Do you kiss your mother with that mouth?

I recently had an editorial in the ISPI Newsletter (I am an instructor with International Spine and Pain Institute).  I wanted to reprint it here as well for readers.


I’m sure many of us used the phrase, “sticks and stones may break my bones, but words will never hurt me” as a child, heck maybe you still use it as an adult. This catchy phrase may be slightly inaccurate based on current pain neuroscience understanding and I propose we offer this more correct version in the future: “sticks and stones may break my bones and words will never harm me, but they can hurt me”. This is of course a play on the popular pain neuroscience metaphor of “hurt does not always mean harm”. We have a good understanding that harm (physical injury or illness producing nociception) is not the same as hurt (the brains output of pain). We actually have evidence showing that the words we use can change the hurt people experience.

In a recent study (Ott J, 2012) researchers found that words associated with pain increase the perception of pain during venous blood sampling. The authors came to the conclusion that words have an impact on the individual evaluation of external stimuli. This finding has been found in other research and fits into Melzack’s pain and the neuromatrix in the brain theory with cognitive related brain areas being inputs into the body-self neuromatrix that can produce outputs of pain perception.

Another interesting study (Beck JG, 2001) used a modified Stroop procedure to assess processing of threat
words in motor vehicle accident (MVA) survivors. The traditional Stroop color-word interference test looks
at reaction time while a participant is asked to name the color the word is printed in, but ignore the word itself. For example the word “red” might be printed in blue ink and your job is to say blue. You will see if
you do this you are inclined to say red and your response of blue is slowed, thus you experience interference.
You can check out Wikipedia for more on Stroop Effect, it’s kind of fun to do (well that is if you’re a nerdy nerve head like myself). So back to the study, they had three groups of MVA survivors one had no problems, the other had persistent pain and the third group had persistent pain and post-traumatic stress disorder (PTSD). The PTSD and pain group had slowed responses with both accident and pain words. While those with just pain had slowed response with just pain words not accident words and those individuals that had no symptoms saw no changes in their responses for either pain or accident words.
This study shows that there was some specificity to processing of words by an individual based on their condition.

So what can we, and should we, take away from such studies? The words we use can “hurt” our patients more than they already are. As health care providers we need to be aware of the choice of words that we use on a regular basis with our patients in pain. While using threat words such as herniation, rupture, tore, etc. with a person in no pain may not affect their neuromatrix to produce pain, but for those in pain it actually could.

Adriaan, along with Ina, David and Louie recently finished a paper that is waiting for submission (Louw, 2012) looking at the difference in the words we use with pain patients with pre-operative education. They looked at two different post-surgery pain education booklets. Booklet A had been shown to have no added benefit to outcomes or cost from previous research with surgical patients. Patients receiving Booklet B have
shown initial signs (from a case series and preliminary multi-center RCT data) to have improvement in function and decrease in pain catastrophization upon using pain neuroscience education approach (Yes, this is Adriaan’s PhD project and the same booklet you are aware of “Your Nerves are Having Back Surgery”).
They had a group of seventeen expert PT’s compare the use of provocative terms in each booklet. What was found that Booklet A had three times the use of provocative terms associated with fear, pain and anxiety compared to Booklet B that utilized the latest pain neuroscience education. The original study of Booklet A did not list the use of pain words as a possible reason why the study failed to show a difference in outcomes with or without the additional patient education. This study suggests that possibly the words we use during our patient education may make a difference in the outcomes we get.

So understanding this important piece of information, that words can hurt our patients, I get a little agitated with the choices some of my fellow health care providers choose to use when it comes to their words. Have you ever seen a patient that reports to you that the physician or some other health care provider stated that their back, shoulder or knee was the worst they had ever seen. Isn't it amazing how patient after patient we here this from, is each patient actually getting worse than the one before? After almost 20 years of practice it is amazing that patients somehow consistently seem to be progressively become the worst case month after month. A statement like this does not help a patient in pain in any way and only has downside as it is laden with fear and anxiety (two of the things we should be trying to reduce). While this kind of statement does give us, the health care provider, with lots of upside. Consider if they don’t get better it’s not our fault because it was the worst case ever; and if they do get better it only shows how good we must be to help the worst case ever. I think we can and should be able to do better for our patients.

