Physical Therapists As Primary Spine Care Providers with Dr. Marcia Spoto, PT, DC

Welcome back to the Healing Pain Podcast with Dr. Marcia Spoto, PT DC

We’re going to talk about primary spine care providers. If you follow this blog for quite some time, you know that spine problems and spine disorders are among the most common, most costly and most disabling problems that we experienced in Western society with regard to chronic pain. For the purpose of this blog, when we talk about spine-related disorders. We’re talking about a group of conditions that include back pain, neck pain, all the various types of headaches and migraines, radiculopathy and other types of symptoms that are related directly to the spine. If you want to know an interesting and perhaps shocking statistic, virtually 100% of the population is affected by this group of disorder s at least once in their life, if not twice.

One proposed solution to treating chronic spinal pain in our healthcare system is to train practitioners who can function as primary care providers for the care of the spine itself. There are already physical therapists and chiropractors who function in a primary care role for the spine, although we don’t have enough that are trained adequately. Some may lack the clinical skills and the confidence to function in this primary care provider role. At times, these can be big shoes to fill because a primary spine care provider requires a particular skill set that includes the ability to apply the latest evidence-based procedures, adequately educate and motivate patients and prevent and manage disability. The interesting thing is that much of this has already been tested and it’s proved to improve patient satisfaction, reduced pain, reduced disability and reduce medical costs.

Joining us on this episode to discuss this important topic is Dr. Marcia Spoto, who is a professor at Nazareth College in Rochester, New York. What’s interesting about Marcia that she holds both a degree in physical therapy as well as in chiropractic medicine. She understands the care of the spine from two very important professions that contribute to the health of spine care throughout our nation and perhaps even globally. She has over 35 years of educating and caring for the spine. She also taught classes at the university level with regards to musculoskeletal management, pain management and differential diagnosis. She’s maintained an active private practice called STAR Physical Therapy, which is in Fairport New York. She also serves on the American Physical Therapy Association Orthopedic Practice Committee and is a Co-chair of the New York Physical Therapy Association Public Policy Committee. Dr. Spoto does serve as a consultant for BlueCross BlueShield where she’s a member of the Spine Care Pathway Program.

If you want more information about this episode and if you want more information to read along and follow along with us, I recommend you download a paper that’s free. It’s called The Establishment of a Primary Spine Care Practitioner and its Benefit to the Healthcare Reform System in the United States of America. To download this free resource, all you have to do is text 133 Download to the number 44222. You can go to the website at and you can download it directly from there. This is an evidence-based paper from a reliable medical journal that talks about the establishment of a primary spine care practitioner. It’s great information. If you are a practitioner who works with spinal care too, check this out and also if you’re someone who’s interested to learn more information about care of the spine. Without further ado, let’s begin with Dr. Marcia Spoto.

HPP 133 | Pain Culture

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Physical Therapists As Primary Spine Care Providers with Dr. Marcia Spoto, PT, DC

Marcia, welcome to the show. It’s great to have you here.

Joe, it’s great to be here. I appreciate the opportunity to speak to you and share information with you and your audience.

You’ve got many great things going on both in your practice and some of the work you’re doing as well as the Opioid Alternative Task Force. That both you and I are involved on through the New York Physical Therapy Association. We’ll talk about all of those things. When I first met you and started reading about your history and your education is you’re a physical therapist as well as you also have a degree in chiropractic. You are a Doctor of Chiropractic. Tell us about your journey into physical therapy as well as your journey through the chiropractic world.

I became interested in physical therapy when I was in college. Way back then, it was not so easy to transfer into a physical therapy program. There weren’t that many programs, but I did transfer into a developing program at Daemen College. This was in the late ‘70s. I had received a bachelor’s degree there. The chair of my program at that time, Richard Schweichler. He was a mechanotherapist. It was a certification essentially in manual therapy and he integrated some of that into our curriculum. I became very interested in chiropractic as a profession to learn more about manual therapies. He encouraged me to go on to school and also at that time, physical therapists were not autonomous practitioners, we are now. That was also somewhat of a lure to go on into a graduate program in chiropractic. That’s how things evolved that way.

Did you practice a little bit between your bachelor’s and the chiropractic degree or did you go straight into it?

