October 2015

S a n M at e o C o u n t y

October 2015

Physician

PAIN

IN S ID E

S A N M AT E O C O U N T Y M E D I C A L A S S O C I AT I O N

Volume 4 Issue 9

The role of cognitive behavioral therapy in pain management

Pain perception: The paradox between elite athletes and chronic pain patients

Benefits of exercise for the chronic pain patient

The CMA/SMCMA’s exclusive new Workers’ Compensation program can help your practice save money!

Savings

CMA members qualify for an additional 5% discount* on top of Preferred Insurance’s already competitive rates. Preferred’s rates are set for long term consistency, and are managed by focusing on safety and injury prevention, fraud prevention and the control of medical costs for your practice by getting employees back to work as soon as practical.

Service Mercer’s team of insurance advisors is knowledgeable about the needs of physicians and is available to walk you through the application process. Preferred’s claims examiners are experts in helping members with an employee injury or illness claim. Plus Preferred’s payroll management and flexible payment plans help you manage your premiums in the way that works best for you and your practice’s cash-flow needs.

Safety In addition to mandatory CalOSHA information and videos on workplace safety, Preferred’s team of Risk Advisors are available for consultations when you need them. They also have a strong fraud prevention policy and as a California-based carrier, they know exactly what it takes to do business successfully in this State.

Stability Preferred Insurance prides itself on its stability, which includes maintaining some of the best and most consistent pricing available for CMA members. And because of its Medical Provider Network of credentialed medical professionals, claim costs can be closely monitored and managed while providing quality care to injured employees.

Call Mercer today at 800-842-3761 for a premium indication.

CMACounty.Insurance.service@mercer.com or www.CountyCMAMemberInsurance.com.

See how CMA/SMCMA’s Workers’ Compensation team can help you save!

Sponsored by:

Underwritten by:

Scan for info:

*Most practices will qualify for group pricing and receive the 5% discount; however some practices will need to be underwritten separately when they do not qualify for the special program terms and conditions. A minimum premium applies to very small payrolls.

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 • Copyright 2015 Mercer LLC. All rights reserved. • 71385 (10/15) 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • www.CountyCMAMemberInsurance.com • CMACounty.Insurance.service@mercer.com

S a n M at e o C o u n t y

Physician Editorial Committee Russ Granich, MD, Chair Uli Chettipally, MD Sharon Clark, MD Edward Morhauser, MD Gurpreet Padam, MD Sue U. Malone, Executive Director Shannon Goecke, Managing Editor

SMCMA Leadership Michael Norris, MD, President; Russ Granich, MD, President-Elect; Alexander Ding, MD, SecretaryTreasurer; Vincent Mason, MD, Immediate Past President Toby Frescholtz, MD; Alex Lakowsky, MD; Richard Moore, MD; Michael O’Holleran, MD; Joshua Parker, MD; Suzanne Pertsch, MD; Xiushui (Mike) Ren, MD; Sara Whitehead, MD; Douglas Zuckermann, MD; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate

Editorial/Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted.

Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.

For more information, contact the managing editor at (650) 312-1663 or sgoecke@smcma.org.

October 2015 - Volume 4, Issue 9 Columns President’s Message: Have a voice on the issues that affect us all........... 5 Michael Norris, MD

Executive Report: Governor Brown signs End-of-Life Options bill........... 7 Sue U. Malone

Feature Articles The role of cognitive behavioral therapy in pain management. . ........... 9 Kimeron Hardin, PhD, ABPP

Pain perception: The paradox between elite athletes and chronic pain patients. . ..................................................................... 10 Mark Sontag, MD

Benefits of exercise for the chronic pain patient.................................. 13 Lauren Denenberg, PT

Of Interest Membership updates, index of advertisers..........................................14

Visit our website at smcma.org, like us at facebook.com/smcma, and follow us at twitter.com/SMCMedAssoc. © 2015 San Mateo County Medical Association

On the cover: “Boy Bitten by a Lizard-Caravaggio (Longhi)” by Caravaggio - scan. Licensed under Public Domain via Wikimedia Commons - https://commons.wikimedia.org/wiki/File:Boy_Bitten_by_a_Lizard-Caravaggio_(Longhi). jpg#/media/File:Boy_Bitten_by_a_Lizard-Caravaggio_(Longhi).jpg

4 SAN MATEO COUNTY PHYSICIAN | OCTOBER 2015

President’s Message

Have a voice on the issues that affect us all In mid-October I attended the annual House of Delegates of the California Medical Association (CMA), held this year at the Disneyland Hotel in Anaheim. Just as Disneyland is referred as “the happiest place on Earth,” the CMA meeting gave me a pretty good feeling, happy that I had attended. The meeting was less crowded than the theme park, though it had no rides or roller coasters.

