiting to give patients these treatments. Number one, you know, it can be really disheartening for patients if, you know, you've tried everything else and then they're just like, oh, we don't know what else to do with you, go see the pain psychologist, right? That doesn't set us up well or the patient up well. And we're finding that even like a prehab approach, right? So giving patients this information and skills and strategies before they go through something like a spinal procedure improves outcomes. So for one example, they are now implementing empowered relief as standard of care for anyone having spine surgery at Cleveland Clinic, Cedars-Sinai. So just anyone, if you're going to have spine surgery, you have to take empowered relief first so you have skills and strategies to help you with the recovery process. We're finding that with that in place, there's less opioid medications needed post-surgically. There's also faster recovery times and less mental health impact. So we really want to catch these things early. Thank you, Dr. Salido. It definitely sounds like a lot of institutions are starting to pick up on the psychology part and making sure that patients are equipped with dealing with their emotions and mental health portion of it. That's great. That's great. I think this is the last slide that we have and this sort of leads into the final discussion point we have today. And you can answer it on your Slido app browser. So the question is, have you used any of these novel treatment modalities for chronic MSK pain management in the past? Immersive therapeutics such as VR or app-based CBD programs for pain, virtual treatment with pain psychologists, virtual groups, or any other kinds of novel treatment modalities? I'll give you guys 30 seconds to answer. Start seeing answers coming in. So virtual treatment with pain psychologists. One person answered that. For the audience that answered others, could you shout out what kind of program they have used? Anyone? Have you ever heard of scrambler therapy? Scrambler therapy? No, we haven't. It's interesting. Good to know. Okay. Yep. I use an equiscope in my practice. The equiscope is an electrical stimulation device, but it's very high-tech. It was developed for the astronauts in the late 60s, and it's used aboard the space shuttle. And it's hardly palpable or feelable by the patients. And most patients fall asleep when we do the treatments. It has multiple modalities, and it has a feedback mechanism. So when the patients come in, we apply the equiscope technology. It gives us an idea of where the neuromuscular blockage is, basically, sort of like dominoes that fall incorrectly. And then the second phase is delivering the treatment. And we have protocols for different body parts and different problems, and it is absolutely miraculous. And I just want to say one thing. I picked up this technology at A4M, the American College of Anti-Aging Medicine. I looked at it for four years in a row, and I said, it has to be focus, focus. It can't be real. And one of the persons bending the instrument asked me just to sit down and try. And at that particular point, and I'm 77 now, and this was 10 years ago, I had almost not been able to get out of the airplane seat and walk to the terminal. My knees were so bad. I had a 20-minute treatment with this, and I was able to stand up pain-free. And although I only had one treatment, it lasted for several weeks, and I went out and I bought the device. And I have to say, there is 100% acceptance in my practice. Nobody refuses it. Everybody gives it a try. Not everybody gets the miraculous cure that I got, but everybody has something that has them wanting to come back for more. And the more we treat them, the better they get. So I would advise everybody to go online and look up Equiscope, E-Q-U-I-S-C-O-P. It has nothing to do with being equal. The Equipart comes from horse because this device is used nationwide to treat horses because they can't tell their trainers where it hurts. It's fabulous, absolutely fabulous. Thank you for that. Sunset horses have better treatments than we do, assuming. So I digress. So let's take a look at the novel innovations in pain care, MSK pain care. So I want to start with some of the new things that we're seeing because we talked about the fact that these rehabs and it requires to be in person, it's time-consuming, and the accessibility is a huge issue. So now things like empower relief programs, and it's really just trying to democratize what traditionally isn't being delivered or that the providers don't have in their toolkit because it's so limited. So one of them is immersive therapeutics, using technologies like VR to package everything together so that the patient can do it in their homes. Dr. Slater, I'm curious if you can talk about what the outcomes of immersive therapeutics are. And I know, Dr. Spiritus, you do use immersive therapeutics at your VA. I'm also curious your experience using it and what your patients are saying their feedbacks are. So I'll just go over the outcomes briefly. So, again, it's all about accessibility and how do we get people to actually do the treatment and like the treatment. So virtual reality has been really helpful in that space. There was a study done with a virtual reality program for chronic pain specifically where it had, you know, that you did a short module, so not long at all, maybe 5 to 10 to 15 minutes once a day for about eight weeks. This covered a number of topics, mindfulness, CBT, breathing. So it was a variety of evidence-based pain interventions. And they measured that against a sham virtual reality, which was 2D kind of nature setting. And those with the sham VR versus those with the active treatment, the results are listed here up on the slide. So you can see there were significant improvements with the