October was national PT month in the USA. Marcos Lopez wrote 16 factoids on the current healthcare environment and some considerations for all consumers seeking healthcare for pain. #ChoosePT campaign is an award winning APTA initiative to raise awareness that Physical Therapy is a safe alternative to opioids for the long-term treatment of chronic pain.
PT Fact #1:
About 20 years ago the rate of people experiencing persistent pain was about 1/7. Most recent reports indicate that over 100 million Americans suffer from persistent pain. That affects more Americans than diabetes, heart disease, and cancer combined. This is 1/3 of Americans. (Institute of Medicine Report from the Committee on Advancing Pain Research, 2011)
Healthcare consumer implications: Exercise is medicine, our bodies have the amazing capacity to heal. When people experience persistent pain, it typically is less about what is happening at the local site of pain and more about the person as a whole. If a provider is only focused on the local site of pain and not the big picture of your well being, you might consider seeking care from another provider.
PT Fact #2:
Definition of pain (The International Association for the Study of Pain – IASP): “Pain is an unpleasant sensory and emotional experience, unique to every individual, associated with actual or potential tissue damage.”
Healthcare consumer implications: Therefore, pain is a complex behavioral experience, not simply a symptom. Just like anger does not manifest from our fist, like love does not manifest from our heart; pain does not manifest simply from our tissues (credit David Butler). Pain can manifest from emotional experiences, from non-physical stressors, that manifest into physical symptoms – like a cold sore.
Up next: We dive deeper into persistent pain
PT Fact #3:
Pain is a complex behavioral experience. The development or maintenance of persistent (chronic) pain is likely due to an individual facing prolonged exposure to physical or non-physical stressors, or potential threats (remember fact #2 and the definition of pain?), associated with the pain that triggers our biological system to activate various systems to deal with the stressors/threats. Although our tissues play a role in the pain experience, it is likely that persistent pain is due to a multisystem issue, not simply a tissue issue. Just like love comes from all the thoughts, emotions, encounters, feelings, physical and non-physical exposures, pain is the same way.
Healthcare consumer implications: The research shows that the better you understand the neuroscience of pain (it being a multiple system output), it is likely that you will experience less pain, less disability, less distress associated to physical activity, and decreased healthcare utilization. (Louw A., et al. Physiother Theory Pract. 2016). So take 10 minutes to watch these two videos to learn about the pain experience. Tame the beast video– Lorimor Moseley
PT Fact #4:
The opioid epidemic is real and it is here to stay.
IMO: A poor understanding of pain and the influence #bigpharma has on the medical environment is a big driver for the over utilization of opioids. The misconception that pain is a symptom, and not an experience is why society believes that there should be a quick fix, like an injection, a surgery, or a pill.
Here are the facts:
- Opioids since 1999
- Prescriptions sold quadrupled (despite no change in pain reported by Americans)
- Deaths from prescriptions has quadrupled (Centers for Disease Control and Prevention – 2015)
- Americans consume greater than 80% of worlds prescribed opioids
- American consumes approximately 99% of all hydrocodone prescribed
- CDC reports that 91 people a day die from opioid overdose in US
Healthcare consumer implications: All healthcare providers should be thought of as consultants, not as the judge and jury for your health. You have the right to question their opinion, to challenge their recommendation, to advocate for your health and wellbeing. If you disagree with them then go find another consultant. When it comes to pain, there are many ways to “skin the cat” and utilizing an opioid should not be one of them. There are plenty of alternative options to address pain, as it is an experience, not a symptom.
PT Fact #5:
The opioids epidemic part 2 and our own personal source of opioids:
My home state of Texas is home to 4 of the country’s 25 cities with highest rates of opioid abuse. As a community we need to take a stand and refuse these prescribed narcotics that are doing significant amount of harm to our family, friends, and loved ones.
These are endogenous opioids like endorphins, enkephalins, and so on that are released with exercise. Most of you know of endorphins from the “runner’s high” experience. Did you know that a 6 mile run stimulates endorphin release equivalent to 10mg of morphine (Janal et al., Pain, 1984), If you cannot run, that is okay! To experience release of the “feel good” hormones from exercise, you need to exercise at 50% of V02 max (moderate to vigorous) for 10 minutes (Hoffman et al., J Rehabil Res Dev, 2005), that is it.
Healthcare Consumer Implications: Exercise is medicine, and in fact, the release of our natural endogenous feel good hormones is more powerful than any pill out there. Moderate to vigorous exercise is different to everyone, it might be a brisk walk for one, a light jog for another, or a cross fit level routine. Find something you enjoy doing that gets your heart rate up, that gives you a sweat, and do it for at least 10 minutes a day, it can make a world of difference.
PT Fact #6:
Currently, in the state of Texas, you cannot see a physical therapist without a referral from another provider. That means that if you want to see a PT you must go to your primary care provider, general practitioner, internist, orthopedist, dentist, etc. In Texas and other states, there can be a 2-4 week wait to see a medical provider, especially for new patients. We now know that some of these providers will utilize interventions that are heavily influenced by #bigpharma. We now know that pain is an experience, and not a symptom. We now also know that exercise is medicine, and has the amazing capacity to release endogenous “feel good” hormones to counter balance any “feel bad” hormones.
