Outcomes Rocket Podcast_Dr. Frank Schwab: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.
Saul Marquez:
Hey everybody, welcome back to the Outcomes Rocket. Thank you so much for tuning in again. I’m super excited because today we have an incredible guest. He is the amazing Dr. Schwab. He’s an internationally renowned spine surgeon specializing in complex spinal pathology, pediatric and adult spinal deformity, and revision reconstruction procedures. Dr. Schwab’s areas of clinical focus include innovating patient-specific operative treatment, optimizing sagittal realignment guidelines, emphasizing the use of preoperative planning technologies and techniques for complex spine surgery. He is widely recognized as a leader in the field and has pioneered many aspects of spinal deformity care, especially for patients with extensive surgical histories. Dr. Schwab also developed the first definitive classification of adult spinal deformity that has become a clinical standard for spinal surgeons all over the world. He is a past board member at the Scoliosis Research Society and board member for the International Spine Study Group, and an active member in the Academy of Orthopedic Surgeons and North American Spine Society. He’s very well published with over 460 original and review articles and has had more than 500 presentations at scientific conferences. It is a true privilege to have him here with us today. So with that intro, Dr. Schwab, thank you for being with us.
Dr. Frank Schwab:
Thank you very much. I appreciate it.
Saul Marquez:
Absolutely, you’ve spent a lot of time and in fact, a lifetime in the field helping people get relief from pain, and so it’s exciting to talk to you about patients suffering from chronic low back pain. Can you give us what that means from a perspective of a surgeon?
Dr. Frank Schwab:
Yeah, Saul, great question. Most patients come to see us in our specialty for either pain, disability, or neurologic dysfunction, and often it’s a combination of those factors. And spine surgery is complex and low back pain is complex because there are so many structures involved and we have spent an enormous amount of time trying to dissect out how can we very accurately diagnose the source of pain, how can we find the least invasive option to address that, and how can we ensure swift recovery from the procedures that we apply for our patients. So it’s been, as you point out, a lifetime of dealing with patients who struggle with pain, but it’s been enormously rewarding and particularly, I would say, the last ten years because of the incredible amount of innovation that’s coming into treating low back pain and treating spinal deformities.
Saul Marquez:
Yeah, thank you for that. And so how does one go about accurately diagnosing the root cause of chronic low back pain? You know, this is one of those areas where there’s still a lot of questions.
Dr. Frank Schwab:
Yeah, that’s a, that’s so, great point to bring up. As I pointed out, the lumbar spine is enormously complex as a structure and I often have patients coming to me saying, well, gee, I don’t understand. You know, I had a bad hip and they replaced and that was it. The spine, unfortunately, has lots of joints, discs, ligaments, muscles, and the potential that any dysfunction in any of those structures can lead to pain. And so we have developed, obviously, over the decades, many imaging technologies that help us assess the anatomy of the lumbar spine, and with that, try to find abnormal structures, and with that a pain generator. It’s just not that simple, because particularly when patients age, or we as human beings age, when we get an MRI or get an x-ray, lots of things start to look a little abnormal, and so it takes a fair amount of experience, a good history from the patient, a good physical exam, and then a process of elimination to get down to the source of pain. So it’s pretty complicated, I think we’re getting a lot better at it, but not very straightforward for sure.
Saul Marquez:
Yeah, it’s difficult then, you know, we don’t want to treat images, and so understanding the true cause of this pain is kind of the goal. You know, I’ve heard a lot about the multifidus muscle, and so can you share more about this muscle and what the link between the muscle and chronic low back pain is?
