Hello, everybody. Thank you so much for joining us for our talk today, Technological Innovations in Chronic Pain Management from Prescribed Digital Therapeutics to Chronic Pain. My name is David Binder. I'm an interventional physiatrist at Spaulding Rehabilitation Hospital. I also serve as the director of innovation. I thank you so much for joining us. Before I get started, a couple of housekeeping items. We're going to leave some time at the end for questions. If you have any questions, you can use the chat function and we'll try to address as many as we can. At the end, we'll also provide our email and contact information if you want to reach us directly. So, with that said, I'm going to get started and just set things up a little bit with regard to some of the innovations for chronic pain management. First of all, no disclosures on my end. As new innovations come through, there's also a lot of new terms and definitions that we all need to be aware of, in other words, so that we can understand what's going on and really speak the language of new technology. I thought it would be good to go over some of the common terms that are sometimes used and, unfortunately, used sometimes interchangeably, which can lead to some confusion. We've all heard about digital health. The way that I think about digital health is keeping track of information. These are technologies that allow us to count the number of steps, for example, that count the number of calories. Our electronic medical records are also a good example of digital health, but we've also heard about digital medicine, and so now we get into diagnostics. Think about the app that takes pictures of skin and can potentially detect a concerning lesion or some of the radiology, artificial intelligence that can detect the lesion in a chest x-ray or other radiological studies. Digital biomarkers is a very exciting new frontier in medicine. This is a little bit conceptually a little bit harder to understand, but the way I think about it is using digital technology that can actually help us guide treatment and help us understand who might be best served by which treatment. One example that I'll propose is at Spaulding, we're actually using virtual reality in the treatment of anxiety and chronic pain. One example might be if we're able to detect a patient that, let's say, does particularly well with virtual reality content in the treatment of anxiety, but we're also able to identify that those people are also able to or respond better to a specific anti-anxiety medication or antidepressant, let's say, then the positive responses to virtual reality might be termed a digital biomarker, which is a very intriguing kind of new frontier in medicine. And then finally, just to a couple words about digital therapeutics, now we're talking about treatment, right? So, and I'm going to get into that a little bit more with a concrete example towards the end of my talk with a company called Paratherapeutics that's developed an FDA-approved treatment for substance use disorder. If you want a little bit more information about these, these are some websites and forums that are particularly useful. HealthXL is an expert. We're not seeing your slides. I don't know if you know that. Oh. Do you see them now? I do not. Oh. Oh, you know why? I forgot to screen share. Sorry, should I just start over again? Now? Yes, sir. Okay. All right. My apologies. I'm going to start over again real quick. Was my audio on? Yeah, we could see and hear you. Okay. All right. So no disclosures. I'll just start off where I was just talking. But these are just some of the forums and societies that are involved with digital health and digital medicine, digital therapeutics that are intended to kind of improve the adoption of some of these new technologies that we talked about. All right. Sorry for the technical difficulties here. All right. So when we talk about new technologies, it's important to talk about regulations and also payments because you can have the best technology in the world, but if it's not going to be reimbursed in any way, it's probably not going to go too far, unfortunately. So the Food and Drug Administration recognized that with these emerging technologies that there's an important need to try to regulate and also authorize the use of these technologies in a structured way. And what they did is they provided a breakthrough device program, and this is intended essentially to fast-track some of these technologies so that what they offer new startup companies with these technologies, healthcare-related technologies, is not only guidance with validation and safety and efficacy that's needed to get FDA approval, but also an expedited review and submission process. So this has been very helpful. On the CMS side, Medicare coverage for innovative technology was proposed in January 12, 2021. So what is that? So similar to the FDA, CMS recognized the need to try to fast-track and also support and reimburse some of these new technologies. This is a new coverage pathway that provides Medicare beneficiaries covered access to some of these. Not an insignificant thing. There's 60 million Medicare beneficiaries in the United States, so this is very important. But one of the key pieces of this is that it provides a pathway that Medicare coverage can start coexisting with the FDA market authorization, and for four years beyond that. So why is that so important? Because in the past, with previous rules, you'd get FDA approval, and then months or years would pass by before you could potentially get Medicare coverage. And so this gap in time was turned the valley of death for innovative products, because great, you've got FDA approval, but now you're sitting there with expenses, you're trying to please investors, and you can't really get things moving forward until you get Medicare coverage and some sort of reimbursement for some of these technologies. And so this was intended to try to minimize this valley of death. Now, so this was proposed in January of 2021, earlier this year. During the comment period, there were some concerns over whether Medicare might end up reimbursing technologies that weren't supported by appropriate data, or could this potentially result in some sort of an unethical incentive for physicians. So unfortunately, two months ago, September 15th, they published a repeal to this with a subsequent comment period that ended October 15th. So the point, you know, it's out there, it's