Getting through the workday used to take all of Olivia Seonbuchner’s energy and willpower. For about 19 months, the 25-year-old would go home and get into bed with a heating pad. She didn’t do much on weekends either. “I was always exhausted,” says Olivia, who had what she thought was severe sinus pain.
Olivia went from doctor to doctor trying to find out what was wrong with her – and how she could relieve her pain. On the scale of 1 to 10 commonly used to measure pain, Olivia’s pain was usually up to 7 or 8.
After living with constant pain for months, Olivia found James Fricton, DDS, MS, professor of dentistry at the University of Minnesota and a pain specialist at the Minnesota Head and Neck Pain Clinic. Dr. Fricton diagnosed Olivia with myofascial pain in the jaw and face.
Myofascial pain is in the connective tissue that covers the muscles. It’s caused by pressure on sensitive points in the muscles, usually from stress-related muscle tension or repetitive motions in jobs or hobbies. Activity or stress can make the pain worse.
Dr. Fricton made a mouth guard for Olivia, which kept her teeth from clenching or grinding when she slept, and started her on physical therapy. “I improved a little, but my pain was constant, and around a 4 or 5,” says Olivia. When the pain was unbearable and she wasn’t at home resting, Olivia took ibuprofen. She didn’t want to take stronger painkillers, like opioids.
Getting to the Root of the Pain
Chronic pain like Olivia’s is the #1 reason people go to the doctor and the #1 cause of disability and addiction. When pain lasts more than three to six months after an injury, it’s considered chronic.
#1 reason people go to the doctor: Chronic pain
“As a pain specialist, I had been disappointed with the current treatments for pain conditions. They just did not work well or long-term, because they didn’t get to the root of the problem,” says Dr. Fricton.
So he developed an approach called Personalized Activated Care and Training (PACT), an eight-week online program to relieve and prevent chronic pain. PACT focuses on helping people:
- Understand their pain
- Identify and reduce the lifestyle-related risk factors that are causing or contributing to their pain, such as stress or sitting for too long
- Build protective activities and attitudes, such as exercise and optimism.
“I was really excited about PACT,” says Olivia. “I’m interested in the holistic approach to healthcare. I knew if I could avoid being prescribed anything, that was the route I wanted to go.”
“To manage our patients’ pain, just getting rid of the prescription pad isn’t the answer. Doctors need to provide our patients with pain management strategies that actually work,” says Dr. Wayne Jonas. Dr. Jonas is a practicing family physician, an expert in integrative health and health care delivery, and a widely published scientific investigator.
During a cross-country tour of successful integrative health programs, Dr. Jonas learned of Dr. Fricton’s pain management program: “I knew Dr. Fricton was on to something powerful with his program. It is a perfect example of how integrative health leads to better pain care.”
Integrating Self-Management and Treatment
PACT uses a whole person, integrative approach that combines self-care with conventional treatment. Each module starts with a self-assessment of the pain, self-management skills, readiness to change, and self-efficacy. Then PACT recommends short video lessons based on the results.
Patients develop an action plan for each module focused on healthy habits, daily pauses and calm practice. “People who are healthiest and happiest are doing those three action plan items every day,” says Dr. Fricton.
A certified health coach reviews the assessments and provides self-management training by telephone to help patients stay motivated, understand the program and succeed in completing it.
“Change is hard,” says Karen Lawson, MD, ABIHM, NBC-HWC, an expert in integrative health coaching who trained the PACT coaches. “Education and information alone don’t change behavior. Coaching is about empowering patients and providing them with resources, support, and a plan.” Dr. Lawson is director of Integrative Health Coaching at the Center for Spirituality and Healing and an assistant professor of Family Medicine and Community Health at the University of Minnesota.
Through her board work with the International Consortium for Health and Wellness Coaching, Dr. Lawson is also a national leader in establishing standards and credentialing processes for coaching education, practice and research. The consortium began national certification for coaches in September 2017.
