The Letter

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.

Professionally,
Keith P., PT

ADDENDUM: (01/31/2015) – After reading the above letter, Dr. Besser reached out to me and some colleagues on Twitter. The details can be in The Postscript.

Related Links:

Segment Transcript: The View

Segment Transcript: LIVE with Kelly and Michael

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13 thoughts on “The Letter

  1. Pingback: Keith's Korner | So I Wrote a Letter…

  2. Pingback: The Letter | HealthSkills Blog

  3. Pingback: So I Wrote a Letter… | Forward Thinking PT

  4. Excellent letter!

  5. Recommendation, please, for the clearest, simplest writing (article or book) to enlighten patients about the falseness of the “nociception-is-pain” model
    other than “Explain Pain”? E.P. is too expensive for my patients at $100 USA.
    Thanks.

  6. Keith,

    Thank you for writing this letter and taking an important step toward changing the conversation on a national level. More of us in the field need to bring these ideas to the forefront in the respectful, yet firmly critical, manner that you managed. I appreciate your work with, your views about and your passion for helping patients living in chronic pain.

  7. Adrian Louw does a very nice “Why do I Hurt?” booklet for patients that is not very expensive and now available as an e-book on OPTP.

  8. Excellent letter by the way. One we should all share with our physicians!

  9. well stated and written Keith!

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