Ep. 38: Acute Low Back Pain Guideline: A Patient Advocate's Perspective*

Episode Summary:

In this engaging and informative episode of the Pain Matters Podcast, hosts Sudheer Potru, DO, FASA, FASAM, and Co-Host Zafeer Baber, MD, sit down with renowned chronic pain advocate, Tom Norris. With a four-decade-long journey through the challenges of chronic pain, Tom shares his invaluable insights regarding the newly drafted Acute Low Back Pain Guideline** (drafted by the Pacific Northwest Evidence-based Practice Center at Oregon Health & Science University (OHSU EPC) and the American Academy of Pain Medicine), recently submitted to Pain Medicine Journal and currently under review. His unique perspective underscores the critical need for clear communication and collaboration between clinicians and patients, especially in the context of guideline development and healthcare delivery. 

Throughout the discussion, the trio delves into practical strategies for managing acute and chronic pain, emphasizing the importance of patient-centered communication, the role of alternative therapies, and the power of support groups. Tom candidly discusses his military background and how it has shaped his ability to advocate effectively for himself and others within the medical community. The episode also explores the significance of understanding non-pharmacologic pain management techniques, such as virtual reality, acupuncture, and Tai Chi, and the need for greater awareness and education on these options. Anchored by Tom's wealth of experience and wisdom, this episode serves as a robust resource for both healthcare providers and patients seeking to enhance their pain management approaches.  

Key Takeaways:

• Patient-Centered Communication: Building trust and understanding between clinicians and patients is crucial in effectively managing pain and implementing guidelines.  
• Integrative and Alternative Therapies: Non-drug approaches like acupuncture, virtual reality, and Tai Chi can be beneficial in managing pain, but public awareness about these methods is limited.  
• Support Groups' Role: Connecting with others facing similar pain challenges can provide essential support and insights, offering solace and practical advice. 
   Empowering Patients: Patients should proactively educate themselves, prepare questions for their providers, and seek various treatment avenues to optimize their care.  
• Guideline Development Insight: Having patients involved in the creation of medical guidelines ensures that the recommendations are practical and resonate with those they are designed to help. 

*Views expressed by our guests are their own and do not necessarily reflect those of the hosts, their institutions, or the American Academy of Pain Medicine.

**The Pacific Northwest Evidence-based Practice Center (PNW-EPC) at Oregon Health & Science University (OHSU) is partnered with AAPM for the development of an evidence-based clinical practice guideline on the assessment and management of acute low back pain (ALBP). This project was financially supported by the Food and Drug Administration (FDA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award [FAIN] totaling $1,999,980.00, with 100 percent funded by FDA/HHS. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, FDA, HHS, or the U.S. Government. The funders had no decision-making role in designing and conducting systematic review, data collection, analysis, and interpretation of the data or approval privilege on the recommendation and good practice statements. As requested, the FDA provided nonbinding feedback and technical support to the guideline panel and methodological team. 

A methodologically rigorous systematic review  on assessment and management of ALBP was conducted by the PNW-EPC to provide evidence for guideline development. An independent, multidisciplinary guideline development used evidence from the systematic review to formulation evidence-based clinical recommendations to the guide assessment and management of ALBP.  

Transcript

SPEAKER_02 0:00

Welcome back to Pain Matters. I'm Dr. Sidir Poacher, your primary host. It's been a little while since we did an episode, but we're happy to get back into it today. In this episode, Dr. Zafir Bobber and I interview Mr. Tom Norris, who's been a chronic pain patient and an advocate for nearly 40 years. Today we're discussing with Mr. Norris the new guidance and recommendations related to the new, currently in draft, acute low back pain guidelines produced by the Food and Drug Administration as well as the American Academy of Pain Medicine. In this episode, we'll discuss practical recommendations and specifically how to best converse with your patients, and if you're a patient, how to converse with your clinician regarding acute and chronic pain. We think that you'll find this discussion highly relevant whether you practice pain medicine, primary care, emergency medicine, or PMR.

SPEAKER_00 0:48

Alright, let's get into it. You're listening to the Pain Matters Podcast, presented by the American Academy of Pain Medicine, the nation's leading podcast for healthcare providers, focused on providing the best care today, tomorrow, and beyond. Each episode we'll share the latest innovations and practical applications that directly impact how we care for patients and measure success in multidisciplinary care. Let's get started.

