Imaging results

“I can’t run, I have arthritis”

“It hurts to bend forward because of my bulging disc”

We speak with physiotherapist, Dr. Bahram Jam, about common medical imaging results, their correlation with pain, and how to incorporate these results into your practice. We also discuss the impact of imaging on the healthcare system and the over-medicalization of pain, which can lead to poorer patient outcomes.

To learn more about Dr. Bahram Jam, read his clinical articles, and download a free VOMIT poster (now titled “Medical Imaging: The Untold Truth”), visit his website.

You can also check out the summarized video interview here.

If you like this, be sure to subscribe to FUNCTIONAL F1RST on Apple PodcastsGoogle Play, Overcast or other podcast apps.


 

Katie Yamamoto: This is episode one of FUNCTIONAL F1RST podcast, where we speak with leading experts in the field of functional health. I’m Katie Yamamoto from FXNL Media and today I’m speaking with Dr. Bahram Jam about the relationship between medical imaging results and pain.

KY: Welcome

Bahram Jam: Hello

KY: Would you like introduce yourself?

Sure! My name is Bahram Jam, I’m a physiotherapist for the last 25 years and I went to the University of Toronto, that’s when I graduated with my Bachelors. Then I went to Australia, did my masters a number of years later after I did all my manual therapy here in Canada, because I decided there must be more. Australia was absolutely a fantastic learning experience. I tell every physio, “Go to Australia if you get a chance”. And then I came back here, I started teaching a lot of courses and doing more research and then I did my doctorate at Andrews University in Michigan. And here I am!

KY: Thank you for joining us here today. Can you share with us some more about your evolution as a clinician?

I remember when I graduated from University, my ultimate goal was to learn to do manipulations – the cracking – because I remember asking my professor in my final year when do we get to learn to manipulate or crack. There was this obsession I had with cracking. And when I did my level courses, they were called EV series at the time, they said no after E1 – V1 you can’t, after E2 you can’t, you gotta go all the way to V4 in order to learn to do this. So I went through the entire program to eventually learn to do those manips and I learnt it and I said, “Really that’s all there was?” So, I went to Australia and I did my Masters in manipulation and still I wasn’t impressed. I mean it’s not like I got any magical results, but it was this obsession that I had with learning to specifically manipulate the spine. And nothing really happened from a clinical point of view or from a personal growth point of view. Then when I did my doctorate also, and it was on classification of low back pain, I did so much research and concluded that a manip was no better off than any other technique. In fact, when I got introduced to Brian Mulligan concepts when I was in Australia, that was far more revolutionary for me than any manip that I had the obsession to learn. And I would say that’s been my thing. And what was brilliant about Brian Mulligan and McKenzie – I’ve done my McKenzie credentialing too – was they both promote patient independence and to promote the patient to have self-efficacy. And that’s my evolution. So, I went from fixing people with a magical manip, now my ultimate goal is to teach people how to fix themselves. It’s actually a 180.

KY: Okay so let’s jump into today’s topic about medical imaging. Do you believe that everyone should get medical imaging for an injury and if not, when is it appropriate?

Obviously, everyone shouldn’t get imaging. You know you get plain old ankle sprain you don’t need imaging. There are certain criteria’s that they have developed, clinical prediction rules in the emergency department for who needs imaging. For example, an ankle if it’s tender in certain bony spots like your fifth metatarsal then you should get imaging to make sure you don’t have a fracture. And in the cervical spine there’s a cervical fracture rule that if you can’t move your neck more than 45° and if you’ve been in a severe trauma you should get imaging. And seniors, if they get spontaneous thoracic pain they should get imaging. The emergency physicians know those rules and criteria. But I still think that a physiotherapist, we’re much more conservative about giving imaging. So for example if I see somebody with an ankle sprain, and if I mobilize them and instantly they say, “I feel better I can walk”, I know they don’t need imaging. But in an emergency department, the doctor will never do a mobilization technique to see if it makes a person feel better. Because if they question it, they’ll automatically say imaging. When they’ve done the studies, actually physiotherapists prescribed less imaging than physicians. When we can put our hands on and do something to somebody’s back and they say, “You know what that feels better”, you automatically know they don’t need imaging.

