“I can’t move,” she tells her husband. “I literally can’t move, everything feels completely locked up.”
People develop chronic back pain, slowly, from seemingly innocuous occurrences at a pace that few pay attention to. Then, ten years later, we have an epidemic.
Sam was working as a checker at a grocery store about 20 years ago. It was towards the end of her shift, she was tired, ready to go home, and only had a few more customers before she could clock out. “Only a few more minutes…” she said.
As she was bagging the last customers items, she rotated to the left and screamed. As she states it “her back went out,” and it was like a pain she had never experienced before; a sharp, shooting, grabbing pain.
The muscle had grabbed on so tightly on her left lower back that she was unable to continue standing and had to have one of the customers and some of her co-workers help her to a chair and eventually, help her to her car.
She felt embarrassed that she was in this much pain and that people had seen her like this, and, she was worried about what she was going to do about this as she needed to work and had young kids at home that she needed to care for.
As Sam is driving home, very slowly, she starts to think about all of the things that it could possibly be, “is it a muscle strain, did I herniate a disc, could it be spinal stenosis, did my scoliosis finally catch up with me?” She gets home, pops some tylenol, goes through her nightly routine with the kids and hopes and prays that it’s better the next morning.
“I can’t move,” she tells her husband. “I literally can’t move, everything feels completely locked up.” After a few minutes of deep breathing, Sam works up the courage to roll over and sit-up on the bed. “Ouch,” she winces. Constant pain. As she gets out of bed and takes her first steps, she walks to the bathroom, takes some more tylenol, and hopes that it helps. It doesn’t.
She goes into work, and her manager immediately lets her know that she needs to go home as she can’t be at work because this injury happened while she was on the job and due to worker’s comp law, she is required to not be working. “What do you mean I can’t work?” she said, “well, the way the policy is setup, you need to go through the worker’s comp process. Don’t worry, we’ve got a great doctor you can see,” the manager says.
After a few more days of very mild relief, Sam heads on into the doctor’s office. It’s 9:35 am, her appointment was at 9 am. Finally, they call her back and she sits in the exam room for another 15 minutes. Tick, tock. It’s now 9:50 am, and finally, the doctor is ready to see her. Dr. M is tall, with slightly greying hair, probably mid 50’s, she thinks. She notices the circles under his eyes, and the rather frantic and preoccupied nature of the introduction as he was running behind from a few other patients earlier in the morning. Once you get behind… you don’t catch up.
Dr. M does the best he can with the short amount of time they have together, asks Sam exactly what happened, tests, to see if she can feel her toes, and concludes that she likely has a muscle strain or a herniated disc that’s pressing on a nerve and just to be sure that they should get an x-ray and maybe an MRI. In the meantime he’ll prescribe some muscle relaxers and tylenol.
Sam feels a bit more nervous at this point as a herniated disc sounds like a big deal. She knows a few friends who’ve had a herniated disc and they ended up having surgery. She’s also frustrated that she wasn’t really able to get her questions answered due to the length of the appointment only being about 11 minutes. Much of it was just taking down her past medical history and she didn’t really get to tell her story, particularly of how much of her family has back pain and that her mom had a spinal fusion that went horribly wrong.
Feeling anxious at this point, she goes and gets the MRI done, which is fairly common in the US when someone experiences back pain, and the results are quite scary, or so she thinks.
- L4-L5 Disc herniation
- L2-L3 Disc bulge
- Multilevel degenerative changes
She gets the results and the radiologist quickly goes over them, “no wonder you’re hurting so much.” “Oh, it’s bad?” Sam, says. “Well, you see here, that disc is pressing on the nerve and ‘pinching’ it, which is causing your pain, I recommend an injection, but you can try physical therapy, too,” says the radiologist.
She decides that she’ll go get the injection because it’s supposed to help with the pain and then go to physical therapy after. She meets with the pain management doc, gets the injection, and… gets no relief.
