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Interviewer: Personalizing treatments for chronic back pain. We'll talk about that next on The Scope.

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Interviewer: I'm talking about chronic back pain with Dr. Julie Fritz, Associate Dean for Research at the University of Utah College of Health. Back pain seems to be categorically different than other types of pain. Can you talk about that a little bit? How is it different and why is it different?

Dr. Fritz: Well, there's a couple things that distinguish back pain perhaps from other pain conditions. One is it's an almost universal human experience. Just about everyone has dealt with some level of back pain, ranging from slightly annoying to completely disabling. So there's a shared experience in it that makes it different than a lot of more rare or less common pain conditions.

The other thing about back pain that really makes it challenging is, in the vast majority of circumstances, we don't have a really good idea of what the cause actually is, what tissues involved, where the pain actually originates from.

So, you know, there's a lot of different structures and tissues in the back, and pinpointing what is causing the pain has proved extremely elusive. And without that, it's a challenge to direct treatment in a way that's going to be effective. And that really makes it somewhat different than a lot of other conditions.

Interviewer: Well, yeah, exactly. I have a friend who's gone through surgery, and yoga, and cortisone shots, and any long list of treatments. And she's basically back in the same position she was a couple of years ago in terms of the severity of the pain. And I mean, would you say that a lot of the treatments that are out there today just aren't effective?

Dr. Fritz: There's certainly a lot of treatments that we should just flat-out stop doing and that really are ineffective, even harmful for patients. And the other reality of treatments that exist for back pain is a number of the treatments, some of which you mentioned, are modestly effective for some people. And the real challenge is figuring out what may work for whom, and there's no magic bullet that works for every patient all the time.

So it's another part of the challenge and the frustration for both patients and providers is there's a lot of individualization that needs to go into treatment, but it's very difficult to figure out what you're likely to respond to and what the next patient may respond to, which may be completely different.

Interviewer: And it sounds like this is kind of the motivation for some of your research. Tell me about what you're looking at now.

Dr. Fritz: Yeah, absolutely. So we have this situation of a number of treatments that have small effects across large groups of patients. And the fundamental challenge that we've tried to address is how to better match treatments to patients, which sounds like a fairly straightforward question, and in some ways it is, but it's proven very difficult with back pain for some of the reasons that we've discussed.

So we try to look at various patient characteristics that might help us decide who's likely to respond to what kind of treatment. And what we found, and many other researchers is that, a lot of those factors that seem at least somewhat predictive are not really specifically related to the pain or the physical injury of the back, but often are related to patients' cognitive and emotional responses to pain, how they tend to cope with pain, what their mindset is relative to pain. And this introduces another level of complexity and trying to figure out the best treatments.

Interviewer: So the idea is that, some people just might be more receptive to getting better and other people are . . .

Dr. Fritz: Well, yeah. I mean, I think we'd say it a little bit differently that whenever any of us experience pain, there's a physical response, and there's a cognitive emotional response to the experience of pain. And that involves our relationship to other people, various other stressors in our life. And all of these things can be positive factors towards resiliency in dealing with pain, or they can tend to lead towards more disablement and more suffering relative to having pain.

It's not a situation where we're talking about pain that's of psychological origin, but of a recognition that all of us have a response when we experience pain that encompasses these domains in our life that get outside of the physical.

Interviewer: As I understand it you'll be looking at different types of therapies including things like mindfulness, which maybe it's something the medical community doesn't routinely turn to when they think about treating pain.

Dr. Fritz: Yeah. Pain conditions like back pain are an area where various integrative medicine approaches, what we've in the past called complementary and alternative approaches, may have a really important role. So in the specific instance of back pain as you highlighted with your example, finding a cure is often challenging.

And many people are left to manage their life with some level of intermittent back pain. And strategies like:

• yoga,
• mindfulness,
• meditation,
• other stress-reduction strategies,

can be really helpful for the self-management of back pain to help people deal with flare-ups that inevitably come, or the experience of pain without having to use physician visits, visit the emergency room, take medication, etc.

Interviewer: And so it's not necessarily about sort of solving the problem or curing the problem, but coping with it.

Dr. Fritz: It is for a lot of patients. We certainly, as providers, seek to cure the problem, to get it to go away and not come back. The reality of back pain is that's often an elusive goal. And as providers, we also have to help give patients strategies to better manage their condition given that we know it frequently tends to recur. That's really what we're all trying to do is help people recover, help people live their lives, and do what they want to do despite the experience of back pain.

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updated: January 30, 2019
originally published: December 12, 2017