Dr. Frank Schwab:
Yeah, so I think this is a really big deal and has really piqued my interest and drawn me to get involved with this technology. As surgeons, our tool kit has been pretty limited in the past until relatively recently. So either we want to decompress nerve structures or we want to fuse or stabilize the spine. So you either have to stiffen something up and stop motion or you had to free up a compressed structure. And as we’re heading into the era of less invasive procedures and more innovation in preserving motion and physiology, we are drawing much more attention to the muscles, the ligaments, and some of the soft tissue structures around the spine. And what we’ve come to learn is that in chronic low back pain, there is a dysfunction in a large group of patients that sets in where the muscle starts to lack the ability to respond to normal displacement and stabilization of the spine. So in a simple way, imagine it’s a knee and you go on and you’re playing a sport or you’re playing soccer and someone bangs into your leg. There is a process of pathogenic inhibition, meaning when a joint gets a little injured, the muscle tends to shut down, and in fact, there are a number of studies that show the muscle can waste. It can actually reduce in size and not fire or function normally. And what we’re coming to recognize is that the multifidus muscle is particularly sensitive, it appears, to injuries and degeneration around the spine. And when that muscle starts to lose its ability to contract and stabilize the lumbar spine, then it appears a vicious cycle sets in where pain leads to limited activity, leads to inhibition of the muscle, and with that you lose stabilization of the trunk, and with that you develop ongoing pain, and the multifidus has emerged to be sort of one of these key muscles that plays a role in the stabilization and the muscular control of the trunk. So it’s not a huge muscle and it’s not designed to do substantial displacements of the spine, but it is there to offer a resting, stabilizing tone so that the other muscles can fire appropriately.
Saul Marquez:
That is super interesting, and so with this muscle, this multifidus, making sure that it’s working well is key. And so you take a look at a patient, they come in to see you with chronic low back pain. They’re not a surgical candidate. What are you able to currently do for them?
Dr. Frank Schwab:
Yeah, so an enormously frustrating population because these are often younger and middle-aged patients who are in the workforce, they have families, and they deal with pain every day. You know, the traditional approach is to start with physical therapy, some over-the-counter medications, some pain modalities, and then we up that when it fails, and many of those patients end up having injections. They see pain management or a physiatrist. They may try chiropractic care. They do a lot of additional modalities to try to strengthen their trunk, but it’s really hard when they have a true dysfunctional, the multifidus, to target that muscle and rehabilitate it is very difficult.
Dr. Frank Schwab:
Yeah, and so there’s this thing called ReActiv8 therapy. Can you talk to us about it and how does this change what you as a spine surgeon are able to do?
Dr. Frank Schwab:
Yeah, so it’s a fascinating new technology that’s been developed to stimulate specifically the multifidus muscle and to let it fire more normally and get it back to a point where it provides that resting, stabilizing tone that the other muscles around the trunk can function normally. So the technology is a targeted pulse signal. There is a small device that emits a signal to the nerve that innervates the multifidus muscle. And that permits with two sessions a day, very brief, half an hour, to intensely exercise and stimulate that muscle if you will. And with that, we’ve come to learn that it resets and recalibrates the ability of that muscle to function and fire normally again, and it’s been a tremendous help for patients who have this chronic low back pain and are not surgical candidates and don’t have other pathologies that we can treat but really have a muscular dysfunction. So it is a, the ReActiv8, in essence, is an ability to stimulate the muscle, to regain its stabilizing force in the lower back, and with that address, this chronic disabling back pain.
Saul Marquez:
That’s super interesting. So in essence, and this is just me wanting to learn, and folks, you’re probably wondering the same thing. When the multifidus starts to weaken, then you get a bit of destabilization. The pain, does it come from the muscle? Does it come from a weakened muscle or where does it come from?
Dr. Frank Schwab:
Saul, it’s a good question. So we don’t believe it’s the muscle itself, but it is the joints and the structures around that area that without the function of the muscle to provide stability, there is subtle but excessive motion and if you will, a laxity that permits abnormal degrees of motion, very subtle, but enough to be that sort of dull, aching, ongoing pain. Some of it is most likely the muscle, as you point out, a fatigued muscle that’s trying to fire but can’t quite maintain the appropriate amount of contractility, so I think it’s a combination.
Saul Marquez:
Got it, thanks for that clarification there. How many of you guys listening to this have back pain? I can imagine a lot of you do, including myself sometimes. You were, Dr. Schwab, you were talking about that middle age guy, I’m like, that’s me. I’m like, thankfully, it’s not chronic, so I’m just, I feel like in a good place, especially after losing 8 pounds of my COVID weight.
