Back pain can be debilitating but it doesn’t have to take over your life. Christopher Standaert, MD, medical director, UPMC Program for Spine Health, discusses options available to patients without medications and surgeries to improve pain and live a better life.
Tonia Caruso: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgments when advising their patients. Patients in need of medical care should consult their personal care provider.
Chronic back pain can be debilitating for so many people when surgeries and medications don’t work or aren’t an option. Are there any other ways in which patients can find relief and a better quality of life? Our next guest works to make that answer yes.
Hi, I’m Tonia Caruso. Welcome to this UPMC HealthBeat Podcast. And joining us right now is Dr. Christopher Standaert. He’s the medical director of the UPMC Program for Spine Health. Thank you so much for joining us.
Dr. Christopher Standaert: Oh, I’m very happy to be here.
Tonia: So, lots of people suffer from back pain, and back pain can really be debilitating. Can you talk a little bit about how you have seen this impact patients’ lives?
Dr. Standaert: Everybody gets back pain to some degree at some point in their life. It’s a normal thing. We all hurt at various points. I think our backs hurt, our shoulders hurt, our hips hurt. You get older, it’s just kind of what happens — fleeting pain that occurs, and sort of goes away, and you go on about your life. Usually not a big deal for most of us. When it gets to be more persistent, when it gets problematic, when it starts to impact your ability to sit, to drive, to get dressed, to mow your lawn, to do your job, to care for your kids, it’s a problem. And, for a lot of people, it really does continue. They get hurt, or something happens with their back, or they just get older and things get arthritic, or they get scoliosis, and they can’t do what they did, and they can’t function well. And, sometimes it can be very acute and very painful, and when they get nerve pain, nerve pain can be incapacitating for people.
Tonia: Sometimes, surgery’s not an option. Sometimes, medication may not be an option. What does that look like first? Are those normally the first routes to go, surgery or medication?
Dr. Standaert: No, they’re really not. We don’t really use surgery as a first line for much of anything. Surgery applies to a few percent of people with back pain. We can fix a few things. We can decompress nerves that are compressed. We can fix things that are unstable. We can create more space for nerves when things are bad. But we really don’t operate much for back pain itself. Surgery doesn’t give you an 18-year-old back; it just doesn’t work that way. So, in the end, a small percentage of people wind up with back surgery.
Medications all have specific purposes. There are none that really get rid of back pain forever. They don’t work that way. Some anti-inflammatories and over-the-counter medications can work short-term, but that’s about what they do. We use medications otherwise for things like sleep, or nerve pain, or some other sorts of things we can medicate. But, again, they’re not a perfect solution, really. The real answer to sort of being better is within them. It’s in how they move, how they care for themselves, how they sleep, how they eat, how they manage their body, and their spine, and their health. And if you can help people with how to understand the way to do that, they can really be better.
Tonia: And, so, you have worked in this field for a very long time. Tell me about your background, and then, how you came to UPMC, and how you came to Pittsburgh, and what sort of the goal was when you set out here.
Dr. Standaert: So, I’m what’s called a physiatrist. I’m a specialist in physical medicine rehabilitation. It’s a relatively small medical field. I went to medical school at Harvard. I did my training in my specialty out in Seattle.
I have always been interested in sort of the human state, how we live, how we move. I’ve always found sort of the spine side of it interesting because the spine is complicated. It’s really hard to find good spine care, and it really impacts a lot of what we do. So, I started in this field. I’ve been in practice for 25 years or so. I spent the bulk of my career in Seattle at the University of Washington.
I realized after a while that our spine care system was a bit off. We don’t really spend enough time talking to people a lot of the time. We are quick to do things to them that may make them feel better for a couple of hours, but don’t really solve the problem at all. Too many people are disabled by their back, and I really wanted to find a better spine care system. I wanted to find a better way to invest in the wellness and the well-being of people with spine problems so there could be a better way to educate them. And, so, I came to Pittsburgh because UPMC really wanted to build a better system. They really wanted to take a patient-first approach to care and help us build a system where we could listen to our patients and give them the resources they need to be better.
Tonia: And, so, what does that look like? What do you do here differently than other places are doing?