KY: If a patient comes in to see you with medical imaging results how do you incorporate that into their care.

Well in my practice I don’t. I’ve never incorporated medical imaging because I primarily see people with persistent pain, which is chronic pain. And my patients pretty much have all had imaging and the vast majority of the imaging results are completely, utterly irrelevant to their condition. So, unless they had a fracture, then I don’t see them anyways. Or if they have a massive disc bulge that is compressing a nerve root, cauda equina sign, with a foot drop or anything like that, I don’t see those patient populations either because hopefully they’ve been on a waiting list for surgery. People who have severe bone-on-bone hip osteoarthritis (OA), they probably get surgery and a hip replacement also. My practice is people whose imaging is not that bad, yet they’re in severe pain and it doesn’t explain it. So, I’m happy that they’ve had imaging, at least they ruled out red flags. That’s what I want to make sure that red flags are ruled out –fractures, tumors, spinal cord injuries and stuff like that. And so that’s rare. In my practice imaging doesn’t help me other than give me the insurance to say, “okay, red flags are ruled out, I can treat you just from a physio point of view.”

KY: In general, do you find the medical imaging results correlate with pain?

There are certain conditions where medical imaging does correlate with pain. When people have severe knee OA, like medial joint line OA, and they happen to have pain in their medial joint line, and they don’t respond to physio and exercises or bracing – then it does. They may benefit from a knee replacement. There’s other people with hip osteoarthritis, it’s severe, is pretty much bone-on-bone, I’ve tried my physio we go for six weeks and after several months of exercising there is no difference I say, “you need a hip replacement.” And they get it and the surgery is extremely successful. There’s certain imaging when the MRI shows that they have a disc bulge and it’s actually compressing a nerve root and they happen to have numbness in their little toe, loss of reflex, and they have a foot drop. Then I say, “You know what, consider surgery.” And so, in those cases where the radiological findings directly correlate with the symptoms, surgical outcomes are actually excellent and I endorse it. But when it doesn’t correlate, it just happens to be there, you have back pain but there are no true neurological signs. Then the good news is, surgeons nowadays don’t operate on those people. They used to in the old days but they don’t anymore because they know the outcomes are not good.

KY: Are there any good research studies to support this?

There’s actually quite a lot of good research studies right now. When people don’t have neurological signs, true nerve root, myotomal, dermatomal loss – no surgery. Whether it’s neck or back, when they’ve done surgery on patients just for the purpose of pain, pain doesn’t get better. They do surgery for the purpose of preventing progressive neurological loss and doctors have become quite good at telling patients that they’re not doing surgery for pain. When they do surgery for the spine, it is to prevent further nerve damage, and if you happen to get relief of your leg pain after surgery, that’s a bonus. And so, there is growing evidence that you avoid surgery and you do it as a last resort. Like rotator cuff, they used to find everybody who had torn rotator cuffs they would do surgery on them. And they don’t anymore because the studies turned out that the satisfaction rate post acromioplasty, post rotator cuff repair, was quite low because people expected to be pain-free after surgery. And when they weren’t, they were disappointed. So now they save the surgery only for people who are not responsive to conservative care for a year, then they think about doing it.

KY: For a specific patient, how do you determine if a structural abnormality on a scan is relevant and either a concern or cause of their pain?

You have to correlate the symptoms. I made a poster called VOMIT, which stands for Victim of Medical Imaging Technology. This is when patients are told they have certain things wrong with them based on imaging and they become a victim, meaning, “Oh it was me, I have this bad thing on my x-ray, MRI, CT scan.” And it’s irrelevant. And there’s another acronym is called BARF, which stands for Brainless Application of Radiological Findings. Just because you find it on an MRI or an x-ray you say, “Aha, that must be the cause of your pain.” Again – BARF, brainless application of radiological findings. I know it has nothing to do with why I go with these VOMIT and BARF acronyms, it is purely coincidental.

KY: What are common mistakes that clinicians make when it comes to interpreting medical imaging results?