SPEAKER_02 1:14

Thank you so much for joining us, Tom, for another episode of the Pain Matters Podcast brought to you by the American Academy of Pain Medicine. We are here today to discuss the relatively new acute low back pain guidelines that will hopefully be published and disseminated soon. The American Academy of Pain Medicine played a significant role in the creation of these guidelines, along with, of course, the FDA. Tom, you know, you lived with pain for nearly four decades. And of course, you've tried many, many, many things, I'm sure, to help alleviate that or to cope with it. How did that personal history kind of shape your perspective while you were reviewing these new draft guidelines?

SPEAKER_03 1:49

First of all, I'd like to thank you for the honor of uh asking me or being and participating in this. I think it's important that the patient uh viewpoint be heard. And if I could put in a plug, I'd like to see more patients as patients, advisors, or patient reps, and guideline development panels. Uh, as from the background, this is my second guideline panel I was working on. And what I'd learned from the first is that there are no dumb questions. You know, uh, I was the only non-PHD in the room. And so I did a lot of listening, and there was a lot of medical terms, and I always ask, what's that mean? If I didn't understand. What I had to do for these guidelines is we narrowed them down, is take them and say, okay, here's the evidence for this, but what how does this translate into how it affects somebody's life? I felt like I needed to know and I needed to express, I have expressed what helps, what hurts, what harms. If I had to phrase it another way, I needed to make sure that the recommendations were practical, not just for the doctor doing his part, her part, but you know, that they made sense to the people, to the patient. And during the the panel discussion, there was a lot of give and take. But you know, being the only one who's actually walked that mile helped me bring things down to the point where the rubber meets the road where I was able to say, that won't work. How are you gonna explain that to somebody? And really bringing it down to common language. How do you take a patient who walks in off the street with a situation and take your education and your knowledge and translate it to the point where I understand it? So, yeah, having had 37 plus years of experience with pain, and I develop was I had at least three months of acute but low back pain with the military while I was in the military. And those experiences were such where I knew the doctors had no idea what was going on, and they weren't able to s to communicate that to me. Uh and you probably cut this out later, but I had one experience where the military said, okay, well, the cure for low back pain is 90 days bed rest. And I did that four times in four different hospitals.

SPEAKER_01 4:49

Tom, that's really insightful. Uh, this is uh Dr. Zapir Bobber here. Thanks for being on our show. Um, thank you. You know, you have a really unique perspective because you were in the military and you are a person who's had back pain for a long time. So, you know, I think about like who would be the ideal person in, you know, helping these guidelines. And when you think of somebody from a patient perspective, it's someone who's dealt with a lot of pain in the past. Obviously, you're in you've been in the military, someone who has done a lot of teamwork, especially with people from varying backgrounds, that would be someone like you and somebody who where uh knowledge and communication is key. I was just wondering, do you think that your military perspective allowed you to be a better advocate for yourself when being a part of uh this group? And if so, like, you know, I know bringing in lots of patients into these types of forums is important to you. What would you say to the non-military patients who might would be interested in doing something like this, but maybe feeling like they're in over their head a little bit?

SPEAKER_03 6:01

That's a tough question. I'm a firm believer in asserting myself, believing in myself, trying to understand what's going on. And that's all prior military. The military did help me a whole lot in problem solving on how to solve a problem. But I think I was engendered with the desire to know what's going on, and the desire to, if I got hurt or I got sick, how to get better.

SPEAKER_02 6:31

So, in thinking about that military background and that teamwork experience, you know, one of the things that we as clinicians, and I think sometimes patients also struggle with, is really how to get well aligned and kind of on the same page about dealing with, you know, any particular issue. So if you, as a patient advocate and as somebody who runs a number of these different types of support groups and whatnot, if you had advice for both patients and clinicians about how to communicate better and kind of how to get on the same page, just a couple of snippets of that would be really useful for our listeners, I think.