Dr. Standaert: So, we’ve built a coordinated care system, really. We looked at our population, we looked at what was happening, we looked at the services that were out there, and we saw a hole. You can go to a physical therapist, you can go to a chiropractor, you can find a surgeon to talk to. You can get an injection. But they aren’t really coordinated well, right? They aren’t talking to one another necessarily, right? The surgeon doesn’t necessarily talk to the PT, who doesn’t talk to the chiropractor, who doesn’t talk to the injection person, who doesn’t talk to the ER doc. They just don’t. It’s scattered. It’s sort of fractured.
And, so, we built a coordinated program. We start with highly trained nurses who answer the phone when people call, and they talk to them about their problem, and they sort through what they might need. We have physical therapists who are specifically trained in the advanced care of spine. They’ve all done advanced training in how to take care of people with back and neck problems. They are linked to our physicians, who are all trained in spine care, essentially nonoperative spine care. They’re all physiatrists like me. And, then, we created a whole sort of coordinated, collaborative structure. So, the PTs work just for us, most of them. They see our patients. The nurses work with us. We all talk to each other. We have a meeting every week. We have a psychologist who works with us. We have a dietitian who works with us. We have a health coach. And, we have a whole team of people who just collaborate, and we talk every week about our patients. We just had a conference this afternoon about our patients, talking through people who are doing well, and people who are struggling, and how we can approach people. And we all think together and work together, and we make sure we’re on the same page, and we make sure we’re finding the things that are in the way of the patient getting better.
I came down to five things I think we need to be well.
We need to sleep. Sleep is when we repair ourselves from the trauma of the day. We need decent nutrition. We really are what we eat. We need exercise. We are use-it-or-lose-it creatures. We are social creatures. We need social engagement. We need other people. And, ideally, we need a mission, a passion, a love, a thing to get up and go do to drive us every day. And, I realize that many of the people I see who’ve been hurt, or have back problems, or don’t even get hurt, but just kind of drift backwards in the system, lose those. They don’t have them. And when you can find the right way to care for yourself, you can get enough sleep, you can find the right sort of mode and intensity of exercise because exercise is not all the same, you can engage with people in the right way, and you can really think about what are appropriate goals for you, what’s going to work short-term, what’s going to work long-term, how do you get there?
A lot of people get hurt, and it’s like they’re in the dark. They can’t see tomorrow. They can’t see what is five years from now. What is — “I’m 40, what is 45, what’s a healthy 50?” They can’t see it. And if they can’t see it, they can’t get there, and then they’re just kind of lost. So, we try to help with that whole structure. And that’s why if you think about our team, we have that. We have a dietitian for diet. We have a psychologist to help with the belief structures and the power to sort of use your own sort of psyche to help yourself. We have highly skilled PTs and health coaches who help with exercise, and activity, and movement. We rebuild that.
Tonia: Right. So, what does it look like when someone comes to see you? What’s that initial assessment like?
Dr. Standaert: So, it depends who they see. So, most people who contact our clinic will start with one of our nurses, and the nurses will talk to them, ask them what’s going on, and where have they been, and what they’ve done. And if people have a relatively acute or new problem, they haven’t really been to PT, they haven’t really thought about how to move or exercise, often, they’ll start with our physical therapist. If they see the therapist and the therapist is concerned or they’re not getting better, they see one of the providers. We have three different physicians and a phenomenal PA who work with us.
Other patients, when the nurses talk to them, they’ll say, “Yeah, you need to talk to one of the medical providers.” And then they come see us. Our appointments are, give or take, a new patient slot is about an hour. We get some information on people, then we talk to them. We ask them what’s going on. We go through their history. We look at them. We like to see all of their films, and MRIs and x-rays, and everything they’ve had. We go through all the testing they’ve done. We talk about all the pills they’ve been given, and we sort through what to do, and we think through our resources, and we think through what’s in between them and getting better. What are the barriers, and then how do we work through them? And then we work through the process of doing that. I mean, it’s going to the doctor. You go to a building and a clinic, and you go to the exam room and all this sort of stuff, but it’s a different experience in terms of what we ask you and what we talk about. Because we’re really after your life, is what we’re after.
Tonia: Talk about the role of the pain psychologist.
Dr. Standaert: So, you get this a lot. People think that when you somehow suggest a psychologist, you’re saying the pain is in my head. That’s not true at all. Right? The pain’s in your back, right? I recognize that.
