Welcome back to the Healing Pain Podcast with Julie Fritz, PT, PhD

Among all other conditions, back pain is probably one of the most unnecessarily and excessively medicalized. Typically someone who exhibits symptoms of back pain would seek the help of primary healthcare providers first. This would kickstart a vicious cycle of imaging, surgery, injections, and opioid medications, most of which is likely superfluous. As a result, these patients often achieve low-quality outcomes from their care, and many even develop opioid dependence. But what if there was another way to deal with most types of back pain we are experiencing? In this episode. Dr. Joe Tatta speaks with Julie Fritz, PT, PhD, a University of Utah professor and researcher focused on examining non-pharmacologic treatments for persons with spinal pain. They discuss why we should be concerned about how we approach low back pain in our medical system, what a typical care pathway looks like for most people seeking lower back care, the impact or use of imaging studies for treating and evaluating lower back pain, the impact of cost on healthcare utilization, the role of physical therapists as primary care providers for the treatment of back pain, and how early physical therapy is associated with decreased opioid use. Tune in of all of these and more!

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The Latest On Back Pain And The Role Of Physical Therapy With Julie Fritz, PT, PhD

We’re discussing lower back pain and the role of physical therapy in managing this condition. My expert guest is Dr. Julie Fritz. She is a distinguished professor in the Department of Physical Therapy and the Associate Dean for research in the College of Health at the University of Utah in Salt Lake City. Her research has focused on examining non-pharmacologic treatments for persons with spinal pain, including clinical trials and health services research. Currently, Dr. Fritz leads research projects funded by PCORI, the Department of Defense, and the National Institutes of Health that focus on clinical trials evaluating non-pharmacologic treatments for persons with back pain and evaluating patient-centered outcomes as well as opioid use.

In this episode, we discussed why we should be concerned about how we approach low back pain in our medical system, what a typical care pathway looks like for most people seeking lower back care, the impact or use of imaging studies for treating and evaluating lower back pain, the impact of cost on healthcare utilization, the role of physical therapists as primary care providers for the treatment of back pain, and how early physical therapy is associated with decreased opioid use. Without further ado, let’s begin. Let’s meet Dr. Julie Fritz and learn all about low back pain.

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Julie, thanks for joining me.

Joe, thanks for having me.

I’m excited to talk about all things back pain. When we look at the literature or if you’ve been in clinical practice for some time, you know that back pain is common. It’s almost like a headache. Everyone gets it at least once or maybe more in their lifetime. We don’t approach a headache as a big medical issue. People get headaches and self-manage them. For the most part, they go away. Why should we be concerned about how we treat back pain in our healthcare system?

Your analogy to headache is interesting in that there’s perhaps a degree of social perception that you’re hinting at where people recognize that having a headache or we could think of other ailments, aches, and pains as a normal part of the human experience. However, back pain, as many of us would agree, has been medicalized to a degree in our society, particularly where we don’t have that perception that this is something that’s part of living life as a human being that happens from time to time.

As medical providers, we have created a situation where we have enough concern on the part of people who experience back pain that many, for understandable reasons, believe that seeking out medical care is their best option. Sometimes, that’s going to be the case but other times, it may start things that don’t always end up where that individual thought they would be when they began that journey.

When I think of the treatment of back pain, there is a multitude of options for people. Everything from different types of practitioners to medications to things you can place on your body that make you feel better. The word typical is hard but what does a typical care pathway look like for someone when they enter the healthcare system and say, “I have this low back pain that’s bugging me.”

This is an interesting question because the challenge in answering it begins to highlight the problem that we have in terms of medical care for back pain, which is one person’s experience is one person’s experience to a degree. Although there are reports and data we can point to say most often, when people make a decision to seek healthcare for back pain, they either do it with a primary care provider or a chiropractor. That varies regionally across the country but that’s the reality of what care pathways look like at the start.