SPEAKER_03 7:08

Thanks for the question. The the the first thing I'd have to draw on is a friend of mine who's a researcher is working on a checklist of how to interface with a patient. And one of the things I told her is you have to be able to have the time to succinctly get the patient to trust you. And uh, whether that's a self-introduction, yeah, saying this is this is who I am, this is my background, this is the reason I got into medicine, this is the reason I specialize in this. You have to find something that allows the trust to build between the two of you. And I alluded to you're not trained in psychology, but you know, I think that's part of it. The patient needs to know that you see them as a person. It goes reverse. You need to see them as a person and vice versa. You can't climb the ivory tower and talk in in you know 25 cent words, you have to bring it down to their level. That's what I'm trying to get people, the patient to do is to say, treat the doctor like you'd like to be treated. And hopefully the doctor will turn around and treat you the same way. That doesn't always work, but you know, at least you're you're putting a good foot forward. And for a patient, I think it's important that they know that if a doctor says something they don't understand either what what it is or why it is, they ask the questions. That's the two-way communication. That to me knocks down the barriers of education where you go, okay, these are two people whose goal is to make the patient feel better or get better. You that's your team. You got a team of two who ought to be able to communicate and work together with a tour and move toward a goal they've set.

SPEAKER_01 9:09

That's a really good point, Tom, because a lot of times guidelines are written by doctors, for doctors. The guidelines usually are, what do you do to the patient? And it often leaves the patient out of it. But you know, if I were to read the guidelines on anything pain related, I don't think about in terms of the patient. Like the patient probably wouldn't understand with a lot what a lot of the words are. So do you think that your perspective in helping write these guidelines or outline these guidelines would help the patient understand what the guidelines are? Because sometimes the patients read as much as possible before entering the room.

SPEAKER_03 9:50

Yeah, I'm one of those. Sorry. Uh well, that's the reason I asked, in fact, was hard over on a patient-facing guideline. You know, I said, okay, this is a guideline basically that you understand, you as doctors understand, as practitioners understand. How are we going to translate this so the patient understands? And I'm hoping that the reason behind this podcast is some of that push that we need to get it down to a personal level. You know, you you're I understand the need for you to have a structure of possibilities. If this this happens, then this might work. But it it it I have to be able to take that, the patient-friendly guidelines, and say, okay, this is what he's probably gonna say, or this is what it is, and this is the reason there's no I I won't ask for an MRI. That kind of thing. I I'm I'm really I'm assuming that most people can understand plain language. And I know that's making an assumption, but you know, somewhere along the line, there has to be a way to get the knowledge that you have about the guidelines down to me and form I understand.

SPEAKER_02 11:20

So since you brought up MRIs, you know, this is often a touchy subject for us, whether that's, you know, to be honest, in our chronic pain clinics, but specifically in the acute low back pain space, you know, we we get patients coming to the emergency room, coming to their primary care doctor's offices, you know, often requesting MRIs. Um, it's a little bit of a tough situation because we know that oftentimes a high percentage of MRIs might show things that might not even necessarily be related to pain. And a number of patients, of course, or will recover on their own in this sort of acute low back pain situation uh without really needing advanced imaging or anything like that. So, how do you advise that patients approach uh the situation, advocate for themselves, as well as how we communicate with them that this just may not be necessary and that we should try to wait a little bit more?

SPEAKER_03 12:14

Thank you for that question. I I'm gonna give you a really simplistic answer. It's really and how things are communicated. You know, I I know we're gonna I'm gonna focus more on basic communications and psychology on the side. But if if you were if I were a doctor and a patient came in and said, Okay, I want an MRI, then I'd have to ask, okay, why particularly do you want an MRI? Do you know that an MRI will not show this, it'll show this. And you may not, you know, that may not be your problem. I think it boils down to your ability to explain the situation. And I know that's a whole lot of pressure on you guys, and you're not trained for it, and you're not, you don't have the time for it. But so, you know, I go the big question I ask researchers along that line is okay, what can patients do to make your job easier so you can help them get better? Yeah, I think that works. Uh so you know, it's to me, it's a dialogue about okay, this is what the guideline says. And and I would rather not do an MRI because and let's try this. I think your pain is from this, and explain it in simple terms. Don't say, you know, this bone is misplaced or this is up against this, and say, okay, if this doesn't work, then let's try an x-ray or do it step by step. Again, it's a really depending upon the rapport you have with the patient. As an aside, I don't have problems with my doctors. I mean, it's a force of personality, but I fired doctors because they wouldn't communicate to me with me. And you know, if a doctor won't take the time to listen to me, I'll go find another doctor. But, you know, assuming all doctors have the patient's health in mind, I think it boils down to okay, what can we do to facilitate the transfer of knowledge, the communication? Whether it's a checklist, whether it's walking in with I have these questions, can you answer them? If not, can you point me in the right direction? What's causing my pain? What's going to make it worse? What's going to make it better? Why can't I have a MRI? Why can't I have a pill that makes me better? You know, that kind of thing. And that, as I said, is in my mind a big drain on you. So I have to figure out how to educate the patient.