How you deal with pain, how you set your goals, how you think about success and progress matters a lot of times when you’re hurt. There are a lot of things I sort of say to patients. One is you really can’t out-will biology. You can be a very determined person, but you cannot make your body heal faster than your body is going to heal. You have to go with the speed of your body. Examples of people who get in trouble with injury and with ongoing pain are, some people get scared, they get fearful, they get told something’s bad with them, they get told that they’re fragile. I’ve had a lot of patients who are told they can never lift something, or run again, or do anything again. And they get scared. And when people get scared, they retreat, and they back off, and that doesn’t work. You have to try to move forward.
Another group of people who really get in trouble are actually people who are highly successful. They’re highly motivated. They put their head down and work through every barrier in front of them, and they think they can apply that to a disc injury or a bad knee. And they can’t, right? They can’t just out-will it. They have to think differently. It’s a tortoise and hare story. The tortoise wins the race. I see an awful lot of hares, and I have to tell all my hares, you’ve got to find your new spirit animal. It’s a tortoise, right? You’ve got to go slowly, and you have to do it deliberately. And if you’re getting better from a chronic injury, every day is not better than the day before. Some weeks are worse than the week before. It’s a month-by-month thing. It takes time. You injure a disc, it takes six or 12 months for the disc to heal. You get a knee replacement, when are you really good? A year later. You get a spine fusion, when are you really good? A year later. It’s a year. Get a shoulder surgery, it’s a year, right? Your body has to heal. And, so, we get people on that clock, and they have to think that way, and they have to accept what is a victory, what is a success? How do I latch onto, I’m getting better? How do I see my life improving? And it’s really hard to do that sometimes. And I think if you’ve been well, how do you acquire the skill to work through a chronic injury that you can’t just make well, somebody can’t make go away? There’s a psychological skillset to that. There’s a way of looking at that. And you tie that in with fear, or anxiety, or despondency, you have to work through that a bit.
That’s what the psychologist does. None of it is that the pain’s in your head. It’s really that you have to discover how you’re going to make your life better.
Tonia: Talk to me about some of the conditions for which people might come to see you.
Dr. Standaert: Yeah. Common things we see, we see disc herniations, which result in back pain and often back-in-leg pain, a pinched nerve sort of thing. We see patients with scoliosis, we see spinal stenosis. We’ll see people who have trouble after trauma and fractures. We see people after surgeries that don’t go so well. A lot of people simply have, they’re getting older, and their spine is aging, and they get a bad hip and a bad knee, and they can’t walk, and they can’t do what they were doing, and it sort of compounds itself. So, we look at how all those things play together.
Tonia: I spent some time at the Program for Spine Health, and we interviewed one of the patients, and he actually injured his back; he was a hard-playing basketball player in college and then decided the back pain became unbearable, and he wanted surgery. When he was told he wasn’t a candidate for surgery and they referred him to the Program for Spine Health, he was very disappointed because he thought, “This isn’t going to help me. I’ve read all this stuff before. How’s this going to happen?” And, then, talk about what happened once Stu came to see you.
Dr. Standaert: We had a long conversation when we met. We talked about his pain and what was in the way. And it was interesting because one of his biggest fears was that he wouldn’t be able to play with his children. He was a very athletic guy, a college basketball player, young. Kids were young. And he was afraid of that, and he was afraid of envisioning a future where he couldn’t play with his children.
Surgery for low back pain is not terribly helpful. We just can’t fix it. And, so, we had to talk through, one, how fear of not being the person he thought he could be for his children was getting in the way. Hence the psychology side of it. We had to talk about his exercise. He was a big guy, used to big exercises. He ran, and jumped, and lifted weights, and that’s how he trained himself. He’s 35 and hurt. He can’t train himself that way now. We have to go back. And when you really think about injury and pain, we don’t get hurt because of what we’re good at. We get hurt because of what we’re bad at. If we go to exercise, we all do what we’re good at because it’s way more fun. So, you have to find what people are bad at. Then, people have to accept that, “Wow, I don’t do this very well. My balance isn’t very good. My flexibility isn’t very good. The way I move my hip isn’t quite right. My gait isn’t the way it used to be. The way I walk isn’t the same.” And then you have to fix those things. But those are seemingly small adjustments. Those aren’t big, huge muscles where you move 100 pounds. They’re little things. And that’s one of the things he said, that he didn’t realize all these little exercises would help him. But they’re all the muscles that really control how he moves, and how he stabilizes himself, and holds himself, and he just wasn’t used to training that way.
