Comparison Of A Multidisciplinary ACT-Based Program Compared To Cognitive Behavioral Therapy For Chronic Low Back Pain With Corinne Cooley, PT, DPT, OCS And Heather Poupore-King, PhD

Welcome back to the Healing Pain Podcast with Corinne Cooley And Heather Poupore-King, PhD

In this episode, we have two incredible guests. I’m excited to bring two guests with some incredible experience and research behind them to talk about an important topic, which is bringing ACT to a multidisciplinary pain clinic setting. My guests are Physical Therapist Corinne Cooley and Psychologist Heather King. First, I’ll tell you about Corinne. She is a Physical Therapist at the Stanford Pain Management Center and a Clinical Residency Faculty Member in the Stanford Orthopaedic Clinical Residency Program in California. She works with pain physicians and pain psychologists to help optimize complex patient care plans, and leads the exercise and movement portion of interdisciplinary outpatient programs.

Psychologist, Heather King, is a Clinical Associate Professor in the Department of Anesthesiology and Peri-Operative Pain Medicine. She also serves as the Director of the Pain Psychology Fellowship at Stanford. Her areas of expertise are Cognitive Behavioral Therapy for pain as well as insomnia, and Acceptance and Commitment Therapy. In this episode, we’ll discuss an investigation that Corinne and Heather were both involved in.

This study included an outpatient interdisciplinary approach with pain psychology using ACT as well as physical therapy, and compared that to traditional Cognitive Behavioral Therapy. In essence, this was an ACT plus PT intervention compared to a Cognitive Behavioral Therapy intervention alone. They got some interesting data and some results to share. They share how they went about investigating this topic and some of the outcomes as well as the patient population, and how ACT flowed through the psychology as well as the physical therapy part of care.

As you know, I’m a little biased toward mindfulness and acceptance-based approaches, to living life to the fullest, especially with chronic pain. That’s why I’m so excited to share Corinne and Heather with you. They also use ACT as their primary form of Cognitive Behavioral Therapy in their treatment. Just a reminder, if you want to learn more about ACT for chronic pain, there are two great resources for you. The first is my book, which is called Radical Relief. The second is our course, ACT for Chronic Pain, here at the Integrative Pain Science Institute.

Take the time to read about some of the topics we’re talking about with regard to chronic pain, both on how ACT can help the psychological aspect as well as the physical aspect of pain. Also, how Heather and Corinne worked together as this tight interdisciplinary team, which is important in the study they created. Hopefully, we can see more of this in healthcare settings. I highly recommend if you’re a professional to download the paper. It’s open access. You can read either the paper and follow along with the show or read the paper after. Without further ado, let’s begin and meet Physical Therapist Corinne Cooley and Psychologist Heather King.

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Comparison Of A Multidisciplinary ACT-Based Program Compared To Cognitive Behavioral Therapy For Chronic Low Back Pain With Corinne Cooley, PT, DPT, OCS And Heather Poupore-King, PhD

Corinne and Heather, thanks for joining me on the show. It’s great to have you here.

Thank you. We’re very excited to be here, Joe.

I’m excited to talk to both of you, a physical therapist and a psychologist, who are doing interesting work in the realm of multidisciplinary and multimodal care. We’re going to be talking mostly about some of the research that you’ve published with other colleagues. I always want to mention the paper because oftentimes, professionals want to read it for themselves or use it as a resource. The manuscript you published is called Effectiveness of a Multidisciplinary Rehabilitation Program in Real-World Patients with Chronic Pain. A Pilot Cohort Data Analysis. Everyone can find that in the June 2021 Journal of Back and Musculoskeletal Rehabilitation.

Heather, let’s start with you. What was the driving force behind developing an intensive outpatient program using ACT as part of the Stanford approach to treating pain? I know there are lots of other approaches happening at Stanford and lots of the things they are researching. Why this particular approach?