HPP 133 | Pain Culture
It’s so critical to make that first step to make the right choice on where to go because that can really lay the groundwork for what happens next.


Yes, I had jobs waiting for me everywhere. I worked as a county health practitioner during the summers when I was off. I taught at the chiropractic college. I taught there physical therapy modalities piece as an adjunct faculty. I also was offered a job there in a hospital on weekends overseeing their physical therapy department. I did a little bit of pediatric care as well. I was all over the place. All of those experiences were all contributed to my career and my path.

Once you’re done with your chiropractic degree, did you start your own private practice? Did you wind up in a hospital working in a PT department or did you wind up in a chiropractic clinic? How did that flow?

I left out a little piece and that was my husband and I got married in the summer. We went off to chiropractic college together. We both went through that program together. We opened a practice together in a suburb of Rochester right after we graduated. That’s STAR Physical Therapy, we are still there now. Although initially, we offered both chiropractic and physical therapy services, we found that the demand for physical therapy services was a little bit greater in our practice. It grew that way. Eventually, my husband retired his practice and managed our physical therapy business. I no longer practice at STAR. I’m proud that my oldest daughter is one of our STAR physical therapists. I have another daughter who is managing our practice. It’s been handed down through the generations.

That’s wonderful because I know how much time can go into practice. It’s great that you have a way to see that evolve and live on potentially be on you and into your children. I know you’ve done a lot of work with care pathways. The word care pathway may ring a bell to a lot of practitioners involved in musculoskeletal medicine and some people may not have an exact idea of what that is. Can you describe what a care pathway is for us?

One of the points of confusion is it’s called many different things. There’s no consistent way to define it. Sometimes it’s called a clinical pathway or an integrated care pathway. There’s a lot of different terms. A care pathway is a way to navigate the healthcare system. In a way that makes sense based on what we know from research, clinical guidelines and so forth. It’s a real challenge in a fragmented healthcare system like ours because we offer, on the one hand, so much choice to patients. Patients want choice. That’s all a good thing except that sometimes it creates unnecessary expenses and it takes people down the road. They don’t want to go down. People need a little bit more guidance. Threading that needle is tough, but a care pathway is a way to do that. It’s much easier in an integrated healthcare system especially with community-based types of services. Having a care pathway establishes expectations.

It’s defined in many different ways. I did come up with my own definition that I thought captured the essence of it and that is the preferred route for patients with a specific condition. It’s a condition-specific. If you have heart disease, this is the ideal pathway or if you have diabetes. In this case, what I’m going to be talking about is spine care for some people with spine pain. It is linked to a specific condition. It’s that root that you would take to navigate the multiple decision-making processes involved in the treatment in an otherwise fragmented healthcare system. That’s the definition. It’s this preferred route that you would take that makes the most sense. You do the simple things first and you wait to do the more complex things later.

We can talk about it through the lens of spine pain. It’s the easiest thing and you’ve done a lot of work in that area. Is the care pathway set up for the practitioner as a guide or is it set up for the patient to navigate the healthcare system?

It’s going to involve both. When I talk about the care pathway here in Rochester, you have to involve the providers and you have to involve the consumers. It’s for both, although I can talk also about some supplemental tools that we have particularly for the consumers or for people with spine pain.

Where does someone get stuck? Where do they struggle with regard to the healthcare system, with regards to finding help for the care and management of their back pain, which has helped inform that care pathway?

That sets the background for the problem. We have right now almost too many choices. Scott Haldeman is an MD, he’s a chiropractor, he’s a PhD and he’s written extensively on spine pain. He published an article back in the ‘90s and it was called A Supermarket Approach to Treating Back Pain. He created this analogy of going into a supermarket and having all these aisles that you can go down. You have the pharmaceutical aisle, you have the exercise aisle and you have the surgery aisle, so on and so forth. To the consumer, it’s too much for them to weigh out what are the risks and benefits of each one of these paths that I would take here. That is the crux of it. That’s a problem. There are almost too many choices and we can get information anywhere now.

HPP 133 | Pain Culture
What you say to patients in the end is a lot more important than whatever you do to patients.


