Training/Program Design

If you are like most people, you may find that the hardest person to train is yourself.  It’s easy to second guess what you are doing and how well you are doing it.  You often may feel as if you are trying and trying but are getting nowhere.   Many times it is simply because you do not have the time or resources to design a suitable training program.

Why not let someone else do the hard work and thinking for you?

Nothing makes more sense than online coaching/consulting.  Look at it this way, a personal trainers fees are high (70-120 dollars an hour) and when added with the gym fees –you begin to feel the crunch.  You don’t need to be told that it adds up quick.  Also, most personal trainers are only doing 2 week courses to get certified!  There is no regulating body around the profession, so logically, how can you be sure you are getting a properly balanced training program?

You are an individual, with your own needs and wants (and perhaps special injuries that need addressing).  So why not be treated that way by a professional who wants to give you a personalized service?

Whether you want to gain muscle, lose fat, improve your speed and agility, look more like an athlete, build strength, rehabilitate an injury or simply have a more meaning full life because you value health and wellness; why not let me take the guess work out?

With a month’s programming, here is what you will receive:

1.  A detailed consultation (questionnaire via skype, phone, email) that will allow me to get the information I need in order to design a personalized program, specifically for you.
2. Video and picture support to showcase proper technique and form for ANY exercise or movement you may be unsure about or unfamiliar with.  This is to ensure your safety and well-being.
3. 4 weeks of programming that includes: soft tissue/self myofacial release techniques, corrective training, flexibility (dynamic and static), mobility and core work, activation work, strength training, conditioning, recovery work, and basic nutritional support.
4. Access to my personal email account 24 hours per day for personalized service.

If you are going to the gym but not getting what you want or feel  you may not be fully understanding how to schedule your training to reduce your time and effort; let me help.  You are going to get the red carpet treatment and not some run of the mill, generic,  magazine program.

Start now: No Obligation Consult

Need more info on my credentials? Click Here

Pause

Life can be tough. As Dr Larry Crabb puts it: ”Nothing makes us lose a proper focus more quickly than pain and nothing keeps us from recognizing a wrong focus more than a life that is going well”

 

 

I have made some major mistakes in my life. With those mistakes, however, has come the opportunity to build trial and discipline. Healthy introspection and confession are excellent tools for building the spirit’s endurance. The result is a strengthened character. Focus on your reputation and your character can suffer; Focus on your character and your reputation will flourish. As Coach Wooden put it:  “Reputation is what others think you are, character is who you really are.”

 

Over the next year I am going to exercise a few self-disciplines. My focus is going to be on achieving solitude and simplicity. Through this time I will not be blogging, facebooking, or, to the best of my ability, using technology.

 

 

 

My goal is to become humbled in a spirit of servanthood. I realize this may sound strange. However, we all wear a mask of some whether it includes a social mask, a family mask, a relationship mask, or a professional mask.  Many of our masks are steeped in egocentric thinking and behavior. My goal is to dissolve this false sense of self.  I want to become a better person, a better lover, a better son, and a better man.

 

 

Call it fanaticism, asceticism, or what you like. I call it a second chance and a new perspective at life. It is when our illusions of self are destroyed that true and real hope can take root. Those who know me best understand where I have been, what I have done, and, ultimately, where I am going.

 

For those of you who do not know me on a deeply personal level, I ask you to remember this: We are unique yet we are all the same, same in the fact that we are all fallible. We all go through trials. If you aren’t in one now you are getting out of one.  If you aren’t getting out of one, you may be ready to go through one. That’s life.

 

Finally, whether or not you choose to forgive is up to you.  It is important to remember, however, that bitterness harbors disease. It erodes both physical and mental health. It creates chronic pain and disability. It cripples relationships.  It prevents healing. It is a wound that if not treated becomes a crippling, systemic infection. We all make mistakes and when we do, remember to be supportive. Giving up should not be an option. We must, including myself, dust ourselves off, re evaluate, and hold ourselves to a higher, stronger standard.

See you in a year!

In Health

Dr Anthony

Controlling your health –part 3

By now you should be aware of how your perceptions affect your health. You have considered internal and external perceptions and how you will be examining your chance perceptions of health. Have you noticed how these perceptions influence your approach to managing your health? If not, please take a moment to think about the benefits of understanding your beliefs, values, and ideas of health. You probably understand how important these belief systems are in taking the correct step towards your well-being and being accountable towards your health.