As physical therapists we need to be aware and improve the therapist portion of our care just as much, if not more, then the physical portion of our interventions. One area of this can be done by paying attention to the words we use during our interaction with our patients. Avoid using threatening words in our explanations to patients in regards to diagnosis, etiology and prognosis from their current condition. These terms only provide the opportunity for the individual to perceive greater threat through the fear and anxiety interwoven into the meaning of them and enhancing the defender response (pain) from the patient.

Proper interaction and education can instill positive expectations and hope through the use of our language to our patients and not create negative connotations or threatening inputs to their body-self neuromatrix. The choice of the non-threatening language and words we use may be another avenue to provide input into the neuromatrix as an adjunct to our management and treatment of their painful condition.



References

1. Beck JG, F. J., Shipherd JC, Hamblem JL, Lackner JM. (2001). Specificity of Stroop Interference in Patients with Pain and PTSD. Journal of Abnormal Psychology, 110(4), 536-543. 
2. Ott J, A. S., Nouri K, Promberger R. (2012). An Everyday Phrase May Harm Your Patients: The influence of Negative Words on Pain During Venous Blood Sampling. Clin J Pain, 28, 324-328.
3. Louw A, Diener I, Butler D, Puentedura L. (2012). The Lanugage of Patient Education for Lumbar Radiclopathy. unsubmitted research.

Interview on Healthy, Wealthy and Smart

I had the opportunity to be on an internet radio talk show today - Healthy, Wealthy and Smart with Karen Litzy.  We talked mostly about using current neuroscience pain education with acute injury patients. 

You can listen to the taped recording at Talkalternative.com under Monday's Shows Healthy, Wealthy and Smart or clinic the link here and it should take you there.

You can leave any comments about the interview on the blog here, would love to get feedback.

Got a minute?

Here is a link to a news release about a study showing that sitting docs have happier patients.  The simple act of sitting in a patient room instead of standing in the doorway gave the patients the perception that the doctor spent more time with them and increased the patient's satisfaction score of the doctor.  The interesting thing was that the sitting doctors actually spent less time than the standing doctors.  A patient"s perception is the reality that us in health care need to remember.

It reminded me of information I had learned from a lecture by Peter R. Kovacek, MSA, PT.  He talked about the importance of being a productive therapist with your patients and to not let distractions interfere with your treatment (like phone calls, staff, or other patients).  When comparing the productive therapist to a lesser productive therapist in his studies it showed that the productive therapist would spend less time with the patient, but the patient perceived that they spent more time them.  While the converse was true for the lesser productive therapist who was more apt to let distractions interrupt the patient treatment time, the therapist spent more time with the patient, but the patient perceived that the therapist spent less time with them.

In today's busy health care environment it often seems like there is not enough time to spend with our patients that we want too.  We often feel rushed and let distractions get in our way.  But if we take a minute and sit down to truly listen to the patient and what their story is and manage our environment to limit distractions, we might find that we can spend less time with the patient, while giving the patient more of what they need.  Sounds a lot like a "Win-Win" to me.

So if we remember the primary things a patient wants during the initial visit:

1. What is wrong with me?
2. How long will it take to get better?
3. What can I, the patient, do?
4. What can you, the physical therapist, do for me?

If we sit down and answer that info for them, we are often starting down a path that is centered on the patient which will help lead to a positive outcome for the patient.

Share any stories of when you noticed a health care provider "sat and gave you a minute" or when the opposite happened and they "stood and gave you a second".  Offer ways that you make sure you "sit and give the patient what they need".

Too many options to change?

I just got done with an excellent book – Switch: How to Change Things When Change Is Hard. It is about how to help you create change things when change is hard.  One point that I thought was interesting and very true is that often when it comes to change we don’t give enough detail to help others with change.   We give vague answers to the questions others have and nonspecific direction to take when it comes to helping them get through the emotional and cognitive changes needed to make the change.   Let me give an example that is probably all too common in health care.  A person sees their doctor and it is finally at that point – borderline high blood pressure, beginning signs of diabetes and cholesterol is too high.   So what happens, usually they are given a blood pressure pill and cholesterol lowering medicine and told they need to eat healthier and start exercising.   I’m sure the first two are specifically given in a prescribed dose with recommendations on type of medicine to take.  The second two are left very vague.  The person probably takes the medicine as prescribed exactly and hopefully tries to exercise and eat better.  But the eating better and exercise probably go by the wayside after awhile.