This was my second meeting as a delegate, and I continue to learn the ins and outs of organized medicine. Several of SMCMA’s more experienced delegates say that it takes a few meetings to understand the mechanics of the CMA. The HOD is tasked with reviewing all resolutions proposed by the membership. Any member may write a resolution on any topic that they believe should be acted upon by CMA. This year’s hot-button item was new policy regarding CMA’s position on the aid-in-dying measure signed by Governor Brown in early October. The CMA Board of Trustees took a “neutral” position on the matter back in May, whereas in prior years it had opposed any physician role in aid in dying. Many feel that CMA’s shift in position aided the passage of the bill through the legislature and to the governor’s desk. At its October annual meeting, the HOD passed Resolution 501-15, which states that (1) CMA will advocate for liability protections for the physician decision to participate or refuse to participate in physician aid-in-dying, and (2) CMA shall remain neutral on physician aid-in-dying for terminally ill patients who have the capacity to make medical decisions.

Michael Norris, MD President

The passing of the torch...

Senator Richard Pan, a delegate from the Sierra-Sacramento Medical Society, was applauded for his efforts to bring sensible vaccination laws into being. The CMA and county medical associations have supported Dr. Pan through a vicious recall effort and personal attacks from the anti-vaccination groups.

This year, the CMA is changing to a year-round system for submitting and reviewing new resolutions. Any member, through their delegation, may submit resolutions that they believe deserve the action of CMA on a state or national level. Members can, and should, get involved in matters that concern us all.

Last year, we crushed Proposition 46, the anti-MICRA legislation, saving all California physicians thousands of dollars in malpractice insurance premiums. This fight was led by the CMA and county medical associations across the state. We are now embarking on a $2 per pack tobacco tax measure to raise money, in part, for Medi-Cal reimbursement for California doctors. This will be another big battle, facing the tobacco industry, but I wouldn’t bet against the CMA.

Members can—and should—get involved in matters that concern us all. Reach out to fellow doctors, write a resolution, be involved!

Doctors often ask, ”What does the San Mateo Medical Association and the CMA do for me?” To paraphrase President Kennedy, ask what you can do for CMA and SMCMA to make them even stronger and help advance the cause of all doctors in California. Reach out to our fellow doctors, write a resolution, be involved! ■

OCTOBER 2015 | SAN MATEO COUNTY PHYSICIAN 5

“Banking with First Republic is like having a partner for all of your financial needs.”

MyFitnessPal

Mike Lee, Co-Founder (left) Albert Lee, Co-Founder (right)

(855) 886-4824 or visit www.firstrepublic.com New York Stock Exchange Symbol: FRC Member FDIC and Equal Housing Lender

6 SAN MATEO COUNTY PHYSICIAN | OCTOBER 2015

Executive Report

Governor Brown signs End-of-Life Options bill in special legislative session on healthcare After a tumultuous year in the California legislature, physician aid-in-dying for the terminally ill is now a reality in California. Governor Brown signed the End-of-Life Options Act on October 5, 2015, making California the fifth state to have legalized the practice, either by legislation or court order. The other four states are Oregon, Washington, Montana, and Vermont.

This legislation was originally introduced in the Senate as SB 128, co-authored by Lois Wolk (D-Davis) and William Monning (D-Carmel), in early 2015. In March, Senator Dianne Feinstein gave her endorsement, and the bill easily passed through the Senate Health and Judiciary Committees.

Sue U. Malone Executive Director

Since 1987, the California Medical Association (CMA) had opposed the enactment of any law that would require a physician to aid in the death of a patient. However, after meeting with the bill’s authors to ensure it offered appropriate physician protections, the CMA dropped its opposition and changed its position to neutral, making it the first state medical association in the nation to change its stance on physician aid in dying. The SMCMA Board of Directors went a step further and adopted a position of support of the concept of physician aid-in-dying.

Despite this promising start, SB 128 didn’t fare so well in the California Assembly. It was scheduled to be heard in the Assembly Health Committee on June 23, but the authors postponed that hearing to garner more support for the measure. When a Sacramento Bee poll of 15 of the 19 committee members showed that just four would support the bill in its current form, the authors withdrew the legislation.