“Having a health coach is especially useful for patients with chronic conditions, which can’t be cured with medication or other traditional medical treatment,” says Dr. Jonas. “Health coaches are key change agents who can help shift the U.S. healthcare system from one that is focused on reacting to disease and injury into one that also supports prevention and health promotion and fosters health and wellbeing.”
Empowering, Engaging and Training Patients
“Self-management strategies empower, engage and train patients to reduce the causes of their chronic pain in all realms of their lives.”
— James Fricton, DDS, MS
PACT helps patients like Olivia understand the important role they play in managing their pain. “Self-management strategies empower, engage and train patients to reduce the causes of their chronic pain in all realms of their lives,” says Dr. Fricton. The program works best for acute and chronic pain conditions, to prevent pain from becoming intractable.
Combining conventional pain treatment with self-management can help patients achieve optimal healing and health. “Eighty percent of health comes from outside the doctor’s office. PACT makes the 20% of conventional treatment for chronic pain more effective,” says Dr. Jonas.
The Institute of Medicine, the National Pain Strategy, the Institute for Clinical System Integration, and other health care leaders all recommend integrating self-management with conventional treatment for chronic pain. Dr. Fricton calls this approach transformative care.
Supporting PACT and Self-Management with Evidence
An early version of PACT was offered as part of a Coursera course called Preventing Chronic Pain: A Human Systems, which Dr. Fricton had developed for providers. But he discovered that over half the people taking it were patients with pain conditions.
After analyzing data from 771 participants with pain who did the online training, he found that:
- 93% of the participants changed their life to improve their pain
- 85% changed their care plan to include self-management
In a pilot study funded by the National Institutes of Health (NIH), Dr. Fricton found that patients with temporomandibular disorder (pain in the jaw and in the muscles that move the jaw) who did PACT had less pain, better jaw function, and less interference with daily living due to pain than usual care patients. This study involved 81 patients (40 took PACT and 41 received usual care).
“Dr. Fricton’s studies and systematic reviews show how integrating self-care with evidence-based conventional treatment are effective pain management strategies,” says Dr. Jonas. “In particular, people with chronic pain who develop healthy habits, and who learn to manage their stress through some type of mindfulness, meditation or relaxation training, can significantly reduce their pain.”
With funding from the NIH, Dr. Fricton developed PACT, a patient-centered version of the course, as part of the International MYOPAIN Society’s Campaign for Preventing Chronic Pain and Addiction. It’s available on the society’s Preventing Chronic Pain website.
Reimbursement for providers to monitor patients enrolled in PACT and to health coaches is variable. Some insurers and health plans provide coverage and some do not.
- Mind: Thoughts and attitudes
- Body: Physical structures and their function
- Lifestyle: Daily behaviors
- Emotions: Feelings
- Spirit: Purpose and energy
- Social life: Relationships
- Environment: The world we interact with
3 Actions Every Day:
- Healthy HABITS (Healthy Actions that Bring Improvement and Transformation):
- Working on enhancing protective factors such as exercise, sleep, diet, healthy substance use, activity level, optimism, and positive emotions in order to decrease risk factors
- Daily PAUSEs (Pause to Assess, Understand, Start new and Enjoy the moment):
- Taking a brief time-out to check-in and notice how you are doing right now in a non-judgmental way
- CALM (Calming Actions that Lift the Mind) practice:
- Spending a few minutes doing a brief relaxation technique, such as meditation or relaxing the muscles and nerves
Building Self-Awareness, Overcoming Barriers
“I realized I have a lot of habits that contribute to my pain,” says Olivia, who started PACT in May 2017 and completed the training in July. At the top of the list were poor posture, including hunched shoulders, and sitting too much at work. As a catastrophe risk analyst for an insurance company, Olivia spends most of her day sitting in front of a computer.
Olivia found PACT easy to use, and liked that the program provides “smaller stepping stones so it wasn’t overwhelming.” She found the self-assessments helpful in shaping her goals and working with her health coach, who she talked to every Wednesday by telephone. “We talked through things that were coming up in my life and my coach helped me set reasonable goals and provided accountability for reaching those goals,” says Olivia.