unclear whether this is actually going to be something that companies can take advantage of. We'll probably find out in the next couple of months, but we'll see. So now on to, I'm going to finish up with a concrete example of a prescription digital therapeutic. And it is exactly what it sounds like. You know, we're used to prescribing medications, treatments such as physical therapy. Well, you know, with the future of medicine ever evolving, we very likely are going to be prescribing a software. And so similar to biologics or drugs, the process for using some of these software and innovative technologies is going to be similar. They're going to go through a rigorous process. They're going to need to be approved by the FDA. And before I get into this concrete example, just a couple of definitions that I think are important with regards to some of this regulatory framework. So the prescribed digital therapeutic is actually a subset of two things. So software as a medical device, which is exactly what it means. It's software, it's basically software that's on an actual device. The software is the key component. And then mobile medical applications, which is one of two things. So the app can be on an existing FDA approved medical device. All right. Or the existence of the app creates an FDA approved medical device. If you want a little bit more information on that, these are just some citations that you can go. There's a lot of information on the FDA website as well as CMS with regards to some of the things that I spoke to previously. All right. So just wanted to show as an example, paratherapeutics. So what paratherapeutics did is they were the first prescription digital therapeutic to get approved for from the FDA to improve disease outcome. And what it is is essentially it's a program through an app or computer that assists patients with substance use disorders. So it's not intended to be the primary therapy. It's a complementary therapy to an existing treatment plan. But what what you're able to do through this program is there's lessons, plant lesson plans, those quizzes. There's feedback that can go back to the provider. The patient can report, for example, cravings and triggers. There's rewards for compliance of this program. And so it's really kind of intended to supplement an existing treatment plan. They came out with two so far that have been approved, Reset and Reset-O. Reset-O is similar to Reset, but it's specific for opioid use disorders. So essentially, it's intended to increase abstinence from substance use disorder. But it's FDA approved. And actually, this is a startup company based out of Cambridge here in Massachusetts. So with that, I'll finish up. I thank you for for listening to me. I'm sorry for some of the technological, which is ironic that we had tech tech issues in a innovation and technological talk. But I appreciate your your attention. I'm going to hand it off now to Zach Isaac, who is going to talk to us about current pain therapeutics and apps. And Zach Isaac is the assistant professor at Harvard Medical School, Department of Physical Medicine and Rehabilitation, as well as the chief of our spine division and pain management. Thank you very much for your time, Zach. Take it away. Thank you, David. Let's see. Give me one second. I am also encountering a technical snafu and I apologize. Somehow, my zoom window has minimized to the point that I cannot find it. Do you have a toolbar on the bottom you can find the zoom the little icon just click on my alt tab up and then I'm on your Windows start bar and click on your zoom icon. And right click on it. So go to the start bar. Yeah. And you see the little zoom icon down there. Yep. Right click on that and click zoom. Yeah, open. So when I do that, it's opening up. I think it's opening up a personal zoom rather than my, it doesn't show the actual conversation, the actual presentation, I mean, the actual zoom window. I'm gonna leave the meeting and rejoin and maybe we'll go out of order and have Jen join and then I'll be back. Okay. Okay. I'll put Jen. Okay, no problem. We can go out of order. I will share my screen. Well, thank you all of you for showing up to this zoom. And I'm excited to talk about this topic, which I think is applicable to all of us, especially if you're in pain care. And the title is pain management in the age of telemedicine. I think it is an opportunity for pain care transformation. I have no disclosures. Just a tiny bit of background. We all know we're in a pain crisis and we have been for decades with one out of three American adults suffering from chronic pain. This was the 10 year old Institute of Medicine statistic. We know that 10.6 million adults have high impact chronic pain. That means they have worse health, use more healthcare and clearly have more disability despite all of the interventions that we keep trying for them. The opioid epidemic also on the rise, maybe not so much in the news because of COVID, but it really took a hit with 88,000 deaths in the past year. That makes a 26.8% increase from the year before. Work disability, SSDI attributed to chronic musculoskeletal and back pain is also clearly a problem and on the rise. And healthcare costs. All of this amounts to healthcare costs are increasing at an unsustainable rate. It's believed 18% of the US GDP, gross domestic product is spent in healthcare, $4 trillion in 2020. And in pain care alone, 560 to 635 billion annually, exceeding the costs for heart disease, cancer, and diabetes combined. And look at this. This is from the patient-centered outcome research Institute meeting, fusions skyrocketing, imaging 300% increased, epidural steroid facet injections also up 250%. And we know these trends are just exponentially increasing as we speak. What's on the decrease is self-reported functioning, self-management, and even worse, down 72% is the multidisciplinary pain centers, which we've always believed in inherently to be the gold standard for chronic pain. Where are your patients on this line? Are they booked out months away trying to get an appointment with one pain doctor or see a pain clinic? Yet no one's online for lifestyle. I asked a CARF specialist, just out of curiosity, how many CARF accredited interdisciplinary pain programs exist today? And sadly, this was the answer, four inpatient interdisciplinary centers and only 52 outpatient. But didn't I just say there are millions, tens of millions of chronic pain sufferers. If