Living Better with Low Back Pain: Dr. Steve Karas

[00:00:00] Dr. Dick Earhart, he used to come in very early to the clinic when I was an athletic trainer and sort of teach us things.

[00:00:06] It's like, you know, you ought to really check out an AOMT conference.

[00:00:09] As I learned here, I would take it back to the clinic and to what we called the pod, right? Five or six clinics would come together. I would teach what I would learn here.

[00:00:17] One day, Dr. E was like, you know, you have to really consider teaching. I'm like, no, that's okay.

[00:00:22] Today on the AOMT podcast, we're joined by a long time educator, researcher and clinician, Dr. Steve Karas.

[00:00:30] Steve has been practicing for nearly 30 years and currently teaches and conducts research at Chatham University, while also working in various clinics owned by former students.

[00:00:41] He credits AOMT with helping him become a better clinician, teacher and researcher through the tools and connections he's gained along the way.

[00:00:50] Steve's latest endeavor is his upcoming book, Living Better with Low Back Pain, which challenges the common narrative around curing low back pain.

[00:01:00] Today, we'll explore why it's time for clinicians to shift their language from cure to management, how his experience informs this perspective, and the role of manual therapy plays in managing chronic conditions like low back pain.

[00:01:14] Don't move. This is Hands On, Hands Off.

[00:01:25] Steve, welcome to the show.

[00:01:26] Thank you.

[00:01:27] Excited to be here?

[00:01:28] Very much.

[00:01:28] Lowell. This is a low right now. It looks like behind us here at AOMT 2024.

[00:01:33] Other famous coffee break.

[00:01:34] Coffee break. Yeah, yeah, yeah. Absolutely.

[00:01:36] How many AOMTs have you been to? I mean, these have you experienced?

[00:01:39] Probably 10.

[00:01:40] Okay.

[00:01:41] Why do you keep coming back? What do you like about them?

[00:01:43] I like the networking.

[00:01:45] Perfect.

[00:01:45] I like to pick people's brains.

[00:01:48] Join up for new opportunities, new research opportunities.

[00:01:51] Yeah.

[00:01:51] Hear what the sort of latest is.

[00:01:55] You know, I met a lot of colleagues and a lot of friends over the years.

[00:01:57] Yeah.

[00:01:58] I went to pitch to the powers that be.

[00:02:00] I said, I don't know if I have a new slogan for you here, but you get hands on experience and a lot of elbow rubbing is what I've heard from everybody and why they come back to this thing.

[00:02:08] Yeah.

[00:02:09] That would be a good saying.

[00:02:10] That's a good one.

[00:02:10] We'll put that on a t-shirt.

[00:02:11] You'll get the first one.

[00:02:12] You get the first t-shirt.

[00:02:13] You wrote a book.

[00:02:14] I did.

[00:02:15] I get excited when I read a book, like when I finish reading a book.

[00:02:18] But you actually went ahead and wrote an entire book.

[00:02:20] Correct.

[00:02:21] Living Better with Low Back Pain.

[00:02:22] That's right.

[00:02:23] A direct approach with patients about the reality of managing low back pain.

[00:02:26] What inspired you to write the book?

[00:02:28] Like why that medium?

[00:02:29] Because it's not a small undertaking, I could imagine.

[00:02:31] Yeah.

[00:02:34] You know, I've treated low back pain for a long time and like everybody, I've just been frustrated with long-term outcomes.

[00:02:41] I mean, we just had a keynote talk about the difficulty of patients with chronic low back pain, about how maybe their function can increase, but their pain remains.

[00:02:50] And just being involved, I still work in the clinic.

[00:02:52] I still work in, you know, I teach as a full-time professor.

[00:02:56] And sometimes I get pulled into the, in the clinic, like you got to look at this person.

[00:03:01] You know, I haven't been able to get him better or them better.

[00:03:05] And I just think maybe we just need a different perspective when it comes to managing low back pain, that we just need to kind of accept that there's probably not a cure for humans with low back pain.

[00:03:16] Sure.

[00:03:17] It is a common occurrence, 90% of people.

[00:03:20] And when it's 90%, I don't think there's anything we can do.

[00:03:24] I mean, obviously, acutely we can help.

[00:03:28] From a short-term perspective, we can help.

[00:03:30] But I think if we look at the literature and we're honest with ourselves, actually promising or telling somebody that we're going to relieve their pain long-term without reoccurrence, I don't think that's possible.

[00:03:43] Yeah.

[00:03:43] What have you, what would you learn from writing a book and going through that process?

[00:03:47] I think I learned that the use of things that are not shown to be successful still exist.

[00:03:57] Oh, yeah.

[00:03:57] Yeah.

[00:03:58] And I will call out the PTs and chiropractors and osteopaths and any other profession that treats low back pain.