People go on the internet. People talk to their friends and family and everybody has got a different story, especially with a condition like back pain because almost everybody has had some experience with back pain so you’re going to hear all kinds of stories. We see a very cumbersome decision-making process out there. The consumers are left with having to use their own experiences and these various inputs. Sometimes it takes them down the road they don’t want to go. What we also find is it’s so critical to make that first step to be the right choice and where to go because that can lay the groundwork for what happens next. With a spine care pathway, a critical piece is the first touch provider if a person is seeking care.

Is there any indication of who those first touch providers should be for spinal care?

For spinal care, the first touch providers as we have seen are the people that are best qualified to serve first touch providers and they have the best educational background are conservative spine care providers. The bulk of that would be fulfilled by either chiropractors or physical therapists. They have a very similar skill set to manage spine pain at a primary care level. Those are deemed the professions that best fulfill this definition of what a primary spine practitioner would look like.

Someone might have been potentially in a tricky situation if they chose a provider that may not be up to date on the latest pain science and pain care. They might potentially go down the pathway of one that does not help them lead a life where they can function better.

Thus the community-wide effort to train and educate all different providers. It’s because people can access the system anywhere so you’ve got to educate the primary care physicians, other specialist providers as well as the chiropractic and physical therapy professionals who will be managing this. I’m sure we’ll talk about it, but Excellus BlueCross BlueShield had developed this training program that I’ve been involved with for several years. They have created a referral source based on those that have completed this training. We can talk more about the training.

I’m interested in training. This is through BlueCross BlueShield. What does the training look like? Are they training practitioners?

Just to step back for a second, the Spine Care Pathway has been a community-wide effort. There’s some consumer side that I’ll talk about, but there’s also the provider side. It’s coordinating this care so you can’t just go to one provider type and educate them. It has to be more universal. The Spine Care Pathway and I’m going to give credit to my colleague Brian Justice, who is a chiropractor but was hired by Excellus BlueCross BlueShield specifically because they had already developed this concept of the spine care pathway. He and some other colleagues. He was hired as a medical director to spearhead and direct the Spine Care Pathway initiative. That has involved not only the education of physical therapy and chiropractic providers.

It has extended to other types of providers, but it’s also going to primary care providers in discussing with them, “What are the benefits of sending a patient that comes to you with back pain to a chiropractor or physical therapist,” one that’s been specifically trained in this pathway. Getting back to the question of the training itself and the education, that has evolved over time. It started with 36 hours of continuing a post-professional continuing education. Currently, we’re at 24 hours of post-professional training for those that are considered pathway trained. I can get in and talk to you a little bit about the curriculum if you want to go down that route right now.

It’s valuable information. People would like to hear about what you’ve developed and what people have benefited from.

The curriculum stems from what we want to see as far as the qualifications of a Primary Spine Practitioner or PSP. PSPs, first and foremost, have to be able to manage most people with spine pain. They can manage most patients. We know that most people with back pain or spine pain are managed very well at the conservative treatment level. That’s the first qualification. In order to do that and fulfill that criteria, you have to be well versed in the differential diagnosis. They have to be able to engage in medical triage or whatever you want to make reference to. It’s the ability to make sure that the person that is in your office belongs there and doesn’t belong someplace else. There are red flag screenings and so forth so that these providers know where to refer patients if they need to be referred out.

HPP 133 | Pain Culture
We don’t want people providing services or any more treatment than is necessary. One of the problems in spine care in the US is we’re overtreating spine pain.


The other qualification is that they have to be very well versed in the biopsychosocial model of healthcare. That’s the piece that I’ve been teaching largely in the training sessions. Part of that means the ability to identify and address psychosocial factors that may be impacting the patient’s condition. That’s another qualification. We also talk about this appreciation for minimalization or a minimalistic approach. We don’t want people providing services or providing any more treatment that is necessary. One of the problems in spine care is we’re overtreating spine pain in the US. That’s another qualification. Finally, it would be the ability to understand the roles and responsibilities of all healthcare providers so that they know when to refer, where to refer appropriately and to follow up on that too. Just like a primary care physician would be managing the health of the patient overall, there should be the central communication. That’s what’s expected of the PSP.