Joe, thanks for having us on. We’re excited to be here and to talk about our program. The process of developing Back In Action started back in 2012. That’s when I came on board to Stanford. I was recruited to come in and work with the pain psychology fellows to be a primary supervisor and bring new clinical programs on board. I come from a restoration program through the Workers Compensation System. I was hired to develop the psychological aspects of a new program that was launched a number of years ago.

When I came to Stanford, I wanted to increase clinical offerings. There was one CBT group that was being offered at that time. I worked with the previous physical therapist to bring in the first coping skills and movement group. It was a CBT-based group, and then there was tai chi and yoga. When Corinne came on board, we started to co-lead that group.

We had the opportunity to work together from that standpoint of running the CBT and coping skills movement group, and also to share a number of individual patients. She was seeing them in physical therapy and I was seeing them for pain and psychology. Our progression started with talking back and forth about the different control-based step strategies. These are the CBT-based strategies. Over time, because I also run an ACT group at Stanford, I’ve implemented that.

I started sharing this information with Corrine to move them toward their goals. Corinne was open and willing to learn more about the psychological flexibility model as another skillset that we could implement to help patients living with persistent pain move for the things that are truly meaningful to them. Whether it’s getting back to work, school or even spending time with their family, learning to say yes versus no.

That’s how it started. Seeing how effective these tools were, Corinne began to do different training. We spent a lot of time going over how do we put this all together? How do we take the Pain Neuroscience Education piece? That’s the foundation of helping people get unstuck. The CBT tools are helpful, but then integrating the psychological flexibility model in an interdisciplinary and outpatient setting.

We started off researching to see, “Why recreate the wheel if someone’s already doing this? Maybe it’s something that we could do.” Honestly, we couldn’t find anything in the United States that was being offered that followed what we were looking for at that time. It was being done in Europe. There was research on it, but these were all inpatient groups. That’s how it started. We sat down. What are the best pieces of all this? We put it together, got support through leadership, and then launched it in this outpatient setting.

HPP 248 | Chronic Low Back Pain
Acceptance and commitment therapy is not about pain. It’s more about taking steps toward the things in your life that bring you pleasure and satisfaction.


You mentioned that no one’s doing similar work to this at that time, or at least you didn’t see it in the literature. You haven’t found anything in the literature. You mentioned control for a minute, and I know we have a lot of questions to go through. I just want to give people some context. I think it will help as we talk about the rest of the episode. You mentioned control. As part of CBT, we teach people techniques or skills to help control their pain. ACT is also a part of this study as well. Can you talk to us about the differences between the concept of controlling pain versus how ACT approaches pain?

It’s such a good question. With the CBT strategies, even when we pitched them to patients and I heard other pain psychologists talk about turning the volume down on pain. The ultimate goal of CBT is to turn the volume down on pain, whether that is through basic self-regulation, relaxation, activity pacing, even cognitive restructuring of changing how we think so that we can change that bi-directional signaling that’s happening.

We are focusing on turning the volume down on pain. Corinne and I presented at Pain Week. We called it the carrot versus the stick or something like that. I can’t remember the name, but the stick is about avoiding, reducing and changing pain. When we think of Acceptance and Commitment Therapy or whether you want to call it the psychological flexibility model, it’s less about pain. It’s more about taking steps at the moment repeatedly that move you toward things in your life that bring you deep meaning, pleasure and satisfaction.

When things show up, your thoughts, memories, sensations, how do you change your relationship with those things so that they don’t hijack your behavior? What we find is that ultimately, it is changing the pain response, but that’s not the philosophy behind it. I think of this as optimizing everyone’s resilience. What are the things that help you be you and motivate you to move forward? We’re tapping into that and that would be the carrot.

That would be the “What are you moving toward?” and helping people get unstuck from these thoughts that tell them, “I can’t do that. I’ll never be able to do that,” or even the fear and anxiety that shows up. The person is changing their relationship with all of that through the psychological flexibility model. They got the roadmap of where am I going? What does that look like today, in an hour, tomorrow? It’s a map to help them live a full and vibrant life with whatever they have going on, whether it’s pain, anxiety, fear or depression.