SPEAKER_01 15:05

Not there yet. You know, when you talk about communication, it communication is hard, but it's even harder when there's a time constraint. And you know, I'm aware of you know, one effective communication is one thing that patients complain about when they talk about the healthcare industry, but another thing is a lack of access. And one way to resolve a lack of access is to increase the number of patients that you see, which would decrease the amount of time with each patient. How do we as physicians maintain effective lines of communication with our patients when the time constraints get shorter and shorter and shorter and shorter?

SPEAKER_03 15:48

I don't know how you would do it, but I know that what I would do, and what I've asked my people to consider, my people, you know, the people I work with, is okay, we're we are very aware that we're getting short sheeted on the time. By the insurance companies. Okay, that's a different issue we're working on. But how to make the most of the time we have with you guys. And I go, okay, part of your goal is to make it easier for the doctor. So you I suggest that we walk in with here's my complaint at the moment. Write it down, give it to the doctor, give it to the the head nurse, give it to the woman at reception, saying, Okay, here's what I've got, here are my questions I'd like to cover today. I don't know how long it would take you to to really work with those, but if you can't answer, say, the top four questions, then you got access to the the uh portal. You know, right now I'm sitting back, and if I'm lucky, I can have an appointment every four months. You can't wait the four months to get back and say, okay, well, this is what's recommended, but I want to do this. Do you understand that? I would think that you know either you or an assistant could answer those questions in the portal and get back to the person. Yeah. I'm trying to look, I'm trying, I you know, I try to look at it simplistically. And and really, you got people who want to know how to get better or how to stop hurting, and you got a doctor who says, okay, I want my patients to feel better. So it's gotta be, you gotta be able to fruitfully take advantage of the amount of time you have to answer the questions that are most important.

SPEAKER_02 17:46

So switching gears a little bit and getting back into some of the guideline stuff. So, you know, we have really nice evidence, and the guidelines kind of demonstrate this too, that some of these, you know, non-drug and maybe even to some extent, non, you know, interventional options, right, can be helpful. Things like acupuncture, things like chiropractic treatments, like spinal manipulation, heat. My understanding is that you have some experience exploring some of these more sort of integrative tools. What should patients be looking for, you know, with related to these non-pharmacologic options? And perhaps maybe more importantly, what should they look out for?

SPEAKER_03 18:25

Again, I'm gonna have to say that most people do not, patients do not know about alternative methods. And I gave a briefing at the Academies of Sciences about alternative methods, you know, everything from uh uh virtual reality to acupuncture to Tai Chi to what have you. And there were doctors there that didn't know about some of this stuff, and I go part of, and this is where I've shoulder set part of the responsibility with the support groups is I am trying to educate the patients on alternatives. Yes, most of my people, the people I work with, are on opioids because they say it's the only thing it works. But I say, okay, this works for me, uh, virtual reality works for me, and I talk about you know how I use it for things like uh cystic scope and what have you. I talk about what works for me when it comes to uh acupuncture and acupressure and Tai Chi and all those things. I believe that people have the wherewithal to make decisions, but I think the education is lacking for the public on alternative methods. How we change things, people's ideas from the from the quick fix to something they have to work at, I don't know. You know, we we society. My my ideal is society has gone to that quick fix. They don't want responsibility, they don't want to have to do uh physical therapy lessons at home, they want the PT to do all the magic there. It's it's an acceptance of the patient's responsibility. I feel like the doctors have a responsibility, but we have a responsibility. Yeah, I'm circling back to the old thing about education. The knowledge of alternative methods, non-medical, is spotty in my perception. And how we educate the people, yeah, it's an ongoing battle. Support groups is one way. Doctors ought to be able to use support groups and say, hey, you know, why don't you try uh say virtual reality and have somebody have you know have access to a list of people who've used virtual virtual reality for acute low back pain. You don't have access to that, right? If I ask you right now, if somebody that you know that works with VR that has acute low back pain, you probably can't say, well, contact this person. And that's that's where I think you guys need to be able to rely on the patients and the patient advocates to help. Again, it's a team effort. You guys are not operating by yourselves, and the patients not by themselves.