virtual reality for pain, with pain intensity, interference. They were sleeping better, mood was better, as was stress. And Dr. Spurto, 30 seconds. Yes. So what I will just say about the virtual reality is, so within the VA we actually have a whole network now of, it's called immersive or XR. And from patients, just from the clinical standpoint, really positive results. And I think it's because some people even describe it as life-changing we've seen. And the difference here is that rather than, oh, I'm going to go to my appointment or I'm going to engage with this therapy, it brings in that fun element to it. It brings in something that's pleasurable where you can even travel elsewhere. In some of these cases you can swim with dolphins and do many different activities and do them every day. I mean, it gamifies this as well. So it can really be a powerful adjunct to what we're doing. Sounds good. And it definitely sounds like it's very fun. There's multiple vendors in this space, and I think it's definitely something that we're going to see that will continue to develop and be available to patients that are suffering from chronic MSK pain. I think the last part, as this is sort of your field, Dr. Spurto, could you tell us a little bit about hypnosis and biofeedback in 20, 30 seconds? Sure. So just my little soapbox here about clinical hypnosis, which I provide and is very near and dear to me. And the main thing that I'll say about it is there's a lot of misconceptions about what clinical hypnosis is because we've all seen either stage hypnosis or movies about hypnosis. Like I think I just saw Get Out, which was terrifying. And that's not what clinical hypnosis is. It's really a tool that might use other therapeutics, including even CBT, relaxation techniques, or using ultimately the patient's own internal resources, the body as a great healing machine in and of itself. And using a state of focus concentration that we call trance with suggestibility and specific suggestions has been a very powerful element to the practice that I have. And I've seen really amazing benefits with using it. And there's, at this point, really great studies and meta-analyses showing that, particularly for those who are medium to high hypnotizable. That sounds amazing. Anybody that wants some more information on this, feel free to talk to us after the presentation. Or if you want to try one of the hypnosis sessions with Dr. Spurto, we can arrange that as well. So as we mentioned that there are resources that's already available to you guys. This is the QR code to the resource website that you can use. And I think this is definitely something that's very important and you can integrate into your practice as well. This is in the handout as well on the Swapcard app. So we probably have a little bit of time for a few questions. And I think there is a question here. Was Empowered Relief class tested in migraine cases? Dr. Slater? Sure. So migraine specifically has not been tested with Empowered Relief. However, a number of participants that have gone through Empowered Relief did have migraine as well. So we know that it's effective, but it just hasn't been studied as a population specifically. Thank you. Questions? Thank you. Very interesting. And I like the many different approaches that you mentioned in this short period of time. They had a virtual reality headset here, applied VR. And I looked at it and I asked him, well, how does it work? He said, well, it helps rewire the brain's circuitry or the neural pathways. And then it made me start to think. I recently was at UCSF and they were presenting some research that they've been doing with psychedelics, particularly psilocybin. And they showed with some neuroimaging, treating people for depression. And they were showing with some neuroimaging, some PET scanning and some other types of things, the dramatic changes in the number of neural connections. And the whole concept is that people who are depressed get into a rut, so to speak, or they get into a way of dealing with things. And then this single psychedelic experience, when combined then with psychotherapy and other interventions after that, produce some dramatic effects, at least it seems, with depression. So I'm sitting here listening to this pain issue, pain presentation. I'm thinking, has anyone considered combining this psychedelic experience with some of these either CBTs or the empowered or the other types of things? The concept being one will help you increase neuroplasticity. And then during this next window, you could then do something. Is there any research on that? I can take this one. So yes, I've done training in psychedelic assisted therapy. And everything's in research right now pretty much, except for the one psychedelic, which is not a classical psychedelic ketamine assisted therapy. There is ongoing research being done in chronic pain specifically. Whether it's CBT, there is some with that. They're using reprocessing therapy, mostly for PTSD, actually. But there is specific research being done in pain showing this neuroplasticity piece, actually. And most of these results have been quite positive that we've seen, because these are all just doorways in, right? How we get to that neuroplasticity, the exact modality, is much less important. It's going to be what's going to be best for the individual. And also what we see in the research is most effective if we actually ever get head-to-head trials. I know we're out of time already. So if you have any questions, feel free to come up and ask us. And thank you for attending our session today. Thank you.

chronic pain management

evidence-based treatments

behavioral medicine

cognitive behavioral therapy

pain reprocessing therapy

whole health

virtual reality therapy

hypnosis and biofeedback

psychedelic experiences

neuroplasticity