What happens from there gets a little more varied but it generally involves some mix of imaging that still occurs for a lot of individuals. Medication management may involve non-steroidal, Tylenol, or other kinds of anti-inflammatory or medications that aren’t advocated for people with uncomplicated back pain like opioids in particular. Those are a very common part of management. A whole bunch of other providers typically become involved. Physical therapists are among them but where physical therapy in particular showing up in this pathway is highly variable and quite unpredictable to patients who are seeking care, which should be a troubling aspect of our healthcare system for all of us who are involved.

The primary pathway sounds like going to primary care providers. The secondary pathway is to chiropractors. Some of that varies probably based on someone’s insurance benefits, where they live, and what their friend said to them. Maybe in the 3rd, 4th, or somewhere, physical therapy is in the mix depending on a lot of different factors. I want to come back to our colleagues in chiropractic later on in the episode but I want to first talk about the management of back pain by a primary care provider.

When we say that, we’re talking about an intern nurse or a family medicine practitioner because there’s a lot of movement in our profession in physical therapy as physical therapists are primary care providers. Let’s talk about the more traditional route first. Let’s take imaging. What happens with imaging when someone with low back pain enters the care pathway with a primary care health provider first?

Data will show that radiographs or X-rays of people’s backs are still very common management on the first visit with the kind of healthcare provider that you’re talking about, a primary care physician, an advanced practice PA nurse, or the people who typically see someone at their entry point into healthcare. This is despite decades of data saying X-rays for uncomplicated back pain are low-value care. Its guidelines consistently advise against it but it still happens in a sizable percentage of cases based on healthcare data that we look at mostly from claims data.

It’s problematic, not strictly speaking when we’re talking about X-rays because of the cost. They’re not terribly expensive for a single X-ray although it aggregates if you think about what the cost is to Medicare or something. That starts to become rather consequential. It has an accelerator effect that we see with patients that we care for as physical therapists or other providers where inevitably, for somebody who’s probably more than about 30 or 40 years old, things show up on that X-ray.

They’re often typical findings based on what happens to the spine as it ages but it tends to accelerate a cascade of services in the pursuit of fixing what’s deemed to be pathological about the spine. That can have a lot of onward effects that aren’t always necessarily what the patient was seeking or in the patient’s best interest when they started that care journey.

There are two things that I want to touch on. The accelerator effect is interesting. You’re saying once someone has an imaging study, they might see something on an X-ray like some degeneration for example. As you mentioned early on, medicalized, means to treat it. Should we not treat things we see in imaging studies?

Oftentimes, we shouldn’t. It comes down to a key question of whether an observed pathology is even a part of a patient’s symptomatic presentation. Even if it is part of a symptomatic presentation, whether there are interventions that directly intervene on the pathology is going to be helpful like a surgical intervention. Even in a pathological finding, we think with reasonable certainty is contributing to a patient’s symptoms. It doesn’t automatically lead to the conclusion that pulling whatever it is out is going to be the best approach for the patient to take over the long-term.

Don’t we need imaging studies early on to make sure that there’s not something dangerous there like cancer, an infection, or a fracture that might be there? What about that?

Sometimes certainly. There are cases where imaging would be considered probably negligent if it wasn’t provided. The patient’s history, presentation, signs, and symptoms can lead a practitioner to make that determination based on the evidence that we have. The cases where that’s the case or where that decision-making makes sense based on the patient’s presentation are a relatively small percentage of the total number of people who present to a practitioner with back pain. The goal of never imaging back pain wouldn’t be a very patient-centered goal but in the proportion of use versus the proportion of patients where the clinical presentation dictates that should be done, there’s quite a differential there.

We’re talking about red flags. For example, Uncle Joe is on his ladder cleaning his gutters. He falls off the ladder and he has back pain that continues for two weeks. It’s a good case to look and see what’s happening inside his spine with an imaging study.

With that history of trauma, almost anybody would say that’s an unnecessary place for imaging to be able to understand what’s going to be in that patient’s best interest.

Sally who works as a cashier in the local grocery store stands on her feet for five hours a day on most days of the week and has no history of falling off a ladder. She probably doesn’t need an image.

There would be more you would want to know about that particular individual but in the absence of any other strange finding or red flag, as you’ve called it, which is far more commonly what we see. It’s unlikely that there would be a rationale for imaging, at least early on in that case.