The curriculum more or less reflects that. We get in depth on different types of spinal conditions and what they’re presenting clinical signs and symptoms would be so that the PSPs can engage in the differential diagnosis. We follow more or less a clinical reasoning process in the spine that was originally developed by Don Murphy who is a chiropractor. He practices in Rhode Island. He is a director of a spine care program at a major hospital system in Rhode Island. He also is a clinical assistant professor in the Family Medicine Department at Brown University so he is deeply immersed in this Spine Care Pathway. He has developed what he calls the CRISP protocol, which CRISP is an acronym for Clinical Reasoning in Spine Pain. What was great about it was it was so congruent with what I was teaching already in an entry-level physical therapy program. I had been teaching the musculoskeletal management part of the curriculum.

It’s very consistent with what is being currently taught in many physical therapy educational programs. It’s this process of differential diagnosis of categorizing patients based on clinical signs and symptoms that would best direct the appropriate treatment. Providing those treatments foundationally, the treatments consist of exercise interventions, manual skills, spine manipulation, heavy emphasis on exercise interventions and patient education. We do touch upon cognitive-behavioral interventions. That’s more or less integrated contextually into the care of the patient and that gets into some of the psychosocial issues that surround spine pain. It’s a good overall broad description of what the curriculum is like.

You mentioned it’s 24 hours, is that a curriculum that is delivered in person in a workshop format or is it something that’s online?

We’re looking now at more of a hybrid model. These sessions had been primarily in the upstate New York regions so where Excellus has reaches, Syracuse, Buffalo and Rochester area. We’ve also gone into some integrated healthcare systems a little bit further downstate. I also want to mention here not to confuse things, but there is now also a certification program for PSPs. It started at the University of Pittsburgh. That is also a hybrid program and it’s 120 hours. Clinicians in large part of these are physical therapists and chiropractors that are going through their program and they can receive a certification as a PSP, as a Primary Spine Practitioner. That is starting to get a little bit more attention. Our program is more of a training. It doesn’t result in a credential. It does result in a recognition that these providers have been pathway trained.

As part of that, the framework that you laid out there with regards to the pathway, you mentioned the biopsychosocial model. It’s seated throughout the entire training, but how much time do you dedicate to that topic and to the topic of pain science?

Because I teach that component, I’d say there’s a good three or four hours. We have to talk about the pain science because that’s the avenue through which the psychosocial factors come in so we set that stage. We go in and talk about pain mechanisms, the difference between acute and chronic pain from a neurophysiological standpoint. We get into how these side factors play into the pain experience. It flows from there as to what you can do to address those in care. There is a strong distinction between psychiatric illness and psychological factors involved in the pain experience. That’s something that a conservative practitioner should be able to manage.

They should manage most of the problems that people have with how they view their pain, how they react to their pain and all these things that can negatively impact their pain. I would say it’s about three hours of in-depth where we go through these side factors. We go over how to screen for them. We talk about yellow flag screening and what do you do when a patient displays these behaviors. We emphasize very much this contextualization of cognitive behavioral intervention within the sessions. One of the benefits of the chiropractic and physical therapy profession is we have time with patients. We spend time with patients. We have these opportunities to educate them while we may be doing other things. It seated throughout the entire 24 hours.

Manipulation, which is common to the chiropractic profession. In the PT profession, it’s not necessarily as common although there are PTs that do study and integrate that into their practice. As part of that training, do you train any practitioner who is lacking in that particular skill because there is some supportive research around manipulation for back pain?

It is an area where the two professions diverged in terms of the level of education. The physical therapy profession has increased its standards with regard to specifically thrust types of mobilization techniques. It’s always been the tradition of physical therapy to provide joint mobilization types of interventions. Thrust techniques or high-velocity techniques that fall under the manipulation area have not been as consistently taught in an entry-level physical therapy education. That is changing. With my background, I had always taught thrust technique to our students so that they had enough where they could take that to any level they want. There are now so many different certification programs available to physical therapists if they want to further their skills, but that is not part of the training.

HPP 133 | Pain Culture
One of the best ways to prevent chronic pain is to treat acute pain effectively.


The expectation is that PSPs will possess the skill. In 120 hours at the University of Pittsburgh, they get into actual instruction in manipulation. Because of our limitations, we don’t do that but it is an expectation. As long as we’re talking about it, there’s almost nothing that’s been studied more than manipulation for treating back pain, no other conservative intervention. What we know about it is that it’s not magical. It does help some people. We’ve got a little bit better at identifying the patients that seem to benefit from manipulation. We do discuss and talk about that in the training on how to better identify patients that would be good candidates for this type of therapy. On the one hand, we try to emphasize active approaches to treating pain. Manipulation is passive so we have to be a little careful about how strong we emphasize that, but there’s no question that it helps patients.

