Are our tools any good?

Are Our Tools Any Good?

Are our tools really the problem—or are we just not using them well?

In this thought-provoking episode, Dr. Fred Bagares, DO, takes a closer look at a recent study questioning the effectiveness of common spine injections like epidurals and facet blocks. While headlines suggest these tools are failing, Fred challenges the deeper issue: our mindset and misuse of short-term solutions in chronic care.

Drawing from over a decade of experience in musculoskeletal medicine, he unpacks the flaws in current research design, the burnout these studies provoke in physicians, and what truly leads to lasting recovery for patients in pain.

If you've ever wondered why spine care feels stuck—or how to bridge the gap between short-term relief and long-term function—this episode is for you.

🔑 What You'll Learn:

• Why injections are misunderstood in both research and real-world care
• The difference between tool failure and clinical failure
• How to help patients thrive between months 4–12, not just days 1–30
• The long-term value of coupling procedures with lifestyle changes

🩺 Ready for care that looks beyond the quick fix?
Visit mskdirectvb.com to work with Dr. Fred and get a personalized plan that moves you from pain to progress—one joint and tendon at a time.

Let me know if you'd like versions for Instagram, YouTube, or your newsletter too!

🗺️ Plan (Episode Breakdown):

[00:00:00] — Introduction
Dr. Fred opens by reflecting on the enduring challenges and evolving questions in musculoskeletal medicine.

[00:00:33] — New BMJ Study Sparks Debate
A recent study questions the efficacy of interventional spine procedures, igniting pushback from pain physicians.

[00:01:59] — The Real Worry: Insurance & Burnout
Research impacts reimbursement. Physicians feel pressure from both science and the system.

[00:03:20] — The Central Question
Are our tools truly failing—or are we failing to use them effectively?

[00:04:00] — Generational Gaps in Practice
Younger clinicians chase high-tech procedures; Dr. Fred prefers effective, simple tools that fit his population.

[00:05:53] — Short-Term Tools, Long-Term Goals
Injections are short-term tools—but they have a clear role when properly explained and integrated.

[00:06:57] — Unrealistic Expectations in Research
Comparing short-term treatments over long timelines leads to misleading conclusions.

[00:08:59] — Missing Piece in the Research
Why aren’t more studies looking at injections + therapy instead of one or the other?

[00:09:48] — Our Job is to Guide Through the Middle
Short-term tools should be the bridge to long-term solutions—like movement, nutrition, ergonomics, and lifestyle.

[00:10:58] — The Bigger Healthcare Cost Crisis
Spine care is expensive. And without deeper change, the system keeps cutting and blaming the wrong things.

[00:11:41] — New Tools, Same Problem
Fancier devices and techniques won’t fix the real issue: a lack of long-term follow-through.

[00:13:02] — A Lesson from Surgeons
Veteran clinicians succeed not because of new tools—but because they know how to choose and support the right patients.

[00:14:58] — Final Thought: The Real Question
It’s not whether the tools work—it’s whether we’re using them to their fullest potential, in service of long-term health.