I want to come back to some of those topics, but I want to bring Corinne into the conversation. Corinne, as a PT, you’re doing some groundbreaking work in the clinic by implementing psychologically informed care via ACT. Now you’re being involved in research. You’re straddling two areas. I commend you. There are probably only a small handful of maybe three or four PTs in the world who are doing this kind of work. You’re working with Heather closely. Heather supports you through this process, but tell me about your initial entry point into ACT and how it differs from what we would consider a “traditional PT,” whatever that means nowadays.

It’s hard to start my journey without mentioning Heather. I never would have learned ACT or been exposed to ACT if I wouldn’t have been at Stanford and had that close relationship with a pain psychologist I could work with. I will go back a little bit before that. I was lucky enough in my residency program to get a pain management course. Even in PT schools, they’re starting to integrate pain management and exposure to CBT, motivational interviewing, and other techniques that you would see a pain PT use in Pain Neuroscience Education.

When I came to Stanford, I was a little bit resistant. I was asking Heather one day about a mutual patient role. If they are fearful. Is the cognitive restructuring going well? She brings in this psychological flexibility of sitting with the discomfort and sitting with thoughts, whatever comes up. That was very hard to hear as a PT, “Fix it, get it better, fix this problem.” Shifting to this pain-control, fix-it mode to still supporting the patient and wanting to help them move forward, but maybe with what they’re bringing took a lot of training, practice and mentorship.

One of the first training I went to was through the American Association of Pain Psychologists. Robyn Walser led a day course, the foundations of ACT, going behind CBT, and the different theories that ACT was developed on. Heather invited me to an intensive bootcamp on ACT and that was a four-day course where you’re watching advanced practitioners show the experiential exercises and take you through those.

It requires you to dig deep internally. It becomes very emotional. You think about your own struggles, and that was definitely a helpful piece for me to understand how the patients are struggling themselves. As a physical therapist, the one thing I value is I’m not going to ask a patient to do something I wouldn’t do, whether it’s exercise. I always want to make sure I’ve tried it on first. Going through that helped me to be like, “This is how it is to be someone that’s struggling with these things all the time,” and how powerful it can be to have a different outlook and strategies rather than the CBT model.

That was my journey. One of the things I did to build upon that was I took your course, which was great. It provided lots of languages, metaphors and handouts that we were already using in our group. For someone that’s not familiar with ACT, it’s a great PT-focused course. That was my journey with ACT. I still use it for myself. I definitely enjoy using it with the patients that I’m working with. It opens up a whole other lane on what you can work on, what they’re willing to do, and gains that you can make in the gym.

It’s interesting for us to think about it as PTs and maybe even for Heather. I’m sure she’s experienced this as she worked with other professionals, not just PTs. Even if there aren’t intentional traditional cognitive-behavioral interventions inserted into PT education, what we do as PTs does fit along the lines of more traditional cognitive-behavioral intervention. Even if you’ve never trained in CBT, we naturally have that mindset.

I look at Pain Neuroscience Education as taking the psycho-education part of it and building it out into a big treatment technique, and the works that are needed to be done. My question for you, Corinne, is in learning ACT and starting to use it in practice, or maybe you haven’t come to this point yet. I don’t want to insert my opinion here but along with this process, where have you come to the point where you said, “This is a much more refreshing way to approach people and it takes some stress off of me as a practitioner?”

That was a huge moment. I have come to that point. It’s been very helpful for me to prevent burnout for myself, also to be willing to explore other avenues that I might not have with patients. I’m still concerned about the outcomes. I still want patients to make progress but less concerned about how those outcomes come about. I’m hoping to try to model psychological flexibility as much as I can, but that point happened at the bootcamp when you’ve taken through all those experiential exercises and feeling it yourself.

ACT is an experiential therapy.

It’s almost hard to explain. I know Heather does a great job when she’s explaining it.

