Most people are unaware of why it has been so difficult to effectively address their pain. That has left people feeling isolated and thinking it is their personal problem that they have not found a solution. They do not know they are a part of a bigger global problem in which the cause of pain is unknown so only symptoms are being treated.
To effectively share this idea of how to identify and address the cause of back pain, I needed to give it a name. Since the focus is that the body works as a system and that the pain can be a sign that there is a mechanical limitation in the system causing the pain, the name is, the System Limitations Approach to Pain (SLAP-ouch.)
As a part of my series about “Big Ideas That Might Change The World In The Next Few Years” I had the pleasure of interviewing Cathy Mahon.
Back pain expert, Cathy Mahon, is a physical therapist, kinesiologist and consultant of 30+ years, specializing in chronic pain. In the first half of her career Cathy worked in over 40 facilities, as either a, staff PT, travelling therapist, or consultant, giving her a wide view of patient’s experiences in healthcare. Cathy returned home, started a private practice and for the past 20 years she has spent over 3 hours on the initial evaluation of her patients. Cathy noticed a strong connection between limitations in range of motion and the positions that bring the pain on. Addressing those limitations resulted in significant success in alleviating back pain. Cathy has spoken on this topic on various stages including continuing-education classes for physical therapists, at the Johns Hopkins Applied Physics Lab for the Conference of Safety Engineers and at Anne Arundel Medical Center in Annapolis for the spine and joint therapists. For more information you can go to her website at cathymahon.com
Thank you so much for doing this with us! Before we dig in, our readers would like to get to know you a bit. Can you please tell us a story about what brought you to this specific career path?
Thank you, I appreciate the opportunity to talk with you on this topic.
In middle school, my friends and I volunteered to work with children with special needs. Each child was partnered with a volunteer, and the physical therapist provided a list of activities that would be helpful. I was partnered with a child who, I was told, would not do anything asked of him. Our first activity was swimming, and, as forecast, he spent the entire time keeping his distance from me. When it was time for us to leave the pool, he approached me so that I could wrap the towel around his back. As I did, I also lifted him up, flipping his legs way up over top of us. He loved it! He wanted to do it over and over again! After that, we were best buds, and he participated in most of his activities. That was when I decided to become a physical therapist. For years my mother would say, “It is not always going to be that easy,” and while, of course, that was true, it was a great decision for me.
Can you please share with us the most interesting story that happened to you since you began your career?
I spent a day in court because I filed a complaint against an insurance company on behalf of a patient who was not well enough to do it for herself. The insurance company had denied her further approval for PT at a time when, because of her back pain, she was unable to sit in a car and had to pay someone to drive her to work while she lay down in the back seat. The complaint was for the denial of approval, and I included that they were not practicing in good business faith. The complaint progressed from the state insurance administration to court. While I was familiar with everything that had been happening with this patient, I was completely unfamiliar with courtroom procedure. The insurance company’s attorney argued with me for eight hours, tirelessly trying to pick apart my position.
It was well worth the time, effort, and stress. In a 23-page opinion the judge found that the insurance company failed to adhere to the contract. Early in the day the insurance company attorney requested that the case be sealed. The judge denied that request and further ordered that the decision be reflected in the State Insurance Administrators records and publications.
Even though I was trained to be a physical therapist, at times my job requires more. It was certainly an interesting day and out of the ordinary for me. While I don’t necessarily wish to return to court, I will do what I can to help my patients.
Which principles or philosophies have guided your life? Your career?
I was fortunate to have two wonderful parents who set the example of how to live a life doing what was right. Seeing their consistent effort with ethics was important because that is often not the easy path. My life and career have been guided by their example: I try to do the right thing.
Ok thank you for that. Let’s now move to the main focus of our interview. Can you tell us about your “Big Idea That Might Change The World”?
I have identified the cause of back pain.
The premier medical journal Lancet published a series of articles in 2018 on low back pain, in which the authors report that for nearly all low back pain it is not possible to identify a specific cause, further stating that the underlying mechanism of back pain is poorly understood.
After over 30 years of industry experience and research, I have determined that the cause of back pain is — -drum roll please — — limitation in range of motion. Let me explain.