Transcript

0:00

What is rehab or rehabilitation? My name is Fred, be Garris, a board certified sports and spine medicine physician in Virginia Beach, Virginia. After 10 years of practice, I still find musculoskeletal medicine both fascinating and challenging. I. This podcast is about the lingering thoughts and questions I've had after residency and fellowship. My hope is to spark discussion, challenge, dogma, and share my experiences in musculoskeletal medicine. Welcome to The Talking Rehab Podcast. I. Every couple years, there is a paper that comes out regarding interventional spine injections and it's efficacy. I'm talking about your classic epidural steroid injections, face injections, radiofrequency ablation, things of that sort. And recently a new, article came out in the British Medical Journal, discussing commonly used interventional procedures for non-cancer, chronic spine pain. And the results. essentially said that these type of procedures are ineffective, quote unquote, Pain physicians obviously got really upset because this is essentially what we do on a day-to-day basis. there's a lot of uproar, a lot of, people starting to write letters to the editor, things of that sort. And, I was talking with one of my colleagues about how this is an outrage and the main concern is not only that, it is it. It demonstrates from a research standpoint that, the procedures we do on a day-to-day basis do not seem to make a long lasting effect. that's number one. But number two a lot of us feel that these injections are extremely helpful and the research does not support it. So it gives us a little bit of, cognitive dissonance essentially. But, lastly, the last thing. Lastly, one of the other major concerns is that insurance companies will typically take papers like this. no matter what the, how they're structured, how well they're designed, they will take the literal words and basically use it as, justification for denial of care. And that's a big deal. it's not nothing but, Again, my colleagues were, really upset about this paper. it's just one other thing in addition to burnout and the administrative stuff that they have to deal with. And the last thing they needed was a paper, with authors in the field. basically. Finding a negative, or reporting a negative study. and that doesn't obviously make us feel very good, but what a lot of people fail to remember is that this is not a new finding, at least from a research paper standpoint. They were doing similar studies like this 10 plus years ago. a big one came out around the time I was in fellowship. And had very similar findings. it was done, and print. It was a very similar paper. they looked at essentially a pretty wide range of patients, pretty wide range of conditions, and found that these interventional spine injections, are effective but aren't necessarily better compared to other treatment options. The questions that trigger today's episode are these tools? truly failing? Or are we failing to figure out how to make these tools work? So I'll say that again. Are these tools actually failing or are we just failing as clinicians to figure out how to make these tools work? I've been doing these type of injections for 10 plus years, and I came from that generation of kind of old school bread and butter, type procedures. when I talk with these new grads coming out, look at the new papers, there's a lot, there's a lot more technology out there than When I was in fellowship. And I never really picked up those procedures. number one, when you're an attending, it's, you can do weekend courses, but some of these procedures, I believe need more than just a weekend course. So I just never really felt very comfortable, taking on some of these more complex type procedures without, actually being in a fellowship. sure, you can learn on. On a weekend, but again, I tend to be a fairly conservative person. Didn't think it was the right choice for me, but again, I also was not really finding the need to, I. To come up with different tools. I see different populations, different ages, And the tools that I have seem to work pretty well. And if fancy tool, a new fancy tool comes out on the market, I do learn about it and I talk with people using it, It's interesting, but I don't really see how it fits in my particular practice. But as I'm talking to some of my colleagues, they, it's, it seems like they have a different population compared to me. It seems that way. they're like, oh, you know this, they'll describe the perfect type patient that is, the perfect candidate for a verti flex procedure or, some discogenic procedure. Spinal cord, modulation, things like that. And I just never really saw that particular patient. I know they exist out there, but I always was able to find. a tool that works for that particular person. And so I never really found the need to do more, and I'm not opposed to referring my patients to, some, for some of these procedures, but I. Again, it, I just thought it was interesting'cause I've been doing, I see the same population that they do. they may see more complicated patients to compared to me, but on the whole, I just seem to find a way to get people better and, yeah, that's, that One of the, my personal hangups with a lot of these studies is that, you can pick any of these interventions, epidural injections, facet injections, ablations, things of that sort. these are relatively short term. I. short term, tools, these are things that can work predictably. they can be very effective long term, but, at the same time, even in the best case scenario, they are expected to work for a relatively short amount of time. So we're talking, maybe less than three months. some people do get much longer effects on people. It's a home run. But on the whole, when I get an, I inject, when I give an injection to somebody. I set up the expectation that this is a short term tool, that fits into a bigger game plan. But when they do these studies, they, they compare like, let's say an epidural injection compared to, physical therapy, let's just say that. And, what they find is that, the epidural injection is very effective for controlling acute pain. But at 12 months people do roughly about the same. And the conclusion there is that, oh, we'll see. There's no significant benefit at one year. And that's true. and in my clinical practice I find that to be the case. but at the same time, physical therapy is not meant to be a long-term solution either. same in terms of like people going to physical therapy for about a year, people will go for, six to 12 sessions. They'll feel better. But then if you measure them at about a year. They also the treatment effect also seems to fall off, but when people hear, how it does against an epidural injection, they draw the conclusion that the epidural injection isn't necessarily better. and it's not, but at the same time, it has a very specific treatment effect. And goal, it's not meant, it's not a magic injection that's got meant to last, two years. Similarly, six to 12 sessions of physical therapy can be super effective, but there's not a lot of treatment in the musculoskeletal world that will have a long lasting effect, for 10 plus years. So I don't think that it's a realistic, From a study standpoint, I think there's an issue with our overall expectations and how we interpret