 "Uncertainty always creates doubt, and doubt creates fear." Oscar Munoz — CEO, United Airlines (personal opinions aside of this guy — I like the quote) Uncertainty is a beast. “I’m really worried about this pain getting worse, I don’t know what to do. Will I need surgery?” he said. A past client of mine sent me a message on Instagram asking if I had some time to talk about a recent knee injury. He ran. It popped. He got scared. What do you think happened? Before I get into it, let’s talk about what he said first. “Will this get worse?” I think I get this question more than baristas at local coffee shops get the question “what’s the wifi password.” It’s a great question but it really is only a surface level question. Why are you worried the pain will get worse? Have you or a family member had previous experiences of something like this getting worse? Getting down to the root causes of the fear of this uncertainty is incredibly important. To battle this uncertainty, people have tried many things… the “sure-thing principle,” was proposed by L. J Savage, an economist as a way to deal with uncertainty. Here is an excerpt from a great book “Made to Stick:” "A businessman is thinking about buying a piece of property. There’s an election coming up soon, and he initially thinks that its outcome could be relevant to the attractiveness of the purchase. So, to clarify his decision, he thinks through both scenarios. If the Republican wins, he decides, he’ll buy. If the Democrat wins, he’ll do the same. Seeing that he’d buy in either scenario, he goes forward with the purchase, despite not knowing the outcome. This decision seems sensible—not many people would quibble with Savage’s logic. After this initial stream of logic, two other psychologists, Amos Tversky, and Elder Shafir had a different idea. Their example is as follows: "For instance, imagine that you’re in college and you’ve just completed an important final exam a couple of weeks before the Christmas holidays. You’d been studying for this exam for weeks, because it’s in a subject that’s important to your future career. You’ve got to wait two days to get the exam results back. Meanwhile, you see an opportunity to purchase a vacation during the holidays to Hawaii at a bargain-basement price. Here are your three options: You can buy the vacation today, pass on it today, or pay a five-dollar fee to lock in the price for two days, which would allow you to make your decision after you got your grade. What would you do? You may feel some desire to know the outcome of your exam before you decide, as did the students who faced this choice in the original experiment. So Tversky and Shafir simply removed this uncertainty for two groups of participants. These groups were told up front how they did on the exam. Some students were told that they passed the exam, and 57 percent of them chose to go on the trip (after all, it makes for a good celebration). Other students were told that they failed the exam, and 54 percent of them chose to go on the trip (after all, it makes for good recuperation). Both those who passed and those who failed wanted to go to Hawaii, pronto. Here’s the twist: The group of students who, like you, didn’t know their final exam results behaved completely differently. The majority of them (61 percent) paid five dollars to wait for two days. Think about that! If you pass, you want to go to Hawaii. If you fail, you want to go to Hawaii. If you don’t know whether you passed or failed, you. . .wait and see? This is not the way the “sure-thing principle” is supposed to behave. It’s as if our businessman had decided to wait until after the election to buy his property, despite being willing to make the purchase regardless of the outcome. Tversky and Shafir’s study shows us that uncertainty—even irrelevant uncertainty—can paralyze us." Heath, Chip. Made to Stick (p. 36). Random House Publishing Group. Kindle Edition.  Isn’t that fascinating?? Due to uncertainty that was created, over an outcome they had literally 0 control over, they still wanted to wait until they had all the answers. And… once they did, they chose to go to Hawaii regardless of the outcome.
