I'm a staff spine and musculoskeletal physiatrist at UCHealth in Colorado Springs, and today's session is meant to be a comprehensive update on exercise-based rehabilitation for the treatment of spinal pain, starting with the basic neuroscience and extending into implementation. As physiatrists, we are all well-versed in the general health, mood, quality of life, and mortality benefits of regular exercise. We also use it as a therapeutic tool for a variety of musculoskeletal conditions. My goal with my talk for today is to provide you with an overview of the proposed mechanisms of exercise for patients with spinal pain. Why use exercise for pain? The spoiler alert is that there isn't one specific mechanism through which exercise works. There are likely many mechanisms contributing to the derived effects, including mechanisms that involve your musculoskeletal, neuroimmunologic, and psychological systems. When we look at research, exercise has been shown to improve a combination of physical and functional impairments, maladaptive beliefs and behaviors, pain intensity, and, of course, disability overall. Spinal pain is associated with an overall decrease in voluntary movement and activity that is usually due to a combination of pain severity, pain avoidance behaviors, and fear of injury and damage. Unfortunately, those beliefs and behaviors may be inadvertently reinforced by healthcare providers to the detriment of our patients. In the acute period, folks should be encouraged to stay as active as they can tolerate because Inability leads to small but very much measurable loss of muscle mass per day, somewhere in the order of a half a percent per day or more for some of our older patients. Not surprisingly, back pain is associated with significant changes in physical performance measures, including lifting, strength, range of motion, as well as changes in the neurologic systems when it comes to movement and recruitment patterns and also shortening of muscles, shortening of connective tissues, and loss of certain muscle types, specifically type 2 muscle fibers. Fortunately, most of these changes are reversible, and this slide, although a little bit busy, is a list of some references for you guys to review on your own. What we find is that a variety of therapeutic exercise programs result in very meaningful improvements in things like range of motion, flexibility, strength, lifting capacity, endurance. There's also evidence for the reversal of changes associated with muscle atrophy from inability for patients with both subacute and chronic spinal pain. Generally speaking, muscles are thought of as having somewhat limited regenerative properties, but exercise is one of the few known interventions for promoting myogenesis in skeletal muscles, and this is accomplished via mechanical stimulation of those muscles. Some work has shown that exercise provokes muscle precursor cell activation, proliferation, and differentiation through a variety of signaling pathways, most interestingly, microRNA and nuclear factor signaling. However, addressing physical impairments alone does not seem to be enough to improve pain or disability in a lot of the patients, especially patients with chronic symptoms. One of my mentors, Dr. Arango and his colleagues, published a study in 1992 that looked at the association between improvements in physical function and performance measures and improvements in pain following an intensive seven-week functional rehabilitation program for a group of patients with chronic low back pain. At the completion of the treatment, all the patients showed measurable and clinically significant improvements across the eight tests that they used to measure functional performance. However, these improvements were not associated with consistent changes in their pain measures, and that leaves us with something important, which is that subjects, especially subjects with chronic spinal pain, can increase their physical performance within their same pain experience without necessarily increasing it or necessarily decreasing it. It makes one wonder why, especially in the setting of improved function, do some pain experiences and disability levels improve following exercise and why some others don't. The best evidence we have right now suggests that maladaptive fears, attitudes, and beliefs play a significant role in pain-related disability. For example, patients with low recovery expectations three weeks into an episode of nonspecific low back pain are at risk for poor functional outcomes up to six months later. A systematic review that was published in 2010 in JAMA showed that the most helpful baseline predictors for persistent disabling back pain was maladaptive pain coping behaviors with a likelihood of ratio of 2.5. Others that were on that list included functional impairment, low general health status, and the presence of psychiatric comorbidities. I doubt you will be surprised to find out that, given this subject matter of our talk, that successful exercise experiences have been shown to improve certain measures of maladaptive behavior, specifically things like kinesiophobia, which is a fear of movement, and it's a common maladaptive behavior that we see in the spine patient population. Specifically, exercises performed in a quota-based manner or a non-pain-contingent manner may function as a tool to decrease fear and alter people's attitudes and beliefs about themselves, about their pain, and about their functions. So in simple terms, exercise can be the means by which these patients learn to confront and overcome their fears. This brings us to the final question and the crux of some of this portion of the talk. How does exercise actually help with pain itself? To answer this, I need to take you on a slight detour to talk about what pain itself is. The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience. It's something that is generated by our neuroimmunologic system. It's rooted in our prior life experiences, and it serves to elicit a protective response on a neurobiological, cognitive, and behavioral level. What we know about pain is that context matters a lot because the body needs to know, often before you are even consciously aware of it, that something is a credible threat and warrants a protective response. In order to do that, your pain system is something that has to be rigid enough to encode prior experiences but also flexible enough to respond to your current environment and also be able to adapt to changes. The pain experience itself usually starts with activation of specialized high-threshold sensory neurons called nociceptors, which can be found throughout your body, including structures such as your skin, muscle tendons, ligaments, your annulus fibrosus, your peripheral nerves, even the dorsal reganglion. Nociceptors warn of potential damage or threat in response to a local noxious stimuli and result in, often, a reflex withdrawal from the stimulus, as well as activation of downstream cascades that lead to behavioral changes and other such responses. Inherent to their function, their threshold stimulus, although considered high compared to things like light touch, can still be activated at levels below what is required to actually damage tissue, as anybody that's been poked with a pin during a neuro exam knows. Once this system is activated, this information is relayed and processed