Healthcare Consumer Implications: Once again, we must advocate for ourselves. You should be in control of your health care. If you want to go see a PT or an alternative treatment plan for your pain, then speak up. Do not let a physician limit your access to alternative healthcare options and do not just settle with narcotics for your pain.
PT Fact #7:
Did you know that pain and imaging findings are not correlated? That means that for spine, joint, and musculotendinous pain, “abnormal” findings on an image are not correlated or causative for pain. (Dunn, et al., J. Bone Joint Surg. 2014; Dieppe; Lohmander, Lancet, 2005; Felson et al., 1987; Hannan et al., 2000; Bedson; Croft, 2008; Deyo, Archives of Internal Medicine, 2002; Jarvik, Spine, 2005; Brinjikji et al, AJNR Am. J. Neuroradiol, 2014)
Healthcare Consumer Implications: Remember pain is an experience, not a symptom. Just like you would not take a picture of your car and take it to the mechanic to get it checked out, you should not simply rely on an image to dictate your health care treatment options. Imaging findings are really good at ruling out the scary things (ex: fractures), but are not so great at ruling in causes of pain. Once again, that is because pain is a multifactorial experience, not simply a tissue issue.
PT Fact #8:
Sorry guys, I missed one!
Did you know that when it comes to glucocorticoid (steroid) injections for tendon associated pain, the risks can outweigh the benefits? A recent systematic review and meta-analysis of the literature found that local administration of these steroids has significant negative effect on the mechanical properties of the tendons, making them significantly weaker on a cellular level. (Dean, et al. Seminars in Arthritis and Rheumatism, 2014)
Healthcare consumer implications: Now that you know that pain is an experience, not a symptom, and that pain is a multi-factorial issue not simply a tissue issue, you should consider all options for addressing your pain. Yes, we know that a localized steroid injection can reduce inflammation and in turn, possibly reduce tissue sensitivity and reduce pain, but it is simply a “quick fix” that can have downstream adverse effects. Targeted tendon loading in the form of exercise can reduce tissue sensitivity and provide similar pain reducing effects.
PT Fact #9:
Injections part 2:
Did you know that current orthopedic surgeon guidelines (AAOS) recommend use of physical therapy, tramadol, and NSAIDs for nonsurgical treatment of knee osteoarthritis and against use of injections and opioids (other than tramadol)? Analysis of claims utilization data found that the top 3 interventions were: corticosteroid injections (46%), hyaluronic acid injection (18%), and opioids other than tramadol (15.5%). Physical therapy was prescribed for only 13.6% of patients. Adhering to AAOS treatment guidelines for knee OA could decrease cost by 45% (Bedard et al., Journal of Arthroplasty, 2017).
Healthcare consumer implications: Remember, medical providers should be viewed as consultants, not the judge and jury for your healthcare. Do not be afraid to disagree with your healthcare providers and advocate for yourselves. Physical therapy is on the top of the list of guidelines but dramatically underutilized. Properly directed and supervised exercise can have significant impact on pain and function associated to knee OA and has the possibility to significantly reduce cost associated to your care.
The AAHKS Clinical Research Award: What Are the Costs of Knee Osteoarthritis in the Year Prior to Total Knee Arthroplasty?
The Journal of Arthroplasty, Volume 32, Issue 9, Pages S8-S10.e1 Nicholas A. Bedard, Spencer B. Dowdle, Christopher A. Anthony, David E. DeMik, Michael A. McHugh, Kevin J. Bozic, John J. Callaghan
PT Fact #10:
Injections part 3:
Did you know that a recent study published in 2017 compared the effects of a intra articular (in to knee joint) corticosteroid injection versus saline injection in individuals with symptomatic knee OA and tracked them over two years? What they found was that in those that received the corticosteroid injection resulted in significantly greater cartilage volume loss and had no significant difference in knee pain. (McAlindon et al., JAMA. 2017)
Healthcare consumer implications: Remember, imaging findings of knee OA do not correlate with pain. The risk/harm associated with these injections is now well known and they continue to be overutilized. These harms are irreversible. I encourage you to pursue alternative options for your pain and your health. Remember, pain is an experience, not a symptom.
PT Fact #11:
Did you know there is no such thing as perfect posture or alignment? In fact, there have been multiple studies that have found that posture is not correlated to pain. The most important thing about posture is the variability of posture, the best posture is the one that is constantly changing. Check out this video by Greg Lehman on posture/alignment. He has his masters in biomechanics and is a board-certified chiropractor and physical therapist.
Healthcare consumer implications: Although sometimes things may feel like they are “off,” or “out of alignment,” that perceived sensation is likely do to an increase in tone from our body’s awesome protective alarm system. Our body is resilient and robust, with an amazing capacity to heal. It also has the amazing ability to adapt to the physical demands placed upon it.