you do the math, there's only one interdisciplinary chronic pain program per 670,000 chronic pain patients. Clearly a mismatch. And as much as we as physiatrists love to believe in interdisciplinary multidisciplinary care, what are the realities? There are few two programs. There's a big access issue, limited access. And historically it's because patients can't travel to these far programs that are located only in big city centers or specific academic centers. The compliance is real. It takes a lot of effort for patients to travel, commit their time, be motivated, and really invest in these long multi-week programs. Yes, there are other programs out there. There's MBSR and Wonderful Mind Body and wellness programs all over the place. But the problem is self-pay. Patients can't always afford these programs. And we know a lot of our population is really limited. It's also not integrated into healthcare the way what I'm trying to do with the program I will discuss will be. There's no universal standardized program. And there's conflicting messages with conventional care so that when patients return to you after they've been through a multidisciplinary program, if they're lucky to get one, they might get the bad messages again of needing more imaging and procedures and just go kind of around and around in that cycle. And long-term efficacy and cost-effectiveness perhaps is not well-established. I found one study by Maruta who looked at the Mayo Clinic's interdisciplinary center 13 years after treatment. And what did over 100 patients say about it? Unfortunately, the long-term efficacy is something we still need to work at. How can we, as really busy clinicians, and I'm on the front line too, I see pain. This is our field. If you went into spine fellowship, you start to see a lot of chronic pain. We have such limited time. We are burdened by the administrative issues, the prior offs. And there's not enough pain psychologists. I always try to find a pain psychologist, which was the whole point of why I went on this mission to invest in integrative care. There really aren't enough. And there's a culture of you fix me. That is a really big problem that might take a lot of effort on the part of providers and patients to try to transform. That patients don't have to be just passive recipients of our treatment. All of this leads to stress and burnout. But I see virtual pain care as a new idea here. This is actually a huge opportunity if we take advantage of this. We actually have something now that can help transform the chronic pain situation. We've actually had telemedicine Zoom apps for decades. We just never used it. We had it from, there's evidence and tons of research, internet journals showing the evidence for these things since the 1990s. We have internet based programs and multiple websites for pain. I appreciate Beth Darnall's Empowered Relief in particular, which is a great NIH funded evidence based program. There's Act on Pain. There's Butler and Mosley's Explain Pain. There's a ton of wonderful pain websites. And there's phone interventions. There's interactive voice response interventions, which involve your touch tone keypad and automated responses right from your cell phone. And of course there's virtual reality. VR is such, you know, it's a hot topic. We all wanted to get into this. I myself, like even invested in getting a headset for patients, getting their pain procedures, all those needle phobic, almost emergently hypertensive patients that just need to get through a little procedure. VR can be very helpful. And then phone apps. Of course, there are multiple apps for pain. And Dr. Isaac, when he comes back, might be able to share some of those with you because there's a ton of evidence for apps. Most of them involve symptom tracking, biofeedback, reminders, and even some behavioral health coaching on these apps. But what I want to talk about is videoconferencing, Zoom, because we are all in it. And this is the new world. I know Zach might talk about this later, but this one study I'll mention for apps because it was impressive with the numbers, 10,264 adults with chronic knee and back pain. They participated in a 12-week digital care app program involving education, sensor-guided exercise, and behavioral health support coaching. And they had some reasonable outcomes. Depression anxiety did decrease significantly. VR, I'll just touch again on it because it's definitely a cool thing and it's a hot topic. There's a lot of research going on. But then in my field of chronic pain, I still question its applicability. And that's the problem with chronic pain. I mean, is this really just temporary distraction? What is the dosing on this? How are we going to send people off with just a VR, some software? Is this really going to change their chronic pain? Hunter Hoffman might say, of course, this works. He was one of the first landmark studies here looking at VR for pediatric burn patients. And he was kind enough to share this with me. It's very painful to get dressing changes. But imagine just being immersed in a snow world with just throwing snowballs at the snowman and how wonderful that could be for these patients who do have to get acutely painful interventions. This was the real game changer. When Medicare decided to cover telehealth, this was big. And all of us use this now, the GT codes. And this is what is going to change, hopefully, pain care. I think a lot about what are the main needs for a good, non-pharmacological, non-interventional, more holistic pain management approach. And I really enjoy Louise Sharpe's study, which was a Delphi study of 44 pain experts, scientists, clinicians in the field of chronic pain. And the consensus was, when all else fails, if you can just do these three things, you can have the concepts of pain education, activity, engagement, meaning physical activity, and finally, cognitive approaches. Any type of pain psychology. It could be ACT. It could be CBT. It could be mindfulness and MBSR. But if you just have these three components, you can really do something and change outlooks and outcomes. I think a lot about telemedicine because we're in it. We use it now. And what are the pros and cons? Let's start with some cons. We can't forget the digital divide, those with low income and without internet. We are in a day where we do think about social inequality, racial disparities, and those who really do not have internet. So they will be excluded. But then