Heather, can you talk to us about some of the components of the program? I know there’s a CBT component, which I believe was like a 6 or 7 session CBT intervention. You compared that to Back In Action. I love that phrase you have there for the program, but tell us how the Back In Action is different from the CBT if you can summarize that for us.

HPP 248 | Chronic Low Back Pain
Optimize your resilience by finding the things that can really help you be you.


The CBT groups are two hours once a week for eight weeks and that’s a basic CBT protocol. We have neuroscience education in everything. It’s the foundation if you’re going to work with people with pain. We go through the difference between acute and chronic pain, the role of the brain, and turning the volume up or down on. Also, things like sleep hygiene, activity pacing, cognitive restructuring, basic goal setting and the standard CBT stuff.

Back In Action is a little different. I’m very biased in this because we developed this, but I feel like we’ve taken the best of everything we have and put it into this program. The way that it works is it’s four hours, twice a week for six weeks. It’s very intensive. We start off with basic Pain Neuroscience Education and a couple of sessions on basic CBT skills. Things like activity pacing, which I think are important.

We also tackle sleep because we know comorbid pain and insomnia is a big issue. I’m also passionate about treating sleep. We go through that, but then we move into the flexibility model. We go through diffusion, mindfulness, values, committed action and self as context. We infuse that throughout the whole program but more targeted experiential exercises. Week three is when it’s a little bit more obvious to the patients, even though we’re talking about values and dropping all of these strategies along the way.

It’s more targeted experiential exercises on weeks 3, 4, 5 and 6 of the Back In Action Program. They’ve got the gym component with Corinne, and then the movement piece as well. We’re targeting avoidance from the physical domains, strengthening, stamina, and all that through what Corinne is doing with them in the gym and the movement piece.

Have any of the patients or clients picked up on the fact that maybe in the beginning, you’re talking about some more skills? You mentioned you’re working on cognitive structuring and then later on working on more diffusion, which sometimes people can pick up on if they’re keen and paying attention to the distinctions between the two.

I try to be as transparent as I feel as helpful, to be honest.

There are two different ways you can approach this, basically.

I might not use the word diffusion with a patient. When we get to week 3 and we’re going through the control agenda, and they’re looking to see how all these control strategies that they’ve used, understandably, they get an A-plus on effort from everything that they have tried. It’s impressive how hard people work to get better. It’s sad that a lot of these things don’t work. When we go through that, they’re starting to see all the control-based strategies and then the impact it had short-term on their pain, long-term on their pain and the impact it had on their quality of life. That’s when things start to settle in of, “That doesn’t work.”

They are utterly confused, which is exactly where you want them to be. We turn that confusion into curiosity and pivoting moments like choice, choosing to do something different, but bringing a lot of this into their conscious awareness so that they know what’s happening. There’s a lot of transparency in how things are being delivered. Most of it is experiential. I’m trying to move them out of this, “Cognitively explain it to me.” I can’t do that. Let’s feel it. Let’s notice it. What shifted? What happens?

We also save a lot of that for week 3. After we grounded them, the camaraderie has been built, trust was built, hope has been instilled. We moved them into more experiential pieces. It’s a little rocky for them. Week 3 and 4 are a lot. As Corinne mentioned, learning to sit with that as a provider is incredibly powerful. If you can’t sit with your discomfort, how on earth are you going to ask the person to sit with their discomfort?

There’s a lot packed into this program.

It’s a lot. One of the most amazing things, Corinne, you can certainly speak on this as well, the change you see is amazing. It’s why we do what we do. Corinne and I are clinicians. We carve out some research time because we want to collect our outcomes, but this is on real-world patients. We haven’t screened out anything for it.

As I’m going through this study, it’s a very well-put-together structured program, which is why you had such good results. What I appreciate about it is that there’s a little bit of a trend depending on what lab you’re coming from and how you’re looking at pain while trying to figure out how can we return the person back to function in the shortest amount of time possible with either a brief intervention of maybe a couple of sessions or one session.

