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A little bit of crazy.

If you choose not to read this article, I will understand. This is an older article, from a journal that is no longer in publication, and on top of that…it is full of statistics and math stuff! I was bored reading it, so I would think that you would be bored with me summarizing it. Anyway, some people may be interested so AWAY WE GO!

 

Dionee C, Bright B, Fisher K. Clinical Characteristics of lumbar disc disease: Retrospective database analysis. International Journal of Mechanical Diagnosis and Therapy. 2009;4(3):3-10.

 

  1. “Approximately 80% of the population experience spinal pain at some point in life.”

This statistic is repeated over and over again in the back pain research and has been mainstreamed by places like MSN health and a quick google search regarding back pain rates. Putting this into perspective, 4/5 people will experience back pain during the lifetime. That one lucky person may have a genetic predisposition to avoid back pain or maybe they just do everything right. I know what you are thinking-“Those bastards”. I too have had back pain and sciatica, so I am also just a statistic, don’t feel bad.

 

  1. “most episodes of back pain are considered mild in nature and usually resolve within one month without medical intervention”

This sentence reminds me of a story. It’ll be good, at least it makes me laugh. I had a job once in which a patient with back pain would call to schedule an appointment. The lead therapist would do her best to get the patient into the clinic on the same day. This would cause me to work during my lunch, so I was none too happy. At a later date (after I had established myself as a work horse), I asked the PT “What’s the rush? Why not just wait until tomorrow?” To this day, the answer gave me a major insight into not just the business aspect of therapy, but the overall ability to “sell” patients on therapy. She replied, “The patient may be better by tomorrow and if we are going to get them better, the patient should at least believe it was because of us.” Now, I get it…this sounds a little disgusting, but I can honestly say that it was the worst thing that ever happened in the clinic that I worked at, which is much better than the stories that I hear from other PT’s. Remember, this is a business, for better or worse, it is a business.

Moving on, most patients will get better over time. When this is the case and I truly don’t believe that I am the “game changer”, I will let the patient know my thoughts and have a discussion about additional appointments. I can typically say with certainty that I am not making the patient worse, but if it is the case, then there will be no additional appointments. If the patient likes attending therapy and believes that therapy will play a role in the recovery, then so it stands. Therapy continues. There is this buzz word that is thrown around “Evidence Based Medicine”, and a part of this ideology is that the patient’s beliefs also play a role in therapy.

 

  1. “in the United States, annual costs for back pain range from 20-50 BILLION US dollars.”

One way to put this into perspective is to try to write all of these zeroes on a check. It’s pretty darn hard! This number is huge and continues to grow decade after decade.

 

  1. “Twenty percent of all people with back pain actually seek medical intervention and up to 25% of those patients seek physical therapy services.”

If you thought that the first number was big, then multiply it by 4-5 and you would have the actual cost of back pain alone if everyone with pain went to a physician or therapist. You can start to understand the business of healthcare. We all want a piece of the pie…I mean we all want to help society of course.

 

  1. “despite the increase in costs over the past 10 years, there has been no significant measurable improvement seen in patient care”

Let’s start by saying this sucks. I have one gripe about this and then I’ll move on. You may not know this, but when you go to a medical practitioner, you pay for your time there. I know, I know…this is obvious. You pay me for what I do to you or for you. This means that the more that I do for you, the more we get paid. Now, start to connect the dots. If I keep you for 10 visits, instead of 5 visits, I just doubled my pay from the insurance company. Well, really I doubled the company’s pay from the insurance company and I get paid the same regardless. There is a concept that is coming down the pike called “pay for performance”. This essentially means that if we get you better we get paid more and if we don’t, then beans and rice for us. You play a role in this. You have to shop around and go to the therapist that 1. You trust 2. Has the heart of a teacher (I stole this from Dave Ramsey) and 3. Is looking out for your best interests. You don’t have to go to a place that your doctor recommends; you have the power of choice. That was a long gripe…sorry.

If you don’t believe that money dictates treatment, our professional organization, the American Physical Therapy Association, acknowledged as much with a recent article.

http://www.apta.org/PTinMotion/News/2016/3/14/SNFsRACs/

 

Again, our ability to treat back pain is not keeping up with the costs that we spend on it. We need to get better at treating this problem, and there are many ideas floating around in the profession with the hopes of either helping patients or learning which patients will not get better with PT. We can’t help everyone and if a medical professional is selling a “miracle”, “amazing”, “astounding”, etc cure for back pain…walk away (or run if your back will let you). You will spend more than the cost of reading a book on back pain from your local library.

