Recently I became the primary caretaker for my wife in the aftermath of a motor vehicle accident. Like all health professionals who face their own medical crises, I immediately discovered that taking care of a spouse is nothing like taking care of a patient! Easier in some ways, much harder in others, it is a tornado of continuing education: hundreds of concepts that were a matter of abstract professional knowledge are suddenly embodied in the pain of a loved one and pushed into my brain with an emotional battering ram.

All good health professionals are emotionally sensitive to their patients’ suffering … but not like this!

Here are three lessons about injury (especially low back pain) and recovery that I’ve drawn from my experience so far. None are particularly surprising to me — not so much learned as reinforced — and I’m sure this list will grow:

1 — Joints pop more after trauma! I’ve said this to patients for years without really being sure of it, but now I’ve witnessed it dramatically. Kim’s back barely popped before, but now pops so much that it’s been a struggle for her to accept that it’s normal. It seems extreme.

2 — Muscle pain is king. My wife crushed one vertebra, snapped a tip off another, and had steel braces screwed into the bone above and below … but that’s not what hurt. She has had some back pain, sure. But muscle pain in the area — especially the hip, many inches from the fractures — has consistently been by far the most significant source source of symptoms. Muscle is clinically underestimated!

3 — And neurology is queen. The evidence is overwhelming that what you think about your pain is a critical factor in your experience and recovery (see Pain Is an Opinion and The Mind Game In Low Back Pain). Countless times I have observed Kim react to similar stimuli in different ways, depending on the mental context. Nervousness makes things hurt more! And confidence makes them hurt less.

ADVANCED TUTORIAL

Save Yourself from Low Back Pain!

There are thousands of low back pain books — what’s special about this one? The problem is that 90% of doctors and therapists assume that back pain is structural, in spite of mountains of scientific evidence showing … exactly the opposite. Only a few medical experts understand this, and fewer still are writing for patients and therapists. Supported by 171 footnotes, this tutorial is the most credible and clarifying low back pain information you can find. Ships with a free copy of SaveYourself.ca’s trigger point tutorial! Add it to your shopping cart now ($19.95) or read the first few sections for free!

  $1995

After three weeks of post-surgical rehab at Aek Udon International Hospital in northern Thailand (read what happened), Kim and I flew home from Thailand to Vancouver on March 1 and 2, with the help of the medical transport company Fox Flight Air Ambulance and their excellent nurse escorts. Kim did remarkably well, and got through the trip with almost no pain — far better than we dared hope. And it was a fascinating experience to:

• fly first class for the first time in our lives,
• watch our medical escorts deal with the maze of logistics and legalities of medical transport,
• and sail through airport lineups on the fast track. (The only thing you have to wait for as an injured passenger is de-planing. You get to be first for everything else — but you’re the last to get off the dang jet! It was peaceful, in a way, because the question “how much longer?” question was pre-answered: until the end.)

It was the medical transport service that was what really made the trip interesting. The basic problem of medical transport is that airlines don’t really want to take injured passengers. From the airline’s perspective, Kim was a legal disaster just waiting to happen. People like to sue airlines. Pilots have the legal right to refuse any passenger, and they do. We heard horror stories about this before we left.

It’s the job of the medical escort company to deal with all of that. Safety is job one, of course, but our nurses were also experts in cutting through red tape. For instance, we all made the decision together that we avoid the use of a stretcher, because Kim was doing so well, and because seeing a stretcher really makes an airline ask a lot more questions …

Stretcher at 2 o’clock, unleash the red tape!

We faced a (minor) crisis when ticket agents spotted Kim being wheeled into the Bangkok Airport on a stretcher. The ambulance attendant thought he was being helpful bringing her all the way in to meet us, but our nurse escort muttered with mild alarm, “I told him not to bring her in here yet! I didn’t want them to see her on a stretcher!”

Sure enough, a supervisor hustled out when he saw the stretcher, and our escort had to play it cool and offer reassurances, even getting Kim to demonstrate her ability to walk. In this case, the supervisor was easily reassured, but it all depends on the person you’re dealing with. Sometimes, apparently, the nurses really have to get clever or pull rank — if necessary, they can even phone up some pretty serious people to tell lowly supervisors to back off.

It was a bit nerve-wracking to watch at time, because time and safety were interconnected for us. But they got us through all the hurdles, and Kim turned out to be surprisingly capable.

First class, ooh la la

So Kim and her escort flew business class on Cathay Pacific Airways — highly recommended — and got utterly spoiled by amazing customer service and assorted luxuries. Some of that service extended to me, as I was a special guest in their section, permitted to visit my injured wife. During my drop-ins, I was offered things like hot towels and wine in an actual glass instead of a plastic cup. Ooh la la! Kim’s nurse even swapped seats with me for an hour, and I got to nap in his fully-reclining booth seat.

However, for 90% of the trans-Pacific flight, I was still stuck in economy class on a particularly crowded and baby-infested flight — as unpleasant as it usually is.

I did luck out a little though: two people were removed from the plane for security reasons at the last second (sucked to be them) … and they were in my row, so I suddenly got elbow room. A little elbow room makes a big difference on a 12-hour flight!

The price tag for this method of travel

Somewhere in the neighbourhood of $30,000.

