For the Sake of Carl
April 6, 2016 Dr. Phillip Snell

Screen Shot 2016-03-22 at 4.25.11 PMAs I write this, it’s currently 2:00am and I am literally sitting in my kitchen wearing nothing more than a hoodie, and needing to write this after I awoke tonight thinking about Carl. I don’t often write in such a state of scanty attire, but in this case I didn’t want to disturb my peacefully sleeping wife rifling through my clothes drawers. So here we go with my first “commando” blog post!

6-7 years ago, Carl (not his real name), a 42 year old strapping, “maturing” athlete sat on my clinic’s treatment table about 50 minutes into our initial 60 minute new patient encounter. Carl was weeping. Carl was happy, but he was having one of those poignant moments in a life where you realize that you unknowingly chose the long road some time ago. You wish you had taken a different route, but you finally see your destination. Carl had been experiencing episodic low back pain after a disc herniation for many years and had found the weightlifting passion he had, and indeed his very image of his personal strength, threatened by his back pain. His sciatica had been severe and daily for weeks. After 50 minutes of working together utilizing my combined gleanings of far too many weekend continuing ed courses, my own personal back pain experiences and many years of clinical experience, Carl was not having back pain. He demonstrated adept transitional movement from sitting to standing and lifting weight from the floor without any pain. Amazed mainly that he had struggled through many weeks in the present episode without being able to perform such simple tasks, he spluttered through the tears, “Where in the [email protected]#k was I supposed to learn this?” His question stuck with me. Where, indeed?

In this age of information, Carl was faced with a hard drive and a connection to an IP backbone attaching him to an endless number of pundits touting the magic answer to his problem. Each of those pundits was educated in perhaps one facet of his condition and offered a shiny solution. Carl had tried many of those options. Most had been slightly helpful, but short-lived. I suppose that I awoke this evening thinking of Carl because earlier I went to bed somewhat chagrined as I thought about an interaction I had on Facebook during the day.

In our clinic these days, we mix and match the fruits of several areas of research to make a personalized “soup” for our back pain patients. The soup is always soup, but it changes with the available items in the larder the person brings to the encounter and what we add creatively daily to try to perfect that day’s rendition of soup. Today, we whipped up a quick, simple soup when we had an acquaintance ask us what we could do for chronic plantar fasciitis just as we were walking out of the door to grab sandwiches at Pastaworks. We were in a hurry, so we trialed a brief screening technique that we have seen to frequently be effective for that chronic presentation to identify what structures might be reporting discomfort in the feet. My colleague reached for a couple of silicon suction cups and placed them on the distal medial part of her lower legs over the course of the saphenous nerves bilaterally. He tugged on them a few times and asked her to try to reproduce her foot pain. She walked a bit, did some calf raises and laughingly noted that the pain seemed to be remarkably better. We noted that we could probably help that chronic condition, that the source of the discomfort might not be in the plantar fascia and we could take a more detailed look later. I took some pictures representative of what we did, posted them on Facebook and was surprised by the large and varied reaction they received.


The responses were emblematic of several of the ongoing threads of conversation that seem to be visible on the “feed” these days. Some were intrigued by the odd cups and wanted to know where they could purchase them and perhaps learn how we used them. These were reflective of the technique junkies on the web that seem to collect new shiny tools to tout to address the ills of humanity. We slyly joked that while the tools were cheap, the access to our knowledge on their use was exclusive, expensive, and even came with a yearly certification.  They could put our certification letters behind their name, and use that new found expert status to market those shiny tools to their patients with painful conditions. We even made up an acronym to represent our “technique”. We were amazed that our jokes received a few earnest entreaties to get on the waiting list for the next course we would be teaching on this ephemeral, non-existent “technique”. Thankfully, most saw our attempt at humor and played along.

Other responses were a bit more confrontational from those well steeped in ways of thinking and in systems of coursework that promote sometimes rigid, may I say…dogmatic, progressions of clinical assessment and treatment. They immediately jumped on the apparent coloring outside of the lines we seemed to be guilty of, seeing it as not representative of their systems of thinking. Thinking outside of the box was clearly a threat to the evidence base.

So why did all of this awaken me thinking of Carl and lead me to my now pantless writing? This interaction today reminded me of the challenges Carl experienced as he tried to get beyond his back pain to regain his sense of power. Those techniques and systems had all been available to him, had been consumed by him, and had left him hungry for more than the gruel he had received. I’m writing because I find myself growingly frustrated these days by the soup making skills of my professional colleagues.

We seem to be surrounded by technique hounds on one side with many shiny machines that go bing, needles that numb, instruments that scrape and exotic manual skills that promise to release us from our pain prisons. On the other side we are beset by the tyranny of the evidence based purveyors whose well-meaning pursuits of research driven methods all too often fail to examine the accumulated knowledge base. Instead, those groups spend more time arguing over the academic iotas of theoretical practice rather than actually involving themselves in the messy business of daily patient care. These research hounds are my kindred spirits but we can all too often find ourselves trapped in our own information silos, not able to see outside of our own confirmation bias. In the middle of that shit storm was Carl.

So for the sake of Carl, I’d like to put some warnings up for folks from the general public that will inevitably find themselves visiting this page. I’d also like to make some requests of my professional colleagues so that we can better serve the needs of folks like Carl.

First for you folks who currently have pain and are being treated by the technique hounds mentioned above, be a bit wary of long term treatment plans, shiny tools, exotic methods and an absence of self help information to help you reduce your need for care.

To my clinical brethren, can we get over ourselves? Can we learn from one line of research and inquiry without rushing to throw away all prior explanations that have come before? Can we advance the knowledge base and build upward rather than insisting on destroying and discrediting the folks that have laid foundations of thought we now tread on? Can we get beyond the acronym thing and the certification thing? There is only so much traction you can get out of breathing, crawling, stretching and rubbing, and calm hand holding, folks. At the end of the day, YAP may be the hokey pokey :). If you are in an information silo, can you toss a line over to the one next to you and go play there a bit so that you can see a different vantage point? There are far too many Carls in the world and we owe them our excellent thoughtful care.

In the realm of low back pain and particularly that variety that frequently involves disc-injury and sciatica we will try to use this venue to apply those inter-connected silos of information and will struggle to avoid systemic dogma and shiny instruments and techniques. We hope you find the process helpful. Peace to all of you, let’s get to work…