through your central nervous system, and it may be changed, amplified, diminished, or ignored. For stimuli that are large enough to produce local tissue injury, a whole series of complex neurological changes occurs both in your peripheral and in your central nervous system. The post-injury inflammatory milieu locally includes things like neuropeptides, neurotransmitters, nitric oxide, growth factors, and other inflammatory mediators that promote up-regulation of local receptors on the nerve terminals, including chemoreceptors, mechanoreceptors, specific nociceptor sodium channels. This results in increased sensitivity to those stimuli clinically. Plus, this process also has a tendency to send signals to the cell body of the primary afferent, usually through neuropeptides and growth factor release, which in turn decides to make more receptors and ship them back out along the axon in all the directions where the axons go from that cell body. These local changes allow for the same magnitude of stimulus to elicit a much larger action potential through both more numerous receptors that are being sent to you by the cell body and more sensitive receptors who have had their threshold lowered by these chemical changes. And this is true not just for the nociceptors, but also for all the neurons that are in that area. This is called peripheral sensitization. And although it sounds terrible, it's actually functionally a useful thing. Lots of people have tried to research some of the evolutionary advantages of the system. And this study, or the series of studies actually, by this group looked at squid. And what they did is they injured them, or they had a group where they injured them and allowed them to have a normal peripheral sensitization response, a group where they injured them and they blocked it through chemicals in a normal group where they were uninjured. And then they released them into a tank with a predator. What they found is that the squid that had their intact peripheral sensitization after an injury were able to detect the presence of the predator in the water much earlier than their two other counterparts and begin making invasive maneuvers earlier than the uninjured squid. And some of them survived, or were more likely to survive. In humans, this is likely a similar purpose, but it's a lot harder to study. So what we can talk about is clinical manifestations of peripheral sensitization, which usually presents itself as a combination of allodynia, which is pain to non-painful stimuli, hyperalgesia, which is increased pain to painful stimuli, and mechanosensitivity, which can also be seen with other forms of sensitization, including central sensitization. The interesting clinical part that can help you differentiate between the two processes when you see them in clinic is that for peripheral sensitization specifically, patients typically exhibit an intolerance to heat, where local application tends to intensify their symptoms. This is not present in central sensitization. If the noxious stimulus continues, or is of large enough caliber, the process of central sensitization occurs. But central sensitization is, in easy terms, a multistage process that results from excessive use or excessive communication through the synapses involved. In the acute stages, it results in activity-dependent synaptic plasticity, where the NMDA and NT1 receptors in the second order neurons start changing their configuration, they lose their magnesium plug, and function as just another ion channel in response to the released neuropeptides from the axon terminal. This is actually a normal part of physiology, and a normal part of the response to pain. As long as you have ongoing tissue damage, that tends to maintain this type of synaptic plasticity. But all these changes will disappear the moment you stop the stimulus. Especially for disease states, there is also a late phase of central sensitization. In that, you get threshold changes in the second order neurons, which sets off a feedback loop where the second order neurons will release further peptides and inflammatory mediators. They then stimulate the primary afferent. This process is called homosynaptic potentiation, and it creates this local feedback loop that changes to the primary afferent, then result in release of more mediators, which then stimulate the second order neurons, and it goes on like that. Over time, these changes also alter the transcription in the dorsal ganglion, they alter the transmission of inhibitory signals, they result in loss of the inhibitory interneurons themselves eventually, astroglia and other immune cells become activated, they start releasing neurotrophins, which also change the chemical milieu. This whole thing results in co-opting of non-pain pathways for nociception, upregulation of non-pain pathways via heterosynaptic potentiation, which is the increased excitability of non-nociceptive synapses and the nociceptor neurons, and it just turns into a mess. When folks get to this stage, that's when you see the chronic pain picture. To make things even more complicated, the second order neurons from the dorsal corn start relaying that information to the brain. It first goes into the supraspinal areas of the brain, where changes in things like serotonin signaling and concentrations, again, inflammatory cytokines, and even mu-opioid receptor expression shifts the balance of modulation into facilitation of ongoing pain. This process is also influenced by higher-order brain functions, including emotions and cognitions, which can affect this process of descending modulation, thereby enhancing the pain experience for the patient. These are thought to exert their effects through the corticolimbic system, which is also very intimately connected with the autonomic nervous system, and dysfunction in any of those can cause persistent pain states. Most of this information we've learned from studying animal models in a lab, especially when it comes to the function of the pain system in general, but specifically as it relates to exercise, so a shout-out to our little furry colleagues who are helping us learn the wonders of the neurologic system and wishing them some ethical and humane treatment. In animal studies, exercise has been shown to reverse some of the injury-induced neurologic changes in the sensory ganglia, the spinal cord, the brain, and the periphery, and also change behavioral markers of pain in the exercising animals. The effects of exercise on pain appear to be generalized in the animals that we've studied, meaning that it's not specific to the type of exercise that's performed. Even exercises that exclude the injured body part still reduce evidence of pain in the affected region, and similar evidence is also accumulating for humans, which Dr. Farrell is going to talk to you guys about in just a little bit. As far as the changes to the peripheral nervous system, in human studies we've found that there are elevated pro-inflammatory cytokines and evidence of oxidative stress in patients who are experiencing low back pain, and exercise has been shown to attenuate these inflammatory processes and help restore the normal activation threshold for the local nerves, thus reversing the changes associated with the peripheral sensitization. This includes shifting of certain macrophage phenotypes, release of certain inflammatory mediators, and