The common mistake that is happening less and less because of a lot of research coming forward, is that purely blaming arthritic changes in the neck, back, shoulder, knee, hip on their pain. And common mistakes is saying that, “Oh you have arthritis in your knee, you have to live with it for the rest of your life. There is no cure for it unless you get a knee replacement.” That’s just wrong, it is just not accurate. Or they see arthritis in their hip they say, “You just have to take these anti-inflammatory pills until you need a hip replacement.” It’s wrong, it’s just not true because there is no shortage of people who have severe hip OA and have no pain. Or they have pain in one hip and then they take x-rays of both hips and they show they have more arthritis in the opposite hip that is pain-free versus the side that has the mild to moderate hip arthritis. So, there’s repeated evidence from our patients and from research studies that most radiological findings are irrelevant.

KY: Can you give us some more examples of findings that may be irrelevant?

Pretty much every single patient that I see with neck pain tells me that they have arthritis in their neck. Or they’ve been told that they have degenerative changes. And then I tell them, “Do you know what percentage of the average adult population has degeneration in their neck on their x-ray?” And they say, “No, how many?” I say, “98% of people have arthritic changes in their neck and have no pain! Two percent of people are freaks of nature, that have no arthritis in their neck when they get an x-ray.” And I say, “You know what age this degeneration starts at, for example in low back pain studies that they’ve done? At age 20.” So I say, “Are you over 20?” They say, “Yes”.  Then you have arthritis. Just except that. It is the normal thing, it’s not cause for any alarm. But when the doctor has told them that, “Your neck pain is from arthritis in your neck”, it’s really hard to change that. Because a doctor in a lab coat has told them that so it must be true. A doctor in a white lab coat has told them that they have a disc bulge in their back. When in fact when I tell them, “Do you know that 70% of all people with no back pain have disc bulges? In fact, 30% of people in their 20s have disc bulges on their MRI.” They don’t know that, but when they’re told by a person in a white lab coat, “Oh yes, your back pain is from your disc bulge”, it obviously is true. And the worst thing that happens after that, they go on Dr. Google.  And they search disc bulges. Back disc bulges, neck disc bulges, neck arthritis. And they get thousands of websites on how to cure it with this thing and this thing, and how their doomed and that they may need surgery. It’s just a horrible state we’re in, in the world of medicine right now, with the excessive imaging and the doctors not telling their patients what is normal and what is truly abnormal.

KY: In your experience, has there been any change in how physicians order and use imaging in MSK medicine?

I feel that there has been, at least in Canada there has been. Less in the United States because the United States unfortunately they have more litigation issues, so the doctors are more likely to say, “You know what, we’re going to get an MRI or CT scan just in case.” Even though they know deep within their heart they don’t need it, they’re not gonna find anything, but they do it just in case. The doctors in Canada used to not recommend x-rays and MRIs because of worries about litigation so much but it was more because patients demanded it. When I asked the family doctors, “Why do you recommend an x-ray for back pain because you know it’s not going to come out as anything?” They say, “We do it just to satisfy the patient.” Because, really, if you go to the doctor for your back pain and they don’t give you anti-inflammatory pills and they don’t recommend an x-ray what else are they going to do for you? So they basically give an x-ray just to shut the patient up. But they’re doing it less and less. Doctors are becoming more confident saying, “No, there’s no need for an MRI.” Even at the University of California at the Mayo Clinic, they have now strong regulations about avoiding giving MRIs for people with acute low back pain. And, one, is because it’s not necessary and is needlessly costly but the second reason is the studies come out repeatedly that it is actually harmful to patients to get MRIs, not because of any damage an MRI does but because of the psychological impact that it has. Because the studies show that people who get MRIs versus those who don’t get it, a year later they’re worse off than their counterpart. But it doesn’t matter if they got the MRI. When they do the studies, and don’t tell patients or the doctors of the MRI results, they have better outcomes compared to the ones who got them right but the family doctors and the patients were told about the MRI results.

KY: Do you think with the amount of medical imaging that there is an impact on the healthcare system?