I put a question mark, because does it exclude the so-called tech-impaired, the Zoom-shy, those patients who just don't seem to get it. They don't want to do a telemedicine visit with you. They don't think it's a real visit. I really think it just takes some training and education because it has nothing to do with age. I have nine-year-olds who are ready for me, waiting with their Zoom, and angry if we're five minutes late. So it's not always related to age. Another con about telemedicine is that the compliance and attrition over time is real, especially when we're talking back in the idea of pain programs, pain apps, websites. If they are unguided, and there's not a clinician behind it, and we just send them off to websites, are they really going to comply? How much are they going to gain from that? And finally, there is a lack of evidence-based, universal, standardized pain apps and programs because it's still a growing field. Sorry, on the positive, there are actually so many more positives to me and why I hope this lasts, and I hope the GT code lasts. Number one is access. Now we can really reach out to our chronic pain population to a much wider degree than ever seen before. And this will be inclusive of those with acute illness, all of the mobility impairments and real disabilities in our patient population, the environmental obstacles, the weather obstacles, all of that can be overcome with telemedicine. Furthermore, 85% of Americans own a smartphone. So if you can zoom in from your smartphone, you can theoretically access an interdisciplinary pain program. Another big fact is that psychological and behavioral health therapies delivered online are comparable in efficacy to in-person care. And I say this with confidence because I did do a lot of background research and I saw the decades of research showing wonderful evidence for psychology delivered online. Yes, we can connect with patients now through the screen in a really great, efficacious way. It's convenient. It's flexible, clearly. It saves time and travel and it's cost effective. I want to touch upon what's happened now with our telehealth consultations, especially when dealing with chronic pain patients. I believe they are effective and helpful. I actually look forward to doing my virtual visits with these chronic pain patients, whereas in the past I would be so stressed for time running room to room trying to fix them, trying to get their MRIs, trying to order everything and do procedures. Now we just talk about what they really need, which is counseling, education, compassion, empathy. This can all come through in the screen. There's a seamless interface with electronic records and imaging. So I no longer have to turn my back to them and try to find their MRI and pull it up and show them. No, we actually share the screen and show the MRI right there. Seamless interface. I find more time to listen, educate and counsel. And of course it's mask free. So we do need that feedback from facial cues and communication. Also there's group therapy options. There's shared medical visit options with group visits, with PTs zooming in, translators, social workers, special consultants, we truly have an opportunity to do interdisciplinary care right away. There's information about our home environment. We can see patients in real time, see their real obstacles, and also talk with their caregivers and family input, which we know is crucial. I know some of you are still skeptical and don't like this whole telemedicine and wish it would just maybe not be so prominent. Will we lose the human touch? And this is a real issue. I mean, yes, we can never let go of the fact that we do need in-person care too. We need our solid physical exam. We need the human touch and interventions that are hands-on. And the truth is this will never go away. But Zoom offers a really great platform, especially when we think about interdisciplinary chronic pain programs. So for the next portion of my talk, I really wanna mention FINR because it's my kind of pet project and mission, and I really hope it sustains. FINR stands for Functional Integrative Restoration. I use integrative because it's not one or the other. It's not conventional care or holistic mind-body care. No, it's that when you combine them together, you get the best outcome. It's a team. It really took a team, and we love teams in physiatry. So you can see my colleagues. Thank you, Dr. Isaac, Dr. Sarno, my co-directors. We also involve pain psychologists. We involve a wonderful, dedicated team of physical therapists trained in chronic pain, and all of these mind-body experts that can Zoom in and volunteer their time for a workshop, whether they're trained in tai chi or yoga or you name it. There's a wonderful field here. And then we have special guest speakers who wanna talk about specific pain-related topics that are pertinent. We had Leonard Perlmutter from the American Meditation Institute teach us how to meditate, for example. And I'll run through quickly the calendar of what just occurred the past two months. This was a lot of effort, but we did online public access virtual workshops for chronic pain, and all were welcome, all of our pain patients. And then we start with Dr. Isaac's lecture on Explain My Pain. And then we move right away into lifestyle medicine because we have to incorporate lifestyle, nutrition, exercise. We forget this, or we don't have time to talk about this, but it is so crucial for chronic pain. I added a pop-up workshop about mindfulness meditation to combat opioid use disorder. And I had my own colleague who's a meditation, a mindfulness meditation recovery coach who himself cured his own addiction with mindfulness meditation zoom in and meditate. And it was really special. We had a surgeon talk. Dr. McNee, a well-respected surgeon of complex spine surgery, talk about the true indications for spine surgery. It's not just because you failed everything else that surgery is the last resort. And then we had taught, so you can see it's a really interdisciplinary kind of growing kind of phenomenon. And then we talk about CBT and ACT and all of the wonderful pain psychologies that we can embed into pain care. It culminates in a way with this Empowered Relief, which is a two-hour evidence-based pain workshop from Beth Darnall out of Stanford. It has a ton of evidence. It's NIH funded. And one of our therapists trained in this program gives a wonderful workshop that has been well-received. You