I Think I can! I Think I can! Mind over low back pain.

Acute low back pain (LBP) is an interesting animal. Affecting 80% of the population and much more popular among the younger crowd, LBP is generally overwhelmingly harmless and in most cases resolves naturally within a couple of weeks. But sometimes this seemingly benign condition takes a turn for the worse. Two weeks turns into two months, two months turns into two years and now your harmless LBP has turned into a disability. LBP is the leading cause of work absenteeism in America for ages 19-45 and the second most common reason for seeing your primary care doctor. Are you curious as to why this happens? What if I told you its all in you mind?

One article in The New England Journal of Medicine compared medication, bed rest, mobilization exercises and simple reassurance and encouragement to continue normal activities in the treatment of LBP and found that simply advising people that it is safe to continue living life normally was more effective than the other options. In fact it has been shown that providing self-care advice and reassuring the patient that there is no need for fear or anxiety provided an nine-fold decrease in risk of LBP becoming chronic.

A fancy term used to describe this phenomenon is fear-avoidance beliefs (FAB). FAB turn acute pain into chronic by mentally disabling you. Vlaeyen stated that a misconception of pain being a threat can cause an individual to completely avoid physical activity and become deconditioned based on fear and anxiety. Deconditioning coupled with a feeling of hopelessness delays the recovery process.

The Agency for Health Care Policy and Research has properly stated that "the main goal for treatment of back pain has shifted from treatment of pain to treatment of activity intolerances related to pain." This means that your health care provider's job is to not simply treat your pain, but to strengthen your ability to live your life normally as quickly as you will let him or her. There is no problem with laying on a table while your health care provider attempts to decrease the pain for you, at least not initially. The problem arises when there is not a speedy transition from passive treatment to active treatment (ie full range of motion exercises).

No, chronic LBP is not purely mental. You can not just think happy thoughts and make it disappear. However, you can control how quickly you will recover. Happy thoughts can help get you pain free again. So be optimistic, the sky is not falling. Live your life, only bed rest could
truly hurt you.

Fear-Avoidance Beliefs Questionnaire

Arthritis Foundation's 2009 Women's Health Summit

I wanted to take a moment write about a first time experience I had on multiple levels. My father, Matt and myself were recently asked to give a presentation on the importance of exercise with arthritis for the Arthritis Foundation's 2009 Women's Health Summit. There were multiple speakers in different rooms with various background ranging from the Chief of Geriatrics at a nationally ranked hospital to the nutritional advice presented by an RD.

As I mentioned, this was my first of many: this was my first public presentation for GCMC, this was my first time speaking in front of an elderly population, this was my first time working with the Arthritis foundation, this was my first time presenting along side MD's and DO's, and this was my first time bring our message of "Life is Movement" to a larger, non-athletic audience. And for all of those reasons I was slightly nervous. We have conveyed our ideas to many types of athletes with great reception; however, I have never tried to communicate our message to those indifferent to exercise.

I thought that my biggest problem would be my message being lost in translation to an indifferent crowd, but the real challenge wound up being much more primitive. When given the choice of which presentation to attend, the vast majority was more interested in attending a lecture on which medication they could use to manage the pain then to listen to about how maintaining a quality of life is two-sided contract. As health professionals at a movement center, our end of the contract is to get them moving again and their end is to actually take responsibility for their health and not to accept a defeatist mentality. What I found was that people are much more inclined to wave the white flag then to fight for their quality of life.

It is sort of ironic in a way, I did include in my presentation how nearly a third of those with arthritis live completely sedentary lives. I knew that the problem was a misconception that movement was the problem and that exercise would only hurt them, when in fact even Harvard has recently published that one to two hours of moderate exercise can prevent pain from osteoarthritis all together.

So I guess that my point is we have more of an up hill battle than I expected. The good news is that those that chose to listen to our presentation were very receptive to our concepts. They very much understood what I said and felt that we understood their battles. Now what is left is for us to really push the concept of exercising to reduce or eliminate pain. We have lived in a sick care nation for a very long time. We have conditioned the aging population to accept defeat: loss of hearing, loss of memory, loss of vision, loss of balance, loss of strength, loss of driving, ect. It is time to take the focus away from pain and towards performance.

