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Take It Easy Is not an Option

Vert Mooney, MD, interviewed by Susan Cosgrove (0:01 to 5:01)

Susan:

Hi. Let me play devil’s advocate. What if I were an injured worker and you said to me do you want more function or less pain?

I might say to you right now I want less pain; I’ll deal with the function later on. What would you say?

Vert:

Well, the truth of it is that you can’t have it that way because if you want to hurt less, which means you don’t want to do anything, then that allows a deterioration of soft tissue function, and that isn’t going to help you at all.

And everybody is aware of somebody who’s been off work for years, and they never do get back to work. And that’s not a goal which the injured worker at the beginning wants to accept.

Certainly the injured worker at the beginning wants to get back to work, needs to get back to work—it’s a financial thing.

All of us need our pay, and there are commitments that are made, and so getting back to work is a reasonable goal from everybody’s standpoint.

Susan:

Let’s talk about evaluating function. I understand you are a strong believer in quantification.

Will you tell us why it’s important and how we ought to do it?

Vert:

This quantification of function supplies the most efficient handle, if you will, on getting the worker and getting the individual back to normal function.

If we say “function,” that is something we can measure. If we say “pain,” we can’t measure it.

So if we focus at function, and this means strength, endurance, power, work, range—these are all things which are measurable.

If we focus at that then it gives feedback to the individual how well they’re performing. Back to the athletic mode.

All the athletes measure their function in something—how far they can jump, how much they can push, how fast they can run.

And they measure their reactivation process, their training, in terms of numbers.

And transferring it back to the industrial athlete, measuring numbers of performance, and then feeding back to the injured person, how they’re doing, is an easy way to get them to do more, and they want to do more, which is even the most important aspect.

Susan:

Probably especially if that person is still in pain and is not feeling the pain lessening, but you can show the person that there’s actual progress being made, nonetheless.

Vert:

Absolutely right. That’s the key to it, because our nervous system doesn’t give up on the pain right away.

And the pain will linger as kind of a safety valve for us. But as we’re performing more, it’s clear that improvement is occurring, and that’s a justification to keep on going.

And, again, this is easily understood by everybody involved, the therapist, the physician, and especially the injured worker.

Susan:

How do you as a physician help the team to keep a strong vocational focus to all of this activity and not for instance do range of motion for its own sake?

Vert:

Well, the injured worker first of all is displayed as a professional lifter, if you will, if that’s the job the individual is doing. And getting back to work activity is the goal.

And so everybody talks about well what are you going to do, what sort of job do you have, what do you have to do.

And as long as we’re focused at that, and not that we’re doing this for some silly reason, just to demonstrate that you have these ranges, again, focus on returning to work is easily understood by the injured worker, and he recognizes that that’s why we’re doing all this, to get him back to work.

The old phrase, which is so current now even of “take it easy” is wrong.

And we know this from much scientific evidence.

But I suppose the best way to demonstrate that is what we’ve learend from space travel, that when people are in space gravity allows our soft tissues to quote “take it easy.”

And that’s an adverse event because the folks who first came back from space travel could barely stand up.

Because the absence of the stresses of gravity was a destructive force for them.

Now the individuals who go into space vigorously exercise on a routine manner just to stay even.

And that’s an important aspect we all have to recognize, that physical stress is a positive event to soft tissues, and taking it easy is a negative event.

Pushing Through the Pain as an Alternative to Spinal Surgery

Fran Antenore interviewed by Len Matheson, PhD (5:02 to 7:46)

Fran:

What happened was the very first day of school I herniated a disc in my back and suffered a severe pain, a severe injury and was referred to the PAR [Performance Assessment Reactivation] Center.

Len:

Can you remember back when you came into the PAR Center what kind of shape were you in?

Fran:

I barely walked in the PAR Center door. I had to be assisted.

I walked very slowly, hunched over, in great deal of pain.

I started the program very slowly. I could not at first do many of the exercises or many of the activities.

And over the weeks I became very mobile, very agile, and I’m back to work now.

Len:

Good. How long were you in the program?

Fran:

I continue in the program on maintenance. I was actively in the program for three months.

I was back to work at the end of two months.

I returned to work on a part-time basis, and have just now finished the semester.

And will return next semester on my normal contract.

Len:

Very often people with pain and problems like you had have a real difficult time being active.

How did you find activity with your pain?

Fran:

For me, the physical activities were wonderful.

And in fact very early in the program I had a series of very difficult days.

And the third day was to be a day at the PAR Center, and I called to say I would not be coming in and was told that in fact that those were the days that I was most to come, that it was very important for me when I was in great pain to get there.

So I managed to get there and walked out in much less pain than I arrived.

Len:

And I found that to be a consistent pattern, that I entered the PAR program with tremendous pain and over the weeks my pain has decreased to the point now where I’m often pain free.

Len:

Are you handling everything at home?

Fran:

Yes. The only difference is I find that I have less stamina than I used to, but again, I’m building that up again as well.