It’s important that we explore those things because if we can return someone back to full functioning within a 1 or 2-hour session, then we should all be doing that. However, when I read those studies and I want to relate this back in the study. You mentioned real-world patients. In my lens, real-world patients are not just a homogenous group of people. There are people with many different types of comorbidities, ages, sex and gender, etc. When I look at something like this, I feel like these fit better into what we see in real-life practices and why you mentioned real-world patients.

I’m a master CBT trainer facilitator for research groups, but we’re clinicians. We know that we can do an intervention with someone by doing an evaluation and providing Pain Neuroscience Education. That sometimes can help someone get better. We do individual treatment and that can help. We wanted to create something that was intensive. It is covered by insurance. We’ve been able to get insurance coverage. We could put everything that we believed as providers into this to help the people we work with meet their specific outcomes. Their outcomes are full and meaningful lives. That’s where we were coming at this from. We ended up collecting some outcomes and publishing on it, which is lovely. Basically, Corinne and I wanted to help people make a change to better their lives. That was our value as providers behind doing this.

Corinne, how did you work ACT into the work you were doing in physical therapy?

HPP 248 | Chronic Low Back Pain
Try something out first for yourself. Don’t ask someone to do something that you wouldn’t do.


We had to be creative with getting the concepts to the gym. This is why the structure of the weeks is sometimes helpful for our program. When Heather focuses on a specific topic, if we wanted to bring up the passengers on the bus metaphor, I created these laminated cards. Whenever someone was doing their warmup on the cardio, they could be doing the elliptical or the treadmill or the bike, they would have these cards as soon as they walked into the gym straight from their pain psychology sessions.

I go around and checking in on how things are going. This is a prompt to bring it into, “What passengers are showing up for you today?” All that means is, what are you bringing in with you? It could be a pain, confusion from the pain psychology part, anger or anything that comes with you. Each week that progresses. The next week would be, who is driving the bus? How would I know as the physical therapist where we’re going?

Hopefully, by the last week, the question is, what is this exercise that you’re doing now? It might be a specific exercise like walking on the treadmill. It might be strengthening something that you’ve given. How is that moving you towards your values? It’s combining the values and the committed action piece together. By the end of the program, they can answer all of those questions on their own.

The other piece that we wanted to create was a program that was comprehensive. We wanted patients to try to do it and be able to answer it once we finished the program so they wouldn’t be left with, “Now, I have to go back to my life and I don’t know how to implement these strategies.” That’s another reason why it’s twice a week is so that on those other days they can go home, practice, see what it’s going to look like for them at home, and not just in our controlled environment in the gym.

I like what you said there, Corinne, “How would I know?” Being a PT, how do I know in essence what you’re thinking, feeling and sensing in your body? What’s the experience you’re having right now? I think that’s so key because as PTs, we are good at graded and pain exposure. It’s our bread and butter almost. It’s interesting to me to think before I learned ACT, I didn’t have these skills and I was exposing people to things that were difficult and challenging. Now that you have these similar skills, Corrine, you can use those skills to support that type of exposure that happens naturally in PT. There is an aspect of physical rehabilitation when you’re in pain that sometimes is not comfortable physically or emotionally.

That’s another thing that Heather sets the stage to show well and having these components together. There is a space where patients can express concern about anything that they have in the gym.

Corinne, what some physical therapists out there would like to know is you have these physical therapy skills that you’re working on. You also have some ACT skills that you’re bringing in. How are you integrating those together? Are they laid over exercise, manual therapy and physical activity? Are there times where you’re reinforcing a metaphor or an exercise that Heather is using in psychotherapy? Do you set aside some time for that? How does that look in your practice?

In group time, I bring specific metaphors during different parts of the gym. That’s planned. However, once you learn ACT, it’s hard to turn it off. You’re always evaluating at that moment with the person. What are my biases? What am I struggling with? What do I want for the patient? Grounding yourself, what does the patient want for themselves? What am I doing supporting that? For example, as physical therapists, we often will have patients who come in like, “I can’t do this now. I’m too flared up,” or “I have too much pain that I don’t want to do my exercises,” or “I don’t think that’ll be helpful.”

