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Keith's Korner

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  • #46
    Wonderful analogy Keith - for many reasons.
    Barrett L. Dorko


    • #47


      Barrett inspired me here, to write this:

      Over the last few years, whenever I (or my colleagues) witness the sharing of erroneous or outdated information on television, in print or through various other media, we complain among ourselves about the power of the culture around us and how we have little influence in changing the perceptions of those not directly involved in our care. Worse still, the patient’s who do receive our care have often been inundated with nocebic information and have entrenched beliefs about their conditions that are challenging (if not impossible) to influence or change. Among the most egregious, in my estimation, is the continued reliance on postural and biomechanical models to explain the occurrence, prevention and treatment of acute and chronic low back pain (LBP).

      While I admire Dr Richard Besser for many of his positive contributions on television and online (for instance, his engaging individuals on twitter this week regarding the safety and efficacy of vaccinations) I found the information being presented last week (specific to LBP on The View and LIVE with Kelly and Michael- links can be found at the bottom of this post) was difficult for me to watch. For instance, there was a graphic of a lumbar spine with the vertebrae outlined in blue with disks that were bright red – I understand the impact of seeing ‘red’ discs rather than white and how this engages different thoughts and emotions in the viewer. There was talk of the spine collapsing. The segment lacks information to inform the audience that disc bulging and degeneration are normal and part of the aging process – not necessarily painful. There was an over-emphasis on posture, and the ‘right’ or ‘perfect’ way of positioning one’s self, as if such things existed – allowing the viewer to blame themselves for their eventual/likely episode of LBP. I decided that this time, unlike all of the other times in the past, I would not sit back and complain in an echo chamber, but instead, try to make a difference.

      Of course, I am an anonymous home care PT blogger with little influence or credibility – and I intend to remain that way. My hope is that a positive online response to the letter (if there is one) will lend it credibility. I have no interest in making a name for myself or engaging in an ongoing dialogue with people who disagree with the views expressed here for an extended period of time (although I will certainly do so for a while). I simply wish to respectfully share information that I have learned with another educator who may not be privy to the information in hopes that he might consider sharing it with a wider audience.

      In regards to the segment on The View, I also wish to be clear that I have no previous knowledge or understanding of Ms. Goldberg’s complaints or her medical history. I acknowledge that there very well may be a primarily biological explanation for her painful complaints, and I am pleased to hear that she is recovering. However, the information that was provided on her television program (as well as LIVE with Kelly and Michael) was presented to a general audience and was not presented as being specific to Ms. Goldberg, per se; as a result, I found that much of the education surrounding the ’causes’ of LBP to be inaccurate and incomplete.

      Insomuch as we understand that psychological and social factors play a significant role in the patient’s pain experience, and we understand that the brain often works via predictive modeling, it becomes increasingly important to change the narrative away from an incorrect view of LBP as a bio-mechanical and postural phenomenon and instead begin to have an honest conversation about the complexity of pain, rather than falling back on tired, outdated cultural memes…the letter linked below is my effort to try to push the narrative in the right direction. Without it, there will be more examples (similar to these) of people thinking their back hurts due to the absence, or incorrectly positioning, of a lumbar pillow.

      (see link for picture)

      I acknowledge that none of us are perfect; I do not expect perfection from Dr. Besser. As my letter reflects, I am pleased that he emphasized the importance of movement to manage and reduce LBP in both television segments. Additionally, he mentions red flags and when it is necessary to see a physician on his appearance on LIVE with Kelly and Michael. Unfortunately, however, I find the information on posture to be too potentially iatrogenic to remain quiet on the subject.

      Please, if you think it is important to change the narrative – to shift the thinking, beliefs and how we discuss LBP in this country – I ask that consider tweeting/re-tweeting information pertaining to this letter and the television segments to colleagues and to Dr. Besser as appropriate. Open up your own bookmarks and share the data, resources and references that you have as well. I ask that you help in broadening the conversation to a wider audience and help add a little credibility to an anonymous home care PT who is trying to get the word out. #talkLBP
      Blog: Keith's Korner
      Twitter: @18mmPT


      • #48
        THE LETTER


        A version was floating around SoS for a few days - this is the published product:

        Dear Dr. Besser:

        As a home care physical therapist, all of my patients are necessarily homebound. As a result, most of them watch daytime television to pass the time and many have had opportunities over the course of the last week to watch your appearances on The View as well as LIVE with Kelly and Michael. Nearly all of my patients suffer from painful conditions; some of their complaints are specific to back pain. With that in mind, I would like to – respectfully – share with you some of my frustrations with the information that you have recently shared with your audience about low back pain (LBP).