Governor Brown then called a special session on health and health care in August, and the bill was reintroduced as ABX2-15 by Assemblymember Susan Talamantes Eggman, with Senators Monning and Wolk as principal co-authors. Many observers believed that Brown, a former Jesuit seminary student, would veto the bill. Indeed, Brown seemed to struggle in deciding whether to approve the bill, whose opponents included the Catholic Church, but he ultimately signed it on October 5. In an eloquent signing message, he wrote, in part:

“In the end, I was left to reflect on what I would want in the face of my own death,” wrote Governor Brown in his signing message for AB x2-15.

I have carefully read the thoughtful opposition materials presented by a number of doctors, religious leaders and those who champion disability rights. I have considered the theological and religious perspectives that any deliberate shortening of one’s life is sinful.

I have also read the letters of those who support the bill, including heartfelt pleas from Brittany Maynard’s family and Archbishop Desmond Tutu. In addition, I have discussed this matter with a Catholic Bishop, two of my own doctors and former classmates and friends who take varied, contradictory and nuanced positions.

In the end, I was left to reflect on what I would want in the face of my own death.

I do not know what I would do if I were dying in prolonged and excruciating pain. I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others. ■ OCTOBER 2015 | SAN MATEO COUNTY PHYSICIAN 7

WHEN IS A CHILD’S BRUISE FROM AN ACCIDENT OR SOMETHING MORE?

Do you know What, When and How to Report?

Take this complimentary online course and: 

Learn essential signs that should be reported 

Earn continuing education credits 

Share with your colleagues.

Pre-register for this free course at: http://www.imq.org/education/caprrc.aspx

8 SAN MATEO COUNTY PHYSICIAN | OCTOBER 2015

COGITO ERGO SUM:

The role of cognitive behavioral therapy in pain management CBT can help patients learn to identify irrational or dysfunctional thoughts around pain and learn to develop strategies for replacing these thoughts with healthier alternative thoughts, leading to less stress and evenutally less pain.

by Kimeron Hardin, PhD, ABPP

How does CBT change the brain in people with pain?

As a clinical psychologist, I have spent the better part of 25 years working exclusively in the field of pain management, across many settings and treating patients with pain along the acute to chronic spectrum. Due to the dearth of pain management training at the time, my early experiences were fraught with mistakes, as I stumbled through our limited understanding of pain perception. I struggled to understand the complex interaction between mind and body, even while the steady stream of referrals from my medical colleagues grew larger.

In the beginning, most referrals stepped into my office only after all reasonable attempts at “cure” had failed and the patients were past the point of frustration, often desperate, and frequently suicidal.

We are born with an automatic stress response to the sensation of pain. It is entirely appropriate that our brains kick into higher gear when we detect something is wrong via uncomfortable sensations. The stress response is a complex chain of events, beginning with a perception of potential danger and including the release of hormones such as adrenaline and cortisol, which ultimately can intensify the sensation of pain in an attempt to help the body deal with the potential danger.

Prolonged and unremitting pain leads to prolonged stress, which in turn affects neurotransmitters such as serotonin and norepinephrine, which also play a strong role in mood.

Effective CBT, which identifies and replaces stress-inducing or otherwise dysfunctional thinking with healthier coping thoughts, reduces the arousal and the release of pain-intensifying chemicals in the body.

Those early experiences forced me to step outside the box of my traditional psychology training and to learn from the rapidly unfolding scientific and technological advances.

My role is two-fold. First, to reduce suffering in my patients in whatever form and second, to work collaboratively with my medical colleagues to help them provide quality care and to achieve the best outcomes possible.

With the development of the gate control theory by Melzack and Wall, and the later iteration in 1990 by Melzack called the neuromatrix theory, I began to understand the critical role of the perception in the experience and mediation of pain. The neuromatrix theory of pain states that “the perception of pain stimuli does not result from the brain’s passive registration of tissue trauma, but from its active generation of subjective experiences through a network of neurons known as the neuromatrix.”

Before functional MRIs came along, allowing us to literally “see” and therefore begin to map these proposed neural networks, psychologists were already helping pain patients to change their perception of pain, largely through helping them to recognize dysfunctional thoughts, beliefs and attitudes about the pain. Mounting evidence suggests that by changing perception, we are indeed changing neural pathways.

Cognitive behavioral therapy (CBT) is an evidence-based approach to addressing many forms of mental health issues and has been the subject of many clinical trials. In many studies, CBT has been found to be as effective, if not more effective, than medications in the treatment of many forms of depression and anxiety.