PT Fact #12:
Backpain part 1:
Did you know that our mental health plays a significant role in the pain experience? A recent study that looked at 43 low-middle income countries found that there are significant associations with back pain and brief onset or history of depression, anxiety, variable stress sensitivity, and with sleep disturbances. (Stubbs et al., Gen Hospital Psych, 2016)
Healthcare consumer implications: Remember that pain is an experience driven by multiple systems. It is evident that mental health plays a significant role in the pain experience. There should not be a stigma surrounding mental health. Our brain is the most important organ in our body. Thanks to our brain we are able to experience life, to love, to learn, to feel, etc. We need to be protecting our brain and our mental wellbeing more than anything else. If you, your family, your friends, or if you know of anyone who has ever experienced any mental health conditions, it’s time to put the stigma away and speak out in support. You are not alone. One in every four Americans experience a mental health condition. Seek out help and protect your mental wellbeing.
PT Fact #13:
Backpain part 2: Adolescents
Did you know that the rates of adolescents with low back pain are rising? These symptoms are leading to time off from school and work, modifying physical activity, and unfortunately taking pain medication. Often time, low back pain in adolescents if very familiar in nature to that of adults, it is non-specific low back pain. A recent systematic review of the literature found that predictors of disabling low back pain in adolescences includes female sex, negative back pain beliefs, poor mental health status, involvement in sports, and altered stress responses. In fact, previously thought predictors of LBP, such as “poor” spinal posture, scoliosis, carrying school bags, joint hypermobility, and poor back muscle endurance, are not strong predictors. (O’Sullivan, JOSPT, 2017)
Healthcare Consumer Implications: We cannot deny that pain is an experience driven by multiple bodily systems, not merely a symptom. We need to acknowledge the fact that mental health conditions, negative beliefs of pain, anxiety, and stress play a significant role in the pain experience. Please I encourage you all to take a step back from the idea that pain is simply a tissue issue, a structural issue, a postural issue, etc and note that it is more complex and our mental health plays a significant role in the experience.
PT Fact #14:
Back pain part 3:
Did you know that about 95% of the time back pain is considered non-specific low back pain? What that means is that the pain is generalized back pain, not due to a specific issue like nerve root compression. Things like spinal fractures, cancer, and true nerve root compression only occur 1-2% of the time (O’Sullivan, Pain Management, 2014). There is also a high prevalence of “abnormal findings” on imaging like disc degeneration and disc bulges in pain free individuals and that these “abnormal findings” are not strongly predictive of future back pain and are poorly correlated with levels of pain and disability (Deyo, Archives of Internal Medicine, 2002; Jarvik, Spine, 2005).
Healthcare Consumer Implications: As we have discussed, pain is an experience driven by the persons entire physical and mental health, not simply a tissue issue. If you see some of these “abnormal findings” on an image do not worry, these may be a tiny piece of your pain puzzle but very likely not the majority of it. You need to connect with a provider that is going to assess your physical and mental wellbeing to determine what is the best treatment option for you. We can no longer deny the impact of our mental health.
PT Fact #15:
Back pain part 4: Ethics of spine surgery (follow link for more detailed information)
Did you know that the number 1 predictor of having lumbar surgery is zip code in relation to imaging centers? Did you know that from the 1990-2000’s the rate of spinal fusion surgery for “degenerative disc disease” increased by 200%, for spinal stenosis by 1500%; discectomies increased by 650%, and the rate of complex fusion procedures increased 15-fold in the mid 2000’s. Did you know that spinal surgery reimbursement is higher than most other surgical procedures?
Healthcare Consumer Implications: Lumbar surgery continues to rise despite poor outcomes, and the guiding predictor of surgery is abnormal findings on an image. We now know that imaging findings are not predictive of back pain, do not correlate to back pain or disability, and are very prevalent in individuals without low back pain. I highly encourage you to exhaust all options at addressing your physical and mental wellbeing before considering spine surgery to address your pain. Pain is an experience, not a symptom.
PT Fact #16:
Somatosensory Homonculus: Brains Body Maps
Did you know there is an area in the brain that is responsible for the visual representation of our self? This area of the brain functions like a map, that helps us identify where our body is in space. When we have a pain experience, or any other symptoms associated with pain (stiffness, ache, tension), our brain has difficulty localizing these maps and they become less precise. This can lead to further symptoms and/or altered movement patterns, decreased coordination, feeling that the site of pain is foreign to us, etc. When we do not have pain, or any other symptoms, the maps are very clear or precise.
Healthcare Consumer Implications: When treating the pain experience we cannot forget the sensory component to pain. Treatment should focus on sensory and motor impairments. We know that utilizing a few minutes of a sensory retraining program can significantly reduce pain and improve quality of movement (Louw A et al., New Zea J Physio, 2015). Attached is a video that helps demonstrate what the somatosensory homunculus is and how it functions. Enjoy!
#PTmonth #GetPT1st #ChoosePT