A very good metaphor would be tugging on the rope in that example. Once they’ve learned the metaphor, you can use that language. If they haven’t learned that, you might need to introduce it, “I appreciate you coming in today. First of all, that’s brave of you.” Acknowledge what they had to do to get here. “How can we help you? You mentioned on day one, your value was you wanted to get back to running or get back to walking with your partner. How can we work towards that value?”

I think for PTs, it’s easiest to get back to values, but then you might need to start with a different type of exercise. Maybe some mindfulness or some diffusion around what they’re coming in with so they can get enough space or meet you where they can take the step forward. My initial response would be that they can’t see how they could get there now. It’s a process to be able to see it. Heather, you can certainly add in.

Corinne does a phenomenal job of incorporating everything that has been taught in the psychological portion with me. She’s able to ask the patients when they are engaging in what may be a physical therapist would see as avoidance to ask, “What’s showing up on your bus? What do you think it would look like? Are you tugging on the rope or are you dropping the rope?” The patients know. We’re using the same language, which is also incredibly powerful. It certainly has been for our program. It’s like all the cooks in the kitchen are working from the same recipe. That does matter because otherwise, someone does it unwittingly. She’s able to ask them. What it does is brings it into conscious awareness for the person who’s experiencing it.

Maybe they sit and do their five minutes of mindfulness meditation or it’s time to do the leaves on a stream and then be able to pivot and make a choice because they get to make that choice. They’re adults. This is their program. They get to make a choice of, “Am I going to choose something different?” They can see the possibilities now. When you’re fused with it, “I can’t do it. It’s not possible,” there’s no room for choice. Corinne is able to bring that into their conscious awareness by asking these questions and supporting them so that they ultimately can make the choice because that’s what we need. We need patients to make a choice to self-manage in a way that brings them closer to their goals, but you can’t make a choice if you don’t realize that there’s a split in the road. It’s always the same road and fear usually drives it.

We should talk about some of the outcomes. Heather, maybe you want to share some of the outcomes that stood out and separated this from what’s been done in the past, as far as the objective outcomes of this study.

I’m going to turn this over to Corinne because she is super excited to talk about the outcomes. As a physical therapist, she likes data.

One of the surprising baseline things that we found when we ran these to look at who in the groups was that their baseline demographics were similar. What that means is they had similar symptoms of mood, interference, anxiety and depression. You mentioned the comorbidities. That was true. Sixty-seven percent of the patients that were enrolled had comorbidities. You’re dealing with not just pain but other factors that might influence the difficulty with activities.

The changes were great that both groups improved on many of our measures. Mood, depression, anxiety, fatigue, social role satisfaction, pain interference, and how much pain interferes with your activities all improved significantly with both groups. We were happy with that. It means both interventions are helping patients. The big difference was that only with the multidisciplinary in the Back In Action Program was mobility. The function they reported they could do and their pain behavior improved, whereas those did not change in the CBT group only.

Something that also stood out to me was in an intensive program, twelve sessions, four hours, twice a week, our attendance rate was very high. Eleven out of twelve sessions were attended. Once the people committed, they were able to commit and come. Sometimes with research, you see dropouts. Even with your own patients, you see they miss a session. It was important to see that they were committed. They made it. There were some differences between the groups.

HPP 248 | Chronic Low Back Pain
The back-in-action program takes all the best things a CBT would have. It infuses the flexibility model throughout the whole program.


The other thing that I wanted to bring up is that we have some unpublished data on their satisfaction with the groups. This stood out to me because they rated the pain psychology, the ACT components of the group versus being in the gym or doing yoga and tai chi. Once they completed the group, the highest ratings were with the ACT components. This is surprising as a PT. They start and their focus is maybe doing the exercise or improving their health, and maybe not so much on the ACT and the pain psychology pieces, but once they finished the program, they can’t stop raving about it and how much it changed their life. That was another thing for me as a PT to see this is very powerful. This is something that lasts and is going to stick with them for the rest of their life.