decreased release of others. In rat models, which is again where most of this work is being done, they tend to use sciatic nerve injury as their study condition. There is a variety of studies that have looked at this that involve giving a rat a sciatic nerve injury and then putting them in scenarios including a swimming protocol that results in progressive intensity increase in the exercise, treadmill running, force versus voluntary exercise, low versus high intensity exercise, et cetera, and they monitor the neurobiologic changes in those animals after their intervention. What they've been able to show is that exercise, all of those exercises, reverse allodynia, reverse hypoalgesia, change their pain behaviors, as well as change some of the signaling and connections in the nervous system. Some of these signaling changes are likely what is responsible for the phenomenon known as exercise-induced hypoalgesia that we see both in animals and in humans. This leads me to the final, final question, which is how does exercise induce all these neurologic changes? And the short answer to that is that we honestly don't really know completely. It's still being researched. A study by McCord and some of his colleagues suggests that inputs from exercise muscles via muscle afferent fibers may affect the nociceptive synapses. Other studies show that exercise muscles release a variety of chemical signals, myokines, insulin-like growth factor, interleukins, BDNF, cathepsin B, change the microRNA profile that's circulating, which is likely affecting some of the signaling and communication throughout the nervous system. And finally, of some interest, is that the serine and threonine kinase called mTOR has been shown to be sensitive to exercise signals such as the metabolic factors released, BDGF, and insulin-like growth factor, and may be a common pathway for the multitude of health effects we see from exercise, including the effects on pain. It is heavily involved in brain cell metabolism, growth, proliferation, aging, survival, and some of the research on that front is very exciting and interesting. But ultimately, these are some of the references for that. Ultimately, we still have a lot to uncover and understand when it comes to both how exercise works and some of the changes involved. Now, my last thought, and I would feel like this talk wasn't complete if I don't mention it, is that for some people, exercise may actually result in increases in their pain, both for healthy adults and patients with both acute, subacute, and chronic pain conditions. Some of the processes behind how this works is thought to be related to stimulation of sensitized tissues because their threshold is down. Others think that delayed onset muscle soreness contributes to the pain experience. This combination of increased symptoms following exercise can definitely lead to pretty significant avoidance behaviors if not preemptively addressed. My best advice or recommendation for this is that patients really do seem to benefit from counseling regarding the potential temporary exacerbation of their symptoms when they're beginning a new exercise program, and this has also been substantiated in the literature. Unfortunately, in the case of spinal disorders that don't seem to have any structural instability, it is safe to push through that discomfort, and it's a message that I give to my patients a lot. So that concludes my portion of the talk. I'd like to introduce our next speaker, who is Dr. Mike Farrell, and he will be talking to you about some of the human studies on exercise and the different varieties of exercise and how they affect, or maybe not. Thank you. Thank you so much, Maria. I, you know, I'm really thankful. First of all, for your great review of kind of all of the, a lot of the bench work and things that have been doing an exercise that might give a little bit more context to my portion of the talk. I'm happy to be a part of this and, and, you know, mostly because it is probably one of the most difficult questions that I'm asked by my patients, and that's kind of to answer with any degree of confidence. Is there one specific type of exercise that for non specific type back pain that has been shown to be more beneficial than others. And if there is an answer to that question, then which ones are they. And so that's kind of what I'm going to try to cover in this, in this next section. First of all, we're going to provide just a brief, you know, basic description of what non specific back pain is, and then discuss about all the different types of exercise prescribed in the evidence that surrounds them. And then also talk a little bit about the safety and adverse effects that can result from exercise that might be a good thing to talk to our patients about. So first, just to give you a little definition of what non specific back pain is, it's really just simply pain that cannot be attributed to a readily identifiable underlying condition, or more simply put, ongoing back pain, in spite of a largely negative diagnostic workup. And this is likely a familiar territory for many of us because many of the patients that are referred to us as physiatrists from primary care fall into this category. And we see just based off of the research that about 85% of the back pain seen by primary care doctors fall into this category. And many of these patients have been prescribed or at least have tried some form of exercise as management, which then brings us really to our primary point of this talk and the question, is all exercise created equal? And from a review of the literature, what we have seen is that really there is no single exercise technique that has been found to have superiority over others. And this may be due, as Maria was just mentioning, that there's really all exercises having some generalizable effects. We know that it attenuates some of the pro-inflammatory cytokines. It actually impacts tissue nutrient delivery and also metabolism. And then there are also the psychological benefits that people have. About this, this can cause different reactions from different people. Personally, I found this incredibly freeing to know that with regular participation in exercise and buy-in from our patients, the choice of which specific exercises that they perform may ultimately have very little impact on their outcomes. And so what we're going to do is actually take a look at the literature to see if that supports that statement. And so let's quickly kind of take a look and go through some different forms of exercise that are prescribed for back pain and see whether or not this holds true. A common question asked by patients in clinic is the specific type or intensity of exercise that they should be performing. And I'm sure we've all had patients who feel that increased effort or putting their tissues under a greater load or strain will lead to either more pain or the opposite and give them more relief. And as a result, the question of whether aerobic exercise or resistance exercise programs are superior for nonspecific low back pain comes up and is common. But when we actually look at the literature, this 2015 meta-analysis concluded that any form of aerobic exercise, which includes things like bicycling, swimming, treadmill walking, or even ellipticals have been shown to be as effective to decreasing symptoms of low back pain when compared