After reading so much literature on manipulation over the years, I have come to view it much more simple explanations for why it helps. I try to view it now as yet another tool that can help patients with pain. We’re not putting bones back in place. We’re putting input into the nervous system that can help to inhibit pain. It does generally temporarily, but enough so to get people to be active. The way we emphasize manipulative therapy in the spine care pathway is that it is another tool, but it should never be used exclusively. You should never try to encourage patient dependence on manipulation to feel better, but it’s a means to an end. If we can get the patient to move into an active approach quicker, it’s utility in treating spine problem. Some of that is my own personal opinions, but that is the way we present it.

Your opinion is welcome on the show. Your opinion is well supported by a lot of research. I want to sit on this topic for a moment about manipulation. It could be helpful for people who read this blog that is not practitioners who are maybe someone who’s looking for relief. The message you’re saying is that manipulation has its place. It can help as part of your care. Can you talk to us a little bit more on looking at manipulation as a technique that helps prevent subluxation or puts your joints back in alignment or prevents things from slipping out of place versus looking at manipulation more from a pain science lens?

First of all, there’s no evidence that manipulation is going to change the relationship between spine vertebrae. There’s no evidence to support that there is a change in the relationship. There may be because of the impact of manipulation on decreasing muscle spasm. We’re not moving bonds even though that was the theory around which chiropractic was developed. Chiropractic has come a long way. Although there are still practitioners out there that adhere to that which is a philosophy now, there’s no science there anymore. It also calls into question because that would also require that we had some ability to accurately determine if there are positional changes in the vertebrae. That has also been shut down by science. There’s the reliability of practitioners to be able to make determinations on the position of vertebrae, for example.

What we instead do is we assess joints dynamically to ascertain the relative amount of movement there. All we’ve been able to do here is to determine is its normal mobility, is it a little hyper or is it a little hypo? Even that is questionable because you’d have to ask what’s normal. You have to use a within-patient reference point or reference standard. There is some research to support the ability to determine whether or not there is normal mobility. We can’t refine it to any degree. When you step back and look at the research, the assessment approach does not link at all to the outcomes, whether or not there’s a favorable outcome. When you dig through the evidence, the need for specificity to make sure we’re on the right segment can’t be supported either. We know that if we put a force into the spine, we’re going to have moved up, down and across several segmental regions. This idea that we can specifically target our segment, that can’t be supported either.

What’s interesting is a shift in the literature and looking at the hypoalgesic effect of manipulation. There is something that we can grow. There have been numerous studies that have shown that there is a pain inhibitory effect of manipulation. If you look at it through that lens, the specificity doesn’t seem to matter as much anymore. We don’t have to worry so much about the reliability of our assessment approach. It’s an easier thing for patients also to grasp and to me, it is better from the standpoint of empowering patients. If a patient comes in and they think, “My spine is out of place,” they are going to depend on someone else to put it back in place. Those aren’t the messages we want to give people with spine pain. We want to empower them that they can help themselves. It all aligns much better if we go to more of the neurophysiological effect of manipulative therapy rather than a mechanical effect.

It’s lots of great information there. I know a lot of practitioners appreciate it. People who have pain will start to look at their pain in a different way with regard to manual therapy. Along the lines of helping people with moving forward and the interventions that we use as a physical therapist, can you speak to the power of language in managing spine pain? How language can help us to change our entire culture of pain?

That’s something that’s emphasized a lot in the pathway training is the language piece. We emphasize things not to say as well as things to say. We’re always trying to build our patients self-efficacy through the way we talk to the patients. They never wanted to hear this, but I always said, “What you say to patients, in the end, is a lot more important than whatever you do to patients.” They don’t want to hear this because they want to think that what they are doing is what’s helping the patient. I learned through my years of practice that’s a critical piece how you’re communicating, the messages you’re providing, what you’re doing to their fundamental beliefs about their pain, their spine and so forth. An example of a term that we don’t want to use is a degenerative joint disease. That’s a term that we’re trying to take out of the lexicon. You are probably familiar with a study that was done in 2015. It was a systematic review where they looked at numerous studies that had been performed with patients without back pain.

