Two known factors are influential for this rise during those years. Physician ownership of MRI and kickbacks from medical device companies.

I don't believe the majority of patients get to a spinal surgeon's door on their own. The majority of patients will be referred to the spinal surgeon. I'd be willing to bet the primary care physician initiates the whole downward spiral. Change the process; change the outcomes. Physical therapists need to be on the primary care team in primary care offices.

The synoposis... lol Working on that right.now! OH, my... WAY too many people are coming. I won't be able to remember who is who! OR who does what!!

And maybe that's what was bugging me with not having some kind of model to help visualize. What's the brain going to do with X information inputted? Will the light go off with an interpretation of pain or not? It changes how the information is presented to the patient.

I'd disagree with #3. I tend to think research supports distraction and providing other thought mechanisms that shift the cognition away from thinking about pain.

Thanks, Richard. We have a model for most everything else, why not a 3-D pain model that responds to help better understand how the brain responds to inputs or thoughts?

What year was that, John? I see the book is 2011, but what year is the diagram which is referenced?

The diagram did have some changes, yes. The 2005 diagram doesn't have trigger points, nor does it have expectations, depression, personality variables, cytokine levels, hypothalamic-pituitary-adrenal system... Does this mean these are eliminated as factors in the neuromatrix just because they are no longer included? Melzack mentions trigger points in Pain Practice 2005. http://kinesiologia.cl/PDF/Actualizacion_Neuromat...

The diagram is bare minimum with the paper providing the explanation. Page 8 of PDF (page 92 of original), first paragraph, first column mentions trigger points for low back pain.

The February 2012 issue of Pain has an article that suggests peripheral mechanisms can be a factor in neuropathic pain. The peripheral mechanisms include axonal hyperactivity and spontaneous activity of nociceptors. http://www.painjournalonline.com/article/PIIS0304...

Thanks for sharing, John. When I originally posted I thought I did post the most recent diagram. @hutchisonac pointed out my error to me on Twitter. Although the diagram was modified to appear even more simple, when reading through the above PDF, it did not appear to me that the subfactors no longer captured in the modified diagram were eliminated from the matrix.

Thanks for sharing your thoughts, Joe. The Pain Game would be on the same level as say a plastic knee or spine model. People like to visualize the content they are learning. The Pain Game would also have the patient actively learning as the clinician provides explanatory feedback on why the light did or did not light. It isn't a distraction technique like virtual reality. Just a potential way to help patients learn. Explain Pain has been helpful... What if the learning was more active and visual in nature? Could it also be more engaging for the patient? Would the model "stick" and create a memorable image & experience for the patient?

Large private employers better understand "business," do not have hidden agendas of supporting strong financial supporters, and are better able to define and measure their goals.

The government refuses to take simple action on known financial sink holes (think referral for profit situations). The government can't define "value." The government has all the data... they spend wasteful money on demonstration projects instead of just using their data to make one decision at a time to slowly reduce what isn't value.

This story needs to be shared outside of our comfortable circle of peers.

Wouldn't employers be screaming for this type of management for low back pain? Wouldn't third party payers LOVE to reduce their costs? And most importantly... consumers! Instead of sitting around, freaking out over the back pain and playing the waiting game and popping drugs... they can be doing something, working and taking care of their families.

This may not be some randomized controlled study, but it is reality. This data... there's a definite worthwhile P value in 21 days versus 52 days to complete treatment. Seeing a physical therapist in 48 hours versus 19 days is substantially significant! Consumers should be screaming for physical therapists - there isn't a valid reason for tolerating low back pain as long as they generally do!

psst... the link to the lumbar manipulation rule is not correct.