to resistance exercise. And so similar to some of the animal models that we were seeing that were presented by Maria, the type of exercise isn't really making that much of a difference when we're comparing aerobic versus resistance. And in addition, there was a 2018 meta-analysis that found that when we do compare aerobic exercise and resistance exercise, there is no specific advantage when you look at it in terms of pain relief. Next up, we're going to take a look at our spine stabilization or motor control exercises. The goal of these exercises is to activate, control, and coordinate the deep muscles. And these exercises have, you know, this type of exercise has gained a ton of support. And we see it a lot on social media platforms and even in clinics because it makes sense, you know, biomechanically when you think about it. However, when we actually compare that to other forms of exercise, a 2016 systematic review concluded that any type of motor control exercise was not necessarily superior to other forms of exercise for the management of chronic low back pain. And a more recent 2018 meta-analysis that looked at movement control exercise essentially found that it was more effective than other interventions for improving short and long-term disability, but it only reduced pain in the short term. So, you know, we have to be mindful of, you know, these types of exercises and recommending them as, you know, we can see some negative consequences that can come from instilling a belief in our patient that unstabilized movements can lead to negative consequences. All right. Our next exercise that we're going to take a look at or group of exercise is directional preference. And many of us will know directional preference techniques. They rely upon this notion that certain movements in a specific direction is the primary pain generator and that when directional movements cause pain to increase or radiate those movements, those movements should be avoided in favor of movement that lessens or kind of centralizes the pain. And so this includes techniques like McKenzie and some others that kind of look at this directional preference. These techniques typically involve assessment by a physical therapist or any other trained provider, and they do emphasize instruction in self-care. But when we look at the research in randomized trials of low back pain patients, either who exhibited a directional preference, who exhibited a directional preference, exercises matching that directional preference were more clinically effective than exercises in the opposite direction in small studies. But when we look at chronic low back pain, I'm having a hard time seeing this. So when we look at chronic low back pain, directional preference is better than generic advice to just stay active, but it's not actually better when compared to other forms of exercise. Our next kind of exercise is graded resistance. And so this refers to exercise programs that begin with a lower intensity and then progress to higher intensity with each session. In a systematic review that compared graded therapies, progressive resistance training and progressive aerobic training in patients with chronic low back pain, both therapies were superior to usual care for pain reduction, but neither was superior to the other. And in addition, we have a couple trials on graded exercise that show that it was no more effective than physical therapy based or standard physical therapy based exercise and pain reduction when they followed up at three or six months. Another kind of trendy term that we see kind of peppered throughout the literature is multidisciplinary rehab. This is really just defined as a combination of both an exercise and a behavioral component. And typically that's provided by different health care professionals. The challenges of really kind of researching this type of exercise is that it's difficult to generalize as the intensity and content of any of every interdisciplinary therapy can vary widely. And that we see that rehabilitation centers may not actually be widely available in many communities. So it's hard to really kind of broadly apply this to the general public. As the regimens can take greater than 20 hours per week. So it's really kind of a more specific type of therapy approach. And when we look at this in a systematic review of 41 trials, multidisciplinary rehabilitation was associated with slightly larger improvements in pain and function than usual care or non-multidisciplinary physical treatments. And the observed differences were about 0.5 points on a 0 to 10 point pain scale and about 1.5 points on the Roland Morris functional scale. In addition, there was an increased likelihood for return to work compared to non-multidisciplinary physical treatments. But again, there are some limitations to doing, first of all, to access to multidisciplinary rehabilitation. And then also, you know, kind of comparing this as in a broad sense, because the different treatment programs can vary so much. So, you know, really, I think the thing that this all comes down to when we're looking at all of this and we see that there's so much conflicting evidence is what is the best formula for success? And that's really just that the best exercise is going to be what do our patients enjoy doing and what are they going to actually perform regularly? And if we can combine those two things for them, I think we're going to find that that's probably the best exercise program and that there's not really specific exercise programs that are superior to the others in the long term for nonspecific back pain. So that doesn't necessarily mean that it's not our jobs to understand the availability of choices that are out there, that's definitely still important. And mostly because on the front lines of spine care, physiatrists are going to play a very crucial role in counseling patients and managing their expectations prior to starting exercise for low back pain. So what we know is that it is very important to use motivational interviewing to improve patient compliance with therapy. And we simultaneously need to be assessing their unique fitness levels in order to find exercise programs that will not only be well tolerated, but will also match their level of ability. And in addition, shifting our discussions away from which specific exercises are going to fix the patient's problem will allow for more time in our patient encounters to really discuss other equally important obstacles that patients will encounter and that Maria had actually alluded to. And this includes addressing patient fears about exercise and the resulting kinesiophobia that will result from that. It will also allow us to discuss kind of the normal spine aging and why imaging findings may be less concerning than people may think coming in. Or maybe identifying specific patients who may actually benefit from supervised PT versus others. And this is going to be patients who are either inexperienced with exercise, they have significant functional impairments, or that they're very deconditioned. The other thing that this is going to do is open us up and give us a little bit of free time so that we can talk about the risk of injuries. We know that any kind of exercise program is going to create risk of injuries to other joints in the body. So hips, knees, ankles. We can also talk about anyone who has any