A similar study was done which posed two three scenarios, go to one of your favorite musicians, study for your test, or watch a new movie that’s out. The group that only had two choices, a larger percentage chose to go to the movies vs. study. BUT, when posed with two “fun” choices and studying, a much larger percentage chose to stay and study. This illustrates how sometimes when we have too many choices, even only three, it can be a bit overwhelming and we’ll choose something that we don’t really want. I think these scenarios apply fairly well to the rehab process, too, specifically when dealing with the uncertainty of what might be ailing us? Is it a muscle, a ligament, a bone, a nerve, is something out of alignment (I don’t believe this BTW), or is it something else? There are so many competing theories as to WHAT is the cause, and how do we find the exact cause of my pain. The amount of options tend to paralyze us and we go with the choice that "comfortable," because at least we "know what we're getting." If we only knew the exact cause in every case then we could be sure that the pain would not get worse, right? You’d think so but it’s not that simple… let’s talk about back pain for a second. Once cancer, inflammatory disorders, infection, fracture, and other red flags have been ruled out, it’s very unclear as to what specific structures are contributing MOST to the pain experience. This is largely in part to the complex nature of pain, meaning it is a combo of biological, psychological, sociological components which we simply aren’t able to measure down to a singular level of specificity (yet). And finally, circling back to our friend with the knee that popped; he heard this pop while running, was fearful of what could have happened, and then the uncertainty, coupled with things he had read created more fear. The conversation we had determined it wasn’t swollen, it hurt to extend it, and it had only been about 1 week since the incident. There was no instability whatsoever and the pain was tolerable. This definitely wasn’t an ACL tear (something this person was worried about), and also, even if it was a meniscal tear (also unlikely), it was way too early to even go down the route of talking injections or surgery. When something happens that we don’t expect and aren’t experienced in dealing with, we often jump to conclusions and choose interventions that may not make the most sense. We jump to the craziest conclusions and often the worst case scenario. Next time something happens in your life that you don’t have much experience with, try to resist that urge to jump to the worst case scenario. Find someone who knows what they’re talking about and get their perspective! It’s totally normal to find uncertainty unnerving — and sometimes clearing up uncertainty with “what it’s not” is the best thing we've got! I’m curious… how do you deal with uncertainty? Do you fear it, or do you come up with solutions to address it?
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Spinal stenosis is something that can be treated or managed conservatively in many cases.
Here's an excerpt from a 2016 Cochrane review, detailing their conclusions of a study comparing surgical vs. non-surgical care for spinal stenosis. "We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects. High-quality research is needed to compare surgical versus conservative care for individuals with lumbar spinal stenosis." As you can see, surgery should be a last option, not first line defense. Side effects reports were from 10%-24% whereas non-surgical treatment was 0% complication. Do you or someone you know have spinal stenosis? BFR is a great way to increase your training volume without having to add in a bunch of heavy heavy volume, particulalry if you are dealing with pain or injury associated with lifting heavier. If you can lift heavy, lift heavy, however this is one way to receive a similar training intensity to maintain your work capacity.
Have you used BFR before? What'd you think? Ever heard of blood flow restriction training (BFR)? Essentially, some blood flow is restricted, the workout is harder at much lighter weights, and you can still realize hypertrophy and strength gains.
Who is this good for? Bodybuilders and powerlifters looking to increase volume but keep load and mechanical stress lower, older adults dealing with osteoarthritis who have a hard time performing heavy leg exercises due to pain, pre and post ACL tear for extra hypertrophy work on atrophied quadriceps. There are plenty of other people who could benefit from BFR, too! Shoot me a message if you're interested in working with me, and getting some BFR training/rehab. BFR is not approriate for everyone, of course, and if you can lift heavy without pain, then lift heavy. This will not necessarily help you get stronger if you're already able to do that.  "The quest for more success and status (for the sake of success and status) often leads to the slow erosion of meaningful relationships" - MEA perpetually happy, exciting, pain free life. It seems like this is what we all want. There is a catch though... we don’t want to put in the work. There is another catch... we won’t always be happy, life won’t always be exciting, and pain will come and go. I’ve been thinking about this quite a bit as of late. When reflecting on conversations I’ve had with friends, family, and patients, I recognize most people are trying to reach an idealized life without struggle or pain. This type of life is exulted on social media, TV, from our friend groups, even our family. Scroll for two minutes on Instagram and you’ll no doubt get bombarded with perfectly edited photos of people, homes, and other trinkets. We want the perfect marriage, the perfect body, the perfect family, the perfect job, the perfect home. We are obsessed with perfect scores on tests, saddened when we are less than perfect. This also leaks over into our expectations of others. We expect others to be perfect, to be without fault, and when a mistake is made we ruthlessly jump