[00:04:05] Not in a way of calling them out, but just a way of maybe we need to look internally and say, you know, these are the facts.

[00:04:12] That opioids don't work, but they're still prescribed.

[00:04:15] MRIs lead to worse outcomes.

[00:04:17] They're still ordered.

[00:04:19] Sometimes manual therapy in patients with chronic low back pain is probably not the best treatment, but it's still performed.

[00:04:28] And injections with very little changes or very little exceptions probably are not effective.

[00:04:38] But just, you know, we have the guidelines and we have the evidence and that's just not followed on a regular basis.

[00:04:47] And that's a bit frustrating.

[00:04:48] And when I really got into the evidence, it took me down some interesting roads.

[00:04:53] Yeah.

[00:04:53] For sure.

[00:04:54] I imagine a good bit of reflection on what either you do or a profession is because you're taking that time to reflect and see what's being done and to write the book.

[00:05:04] Yeah.

[00:05:05] Yeah.

[00:05:05] And, you know, there's certainly a lot of research that has been done that has gotten us to this point where we're better than we were.

[00:05:12] But I tried to write the book in a perspective that would be sort of patient focused.

[00:05:16] So people that don't have a lot of experience or no experience, right, with anatomy or physical therapy or medicine can pick it up and read it.

[00:05:24] And maybe also a clinician could pick it up and read it and say, you know, maybe I need to do a few things a little bit better.

[00:05:31] Yeah.

[00:05:31] I love that.

[00:05:32] That's a good way to look at it.

[00:05:34] You mentioned a second ago that maybe telling patients or telling anybody we can cure low back pain, especially chronic, really sets them up for failure.

[00:05:42] How should clinicians be framing what we can bring to the table?

[00:05:46] What is a better way of saying that?

[00:05:48] Because I can cure this.

[00:05:49] It gets the clicks, right?

[00:05:51] Right.

[00:05:51] It gets the attention.

[00:05:52] But how should we be framing that to maybe get a better outcome?

[00:05:55] In my opinion.

[00:05:57] All right.

[00:05:57] I think that when you explain to somebody what the vast majority of the literature says, like, okay, you just hurt your back.

[00:06:07] I'm very confident that in about three weeks you will be feeling pretty good, right?

[00:06:12] Because most acute low back pain really sort of resolves itself 80, 90% of the way, right?

[00:06:18] Two to three weeks.

[00:06:20] And then I think, you know, what are your goals?

[00:06:23] So you make it patient-centered.

[00:06:25] Rather than pulling out the Oswestry or anything, you let them decide patient-focused goals or patient-centered goals.

[00:06:33] And then talk to them about what you think the prognosis is.

[00:06:36] I mean, and clearly there's exceptions, right?

[00:06:37] So if somebody has discogenic pain that is causing them to lose a reflex and they're having continuous and dramatic loss of leg strength, right?

[00:06:48] That's a particular situation that maybe would warrant a surgical referral.

[00:06:53] Not necessarily surgery, but we probably want to get them somewhere else.

[00:06:57] I hate to say non-specific, non-complicated low back pain, but that's, you know, that's the way we sometimes define it.

[00:07:06] Having, make sure they know that there's a prognosis and that it is likely to reoccur.

[00:07:12] And, you know, people say you don't want to make them sort of dependent on you, but I think it's a bad idea to say, hey, if in four months this starts to bother you again, you know, come on back in and we'll take another look.

[00:07:22] So I think giving them a bit of a prognosis, reassurance, making sure you tell them that you've ruled out the bad stuff, I think is probably a better way to do it.

[00:07:33] I'm not saying people aren't doing that, but overall when there's competition between professions and within professions, saying that you think you're going to make somebody 100% better might not be the best way to go about it.

[00:07:47] Right. Not a good way to start and set up that relationship. I think there's a difference between having someone become dependent on you versus building a relationship with that person and saying we can, I can, I can treat a variety of things if this ever comes up.

[00:07:59] Right. And there's also just listening. Sure. Right. So asking with a very open-ended question and then just waiting for them to tell you what they need to tell you.

[00:08:09] And at least in some of the research that I'm familiar with, that's about 90 seconds. Yeah. And I know we're all busy. Yeah. And I know we have a lot of patients, but we have 90 seconds.

[00:08:19] I had a professor in PT school say, sort of start to set the context, which is somebody might have been waiting for weeks before they ever bit the bullet to go to their primary care doctor.

[00:08:29] And then they might've taken a few weeks to get that appointment and you might've been busy. So it might've been weeks before that. So that person might've been waiting for three or four months before they get to see you. And in some extreme circumstances, maybe we wait more than 90 seconds before we jump in and interrupt them.

[00:08:42] Right.

[00:08:42] That's probably a good example. So you teach and conduct research.