Does exercise and eating right not get followed up on because people don’t want to do them, or because they don’t know what to do?  The book Switch detailed an interesting study:  There was a jelly stand in a supermarket.  One stand had 6 jams to pick from, the other 24.  People bought more from the jam display with 6 items compared to the stand with 24 items.  There were too many choices with the 24 item stand, and we go through “analysis paralysis” and just choose not to get anything since it is too hard to pick with so many options.  So do people take their medication since it is specifically directed in one way to do it, where as eating right and exercising has a few million options?  It is an interesting thought, to think about.

Just think if the patient was told to go to the drug store and get a couple of medicines with no direction, would they do it?  What if they were given specific guidelines on exercise and a precise diet to follow on a daily basis, would they be more likely to follow?

I love this quote I picked up from a therapy conference from my good friend and fellow Physical Therapist Mike Muffenbier: “Study principles not methods, a mind that can grasp principles will create its own methods.”  I use this often, as I want to understand the principle of how an exercise works or a specific mobilization or facilitation technique in therapy and not just blindly use it.  I need to understand the science principles behind it, so I can expand its use to the patient’s specific needs.  But I am now seeing I have been guilty in the past, maybe not helping my patients, because I might have overloaded them with tweaks to exercise to show them they can create hundreds of exercises from a few basic ones with utilization of Tweakology^TM principles I have learned.  I now see that might be like being at the jam stand with 24 options.  If they do not understand the principles, I need to keep the methods easy to follow.  Especially since in today’s current health system I do not get to follow up as I would like and continually progress a patient’s exercise program appropriately.  Yes learning all the various tweaks is maybe better for you (24 options), then just a couple of exercises (6 options).  But if this increases the chance of the patient making the change and doing the exercises, 6 of them, is better than 24 they do not do. 

It's hard for many exerciser's or those that want to start to exercise with so many exercises to pick from.  But we have to understand where most people are, which is lost in the endless sea of exercise options without knowing what to do.  This causes "analysis paralysis" and many choose to do nothing.  Our current culture does not help it any, just watch a few infomercials, stop at the local gym or fitness section of a store and you can easily see how most are probably overwhelmed with too many options. Plus ask 10 fitness/exercise specialist and there is a good chance you will get 10 different stories of the "best" exercise plan. Which is best for me? How do I know how much and what type to do?  This one says it is better because it burns more calories, but this one builds more muscle, which is better?  Or do I need both?  What if I have a problem with this or that, can I do this or that exercise?  Do I need a fancy machine or is one trainer DVD better than another?  One can easily see "analysis paralysis" setting into the brain and the brain choosing to not do any of it.

The truth is that pretty much all of them are good we just need to move.  You need to follow the basic guidelines:

• stretch daily (a good Physical Therapist can show you 4 or 5 stretches that are best suited for you and your current fitness status)
• cardiovascular exercise 5-6 times a week for 30 minutes at moderate intensity (this should be an activity that you enjoy - walking, biking, swimming, etc.).  If  30 minutes is to long, start at whatever level you feel safe to do and add 2 minutes each week, until you can do 30 minutes.  Moderate intensity is a pace that you can do without becoming short of breath, but still notice that you get a little tired at the end.  As you can see this is a little different for everyone.  To go to higher intensity or time make sure you gradually increase with the help of a physical therapist.
• Strength training 2-3 times a week.  Do some basic total body and core strengthening exercises appropriate for your fitness level.  Again look to get some help from a physical therapist to set you up with a simple program that can be done in about 15 minutes.

This is a great basic exercise plan that will serve anyone well to improve their health and well being.  But you should consult an exercise expert like a physical therapist for some guidance if you have any medical concerns or want to expand your workout further. You wouldn't go into a drug store and just take medicine without a proper frequency, intensity, time and type without consulting your doctor and pharmacist, exercise should be looked at the same.

So do you sometimes wonder how much or what type of exercise to do?  Does it cause some "analysis paralysis" with you?  My fellow PT's, additional thoughts when helping set patients up with exercise programs?

It might not be just about fixing parts

There was a great segment on Good Morning America about back surgery this week, for those that didn't see it, here is the link - Back Pain Relief.  This patient is one of unfortunate millions in the world that suffer with chronic persistent pain.  I have the fortunate opportunity to be at course this weekend Explain Pain, presented by Adriaan Louw, a PT right here from Iowa (that's kinda cool, at least to someone that lives in Iowa).  It is based on the book Explain Pain by David Butler and Lorimer Moseley.  I have mentioned this book previously in a post Back Pain - Now What.  If you treat patients that have pain, or are a person in pain, I highly recommend this book.  It will help explain the biology behind pain, and if you really like this stuff (as I do) then this course is one to look at attending as well.