 

  1. “Physiotherapists also agree that classification of back pain is necessary to group patients with similar characteristics to determine more specific standards of care with improved clinical outcomes”

We all classify our patients. I remember reading “Oh Great Guru Tony Delitto” write this in a previous research article. Some people have a very rudimentary way of classifying patients. For example, treating a patient with whiplash after a car accident is a pain in the A$$ to treat because not only do we have to try to help the patient, but we also have to play the legalese game of whether or not the patient is just out for a big payday. This patient would be in the “Pain in the A$$” category. For real though, expert therapists are classifying patients based on more than just personality and external aspects of the patient’s case. For instance, I don’t hide that I practice MDT. This system utilizes the scientific method by playing with variables in order to classify and then treat orthopedic conditions. It is a great classification system in the hands of those that have studied and passed the test to use the method. You know what they say…”With great power comes great responsibility”. This holds true both on a personal level and on a societal level in order to do what’s best for the patient and the healthcare system as a whole.

 

  1. “for example, characteristics of increased psychological distress, anxiety, and fear-avoidance have been associated with severity of back pain, resulting in poorer clinical outcomes in these patients.”

I won’t be politically correct with this one. If you have a little bit of crazy in you, then it may take a little longer to help you if I can get through the forest of crazy-trees. We all come with baggage, myself notwithstanding. This plays a role in how much pain a person experiences because pain is a personal thing. I hear frequently patients tell me that they have a “high tolerance for pain and someone else may report a higher level than I would”. Patient’s say this with a badge of honor, not realizing that when you are in front of me, I am not comparing your pain levels with another patient’s pain levels. In front of me, your pain level is the only one that matters, but I still chuckle when patients give me this tough guy persona. If you’re in healthcare, then you understand.

 

  1. “Investigators have found that the disc ages rapidly within the human body at the vertebral endplate by the second decade of life”

I’ll give you the good news first, then the bad news. Your first 19 years on earth are going to be great. After the first 19, your body will start breaking down. You will limp when getting up in the morning, you will need a hot shower to wake up and feel limber, you will have a yearly supply of ibuprofen in your cabinet. Sorry…I don’t feel that old, but all of the above describes me to a tee. One of the PT professors at GSU describes getting old like this “when you are young, you are a nice and juicy filet. As you age, you become more like beef jerky”. I have to give Dave Diers, PT credit for this analogy. If you like it though, he got it from me!JK.

 

  1. “Physiotherapists use the diagnostic imaging information and clinical presentation of signs and symptoms to formulate intervention guidelines. But, the individuals with seemingly pathologic changes observed on MRI can profess no symptoms of back pain while other with negative MRI results can describe significant back pain and disability”

That’s a knee slapper! GASP! What this means is that imaging may not tell the truth, the whole truth, or nothing but the truth. We place so much faith in these pictures. A patient that only has pain during bending forward, but then has imaging performed while lying down (a position that is pain-free), may not get the true picture or the real problem caught in the image. It’s like trying to find a ghost on camera. Sometimes you get lucky and there is the black figure in the background staring at you, but mostly you get orbs and are trying to determine if it is dust or an actual ghost. Point being-imaging doesn’t tell the whole story. If you really want to have surgery, go get an MRI and I’m sure someone will find a reason on the MRI to operate. Getting off track…When a tissue is pathologically stressed, it will cause pain. This is described by another researcher (Willaim Boisenault) when discussing red flags and cancer. If there is no pain, then the tissue is probably not being stressed. If you don’t feel pain during imaging, then it probably won’t show the problem, based on logic.

 

You know what, I am done with this article. The rest wasn’t very interesting and I don’t want to bore you with the details, but the end result is the following:

 

  1. If you were in a previous accident and the onset of symptoms prior to receiving therapy is greater than 21 days, then you have increased odds of having a disc dysfunction.

 

  1. If you have a little crazy in you and you waited longer than 21 days to seek care, then you have an increased risk of discogenic dysfunction.

 

Until next time. I am actually very surprised at all I had to say on this article because I thought that it was overall very boring to read.

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Categories: Physical therapy

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