The object of the physician is to find health.

Anyone can find disease- A. T. Still, M.D., D.O.

Christopher T Caldwell, D.O.Medical Director, Montana Spine and Pain Center

Board-certified, Neuromusculoskeletal Medicine

Boar-certified, Osteopathic Manipulative Medicine

Fellowship-trained, Pain Medicine

Conflict of Interest Disclosure:

Christopher T. Caldwell, D.O.

Has NO real or apparent

conflicts of interest to report.

Pain is hard-wired to fear

• Fear of Damage– Your back is Shot– What a Train Wreck– Worst I’ve ever seen

• Fear of the Future– Lucky to Not be Paralyzed– You’ll end up In a

wheelchair

• Fear Sells – You’ll end up Needing

Surgery

Need to Compensate for patients’– Negative Attention Bias– Catastrophizing– Fear-avoidance– Low self-efficacy– False beliefs about pain

Stop Catastrophizing!!!

Inflammatory• Degenerative• Arthritis• Stenosis• Annual tear• Disc protrusion• Facet arthropathy• Bone spur• “Out of place”

“Translate” for the patient

Inflammatory• Degenerative• Arthritis• Stenosis• Annual tear• Disc protrusion• Facet arthropathy• Bone spur• “Out of place”

Reassuring = No Danger• Candles on your cake• Wear and tear change• Less breathing room• Normal wear• Gravity wins• “Knuckle joints”• Calcium inside a tendon• Stuck

Finding Health is about Language

• Radiologists aren’t talking to patients– Don’t read reports to patients

• You are talking to their limbic system

Case 1

• MD, 56 yo female, changing insurance – establishing with new pcp

• 9 years of low back pain• 6 years of “total body” pain• Methadone 90 mg three times daily• hydrocodone/acetaminophen 5/325mg as needed – up

to 6 tabs daily• Pain Diagnosis : chronic pain syndrome, fibromyalgia• Other Medical history: Type II diabetes, hyperlipidemia,

fatty liver disease, obesity, remote tobacco history, depression, insomnia

Case 1 – More History

• Immigrated from Cuba in 1997 where she was a lawyer – Spanish speaking only

• In US worked at Goodwill sorting clothes• Lived with alcoholic husband and 2 children

Husband left soon after arriving and currently only one child living with her

• Injured back at Goodwill in 1998 and some time after that was declared disabled

• Brought Mother over in 2002

Case 2

• BG 56 year old male• Active problem list

HIV+• Bacterial pneumonia , twice in last 5 years• Neuropathy – HIV?• lipodystrophy

COPD > 40 pack years of tobacco

History of poly-substance abuse, clean since age 42

Orthostatic hypotension

Hypogonadism

Depression with anxiety and insomnia

Hepatitis C

Chronic lumbar pain with radiculopathy• Arrives by wheelchair, flat affect, on oxygen• Doctor appointments are only time he leaves house

Challenging discussions

• Are you saying this is all in my head?• It’s really not safe for a person with a

condition like mine to do _____.• But I have something real going on, so all

of this doesn’t really apply to me.• I need to get my pain under control before

I can get back to_____.• But what are you going to do for my pain?