A second possibility for how CBT changes the brain involves the specific functions of two key regions of the brain. The region that handles emotions such as stress and fear is commonly referred to as the “emotional brain,” while the structures that deal with planning, logic and reason are referred to as the “logical brain.” The logical brain is able to override the emotional brain—for example, when a person experiencing the pain of getting a tattoo is able to understand that the pain, while uncomfortable, is a natural and expected part of the tattoo process, and not typically a sign of danger, and they are typically able to withstand the discomfort.

Every time the logical brain overrides the emotional brain by using abdominal breathing or thinking positive calming thoughts, especially while experiencing chronic pain, new neural pathways become reinforced, making it easier to deal with future episodes of pain and stress.

What are the essential components of CBT in pain management? How does it actually work?

CBT is typically focused on the present, is time-limited, interactive and goal-directed and typically begins with a thorough pain and family history. During this process, the therapist identifies specific goals with the patient, most commonly around successful pain management. Examples of goals include better coping with acute flare-ups of pain, identifying

Continued on page 13 OCTOBER 2015 | SAN MATEO COUNTY PHYSICIAN 9

PAIN PERCEPTION: The paradox betwen elite athletes and chronic pain patients In the past ten years, our improved understanding of the central and peripheral nervous system has given us a new model to explain this paradox between pathology, pain, and function.

by Mark Sontag, MD I have had the opportunity to be a team physician for five professional sports teams (National Football League, National Hockey League, Major League Baseball, Arena Football), numerous Olympians, and retired professional athletes. I have also cared for thousands of injured workers, many with chronic pain. I daily ponder the contradictions between these two groups. My elite athletes present with high pathology (i.e., herniated discs, torn ligaments, even fractured bones), yet describe low levels of pain, respond remarkably well and quickly to my treatment, and perform consistently at a high level. Many of my chronic pain patients, in contradistinction, present with low pathology (i.e., normal imaging studies, few or normal objective findings), describe high levels of pain, respond slowly and poorly to treatment, and function at a very low level. What is clear is that there is no direct correlation between soft tissue injuries, perceived pain, and one’s level of function, as doctors were taught in medical school.

The paradigm of pain perception in response to soft tissue injuries, and how one functions, needs to be reexamined.

We are in a new era of understanding pain and how to manage it. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Having worked in pain clinics, multi-specialty sports and spine groups, occupational medicine and urgent care clinics, and a private practice setting incorporating Eastern (acupuncture) and Western medicine, I have observed the following: physicians have inadequate training in appropriate chronic pain management. The treatment for acute, adaptive pain (i.e., an acute painful ankle sprain) is different from chronic maladaptive pain (i.e., chronic low back pain with little or no objective abnormalities on imaging studies and physical examination).

The majority of pain practitioners (i.e., anesthesiologists, orthopedists, neurosurgeons, rheumatologists, physiatrists, internists, chiropractors, and osteopaths), emphasize treating the actual or perceived nociceptive pain generator while not adequately managing the patient’s emotional experience of the pain.

It is clear that an acute injury (i.e., injury less than six weeks old) usually responds to physical modalities (i.e., range of motion, anti-inflammatory modalities, exercise, bracing, 10 SAN MATEO COUNTY PHYSICIAN | OCTOBER 2015

injections), and requires strong pharmacological agents to block pain impulses so that chronic pain does not develop.

Neuroscientist Allan Busbaum at UCSF defines chronic pain as “a disease of the nervous system mis-processing information.” We realize that an inadequately treated acute pain condition can evolve into a chronic pain syndrome. The more challenging phenomenon is the more common situation of an appropriately treated acute pain syndrome that also evolves into a chronic pain syndrome. Clinicians are perplexed by these recurrent phenomena, and frustrated by their inability to adequately help these patients.

New information In the past ten years, our improved understanding of the central and peripheral nervous system has given us a new model to explain this paradox between pathology, pain, and function. In the 1980s, we thought each individual was born with a finite number of brain cells that did not replicate and could perform only one specific function. We now know that the central nervous system does produce new cells, is “plastic,” and responds to the environment.

Early neurological development Recent research of premature infants demonstrates the plasticity of the central nervous system and how this relates to the development of chronic pain. In the 1970s, when premature infants first started surviving in technologically advanced pediatric intensive care units (PICUs), clinicians thought that, due to immature nervous systems, the premature infants could not feel pain when needle sticks or procedures were performed. Thus these invasive procedures were often performed repetitively without adequate anesthesia. Unfortunately, these premature infants reached young adulthood and developed an inordinately high percentage of substance abuse and addiction, chronic pain, and mental illness problems. Biopsies of their central nervous systems demonstrated three times as many nerve cells that transmit pain than other agedmatched adults who had not been subjected to daily painful events as children.