Len:

Was surgery an option?

Fran:

Surgery was offered as an option, and it was suggested that I do instead the PAR center and the McKenzie program and the exercises with the idea that if it was not successful that I would have to reconsider surgery.

And I have to tell you that a number of people during the course of this when I was in such bad shape would say to me, “Oh I had surgery, and I think you should have surgery, and why are you doing this alternative route.”

Now when I talk with them and they find out how good I am and that after their surgery they still have some symptoms, and I’m nearly symptom free, they have a change of tune.

Len:

[Chuckling]

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Ted White Interviewed by Len Matheson, PhD

Len (voiceover):

Depression is a common and serious consequence of chronic pain. Because it interferes with a person’s ability to develop effect symptom control strategies, it can cause a person to give up.

Ted White is such a person. Although he successfully returned to a satisfying life, he almost didn’t make it.

Ted:

I was working for Knott’s Berry Farm at the time. I was up in a crane 90 feet in the air.

I was putting up a tent that I’d made to go over one of the rides, and I was leaning out of the crane basket and when the tent unfolded, why I had a hold of it and at the end of it why it snapped and whenever it did it jerked my back all apart.

Len:

And you ruptured a couple of disks I understand.

Ted:

Right, yeah.

Len:

Surgery was recommended, but you didn’t want that.

Ted:

No, I was afraid of it and I saw several different doctors, and they said it was possible that it would help, but anyone over 40 years old that has a surgery like that that 9 chances out of 10 I wouldn’t be able to work or anything.

And the third one said that he wouldn’t do it as long as I was able to cope with it, you know…

Len:

Um hmm. When you came in here you were pretty down, weren’t you?

Ted:

Oh yeah, extremely. And I had a bad attitude I guess you’d call it.

Len:

Just because of the pain?

Ted:

Right. And that I couldn’t work, you know? Because I’ve always been a workaholic all my life and I was … I got … the pain was so bad and everything that I got to drinking pretty heavy also.

Len:

Yeah.

Ted:

And I never did get on drugs or anything, but I was drinking awfully heavy.

And then I couldn’t ride my bike anymore. I couldn’t do a lot of things, you know, so therefore I wasn’t doing anything.

And the depression, you know, set in to where I was in real bad shape.

Len:

We were real concerned about you.

Ted:

Right. Because I was thinking about suicide awfully bad there a lot until one day you looked at me and said, “Ted, you’re thinkng about suicide, aren’t you?”

And that’s whenever I broke down because I don’t think that if you hadn’t have noticed it, I don’t think I would have been here today, I honestly don’t.

Because I’m not the type of person to sit around and not do anything. And if I can’t do anything, well then that’s it, you know?

Len:

What helped you about the program? What got you back on the right track?

Ted:

Well, they started teaching me about how to use the tools in a way that it wouldn’t put the strain on my back.

And then to sit down a certain length of time and then stand up a certain length of time.

Which I have to do that today. And the chair that they gave me for my sewing machine is the best thing that I have in my shop, because I sit on it and I don’t — it doesn’t jar me.

Len:

For me in remembering your experience, I recall that work was the best thing for you.

Ted:

Right. Yeah. ’Cause as long as I knew I could work, then I was happy.

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Len Matheson discussing the MTAP:

Hello and welcome to a brief introduction to the Multidimensional Task Ability Profile, MTAP, a new strategy for functional capacity assessment.

MTAP begins with stop-action photography that is used to provide an image to a skilled artist to focus on the foreground and minimize background or extraneous information.

Several hundred drawings have been married to simple task descriptions and provided a six-level rating scale and then analyzed with about 30 thousand patients …

… in terms of the difficulty level of each item using the Rasch model of item response theory. Given the difficulty level of each item, items are able to be combined into a comprehensive task ability profile …

… that allows us to sample across a broad range of difficulty levels beginning at a very low level and ending up at a very high level.

Computer administration using the touch screen or mouse allows the 50-item MTAP 2.0 to be administered in about 8 minutes to 10 minutes.

Sophisticated analysis of the data is immediate and automatic and provides output in terms of the work demands that the person is capable of performing.

There's a rating in terms of full physical demand characteristics of work and the three major factors that compose PDC level: handling, walking and climbing, and lifting and carrying.

Output is also automatically provided in terms of four levels of activities of daily living.

The ability scores by each type of demand are provided in terms of ADL self care, light housekeeping, heavy housekeeping, and heavy home maintenance.

A simple and easily understood report card is provided to the patient that allows the person to focus on their progress and identifies those activities that still need to be worked on.

Research conducted under the auspices of the U.S. Spine and Sport Foundation has been published in peer-reviewed journals looking at the reliability and validity and utility of the MTAP in clinical studies.

Thank you for your interest in MTAP. For further information, contact Dr. Joe Verna at the U.S. Spine and Sport Foundation in San Diego, California. Thank you.