Exercise at 35 is not the same as it is at 20. Exercise at 55 is not the same as 35. Your body changes, and you have to move appropriately for it. But that idea that you have to shore up your weaknesses to get better is critical. But that means being deliberate and slow in thinking and working with a therapist who really is going to look at you, and how you move, and how you do things. And that’s what he really had (to do). He had to make that mental leap to sort of do that to go forward.
Tonia: Do you find patients are often surprised when they get results?
Dr. Standaert: I do. It’s interesting. People tell me they never thought they could be this good again, getting over what they were trying to get through. It was dark in front of them.
Tonia: Obviously different for every patient, but is there a typical treatment process, timeframe? How often does someone in a program come to see you?
Dr. Standaert: We probably work with people over three months or so on average. I mean, I will see most of my patients two, three, four times. They see the physical therapists maybe six, 10, dozen, somewhere in there. When they see the psychologist, she averages about three visits with most people. We have a health coach who will work with people sort of indefinitely if they need it for a while. Dietitian works with people a few times — two, three visits, if they see the dietician. When we look at our numbers, it’s sort of in the 15%-ish range who will see the dietitian. Not everybody needs a dietitian, but the ones who do, it’s helpful. Not everybody needs a psychologist; the ones who do, it’s helpful. It’s there. It’s a resource that’s there. The vast majority of our patients go to physical therapy.
So, it’s over a few months that we work with people. You have to change your body to change how you move, how you exercise. Yeah, if I had a magic wand to get everybody better next week, I’d be happy to, but I don’t have that. It takes some time.
Tonia: Tell me about the work of the health coach and some of the things that they do and how they play into this.
Dr. Standaert: So, UPMC has a number of programs the health coaches do. They have some programs for stress and anxiety, and smoking cessation, and weight loss, and a bunch of other ones.
And what we find is that one of the biggest issues here, so a lot of people go to physical therapy. So, this isn’t our physical therapist. But a very typical physical therapy experience is you go, they give you little pieces of paper or an app with, I don’t know, six, 10 exercises. Maybe the next time you get six or 10 more. And maybe by the time you’re done, you’ve got 20 different exercises to do, and you don’t really know why you do them. And you do them for a while, and they’re kind of boring, and you go to your PT, and you’re kind of guilted into doing them because you don’t want to go to the PT and say, “I didn’t do it.” When you stop going to PT, there’s nobody to guilt you. So, you sort of stop doing them. Or, I have a lot of people who say, “Well, I felt better, so I just kind of stopped.” Getting better and staying better are two different things. So, I talk to a lot of people who have recurrent problems with back, and I talk about there’s a difference between getting out of trouble and staying out of trouble. And, so, some things can get you out trouble, but they don’t keep you out of trouble. A lawyer may get you out of trouble, but a change in behavior will keep you out of trouble.
And, so, we have to get to, how do we stay out of trouble? Meaning, how do I keep my back from flaring up and getting in the way of my life as often as it’s been doing? How do I stay out of trouble? How do I not have to call you? How do I not need steroids? How would I not have to go to the ER? How do I stay out of trouble? That means something has to change. You have to be different.
And, so, the health coach helps with that. They help with the barriers, they help with how do you incorporate exercise into your day, how do you put it into your schedule and calendar?
I was talking to a patient the other day about, the patient has a very busy work schedule and recognizes the need for self-care and time. And we talked about actually taking the work calendar in Outlook on the Microsoft thing and blocking out (time). She’s like, “I’m just going to put Dr. Standaert in this block.” And create time for yourself. How do you do that?
And that’s what the health coach does. And the health coach will help with time management. He’ll help with how you sort of balance out your exercise program. He can even help with meals, and what do you buy when you go to the grocery store, and how do you make a shopping list that’s more healthy than just sort of impulse from all those unhealthy things they put at the checkout register? How do you do that? So, the health coach helps with how you institute these things in your life a bit and how you create a little more structure to help yourself, right? I said there’s a staying out of trouble. And there are things you can do to stay out of trouble, but if you can arrange your life so there are less temptations to pull you into trouble, it is better, right? You can work on the structure of your life so that you are more likely to be successful, and that’s what he helps with.