[00:08:46] Yes. A variety of different things and work in multiple clinics. So you're, it's like a little bit like a triathlete right there. How do you balance those roles? What, and what do you, what do you, what do your clinical work and form your research and teaching? How do, how do each, how do each of those things help the other?

[00:09:00] Um, so clinic work, I have a, a, a nice situation now at Chatham where I'm, I'm given release time, right? Technically eight hours a week. Um, but it usually comes to when I have to cover for a clinician that's, that's off. Um, so you usually will do like a Thursday, Friday or a Friday, Monday. Um, and I love being in the clinic.

[00:09:21] Sometimes I will get sort of in the clinic. I will, they will give me a quote sort of complicated patient. Um, and it's sometimes I make a little change and oftentimes I'm like, I'm not sure I would do anything different, but look, they started at eight out of 10 and they're at two out of 10. That's pretty darn good.

[00:09:38] Yeah. Like, you know, you could probably discharge them at this point. Um, my research, I really, I work with a North American Institute of Orthopedic Manual Therapy. Um, and my research really recently has been student centered. So I try to really push sort of like younger energetic, either clinicians or students. I work with some DSC students, um, who have really good research ideas or capstones or dissertations to take the next step.

[00:10:08] And try to publish it. Um, and I've been really lucky, like within IOMT and with Andrews University where I sometimes help some students and within Chatham, there's, there's some pretty good students with some, with some good ideas. And even here, the presentation I'm doing, um, I will take credit for presenting it and making the PowerPoint, but it was, um, it was pretty, it was student driven. It's great. They did the work. That's great. Uh, good, good, good outlook for the profession. I think so. Yeah. Yes. Uh, you've credited IOMT with helping you grow as a

[00:10:38] clinician, clinician teacher and researcher, the three things we just mentioned that you do. Share more, can you share more about how the academy has helped shape, shape your career? Cause I think when you're in school, you maybe you can get overwhelmed with all the different options of where you can go to continue that lifelong learning. So you've credited with IOMT with helping you do that. Like help me understand how, how that happened.

[00:10:58] Um, so clinic wise, um, boy, I feel like an old man when I tell you this, but, uh, clinic wise, um, Dr. Dick Earhart, who has since passed away, but he's a founding member of IOMT. Um, he used to come in very early, um, to the clinic when I was an athletic trainer and sort of teach us things. Um, he sort of inspired me really to, to, to, I was an athletic trainer at the time to go to PT school. And then when I sort of interacted on after with PT school, um,

[00:11:28] it's like, you know, you know, you ought to really check out an AOMT conference, um, and just learning techniques. I like the conferences cause you know, sometimes in the breakout sessions, they set up the treatment tables and you learn things. Um, so as a clinician, I was in the clinic, my beginning of my career, about eight years. And as I learned here, I would take it back to the clinic and to what we called the pod, right? Five or six clinics would come together. And, um, I would, I would teach what I would learn here.

[00:11:57] Um, and, um, one day Dr. E was like, you know, you had to really consider teaching. I'm like, no, that's okay. Which meant going back for a terminal degree. Sure, sure. Um, and so I sort of reached out to a lot of members within AOMT, right? That were academics or in the clinic. And, you know, back then they returned my email. They would send me their papers. They would send me unpublished papers. Um, they would pick up the phone and talk to me. Um, a couple of times I just sort of

[00:12:25] showed up at their, not unannounced, but, uh, showed up at their, that their, um, university and met with them. Um, so there's really a lot of, um, collegiality and a lot of sharing. Um, and a lot of, you know, I think it's even more than networking within AOMT because there's just a lot of dedicated, really smart people within the organization. Um, so currently I think the reason I work with a lot of students is I sort of learned from their example and thought like, you

[00:12:55] know, they sort of helped me out when I was starting cause you know, academia can be a little bit challenging first, maybe three, four years until you get sort of used to what the expectations are. Yeah. So I think I've always tried to do what they've done for me, right? With, with new students and, and, um, new academics. Yeah. So, but it's a, it's in terms of conferences, it is absolutely my favorite conference to attend. Um, and I usually tell people that go to larger conferences, you're never locked

[00:13:25] out of a session at AOMT. You can always get in. It's a good sign. Yeah. We have these social devices and these social networks where you can connect with lots of different people. Um, but it's not as deep, right? When you're, when you're sitting with someone and having a conversation. So it might be wider, the ceiling might be higher, but at a place like this, I feel like the connections can be a lot deeper and you've, you've sort of shown that. Yeah. Yeah. That's gotta be a value add. Um, let's go back to your book. Your, your book focuses on empowering patients to live better with low back pain. What are the key strategies you found most effective?

[00:13:55] We talked about education, but is there anything else that you really keyed in on? You did a lot of research and you looked in and did some self-reflection on our profession. Anything else that jumps out if someone was, was going to take a read?