Chance health perceptions

Einstein once stated that God doesn’t play dice with the cosmos, and neither should you in regards to your health. Now it may seem fairly devious that having no plan of action or control of your health is a bad thing, however, many still act with self-defeating attitudes towards their health. Moving from acute to chronic lumber pain is a prime example of when you leave your health to chance.  Your chance at health becomes a bet, and why bet with your health?

Identify your chance health perception

For each of the following, mark the most appropriate answer. Do this in private and be honest with yourself, knowing that you won’t be judged.  Score each answer from zero to ten.  Zero being no confidence and ten being maximum confidence.

1. My belief that health and healing are a matter of fate and nothing changes that result.

2. My belief that when I get sick or become disabled, it is a purely random event over which I have

no control.

3. My belief that regardless of what I do, it will not affect when I will die or how sick I will get.

4. My belief that one genetic makeup determines one future regard lees of what else may happen.

5. My belief that we have little control over when we get a disease or die.

 

Scoring your chance health perception

0-25:  Low confidence in random health actions

26-37:  Average confidence in random health actions

38-42:  High confidence in random health actions

43-50:  Very high confidence in random health actions

Understanding your score

What if you fail to see a link between no belief in yourself and poor health? Imagine that your health is simply a roll of the dice. You’re probably starting to feel how these thoughts are in some way crazy.

Passive coping

Passive coping  (thinking the pain will simply “go away”) and fear avoidance (avoiding specific activities out of fear) are both forms of a chance health perception.  It is within these perceptions that disability blooms. Disability and chronic pain are direct by-products of self-perceived poor health (Linton, 2000). The lumbar spine, in particular, requires identifying these ill-fated perceptions to avoid the reality of becoming non-organic (chronic). It may seem common sense but, as you already know, sense isn’t always that common. If you don’t see any point in taking care of your diet, managing a healthy life-style, taking your medication, or listening to your health care provider’s instruction, then you shouldn’t plan on living an optimal life. Simply put, there is no upside to a high score. The good news, however, is that there is a positive association with a lower score. The lower the score the more accountable you are and the more you are seeking the ultimate solution to your predicament. I trust that, by now, you are realizing how your perceptions affect your health. Develop new skills, get support, learn the true depth and value of how amazing you are, and feel empowered to take charge now.

Acknowledgements

1. Dr Frank Lawlis

2. Dr Craig Liebenson

3. Dr Phillip Mcgraw

Controlling Your Health – Part 2

 

In part 1, you learned about the four pillars of health and fitness.

1. Muscle and Joint (Musculoskeletal)

2. Cardiovascular and Pulmonary systems

3. Dietary Habits

4.Mental Well-being

You also became aware of self-efficiency and how it relates to your perception of health. By now, you should have a better understanding of your internal beliefs, perceptions, and how they relate.

In this article, you will be examining your external perceptions and understanding how they may be adversely impacting your health.

In this article you will be understanding you external perceptions and how they may be adversely impacting your health. In addition to discovering what can be done about it. Remember that the best indicator of how much control you have over your health is how much control you believe you believe you have.

The test used in this article is from Dr Frank Lawlis (Jeanne Achterberg and G.Frank Lawlis, The Health Attribution Test, Champain, III.: IPAT 1979). As a reminder this is a three part series covering the entire health attribution test. In part 1, we examined internal health perceptions, this time we are examining external health perceptions; and in part three we will be examining chance health perceptions.

 

External Health Perception.

External health perceptions are important to be aware of so that you become more empowered and accountable toward your health. Having the idea that you are going to be healed by your Doctor can lead to disappointment and the inability to create coping strategies.

Remember that accountability counts. A lack of self-accountability means that you are allowing yourself to become a victim. If you are overweight, you are accountable, if you have lower back pain, you are accountable, and so the list goes. If it’s something you have no control over then you are accountable for doing all you can to minimize future risks. By understanding you perception of dependence on others, you may stop relying on others to resolve your health predicament.

 

Identifying your External health perception.

For each of the following mark the most appropriate answer. Do this in private and be honest with yourself, knowing that you won’t be judged.

Score from 0-10: 0 being no confidence, and 10 being maximum confidence.

1.   My belief that my Doctor will heal me.
2.   My belief in medicines to heal my body and mind.
3.  My belief that if I follow all instructions given to me by my health care professional, I will be healed.
4.  My belief in the concept that if I have faith in my religious symbols of teaching,                        I will be healed by my spiritual power.
5. My belief in the healing power of my friends and family as crucial to healing my body    and mind.