What they did was imaged all these people that did not have back pain or spine pain. They look for specific pathologies. They presented their findings based on age groupings. What they found was if we look at degenerative disc disease, at the young age of 30, over 50% of people have some evidence of degenerative disc disease. By the time you get to 40, it’s almost 70%. By the time you’re 60, it’s clearly normal to have degenerative disc disease. This creates a completely different perspective for patients. If you step back and think for a second on what a patient thinks when you tell them they have degenerative disc disease, the first thing they heard is disease and the second thing they hear is degenerative. What’s the message there? It’s deteriorating and it’s only going to get worse over time. There’s nothing I can do about it. It’s all the wrong message so we have to be careful.

We encourage the practitioners to make reference to the grey hair of the spine. We don’t look at people with grey hair and say, “They have grey hair disease.” It is part of the aging process. It also doesn’t equate the pain. Just because it’s present and the person is in pain, it does that mean it’s causing the patient’s pain. We tried to get away from that. As a side note, one of the things Excellus has been able to do with this initiative is that for our local radiologists, they are providing the normative data on their imaging reports, which has changed things.

HPP 133 | Pain Culture
You have to look at the outcomes along with costs to make a judgment on value. It should be the best outcomes for the least cost.


Many people come in with their MRI report in their hand and that’s the typed-out version. They’re looking at all these fancy medical terms for things that are normal. There’s an inherent conflict though because you have a patient who saw a very highly skilled physician, who spent a lot of years studying how to image the body and provides this report with the degenerative disc, bulging this, this is lipped, this is protruding and there’s a spur here or an osteophyte. As a conservative pain care practitioner, we’re trying to normalize the process for them. These are competing beliefs that we as PTs and chiropractors now have to spend time and spend the whole chunks of the session or weave throughout our sessions over the course of however many weeks you were with the patient to normalize that process. That can be very challenging.

Once those seeds are planted, it’s difficult to change that. That’s why the first touch provider is so important. If the patient never hears that in the beginning, it’s much easier. The other thing about language that I want to mention too is it’s not just the language we’re using with patients, but the language we’re using with other providers. I want to talk a little bit about this interesting exchange that we had in one of the training sessions. We were in an integrated healthcare system. We had the good fortune in the audience of having a nice provider mix. We had an orthopedic spine surgeon. We had an internal medicine physician there. We had nurse practitioners. We had physician assistants. We had physical therapists and chiropractors. This provided this great opportunity for communication among different providers. The orthopedic spine surgeon raises this issue of this term that a lot of patients use when they come in that they’ve been told by their physical therapist or their chiropractor that they have instability. There’s this term instability. In our profession, we talk about this lumbar instability syndrome and we spend a lot of time talking about that.

There is a difference between true mechanical instability where there’s this loss of integrity of the joint versus what we mean, which is more of clinical instability. It is more of a motor control impairment or in-patient language, it may be a lack of coordination of movement. There’s a big difference between saying you have a problem with your muscle coordination versus you have instability in your spine. If the patient thinking, “I’m unstable,” that provokes fear and these things that negatively feed into the pain experience. On the other side of it are these physicians who don’t know what we’re talking about when we use terms like that. One of the other emphasis in the educational program is creating a common language so that we can also communicate with each other as providers because the successful management of people with spine pain requires coordination among different providers. The language piece is important. The other thing is providing these messages that encourage self-efficacy that encourage the patient taking responsibility for their problems. All of this falls under that language piece so that is important.

We almost need a second language course on how to message what it is we’re doing and how it’s beneficial for people. It’s a big part that’s missing from all of our practice even those of us that have studied pain science. It may be different for the new PTs that are coming out of school because, in some way, they’re more exposed to this. For someone like me who’s been practicing for quite a while, even in my brain, I had these competing little nuggets of information that sometimes I have to double check like, “Am I saying this in a way that is consistent with what some of the newest information out there?”

The students coming out now should know the difference between acute and chronic pain. One of the things that led me down to this interest in pain was that I didn’t know the difference. I thought I had all these tools when I graduated. I’d been in school for eight years for higher education. I was ready to hit the ground running. Some of my early experiences with patients were eye-opening. I was using these tools that are effective for acute pain to tragic chronic pain and they don’t work. If you don’t understand the difference, that’s a problem. On the flip side of that, one of the best ways to prevent chronic pain is to treat acute pain effectively.