It is clear that our DNA is not just a fixed blueprint that is expressed regardless of its environment, but rather a data processor. In the premature infant scenario, the developing

spinal cord and brain is bombarded with pain impulses. The plastic neuronal cells respond to this environment by producing more pain sensitive cells, which predisposes this individual to chronic pain, substance abuse (the individual uses addictive medications to self-medicate the pain), and often mental illness in young adulthood.

Sleep factors

Hormonal influences

Recent sleep research has shown that lack of delta sleep contributes to or causes substance abuse and chronic pain. During delta sleep, the brain produces endorphins and serotonin.

Individuals who sleep poorly due to chronic pain or genetic sleep disorders will seek artificial means to restore the brain neurotransmitters, which can lead to substance abuse and addiction. These individuals also produce less endorphins, predisposing them to chronic pain. It is well established that fibromyalgia patients have sleep disorders that contribute to their muscular pain syndrome. Tricyclic antidepressants have documented analgesic and sleep restorative properties, and thus are a cornerstone in chronic pain management because they alter serotonin levels. Serotonin and norepinephrine reuptake inhibitors (Cymbalta, Effexor, etc.) are also very effective in treating chronic pain with depression and anxiety.

Neurological conditioning

Operant conditioning

In contradistinction, young athletes condition their nervous systems to block out or minimize pain. At a very early age, the young athlete who falls down and scrapes a knee is encouraged to brush it off, get up, and return to competitive play immediately. They are rewarded for this behavior with positive comments from teammates, coaches, and parents. These young athletes become physiologically less sensitive to pain, and probably develop less pain fibers and pain chemicals.

Interestingly, this phenomenon is not limited to physical pain, but also applies to patients who were emotionally, sexually, or psychologically abused as children. Dr. Charles E. Nemerof (Chairman of Psychiatry and Behavioral Scientists at Emory University School of Medicine, in the August 2000 issue of The Journal of American Medical Association, published data demonstrating that women who were physically or sexually abused in childhood show exaggerated physiological responses to stressful events as adults. Women exposed to mild stress who have histories of depression and child abuse showed levels of ACTH, a hormone secreted by the pituitary gland in response to stress, six times as high as those women without such history. Women with a history of abuse, who were not depressed, still showed hypersensitivity to stress, yet to a lesser degree. Dr. Rachel Yehuda, Professor of Psychiatry and Director of the Traumatic Stress Studies Program at the Mt. Sinai School of Medicine, has documented similar abnormal stress responses in combat veterans, rape victims, holocaust survivors, and others who have endured traumatic experiences. It is clear that extreme physical, emotional, or psychological stress during early development lays the physiological matrix for hypersensitivity to stressful events in later life, contributing to chronic pain syndrome, addiction, and mental illness.

Life-control The under-management of real or perceived pain, and the unpredictability of the severity of one’s pain response, can lead to mental illness. Researchers have demonstrated that rats that are persistently shocked after eating survive and actually thrive. However, rats that are shocked less frequently, yet randomly in relationship to eating, stop eating and die. The unpredictability of the event and the loss of control can lead to mental illness. Currently, the majority of chronic pain patients are under-medicated with short acting narcotics, which contributes to the above phenomena, in addition to contributing to the patient’s excessive craving for the short-lasting “high” from the medication. Long-acting narcotics often eliminate the unpredictability of the pain, and eliminate the peak and trough delivery that is so detrimental to their well-being.

Finally, the environment and expectations of where and when pain will occur play a huge role in how one perceives pain. A professional athlete enters the arena knowing he or she might be injured, but confident that proper medical care is available. That same athlete, who might be unexpectedly attacked while protecting his or her family on a street comer, will interpret and experience the identical pathological injury (i.e., a concussion) in an entirely different manner. The majority of injuries are random unexpected events that often lead to various adverse emotional responses, which can delay recovery.