Scoring Your External Health Perception

0-20: Low Confidence in others as healing agents.

21-30: Average Confidence in others as healing agents.

31-40: High Confidence in others as healing agents.

41-50: Very high confidence in others as healing agents.

Understanding your score.

If you have a high of average score you may be highly dependent on other people or influences to get you out of health troubles. You may believe that someone or something is the holy grail of health. This leads you to believe that your doctor has magic hands, your specialist has the magic technique, or your spiritual leader has the secret formula to prayer. In other words you are totally convinced they, the individuals and their methods, will work.

There is an upside to having a high score. You may be more likely to reach out for professional care, supported or trusted expertise. If this sounds like you, make sure you choose your health care professional wisely. As a health care professional, I can personally say that people presenting with higher score in this area are typically more compliant with rehab regimes. In other words you may be a doctors “perfect-patient.”

The downside is that you may lack healthy skepticism regarding the promises of a magic cure. No one is better at managing your health than you. Remaining inactive and passive toward your wellbeing creates a victim mentality, whereas being in control and accountable, helps you to take ownership. In the long run, maintaining such ownership increases your chances of success. Be responsible and take control now, without blaming others. I acknowledge that this may sometimes be difficult. If you have bad knees, or if you are overweight and under-active, then you need to address the contributing factors. If you believe that you are genetically predisposed to certain medical issues, then you have an even higher onus to live a lifestyle that minimizes your elevated risks. Cigarettes, alcohol, stress, your job, in-laws, none of them are to blame. Your own choices and actions are! Be accountable and active in influencing your wellbeing.

In regards to lower scores, the upside is an “I can do it myself” attitude. While foolish pride isn’t the answer, a rebellion against authority isn’t necessarily a bad thing. An example is the biomedical model for lumbar pain. Advanced imagery, surgery, bed rest, and narcotics aren’t necessarily the problem, let alone even beneficial! 

The downside of a low score is that you probably don’t trust anyone or believe that anything will work, in parallel, you may be overly skeptical toward the health care profession. Therefore, you may not seek treatment because you are not convinced it will help. You are “the glass is half empty” type. Unfortunately, that won’t solve health challenges.

In the next part of this series we will test your chance perception of health. If you are comfortable with it, leave your score and comments below.

Controlling your health. Part 1

Health and fitness is, without a doubt, one of the fastest growing fields in healthcare; and for good reason. The top six killers around the globe are heart disease, stroke, COPD, cancer, accidents and diabetes. What do most of these have in common? They are lifestyle based. Of course there will be medical elements to some of them but its hard to argue that a healthy lifestyle wouldn’t be beneficial.

I believe health and fitness is a state of balance between body and mind. This equilibrium in-duality  is accomplished by achieving wellness in four primary categories:

1. Muscles and joints

2. Cardiovascular system

3. Dietary habits

4.Mental health

When these four systems are healthy and happy, I believe you are in a balanced state of health and fitness. Doing so can be challenging, especially if you are lacking in self-efficacy. It will be our goal in this three-part series to get to grips with your own perception of health and self-belief. Your mindset creates, controls and influences your health, It is your beliefs, values and expectations. Ultimately, you will identify how you perceive health on three separate levels.

1.  Internal perception
2.  External perception
3.  Change perception

Once identified you will allow you to have an idea of your health expectations and beliefs. By knowing what you believe you can begin to halt destructive behaviors and begin to take action to improve your health. You are the ruler of your temple, no-body else manages your body but you.

 Internal health perception

In practice I have witnessed the difference between those who believe they can and those who don’t. The difference is huge in terms of recovery and relapse.We all know someone  that has overcome a great health crisis. Were they positive or pessimistic?

Pessimism, defined as stress resulting from hostility, resentment and despair, has been linked to a host of diseases. Men between the age of 40-55 who have high levels of hostility have a 42% higher risk of death, so relax guys because the stress is literally killing you.

Identify your internal health perception

For each of the following mark the most appropriate answer. Do this in private and be honest with yourself, knowing that you won’t be judged. Score them from 0-10. 0 being no confidence and 10 being maximum confidence.

1. My willingness to follow a good nutritional program in order to maximize my body’s healing abilities.
2. My willingness to exercise my body in order reach maximum recovery.
3. My belief in my ability to use focusing techniques to accomplish my goals in health.
4. My belief in my ability to calm my stress issues and use that energy to succeed in my physical healing.
5. My belief in my inner strength to heal my body.