The accelerator effect that you mentioned earlier leads to things like injection, surgery, and medication use. Let’s talk about the dollar impact of that first. Do you have any sense of what that looks like in hard dollars and cents to us? Healthcare is not free in the United States. We’re all paying for it in some way.

As soon as you start talking about costs, you have to first define that cost in the hospital, the insurance provider, the patient with large deductibles and out-of-pocket costs, and any of these perspectives. The way you quantify the cost differs. However, when you’re talking about the cost to an individual patient, this can run in the thousands of dollars. That’s not even taking into account the lost time at work or other kinds of lost productivity issues. Let alone the quality of life and enjoyment of recreational and social activities that are going to come along with the kinds of interventions that we’re talking about, especially when we start to talk about surgery.

Do you have an idea of a national number of how much back pain cost us as a national average almost?

There was a publication in JAMA by some economists who used some interesting methodologies that I would be ill-equipped to explain in detail other than to say they took a very holistic approach to the cost to society, which is healthcare costs and these issues about the loss in productivity, wages, and opportunity costs. I can’t remember the number. If I try to recall it from memory, I’m going to get it wrong.

I’m going to refrain from the actual number but what struck me about that article was that whatever that number was, it was higher than any other healthcare condition that’s dealt with in the United States. Heart disease, diabetes, asthma, depression, and things that we think of perhaps as more common, more costly, and more impactful. Spine pain was higher than all of them.

There are several reasons for that. One of them is when you take a look at it from that economic perspective unlike let’s say heart disease or diabetes where the prevalence tends to go up as people age. Back pain is most problematic when people are in their prime working years. The impact on work output and such becomes much more noticeable with something like musculoskeletal conditions and back pain.

We’re not talking about thousands of dollars. We’re talking about billions of dollars to the system.

Whatever that number is, it has a B with it.

Opioids are always on our radar. When I think of some of the patients who I’ve seen with low back pain and what they were prescribed in the beginning, it’s very concerning. What does improper low back care look like with regard to its impact on our opioid epidemic?

Back pain has been historically, and I believe this is still the case, the most common diagnosis for which an opioid prescription is given. That’s despite at least a decade or more of beginning to understand the problem we have created in the medical system with respect to opioids. The fact that they’re not that effective for chronic back pain and other chronic musculoskeletal conditions and the awareness of the onward effects on society and the individuals who get these prescriptions has become much more front of mind than it was years ago.

Back pain has been a major contributor to the prescription opioid problems that we continue to deal with in this country. While there’s data that shows the prescribing behavior specific for back pain have declined in some instances, there seems to be some rebound in that, particularly as we have been dealing with the effects of COVID. Data from the early part of the COVID pandemic showed perhaps understandably to a degree shifting away from non-pharmacologic interventions that were not always available back toward more reliance on pharmacologic interventions, and opioids are a part of that.

A lot of your work and research centers around the role of the physical therapist in all of this. A physical therapist’s role in mitigating the use of imaging and the role of physical therapy or the impact that physical therapy could have on our opioid epidemic. Since we’re talking about opioids, let’s go here first. Should we, as physical therapists, play a larger role in treating people with opioid use disorder?

Traditionally, there was this approach, “This is someone with an addiction problem or an opioid use problem. They should see a mental health provider first. They should address that. If they still have a problem, they can come back to care for me.” It’s this idea of, “Screen and refer out. Wash my hands of it.” What’s your take based on the research and where we’re going with that?

It’s an excellent point and an important issue for our profession to think more about what our role is. There’s a need for us who are on the research side of the profession to look at this more carefully. What I’m referring to is as we have talked about physical therapy and opioids, we have often framed it as physical therapy is the non-pharmacologic alternative to initiating opioids when a new presentation of back pain arrives in a provider’s office.

That’s accurate. That’s something that physical therapists should and do advocate for but we haven’t talked as much about our role in individuals who are long-term opioid users or who perhaps have transitioned into some misuse behaviors or addiction. A couple of thoughts come to mind based on what you said. One is we could have a hypothetical conversation about whether we should see those patients or not. The reality is we do it every day. Physical therapists in an outpatient orthopedic practice are seeing these patients. The question is whether we identify them or we see ourselves as having a role as part of their team of care.