Treatment This discussion opens new frontiers for acute and chronic pain management. Under-treating acute pain symptoms can contribute to developing a chronic pain syndrome. Chronic pain patients are often psychologically programmed from prior life events to experience and suffer from more pain than individuals who have had less traumatic childhoods. The central nervous system is adaptable. By appropriately managing perceived pain with medications, increased activity, restorative sleep, and cognitive restructuring, one can reduce the level of pain, while also physiologically changing the actual neurons to assist in dampening or blocking the pain responses. Awareness of the patient’s emotional state, and past/current psychosocial environment and stressors, is as important as placing a needle on the pain generator. Chronic pain patients, who often present with co-morbidity (i.e., depression, anxiety, substance abuse, psychological problems), need specialized chronic pain management that includes identification and treatment of the perceived pathological cause of the pain. It is well accepted that individuals who present with numerous Waddell signs (non-physiologic signs or symptoms) rarely are malingering, but rather indicating that their pain problem also has a strong emotional component. These individuals require comprehensive emotional and psychological care, in addition to traditional methods of pain management (medication, injections, exercise) to facilitate recovery.

continued on page 14 OCTOBER 2015 | SAN MATEO COUNTY PHYSICIAN 11

Benefits of exercise for the chronic pain patient Chronic pain leads to a disinterest in exercise, which promotes inactivity, leading to muscle weakness and an overall decreased fitness level, fostering pessimism, depression and— yes—more pain.

by Lauren Denenberg, PT When I was a new physical therapist, my clientele was heavily comprised of acute and sub-acutely injured individuals. In the majority of cases, there were clear cut protocols to follow.

Subjective complaints were consistent with objective findings, and treatment outcomes were consistently favorable.

Clients were commonly seen for one hour sessions, two to three times per week, overlapped with other patients.

Increasingly over the years, the number of chronic pain patients I have come into contact with appears to have increased exponentially. The same protocols that were successful with acutely injured patients were simply no longer effective. The main difference between the two groups appears to be the fact that both the level of objective dysfunction, as well as the patient’s perceived level of dysfunction, are commonly not consistent with objective findings.

Prolonged pain and other symptoms appear to have eventually impaired the chronic pain patients’ ability to exercise, participate in recreational activities, and perform simple activities of daily living. An inactive lifestyle is undertaken, which ironically leads to an increased level of fatigue and pain, which in turn results in diminished aerobic capacity and an increased propensity to further injury. It also inevitably leads to increased perception of and sensitivity to pain, and so the chronic pain cycle begins—chronic pain leads to a disinterest in exercise, which promotes inactivity, leading to muscle weakness, and an overall decreased fitness level, fostering pessimism and depression, and—yes—increased chronic pain.

Athletes have been shown to have a higher tolerance for pain than non-athletes. However, their pain threshold, that is, the point at which they first begin to experience discomfort, is the same. What this means is that both athletes and nonathletes feel discomfort at the same time, they just deal with it differently. The athletes are conditioned to “work through the pain.” They commonly understand the difference between “good” pain and “bad” pain, and are motivated to maximize their functional capacity for every activity. The chronic pain patient, contrarily, is extremely fearful of aggravating their condition, is extremely sensitive to minimal pain increases, has no idea of the difference between “good” and “bad” pain, and is fearful about increasing their functional capacity beyond the relatively sedentary existence they have been living.

12 SAN MATEO COUNTY PHYSICIAN | OCTOBER 2015

The challenge with chronic pain patients is being able to reverse the chronic pain cycle. This begins with instilling an interest in exercise, which increases their activity, strength and mobility, their aerobic capacity and their functional capacity.

This all results in decreased pain, decreased depression, and increased optimism.

There have been a multitude of studies examining the effects of exercise on the brain activity of patients with Parkinson’s disease (PWP). Ahlskog, et al, in 2011 demonstrated that brain-derived neurotropic factor (BDNF), a key protein modulating brain plasticity, was shown to rise in concentrations after exercise in PWP. Enhanced neuroplasticity results, and may be linked to improved cognition that is also seen to occur in animals following exercise. Petzinger et al in 2010 demonstrated that exercise induced quantitative cortical changes in humans. Tillerson et al, in 2003 essentially demonstrated that inactivity leads to neurodegeneration. The effects of exercise on reducing the risk of chronic diseases including CHD, cognitive impairment, dementia, depression, osteroporosis, and diabetes, to name a few, is widely recognized. In 2008, this prompted the American Medical Association to pilot a program entitled “Exercise is Medicine”, the main objective of which was to educate medical practitioners about the importance of exercise for their patients.