Dr. Frank Schwab:
And, you know, we have to say in all of this, when we’re talking about this technology and we’re talking about chronic low back pain patients, these are not, you or I that have occasional back pain. These are patients who have had 50 sessions of physical therapy and 5 to 10 years of pain and really slogging through it on a pretty much daily basis. So very different from the occasional low back pain, which is exceedingly common, just the way we’re designed and the lifestyles that we have. So I just want to differentiate that this isn’t an approach for someone who has occasional back pain.
Saul Marquez:
Got it, great distinction there. So whether it is you’re feeling the back pain, it needs to be chronic and debilitating. And so whether it’s you feeling it or somebody that, you know, feeling the pain or maybe you’re thinking about how to address your employees that your very large company or your health system, this is key to think about the growing opportunity for a therapy like this that is less invasive and an opportunity to address it in a more long-term way. What would you say is the economic impact of being able to treat these patients who previously didn’t have a long-term treatment option, Dr. Schwab?
Dr. Frank Schwab:
Yeah, so great point. I think one other thing to call out, I think is important, there are a number of technologies that are coming to the market that are there to either mask pain or cover up to a certain extent and are focused really on the perception of pain. You, one example is, for instance, dorsal stimulators or spinal cord stimulators that are so often called. But this is very different, this is not a therapy that is directed at masking pain or treating the perception of pain. This is really to treat an underlying dysfunction and muscle. I think that’s important that people don’t think, well, gee, it looks like it’s an electronic device and it’s got some wires and there’s some stimulation. So very different from other technologies, and I think that’s super important to call out. So the question that you brought up, I think what’s the economic impact, right? And important to recognize that there is a societal impact of patients with lost days of work and inability to work at a high level, the consumption of healthcare resources for these patients who have now talked about pain for many, many years and are taking medication, many of them taking opioids and requiring injections and physical therapy, so substantial cost, and in these patients, it at best holds their pain at a certain level. What this new therapy offers is the ability to discontinue strong medications. In fact, a substantial percentage of patients, about 70% of patients in one of the studies reduced or altogether stopped opioid use. So really dramatic reduction in opioid consumption, a reduction in physical therapy, a reduction in pain, increased workdays. So the economics are rather compelling when you can develop a therapy that doesn’t just mask a symptom, but actually addresses the underlying dysfunction and gets these patients back to a normal level of function, and that’s what’s pretty dramatic. So I think when you’re thinking about the economics, any therapy or intervention has an upfront ticket if you will, a cost, but if you have durability in the relief of symptoms and if you start eliminating things like opioids and mistakes from work and injections, physical therapy, over time, with durability, it can become very cost-effective. And some of the latest data, which is really exciting with ReActiv8, has shown that patients respond in that sort of 6 to 1 month, a six-months to one-year mark, but there is continued improvement to years, and further improvement out to three years. So it really has durability, and I think that’s the remarkable part of this. It’s not a Band-Aid, it’s not a short-term fix, it’s a long-term solution.
Saul Marquez:
That’s fascinating and a relief to hear that there’s an option that addresses the actual cause, doesn’t mask it. What’s a surprising lesson that’s come out of your work in this therapy, Dr. Schwab?
Dr. Frank Schwab:
So, I think what surprised me initially, because I’m kind of a distrustful guy when you’re bombarded with all sorts of new technologies on a regular basis and was impressed with the response rate initially from patients of some of the FDA trial work that was done. But what really surprised me was that patients not only got a little better, they got substantially better, and over time showed increasing benefit. And a lot of therapies we apply there’s sort of a near-term benefit and some of those benefits fall off over time, and here’s a therapy that really stood out as showing durability but also ongoing further improvements in patient self-reported function. So pain, yes, but also function, we talked about that earlier on. I think that’s a critical distinction. Yes, they feel better, but they also function better and they can get back to doing a lot of things that they couldn’t do before. And I think to me, that was probably one of the most surprising things. I’m a spine surgeon, as you know, and over the years have become more specialized and less you get more senior, you tend to get more and more complex cases and revision cases, and there was always this one tool missing where we don’t want to fuse the patient, we don’t want to disrupt normal anatomy. We don’t need to decompress something. But gee, if we could find a way to just get that spine to function better and get those muscles to fire better, and here’s kind of this aha moment like, wow, looks like we found that therapy. So that’s been the most surprising, that it’s a therapy that really rehabilitates the muscle and has durability and in fact, increasing effectiveness over time.