Like any other co-occurring medical condition that we frequently see with chronic pain, we think about this as the spectrum that you laid out of individuals who have what I would consider passive or less than ideal pain coping strategies that include opioids and perhaps a long-term opioid user. This is my opinion. There is a role for physical therapy as part of a management team to teach more adaptive coping strategies and help reduce the reliance on opioids for pain management for that individual.

As we begin to move into individuals who have misuse or addiction issues, there are going to be some thresholds there where our role is more one of identifying the issue if it hasn’t been identified and referring to appropriate medical care for individuals who are at these levels of this particular disorder. It’s like we would for an individual with a mood disorder or other kinds of co-occurring medical conditions. I don’t think we have thought about this quite enough as a profession and talked about, “What is our role? How do we do this? Are we training ourselves well enough? Are educational programs dealing with this issue appropriately?”

Maybe it’s 1 or 2 sessions at CSM in San Diego but for such a large conference, that number is quite low considering the magnitude of the problem. Whether you want to or not, you’re facing this in some way as a physical therapist at every level of the system, whether you’re in education, treating patients, or involved in research in some way.

I want to highlight something from your research. I pulled this from a study. Early physical therapy is associated with a decreased risk of advanced imaging, additional physician visits, surgery injections, and opioid medications. On average, it costs people or the system somewhere between $2,700 and $4,793. When people are referred or when physical therapy is used appropriately as first–line care, it prevents the overuse of all the things or the misuse of everything I mentioned and it saves our healthcare system money.

I’m a researcher, so I’m duty-bound to point out the shortcomings of the designs of studies like this and exercise caution about cause-and-effect relationships. You’re reading things that I wrote. These aren’t strictly things that I’ve done. When we look at this claims data, “Does physical therapy show up in the plan of care? Does it show up early or late?” we tend to see these kinds of associations, particularly when we look at physical therapy that appears early in care versus late.

If we look at physical therapy appearing early in care versus not showing up in care, some of those numbers shift a little bit, particularly on the cost side. However, those associations are compelling in claims data that individuals who utilize physical therapy early in care tend to have less of these low-value outcomes than when physical therapy gets pushed out further away. That probably does say something about the patient as well as the care being provided by physical therapists. People who are amenable and want this care are probably also showing up in that data but those of us in the profession could also recognize that the care itself is hopefully contributing to those outcomes.

This will probably relate to other professions like chiropractors but how should we best evaluate an episode of low back pain in the clinic?

Do you mean evaluating the individual patient?

We’re not going to get into reflex testing and things like that but in general, what should our approach be to the evaluation of someone who comes in with an episode of low back pain?

To think of it broadly, there are people you could have on the show who could talk more about the nuances of the physical exam, understanding impairments, and how they contribute to the presentation of low back pain. The bread and butter of physical therapy is the physical assessment of the patient’s spinal condition. What we’re becoming more appreciative of even quite recently is a fuller assessment of what we could label as social determinants of health or understanding a more holistic perspective on the particular patient to understand the context in which they’re dealing with this pain condition and how that may be either facilitating or creating barriers to their recovery.

That’s a skill that physical therapists are learning. We educate our students quite differently about how to interview patients and how to help the patient that is before you to connect other aspects of their life to pain and dealing with pain. Something that’s still relatively emerging in our profession is understanding how to put all that together with what still is the bread and butter of our profession to do the very best service that we can for the patients that we see.

There can be a lot to put together for certain people. What you’re saying is it’s hard to put your finger on one contributing factor to low back pain. It’s multifactorial and multidimensional.

Particularly when we’re talking about individuals who have chronic or current pain. Inevitably, it’s impacting and being impacted by other aspects of that person’s life. That introduces a whole level of complexity. How comfortable we all feel in being able to sort through that is a variable. There are a lot of issues that can come up in there that we have to at least prepare ourselves to know how to manage.