At GCMC we acknowledge that everyone has a goal and desired level of performance. That can mean you want to run an ultra-marathon or that could mean you want to walk pain-free around the mall. The point is we are all training for something and that, at the very least, we are training for life.

The Problem with Pain

What is your pain from zero to ten, ten being the worst pain you have ever felt? Does that look like anything you have come across before at a doctor’s office? If you have a child you may have come across the faces pain scale. A common variation found in many pediatric clinics. There is a long list of pain scale variations, each with their own set of advantages and disadvantages. The major problem across the board is that you can not collect true objective data in a subjective manner.

“Pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. The discomfort signals actual or potential injury to the body. However, pain is more than a sensation, or the physical awareness of pain; it also includes perception, the subjective interpretation of the discomfort. Perception gives information on the pain's location, intensity, and something about its nature. The various conscious and unconscious responses to both sensation and perception, including the emotional response, add further definition to the overall concept of pain.”(Online Medical Dictionary)

Philosophy has dealt with the problem with pain as far back as Plato’s The Republic, written in 380 BC. Plato speaks of reality through his theory of forms. In his famous allegory of the cave, Plato speaks of reality being like shadows on a wall. We do not ever see the truth, just the shadows that we use to make inferences of reality. Rene Descartes (1596-1650) proclaimed “Cognito ergo sum” or “I think therefore I am.” He explains how perception must be part sensory and part cognitive. This is, for example, how one can observe a candle melt into liquid wax yet still know that the solid candle and the melted wax are one in the same. In fact, the oldest quantitative law in psychology is the Weber-Fechner law, a law concerned with the relationship between the intensity of physical stimuli and their perceptual effects. Ernst Weber found a logarithmic relationship between stimulus and perception.

What all of this means is that on a pain scale, my severed arm might feel like your stubbed toe. But with a stubbed toe and a pain rating of ten, I have learned something valuable about you and your road to recovery: you have a very low pain threshold and it’s going to be a long road. And that is in fact the value of the pain scale. Its benefit and its downfall walk hand in hand. You can not accurately describe pain with severity alone but you can use the data for other purposes. Maybe you will be less aggressive; maybe you will start with a more passive approach, either way you can avoid scaring off a patient and formulate the best way to approach his or her treatment.

And what if I walk into your office years after my severed arm and I circle a ten again for my pain? You better give me some immediate medical attention because something is seriously wrong. Unlike the other guy, when I cry wolf granny has been eaten and I am about to be dessert. However, if I walk in with a stubbed toe and a pain level of two you can more than likely be as aggressive as you would like for a quick recovery.

Pain scale ratings are important and very necessary. Use them as a basis for treatment approach and use them as a way to monitor progress. If you would like something more reliable, use more complex pain scales such as the McGill Pain Questionnaire which uses twenty subclasses of words that break down into four major groups to describe the sensory qualities of pain, the affects of pain, the overall experience of pain and some miscellaneous characteristics of pain. No matter which pain scale you use and how you use it just remember this: perception is reality and perceiving is believing.

The Chiropractic School Self-Esteem Issue

Coming from a family of 7 chiropractors has allowed me to see some of the amazing benefits of the profession. Growing up in a large chiropractic family went so far as to provide me the delusion that chiropractic was as main stream as any other health profession. I was rarely sick, I was surround by successful doctors and all I encountered were amazing testimonials to the credit of chiropractic care. Attending chiropractic school has given me a much different perspective.