I will get into some of the mechanics of pain in future posts...but for now I want to pose some questions and thoughts.  As a Physical Therapist I was taught that there are very specific mechanical problems that are the cause to all injuries that we treat.  Don't get me wrong there is, but there is more to it than that as I have learned since graduating over 15 years ago.  We as human beings are an amazingly complex system (and we understand a lot of it, but by far not all of it).  Sorry to burst anyone's bubble that their doctor or physical therapist or whatever healthcare provider you see does not have all the answers.  If they say they do, my advice - RUN!!!!  Let's take a simple look at the body: There are just over 200 bones in the body.  Each of these bones come together to form joints, about 250-350 total depending on how you classify them. They are held together by multiple ligaments at each joint area.  The joints are moved and also held together by muscles. We have around 500-600 of them in our body, again depending on how you classify them.  These muscles are controlled by our nervous system.  It is just a little more complex, we have about 100 billion neurons (give or take one or two) in our brain controlling these muscles, along with all the other systems in our body.  Each of these neurons makes around 5,000 connections with other neurons to communicate all that we do.  Each connection is controlled by a multitude of neurotransmitters and other substances.  I apologize to the anatomist and neuro-scientist for this simple explanation, but I think that you get my point - it is pretty complex.  This amazing system allows us to function in our continually changing world we live in, hopefully in perfect harmony.  I like the analogy of a symphony, that our body plays a beautiful tune when everything is just right - it just happens to have more instruments than particles in the universe.  How cool is that!!!

So, when someone tries to tell you that they can fix your pain with just a fixing one thing as this women in the clip thought was lead to believe, be careful.  Again hear me closely, I am not saying that it may not help with your pain and fix a mechanical fault, but it could very well be due to more than one instrument not playing the right tune.  And the instrument you fixed may not necessarily be the right instrument.  But do not despair either and think if surgery or a drug or therapy can't fix me who can?  Realize your body heals itself every day and you usually don't have to do anything.  Have you ever got a paper cut on your finger?  Is it still there?  Did you have to put any thought into how to fix it?  Your body did it all on it's own, pretty cool!  Yes we might improve the environment a little with a band-aid and some triple antibiotic on it.  So does that mean I never need surgery or need to go to a doctor or physical therapist to help me recover from an injury?  No, not exactly, sometimes we need to help improve that environment for the healing to happen so something wrong does not happen and not allow the body do what it was designed to do.  But just something to think about...fixing something mechanically may not be the end to your pain.

We often compare our bodies to machines.  I do this often when educating patients to understand mechanical deficits that may be contributing factors to their pain.  (Realize I said "contributing" not "causing").   But as humans our bodies are far more complex than any machine.  Does anybody have a car or any other machine that repairs itself?  How about that has logic, reasoning and emotions?  Our body is far more complex, so fixing a broke part by replacing it, taking it out, strengthening it, stretching it, or giving it a drug may not be all it needs.

So what's everyone's thoughts?  Can we or should we be able to "fix" everything by working on the mechanical parts?  It may be a different way of thinking for some of you, but I think we need to make changes to truly help so many people in pain.

Expert Practice

x

I had a great opportunity to attend the Advanced Clinical Instructor Education and Credentialing Program through the APTA.  One portion that I really enjoyed was going over a few studies that looked at Expert Practice in Physical Therapy see here and here.  It made me look at myself to see if as a clinician was I working toward becoming an expert physical therapy practitioner.  Hopefully the other health care practitioners reading this will reflect on their own practice to see how they measure up.  If you need a health care practitioner, check to see if they measure up, if not you may want to look for one that does.

Common things found in many clinicians that did not differentiate average from expert, as one may think, were things like:  having a certain number years of experience or working specifically in a specialty area, caring for their patients and commitment to professional growth, and utilization of opportunities for continuing education.  While these are good qualities they did not differentiate an average clinician from an expert clinician.