the actual data. these are short term tools being compared to short term tools. Now, interestingly, I did talk with a researcher, not gonna name them, several years ago, again, talking about epidural injections, facet injections, and I said, have they ever done a study? Where they did, one group got an injection. At this point, it doesn't make a difference what kind, let's just say any injection. And the second group got an injection plus physical therapy, and this primary author said no, but that would be a good study. And that paper eventually did come out maybe about seven years after I asked that question. But. I was just really shocked. That was not a study that has had come out at that point to me. Anytime I do. In intervention, it's usually coupled with something. And I think that's where people tend to get stuck is that, particularly with people being more interventional, they like to just do procedures and from a patient standpoint, they just like to receive stuff. No one really likes to do extra, but when you treat a chronic, a potentially chronic problem like spine pain with short-term tools, you can only guess what kind of result that you're gonna get. it's going to be short-term relief. It's never really going to do it for forever. the real magic happens when you take the short-term tool. Get yourself comfortable so you can do other things for a long-term solution. Things like generally living a healthier lifestyle, sleeping better, eating better, keeping our weight down. learning different ways to use our back learning, our personal environments. in, in terms of workspace and recreational space, sometimes, we have to adjust the things in our spaces to be in a better position so it doesn't bother our back. But realistically, humans don't really do that. We just say, Hey. Gimme an injection. I have pain, gimme an injection, make it go away. Now that it's gone. I don't have to adjust anything in my life. And again, that's a very shortsighted way of receiving the injection. But even from a clinician standpoint, it's a very shortsighted way, for us to treat our patients. And that's where I see. Why these papers come out is that spine pain is one of the most debilitating conditions in the world, but it's also one of the most expensive. the cost of time off injections, physical therapy, surgeries, postoperative recovery, complications from surgeries, complications from just about anything. It's super expensive. So I understand why. these type of procedures essentially are on the chopping block. every year there is some sort of cut in reimbursement with respect to interventional pain. there's more of these negative studies and the clinical, community, their main response is just to write to the editor and, print this retraction, so on and so forth. And again, they're chipping away at the wrong problem. I, I. I've been practicing 10 plus years, and I do see these younger grads coming in and they're just super interventional. They're not really working on all the other long-term solutions, and so what they end up doing is that they, they learn the bread and butter. Then a new fancy technique, interventional spine technique comes out. Again, it's a short term tool. It's a short term tool. even some of the minimally invasive spine stuff, the medical devices that are going in, into, the spinal column, the non-surgical solutions, but these minimally invasive solutions, it's the same thing like you put the device in, it helps temporarily, but if you don't make all these other changes, it tends to just land in the exact same spot. At the 12 month mark. overall, I think it's a really good question as clinicians, to ask ourselves are these tools actually failing? Meaning is there really no. Is you take intervention, x you test one group, you test the other group. one group gets the treatment, the other one doesn't get the treatment. group X that receives the treatment has a short-term benefit at three months, but then long-term it, they wash out, So did the tool actually fail? I would say probably not it, if you had acute symptoms, acute pain, in that three month period. maybe it did its job. The problem is that what happens from, not months one through three, but from four through 12, what happens in the other nine months? that's really the goal. I think as clinicians, we keep waiting for papers to show that our short term tools actually last lifelong, and that's just completely unrealistic. I, if anything, I do hope that people are. Working and adding to these tools, not necessarily just learning new shiny ones, and it's, maybe I'm just, a lot more experienced now, but I see similar, a similar phenomenon in some of the older surgeons. these new techniques come out, but at the end of the day they, you talk to an older surgeon, they can tell you what's going on. They can tell you. Yeah, that's gonna work. That one's not gonna work just because that they know that, again, I'm not a surgeon, but I have talked to them over the years. The older surgeons know that the secret isn't necessarily the surgery. It's knowing who not to operate on and. The ones that you do operate on, you know that these are the most well adapted patients, so these are almost like the quote unquote perfect patient that's going to do lifelong because they have the skills not only to survive the surgery, but they know how to manage their backs from months four through 12. So it's not necessarily they're doing, they're not actually managing the postoperative period, for the rest of their life, but they have developed a sense on who, what kind of patient, profile. It can take care of their backs, and that's who they pick to operate on. It's a similar thing with interventional spine injections. It does also come down to patient selection, but selecting the person, the best person, to receive your treatment, that's, I don't wanna say it's easy, but that's a, that's a relatively small population. There's a lot of people that need more than just the injection. And so I find, I think that the people, I think that the goal of the clinician is not to find, the perfect patient. It's to learn how to manage. All the full spectrum, of complications, are complicated or maladapted patients. Those are the ones that need the most assistance. And, that's again, part of my drive to do this podcast is to raise awareness that, there's a lot of information out there. Yes, the injections are a short term solution. yes. Surgery sometimes is a short term solution. You have to find someone who is going to walk you through months four through 12, not just someone who's gonna do the injection. Just do the surgery. the goal to reclaiming your body, reclaiming your independence. I. It happens way past the intervention. So just something to think about, are we, failing to use these tools correctly or are we failing to find ways to use these tools successfully? Anyhow, thanks again for listening. I hope you guys enjoyed this one. if you have any questions, you know where to find me. Take care. Thank you for listening to The Talking Rehab podcast. I hope that this podcast stimulates you to question your own practice and how you approach rehabilitation. I truly appreciate your time and attention. If you enjoyed listening, make sure to like and subscribe to the podcast. I wish you a movement filled day. Take care.