Introducing exercise to the chronic pain population requires the support of a multi-disciplinary team. As a result of inactivity, the endorphin release mechanism will initially not be activated effectively. Thus, initial attempts at exercise are commonly associated with a flare-up of symptoms, or discomfort in unused muscles. Once the patient realizes that flare-ups are a reality, the fear of flare-ups dissipates. After accepting that flare-ups can happen, the objective then becomes learning how to manage the flare-ups when they occur, rather than be consumed with “fear of the unknown.” The support of a pain psychologist to assist with pain management, as well as the support of a pain management physician to manage medications and alleviate the fear of worsening pathological findings, is crucial. Once the patient BELIEVES that, even if there is more pain in the beginning, re-training their body to move and increasing their activity level is the first step toward breaking the chronic pain cycle, they begin to feel safe in their ability to control their path toward maximizing their full functional potential.

Foremost, the chronic pain patient needs to firmly believe that the benefits of exercise include decreased pain, decreased

fatigue, decreased joint and muscle pain, decreased blood pressure, decreased resting heart rate, decreased risk for other chronic diseases, decreased anxiety and depression, improved sleep, increased ability to burn fat, improved regulation of endorphin release, improved aerobic capacity, increased functional capacity, increased muscle strength, increased energy, improved cholesterol profile, improved self esteem, improved ability to perform recreational and simple daily activities, and an ability to return to work.

It is strongly believed that the best way to effect a multi-disciplinary approach to maximize the functional capacity of the chronic pain patient, regardless of the underlying pathology, is through a functional restoration program. The patient attends the program on a daily basis, regardless of any flareups; the patient is seen daily by the pain psychologist, physical therapist, and physical trainer. The patient sees the pain physician and nutritionist once per week, and the vocational rehab counselor as needed. This program cannot be supported in a traditional out-patient physical therapy setting.

There are additional things to consider in the attempt to maximize the effectiveness of a functional restoration program.

In order to establish a setting that promotes “health” versus “sickness,” the treatment area should be as non-clinical in design as possible. An area including bright colors, mirrors, and equipment designed in a fashion to more resemble a “gym”

setting is optimal. Clear and realistic long-term functional goals should be established at the beginning of the program.

Achievable short-term goals should be established on a weekly basis. Patient progress should be processed in a form (chart or graph) that is easy for the patients to be able to realize their objective functional gains. A subjective measure of the patient’s perceived level of disability, such as the Oswestry Disability Index, should be additionally utilized to realize improvement of how disabled the patients perceive themselves to be.

Ultimately, exercise as part of a multidisciplinary approach to the treatment of chronic pain is invaluable in allowing the patient to effectively regain their maximum functional capacity level, improve their level of optimism, decrease their level of depression, and take control of regaining their life!

ABOUT THE AUTHOR LAUREN DENENBERG, PT, is a licensed physical therapist with more than 25 years of experience and physical therapy director at SPARCMed. She specializes in both chronic and acute orthopedic and neurological disorders.

Cognitive behaviorial theory in pain management (continued from page 9) behavioral pain coping strategies in order to reduce dependence upon habit-forming pain medications, avoiding invasive procedures, reducing symptoms of depression around pain and disability, and improving function despite the pain.

These general goals are then made more behaviorally specific, and problematic thoughts or feelings are tracked for frequency and intensity of emotional arousal.

CBT assumes that triggering events lead to automatic thoughts, which in turn, lead to feelings followed by actions or behaviors. Automatic thoughts are part of a deeper system of core beliefs and values that we accumulate from life experiences about who we are, our self-worth, and the trustworthiness of others around us.

Those early experiences shape our reactions to, and interpretations of, the events in our lives. Sometimes, our interpretations are accurate and our responses are appropriate. Often however, our thoughts are based on superficial information and in our current world, are irrational or dysfunctional, leading to excessive anxiety or depression.

Many studies of the thinking patterns in people with pain have found that catastrophic thinking, or worrying about the future worst-case scenario about their pain and health, is common. CBT in pain management therefore is often focuses on helping the patient learn to identify thoughts around pain that increase stress, muscle tension and thereby exacerbate the pain even more.

Over time with practice, patients learn to not only identify irrational or dysfunctional thoughts around pain and learn

strategies for stopping and replacing these thoughts with healthier alternative thoughts, leading to less stress and eventually even less pain.

Although often initially CBT is focused on managing the immediate experience of pain, it is a natural transition to reducing the negative thinking characteristic of depression and feelings of helplessness that is often a consequence of living with chronic pain.

Unmanaged or poorly managed chronic pain inevitably leads to feelings of hopelessness, helplessness and depression but we also observe that depression, without injury or obvious structural pathology, leads to the experience of physical pain.

Current thinking about this relationship revolves around the shared neurotransmitters and neural pathways between pain and depression. In many cases reducing depression with CBT often leads to both reduced pain and improved pain coping.