What they found was what they labeled a Patient-Centered Approach in Expert Clinicians.  This is when the clinician made sure the patient was an active participant and the therapist primary goal is to empower the patient.  This was done through collaboration between therapist and patient through patient education and establishing a good patient-therapist relationship.  The expert clinician shows a high level clinical reasoning that is centered around patient needs.  They use their strong knowledge base along with skills in differential diagnosis and continual self reflection.  This knowledge base is grounded not only in academic knowledge but field experience in other areas outside of physical therapy.  Their knowledge is also used extensively with the use of movement observation.  The expert practitioner has a love of clinical care with non-stop inquisitiveness about life long learning.   They also have amazing humility even with their high level of expertise.  Their patient clinical style is one that patient education is central to their practice.  They individualize their treatment interventions to the patient, you will see every patient getting a different treatment based on evaluation of patient needs body, mind and spirit.

I have started reflecting more before, during and after each patient intervention to see if I am moving more toward patient-centered care approach.  I having been trying to keep in mind a few quotes when setting up patient intervention treatments:

• "Everything should be made as simple as possible, but not simpler." (Einstein)
• "You know you’ve achieved perfection in design, not when you have nothing more to add, but when you have nothing more to take away." (de Saint-Exupery)

So what are you challenging yourself with to become more of an expert in your practice?

Health Care Reform? What's next?

Well who has read the new Health Care Reform Bill?  Nobody has glanced through all the pages?  Well I haven't either, there are more important things to read...like Pinkalicious to my 5 year old daughter at night for her bedtime story.

I think only time will tell what it will mean to American Health Care.  I do have faith that we have some of the greatest clinical practitioners in many areas (Physical Therapy being one that I am obviously most biased towards) and that patients will receive excellent caring and compassionate care.  But I often wonder if we may see more a shift toward health care providers being more educators and teachers to patients and families.  With the increase in people supposedly accessing the system with all people covered, there may be delays in care.  And when one does get in to be seen, there may be increased time between appointments.  I'm thinking of Physical Therapy for example, typically most patients in the outpatient setting I am in are seen 2-3 times per week.  But if there is more patients to see and most likely not an increase in staff, we will have to decrease the number of times each week the patient is seen to allow access for the additional patients.  The patient and family will take on increasing responsibility to know and understand their injury or illness along with what they need to do for their care.  While in many ways this can be a great thing for people to take increasing ownership in their healthcare, but will they?

Also with growing new research in neuroplasticity, The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science (James H. Silberman Books).  We are learning the amazing capabilities of our brains to continue to change and relearn things even after severe brain damage.  These changes for stroke, traumatic brain injuries and others are amazing to our once thought of a very static brain that once injured did not have much chance for recovery.  We are now learning with gradual properly graded therapy, significant changes in their function can be achieved far beyond our previous expectations.  The big thing that is needed is patience and persistence in the treatment approach.  I am not sure the health care system will be willing to pay for either.  But patients and families can be trained to carry out this treatment on their own with monitoring and ongoing training from qualified health care providers.  The delivery might look different, but it may actually get better.

While I don't know exactly what health care reform will bring, as none of us do (even though most everyone has an opinion), I do know the brain does change itself and it is was created for survival.  And spending time with my daughter reading books is far more important than worring to much over health care reform.

I'm curious to hear others thoughts on what the changes may mean to health care in America?

Interesting thought about ankle sprains

An article came out in USA Today Vulnerability to ankle sprains varies with age.   I wanted to add a few interesting thoughts from a Physical Therapists perspective.