It’s the beautiful thing about psychological flexibility. As a construct, you can measure it. I’ve seen it measured a year later. There’s a paper out there that talks about it as far as the resiliency factor. It’s important to think about how we can help people be more resilient. For many of these patients, especially with comorbid health conditions, the pain might come back around at some point. Once they’re done with the program, maybe a few years from now, there might be something that happens in life, a stressful event or another injury that requires resiliency of you as a human to be able to say, “How can I face this? How can I overcome this?”

Heather, I want to ask you a question. I read this and what Corinne mentioned is in the Back In Action group, physical function and pain behaviors changed. Where in the CBT group alone, it did not change. I understand that the CBT alone group is like 7 or 8 sessions. It’s sixteen hours of treatment. That’s not small necessarily. Sixteen hours is significant. My question for you and I know this is hard. We’re talking in hypothetical and I’m biased on ACT. This is why I asked this question.

If a psychologist is only trained in traditional CBT and has never trained in ACT or mindfulness, which I know nowadays is hard to find because a lot of these things are starting to overlap. With the activity pacing, scheduled pleasant activities, flare-up plans that are so common in CBT, do you think you would see such powerful changes in the physical function of pain behaviors without the values and exposure component that is so innate in PT/ACT? I know that the correct answer is, “We need to study that,” but let’s be a little more playful and look at the difference between scheduled pleasant activity versus values-based living.

I also have a deep love affair with ACT. You’re biased and I’m biased. Everybody should take that into account when I answer this. There are some nuanced differences that contribute to those outcomes because I also see those outcomes when I teach the ACT group alone without the physical therapy piece. There’s something about ACT that’s different. I’m not saying it’s better.

It goes back to that carrot. People are lining up their behavior in an ACT group for chronic pain. We can categorize everything under behaviors quite honestly. They’re lining up all of their behaviors to be in line with who they want to be. One of the things that we explore is how do you want to show up for yourself now? How do you want to show up for the people in your life? It’s this conscious choice that we are shining a huge spotlight on and then magnifying that bigger and bigger. It would have to be studied. I’m coming at this from a clinical lens, but I can’t help but wonder if it’s that component that’s making the difference in what we’re seeing. Corinne, what are your thoughts on that? You’ve been involved in the CBT groups and the Back In Action.

I agree with you, Heather. When you’re struggling with something difficult and focusing on the struggle versus where you want to go, it’s hard to see and you get lost. That’s the difference that I see with the people that can participate in the groups. They’re still focused on the struggle. They might not want to be, but it’s not changing their shift from where their attention is to where they want to be. That’s what I noticed when people complete both. We’ve seen many people complete both and we’ll see them a year later when something happens and derails them. The people that have finished our program or even an ACT-only program are more resilient. We should try to measure that somehow as well.

Maybe we can pump that to our research team or some research team somewhere in the world who’s reading this, please explore this so we can see if we’re correct or not.

On that topic, do you guys have the next steps for Back In Action?

We do. We are very excited about our next steps. With COVID, it’s opened up a platform that wasn’t available to many people, which is are the virtual visits. We were running a Back In Action Program when COVID hit. Previously, we would have them come in Tuesday and Thursday, twice a week, six weeks for four hours. They would have to drive there, participate and drive home. With all the opportunities for virtual visits, we would like to be able to launch this virtually. It takes a lot more creativity on Corinne’s end. Mine, I could launch tomorrow because I’ve got it all set up. I’ve got the booklet and the manual and all that. The gym and the movement piece are far more complicated.

Part of what we’ve been doing this whole time is we’ve been trying to launch the pieces a little bit separately and see how they work before we integrate it back together and relaunch.

