Month: August 2016

Not all back pain has a definitive cause

“Findings such as disk height loss and disc bulges are coming in individuals without low back pain.”

Disc bulges, degenerative joint disease, spinal stenosis, do you all a result of living in this world. We have gravity acting a force on us almost 16 hours a day. Anytime that there is a problem, we want to blame something or somebody. Low back pain is an enigma at times. we can draw correlations, we can come up with risk factors, we can even tell you how to treat it sometimes, but what we can’t do is tell you exactly what causes your back pain.

“Surprisingly, disc protrusions were associated with a lower risk of subsequent back pain. Nerve root contact and central stenosis had the largest hazard ratios on baseline imaging findings, and they were associated with incident back pain in the expected direction but not statistically significant. Self identified Depression was the strongest predictor of subsequent back pain, with a greeter hazard ratio than any imaging findings.”

What should be taken from the above statistics is that mental health plays a role in pain. There are a lot of new studies that are associating catastrophizing and external locus of control with increased pain levels. Work by Nadine Foster demonstrates screen for patients who will have a difficult time improving with therapy alone. New were books, such as the one by Annie O’Connor and Melissa Kolski (two people with whom I’ve studied at our RIC), goes into great detail regarding pain science. Big picture, we can not neglect the patient’s emotional well-being when attempting to treat the patients physical complaints.

“Our results indicate that depression is a strong predictor of who will subsequently reports low back pain then baseline imaging findings.Subjects with self reported depression at baseline were 2.3 times is likely to have back pain compared with those who do not report depression.”

There is obviously a psycho social component to low back pain. The question is… Chicken or the egg. Is a person more likely to be depressed because they have back pain that is not improving? Or is that person more likely to have back pain because they are depressed? I don’t think that there are cause and affect articles in the literature at this point, but there is definitely a high correlation between patients who are depressed and patient who continue to report low back pain.

“In our analysis of baseline data, we concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings related to prior low back pain. Our current analysis indicates that central stenosis, disc extrusion, and route contact may also be risk factors for future low back pain.”

In other words, if you have a major deformity you will probably have pain. This doesn’t mean that you will definitely have pain, it just increases your risk of experiencing symptoms.

The moral of the story is that we cannot deny the brain. The brain has the ability to see pain, and some patients are more susceptible to seeing this pain. Don’t get me wrong, a thorough mechanical evaluation should be performed when a patient has pain, but when this patient is not inclined to respond to mechanical therapy, the patient should be referred to someone that can better handle this patient’s pain.Sometimes, that person will be a behavioral therapist, a psychotherapist, or a clinical psychologist. Physical therapists are not always the go to in order to treat a patient’s pain.
Excerpts from:

Jarvik JG, Haegerty PJ, Boyko EJ. Three-Year Incidence of Low Back Pain in an Initially Asymptomatic Cohort. Spine. 2005;30(13):1541-1548.

Know your strengths and weaknesses

“Findings such as disk height loss and disc bulges are coming in individuals without low back pain.”Disc bulges, degenerative joint disease, spinal stenosis, do you all a result of living in this world. We have gravity acting a force on us almost 16 hours a day. Anytime that there is a problem, we want to blame something or somebody. Low back pain is an enigma at times. we can draw correlations, we can come up with risk factors, we can even tell you how to treat it sometimes, but what we can’t do is tell you exactly what causes your back pain. 
“Surprisingly, disc protrusions were associated with a lower risk of subsequent back pain. Nerve root contact and central stenosis had the largest hazard ratios on baseline imaging findings, and they were associated with incident back pain in the expected direction but not statistically significant. Self identified Depression was the strongest predictor of subsequent back pain, with a greeter hazard ratio than any imaging findings.”
What should be taken from the above statistics is that mental health plays a role in pain. There are a lot of new studies that are associating catastrophizing and external locus of control with increased pain levels. Work by Nadine Foster demonstrates screen for patients who will have a difficult time improving with therapy alone. New were books, such as the one by Annie O’Connor and Melissa Kolski (two people with whom I’ve studied at our RIC), goes into great detail regarding pain science. Big picture, we can not neglect the patient’s emotional well-being when attempting to treat the patients physical complaints.
“Our results indicate that depression is a strong predictor of who will subsequently reports low back pain then baseline imaging findings.Subjects with self reported depression at baseline were 2.3 times is likely to have back pain compared with those who do not report depression.” 
There is obviously a psycho social component to low back pain. The question is… Chicken or the egg. Is a person more likely to be depressed because they have back pain that is not improving? Or is that person more likely to have back pain because they are depressed? I don’t think that there are cause and affect articles in the literature at this point, but there is definitely a high correlation between patients who are depressed and patient who continue to report low back pain.
“In our analysis of baseline data, we concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings related to prior low back pain. Our current analysis indicates that central stenosis, disc extrusion, and route contact may also be risk factors for future low back pain.”
In other words, if you have a major deformity you will probably have pain. This doesn’t mean that you will definitely have pain, it just increases your risk of experiencing symptoms.
The moral of the story is that we cannot deny the brain. The brain has the ability to see pain, and some patients are more susceptible to seeing this pain. Don’t get me wrong, a thorough mechanical evaluation should be performed when a patient has pain, but when this patient is not inclined to respond to mechanical therapy, the patient should be referred to someone that can better handle this patient’s pain.Sometimes, that person will be a behavioral therapist, a psychotherapist, or a clinical psychologist. Physical therapists are not always the go to in order to treat a patient’s pain.
Excerpts from:

Jarvik JG, Haegerty PJ, Boyko EJ. Three-Year Incidence of Low Back Pain in an Initially Asymptomatic Cohort. Spine. 2005;30(13):1541-1548.  