underlying cardiac problems that could put them at risk for an arrhythmia or sudden cardiac death. And then also discuss some of those things that Maria was alluding to with the initial pain exacerbation that comes from maybe that central sensitization and kind of educate them on this so that they can kind of anticipate that's coming and when that does be able to overcome that. So in summary, no single exercise technique has been shown to be superior to others. So when we take a look at the literature, we concluded that the best exercise is really going to be whatever the patient enjoys and is going to perform regularly. And also that a clinical paradigm shift may allow us to discuss more patient preferences, spend more time dispelling fears, and also providing our patients with motivation to be able to complete their exercise. And that also adverse effects should be discussed to both foster expectations and to help patients overcome some of the difficulties that result as performing exercise is going to cause some unintended consequences. And that's really all I have. So I'm going to call up our next speaker in our presentation who really needs no introduction, but we're really happy to have him here to discuss some considerations for value-based spine care. So Dr. Standard, if you would take it away. Thanks, Dr. Bell, I appreciate that. Yeah, my talk is to build a bit on what you've heard and getting the idea of value and value-based care, but how does exercise fit into paradigms of health care delivery and how that may impact us in our practice and the sort of future health care delivery structure we're all going to find ourselves in. So if you think about value and value-based care and how you might approach treatment or exercise, there are a few things we're going to talk about. Why do we worry about value in the first place? Like, why is this part of our conversation today? And does that really impact me in some way? How might that impact what I do in practice? And you get down to your treatment choices, why exercise and how does that fit into some sort of value-based paradigm? I'm going to start touching on implementation, which Dr. Eubanks will carry a lot further in terms of how you think about this. So I don't have any financial disclosures. So value really means cost over benefit, right? That's what the phrase means, or the math equation. And essentially, the people paying for the service want good value for what they pay. And you can view receiving the service as the patient receiving the service and what they pay, or you could think about it that essentially by being paid by a health insurer, you are working for them, essentially, and you're delivering a service to their customer, and they want good value for what it is they are paying. And that's a central idea of a lot of economic issues. So in the U.S., we have a traditionally fee-for-service structure where basically you submit a bill and you get paid. And that's a complicated system for how that's all determined, but it largely is determined by intensity and volume, right? It's not really determined by whether or not the treatment helps. That has nothing to do with whether or not you get paid or how much you get paid. In this, people have long argued that we have very perverse incentives, right? That we are really incentivized as clinicians to focus on volume and intensity much more than we are over outcome, because frankly, in a pure fee-for-service system, the outcome just is irrelevant in terms of your payment. In the long run, this becomes financially unsustainable. So to look at what's happened in the U.S., this is per capita healthcare expenditures from 1970 to 2018. The orange line on top is really 2018 dollars, and it has just gone up dramatically. We're now over $10,000 per patient per capita or per patient per year. And it's roughly twice the cost of any other westernized country that we spend. And if you look at cumulative growth in spending by insurer, by insurance per enrollee, the orange line in the middle is Medicare. And we often hear about what Medicare is doing and how they may change payment and how they may impact us on what incentives or disincentives are put on clinicians. We don't talk quite as much about the private payers, but if you look at that blue line, that is not sustainable, right? The private payers are really interested in altering the trajectory of that curve. And if you follow the lines out, we are running into trouble way sooner than we thought. And as of September of this year, the Congressional Budget Office released a new estimate on the viability of the Medicare Hospital Insurance Trust Fund, which funds Medicare Part A. And they now predict it will be insolvent by 2024. So that's about three years from now. This is a lot sooner than it was even just a couple of years ago. And so Medicare essentially is running out of money. And so in the system we have, it's not going to work. We need a better solution for this if we're going to keep delivering health care to our population. So what is that? Why does that affect us? How does that affect us if they start changing the way they pay or what we do or how might we do this, right? What you see is that we really have an increased need to focus on value and get away from fee-for-service. That's in the best interest of everybody paying the bills, essentially. And the things that really seem to be holding more promise as being more effective in doing this are various shared savings models and population health models. Shared savings models are things like accountable care organizations or arrangements with payers where clinicians are given a financial incentive to address utilization of various aspects of care or even meet population sort of health metrics. In population health models, you're really paid more, you know, sort of fixed fee based on a condition, perhaps a bundle like a total hip replacement or even capitation for the global care of a patient over the course of a year or so. As you get into things, these models are a few things to keep in mind, right? So the shift in this becomes not just do things and get paid. It becomes do things well, improve the health of your patients, get good outcomes and get paid. To do that, you have to track outcomes and you really have to start thinking about what is low versus high value care and get away from low value care. This means we need as clinicians to focus on what works. And this is really hard for us, right? We need to really use data and be brutally honest with ourselves as to what helps and what doesn't help. What Dr. Farrell just talked about, that idea that we don't have any data, that one exercise is any more efficacious than any other exercise, including all the core stability things that is done essentially for every single patient I see who goes to physical therapy. They get the same things and there's no evidence to support that that's what they should get. Right. And we need to look at things like that and make sure we're really trying to direct people into things that work and really using our data. As you get further into value based care, what we think of as the metric now, the RVU or the payment we get for procedure becomes a lot less relevant. We're going to hit a point where we're getting paid for cost effective care, not so much providing care. They're different things. So we try