Yes there is and, unfortunately, it’s gotten worse and worse. The amazing thing is in the last number of decades, say in the last 30 years, let’s just talk about low back pain. The treatment of low back pain has increased exponentially. Meaning people rarely got treatment for the back and now we have rehab clinics open up on every block. Chiropractic use for low back pain has increased dramatically. Massage therapy for low back pain has increased dramatically. Physiotherapy use for low back pain has increased dramatically. Acupuncture has grown dramatically. Naturopathic treatment of low back pain has increased. For a few decades, surgical treatment of low back pain had increased dramatically, now it’s on the downhill again, which is positive – at least in Canada. In certain countries, like in the US or India and stuff where they still do surgery for financial purposes, it is actually on the rise. So amazingly, medicinal use for low back pain has increased dramatically. Oxycontin’s and all kinds of opioid usage has increased. But the unbelievable fact is that in the last three decades, disability rates for low back pain have actually increased also. You would think with all these interventions that we’ve, with all the treatments that we do, low back pain and disability would have decreased. It hasn’t! Not only has it not stabilized, but it has actually increased. And I blame over-medicalization of low back pain and the ultimate culprit, one of them, is radiological findings and it is even healthcare providers. We’re over medicalizing neck pain and back pain. We’re trying to find the exact structure at fault, telling people, Oh ya, your neck hurts because of XYZ, this structure. Your back hurts because of XYZ.” And thanks to the invention of Google and the Internet it’s made things a lot worse. Therefore, it’s been disastrous from a disability point of view. When people believe they have something wrong with them and the Internet proves it and their healthcare providers give them the same explanation, “The cause of your neck or back or shoulder pain is because of this X, Y, and Z”, they do a lot worse. However, when a farmer in Bangladesh hurts their back, they get up to go plow the field the next day. They don’t have the option of getting radiological findings. Guess what? They recover a lot faster.

KY: In your experience, what are patient’s thoughts and attitudes towards imaging?

Patients want to get imaging because they feel it will finally give them an answer to what is wrong with them, and they’re so upset when it takes three months in order to get an MRI for the back. Meanwhile I’m rolling my eyes, “You don’t need an MRI of your back.” But they find that once they get an MRI then they’ll know exactly what to do with them. When in fact, I tell my patients it makes no difference whether you get an MRI or not because you don’t have nerve root compression findings, there’s no damage to your nerves, which is wonderful. I tell them the only time I recommend you getting an MRI is if you need surgery. And obviously you don’t need surgery, and people say, “Yeah I would get surgery anyways.” “So why are you so adamant about getting an MRI?” I don’t tell them this but I say, “I only recommend an MRI if I suspect somebody has a tumor for example.” But I don’t use the “tumor” word on my patient because it would send them off in a panic: “Oh I need an MRI to see if I have cancer!” To me that’s extremely rare and there are certain signs we look for if there is a risk of that. Put it this way, I’ve never had a patient in my 25 years with a tumor.

KY: So, as a patient, if I’ve had a scan that shows abnormal findings should I be worried?

Well it depends what the abnormal findings are. I mean, if it shows that you have a spinal cord compression and you’ve lost bowel and bladder function or you can feel your feet and you can’t walk because your walk is, we call it ataxia, then yes, it’s emergency medical care that you need. But I’ve never seen that! People in emergency department see it once in a while which is a true spinal cord injury but it is so rare. So, I’m going to say, “No, you shouldn’t be worried.” Pain can be severe, but the majority of cases it’s not dangerous, there’s an importance to distinguish between severe pain versus dangerous pain. So, if it shows arthritis or regular disc bulges with no sign of compression of the nerve, or spinal cord injury, then I suggest you move as much as possible, reduce your anxiety over it and you’ll eventually get better with the right amount of movement and exercise. When you worry, you won’t move. Whether it’s your neck or your back. For example, people are told in the shoulders that they have rotator cuff tears. Forty percent of professional baseball pitchers have rotator cuff tears and still manage to throw 100 mph fast balls and have long careers. But when they’re told they have a tear, when they try to lift their arm up, “Ah, I can’t lift my arm up I have a tear! My doctor told me I have a tear.” And what that does is it actually sensitizes the area. If you didn’t know about the tear, the big chance is that you lift your arm up and say, “No worries, I feel it but it’s okay.” Versus if you’re told it’s torn then your brain says, “It’s torn! What if I lift it and I cause more damage?” So, the area becomes more sensitized. Pain literally is enhanced and increased when people fear.

KY: what language do you use to describe imaging and assessment findings to your patients?