SPEAKER_01 21:32

You know, that's a good point that you made about alternative treatments. And I and I was thinking about that. And, you know, a lot of the alternative treatments that have been proven to help are uh behavioral medicine in the behavioral medicine realm, you know, like seeing a psychologist, cognitive behavioral therapy, biofeedback. You mentioned Tai Chi. Tai chi has been shown to be effective in many chronic ail ailments like fibromyalgia, support groups have been shown to be effective in um. In chronic pain. There's been high associations between depression and chronic pain. How do we bring that method of treatment up to the patient? Because a lot of times when I talk to the patient about these alternative therapies, what they're hearing is, I think you're crazy. I think it's in your head. Go see a shrink. But it is one of the tools in our toolbox, a major tool in our toolbox as physicians to help treat chronic pain. So, you know, how do we uh circle those squares when it comes to that with the patient?

SPEAKER_03 22:36

Are you familiar with the the uh let me see if I could remember the the AAC IPM dot uh diagram of alternative treatments, AACP? I'd have to look it up, but it's a circle with that shows a person at the center and all the alternative treatments around it. I would use a tool like that to say, okay, you've got X. Right. I, you know, we can either go this way or we can go this way. I prefer that we go this way. And again, this builds on respect uh and the rapport that's that that I hope you have built. And then people could say, okay, well, I'm gonna try this. What's it gonna cost? What's it covered? What is covered, and what do I have to do? I was I was on fentanyl and uh for 10 years and came off of it because I didn't like the way my brain, it affected my brain. So I was I was barefooting it. I mean, it was not fun. And I happened to be my it was my first uh opportunity as a patient advisor on a clinical trial, and the researcher turned to me and said, Have you ever tried virtual reality? He just happened to be doing a study about virtual reality, which is not the study I was working on. So I got introduced to virtual reality, took it, took the headset home, did the uh Beth uh uh Darnell's modules. I think she had 13 then. I did them all in one day, and I was sold in virtual reality. I still use virtual reality 20 years later. It worked. See, that that that's that's a point that that everybody needs to realize. Everybody's pain is different. You know what works for me, and I've got a big box of alternatives, it's gonna work for everybody else, whether it's an attitude or a religious background or physical situation or whatever. It's you you have a hard time making the shoe fit. The hardest thing I think is gonna be for is you guys with your education, and you're already down the road. You know, you identify the problem as from your perspective, and you've got a possible solution. You got to bring the patient along, make them a partner. And I don't envy you your job at all. But you know, that's a lot of partners. That's a lot of partners, and you know, you you've got 15 minutes with a person. If you add maybe a 15-20 minutes waiting in the waiting room and interaction with the the front desk, uh you might have 45 minutes, but that's it. So I go, I've got to come armed. But how how do we turn around and take your guidelines and educate the person who walks in the front door saying, My back hurts. You know, I go, okay. Uh do you have a screen in your office that says, okay, this these are the causes of low back pain. This is awesome. This this goes to this. Educate the person before they actually see you.

SPEAKER_02 26:01

One of the nice things about acute pain is that usually it's self-limited and the patients get better. It goes away, right? But we know the recurrence often can be high. So as we're thinking about, you know, so many patients, whether they're they have acute pain, they have chronic pain, they say, I want to be out of pain and I never want to feel pain again. You know, we we hear that all the time, right? Whether that's in the ER, whether that's in our our chronic pain clinics, whatever that is. So how do we, and I know this is a hard question, but I'm gonna try to pin you down here. How do we try to help patients, whether they have acute pain or chronic pain, try to build resilience, right? And try to build, you know, a more resilient back or spine, for lack of a better term, right? Uh, in order to try to prevent future recurrences or prevent future, you know, exacerbations of pain that land them in the emergency room. I mean, what advice do you have?

SPEAKER_03 27:04

I would say don't just expect them to do that. You gotta explain it to them. You gotta give them a reason to buy into what you're saying. Say, okay, you know, this you this is what's caused your pain, as far as we can tell. This is where we're gonna do work toward building your resilience, building your back core, but whatever the term is, and you know, say, okay, here are the goals. This is what we expect in two weeks, four weeks, whatever, and say, okay, then we say you're gonna recommend somebody to PT. And you know, they've got uh, was it 12 visits now or eight visits or whatever? You know, they should should have goals that they can shoot for. You know, you're gonna be able to do 10 sit-to-stands and at the one-week point and 20 and in a two-week point, you know, goals all the way through, and then say, okay, this is the reason. The reason we're doing all this is to make sure that you hurt less in the future. A personal experience, it I did a lot better in physical therapy, for example, when uh the PT explained what we're gonna do, why we're gonna do it, and what the my ex the expectations for me were, and what would result. And I was brought along. Other hand, I had another PT who spent more time looking at the the other men than than he did looking at me. So he didn't care about me. And so it showed. I just kind of went, I gave him uh the index figure and moved on. But I again I think it's rapport, it's communication, it's education. It's it's treating people like they're people.