to take a look at this through AAPMNR. We wanted to start understanding value and costs and where the money goes in spine care. And so we looked at, we did a study again with the support of AAPMNR, looking at costs of treatment of low back pain and other low back disorders. We looked at everything from back pain to disc herniations to spinal stenosis. We included a whole bunch of lumbar diagnoses and we compared the cost for seeing a podiatrist versus a surgeon and we looked at what drove that cost. We looked at CMS data from 2011 to 2014 and we took patients who saw a PCP for a lumbar spine disorder who had not had a similar visit within six months to that index visit with their PCP. If they then went on to see either a podiatrist or a surgeon, neurosurgical or ortho for a lumbar disorder within six months of that PCP index visit, then they made it into our study. And that was about 12,000 subjects and we followed them for two years. In the end, our groups, I'm not showing the comparison data, they were quite similar in all the metrics we could find between our two groups. And we did a regression analysis for what differences we had and it really didn't change the numbers at all. What we found in general was that surgical rates were much lower in the physiatric cohort, less than half, so 7 or 8% for PMNR versus 19% for surgeons. The cost was a lot lower, so total Medicare expenditures were $122 a month lower per member per month for Medicare, which adds up to a lot of money. When we looked at just spine-specific spending, how much we spent on the spine, physiatry was a lot lower than surgery again, $3,800 versus $7,400. And although it is a lot less, that's still a big number. That's per person, right? That's the mean. It's a lot of money. So this is a very expensive problem for payers. When we looked at what drove costs, we found the big driver of costs was surgery. This is about a third of the cost for the physiatry cohort and about half of the surgical cohort. Following surgery, the next two biggest drivers of costs were imaging and injections. And these three, even in physiatry, accounted for well over half the spending of spine-specific spending for these groups. The other interesting thing we found that we really weren't expecting was that the cost of healthcare, total care from Medicare was substantially higher even two years out from the index visit for back pain. So these patients on average had about $650 a month that Medicare was paying for their healthcare services up until their index visit for their back issue. And two years out, they're paying about $950 a month. For both groups, it was identical. And we don't really understand why that is. But the healthcare expenses were a lot higher once they had a back problem that put them into the category that they would make our study. So how does all this become relevant and why exercise? The truth is, if you look at the data we have on low back pain, most treatments for low back pain have little to no high quality evidence of benefit, particularly long-term benefit. Our system really struggles with variability and over-utilization issues. The rates at which we operate or inject or MRI are all over the map when you look across the country. We don't seem to follow any pattern that makes us think that we're really doing this rationally or in any true sort of objective-based manner. And if you're trying to improve the healthcare system and the structure in which we deliver care to make it financially viable, we have to look to improve value. So why exercise? Again, we don't have good data on most of what we do. If you look at what we provide for low back pain, the data really isn't very good. Medications are largely ineffective. The data does not support much of anything in terms of long-term treatment of low back pain from a medication standpoint. There's some data in recent reviews talking about manipulation and acupuncture, but this is very low-level data, and they talk about a very short duration improvement with a very small magnitude. It doesn't really change the course much. You can get into procedural things like placenta RFA. Again, very low-level data and affects a very highly selected patient group. The best evidence we have for any type of intervention for back pain really is exercise combined with cognitive behavioral therapy of some type. And this is superior to exercise alone. And again, what exercise is not so important, right? We don't really have evidence that something is better. It could be CORE, it could be McKenzie, it could be all sorts of other things. We don't have that data. We also know with fairly high-level data that when you evaluate patients, assessing psychosocial factors is important when considering their risk of transitioning from acute to chronic pain. And that is a lot of the target, trying to get at people who will linger in the system and get into a chronic pain state if we can't alter their course. In terms of implementation, if you're gonna think about this and say, really, we should shift towards a much more exercise cognitive behavior-based approach to our patients, how do you do this? How do you start thinking about that in terms of your practice or your healthcare system or your structure or your clinic? Like a lot of things, you have to start thinking what is the problem, right? The problem really is we are focusing on pain. We're not focusing on long-term health. We're not focusing on outcomes. You go back to the study we did, long-term healthcare utilization is high once people start having low back pain, it seems. So what is the problem there, right? We're not focusing on long-term health. We have a very disjointed system of episodic care. We focus on injury and illness rather than health. And the spine world really has been built on a very surgically procedurally oriented structure based off of fee-for-service revenue. The solution to all of this is to really focus on optimization of health, which is a shift in your thinking. It's not about the short-term pain. It's about long-term health and well-being. And that may be where you get more benefit. If you're going to do this and implement stuff, how do you think about this? Right, again, you think about your problem and your goals. I think as you consider how you might take care of patients in a way that provides more value and gets at improving their health and quality of life, but you should think about a few things. One, there's a lot of benefit to talking to your patient. Visit times get short. People talk about all sorts of things, but really talking to your patient about where they are in their life, what's in their way, what they're struggling with, what they want and what they need, helping your patient with realistic goals. What are they? Collaborative care becomes an important part of every alternative payment system essentially, right? You have to start to learn to work with other care providers who can help you provide more effective care for your patients. Behavioral health becomes a very important thing to address, and it probably is under addressed throughout our healthcare system. In the end, a structured individualized exercise program works better than other things, especially, again, when combined with behavioral health. And you have to refocus yourself a bit on improving global health of the patient rather than just focusing