can see I love yoga. So I always incorporate yoga, mindfulness, and a really special type of pain psychology called ACT, acceptance and commitment therapy. And by planting these seeds in our patients' minds and kind of leading them through these talks and then engaging them with the live classes, we really can find some true outcomes here. The structure, oh, I'm sorry. What happened there? Okay, the structure of the program is that we have Friday workshops, one to two hours long, open access. But then this is the more involved component. This is where it truly gets interdisciplinary. We had an evening group that involved 15 to 20 patients, two pain physicians, myself and Dr. Sarno, and we're treating our own patient population. So these are patients we know, we've consulted with, and a therapist trained in chronic pain. And we all work together as a group. And the time goes really fast, but we get some really good work done together. And the ideas in a nutshell are teaching patients about pain. Yes, it's the brain, it's the central nervous system. We talk about SMART goals early on, and this kind of coincides with the lifestyle medicine workshop, because we want to invest patients. We want to get them involved, like they can get a SMART goal right now. I walk a mile a day, I try to eat better, I try to meditate. And then we teach pain psychology. We just embed it right into the program and learn the skills from CBT and ACT and mindfulness, and practice together, ending in a group-guided pain meditation. And this is the basic format. We have a 15-minute discussion about the concepts maybe from the workshops. The little breakout rooms are a wonderful Zoom feature, which allows deeper engagement. And then we do a little PT. We actually physically get up and move, and we have the physical therapist show us alignment, pelvic tilts, core training, and then finally a guided meditation. And I know I'm trying to be respectful of time in Dr. Isaac's talk, so I won't run through the entire program step-by-step, which I wanted to do, but it was a really interesting experience. And we talk about so much, so I'll just run through it quickly, whatever you can take from it with these slides, the stress response. Of course, that's involved with chronic pain, and we have to counteract that with the relaxation response, which we can learn and we can practice. And these are the steps, according to Herb Benson, the founder of the term relaxation response. It's the same definition as mantra meditation. And if you want one good study to think about when you're asking this question, does any of this decrease healthcare? Yes, it does. Stahl plus one study looks at 4,452 patients who underwent a similar program. It's called the SMART program, which is given through MGH right now, Benson-Henry. And everything decreased. The encounters decreased, the imaging decreased, the labs and procedures all decreased in this population. With the mindful eating lifestyle, we actually practice this in the group. We do the mindful eating of a raisin over five minutes, savoring the raisin, going through all of the sensations. And it's really interesting what happens and all the thoughts that go on. I won't have time to go over this in depth, but CBT, a wonderful, most, probably one of the most evidence-based pain psychologies, we can all learn tips from CBT. And some of the ideas is that we wanna change the maladaptive negative views about pain, which we sometimes initiate, sadly, with our labeling and overly focused on diagnoses and imaging. You know, degenerative disc, what a terrible sound. That is, oh, I'm gonna get worse with age. But actually, many people who are asymptomatic have the same exact findings. And I love doing this, I hope you don't mind, really quick exercise of CBT, going from a maladaptive view to a positive view. All treatments have failed, you have to be missing something, order me another MRI, you're missing something here. I'm glad more serious conditions have been ruled out. And the patient says, oh, I injured myself doing X, Y, or Z, I can never do that again, can't lift that box, can't go back to work, PT makes it worse, PT, physical torture. I heard a patient tell me that. No, balanced exercise is rarely harmful. Movement and activity can make you stronger, you can feel good from exercise. This is just gonna mask the pain, why are we doing steroids again, it's just masking. Recommended treatments can help me cope with the pain so I can function better and get through it. And finally, I can't do anything, Very common maladaptive view. No, we in rehab believe I am more capable than I think I am, I can function despite having pain. ACT therapy is a whole other discipline because we'll still encounter very challenging patients who can't change negative thoughts, they are too fused with their thoughts. And sometimes it really is impossible when they've lived an entire lifetime with maladaptive negative beliefs. So this is the answer, ACT. It does not attempt to change thoughts, it actually instead allows people to be with their experience, just be with the thoughts, be with the sensations. And the goal is to facilitate commitment and action towards a valued life. And we always end with meditation because it's so crucial and part of any wellness, any pain management program, the idea that we can focus our attention, we can redirect our attention. And it helps separate the sensation of pain from thoughts about pain. It's our thoughts, it's the thinking mind, the constant distracted, distressed out, you know, primitive brain part of our mind that causes the suffering. And this of course may make you think of John Kabat-Zinn, we are all familiar with that name I hope, because he founded the MBSR Clinic in UM Mass Worcester back in 1979. And there's a ton of evidence for this. The idea that mindfulness does work for pain, the awareness that emerges through paying attention on purpose, in the present moment, non-judgmentally. So I really try to embed that into the program. And yes, we can also incorporate the physical activity. Remember one of those three components of a good program, physical activity, engagement. So Tai Chi, yoga, these are real pictures from my own patients here. And Rick Wong, he was wonderful. He just gave his workshop last week. And we were all practicing it and feeling really grounded and breathing. And it really helps patients who feel that they cannot move. And here are more pictures, just