You’re involved in the American Physical Therapy Association Orthopedic Practice Committee and you co-chair the New York Physical Therapy Association Public Policy Committee. You’ve been well-rooted in the physical therapy profession for a long time in a lot of different areas. What do you think we need to do in our healthcare system overall to improve pain management beyond what we’ve spoken about?

One of the keys with the pathway is that it’s translating new knowledge into actual practice changes and that’s hard. We have a very fragmented healthcare system. It’s the most confusing healthcare system in the world. We all know that. We have this mix of government-run programs, private programs, we have systems within systems, we have worker’s comp, we have no fault with the VA system. It’s complex and it’s hard to create changes. We also have a competitive system. We’re competing. We’d like to think everybody is there and everybody wants the same thing. Everybody wants a healthy population at the lowest cost. That’s not what we find. People are all for change as long as it doesn’t negatively impact them. We have these cultures that are very rooted and that’s been the biggest challenge of getting any change accomplished. That’s one of the reasons why I am involved in advocacy work.

One of the problems is in our health care system, we now have more non-physician providers than physician providers, yet, where are they at the policymaking level? We need more people at the table. We need more diverse voices because policy change is one way to do it. That’s the top down part. There are some top-down things that we can do. There are bottom-up things that we can do. Another thing before I leave that topic of top-down is that I do think we need to change the incentives in the system. Our system, even though we talk about value-based care, it still has not manifested in the way that we’ve been told it would. We still predominantly feed for service. In our system, the more provider does, the more they get paid. As long as we continue to have that, we’re going to continue to have these problems. We also need to work toward that and that takes people in the trenches of practice working with the policymakers. That’s another piece. I also think it has to be bottom up. There has to be more public education on pain creating expectations.

One of the problems here is a lot of people think that zero pain is the only standard and it’s not realistic. I remember Stephen George at one of our professional meetings made this comment that zero pain is not always the goal. We don’t like to talk about having to cope with pain, but sometimes that’s realistically what we have to do. We have to establish more realistic expectations that we just can’t keep throwing drugs at you until you’re at zero because that may not be an attainable goal. There’s a lot of things that we need to work on from a public education standpoint. I will mention one project that I’m working on with Excellus currently and also through one of our higher education institutions, Rochester Institute of Technology. We’ve been in the process of trying to create a patient decision guide for people with spine pain. We’re trying to build an app that people could use to help them navigate these multiple decisions that they make when they have spine pain so that we can create more guidance for the consumer as well. That’s in the process right now with more educational tools.

That patient decision guide can be so important because people who are reading my blog, they are moving their own thought about pain from that biomedical to that biopsychosocial. They’re getting the message from reading my blog. Once they had your message, they’re like, “I understand there are multiple factors that influence my pain, but where do I begin? Where do I start? Who understands this the way the experts on your show are talking about it?” The care pathway is important with regard to that. A patient decision guide is important with regard to that and then advocacy.

You’re talking about we need more boots on the ground, PTs, chiropractors and people who can be that primary care pain provider to push some of these pathways and education is important. I don’t think enough of us are doing that. Your bio lists a lot of places where you’re obviously donating your time. You’re not being paid to talk on these committees. One committee that you’re on through the New York Physical Therapy Association is called the Opioid Alternative Task Force headed by Brendan Sullivan, who’s a great PT. He’s done a lot of work in the state with regard to payers and getting our services paid for with regards to physical therapy. Can you tell us a little bit about that Opioid Alternative Task Force and some of the things that you’re working on there?

We’ve created a multipronged strategy with your help as well because you’re on that committee as well. We’re very fortunate to have you. It’s a multipronged approach. Some of the things we’ve done were Health and Human Services put out a major document on best practices for pain management. Looking back on things we talked about, there was no physical therapist. There were no chiropractors on that task force to put this document together. The document quite frankly looks like that. One of the things we’ve done as a task force is we’ve been able to provide some input into that document and hopefully will translate into policy changes. There are opportunities right now that CMS has put out for improving access to non-opioid therapies for musculoskeletal problems. We can take advantage of some of those opportunities. We’ve also talked about working through the legislature. There are some very positive bills that had been introduced that would improve access for people with pain to some of these nonpharmacologic options, which is not anything we specifically talked about.