Plain old English and I work so hard at not giving a patient an excuse to catastrophize. The word catastrophize means me saying anything that they could blow out of proportion. I used to tell people, “Oh yeah, you have a disc bulge in your back” so innocently for the first 10 years of my career. Meaning that I had done my McKenzie courses and we were told that when you bent forward the disc comes back, and when you go backwards the disc comes forward. It was a jelly donut theory and it was so convenient and so logical. It turned out to be so untrue and false. And maybe I thought it was innocent for me to tell patients about the jelly doughnut. So, when you bend forward the jelly donut comes back and you go backwards the jelly doughnut goes forward. It was so innocent, but in hindsight I didn’t realize how horrible it was of me to tell people that. Because what that did was tell the patient they’re so fragile like a jelly doughnut. So when you bend forward and they get their back pain when changing bedsheets, “Oh! My jelly just came out! Oh, it’s out, my jellies out.” But I said it so innocently and I didn’t mean any harm by it but it actually did harm. Or when patients are told they have osteophytes in their neck, I remember I had a patient she would turn her neck only this much and I treated her for like 2-3 sessions and I couldn’t get much range out of her. Then casually I talked to her and built rapport with her, “Why do you think you can’t turn your neck more?” And she said, came out bluntly, and said: “It’s because I had an x-ray and I know I have bone spurs in my neck and I’m worried that if I turn my neck too much those bone spurs will sever my spinal cord and I’ll become a paraplegic and I don’t want to be a burden on my family.” Patients don’t know that. When they’re told they have bone spurs, you have no idea what they’re thinking. They’re thinking that there are these jagged knives in their backs and necks. So, the words we use are so important. So, pretty much all I say is that you have strained your neck, you’ve strained your back, you have muscle spasms. I don’t use the word “arthritis”, I don’t use the D word, meaning the disc word, none of that. I say, “You’re stiff, you have weak muscles, that’s the cause of your back pain.” And if ever a patient says, “What do you think specifically the structure is?” I blatantly tell them, “We don’t know actually.” And I like to quote one of the world gurus in the world of medicine and back pain, his name is Alf Nachemson. He is an orthopedic surgeon, he passed away a few years ago but I regarded him so much. He goes up on stage at one of these World Congresses and he says, “I’ve been studying low back pain for the last 50 years of my life, and if anyone says they know where back pain comes from, they’re full of shit!” So, I really admire him I say, “If Dr. Alf Nachemson, the world renowned orthopedic surgeon and one of the most researched in the world says he doesn’t know where back pain comes from, I don’t think I can say where back pain comes from or can I lie to my patients and pretend I know where it comes from.” I don’t. But I know I try to treat their impairment, their functional disability. So, if the problem is that they can’t bend forward to put on their shoes, I give exercises to help them do that. If they have trouble walking with their back pain, I help them achieve that. If they have trouble twisting, grabbing something or golfing or playing tennis, my goal is to improve function not to treat structures at fault.

KY: Do you think that language influences pain?

Amazingly it does. The words we say to our patients influences their pain because we have the chance to make them feel better before they leave the appointment or make them feel a lot worse and anxious. And I choose to make them feel better. So, the language I use are non-catastrophic, “You just sprained your back. You just have a stiff back. You just have weak muscles. And your shoulder pain, it’s just because you haven’t lifted it up in so long, the muscles have tightened up. They’ve seized. So, we need to move them again.” So, people won’t catastrophize.

KY: What are common mistakes that clinicians make with patient communication?

Common mistakes that clinicians make is they believe that if patients are told exactly what structure is at fault, they’re more likely to comply with exercises, or more likely to respect them as a healthcare professional because, “They figured out exactly what structure is wrong with my back.” In my experience, because I see lots of patients, and patients have to wait a few months to see me, I don’t give them a specific diagnosis and they seem to be pretty satisfied. I have a pretty good caseload of patients who really like me and the diagnosis that I give them, despite me not ever telling them exactly what is wrong. So, the miscommunication is that for clinicians, physiotherapists doctors, feel like they have to tell patients exactly what is wrong with them when all they really want to know is that it’s not serious, it’s not a tumor, it’s not a fracture, it’s not a spinal cord injury. And you say, “It’s nothing serious,” that’s all they want to know.