enjoying the yoga, enjoying the group support, the group community. So I'd love to share a few testimonials. The program taught me my brain is more powerful than I think it is. And that how I talk to myself about pain is so much more important than I ever thought it could be. And I have never felt better in over 10 years of pain-related symptoms. I have a much better understanding of my pain and feel confident I can live life to the fullest and practice self-care. I would need a while to tell you what the program has done for me. My approach to pain is so empowered. And finally, I love this one because it's from a patient who is a particularly high-end utilizer of healthcare. You know those patients who have to see specialists as specialists, their entire life is taken over by doctor's appointments. She says, the only thing I use now to manage my pain is Finer, which was shocking to me. I couldn't believe that. I believe we can all work better to integrate the interdisciplinary psychological mind-body therapies into current clinical practice right now. All we need to do is some pain education, teach the coping skills, teach the lifestyle medicine skills, and embed a little bit of psychology. I took my own online courses in ACT, Mindfulness, MBSR. They're readily available to us. And we need to start embedding that into practice and become our own pain psychologists when there are not enough of these people out there for us. And then finally, engage patients in physical activity. I believe telemedicine and teleconferencing is a new, feasible, accessible platform for delivery. And we can extend this to a much wider population now. It is the guided programs given by patients' own clinical providers. When they see their own pain doctor delivering the material and the content and doing the yoga and Tai Chi and meditation, that is what is going to truly improve compliance, accountability, and change outcome. So finally, I feel like us as physiatrists are best positioned in pain care because we can lead and facilitate interdisciplinary Zoom groups. It is by nature our training. We were trained to lead a team. We want to teach. We want to be able to educate, counsel, use the psychology, use the pain coping skills. And finally, all of this to improve their function and their quality of life. I think virtual pain programs improve access, improve patient satisfaction, empower patients, improve their function, enable the group support, which is truly important, that social connection, which we can't get with any other platform. And then strengthening the patient-provider relationship. I've actually become much stronger in my relationships with patients because of Finer. And I'd like to end with a nice quote from a pain psychologist, This stuck with me like 10 years ago. So it'd be when I was starting to feel the burnout from chronic pain. Thank you so much for paying attention to this video. I hope you found it helpful. And I hope you found it helpful to share your pain stories with your loved ones. to me today. I want to thank Dr. Binder for inviting me to this talk. He's the director of our innovation group at Spalding. Dr. Isaac, he's one of my colleagues, mentors, and always truly supportive of the program, a contributor, along with my other great colleague, Dr. Starnow here today. And this is my email because I really want to share and converse. If anyone wants to reach out and discuss how maybe they're implementing their own pain program or how we can combine efforts, I would love to talk further with you and collaborate. Thank you very much. All right, guys, can you hear me all right? This is round two trial. We can hear you. All right, perfect. So my screen should be sharing, correct? Yep. We see it. All right. We see the thumbnails. So we need you to go into presenter mode. There we go. All right. Thank you all for your patience. And thank you, Jennifer, for that amazing outline of the scope of what's possible with telemedicine combining with group care for patients with complicated chronic pain. I'm going to focus on a little bit more of a, for patients that are a little bit more motivated to be a little more independent. So therapeutic apps and some things in the digital platform kind of require a more motivated patient, a little bit less individualized kind of therapies, but offer a surprisingly amazing opportunity in terms of management for chronic pain. I have no disclosures. So the big challenge of chronic pain, it's really quite onerous. You've seen it a lot, right? A lot of patients bounce around from doctors to doctors with completely variable diagnosis, such as SI joint pain versus piriformis syndrome to I've got sciatica to my back keeps going out to I'm out of alignment. And we face this challenge that when it comes to pain, the provider's background really heavily biases their perspective of what is the so-called diagnosis. And this consistently inconsistent diagnostic view of what is the cause of pain, what is the root source of pain creates a lot of angst for our patients. So if we step back from trying to be so hyper-focused on diagnosis and we step more towards looking at what are the patterns that are associated with better outcomes, such as healthy wellness and fitness, along with healthy cognitive strategies, we might be able to make some headway. And this is what's turned out in a lot of these modern techniques in the digital space. There's certainly a rationale for this. And when we look at MBSR, Mindfulness Based Stress Reduction, when we look at self-reported pain ratings with just four weeks of MBSR, MBSR actually helped back pain and changed brain hemodynamic activity on functional MRI. And when we look at patients who are already committed to getting their spinal surgery, patients who did a month of MBSR at a month after their surgery, they actually had better pain scores than those that did not. So there's definitely rationale for emphasizing cognitive strategies in our patients, whether they're getting surgery, whether they have a specific musculoskeletal diagnosis or not, there is certainly a role for improving their quality of life and pain. And over the past seven years, we've seen a lot of emerging data. As recently as 2014 to 2019 interval, there's a big shift. In 2014, a Cochrane review looked at 15 studies, all totaling 2000 participants. And they found that whether it was in-person or remote, they had similar improvements in pain and disability with