on their short-term pain. As you do this, there's some benefits you might think about, things you can expect to get out of this. I think you will get much more engaged patients if you focus on them this way. You can really focus on team-based care delivery, which does several things. It provides for coordinated care. It also essentially extends your capacity, right? If there are multiple people of different specialties that you work with providing care for your patients, your expertise can be spread across them, and you can reach more patients and touch more patients more effectively. You can really get to a long-term change in health. And again, you look at much of what we do. It's very short-term, and our data is very short-term. If you really want a long-term change in someone's health, function, behavior, life, well-being, it's going to be sort of exercise in behavioral health approach. You're trying, ultimately, to decrease utilization of low-value care. And I think for physiatrists, in the end, this is a tremendous opportunity for us because it really increases the need for expertise and rehabilitation to do this. So in the end, whether we like it or not, you like it or not, anybody likes it or not, change is coming. We work in a low-value system, and there's a finite amount of money, and we're hitting the end of it in some circumstances. Kind of like Dr. Farrell said, some people find the nonspecificity of exercise frightening. Some people find this frightening, the idea that the system's running low, but actually, it's a good opportunity for us. We are trained in multidisciplinary coordinated care and focusing on the long-term well-being of our patients. That's an opportunity for us. Every specialty doesn't think that way. Whatever you do, the risk for cost is shifting to us. We will need to be accountable for our patients and accountable for our outcomes and accountable for our spending. As you think about that, there's a lot of benefit to exercise in behavioral health, as they seem to be the most effective treatments we have. To be effective in delivering all this, you need to learn to focus on your data and really pay attention to it, and then focus on long-term health and function. So that's what I got. So that's my email. If you have any questions or comments, I wish we could be talking to you all in person and hearing what you say and having a discussion. So if we can do it virtually, we'll do it that way. But thank you. Next, Dr. Eubanks is gonna talk more and go into a deeper dive and implementation for you. All right. Thank you all very much and Dr. Standard for setting up my talk so well. I'll be discussing implementation of exercise here. So no disclosures. We will be looking at physiatrists as educators, health behavior change models, and some strategies for implementation of exercise. So health behavior change consists of coordinated intervention, consists of coordinated interventions to change health-related behaviors, which are reinforced by individual, social, and environmental factors. Importantly, physiatrists are educators and messaging matters. As physicians, we can introduce and reinforce positive health behaviors. Our words really do have impact. And this suggests that we should be talking to our patients as Dr. Standard mentioned. In fact, if we look at just talking to patients, we can have a pretty profound effect and recommending that patients engage in recommended activity levels will convert one in 12 roughly to actually doing so. And that has a comparable effect as smoking cessation, even though smoking cessation takes a much more effort and is one of our more difficult health behavior changes to make. Words are, of course, the most powerful drug used by humankind, as Rudyard Kipling once said. There was an interesting study looking at the role of words in exercise. And as we consider our role as educators, we want to really appreciate how our words can either empower or disempower our patients. There's an interesting phenomenon that was mentioned earlier about the use of words mentioned earlier about exercise induced hypoalgesia. And this is a normal physiologic response that most people enjoy as a result of merely exercising. But it turns out that one particular study tried to analyze the role that pre-exercise negative information may have on this physiologic phenomenon and found that if we primed people with negative information, they actually could completely interrupt the expected hypoalgesia after exercise. And that's just with information. It's not all bad news though. We also can empower our patients with our words. And it turns out that this can be useful in our messaging when it comes to exercise. There was one study looking at a group of female room attendants working in different hotels and they divided them up into an informed group and a control group. And basically the informed group was told that they could achieve the recommended levels of physical activity by merely doing their occupationally related work. The control group was not given this information and they tracked this group of 84 women over four weeks. There was no actual change in physical activity levels but what they found when they started looking at physiologic parameters after the fact was a decrease in weight in the informed group, improvements in blood pressure, actually improvements in body fat in the waist to hip ratio and body mass index. And this is a pretty interesting study that suggests again that our words have a profound impact and we need to be enlisting them more as clinicians and particularly as physiatrists. When it comes to back pain, there are concerns about messaging that we want to pay more attention to. Peter O'Sullivan this year put out some recommendations in the British Journal of Sports Medicine about helpful information that we might be more inclined to tell our patients. One, these are the pertinent points to our discussion here about exercise but one is that it's rarely dangerous to have back pain. Patients need to know this if we're going to be talking about physical activity. Pain can be normally associated with aging but does not tend to worsen just because of age alone. There is a graded exposure to exercise and movement. There's a strategy that's safe and healthy for the spine in doing that. We want to make sure that they understand posture during sitting, standing and lifting does not predict back pain or its persistence. Furthermore, we want to emphasize that no specific exercise fixes back pain as we've been discussing throughout the talk. Also that it's safe to move and load the spine in a graded fashion that builds structural resilience and that pain flare-ups may expectedly occur and are rarely indicators of worsening structural changes to the spine. And finally, that effective care for back pain depends on a positive mindset and good physical and mental wellbeing. We can see here that the way we think about physical activity with our patients matters in a very comprehensive sense. We can use the biopsychosocial model to understand that we have an effect through physical activity, whether it is for recreation or occupational purposes or even domestic purposes in our daily life. And it's okay to enlist these as sources of physical activity for our patients to allow them to understand that it is easier to integrate physical activity and exercise