1. This is something I have noticed with ankle sprain injuries for many years and in some ways seems kind of strange.  Why is there more sprained ankles in basketball (40%) compared to soccer (8%)?  Granted I don't know in this study if it is matched to the percent of those actually playing the sport, which could skew the percentage if a higher number of people possilbly play basketball compared to soccer.  But think about this:  basketball is always on a flat surface and players often times wear hightop shoes and brace or tape their ankles, compared to soccer which is usually on a grass natrual field, with tiny not very supported shoes and they are always moving around a round ball on the ground.  From the outside one would think that soccer would probably see more sprains.  Or, because soccer players actually train in a more challenging situation that they are better prepared to reduce the risk for ankle sprains.
2. I thought another interesting statement in the article needs to be looked at deeper as well:
• "The good news is that most ankle sprains feel better in a few days and heal completely in a few weeks. But previous studies suggest 60% of people who have one sprain will have another or will suffer long-term instability, weakness or pain."
• My question is do they heal completely?, if 60% will suffer long term difficulties.  I would like to think that this is not healing completely.  If we take simple knowledge of tissue damage, we need to see that complete healing probably takes longer than a few of weeks.  This is true probably for most injuries.  I am afraid we don't allow the body go through all the stages of healing and work to fully rehabilitate from an injury like an ankle sprain usually.  There is loss of strength, flexibility and proprioception after an ankle sprain.  Unless we work to retrain all of these appropriately we are most likely looking at further problems.  Also we need to look to see if there was a movement impairment that may have been the cause behind the injury.
• An example I can give is a patient I had once that I saw the day after her ankle sprain and talked to her about acute treatment (RICE - rest, ice, compression and elevation).  Then importance of working to normalize her walking as soon as possible.  She came back about a week later and said she was fine and did not think she needed any more therapy.  I asked her to try and stand and balance on that one foot.  To her amazement (not mine) she couldn't!  I explained what all happens after an ankle sprain and that just because the swelling and pain was down, did not mean that it was completely healed.  So after a couple more visits over about 4 to 6 weeks and instruction on proper exercise progression to regain strength, flexibility and proprioception her ankle was fine.

My advice if you suffer an ankle sprain, do not think it is fine just because the swelling and pain are less in a few weeks.  See a physical therapist to get proper treatment to make sure that you do fully rehabilitate from an ankle sprain and reduce the risk of reinjury.  If you do play sports you are at higher risk for ankle sprains, so as part of your training do specific functional exercises to reduce your risk of injury.  Talk to a physical therapist to learn functional training exercises that you can do for your specific sport.

picture by: By Suzy Parker, USA TODAY

Effects of good health practices on therapy outcomes

I wanted to share with my readers something I have been working on to give to our new patients that come in for Physical or Occupational Therapy at our clinic.  I wanted to give the patient some additional information on other things that can help their outcome with therapy.  Here's what I have put together so far, let me know what good and bad you see in it.

Welcome to CRMC Physical Medicine and Rehab, maximizing your outcome from your Physical or Occupational Therapy treatment is our goal. Here are a few additional things you can do to help maximize your outcome, if you are not already doing them.
Stop Smoking. You probably already know that smoking affects your lungs and heart health in detrimental ways. And if you are a smoker it is not easy to quit, so talk to your doctor or therapist about options to help you quit. With the lungs and heart it affects the oxygen uptake in the lungs and narrows our arteries decreasing the blood flow to our muscles and organs. With decreased oxygen and blood flow our muscles are not getting the energy they need to repair them and work optimally. Smoking also has an effect on brain neurotransmitters (chemicals in the brain) these help our brain and nervous system function optimally. When our nervous system and brain are not working optimally it effects how our muscles work along with other systems in our body. It also affects our metabolic system (the part of our body that breaks down food and medicine into parts it can use). So our body does not get the food and medicine it needs in the same way those that do not smoke do. There are other side effects of smoking, but these are some of the primary effects that will reduce your optimal outcome with therapy and effect your healing from your injury.
Get proper nutrition and water intake. Our body uses the food we eat to help repair any damage that has been done to it on a daily basis. The better the food choices we make the improved healing abilities our body will have. Please consult with your doctor, dietician or therapist if you want specific information to help you eat better. Generally following the web site info at http://www.MyPyramid.gov is a good guideline. Water intake is also important as most of our body tissues, especially muscles and fascia (the tissue that holds all of our muscles together). Our muscles and fascia are primary reservoirs for water storage; if they are dehydrated they will become stiffer. Take a sponge as an example – when the sponge is dried up it is stiff, when full of water it is more flexible.
Get adequate sleep. Our bodies require 7 to 8 hours of sleep each night. Some people “think” they do can go on less, but every major study done on sleep always points to the body needing 7-8 hours of sleep (more if you are a child) to function optimally. Lack of sleep will affect brain function and attention. These can affect our muscles and nervous system to not work as well. Also it has been found to decrease healing when we have a lack of sleep. Unfortunately pain can be a factor in inhibiting our sleeping, so talk to your doctor or therapist if you are having difficulty sleeping due to your injury.
Decrease your stress levels. This like sleep is a double edge sword for some of you with an injury, as the injury is the cause of your added stress. Small amount of stress is good for the body as that is what makes us stronger by “stressing” our muscles. Unfortunately prolonged or too much stress puts our body into distress, which is what is detrimental. Our body uses its sympathetic nervous system to respond to stress. This system increases activation of our peripheral muscles, raises our heart rate, and over activates our nervous system making us more sensitive to everything. This is helpful in short durations, such as needing to run away or fight in a dangerous situation, but long term can cause negative effects due to increase in the chemical, cortisol, in our system which affects our brain and nervous system as well as immune, respiratory, cardiac and digestive systems. It can also lead to increase in depression, anxiety, and increase in disease (you are more likely to catch a cold when over stressed). We need an equal balance of our parasympathetic system (the opposite of the sympathetic system) to keep our body systems working properly. The increase in activation of your nervous system is one reason why when stressed your pain will most likely be more. Talk with your doctor or therapist on techniques to help improve relaxation and decrease stress.
Understand your injury and know what you can do to make it better. There is power in knowledge. We will do our best to try and explain why you are having the problems you are having, but please ask questions if you don’t understand. While we will do everything we can to help you for the half hour or hour that you are in therapy, but you will need to help yourself the other 23 hours out of the day, so in many ways you have a larger impact on your health than we will.
Make every effort to make your scheduled appointments. Obviously there are things that might come up that limit your ability to make an appointment, but we can only maximize your outcome if you come to your appointment. It is your body and your health, while we appreciate the opportunity to help you recover; you ultimately hold the key to helping that become a reality.
This is a short summary of the few effects other health practices have on your outcome with Physical or Occupational Therapy. If you want more detail on any of them talk to your doctor or therapist. We look forward to working with you to maximize your optimal movement and achieve efficient function with your body as you rehabilitate from your injury.