Saul Marquez:
That’s fascinating. Yeah, and you know, a question that just occurred to me is, you know, so let’s just say you have a patient that’s been previously operated and they start experiencing that, you know, adjacent level pain. Is this something that could help with that?
Dr. Frank Schwab:
That’s a great question. So I think at this point, the regulatory landscape is such that it’s really for a very specific, indicator for a very specific group of patients, but I share your curiosity. And then I do believe that there is going to be an opportunity to apply this technology to other patients, whether it is patients who’ve had previous fusions or previous laminectomies and now have a dysfunction in a muscular sense in pain, or together with, synergistically with other procedures where you may say, well, gee, I have to stabilize one segment of the spine that’s unstable, but want to limit the intervention. Maybe we can combine a partial stabilization or decompression with this technology that also enhances muscular control and with that a function for the patient. So I think there are a lot of exciting things coming towards us. I think at this point there’s a very narrow indication, but over time, we’ll learn a lot more about the technology.
Saul Marquez:
That’s fantastic, thank you for that. Yeah, you know, and when you get a technology like this that addresses the problem, it’s awesome. When you don’t have to chase symptoms, you get to the cause, it’s exciting. And the question that has to be asked is cost, right? So what’s the difference in cost to address chronic low back pain with traditional methods versus this method?
Dr. Frank Schwab:
Yeah, so cost analyses are complicated, right? I think you need to think of what is the immediate near-term cost, what is the intermediate-term cost, and what is the long-term cost? And if we look at calculations of incremental cost-effectiveness or comparative cost-effectiveness, I think it’s really important, particularly for this population that’s a chronic, low back population, to say, well, what are the last ten years of care? What have they cost? What do we project that current therapies will continue to cost over the coming years? And then what is the near-term cost of this technology? But if it has the durability, then what is its cost-effectiveness over, let’s say, a three-year period or five-year period? And I think a lot of those analyses are still ongoing. I don’t think we have a definitive answer where the break-even point comes, but based on the effectiveness that I’ve seen and the dramatic improvement in patients, I would venture to say there will be some mark, whether it’s a year out or two or three years out, where we say, wow, now this is really, compared to traditional care or current care, this is absolutely cost-effective. And if it has that durability that we’re seeing, it will continue to show a dramatic economic benefit over the long term.
Saul Marquez:
Thank you, yeah, it’ll be a conclusion that we look forward to learning more about, and maybe a year from now or two years from now, we’ll be able to explore that topic. Dr. Schwab, this has been fun, thank you. You’re obviously a legend in the space, so appreciate you coming on to talk about this. For those of you guys that don’t know, in the spine world, Dr. Schwab is a pretty, he’s like a rock star. So, it’s great.
Dr. Frank Schwab:
You’re making me feel really good today.
Saul Marquez:
It’s great to have him here. What call to action would you leave our listeners with and what’s the best place for them to follow your work and learn more about you?
Dr. Frank Schwab:
So I think a couple of things. One, Northwell I think, has a real innovative approach to low back pain care and spine care overall, as you know, we’re a substantial healthcare system in the Northeast. So lots of great information about Northwell and about our orthopedic and spine care program that people can follow. I think regarding this technology, there is a lot of information that is going to be coming out, some of it through traditional channels, through education and training, some of them at the larger conferences, and certainly a lot of it online. So there’s lots of ways to learn more about this and to kind of follow the story, and it’s an exciting one, so I encourage everyone to keep your ears open.
Saul Marquez:
Love it, appreciate that. Folks, make sure you check out the show notes on today’s episode with Dr. Schwab. We’ll link you up to all of the great things that we chatted about today, as well as resources and links to continue your learning on this topic. Dr. Schwab, thanks again.
Dr. Frank Schwab:
Thank you very much. Have a great day.
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