You’ve researched back pain now for a number of decades. What are you currently working on? What should we be thinking about as we’re moving forward and looking at this condition?

I’ll go back first to a topic that you were talking about a moment ago in terms of a physical therapist’s role with individuals who are long-term opioid users into a little bit of misuse. We’re getting a couple of interesting projects of trying to think about how can physical therapists be more intentional and explicit about managing that type of patient with the goal of reducing opioid use. In one of those projects, we’re particularly working with a post-surgical population. We’re looking mostly at how we train physical therapists to feel comfortable with this.

The techniques that we’re using are trying to integrate mindfulness-based techniques, which have been shown to be helpful in people who have substance use disorders and problematic opioid use in terms of increasing attentional awareness on the part of the patient. Also, how we integrate that with the bread and butter of traditional physical therapy approaches to people with back pain or post-surgical pain. They’re important that we don’t lose track of. I’m excited about that work. There’s a lot to be done on helping to understand this. Beginning to even survey physical therapists on their attitudes about this thing is fascinating. I’m finding that very rewarding.

Other projects that I have going on are focused a lot on these care delivery questions that we started out talking about. As a physical therapist, I’ve often focused a lot on what technique the physical therapist is doing. That’s interesting, but to step back and say, “When people go to seek care for back pain, what starts happening? How do we study it? What’s the best pathway?” It become more of interest to me and other researchers because it feels like that’s more where we can have hopefully a positive impact on the patient experience. It’s these pathways of care that people tend to fall into. That has also been exciting work for me.

What you’re saying there is we know that physical therapy has an added benefit but you’re trying to dissect what is it about physical therapy. Physical therapy is a profession. It’s not necessarily intervention. You’re trying to figure out, “What is it? Is it exercise? Is it manual therapy? Is it more the psychosocial part of things?” Do you try and dissect that piece out of it?

It’s some of that but it’s also some of like, “As long as we put a few parameters around what physical therapy is and keep it broadly in the evidence-based space, I’m going to shift my focus from not so much worrying about what exactly is that physical therapist doing to, who are they doing it to, when are they doing it, what has happened before, and what’s likely to happen afterward.” It’s a little more of a 30,000-foot view of physical therapy versus, “Did you use this technique or that technique?” There are important research questions across that whole spectrum but I’ve become more interested in, “Where do we insert the physical therapy relative to other things? What does that look like? What outcomes does that get?”

Julie, thanks for joining me. Your research on low back pain, especially how it has informed what we do as physical therapists is important. We will look out for new research and new studies that you’re publishing. Let people know how they can learn more about you and follow your work.

I’m both old and a pretty traditional scientist. Probably the best place you could learn more about my work is in peer-reviewed literature where we publish these things. I’m not much of a social media person but I do have a Twitter account @JFritzPT. I like to engage in interesting research and ideas in the field in that forum as well. I’m always interested in what other ideas people have around these kinds of issues that we have been talking about.

As I mentioned in the introduction, you can find Julie at the University of Utah, which is the center of her work around low back pain. At the end of every episode, I ask you to share this with your friends and colleagues on Facebook, LinkedIn, Twitter, or wherever anyone is talking about conservative care of low back pain and physical therapy’s role in the treatment of low back pain. I want to thank Julie for joining us. Make sure you subscribe to the show so you can receive the latest episode. I’ll see you.

 Important Links

• Dr. Julie Fritz
• @JFritzPT – Twitter

About Julie Fritz

Dr. Julie Fritz is a Distinguished Professor in the Department of Physical Therapy and Athletic Training, and the Associate Dean for Research in the College of Health at the University of Utah in Salt Lake City. She received her PT degree from the university of Indianapolis and PhD in Rehabilitation Science from the University of Pittsburgh. Her research has focused on examining nonpharmacologic treatments for persons with spinal pain, including clinical trials and health services research. Currently, Dr. Fritz leads research projects funded by PCORI, Department of Defense and the National Institutes of Health that focus on clinical trials evaluating nonpharmacologic treatments for persons with back pain and evaluating patient-centered outcomes as well as opioid use.