Limitation in range of motion is similar to decreased flexibility. In this case, the loss of range of motion or flexibility prevents a specific joint from moving in a specific direction.
Loss of motion causes trouble for the activities and positions that need that motion. When someone does an activity or is in a position that needs that motion, another joint in the body substitutes to provide the motion. With back pain, it is the back that is forced to move to compensate for the loss of motion. Pain is how the back lets you know there is a problem.
The best example of how limited motion impacts the back is when sitting increases low back pain. A person needs to have at least 90 degrees of motion at the hip to bend to sit. When a person only has 70 degrees of motion at the hip, the spine is forced to flatten in order to reach the 90-degree bend to sit. That flattening over time is a problem for the spine. Again, pain is how the back lets you know there is a problem.
Other mechanical issues, such as strength, stabilization, and postural alignment can be limited and contribute to the cause of pain too. I have found that range of motion is the most significant problem because it is the most prevalent and the most difficult to improve. If range of motion was easy to improve, I would be on the street corner giving out exercises because so many people are in trouble. However, increasing range of motion is difficult, which is likely one of the reasons that back pain has been so difficult to eliminate. I have found the other mechanical issues easier to improve, although they take a long time, particularly stabilization.
It is consistent with the statistics that up until now the underlying cause of back pain has not been identified for most people with back pain. If the cause is not known it is not treated and so the problem persists. As such, back pain is the number one cause of disability in the world and has been for the past 30 years. It affects 540 million people at any point in time.
Most people are unaware of why it has been so difficult to effectively address their pain. That has left people feeling isolated and thinking it is their personal problem that they have not found a solution. They do not know they are a part of a bigger global problem in which the cause of pain is unknown so only symptoms are being treated.
To effectively share this idea of how to identify and address the cause of back pain, I needed to give it a name. Since the focus is that the body works as a system and that the pain can be a sign that there is a mechanical limitation in the system causing the pain, the name is, the System Limitations Approach to Pain (SLAP-ouch.)
In addition to identifying the cause of back pain for many people, there are a number of advantages that come naturally with this approach.
First, this approach is systematic, measurable and reproducible. The evaluation is the same for everyone, it is the data from tracking the pain and the data from the measurements that reveal each individual’s unique pain and unique combination of mechanical problems.
Second, this approach helps to readily identify subgroups and patterns, both of which help patient education and the development of a treatment program.
Third, this approach is centered around the position(s) that increases the pain. Identifying the position that increases the pain helps the PT focus on the mechanics specifically needed for that position. To the patient the focus on the position that increases the pain is helpful because it means something to them. Also, it is important that the patient track how long they are in the position before the pain increases and the intensity of pain. Those two measures help track their progress.
Fourth, a daily home program, with intermittent follow up to progress the program, is the focus of treatment, making this approach cost efficient.
Important to note, regarding the evaluation, there is a difference in the timing of when people will tolerate the measurements. There are people who will tolerate all of the measurements at the initial evaluation. However, most people will need to make progress before they tolerate certain measurements. Then, there are people who will never tolerate the measurements their spine is so fragile. Typically, they have a long history they can share instead.
A wide net should be cast during the evaluation to minimize the risk of missing problems. In 20 years of spending over three hours evaluating each patient and doing a deep dive into the mechanics of range of motion, strength, stabilization, and postural alignment, I have found that over 90% of my patients had a lack of range of motion needed for the positions that increase the pain. When we effectively increased their range of motion, the pain significantly decreased or completely went away, identifying the loss of motion as the cause of their back pain.
How do you think this will change the world?
Back pain is a humanitarian crisis. In addition to the astronomical numbers of people impacted, back pain triggers other serious problems such as drug addiction, loss of jobs, loss of relationships, depression, and suicidal thoughts and actions to name a few. This is happening in every country in the world.
Decreasing and eliminating current disabling back pain will significantly reduce the financial cost of back pain. More importantly, for many, it can eliminate the path to depression, addiction, homelessness, and death caused by back pain.
The ultimate goal is to help people reclaim their lives. Helping millions of people shift from disabling back pain to a life where they can contribute to their family, community, and society, will change the world.