Scoring your internal health perception

0-30 Low confidence in self direction

31-40 Average confidence in self direction

41-45 High confidence in self direction

45-50 Very high confidence in self direction

Understanding your score

Our perception of our health is so important to how we live, work and play. It’s within our beliefs and expectations by which we base our decisions concerning our well being. If we believe in a system there is a much better chance that it will work.

Take for example, chicken noodle soup for a common cold or flu. If you believe in it chances are it will help. Your internal health perception is how much you believe in yourself as the manager of your health and body. Your belief is important if you don’t believe in yourself you don’t have control. With that being said, there are cases and issues outside of such control. Hereditary disease or any uncontrollable events may also negatively impact your health. These are not your fault and there is no point in beating yourself up over it but instead focus on the future by what you can do now.

People who score low on this test need to understand that they are accountable. Now there is no reason to feel guilt but if you do feel guilt it is because you have violated one of your biggest standards. Now that you have acknowledged that move on!  Commit yourself to making sure the behavior doesn’t persist.Use the guilt as leverage to never violate your own standard even again.

If your scored high, congrats. Scoring high is for the most part a great thing It means that you take responsibility for your health The higher the score the more likely you are to:

1.Acknowledge your perceptions

2.Own your perceptions

3.Find solutions of your health issues.

4.Make the solutions happen

The down side to having a high score is that you may be overly self-sufficient. In this case, you may fail to seek advice or mentorship. You may fail to reach out to others that have a wealth of information. Again if the health concern you may have isn’t your fault (blindness, heart disease etc) don’t pressure yourself. Blaming yourself for issues outside your control is worthless. Focus on what you can do now to make a better future. Hold yourself accountable for your actions from here on.

In the next part of this series we will be looking at your external health perception. How you view others in regards to your health and wellbeing. If you feel comfortable leave your scores below; its alway nice to compare notes. There is nothing wrong with a low score as long as you own up to it and seek out advice or support.

In Health

Dr Anthony.

Acknowledgments.

Thank you to Doctor Frank Lawless for his health perception test.

Wellbeing App Released

“Would you tell me, please, which way I ought to go from here?”

“That depends a good deal on where you want to get to,” said the Cat.

“I don’t much care where-” said Alice “Then it doesn’t matter which way you go,” said the Cat.

“-so as long as I get somewhere,” Alice added as an explanation.

“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”

-Lewis Carroll, Alice’s adventures in wonderland

Imagine traveling without being able to recall where you have been. In order to know where we are going, we need to know where we are coming from and there is no difference when speaking about our wellbeing. For example, if you call me and ask, “how do to I get to Wellington,NZ?”, I will certainly reply, “where are you coming from?”.  We often have a goal but oddly enough we are blind to our progress (or lack thereof). For instance, ask yourself what your mood was yesterday. Now ask yourself how your mood was two weeks ago. I am certain you are slightly foggy on the last one. But what about your mood 3 months ago? 1 year ago? I imagine you truly don’t have a clue- unless it falls on a memorable day good or bad. Not having access to this information can be problematic when tracking progress and measuring outcome.

In practice I identified a problem with asking “on a scale of 1-10, what is your pain today?” The problem was not the question being asked but rather the frequency at which it was being asked. I do not see my patients daily nor do I want to see them daily, I want my patients to recover quickly and efficiently. But identifying progress can be difficult when it is sporadic and spread out over  several weeks. It’s simply better to know how the patient is coping daily.

Before the wellbeing apps creation I took on the tedious job of emailing clients an outcome based spreadsheet. The spreadsheet was simple and it allowed them to enter an 0-10 rating for pain, mood and sleep, everyday of the week. Once the spreadsheet was returned I would graph the data and use it to demonstrate progress to the patient. I found this very effective in unmasking ineffective treatments, demonstrating the harmless nature of flare ups and empowering self-care.

As my clinic grew this system became overly tedious. However what I found during early graphing was exciting. I found that once patients graphically visualized progress, it reinforced their attitude towards improvement. Often patients will forget where they came from (early pain episodes) but simply reminding them with the graph allows them to understand the progress made.

Because I was graphing data on pain, mood and sleep, patients were able to better understand the correlation. This can be simple to understand but also empowering to envisage. When my patients began to see the graphs and realise they were managing their pain, it was a lightbulb moment for them. They knew what was working and what wasn’t. That to me was empowering my patients. Moreover, it was done through powerful visual feed back.

