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Psychology of pain improvement

April 28, 2018

CNHP alumnus Won Sung, PhDWon Sung, PhD started his college education as a psychology major at Arcadia University thinking he would find a doctoral program in behavioral neuroscience. He had been doing research on motor behavior and cognitive processes specifically movement control in mice with strokes when his research advisor, a physical therapist, suggested he look into physical therapy (PT). “I had most of the prerequisites completed and there was some common interest based on the research I was doing,” Sung said. What he found appealing about this path was the intersection of his interest in motor control and coordination and the cognitive processes that take place in patients with chronic pain.

He received his PT degree also from Arcadia and worked for ten years before deciding to get his PhD at Drexel. Sung had a different approach than most traditional students looking for a PhD program. He was already working and not worried about finding a program that would help him land a specific job, so he took five years to find a PhD advisor working in the area in which he was interested. As luck would have it, Drexel’s College of Nursing and Health Professions was geographically pleasing to Sung as was the possibility of having Sheri Silfies, PT, PhD, an associate professor in its physical therapy and rehabilitation sciences department, as his faculty advisor. Silfies research on low back pain in relation to neuromuscular control appealed to the behavioral neuroscientist in Sung.

It was during his training and work in physical therapy where he learned about the many methods being used including the McKenzie Method (MDT). Without the use of expensive diagnostic testing, MDT uses patients’ pain responses to their own movement to create a treatment plan. It is a treatment approach that emphasizes patient participation in pain reduction and facilitating movement. To Sung, the rapid change in pain that can occur within a treatment session with appropriate patients suggested that there was something more than just muscle and tissue related. “There had to be something else from a central nervous system, some sort of neuro signaling that had to be happening,” he commented. “As I continued to work with patients with low back pain, and learn more about it, I certainly started to understand that not everybody fits into this one type of treatment plan or approach.” This is where his psychology degree spoke to him. Sung started to see the impact of chronic pain in terms of depression and anxiety and began wondering if cognitive components played a role in patients’ pain levels. Certainly musculoskeletal dysfunction, for which many sufferers find adaptive behavior, plays a part in chronic pain, but Sung contends that there are psychosocial issues that may also contribute. Is there a personality type that's more anxious to begin with where, perhaps, the pain makes them change their behaviors sooner or more readily than somebody else who might not have these anxiety driven behaviors? Does the intensity of pain at the onset force somebody who is very strong and well-adjusted into anxious states? These are the questions Sung wanted to answer. “When you're dealing with more anxiety-driven pain, people have guarding behaviors and tend to walk around tense. It's an anxiety behavior we need to get to first and make sure that the patient understands everything's going to be okay,” he shared. “A lot of people end up in this situation of desperation—‘This is the only thing that's going to work’—and that's when we, as clinicians, have to get down to the psycho-social issues and maybe spend a little bit more time talking to them about the situation and the condition.” Sung suggested that there may only be one or two main issues that manifest in a myriad of symptoms, but in order to get to them, he helps individuals settle in with and accept what’s happening to reduce tension. Then he can focus on their contributing behaviors with appropriate actions.

Sung has been working at Good Shepherd Penn Partners for more than 13 years as the spine team leader where he oversees the orthopedic residency and evaluates and treats patients. His way with the people he sees is gentle and creates hope for those individuals who come to him as a last ditch effort before a surgery which they feel is imminent. He listens intently to a person, wanting to hear their stories, as it helps him understand and gauge where a person is mentally and physically. Sung’s approach is always conservative and favors assigning things a patient would have no trouble doing at home. “There's nothing that is as concrete as, ‘This is the only thing.’ There's typically several alternatives to getting to the desired goal,” he articulated. He must be pragmatic in his thinking—how much time does a person have, how many exercises can they get through in that time and what is the most efficient way to reach the goal. “It's like learning to play an instrument—you need to repeat it over and over and over again to learn that new pattern.” He contended that if you have to do that for ten things, it will take forever and may seem insurmountable. “If you start with one or two different things, it becomes a little bit easier, and then you're able to actually focus on changing that behavior,” he concluded.

Sung also believes it's beneficial for people to know that his first focus is to improve function and hopefully make them a little bit more comfortable. “There is an aspect of making sure people understand that you might not always be pain-free because structures do break down,” he admitted. “But even with these people who have this grim, dire outlook on things, for some reason, when they start accepting that, they actually start to have less pain and start to feel better.”

Where does Sung see the future of physical therapy going? It seems predicated on insurance and technology. Gone are the days of seeing patients in the clinic a few times a week for 60 to 75 minutes. “The insurance companies are forcing us to be more efficient. I don't think that's necessarily a bad thing. I think, across the board, the health system can become more efficient, but I think we're going to have to change how we do things and how we think about the situation and the patient in front of us,” he cautioned. Physical therapists will have to become more proficient in exercise prescription and reassessment because they won’t be seeing a person as frequently over the course of their care. “It's maybe not the best change, but it might drive us certainly to be more efficient and be more critical of ourselves as a profession.” How would a physical therapist be helpful then to a person who they aren’t seeing as often? Sung hypothesized that new technologies might support them. Telemedicine, for instance, would work just to touch base with their patients—to check in with them and see how things are going. Videos of prescribed exercises could be downloadable providing a different way of patients getting their interventions. Then there’s live, online interaction between patient and therapist where they can talk. “I can see how they're doing. Are they smiling? Are they not smiling? Sometimes that's all you really need to do,” Sung explained. It may not be what’s called for an initial evaluation which would have to occur in the clinic. “Maybe there are different stratifications of what's going on. If it's a very simple problem when you really just need to show the therapist how your arm is moving, maybe that is something that's eligible for a live, online environment.” Even if the field embraces technology, he warns that, if it’s not working for clinicians or patients, they will have to advocate for the patient. Regardless, Sung feels that that physical therapy will be facing some challenges in the next few years.

As far as what’s in store for him for the next few years, Sung says he hasn’t figured it out yet. “I guess I’ll still be at Penn, depending on if there are enough things that continue to challenge me and keep me thinking like clinicians who need to be mentored or new projects being undertaken. As long as I’m not bored.”