At this point, she’s really frustrated, still in a ton of pain, is barely even able to walk around, and it’s been 2 months of agony. She finally sets up her evaluation with a physical therapist.
Let’s stop the story here.
This is an EPIC FAIL! How could our healthcare system have failed so monumentally?
Above is a fairly common scenario, one that I hear quite often, and one that frustrates me to no-end. A perfectly healthy person experiences some pain and is subsequently gobbled up and spit out by the system; often becoming worse than they would have if they’d seen no-one.
Here is a recap of the series of events that happened…
- Back pain with twisting at work (mechanical)
- Work telling her she needs to claim this as an on the job injury, by law.
- Referral to general practitioner
- Short, 11 min evaluation, told it’s a muscle strain or herniated disc
- Referred to imaging “just in case.”
- Get’s MRI, learns about herniated disc, disc bulge, and “degenerative changes”
- Radiologist explains that these are the cause of pain
- Suggestion for an injection or physical therapy
- Sam is now anxious and nervous because each of those diagnoses sounds bad and worried that she’ll turn out like her friends or mom.
- Sam is now at a higher risk of chronic disabling pain, and surgery.
- Total time that has elapsed before seeing a physical therapist, 2 months.
- Total health practitioners patient has seen prior to rehab professional, >3.
Here is how it should have gone…
- Back pain with twisting at work (mechanical)
- Referred to physical therapist or general practitioner
- Screening of red flags, cauda equina syndrome, fracture, infection, cancer, etc.
- Once red flags have been screened, movement assessment to determine movements that are helpful and not helpful.
- Information shared that her back is safe and that all “dangerous,” pathologies that would require immediate medical intervention are clear.
- Progressive movement and exercise program, potentially coupled with manual therapy, tailored to the movements that Sam will have to perform on a daily basis
- Sam still hurts for the time being, but feels encouraged that she has a plan moving forward and that this won’t be a permanent thing.
- Sam now has a much better chance of recovering fully and getting back to work much sooner.
- Total time that has elapsed before seeing a physical therapist, one week.
Here’s my educated opinion on the topic…
If the system followed the approach below, we’d have less chronic low back pain and less chronic pain in general, less surgeries, a drastically healthier population, and healthcare that we could probably afford.
“Early MRI without indication has a strong iatrogenic effect in acute low back pain, regardless of radiculopathy status. Providers and patients should be made aware that when early MRI is not indicated, it provides no benefits, and worse outcomes are likely.” – [Webster et al. 2013]
Regular everyday people are being made worse by the shitty care they are receiving and the misinformation that is fed to them. Diagnostic imaging is given out like candy, people are told they need surgery when they don’t, and thinking that your body is broken is often a self fulfilling prophecy.
If you’re a healthcare provider reading this. I challenge you to educate yourself on the dangers of telling people false and harmful information. Look-up nocebos in medicine and the iatrogenic potential of physicians words. It will blow your mind.
If you’re the person that went through the first series of events above, i’m sorry. It really is awful that you became another victim of the system. BUT, there is still hope, and you don’t need to continue to suffer endlessly. There are solutions that don’t include more medication and more surgery that typically include exercise, understanding pain, and various other methods to reduce the suffering that is so prevalent with chronic pain.
You can find some great information about pain and how to think about it from:
Peter O’ Sullivan (twitter)
Jarod Hall (blog) – Dr. Jarod Hall (@drjarodhalldpt) (instagram)
Ben Cormack (blog) – Instagram
Sarah Haag (twitter)
Bronnie Lennox Thompson (blog)
Greg Lehman (blog) – Twitter
If you’re a part of the general public, please, educate yourself on nocebo’s, how our thoughts and beliefs can influence how we respond to pain, and most of all, if you need it, how to find a provider who is up to date on the pain literature. It could quite literally save your life.
Have you or a family member received this terrible type of care by the system? Did you realize it at the time? Comment below, i’d love to hear your experiences.