Defining Moment Physical Therapy to the Rescue A veteran finds that his rallying motto still resonates. By Paul Caudillo, PT, DPT | March 2019 Listen to 'Defining Moment' Sic vivant ut alii. That phrase is repeated during training and afterward among the brotherhood of SAR (search and rescue) swimmers in the US Navy and US Coast Guard. It's SAR's motto. It's Latin for "so others may live," and it's been my motivating theme—in military life and beyond. In August 2001, I left the comfort of home, family, and friends to do something more with my life. At 18, I enlisted in the Navy to be trained as a helicopter SAR swimmer, seeking camaraderie in the form of training, discipline, and service. A month later, while I stood in ranks with my shipmates during basic training in Great Lakes, Illinois, the second of the World Trade Center's twin towers fell in New York City. That moment changed my life. I was fully prepared to pay the ultimate sacrifice in defense of my country and to defend those who could not defend themselves. I proudly served in the Navy for 5 years—including 2 tours of duty to support co- alition forces on the ground during Operation Iraqi Freedom in 2005 and 2006. I later earned my doctor of physical therapy degree and now have been a physical therapist for 5 years. Search and rescue has continued to be my calling. The United States spends more health care dollars on imaging, surgeries, and pharmaceuticals—by far—than does any other industrialized country. Yet we continue to report a high prevalence of chronic pain, illness, and disability. We are in the midst of an opioid epidemic. Every time we turn on the television, it seems, someone is frolicking in the meadows, pain and disease-free, promoting a super pill that somehow will solve America's pain problems. Is it any surprise, then, that opioid dependence is rampant? Currently, there are about 120 nonopioid drugs under review by the Food and Drug Administration.1 But is that the answer? Hardly! As a society, we largely continue down the self- defeating path of chasing chronic pain, rather than promoting affordable and effective ways to prevent it—including physical therapy, as highlighted in APTA's potentially game-changing #ChoosePT campaign. I practice in Bakersfield, California, an underserved community. Some 90% of my caseload has a managed care health plan. A few weeks ago, I evaluated a young man who appeared to be almost 20 years older than his actual age. He was significantly underweight. His pupils were pinpoint and his eyes were glazed. He had dry skin. He was lethargic and irritable. He reported chronic low back pain and also frequent pain in the upper abdomen. Over the past couple of years I have learned that dyspepsia, or indigestion, is an adverse bowl dysfunction that often is caused by chronic opioid use. I asked my patient how long he'd been taking Norco— a commonly prescribed narcotic for unspecified low back pain. Unsurprisingly, I learned that he had been taking prescribed and nonprescribed opioids for more than 5 years. He reported feeling disconnected from his right lower leg. At one point, he even asked me to cut it off! Needless to say, I steered him away from that "solution." My treatment plan for him, rather, has consisted of basic pain science education, restoring nonpainful mobility with motor-control exercises, and using directional preference and manual therapy techniques. While it has been beneficial for him, such patients also need the services of psychologists and cognitive-behavioral therapy to help ween them from opioid dependence. I try to connect them with the appropriate providers, but in our current health care environment it's an uphill battle to get such patients the type of coordinated, intensive, and ongoing care they need. Another of my patients, who's in her mid-30s, also battles opioid addiction and chronic pain. Through her health maintenance organization plan she's been taking Percocet since early 2015. Percocet is a combination of oxycodone and acetaminophen, which work together in the central nervous system to block pain by binding with opioid receptors and inhibiting inflammatory chemical messengers. This patient disclosed that she had been prescribed opioids by multiple providers. Her initial prescription was for 5 milligrams twice per day. That has escalated to 10 milligrams 3 or 4 times a day. Her appearance is one of overwhelming fatigue, with a flat affect. I would describe her condition as "conscious sedation." In an outpatient, orthopedics-driven environment in which 45-minute to 1-hour treatments are the norm, how I am to keep patients with drug addictions engaged? I had no training in my DPT program that covered physical or functional rehabilitation of individuals who have abused narcotics over the long term. Far too often, patients with chronic pain are prescribed physical therapy as a mere formality for the insurance provider—a pro forma precursor to imaging and surgery. What if our profession was widely regarded as a treatment key in and of itself—obviating the need for less-safe and more- invasive care approaches? Also, is it any wonder that catastrophizing can result when patients are informed that byproducts of physical therapy may include degenerative disc "disease"—with disc "herniation" or even "severe" canal stenosis? Is it any surprise that individuals hearing such terms might not only respond favorably to calls for unnecessary testing and even surgical intervention, but might even seek those things? It's not difficult to see why chronic pain has become a leading industry within medicine, costing the United States an estimated $635 billion annually.2 I constantly search for answers and consult with other providers. Not that physical therapists are alone in this challenge. Providers across health care and around the world have learned that there is a dire need for more interdisciplinary communication, training, and willingness to work together to problem-solve. So, no, I've never left search and rescue. As a physical therapist, I remain part of an elite unit that has enlisted in the fight to serve, protect, and try to rescue others. We are trained to optimize human function and to help people recover from physical, neurological, and even emotional afflictions. We believe that the most realistic lifelong prescription for optimal health is movement through exercise—not altering the body's chemical response through dosed medication. Often, our most valuable tools as physical therapists are simply empathy and patient education. My calling is to reverse dependency on narcotics and to shift patients away from unnecessary and costly procedures by educating and rehabilitating them in a manner that holds them more accountable for their own health and well-being. It is my job—it is our job—to navigate these issues, and to find ways to ensure that "others may live" robust lives without bearing the weight, and engaging in the despairing cycle, of opioid addiction. Paul Caudillo, PT, DPT, is a clinical director at Pair and Marotta Physical Therapy in Bakersfield, California. He also is a certified strength and conditioning specialist.