to conclusions that they were acting out of malice. We expect perfection of others yet expect others to take us as imperfect. This obsession with perfection also ties into how we view success. Success and wealth go hand in hand with this perfect life, so society says. Many of us want this success and wealth, however, I’ve observed two things: 1. We want wealth but are envious but also spiteful of those who have it, 2. We expect that if we had wealth, life would be infinitely better and we would be exceedingly more happy. It’s true, that people living in poverty would have a better life with more wealth, and increase in happiness, to a point. It is not true, that massive amounts of wealth lead to a greater and more fulfilling life. There are plenty of people who are wealthy and miserable, routinely logging 60+ hr work weeks and sacrificing everything they care about. In the past couple years, I’ve interacted with hundreds of business owners and entrepreneurs, and individuals in the workforce who are so focused on building and growing their business, progressing in their career, and working seven days/week for months, sometimes years at a time. This sacrifice of time with family and friends often leads to burnout and the severing of the relationships that they initially got into business for. Many business owners got into business as a way to a better life for them and their family but it turned into an all consuming force that has wreaked or is wreaking havoc on their relationships. I see this all too often with professionals. The quest for more success and status (for the sake of success and status) often leads to the slow erosion of meaningful relationships. If you are this person, stop. Stop and read this paragraph again. Why are you working so hard? Hard work, embracing struggle, and being persistent is certainly necessary for any type of success in this life, however, the priority should not be these things. Could you accomplish the same if you also maintained healthy relationships with your significant other, friendships, and family? (This question was rhetorical, of course you can). Hard work does not equal smart work. Let’s not be consumed by the struggle and the act of working hard. Let’s prioritize our relationships and the positive impact we can have on others. If we do this, we’ll likely be able to accomplish more than we ever thought possible and to live a life filled with meaning and purpose. AuthorNathan Kadlecek is a Doctor of Physical Therapy, health nut, powerlifter, and seeks to answer somewhat unanswerable questions. HERNIATED DISCS.
The scapegoat for so much back pain. Could a disc herniation be the cause of pain? Sure. Could it be other things as well? Yep. True symptomatic disc herniations are actually quite rare AND most people will be able to recover from these without surgery. Many people think that in order to feel better the disc must "heal" or resorb. This is not always the case. Many of us are actually living with disc bulges and herniations and we don't even know about it. We don't need to fear herniations so much! What are your thoughts? Have you had a disc hernaition in the past, were you able to recover from it? Would love to hear your experiences! Get out there and MOVE.
If you look up all the national and international guidelines for management of osteoarthritis, the first thing is EXERCISE. That is all. Have a great day! Many Many Many people have a meniscal tear and don’t even know about it.
Similarly, many people who have knee pain, who receive an MRI often find out they have a meniscal tear. In the USA we perform TONS of unnecessary meniscectomies (removal of portions of the meniscus) and I’ve seen way too many botched meniscetomies to ever recommend this, UNLESS there is mechanical locking of the knee which is not spending to non operative management. There have been a few great research studies now documenting how surgery vs. sham surgery (fake surgery) have the same outcomes when it comes to menisectomies. I’d highly recommend the clinicalathlete podcast, particularly he episode which talks about meniscal tears and surgery outcomes. What are your thoughts? Ever had a meniscectomy? There is a lot of fear which surrounds back pain.
Much of this is likely due to societal norms and the acceptance of false narratives pertaining to lower back pain. If we know that 95%+ of lower back pain is not dangerous, then why do we have such a large swath of the population suffering with chronic lower back pain issues? This is not to say that there are not some genetic predispositions for developing lower back pain, however how much CONTRIBUTION is biological vs. environmental? Some of you reading this might be dealing with chronic issues and what I am not saying is that it’s all in your head, or, that you should just suck it up and get better. Chronic pain is incredibly challenging to deal with and the best thing we know to do with this is to focus on meaningful activities, improve sleep patterns, manage stress, improve exercise habits, and potentially pharmacological management in more challenging cases. What are your thoughts on this, anything to add? If you’ve been following me for a while you’ll know what my position is on back pain and surgery.
It’s not that surgery is never an option, in fact, it can be very helpful for some individuals with specific symptoms that are not getting better with conservative management. My problem with our current system is that people are still rushed into getting an X-ray or MRI when it is not indicated. Patients, you also have a role to play in this as I’ve met MANY who demand they absolutely need an MRI to “find out the root cause.” It’s not that simple and often may lead to worse outcomes if you get the imaging early due to various beliefs that may come out of receiving this imaging. What questions do you have for me? Anything I missed? |
Dr. KI write about pain, wellness, positivity, our healthcare system, and sprinkle in a few rants. Archives
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