SPEAKER_01 29:05

I was just thinking about getting a shirt that says core strength. It's not just for the beach anymore and giving it to all my patients. I think they'd have to be. Go for it.

SPEAKER_03 29:13

But but do me a favor, explain what it is because most people I you know, and and what it does. I mean, take advantage of that that TV screen in your office.

SPEAKER_01 29:25

Yeah, definitely. And explain it. You gave a lot of good advice uh from a patient perspective uh to the doctors, but I'm thinking about uh the patient perspective to other patients, right? So let's say a patient just hurt their back and they Googled, you know, patient perspective for low back pain, and they found this podcast and they're listening to it. They're they hurt their back a week ago. What would your advice to that patient be on like the first steps, expectations, what they should do to get better, what they should do to uh what they have a doctor's appointment the next week, let's say, what they should expect from that doctor's appointment, how they can prepare for that doctor's appointment.

SPEAKER_03 30:07

I'm gonna take it back even further, if I may. The first thing that that I would recommend for somebody who has acute pain is try to find somebody else who is going through the same kind of thing. Now, with that knowledge that, you know, if I have back pain and you have back pain, even though it's lower back pain and it may be acute, it's probably from two different directions. But you know, it's one is each patient winds up thinking they're alone. This is the I'm the only one this has ever happened to, and that's not the case. You can learn from others and get support from others, you know, and and that's I have people pop into to my support groups all the time. You know, I just want to know that somebody else has this problem. And and you know, it's you're not gonna like this. But what I tell people is talk to others in advocacy groups, talk to say a U.S. Pain Foundation, the American Chronic Pain Association, find somebody who is walking the same path you're walking, whether it's first time in a doctor, uh, first time PT or PT doesn't like me, or that kind of thing. There is so much support in support groups, not to be redundant, but I think that's one of the keys of facilitating the interaction between you and the patient. The patient is more confident, more prepared, more aware of the possibilities. You know, and and I what I've seen is people are less afraid. You know, I I have at least one woman who is terrified that she she does not have a chronic low back pain. She still has acute. And she's terrified of tests, and she's terrified of uh uh epidurals. You know, she's got so much fear that it radiates through the phone. And just having the knowledge that somebody else has been through that should make it easier for you to help somebody.

SPEAKER_01 32:18

Absolutely, and that's not just true for pain, but for all forms of suffering. Oh, yeah. Knowing that you're not alone is a first major step to uh help with that. So very good advice, Tom. Thank you so much. Oh, I could talk for hours.

SPEAKER_02 32:35

Sorry about that. Unfortunately, I think we probably are at our closing, getting close to our time limit here. You know, people are interested in joining some of your if you have virtual support groups or or online groups. Uh, how do people actually get a hold of you?

SPEAKER_03 32:50

Either through my email, I have a website, I'm on Facebook, I'm on LinkedIn, uh, just Tom Norris. Uh, the website is split between chronic pain information and patient engagement, patient empowerment. It's split in three ways. I also have a sub stack.

SPEAKER_02 33:11

Yeah, this has been really educational, I think, for both myself and Dr. Bobber, and hopefully it'll be wonderful for our listeners to um appreciate all of your hard work, uh, both in this podcast and of course uh as a patient advocate for the Q back pain guidelines. Thank you so much.

SPEAKER_03 33:25

Thank you. And you're allowed to I I appreciate it. And if there's anything I can ever do, please let me know.

SPEAKER_00 33:31

Thanks for listening to the Pain Matters Podcast. If there's anything we mentioned in today's show you missed, don't worry. We take the notes for you at painmed.org slash podcast. If you're not already a subscriber, please consider pressing the subscribe button on your podcast player so you never miss a future episode. And don't forget to leave us a rating and review to help us reach and educate even more of our peers in pain medicine.