In the exercise part, you have some gentle yoga in here, tai chi and graded aerobic exercise. Some of them you can do online and some of them are a little bit more challenging. Although it does, from a PT perspective, puts you in the place of working on your counseling skills versus working on the actual doing to someone, which is so common in PT.

There is a lot of creativity involved with this. Going back to even the program itself, I can be very transparent and say, “There wasn’t a lot of doing things to people in that program.” The whole goal of the program was to have people learn how to take care of themselves and be resilient with that. We may have instructed people or done things maybe for weeks 1 and 2, and they were taking care of themselves. With us supervising that also provided a safe place for them to learn the skill that maybe they needed to use to take care of themselves.

I also wanted to comment that they’re not just taking care of themselves, they’re taking care of each other in a very supportive way. I would pop into the gym also to go around and touch base with people. I would see people doing single-leg balance. The person’s struggling and they’d be like, “What’s your value around this? That’s right. Your kids matter.” It was incredible to see that camaraderie from the group or when someone has a bad week and they’re struggling. It’s like, “I’ve got that same passenger on my bus, but you had this last week. You still got this. This is just more difficult.” To see participants supporting that language made my heart sing. It’s incredible. We would also need to figure out how to recreate that piece of it, which I also think is incredibly important. It would be harder virtually but I still think we can do it.

HPP 248 | Chronic Low Back Pain
If you can’t sit with your discomfort, you won’t be able to tell anyone to sit with their discomfort.


Maybe a group component might be interesting too.

The gym is a group component. That’s a creativity part that Corinne would have to come up with of how would we set that, but then they also have the psychological component where they could certainly share those things as well. All of these little pieces matter. It’s not just launching it virtually. You have to think of what are the things that you can’t measure like that. It makes a difference. These are real-world treatment options.

I should remind everyone that they can find this study in the June 2021 Journal of Back and Musculoskeletal Rehab. The paper is called Effectiveness of a Multidisciplinary Rehab Program in Real-World Patients with Chronic Back Pain. A Pilot Cohort Data Analysis. I want to thank Corinne and Heather for joining me on the show. Let everyone know how they could follow you and your work, Heather and Corinne. How can we follow you and keep up to date on what you’re doing?

I’m on Twitter. I’m @DPT_Cooley. You can follow me there. I’ll always be posting any new publications or talks about our programs there and also the Stanford website and the hospital website.

I’m @DrHeatherKing on Twitter. Going to the Stanford website or even reaching out by email. If there’s anybody, it’s [email protected].

For everyone who’s reading, if you’re on Twitter, you can tweet to them and thank them for the work that they’ve done in this great study, and for all the input they provided on this show. Please tweet to them. Reach out to me on Instagram. My handle is @DrJoeTatta. Take a screenshot of this episode and tag me, and I’ll make sure to tag you back. I ask you to share this with your friends, family and colleagues on Facebook, Twitter, LinkedIn, Instagram or wherever anyone’s talking about the non-pharmacologic safe and effective ways to treat people with chronic pain. It’s been great being here with you. I’ll see you in the next episode.


Important Links:

About Corinne Cooley, PT, DPT, OCS

HPP 248 | Chronic Low Back PainCorinne Cooley, PT, DPT, OCS is a Physical Therapist at the Stanford Pain Management Center, and clinical residency faculty member in the Stanford Orthopedic Clinical Residency Program in Redwood City, California. She works with pain physicians, pain psychologists and physical therapist to help optimize complex patient case plans and leads the exercise and movement portion of interdisciplinary outpatient programs.

About Heather Poupore-King, PhD

HPP 248 | Chronic Low Back PainHeather Poupore-King, PhD is an Associate Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University. She serves as the Director of Pain Psychology Fellowship and developed and runs the Medical Fellowship Wellness Program. In her clinical roles she specializes in the development of novel interdisciplinary treatments, cognitive and acceptance based behavioral therapies including biofeedback and hypnosis. She is also a master CBT trainer for multiple NIH grants and serves as the Director of Behavioral services for the PCORI-funded Stanford EMPOWER study.

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