KY: Is it okay to use a pathoanatomical explanation for pain and if so when?

It is. I have used a pathoanatomical diagnosis on my patients, I can’t say never use them because that would be wrong. For example, if people come to me with an x-ray and it shows it’s bone on bone and I try to mobilize their hip by doing like 3-4 treatment sessions and I make no change and they’re still in pain, I say, “You know what, you seem to have arthritic changes in your hip and I suggest that you see an orthopedic surgeon and get a consult.” And inevitably the patients I’ve told that too, they’ve gotten a hip replacement and they love me for it. Because I can’t lie to my patient that it’s not there hip OA, or when they, for example, get an MRI and it shows subscapularis tear, I say, “You know what you may need surgery.” Especially when they’ve had recurrent shoulder dislocations I say that, “You need to repair that shoulder problem.” when they have labrum tears I say, “You need to have surgery.” when they have a meniscal tear, a bucket handle meniscus tear, their knee’s buckling and it’s locking on them, I need to tell them, “I think it’s a meniscal cartilage tear, I need you to get a surgical consult.” I will never lie to my patients when I feel it’s a true anatomical cause. But when I don’t know, I don’t lie to my patients and pretend that I do know.

KY:  Can you share a memorable patient experience that’s relevant to our discussion?

Yeah, just two days ago I saw a patient, this girl that I’ve seen for – this was the fourth session – she’s in her 30s and she is a young mother and she’s had this pain down her leg. And she has this severe pain, but she’s had an MRI and it’s come out negative. I concluded she just had a sensitized nervous system because of all the stressors in her life. I told her when I saw her, it’s not serious and you are going to get better. I wrote, literally on a piece of paper, I expect for you to get 100% better. I wrote the word 100% better. I don’t give a timeframe. I saw the tears come down her eyes and I said, “You felt very emotional when I said that.” She said, “Because nobody’s told me that.” I said, “Of course you do, because you’re a young, healthy person. This is just a temporary thing. Nobody with your health, you know you’re in good shape – and of course the MRI has come out negative – lives with this type of pain. You won’t. The chances are you are going to get better.” And she just wanted to hear that and nobody’s ever told her that. And it was true. And again, I don’t lie to my patients because I DO expect her to get 100 percent better based on research studies, based on my 25 years of experience. Now, I don’t give a timeline because I don’t know if it will be in three weeks, or it will be in three months, or in another two years. I really don’t know. But she will get better. And when people believe they will get better, of course they will get better faster. That’s been shown in studies repeatedly again and again. When a physician tells a person with back pain, “You are going to get better”, their average absent days, sick days, was 14 days of absenteeism. When the doctors did not tell them those simple words, “You will get better,” for acute low back pain, it took them 33 days to get better. It was almost more than double the time of worker absenteeism. And the only difference was a doctor telling them that, “You will get better.” So I make a point of telling my patients that they will get better and writing it down on a piece of paper, if I know they’re going to get better. But in conditions that I don’t know, like for chronic WAD – whiplash associated disorders – I don’t know. Because those are different. When I know they have psychosocial issues, I will say that they will get better functionally – in life – if they follow the protocol. I will say, “You will get stronger. You will increase your walking tolerance.” And so, whatever I think they will improve, I will tell them that.

KY: Okay can you tell us about your book?