I was a rather distinguished undergraduate student. I graduated with a gpa north of 3.8 and dual degrees in Biochemistry and Chemical Biotechnology. I won many awards and made many friends. My original thought was to pursue medical school and specialize as a non-surgical sports physician. I had the ability and honestly figured, "why not?" To make a long story short, just before I officially signed off on my acceptance to medical school and began that journey I decided that, if I was going to be non-surgical then why not just be a chiropractic sports physician like my father. He does very well and I could finish with a lot less debt and in less time. When I told my parents I had changed my mind and would be attending chiropractic school instead they all but disowned me. You would think I told them I was quitting school all together and telling them I would just live off of them at home for the rest of my life.

The reaction confused me as I'm sure it confuses you. Why would a successful chiropractor coming from a family of chiropractors be upset that his first born was following his foot steps? The answer was quite simple, he warned me that I had only been exposed to one side of the profession. He warned me that I would not be challenged and that I was throwing away everything I ever did in undgrad. He told me anyone with a pulse can go to chiropractic school and that that was one of the professions largest problems. I did what any other good child would do, I ignored him.

Going into my third year of chiropractic school, I have seen where my father was right and where he was wrong. I am very much proud of my decision and of chiropractic. I was fortunate to go to a good school with some amazing professors. In a profession that is a relative underdog in main stream health care I can say I have been given the best advantage at UBCC. I have been given a much larger diagnostic ability than I ever imagined and arguably more than I ever cared to know. This truly is pleasing because my father has always said, "the manipulation does not make the chiropractor a doctor: anybody can master that skill. What makes us doctors is our ability to diagnose. That is what differentiates us from the person that cracks their friends back", and I feel whole-heartily that he was right. Nothing aggravates me more than when someone references a student that has recently failed out of chiropractic school and they say "its a shame, he was such a great adjuster." The adjustment is a tool and a skill that anyone with a good book and a daring friend can master with enough time.

My father was wrong about the level of education I could attain from chiropractic school. It is something he gladly admits defeat in. If anything, I have made him a believer again in the longevity of the profession. Where he was undoubtedly right though was in the acceptance issue of chiropractic schools.

Our best doctors in chiropractic dominate over the medical general practitioner when it comes to soft tissue dysfunction. However, our worst chiropractor doctors make the worst medical practitioner look like a Nobel laureate. It is a conflict that must be reconciled for us to achieve true positive recognition from our medical peers. Dissenters do not look for the best chiropractor to make an example out of, they look for the worst and we give the worst to them.

Chiropractic suffers from a self-esteem issue. It believes it isn't good enough to attract the eights, nines and tens out there so it settles for the threes and fours, discarding of any self-worth or value. It is insulting to someone that truly wants to be a chiropractor to sit next to the students that simply do it because they know they can get in and that if they can pass the classes they can make a good living. The schools are not doing the profession or the student any favor when they blatantly ignore the fact that a particular student should not represent the profession and probably will not succeed either as a student or as a business person. It would seem unethical to allow someone to go into great debt knowing that they will undoubtedly fail, harm every other chiropractor, or even worse harm a patient. A pulse is simply just not good enough to be the test for admission. We desperately need to raise our standards. Life as a chiropractor does not have to be an uphill battle. I am tired of defending our profession due to the below average students we falsely label doctors. Chiropractic schools, I say to you, have some self-worth and stop proselytizing yourselves to the low caliber applicants. Is it really that simple? Probably not. This may mean the closure of the privately owned schools and growth of the chiropractic colleges that exist with the university setting. Perhaps this will be my next blog. Thank you for reading.

Share Openly and Share Freely,

John Giacalone Jr

Type and Number of Schools	% with Bachelor's Degree	Avg. Minimum GPA Required	Avg. GPA of Enrollees
Medical (17)	99.35%	3.16	3.56
Optometry (16)	76.88%	2.55	3.30
Osteopathic (16)	97.00%	2.68	3.26
Dental (15)	66.87%	2.79	3.13
Podiatry (7)	89.40%	2.76	3.06
Chiropractic (16)	42.25%	2.38	2.90

Reference

1. Doxey TT, Phillips RB. Comparison of entrance requirements for health care professions. Journal of Manipulative and Physiological Therapeutics 20:86-91, 1997.