Setting realistic goals, and finding ways to work around or through barriers to achieving them, was important to Olivia. “I tend to be an overachiever and set the bar too high. It was nice to have someone to talk with about what’s actually attainable.” Coaching in PACT is personalized to the needs of each person. “It’s focused on where you are now, where you want to go, and what’s important to you,” says Dr. Lawson.
The self-assessments also helped Olivia figure out which habits she needed to focus her energy on changing. Her diet was already healthy, for example, but she needed to get more exercise. “After a long time of feeling I needed to lay down a lot, it was hard to get back into exercise,” she says.
Olivia is trying to do more power walking and biking. On days that she can’t fit in a longer workout, she does at least 20 minutes of brisk walking. Sometimes she takes the stairs up to her office, which is on the 11th floor.
“Many patients are hesitant to move when dealing with chronic pain,” says Dr. Jonas. “However, movement is exactly what many need. We used to recommend the RICE strategy (Rest, Ice, Compression, and Elevation) following an injury. We’ve now found that for most injuries, active recovery is better. By letting the person’s pain be their guide, they can carefully move as much as their bodies allow.”
During the workday, Olivia sets alarms on her computer to avoid sitting too long and to relieve stress. When the alarm goes off, Olivia pauses to check her posture and think positive thoughts. She may also walk to the farthest water fountain to get more water, or do some of the strengthening and stretching exercises for her shoulder and neck that she learned through PACT. Olivia does these exercises throughout the day whenever she starts to feel uncomfortable.
Practicing mindfulness and brief relaxation is also part of Olivia’s day. Using the Headspace app and/or a CALM practice technique from PACT, she does this in the morning and a few times during the day.
“The experience of pain is enhanced by stress and emotion,” says Dr. Jonas. “Mind-body and relaxation techniques can help reduce the suffering that accompanies pain.”
“PACT made me take a really hard look at my life and my habits.”
— Olivia Seonbuchner
Changing some of her bad habits was difficult for Olivia. “PACT made me take a really hard look at my life and my habits. It was difficult to change my expectations about what I can accomplish in a given day,” she says. Olivia continued to see Dr. Fricton while doing PACT, and he used the PACT dashboard to monitor her progress and outcomes.
Since Olivia completed PACT, her pain has gone down to 1 or 2 (on the 1-10 pain scale). Occasionally, the pain flares up, but Olivia knows how to manage it now. “I have more awareness that I was really stressed out and not keeping up with my good habits,” she says. Within a few days of going back to her good habits, Olivia feels better again. Key benefits of PACT, according to Dr. Lawson, are developing self-awareness of what triggers a person’s pain and getting tools to control or head off pain before it gets big.
Training for Providers
In addition to the program for patients, Dr. Fricton teaches a 10-week Coursera course meant to help providers learn how to use PACT with their patients. The online course is free, but providers can earn CME credits by completing the fee-based version.
Participants develop a greater understanding of chronic pain and how to apply a human systems approach to self-management strategies to reduce risk factors, enhance protective factors, and prevent chronic pain. The course is one of two ways that providers can train to use PACT with their patients. The other way is by completing a one-day certification seminar offered through the International MYOPAIN Society.
Helping Patients and Providers
“Every provider wants their patients to get better,” says Dr. Fricton. “PACT provides a simple solution to integrate self-management and telehealth coaching with their treatment to improve long-term outcomes for patients with pain disorders.”
“PACT does take work, but my quality of life has improved drastically,” says Olivia. “I feel positive that I’m going to continue to get better.”
While PACT was developed for people with chronic pain, the model can easily be applied to many other chronic conditions, says Dr. Lawson. “The approach of combining education, empowerment and coaching is a model that could be brought very easily to diabetes, heart disease, cancer or most other chronic illness.”
LEARN MORE: LINKS AND RESOURCES
Integrating Self-Management Training to Prevent or Relieve Chronic Pain, Healing Tools summary
“Healing Tools” summaries are a collection of evidence-based resources to help providers and patients use integrative health approaches to improve health and wellbeing.
- International MYOPAIN Society’s Preventing Chronic Pain website