Our we worth it?

“First, we must actually prove the value of our services, ourselves, and our profession. And we must do so objectively – with outcomes data. ”
I agree to a certain extent, that we need to prove our value with outcome data. Patients, so need to be educated on what this data actually means. We are slowly transitioning to a point in which patients are paying for a majority of their healthcare when compared to insurance companies. Co-pays are rising. Outcome data needs to be measured, but explained to patients in a way in which it makes sense. We do need to prove our value, but proving our value to patients will be completely different than proving our value to insurance companies.
“That that that tracking patient outcomes… The demand for this type of data collection has amplified in the last few months…”
The demand for this type of data is increasing from insurance companies. Do you think insurance companies are demanding this data in order to increase our pay? I highly doubt it. They’re demanding the data to determine whether or not therapy in actually valuable. I, as the therapist, sometimes question the value of physical therapy. Not all therapists practice alike, so is there one best practice? As a profession, we have clinical practice guidelines. Not all therapists are utilizing clinical practice guidelines. Can we weed out those therapists that are not using the guidelines, or can we coach up these therapist to ensure that they are practicing in a way that is supported by the evidence.
“… The federal government is not wasting any time and it’s quest to reduce healthcare spending that ”
We all know that our country is broke! if we ran our household in the same manner that our government runs the country, we would all be filing for bankruptcy. The government is trying to find ways to reduce costs. Healthcare appears to be one way in which to reduce costs. I am not saying I totally disagree, because as a country we spend a great deal of money on healthcare, but do not get the results commensurate with the spending. We have to find a way in which to incentivize good care to ensure that patients are no longer getting sick at the same rate they’re getting sick currently.
“So, in all likelihood, most – if not all – payments will be linked to value within the next few years quote
This same line has been stated year-to-year for at least the last six years. At some point I am waiting for the boy to stop crying wolf. I welcome the day when pay-for-performance actually takes place. Therapy consists more than simply ultrasound,hot pack, electrical stimulation, and massage. The best evidence we have is regarding exercise. It’s sad because not all therapist coming out of schools are proficient at analyzing, providing, and creating exercises in order to address the limitations seen during the initial valuation. I spend a great deal of time with the students that I have teaching them how to create and how to analyze movement patterns. They do not learn this very well in school.
“… There is a big difference between merely recording numbers and generating meaningful, actionable insights, because when you do the latter, you can achieve three really important things: ”
As a profession, we need to start by “merely recording numbers”. I started as a therapist in 2007, and during those first few years recording numbers was not happening. We have come a long way in utilizing functional outcome measures, but this is because insurance companies have forced our hand in order for us to receive payment. I do not believe that our profession would have policed itself into using outcome measures.
Excerpts from:
Jannenga H. IS PT VALUABLE? ONLY OUTCOMES DATA WILL TELL. IMPACT. June 2016: 46-51

Brother my Brother

Today’s blog is very different from any of those written before. This is an insight into my life, into my thought process, into my experiences, into those things that made me who I am. I started this blog to teach people about healthcare, but there is so many more things that people can learn from my experiences. I dictate today’s blog on my way to the cemetery. It’s a little bit more emotional than anything that I would typically write. 
 Life is precious. My brother is a fucking idiot, in 2008 he overdosed. He never really saw anything outside of Joliet Illinois. I want to live until I die. There is too much to see and too much to live for in this life. After eight years, I still think of everything that he missed out on. He missed out on having a family. My family is the greatest thing that ever happened to me. I would be my fathers son, I would be content to stay at home and work hard and live my life in that fashion. My wife loves to travel and loves try new things. If it wasn’t for her I would’ve never traveled to Europe, I may have never made to Alaska. If it wasn’t for my daughter, I wouldn’t slow down and slide down the big slide. I probably wouldn’t go to another waterpark, I probably wouldn’t climb in the tunnels at Odyssey fun world. My brother missed out on a lot, when I go visit cemetery it just my heart.. Life is precious. For those going through difficult times, Know that life is precious. There are people that love you and people that will miss you if you’re gone. I miss my brother frequently. Life goes on, and life will go on without you. I hate to say that because it sounds harsh but it will. I am happy, and unfortunately he’s not here to see that. 

At what age does dreams die? I don’t know that answer. At what age do we throw in the towel? At what age do we give up? I don’t know what was going through my brothers head those last days And it kills me eight years later. 
In memory of Michael Anderson. I miss you brother