throughout their day than they might initially presume. These are a few of the domains of physical activity, again, emphasizing the different locations, in the home, at work, when we're commuting even, and then the more overt resistance training or fitness activities. So implementation strategies are best done when they're delivered either face-to-face in a group or a gym setting. There has to be a goal setting involved and self-monitoring and behavioral practice or rehearsal need to be a component that we emphasize. These factors are all associated with beneficial changes and multiple motivational constructs that have been identified in research as integral to successful adaptation over time. They also enhance self-efficacy, which is a foundational characteristic in patients who adhere to exercise programs over time. And so as physiatrists, I think it's important for us to really be aware of the role in adherence that we can play and emphasize this with our patients who have back pain. When we're considering implementation, we want to use existing health behavior models as this has been shown to improve adherence and success with exercise. One is the trans-theoretical model of physical activity and the other is the behavioral model of change, which really breaks down stages of readiness. There is the pre-contemplation stage where there's no recognition yet. There's the contemplation stage, the preparation stage, action and maintenance. This is important to us as physiatrists because we can identify where a patient is on this spectrum and target our approach based on that. And so with the pre-contemplation stage, they may need more basic education about the role that exercise can play, whereas with contemplation and preparation, they may need more coaching or therapist-directed information. And action and maintenance may require less input from the team. Here is a model of the motivation and behavior with the stages of change and what's called the health action process approach, which talks about the intentionality of the patient. There is non-intender, intender and actor. And we can see the role of goal setting to help move someone across that motivation change. So as Dr. Farrell mentioned, motivational interviewing is an important skill that is actually designed for clinicians. It was important to the primary care world and has been shown to be important in the efforts to really move behavioral change along. This is a good mnemonic that can remind you how to speak with patients and identify where they are on the process of change. We want open-ended questions. We want affirmations to reinforce that positivity. We want reflective listening so that we can hear where they are in the process of change. And we want to summarize for them so that they can hear what they are saying to us and start to understand for themselves where they are in this process. All right. So we can use exercise to support patients with back pain. We want to make sure that there are certain factors that we consider, such as the time, the feedback. We want to encourage the self-regulation and monitoring that we've mentioned. This should be individualized, enjoyable and relatable to the patient's goals. We do want them to understand some elements of basic pain physiology, particularly that hurt does not always equal harm. There should be a strong element of reassurance and we want to help develop and restore movement confidence for the patients. This next image here is just a model that can be used in the clinic that Beth Fradies, who's a lifestyle medicine advocate, put together to sort of show how you can integrate it with more medically oriented questions that Dr. Farrell also mentioned at the end of his talk in terms of safety and risk stratification. I'm happy to share references in full with anyone. We also want to think about the role of exercise and graded exposure, that is taking someone where they currently are and setting realistic goals to help them achieve progress. Greg Lehman, who's a physical therapist and chiropractor that studied with Stu McGill at the University of Waterloo has come up with this nice illustration of how we might change our approach with a patient based on their level of sensitivity to pain. And we can use that in a graded fashion to help move them along. So it's important to also remember that exercise does not have to be complicated. There have been some really well done systematic reviews and meta-analyses in 2018 and 2019 that looked at simply walking and found that walking is a commonly recommended activity for persons with back pain, particularly chronic low back pain and that pain disability and fear avoidance actually can improve through a walking program just as much as other types of exercise. Adding walking to exercise does not further improve benefits, but it may be a less expensive alternative to physical activity options for patients and one that we really want to consider as we advocate for this type of behavior change. This is an illustration here just sort of showing the relationships between exercise and more global changes in health, which is important as Dr. Standard mentioned to the overall role that exercise has in the improvement of someone's experience with back pain. So we see that more active persons can decrease their sensitivity to pain, but also importantly, decrease their perceived disability, increase their quality of life and decrease other lifestyle related diseases. So one special note here about older persons, we wanna make sure that we're not perpetuating myths. And there was a well-done randomized control trial called the LIFTMORE trial that looked at postmenopausal women with osteopenia and osteoporosis and put them in a high intensity resistance training program and found that not only did they tolerate that well, but it improved bone density. So I think that we want to remember our goal as physiatrists is really to empower and improve function and that it is important for us to think about these basic principles we've been discussing today for our older patients who are perhaps at unique kinds of risks of inactivity in particular. So what's the best exercise for back pain? This is the best exercise. This is the one that the patient will do. So some key questions to consider, where's the patient in the change process? Meet them there, educate, encourage, and enlist support from your rehab team. Ask what kinds of activities they enjoy because those are the types that they're more likely to commit to long-term. Ask the realistic exercise goals that they may have given their weekly schedule as well as their personal values. And we might ask how specific physical activities promote other types of functional goals and improve quality of life. So in summary, physiatrists are educators. Health behavior change is possible using well-described implementation strategies we can empower our patients to make positive health behavior changes and exercise can improve the experience of persons with back pain and make them healthier in the process. So I thank you all for your time and it was wonderful to be on this panel with these excellent colleagues. Thank you.

exercise-based rehabilitation

spinal pain

physical impairments

pain intensity

disability

musculoskeletal factors

neuroimmunologic factors

psychological factors

maladaptive behaviors

pain reduction