Visual feedback is an invaluable tool. Whether it is EMG, biofeedback or wellbeing, seeing is believing. The primary goal and vision of wellbeing is this,

“empowering the users perspective in regards to health and wellbeing.”

It is a must for anyone wanting to know and see their progress. Wether it be pain, sleep, mood or your own unique category, you are now able to track it easily.

Finally to put the icing on the cake, you are able to overlay and compare graphs. Overlay strength with motivation or strength with impact on others. What ever you can dream up you can monitor. Wellbeing allows you to simply and easily track your progress on a consistent basis. After all how do you know were you are going if you don’t know where you have been?

Buy Here

Summary

1. Wellbeing allows for graphical mapping of your pain, mood, sleep, and motivation.
2. Input your own category to track (i.e. strength and eating behavior)
3. Wellbeing unmasks ineffective treatments and poor progress.
4. Touch screen monitoring. This is simply just cool.
5. Empowers the user to monitor outcomes daily, not at every doctors visit which could be at weeks apart.
6.  Email your graphs directly to your doctor, trainer, or therapist.
7. It costs less than a pizza and is better for your health.
8. Allows the patient understand that hurt doesn’t equal harm.

3 Major Myths Concerning Back Pain

1. The need for an accurate diagnosis
2. The need to rest until pain is gone
3. The pain will lead to chronic disability

The need for accurate diagnosis

The spine is a unique structure and is often subject to debate in various circles of study.  During your lifetime you have about a 70% chance of developing acute lumber pain.  I am sure if you have experienced significant pain in your back, you have had concerns regarding accurate diagnosis of where the pain is coming from.  In fact, many form their own lay mans version of a structural cause, such as the muscles, ligaments or disc.  What is interesting is that research shows that none of these can accurately be diagnosed as a source of pain.  What is even more important is that structural causes need not be identified in 85-90% of back pain patients for a successful outcome to result.  It should put you at ease knowing that serious medical disease resulting in pain is less than 2% of all back pain causes.  What’s more exciting is that the fact that these 2% maybe ruled out through a proper history and simple exam.  So what is causing the pain?

A better question is to ask “what is my pain trying to tell me?”  The perception that pain is a negative sensation is harmful; pain is simply trying to tell you that if you keep doing something (such as lifting improperly a certain way) the tissue may be harmed.  It doesn’t mean you have already harmed the tissue.  In the case of a simple back ache, pain doesn’t equal harm!  Therefore the pain is simply telling you to be more active or aware of your movements.

Need to rest until pain is gone.

The biomedical model has often prescribed bed rest for lower back pain (LBP); however multiple studies have shown bed rest to be more harmful than good.  In fact, 2-3 days bed rest is maximum for acute, simple back aches.  More over this should only be recommended when pain is severe.  Bed rest isn’t treatment for the pain; it is a consequence of the pain.  Even though uncomfortable, being astutely active is the best and most efficient form of treatment. For simple back pain when should you use bed rest?  If the pain is severe (9/10) then consider it, but only for a few days (remember rest isn’t always best).  Excessive bed rest may lead to chronic disability.

People experiencing back pain often become fearful that the pain will cause serious disability.  Such disability is highly unlikely; moreover, people who remain positive, active, and motivated are likely to recover quickly.  People who equate hurt to harm or exaggerate pain tend to become worse.  When a person experiencing back pain stops becoming active, the joints and muscles become inactive, this inactivity leads to de-conditioning and the de-conditioning results and more prolonged pain.  Do you see the downward spiral?  So how do we keep the pain from becoming chronic?

1. Remain active
2. Exercise regularly
3. Remember hurt doesn’t equal harm

If you are fearful, use a quota-based approach, gradually increase your activity in a step wise manner.  Limit activity by quota (set-reps) not pain.  Gradually encounter the things you fear and are safe and low load environment.  You can’t get over the fear of running by sitting on the ground, you get over it one step at a time!

Summary

1. Bed rest may have harmful effects on back pain.
2. The benefit of activity exceeds the risk the rest.  Swimming and walking are great for active recovery
3. Hurt doesn’t equal harm.
4. Flare-ups aren’t a failure they are expected.  Simple movements like a cat crawl or back bridge can immediately reduce symptoms.
5. Exercise is the best way to prevent future back pain; however, 25% of patients fail at sticking to a plan.  What can you do to stay motivated?