I wrote a book called “The Pain Truth” about five years ago now, and I’m happy to say it sold thousands of copies right now and mostly in the hospitals that deal with chronic pain, in any chronic pain centers. The purpose of the book was to reduce people’s anxiety about their pain. And there are numerous research studies. This is all the work of Lorimer Mosley and David Butler. A book that I strongly endorse more than my book is called “Explain Pain”.  That book has been shown, when people are given the information in the book, they have a significant reduction in disability rates, faster recoveries, reduction in use of medicines – in opioids – just by being educated. So, the purpose of my book is a simpler version, which takes only roughly 20 minutes to read. I’ve even turned it into a video now because I found that the last five years some people just don’t want to read, even if it’s for 20 minutes. So, I made three videos, it’s on YouTube, available for free to everyone to view and you just have to YouTube “The Pain Truth”. The first part is 10 minutes long. It’s to explain to people how “hurt does not always mean harm.” We may feel pain but it doesn’t necessarily mean something is injured, with video clips that help to explain that. The second part is to try to explain to people how their emotions can contribute to pain. And when patients learn that, they say, “Yeah, stress does increase my pain. My financial troubles, the divorce I’m going through, my social life, the fact that I’m alone or all that stuff” contributes to the pain. You don’t have to fix these problems, you just have to become aware of them and people get better. In the third part of the video, it is to give them 10 solutions of reducing their emotional anxiety related to their pain. In fact, the research studies have shown that it reduces people pain. Everything from improve their sleep, improving their diet, reducing their anxiety about their stress and walking more, exercising more, mindfulness, meditation, getting involved in yoga. So, everything that I recommend is based on evidence and I’m happy to say not one of the recommendation that I make involve selling of any lotions or potions or anything. None of them cost a dime. It’s all free, meaning that there’s nothing you really need to help you when you’re in chronic pain. That’s what I want to promote, because I don’t want to sell anything to patients other than independence.

KY: You’ve already touched on your WOMIT poster. Is there anything else you’d like people to know about that?

Three years ago, I made a VOMIT poster, which stands for victim of medical imaging technology. I’m happy to say after three years now, it has been translated into six languages because various doctors and physiotherapists in various countries have come to me and said, “I wish this was in my language.” And I said, “Sure, translate it for me!” I’ve turned it into a poster, into Norwegian, into French, into Dutch, to German and Italian I’ve got it. Russian right now I’ve got it. So, I’m extremely happy that it’s been translated and all across the world it’s been put up in clinics. My goal is to have it up in every clinic around the world. It’s actually available on my website www.apeti.ca. Underneath it is called “Pain Education” and the posters are all up there in English and French. It’s high quality JPEG. I want people to print out the PDF file if they wish or send the PDF file to the printer themselves and have them print out the poster themselves. I made the posters, not to make money off them. I’ve been selling the posters – thousands of them – in the last number of years. But in fact, I promote people to print it yourself if you want multiple copies of it. I’m just happy to have the information passed down and all the information about radiological truths. For example, this is the smaller version of the VOMIT poster. I no longer call it VOMIT because I had a couple of complaints about it. Not that the word VOMIT was bad, they recommended not to use the word victim and I agreed with them. Remember we said the words we use make a difference. I didn’t want to use the word victims so patients don’t feel I’ve told them they’ve been victimized. So, I just changed the poster to “Medical Imaging: The Untold Truth.” This is the card version of it and my goal is to have this up, not only in every rehab center in physiotherapy, but my ultimate goal is in every doctor’s office and every radiology office, where patients are waiting for their x-ray, that they are told what are normative findings.

KY: And how can people find out more about you?

They can go on my website www.aptei.ca. It’s meant for healthcare providers, mainly for physiotherapist, or physical therapists. They can see my videos, I have a video library there, I have a clinical library, where were summarize research studies. I have written a number of papers that question some mainstream medical treatments that we do and that’s on my website, under “Clinical Articles.” For example, static stretching. I’m so much against static stretching before an activity just for the sake of stretching because it prevents injury. It doesn’t. Or to stretch so you prevent post-exercise soreness. The studies show it doesn’t. Or to improve your performance. It doesn’t. So, I’m for warming up, I’m a fan of strengthening, eccentric strengthening. Those are the things that prevent injuries. The other thing is I’m against the use of anti-inflammatories for acute soft tissue injuries. Don’t use anti-inflammatories! I know there’s research studies that supports that people using anti-inflammatories get better outcomes, but nobody talks about recurrence rates. Good animal studies show collagen healing is worse when we take anti-inflammatories. I want inflammation when you get an acute injury. We evolved for millions of years to have inflammatory mechanisms in our body that perfectly allow those tissues and the collagen to heal at the right time, the right amount. We take NSAIDs to reduce pain and we get back to activities faster than we should of, that’s a recipe for disaster. And so, people wonder why chronic low back pain recurrence rate is growing, I’m going to say that one reason could be the overuse of medicine. Because it numbs the pain, so we do stupid stuff that we should have done when we should’ve allowed our tissues to properly heal.

KY: Is there anything else you’d like to touch on?

No