We recognize now that there are better ways to treat pain. If you look at the direction that clinical guidelines are going, they’re going way away from any pharmaceutical as a first option and suggesting that we go to a different route because that is purely passive. We know that more active care where people are involved in their care is better. It’s better for everybody. It’s more effective. It’s less expensive, but we have to be able to allow people to access those services and to reduce some of the barriers. That’s part of it as well. As a task force, we also are putting ourselves out there to help educate different groups. The opioid epidemic has been tragic, but it has highlighted the problems that we have with pain management in our culture. It has evolved out of that culture. It has been a wake-up call for all of us to do things better. I believe very strongly in the work of this task force because it’s going to translate into truly valuable healthcare. You have to look at the outcomes along with costs to make a judgment on value. It should be the best outcomes for the least cost.

Our task force is starting to get the wheels turning, but I see momentum already with some of the things that we’re doing. We gave input to that important document where there was not a PT in that process. That’s going to be important. We’re starting to now look at some data. We’re in New York State task force so we’re starting to look at some data around the state. I have some of these data that I’m working on specifically. I look at Bronx County. The Bronx is here in New York City. I look at Erie County and Upstate New York. There are two counties that have been devastated by the opioid epidemic as far as overdoses and as far as deaths. When we release that information, PTs will have some of that and they can say, “I can be a major player at the table and helping prevent either someone being placed on an opioid that could send them down a bad route or help them overcome if they are addicted and they’re starting to be tapered off that opioid,” which many patients now are starting to be tapered.

I can be a key player of that team to help them taper off in a way that is more successful and the way that can help them cope better. I’m excited to be on that task force. We’re going to have great stuff developing in the future. It’s been great chatting with you on the show and great talk to you about many years of work that you’ve put into pain care and some of the things you’ve developed. I love the pain pathway. We need to develop more pain pathways, not only with regard to spine care but also other parts of the body and other types of diagnoses. Migraine is a big one that we need. I was working with a migraine patient. It’s amazing how much information she has and she doesn’t know what to do with it. Those things are interesting. Tell people how we can learn more information about you and the things that you’re going to be doing in the future.

One of the websites I wanted to share with you was with the PSP training. For any clinicians out there that have an interest in looking at becoming a primary care provider, I can share with you the website of their program that was featured on a local news show. I have my own STAR Physical Therapy website. We tried to put out a lot of patient education materials on our website. I can share that with you. Those are the major avenues.

If you want to reach out to Dr. Spoto, her website is You can reach out to her there. I want to thank Marcia for being with us and sharing that great information on pain care pathways, pain science and how we’re going to move forward in the future. Make sure you share this information out with your friends and family on Facebook, LinkedIn and Twitter. Grab the link and drop it into your favorite Facebook group page where there are PTs and chiropractors who could benefit from this information. I want to see you all next time on the show where we’ll share more and great information about pain care and pain science. Thank you.

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About Dr. Marcia Spoto, PT DC

HPP 133 | Pain CultureDr. Spoto is Professor Emerita at Nazareth College in Rochester, NY. She received a bachelor’s degree in physical therapy from Daemen College in Amherst, New York and a Doctor of Chiropractic degree from Palmer College in Davenport, Iowa. She is certified as an Orthopedic Specialist by the American Board of Physical Therapy Specialties. Dr. Spoto has over 35 years of clinical experience, with a practice focus in spine care. Her teaching responsibilities were in the areas of musculoskeletal management, pain management and differential diagnosis. She is the owner of STAR Physical Therapy in Fairport, NY. She currently serves on the American Physical Therapy Association Orthopaedic Practice Committee, and is co-chair of the New York Physical Therapy Association Public Policy Committee. She is a consultant for Excellus Blue Cross & Blue Shield, and is a member of the faculty of the Excellus BC & BS Spine Care Pathway program. She also serves as a member of the greater Rochester’s Community Principles of Pain Management advisory board.

The Healing Pain Podcast brings together top minds from the world of pain science and related fields to discuss the latest findings and share effective solutions for persistent pain.

If you would like to appear as an expert speaker in an episode of The Healing Pain Podcast contact [email protected].

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