Dr. Cady's Blog

From Medicine to Fitness to Pain, There is Something to Gain!

The Kerr-age of Pain


Anyone who follows basketball, the Golden State Warriors, or Steve Kerr in particular is keenly aware of the challenges Kerr has had with his low back pain in 2015 and his unresolved post-surgical cerebrospinal fluid leak complication. Ultimately his pain went from his back to his head and beyond.

Kerr’s story reminds us of the profound impact that chronic pain can have on one’s entire life, even if you are the head coach of one of the most profitable NBA teams in the country. And the realization that a “simple” surgery has its real risks was felt intimately by Kerr and those close to him.

As a consequence, Kerr told the Washington Post, “I can tell you if you’re listening out there, stay away from back surgery. I can say that from the bottom of my heart. Rehab, rehab, rehab. Don’t let anyone get in there.”

As much as surgeons will cringe at the above statement, the truth is that there is a higher risk when it comes to surgery as a medical treatment option when you compare it to injections, medications, and various forms of non-invasive therapy. The onus is on the surgeon to be selective on who receives surgery. And of course, skilled surgeons should be valued when the surgery is truly needed; however, risks from anesthesia, surgery, or poor patient health status are always going to exist no matter how small they may be. 

Yet, one of the most troublesome issues with back pain is that it is not always straightforward and most physicians are poorly trained at subcategorizing or diagnosing the root cause. Non-specific back pain or sciatica are not very precise diagnoses and do not help the patient understand the root cause.

In addition, what many patients are lacking is the understanding and appreciation that imaging such as MRI’s will reveal disc bulges, disc degeneration, and even nerve roots touching discs in people WITH and WITHOUT PAIN. Those imaging findings are an easy way to make patients worry about the findings, especially during times of pain and desperation. If the pain is going down the leg, whether referred pain or a true radiculopathy (which is more specific to a nerve root impingement or irritation), then the easier it is to believe that surgery is indicated. When anatomical changes do not always correlate with pain, then having surgery just for pain is a gamble.  

According to what Steve Kerr’s wife Margot stated in the Washington Post regarding her husband’s initial back pain, “He’d walk through the casino and have to stop every 20 yards to sit down at those little chairs they have in front of slot machines,” Margot says. “He had no choice, he had to get the back surgery.”

This is concerning. That last sentence emphasizes the genuine concern and BELIEF that if the pain is that severe then nothing but surgery will fix it. However, Kerr did have a choice; but we do not have all the data from his full back evaluation. If Kerr’s pain was mechanically reversible with proper therapy, then it is possible he would have never ventured to surgery. What many people do not realize is that severe debilitating pain can occur with mechanically reversible pain that can be treated with appropriate therapy and not surgery.

The problem is that many physicians (surgeons included) have not learned nor do they have a deep appreciation for assessing or treating reversible back pain.

Who does have that training?

There are multiple frameworks of addressing biomechanics, but the first one below, the McKenzie Method (aka MDT or Mechanical Diagnosis and Treatment), is mounting great evidence. In fact, it is even changing several orthopedic surgeons’ approaches:

[Hear Mechanical Care Forum Podcasts #140-143 for surgeons discussing this]: http://www.mechanicalcareforum.com/podcast/140, http://www.mechanicalcareforum.com/podcast/141, http://www.mechanicalcareforum.com/podcast/142, http://www.mechanicalcareforum.com/podcast/143]  

1.    Physical therapists, especially with McKenzie Method training [MDT designation], have a highly specialized but patient-centric, educational approach. Instead of focusing on a patho-anatomical diagnosis (e.g. herniated disc) that is common for many physicians and patients to fixate on, it assesses the mechanical diagnosis using pain as a guide when assessing the patient’s directional preference. Effective treatment is based on those evaluations. In studies, nearly half of those anticipating surgery for disc-related pain have resolution of their pain without need for surgery when treated by a well-trained MDT therapist.

2.    Osteopathic Physicians (D.O. - Doctors of Osteopathic Medicine) who specialize in Osteopathic Manipulative Medicine/Treatment (OMM/OMT) use a variety of techniques to assess or address pain. Education and techniques can vary greatly but can incorporate approaches that look similar to physical therapists, chiropractors, and/or massage therapists to the lay person. (Four Tenets of Osteopathic Philosophy)

3.    Chiropractors, especially those who use Selective Functional Movement Assessment (SFMA) training. SFMA is a movement-based diagnostic system, designed to clinically assess 7 fundamental movement patterns in those with known musculoskeletal pain. It is intended to break down dysfunctional patterns to decipher if the root cause is a mobility or stability/motor control problem.

As a reminder, there can be variability of perspectives, techniques, and practices by any practitioner even within a specialized profession. Second opinions within or across specialties (beyond those mentioned above) may offer other options. Any of the above approaches should be accompanied by educating patients and offering ways or skills for patients to help themselves.

Until physicians have more extensive appreciation and/or skills for better diagnosis, then patients will be unintentionally misguided down a more aggressive or riskier path. That can mean more surgeries and complications such as what Steve Kerr endured. Imagine the patients about to undergo surgery were some of the fortunate ones to meet a more conservative professional who helped them reverse or minimize their pain. Here's the scarier question to ask, "What about those patients who were unaware or never evaluated for a potentially reversible condition yet went to surgery?" If they still have pain, then another label will be given...possibly post-laminectomy syndrome. And the pain continues.

Pain can test the best of us and may not always have a solution. However, part of having Kerr-age with pain is not just coping with the pain itself and decreased quality of life—it’s also the pain of navigating the medical system to truly understand what the pain is trying to tell them, who can help them, and the most logical way to address potentially reversible pain while minimizing unnecessary risk, whether it is surgery or something else. With egos aside, any rational mind would con-Kerr.

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