        Firstly, I appreciate that your role on each of the aforementioned programs is to inform – while being captivating and entertaining – in a very short period of time. In each television segment, you were afforded approximately 4 minutes to speak on a very complex subject and I am quite certain that few people have the requisite skills to pull off such a demanding task (I know that I don’t).

        Secondly, it is great to hear respected medical professionals speak frankly on television about how movement – not rest – is important for the resolution of painful problems. For far too long, people have been (unsuccessfully) managing the onset of painful neuromusculoskeletal complaints with passivity, rather than actively participating in healing/wellness behaviors. Kudos to you for bringing forth this information to your viewers.

        What I found to be disheartening, however, was the perpetuation of some potentially iatrogenic myths surrounding LBP, and the language/terminology that was used in each broadcast.

        One of the biggest myths (1) that has been thoroughly vetted by research is the notion that LBP is correlated with strength (2), lumbar (3) or cervical (4) posture and/or degenerative changes (5,6). While it certainly makes sense mechanically when we look at spine models, and the physics seems intuitive, the literature does not support the idea that postures are a significant ‘cause’ of LBP. As a result, to claim that there is a proper or (in your words) ‘perfect’ way to position oneself, and that to attain or maintain a less-desirable posture is somehow necessarily ‘bad’, is simply not supported by the evidence that we have available to us at this time. Unfortunately, it is my experience that the provision of such advice has unintended consequences including the patient blaming themselves for their painful condition and forcing themselves into ‘proper’ postures (as you defined on recent broadcasts) when they begin to experience pain, even if the position is a painful one.

        The scientific literature now informs us that pain is multi-factorial bio-psycho-social experience; therefore it is terribly important to be sure not to assert that we know of any one particular ‘cause’ of an individual’s pain in the absence of obvious pathology (Ronald Melzack has done some strong writing on the subject). This view of pain as an output of a neuromatrix (as coined by Melzack) affords us the opportunity to understand pain as something more nuanced than the traditionally dualistic view may provide and instead allows us to see pain for what it is – the brain’s response to a perceived threat that may or may not be the direct result of nociception.

        As science/medical educators (you on a far larger scale than I), we understand and appreciate that the words that we choose have a significant impact on the views and impressions of our audience – for you this is a national television audience, for me it is a patient with their family or caregiver in their home. In each instance, when we discuss pain, it should be imperative for us not to use the word ‘cause’ when discussing painful conditions while (at the same time) avoiding the inappropriate conflation of nociception and pain. It is also important to use consistent language (e.g. disc bulge, disc herniation, disc sequestration) without providing a nocebo to those who we intend to help. We need to inform people that degenerative changes are a natural process of aging that need not necessarily be painful and (as you mentioned in each segment) encourage individuals to maintain healthy and active lifestyles.

        We now understand that pain is a bio-psycho-social experience with a multitude of factors that play a role in the patient’s unconscious assessment of whether their personhood is threatened. Meanwhile, as discussed on LIVE with Kelly and Michael, the prevalence of LBP is staggering and traditional/postural models on the prevention and treatment of LBP continues to fail to reduce the financial burden that such inadequate care places on our health care delivery systems. It is with that in mind that I ask you, sir, to please consider moving the national conversation forward and stepping away from the traditional, dualistic, nociception-is-pain model and share a new model of thinking with the general public. Instead of teaching a scientifically tenuous biomechanical model that focuses on static postures while encouraging the patient to fear particular positions or movements, I ask that you instead consider teaching others how they are strong, robust, self-healing and incredibly adaptive; to think of the person’s pain experience not as the necessary result of nociception, but rather a complex interaction between biological, psychological and sociological variables. But mostly, I ask for you to be an informed voice of reason for my home-bound patient in pain who is still trying to understand why they hurt like they do.

        If you have any continued interest on the subject, I would like to kindly mention that one of the leading researchers and science communicators on pain, Lorimer Moseley, is going to be traveling from Australia to visit San Diego, CA for a conference in February this year; there are few who can equal his communicative skills and knowledge of pain science.

        Keith P., PT
        References are hot-linked on the site.

        Please - do what you can to get the word out - #talkLBP

        Blog: Keith's Korner
        Twitter: @18mmPT