technology-driven interventions. And in a 2019 study, looking at RCTs with close to 5,400 participants, various e-health modalities ran a wide spectrum of different types of interventions. And mobile apps and virtual reality for pain were some of the two most effective regions, but these were the most represented too. And cognitive therapies such as CBT or MBSR can be a valuable addition to standard care. Because when we look at 30% reduction in pain bothersomeness as a metric of success, patients who participated in MBSR or CBT had close to 60% success rate, as opposed to if they just were committed to standard care, less than half had a 30% reduction in pain bothersomeness. So this has resulted, I think, in a big role for apps for pain from a cognitive standpoint. And a recent systematic review of 939 pain apps in the Google Play and app stores, they willed it down to 19 apps that met review inclusion criteria. And the most common were really meditation and guided relaxation that had a self-management role strategy for management of pain. And three apps really stood out as having the most number of criteria to foster self-management and pain. And these were the Curable app, the Pain Scale Diary and Coach, and SuperBetter. And two health apps, Headspace and SuperBetter, were associated with improved health outcomes in general, but none of the apps really evaluated dedicated persistent pain. So there's a lot of role for research, but a lot of this is very promising for a large swaths of patients that commonly will make a lot of excuses about time, too busy, this and that. This is all in the hand of your smartphone. A study by Mercado looking at, in clinical research and rheumatology, looked at 61 apps and applied a criteria for inclusion and exclusion to rate the quality of the app. This wasn't looking at outcome-driven, more like quantification of quality. And they made this mobile application rating scale, this MARS scale. And they looked at how engaging is the app? How functional is it? What's the aesthetics? What's the information quality? And what's the overall quality scare? And there were a variety of things these different apps would look at, from biomechanical exercises to aerobic exercises, to mind-body exercises, to combinations of mixed modalities. And four apps basically came out. And all of them, 95% of the apps that were there in the app stores, really followed the National Institute on Healthcare Excellence guidelines for low back pain. So there is a strong push to try to follow medical guidelines as they construct these apps. What came out as the highest scored using their MARS scoring system, was the Low Back Pain app version 2.2, Three Steps to Cure Back Pain, Backache, and Yoga for Back Relief HD. Now, even further developed from here was is a 12-week digital care program for low back pain published, authored by Shadib et al in NPJ Digital Medicine in 2019. And this was a 12-week digital care program that was really comprehensive. They had sensor-guided exercise therapy, so sensors that would be attached to the patient, educational articles, cognitive behavioral therapy, team discussions, activity tracking, symptom tracking, one-on-one coaching through the app, and they compared it to digital articles and whatever the patient usually did in their care, their medical care. And you can see that their VAS, the orange is the intervention group, and you could see that their VAS pain differentiated, their interest in surgery declined, their disability improved, their pain decreased, their oswestry improved, their VAS impact on life improved, and their overall understanding of their condition actually increased. I can't tell you how many times I've had an MRI, done X-rays, looked at the hip joint, the cramping, all these other areas, and tried my best to explain to the patient what I think is going on, only to be sent an in-basket message the next day, but you didn't really tell me what's really wrong. And so the fact that this kind of tool can actually help them feel that they're understanding their condition more, I think speaks volumes. And there's also other apps that look at exercise and artificial intelligence kind of feedback, and a multidisciplinary mHealth back pain app called K, or K-I, I may be mispronouncing, I apologize. They looked at RCT, industry-sponsored, the authors declared no conflicts of interest, and they looked at 101 patients with nonspecific back pain. And in the intervention group, the K-I app was provided for three months, and the control group did six physical therapy sessions and online education. And they looked at pain intensity at 12-week follow-up. And you can see that in the solid line group here, which is the K app, and the dotted line group is standard intervention, both had improvement over the 12-week window, but the K app did differentiate itself from the standard care group in the pain rating. So their conclusion was that the multidisciplinary back pain app is an effective treatment in low back pain, and it's superior to physiotherapy and online education. So I think that given the accessibility and potentially less cost and the convenience aspect of it, this really is a potential disruption in the normal presumed assumption that you have to have hands-on, you have to see the person direct, and you have to have all of these aggressive things done to really get to the bottom of it. So in summary, apps for pain are really focusing on areas that are currently not emphasized by the current fee-for-service model. And they're really working on cognitive therapies and exercise-oriented therapies. And this may be a real profound shift in how pain care is approached. Patients may have less expensive options than previous to improve their pain and function that are at least as comparable, if not better than current existing standard care. And with that, I'll conclude, and I thank you all for your time and your patience with all the technical challenges. Thank you. Thank you so much, Dr. Isaac and Dr. Kurz. That was wonderful. And I appreciate all the great comments that we've had, and I definitely wanna get to as many of them as possible. I'm just gonna, I just wanna recognize one more person before we move forward. I just wanted to recognize the chair of our department, Ross Stefans. He's also the president of Spalding Rehabilitation Hospital, because he's been extremely supportive of a lot of the things that we've talked about today within our department. And