So buy travel insurance! And if you’re ever stuck abroad due to illness or injury, you will probably need a medical transport service to get you home. And ask your insurer to work with Fox Flight Air Ambulance — they were truly amazing. Even if you’re stuck without insurance, still contact them — they have the skills to get you home as safely as possible, and maybe for $30,000 instead of $50,000!

If you have a private jet, please come and pick us up, or my office will continue to be a laptop in a Thai hospital for a while yet! I’d hoped to keep up a trickle of writing during Kim’s rehab, but phew ... it’s tough! (If you missed the news, see the post about my wife’s nasty car accident.) Although she is recovering well, it’s still an extremely challenging situation, and we face some delays getting back to Vancouver. Flights are packed due to the Olympics, and we need several seats for Kim’s stretcher. We still don’t know when we’ll finally get out of here, but it could be anywhere from Mar 5 to late March.

Quite a bit longer than I want to live in a hospital, even with the shorter scenario.

I have no idea when I’ll get around to it, but this experience is certainly going to inspire some writing. I am getting a lot of really intensive, personal experience with spinal injury rehabilitation. Like I didn’t know enough about back pain already …

People think of massage therapy as a “safe” therapy, and of course it mostly is. But things can go wrong. Fortunately, serious side effects in massage therapy are rare, and common side effects are minor. A 2007 survey of 100 massage patients found that 10% of 100 patients receiving massage therapy reported “some minor discomfort” in the day following treatment. Interestingly, 23% reported unexpected, non-musculoskeletal benefits.

I’ve written a new short article inspired by this research:

Most people — both patients and many professionals — assume that muscle relaxants are effective, especially for injured necks and backs. This does not appear to be a safe assumption.

A new study in the Canadian Journal of Emergency Medical Care compared ibuprofen and a muscle relaxant (cyclobenzaprine or Flexeril) for patients with serious soft-tissue injury in the neck. Groups of about 20 patients received one, the other, or both. Results were statistically identical for all patients. This test showed no benefit to using or adding a muscle relaxant for acute muscle strain in the neck. The study is too small to be powerful, but it certainly shows that there’s no clear advantage to muscle relaxants in a situation where they are often assumed to be an important medication, and the results are consistent with other research results.

The surprise here is not just that muscle relaxants weren’t obviously superior, but that they even performed as well as ibuprofen! Despite the many kinds of muscle relaxants, and their many possible uses, as a class of drug they are remarkably unimpressive in the management of common pain problems. A 2008 physician tutorial in American Family Physician (see See et al — that’s not a typo, the lead author’s name is actually “See”!) nicely sums up the blah state of the evidence:

Skeletal muscle relaxants are widely used in treating musculoskeletal conditions. However, evidence of their effectiveness consists mainly of studies with poor methodologic design. In addition, these drugs have not been proven to be superior to acetaminophen or nonsteroidal anti-inflammatory drugs for low back pain.

And “skeletal muscle relaxants should not be the primary drug class of choice for musculoskeletal conditions.”

Medical care for low back pain has a split personality: the experts “get it” and their opinions are widely published and accessible, but general practitioners either haven’t read the guidelines or ignore them. A new study in the Archives of Internal Medicine shows that family doctors aren’t caring for low back pain the way that their own expert colleagues recommend.

The paper presents strong evidence that general practitioners are simply not using best practice guidelines for the care of low back pain, even many years after they have been widely publicized in the medical literature. Williams et al looked at more than 3500 new cases of low back pain, comparing the advice patients got to the advice they should have gotten:

…the usual care provided by GPs for LBP does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. This situation has not improved over time.

In particular, GPs:

• failed to reassure patients
• prescribed unnecessary, expensive and emotionally intimidating medical testing to look for largely non-existent and/or irrelevant “structural” problems
• failed to prescribe simple pain killers which could reduce symptoms and anxiety with virtually no risk
• failed to recommend massage therapy, even though it has always been an intriguing option, and is now also an substantively evidence-based treatment option (as established by a good quality scientific review in 2008)

(The Williams paper doesn’t discuss that last one — indeed, the survey predates the evidence — but it’s a pet peeve of mine that strongly fits in with the pattern of failing to give good advice.)

In a weird way, this website depends on front-line health care professionals failing to give good care. The whole point of SaveYourself.ca is to provide better information — the kind of information that you should get but often don’t get from most health care professionals. So it’s strangely reassuring to me when doctors and scientists publish detailed criticism of their own practices, confirming that there really are common problems with low back pain care, and that there really is a need for better information.

So this new paper strongly validates my position that patients are routinely getting poor quality information about low back pain — and could really use a readable and current guide to low back pain management. And, interestingly, so can the doctors. I know I have have many GP customers already, but I’d like to see more of them buy and read my ebook — they could clearly use it, and would probably find it much more enjoyable to read than a scientific journal.

ADVANCED TUTORIAL

Save Yourself from Low Back Pain!

There are thousands of low back pain books — what’s special about this one? The problem is that 90% of doctors and therapists assume that back pain is structural, in spite of mountains of scientific evidence showing … exactly the opposite. Only a few medical experts understand this, and fewer still are writing for patients and therapists. Supported by 171 footnotes, this tutorial is the most credible and clarifying low back pain information you can find. Ships with a free copy of SaveYourself.ca’s trigger point tutorial! Add it to your shopping cart now ($19.95) or read the first few sections for free!

  $1995