Effective management includes both wise medical intervention and improving the patient’s sense of control by increasing awareness of effective behavioral and cognitive tools.

ABOUT THE AUTHOR KIMERON HARDIN, PHD, ABPP, is a board-certified clinical psychologist and clinical director at SPARCMed, an interdisciplinary pain management practice in Redwood City. He provides behavioral management services, cognitive behavioral and pain coping skills. He is currently the President of the Northern California Association of Pain Psychologists.

OCTOBER 2015 | SAN MATEO COUNTY PHYSICIAN 13

Pain Perception

Please verify your information for the 2016 SMCMA Membership Directory

(continued from page 11) Trying to treat a chronic pain patient during a relatively brief office visit is a disservice that is certain to fail. These patients require comprehensive pain management, often involving an interdisciplinary day-treatment program with:

Production is underway on the 2016 SMCMA Membership Directory and Desk Reference. The Directory will be mailed to all members in February 2016.

1. physician and staff expertise in pain management,

Verification forms were distributed to all members in late September. Please be sure to return your form with any changes no later than December 1, 2015.

2. education for the patient and family that chronic pain is a disease of the nervous system mis-processing information,

If you need a new form, or any other assistance, contact us at (650) 312-1663. You can also update your listing on our website at www.smcma.org/directory-update.

3. appropriate pharmacological management of pain to restore function, 4. restorative sleep,

Tracy Zweig Associates

5. work conditioning and aerobic exercise, 6. cognitive restructuring with a professional behavioral therapist, and

INC.

A

REGISTRY

&

PLACEMENT

FIRM

Physicians

7. outcome parameters that are measured scientifically, emphasizing return to prior responsible social roles and return to work. â–

Nurse Practitioners Physician Assistants

ABOUT THE AUTHOR MARK SONTAG, MD, is founder of the Remedy and SPARCmed Medical Groups in Redwood City, both focused on Physical Rehabilitation and Pain Management. He is board certified in Physical Medicine & Rehabilitation and Neuromuscular & Electrodiagnostic Medicine..

Locum Tenens Permanent Placement

INDEX OF ADVERTISERS Cooperative of American Physicians.................................Inside Back Cover First Republic Bank........................................................................................................6 Institute for Medical Quality.....................................................................................8 The Magnolia of Millbrae..........................................................................................4 Mercer............................................................................................. Inside Front Cover NORCAL.......................................................................................Outside Back Cover Tracy Zweig Associates............................................................................................ 14

V oi ce: 800- 919- 9141 or 805- 641 -9 1 4 1 FA X : 805- 641- 9143 t zweig@ t r acyzweig.com www.t r ac yzweig.com

SMCMA welcomes new members

Latifat Apartira, MD *Internal Medicine San Bruno

Allen Eskenazi, MD *Pediatrics Redwood City

Claire Larson, MD Geriatric Medicine, *Internal Medicine - Redwood City

Elizabeth Palkovacs, MD *Ophthalmology Daly City

Marija Petrovic, MD *Psychiatry Daly City

14 SAN MATEO COUNTY PHYSICIAN | OCTOBER 2015

San Mateo Co. Medical Association

Success.

It’s what California’s finest physicians strive for... and what CAP can help you achieve.

Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT).

As a physician-directed organization, we understand the realities of running a medical practice, and are committed to supporting you with a range of valueadded programs and services. These include a 24hour adverse outcomes hotline, HR support, EHR consultation, a group purchasing program, and payment and reimbursement education and support, to name a few.

Protect Your Online Reputation With CAP’s Free Physician’s Action Guide!

The Physician’s Online Reputation Action Guide can help you build a strong and positive reputation.

Learn how to: • Encourage patients to post positive reviews.

• Appropriately respond to negative reviews.

• Optimize social media to establish your credibility.

Request your free electronic or hard copy today!

800-356-5672 | CAPphysicians.com/ReputationPro

Proud to be endorsed by the San Mateo County Medical Association

GUIDE GUARD ADVOCATE

MEDICAL PROFESSIONAL LIABILITY INSURANCE

CALIFORNIA PHYSICIANS DESERVE Your Guide: Awarding more than 35,000 CME certificates in 2014* Your Guard: Resolving 89%* of claims without indemnity payments Your Advocate: Largest contributor to the No On 46 coalition

Our heart beats in California ... and has for almost 4 decades.

Talk to an Agent/Broker today about NORCAL Mutual. Š 2015 NORCAL Mutual Insurance Company. * Based on 2014 data.

844.4NORCAL | CA.NORCALMUTUAL.COM