Tonia: So, what do you want to say to someone who still might be hesitant or skeptical that anything you just talked about can help them? What do you want to say to them about potentially coming to see you?
Dr. Standaert: So, there are a couple of things. One thing I do tell people a lot of the time is the whole point of seeing me is so you don’t have to see me. Will I take care of you your whole life if you need it? Yes, I will. Do I really want you better so you don’t need me? I want you better so you don’t need me. Right? I’m trying to empower people. We’re trying to give people the skills to stay well. If you are happy with your life, and you’re happy with how you feel, and the treatment you’ve gotten has helped you, and you can do what you want to be doing, you probably don’t need me.
If what you’re doing isn’t helping, I use this analogy a lot of, “If you think about, you sort of get lost in the forest, and you can see the light at the edge of the forest, you’ve got to get out.” And if you’re in a state of injury or pain, and you’re lost in the forest, and there’s light somewhere, and you want to get out, you go to that light. There may be several ways you can do this. There isn’t necessarily a physical therapy tree or a chiropractor tree you have to touch. You can sort of go around these, and all of these people, well-meaning, may help you.
What you want to make sure of is what you’re doing is moving you towards the light. You want to get out. If things you’re doing are moving you away from the light or just spinning you in circles, and you’re better for an hour but then you’re the same, and you’re better for an hour but then you’re the same or you’re getting worse, you’re gradually seeing things drift away, or your friends don’t want to talk to you anymore because all you talk about is your back — if you’re in that state, maybe there’s a better way to sort of go about this, right? And, if you need to understand, “Why would physical therapy help me? What would be good about that? What kind of exercise should I do? Why would I want to change my diet? How do I sleep better, and why is that important for me? And how do I prioritize this so I can be better?” That’s what we do. We help people through that forest.
Tonia: How is it, then, that patients come to see you? Can a patient self-refer? What sort of conversation should they be having with their PCP, and when is it a time to come and see you?
Dr. Standaert: So, the time to come to see us is when you really don’t know what to do and things aren’t working. Like I said, if your pain is fairly straightforward and goes away, you probably don’t need to talk to me. If you go to physical therapy or you go to your chiropractor, and you’re doing well, and they’re helping you, and you’re getting better, and you’re moving back towards the life you want to be living, that’s all fine.
If good advice, well-intentioned providers trying to help you aren’t really helping you, you’re not getting better, you don’t understand what’s wrong, it doesn’t make sense, what you’re hearing doesn’t fit with what you’re experiencing, we may be able to help you. That’s really a large bulk of what we see.
We have a lot of expertise in spine, and so you can talk to your PCP and say, “This seems like it’s complicated. I’m not getting better. Do you think they could help me?” And the PCP can guide you. A lot of our patients come from our surgical colleagues who do a phenomenal job and say, “Is this an option for me potentially because this isn’t working, and I don’t know about that surgery, and you don’t know about that surgery.” So, that’s the sort of space most people are in when they come to see us.
You can definitely self-refer. We get a lot of people who just kind of call because they hear about us from friends, or family, or other people. And your medical provider can refer you. There’s a referral process through the computer system, through the electronic health record, and we have a referral process for your health provider. So, they can certainly refer to us. If you want to call, we have a phone number. You call 412-219-0386. If you’re curious about our program or want to reach out to us, you can do it through the web as well. Our website is UPMC.com/spinehealth.
Tonia: What is a good day on the job for you?
Dr. Standaert: When I can really learn about the people I see, when I can find a way to help them when they need me, and when I can work with the staff that I really do enjoy and respect, and I can see the benefit of the collaborative care we provide, I can see people getting better. I hear them talk about other patients and how they’re improving, that’s a good day.
Tonia: Well, Dr. Christopher Standaert, we thank you so much for coming in and spending time with us today. We certainly do appreciate it.
Dr. Standaert: No, it’s my pleasure.
Tonia: I’m Tonia Caruso. Thank you for joining us. This is UPMC HealthBeat.
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