so we thank him for all the support. So I can't get to all of these, I'm gonna try to get to starting from the top, but a lot of these comments were directed to Dr. Kurz. And a couple of these, Dr. Kurz, are these Zoom calls available to chronic pain patients in other states? So we have the Friday workshop, which I make open access as soon as they get a Zoom link. And I do dream of having a finer webpage other than the one I sent in the chat room, because that one's just not ideal. Anyone can join from anywhere, because we're not charging, it's free. And then the Tuesday group is something that we're really investing time into. It's an interdisciplinary component with providers interacting, and it's actually billable. This is the big thing I didn't get time to talk about, but we can bill groups, because they are our own patients, and that adds to the feedback and accountability factor, compliance factor, and we follow up with these patients. We see them in the Zoom group, and then we'll follow up in the clinic. So that is a big component. The Tuesday groups is something we're developing, and actually Dr. Sarno, who's here today, is gonna study it, and we're gonna get some outcomes for all of you for next conference. And I believe we can all do this. If you have the energy and desire, any one of you can do your own interdisciplinary Zoom group, and you'll be astounded what it does for patients, that group connection, and just feeling like they're really supported. That's great. And I'll try to combine two questions into one. Again, this is directed for Dr. Kurz. Can you please speak to how a provider can bridge the holistic approach versus the traditional approach? And in a somewhat related question, we had an interesting situation with a pediatric rehab provider who reports an increase in generalized pain disorders and fatigue and a lot of generalized pain kind of symptoms in some of their patients. And unfortunately, there seems to be coexisting parents that also have chronic pain. And so question number one, how can you bridge the holistic and traditional approach and how could you potentially bridge between the pediatric patient and maybe their parents? Do you potentially do like family kind of group finer therapy? There's so honestly, the potential is endless. And if you have the dream, you know, you have the energy, you have to get a little training. So I myself during the pandemic year, I took it upon myself to do some training. I learned ACT, I learned mindfulness-based stress reduction and mindfulness and there's some wonderful talks and like gurus out there who teach. I can give you names, I put them in the chat room. But once you get some training and expertise, then you deliver the care and you know, it starts slowly, it's not overnight. You start to plant the seed, you give them some evidence for why ACT or CBT works or why Tai Chi for chronic pain can work. And there's a ton of evidence once you start looking into it even a little bit, there's evidence for all of the things I mentioned. And you do start to train, you have to train the parents, you have to train the kids from early on. I think we all need some meditation training. So just starting with meditation practice alone is a step forward for me. Like, yes, we can train to change attention to pain. All right, great. And question for both of you have, I guess for myself as well, have we noticed any differences in patient response or openness to some of these technologies based on whether they, you know, chronic pain for a long time, short time, work-related issues, workman's comp versus no previous history of injury, you know, that type of thing. Are there any sort of kind of patient identifiers that seem to either kind of indicate a patient may be more open to some of these technologies? Do you wanna answer that, Deg, or I can answer from my experience? I think that's a huge challenge, right? Because these populations of patients really have a defense mechanism. They want an anatomic structure to validate their experience. So they're very much more, when they have a personal injury or a car accident, they're very much fixated on the anatomic structure because they were a strong person. This concept of, I'm a strong person, I can't develop chronic pain is so in our society. Like, if you're a strong person, that doesn't mean you should do cognitive practices or exercise, I don't get that. But we really do fixate on anatomy as being a simple explanation as a society and even as medical providers. So having the conversation within ourselves and educating other providers and educating lay people also that fixating on a single structure doesn't explain the pain always. And that is a conversation that over decades may evolve to the point that just because you had a car accident, you can work on cognitive strategies. But I think that it's hard to change the mind of a human always. And I think that requires a robust engagement with that individual, a number of conversations and the transition is very slow and is an iterative process. And I feel like if we emphasize the fact that if everyone has the same message and the group idea, that's what always worked. Why do these interdisciplinary pain programs work? It's because there's a team and everyone's on the same page. So that is a crucial element. And I think telemedicine can be a way to do that more easily now. We don't have to worry about the commuting and finding one institution to host all of these resources. We can all do this online and I've shown it can happen because we're now in our fourth round of Finer for the spring and the wait list is long. We have patients lining up for it. Patients wanna do it again and again and it can be done. So don't give up, even the tech shy, tech impaired, you just teach them how to do it. And it's really not hard to zoom in. Anyone can learn to zoom in. Well, thank you both. And thank you everybody who attended our talk. An hour flies by quickly when we're talking about important and interesting topics. So thank you so much and please reach out to us if you have any questions and we hope you enjoy the rest of the Academy meeting. There were some questions I didn't get to but you can email me also and I'll send you resources that way. Sorry. Thank you. Thank you all for having us.

technological innovations

chronic pain management

digital health

digital medicine

digital biomarkers

digital therapeutics

FDA

CMS

telemedicine

mobile apps