Acknowledgements.

Special thanks to Craig Liebenson for valuable insight

Proprioceptive warm-up

In a previous blog I briefly touched on reducing sensory information, in order to improve squatting mechanics. The purpose of this blog is to show a novel approach to modifying a warm-up to compound or Olympic lifts.

In all aspects of movement, such as strength and efficiency, lies the master control; otherwise known as neurological factors. The most notable factors being the sense of kinesthesis and proprioception. It’s important to consider that the joints, through these senses, talk to the brain in two general manners. First, they relay information regarding their individual position in space and time and secondly regarding their relative positions to one another. Moreover, when combined with other senses such as sight, sound and touch we are able to perform movements with incredible accuracy and skill (assuming all are operating efficiently).

In training, improving proprioception, is something that time is hardly devoted to. As a practitioner of manual medicine it is a fundamental piece in the perfection of optimal movement. Any practitioner using PNF techniques or sensory motor training understands and has most likely experienced the positive effects of improving the Proprioceptive system. The results are improved movement patterns, speed and timing of information.

The following is a simple system that I have personally found beneficial in improving proprioception and ultimately perfecting secondary movements and compound lifts. It is both time efficient and easy to monitor improvement. Moreover, this methodology may be used for any movement that may be in need of correction. Usually the person being trained is unaware of errors in movement and believes that the movement is being performed properly. Try using this system to allow the individual to ‘feel’ the errors described by the coach more appropriately.

Step One: Have the client cover their eyes with a soft blindfold or night mask (as used in sleeping).

Step two: Have the client get into the starting position of the lift, without weight or resistance. If the exercise being corrected uses a bar, replace it with a dowel rod or broom stick… Use appropriate touch and verbal cuing to correct any errors. Also, it is important to have them focus on what they are feeling from their feet to their head. They should be aware of both location and balance. Repeat this five to ten times or until satisfactory starting position is naturally achieved.

Step three: Remove the blindfold and allow the client to perform eight to ten reps of the movement in question. Light weights may be used at this time. (I.e. 20% IRM) Afterwards, place the blindfold back on and have the client repeat the movement for another eight to ten steps. As the client becomes proficient at the movement, guidance and correction will diminish. In addition, the movement will become perfected and stable. The client will become more aware of the movements natural feel with eyes open and closed.

In summary, this methodology is a wonderful way to clean up movements. It may be incorporated prior to the warm-up set of any lift or movement pattern. Be creative in how you use it but always be safe. It may be a valuable tool, not only for strength conditioning, but for rehabilitation as well.

Controversy: Imaging, is it helping your patient or wallet?

Controversy: Imaging, is it helping your patient or wallet?

When diagnosing the culprit of lower back pain, many clinicians rely on diagnostic imaging (i.e.: x-ray, MRI, CT). Lumbar pain is reassuringly benign, 85-90% of the time. Lumbar pain involving nerve compression comprises 10% of lumbar pain patients. Sinister or serious disease make up the remaining 2% of lumbar pain patients. The great news is that these ‘sinister’ conditions are ruled out by a proper history and exam. However, many clinicians still seem to be ordering imaging during the initial exam. The question often raised is

“structural pathology is often evident in images, so why wouldn’t we (the clinician) want to identify such abnormalities?”

While structural pathologies do have there place in medicine, they usually have little to do with lower back pain. In fact, most lumbar pain patients do not have a structural pathology that can be precisely identified as being a cause of their symptoms. McGuirk et-al found that 1.4% of lumbar pain patients had serious causes as a result of their lumbar pain, but they were suspected from the initial exam and history.

What about disc herniation?

Because the false positive rates are so high, in identifying a herniated disc, it makes imaging inappropriate as a screening procedure. Moreover, it can lead to labelling thus allowing the patient to assume a sick role or cause the doctor to prescribe unnecessary treatment. In a study performed by Bonenstein et-al, 67 asymptomatic individuals received MRI’s. The results were staggering, in that, 31% of them showed abnormality of the disc or spinal canal. Moreover, additional studies showed that these abnormalities didn’t predict a greater chance of future problems. Multiple studies have also shown that common “positive” findings are present in 28% to 50% of people with no pain at all! Disc herniations have a tendency to resolve in a natural process without surgery. But, what about the herniations that require surgery? The Danish guidelines show the following as being surgical indicators for herniated discs. 1: No improvement after 4-6 weeks 2: Progressive weakness in the leg 3: Leg symptom remains severe despite treatment and medication 4: There is a positive correlation between clinical findings and imaging reports. What about spinal degeneration (decay)? Again this is a term that instils fear into a patient. Disc degeneration is demonstrated with equal properties between those with and without pain. The prevalence of disc degeneration in people without pain and in their middle ages ranges from 46% to 93%! Therefore there is little correlation between radiological signs of degeneration and clinical symptoms.