[00:14:06] I did a lot of research and the interesting thing is that the, the reference section I think is now eight point font because it was almost as much as the text. It's about 120 pages, but, um, now just educating them on, on the, maybe the lack of need for imaging, um, the lack of our ability to really

[00:14:25] give a specific diagnosis, um, maybe what the serious things are, um, to sort of calm them down. Sure. Um, and then really I try not to take, I try to say, yes, I'm a physical therapist and why I would advocate for that. If you have a provider, um, it wouldn't make sense to go to a chiropractor if you didn't want spinal manipulation.

[00:14:48] Right. Cause that's their most commonly used billing code. And it probably wouldn't make sense to go to a physical therapist if you have no desire to do exercise.

[00:14:57] Um, DOs, it gets a little tricky, right? Cause they're also primary care providers. Um, but just to pick a provider and as a patient, just to make sure that they listen to you, you have a say in, in what your treatment is and you have an understanding of maybe what is, you know, what is happening with your back.

[00:15:14] Like I talked briefly about maybe just sort of like nutrition and sleep and stress, um, and depression and managing those things along with just general exercise and trying to be a bit fit.

[00:15:28] So the, the, the overall point is that the things that we do to be healthy to begin with can also help us manage our back pain.

[00:15:35] Yeah. Yeah. That's what we like to hear as somebody who's been in the field for 30 years.

[00:15:38] What are your thoughts of the, of the future of chronic, uh, back pain management and physical therapy?

[00:15:44] What are the, what are the things that you hope to see? What are the things that you're hopeful for?

[00:15:48] Um, well there's, you know, I don't even want to speak to some of the new research coming out.

[00:15:53] Um, because it's probably beyond what I can intelligently discuss with you.

[00:15:59] Um, some things about phenotyping and how we know which patients are best suited for which treatment.

[00:16:06] Um, I think that's probably fairly interesting and there's going to be some good things coming out of that.

[00:16:12] Um, mechanisms of manual therapy, why they do what they do and then how that might inform future research.

[00:16:19] Um, and I think there's probably a place right for traditional therapy, of course, exercise, manual therapy, education, the things that we do.

[00:16:28] Um, and maybe on the horizon, you know, um, um, um, cognitive behavioral therapy or cognitive functional therapy, um, may have a place maybe for people with chronic low back pain.

[00:16:39] Um, but I, again, I also think we need to look within ourselves, physicians, chiropractors, osteopaths, BTs, and just understand where the evidence is.

[00:16:51] And as much as we want to hold on to that dogma of getting an MRI or getting an X-ray or doing manual therapy or whatever it is that we just, or, you know, the, the maybe biomechanical approach to manual therapy.

[00:17:05] That we, we just have to really move forward, um, and accept the evidence, right?

[00:17:13] Where it changes and the treatment paradigms, how they have changed and, and change either what we teach or how we practice.

[00:17:19] Um, and you know, we're human and that's easier said than done, right?

[00:17:24] Humans are going to human.

[00:17:25] Right.

[00:17:25] Humans are messy and that's what we love about them, but also that could be the frustrating part as well.

[00:17:29] Yeah.

[00:17:29] So I think if we're open to the new research and willing to maybe let go of things that don't have as much support to them, um, you know, certainly I'm a big advocate for physical therapy.

[00:17:40] So, you know, I think things look good provided we do that.

[00:17:43] All right.

[00:17:43] Last thing we do on each episode, we've been having guests do what's called a parting shot.

[00:17:47] What, what's the last thing you want to leave with the audience of people that listen to the, uh, AMT podcast?

[00:17:53] You know, sentiment, idea, quote, what, what do you want to leave them with?

[00:17:56] Um, boy, I only get one.

[00:17:59] Okay.

[00:18:00] You can go with two.

[00:18:00] I'm not going to stop.

[00:18:01] You can have a double shot.

[00:18:02] Um, well, I'll do two.

[00:18:04] Okay.

[00:18:04] Um, drink good coffee.

[00:18:06] Got it.

[00:18:06] Would be the first one.

[00:18:07] Check.

[00:18:07] Um, and the second one would just be, oh, you know, just a little continuation of what I just said.

[00:18:13] Always be willing to learn.

[00:18:15] Um, you know, I teach and I learn from my students.

[00:18:17] I'm in the clinic and I learn from my patients.

[00:18:20] Don't, don't hold so strongly to any one belief, um, or treatment paradigm that when you learn something else, a different way to do it or something else that works.

[00:18:29] Um, just take a deep breath and, and it's okay to do something a little bit different.

[00:18:34] Steve, appreciate your time here.

[00:18:35] Thanks for coming back again and again.

[00:18:37] You're welcome.

[00:18:37] It was fun learning from you.

[00:18:38] All right.

[00:18:39] Thanks, man.

[00:18:39] Thank you.