I'm curious to hear what everyone thinks.  I know in today's age of Twitter and 140 characters for communicating or articles that should be 500 words or less this goes beyond that, so let me know if you think it is too long or not long enough to cover in detail enough.  Also, for the normal healthy individual most of these are common practices, but unfortunately most of my patient clientele does not meet these criteria.  I am a believer that if you can plant seeds that change is possible.  So I am excited to see comments on what others think.

Back Pain - Now What?

Estimates are that 9 out of 10 people will experience back pain at sometime in their life.  Having back pain is the fifth most common reason to visit a doctor in the U.S.  So with such prevalent numbers of occurrences, one would think we would be pretty good at treating it and have some consensus on the best methods.

Sorry, I'm not going to be able to cure everyone's back pain that reads this posting, but hopefully give you some valuable insights into finding your answers.  Also I am not going to argue for the best method to fix their back pain.  Obviously there are lots of "so called" experts that through their marketing and advertising can convince you they can cure it all in just a few simple steps.  But if this was truly the case I don't think we would see the numbers of occurrences staying the same as we have over the decades with no large changes in reduction.  Remember as health care providers we have specialties that we are trained in to solve problems.  A physical therapist, like myself, is going to use exercise and manual therapy (hopefully not many modalities such as ultrasound and electrical stimulation, as the research is not very good they actually provide much change).  Chiropractors will use their manipulation skills.  Surgeons will use surgery.  Physicians will use medication.  A massage therapist will use massage.  Acupuncturist will use acupuncture.  We are going to use what we know, and believe that is what you need.  So don't be surprised if you see a surgeon and he suggests surgery and when you talked to a different health care provider they didn't suggest surgery.

The other upsetting part is that there are some usual standard care guidelines, that research has shown to be most effective are not always followed through with by many general care practioners as found in this study.  And as pointed out in another study sometimes we have become to dependent on imaging to try and diagnosis everything.  While diagnostic imaging has made great advancements in the last few decades and has given us pictures of inside the body, we need to remember that the picture doesn't always tell us all the answers.

So what should you do if you have back pain?  Find a health care practitioner that you can trust and is up to date with current standards of care.  They should be open to other methods other than their own to assist you in your back pain.  They should be able to give you detailed explanation as to why you are having pain based on their findings from their evaluation as well as other tests such as imaging.  They should be able to back up everything they plan on doing with current research (check to see if they read current research, if not I would be cautious).  Realize that most back pain is not seriously life threatening, yes an inconvenience, but not life threatening.  It can usually be treated with conservative measures and not surgery as pointed out in this study.  If you do suffer from persistent/chronic low back pain I suggest that you learn to understand more the mechanisms of pain further.  I would suggest viewing Neil Pearson's 3 part webcast or get the book Explain Pain.