When is imaging appropriate?

Most acute lumbar pain patients resolve quickly and with little intervention. In fact, It has been shown time and time again that reassurance, simple pain relief and staying active, is the best strategy for managing active lumbar pain. If there are red flags (sinister conditions) present, they should be picked up during the initial history and exam. Red flags of the serious disease are as follows: Mri of the back 1: Age younger than 20, older than 50 2: Trauma 3: History of cancer 4: Night pain (unremitting) 5: Fevers 6: Weight loss (unexplained)\ 7: IV drug use 8: Cortico steroid use 9: Recent infection 10: Cavda Eqvina 11: Generalised Systemic Disease (diabetes) 12: Saddle Anesthesia 13: Motor weakness of lower limbs 14: Sphincter Disturbance 15: Failure of 4 weeks conservative care Given these guidelines we are able to form a simple strategy. If there are no red flags, consider: 1: Reassuring the patient no serious disease is present 2: Relieve and reduce pain (simple analgesics, manipulation) 3: Reactivation (stay active, no bed rest) If there are red flags present consider the following: 1: Imaging 2: Lab work 3: Referral Informing your patient that you are able to rule out sinister conditions, even though an exact cause of their pain may not be identified, will register as very reassuring news. Craig Leibenson gives a wonderful analogy for simple back pain:

“liken the pain to a common cold or the pain experienced from gardening for the first time after a long winter”.

Conclusion

In a study by Kendrick, patients who received x-rays were likely to report a longer duration and greater severity of pain. Why reinforce a patient’s belief that they are unwell and cause them to limit their activities and in essence promote a more negative outlook? Yes patient satisfaction may be higher but the patient must be educated on why radiography is unable to improve therapy, decision making, or outcomes. If after 4-6 weeks there is no sign of improved function or red flags are identified from the patients history and exam, then consider (imaging or appropriate refferal). But always remember, a picture of a car doesn’t mean its running.

References. Leibenson C, Rehabilitiation of the spine. 2nd edition: 2007 Bonenstein DG, et-al. The value of MRI of the lumbar spine to predict lumbar pain in asymptomatic subjects. J Bone and Joint Surg 2001:83-A:1306-1311. Boden SD, abnormal MRI of the lumbar spine in people without back pain. N engl J med 1994;2:69. Kendrick D, Radiography of the lumber spine in primary care patients with lower back pain: Randomised controlled trial.  BMJ 2001; 322: 400-405. Jaruik JG, the longitudinal assessment of imaging and disability of the back study.  Spine 2001; 26:1158-1166.

 

16 simple rules to inner well being

Today I had passed onto me some well meaning axioms that were supposedly written by Buddha. I personally found them enlightening and thought I would share.

1. Take into account that great love and great achievements involve great risk
2. When you lose, don’t lose the lesson
3. Remember that not getting what you want is sometimes a wonderful stroke of luck
4. Learn the rules, so you know how to break them properly
5. Don’t let a little dispute ruin a great relationship
6. When you make a mistake take immediate steps to correct it
7. Spend some time alone everyday
8. Open your arms to change but don’t let  go of your values
9. Remember that silence sometimes is the best answer
10. Live a good and honorable life that way when you are older you can enjoy it a second time
11. A loving atmosphere in your home is the foundation for your life
12. In disagreements with love ones, only focus on the correct situation , don’t bring up the past
13. Share your knowledge, its a great way to achieve immortality
14. Be gentle with the earth
15. Once a year go somewhere you have never been before
16. Follow the 3 R’s

• Respect for self
• Respect for others
• Responsibility for all actions

In life we are merely passengers, so its best not to “back seat” drive. We are architects of our lives and great plans require great work. In many great projects there will be disappointment, discouragement and dissolution. These are nothing but tests and traps. True character is found in times of crisis. Focus on what lies ahead, stick to your true beliefs and values; and you will forge a noble reward. Remember that on the horizon of every dark  and cold winter, lies the promise of a sunny and warm summer.