Keeping “Black Mirror” and the “Law of Unintended Consequences” in mind, can you see any potential drawbacks about this idea that people should think more deeply about?
The only unintended consequence would be the creation of competitiveness or division between healthcare providers, researchers, or organizations. Given the gravity of this crisis, it is best to have a coalition, an all-hands-on-deck effort, to tackle this enormous problem.
Was there a “tipping point” that led you to this idea? Can you tell us that story?
There were two parts to the tipping point. The first occurred in 1994 when I worked in Molokai. I attended a course given by Beverly Biondi in Honolulu. Beverly recommended that we make sure the patient had the range of motion needed before starting stabilization exercises. I returned to Molokai and formally measured each patient’s range of motion. I was surprised how limited people were.
The second part of the tipping point occurred when I returned to Annapolis. In 2002, I started a private practice where I could take as long as I needed to evaluate a patient. I heard each person’s experience with pain in measurable terms, which helped us figure out the positions that increased their pain. Then I took a deep dive into the mechanics, formally measuring their range of motion and comparing that to the activities and positions that increase the pain. That is when I realized that the pain was brought on because people did not have the range of motion needed for the position that increased their pain; this was compromising their back.
I realized I was onto something new after I looked for articles. I went to the National Library of Medicine at NIH to search for articles on range of motion. There was only one old study about hamstrings in which they reported that there were no consistent findings. I belonged to an orthopedic association and in 2008 they published a continuing education course on low back pain and the evidence for treatment, their comments revealed that they had not identified this as the cause of back pain.
What do you need to lead this idea to widespread adoption?
There are two main steps needed to lead this idea to widespread adoption.
First, people with back pain need to be educated that there is an approach that might identify the cause of their pain. It would be helpful to have people — — such as leaders, media personnel, and celebrities — — who have platforms reach out and educate those in pain about this approach. Millions of people asking for this help will provide momentum towards widespread adoption.
Second, the 2018 article Low Back Pain: a call for action, in the medical journal Lancet, bulleted the points needed to implement an international response to the global problem of back pain. Those points focused on three areas: politics, public health, and healthcare. It is a comprehensive list. They included that a solution for back pain is needed and it needs to be a context-specific cost-efficient solution. The cause of back pain I present here the context-specific and cost-efficient solution they are looking for.
The bulleted points in the call-for-action married to this solution provides the road map for widespread adoption.
I will share one important step that can help people with back pain immediately. Provide physical therapists and physiotherapists the time needed to do a full evaluation, educate the patient, and develop a treatment program. In most cases, other than getting films taken, evaluations for back pain are 45–60 minutes at most before treatment is started. That is not enough time, and, it is not easy for most clinicians to increase the time they are scheduled to spend with patients.
It is possible to allow more time for evaluations in health care. My husband had cancer, his initial evaluation was in July, he was seen regularly and the treatment started in September. He was at Hopkins and the surgeon said they could not do it any faster and be safe. It is possible to allow more time for patient evaluations. Back pain would not take months to evaluate, however a day is reasonable and that would likely be more successful and cost less in the long run.
This back pain evaluation is basic and requires the skills physical therapists already possess. Resources to facilitate their understanding of patterns and details for the evaluation are immediately available.
What are your “5 Things I Wish Someone Told Me Before I Started” and why. (Please share a story or example for each.)
5 things I wish someone told me before I started:
1.) Before I started, I wish someone told me how hard it would be. It is hard. The days are long and there are many nights with just a few hours of sleep.
2.) Before I started, I wish someone told me that I would get in my own way. I am a healthcare worker, and my skill set works well for being in healthcare. It turns out that maybe it is not the best skill set for sharing a big idea. For instance, I wrote a book which has a lot of good information. Yet when the opportunity arises for me to say something about the book, I often find myself shying away, for a number of reasons, such as I don’t want people to feel like I am trying to sell them something. In short, there are times when I have definitely gotten in my own way.
3.) Before I started, I wish someone told me that there would be current ideas that would present resistance to sharing my big idea, even if it is unintentional resistance.
The example I will share regards research. I have the utmost respect for research and for researchers. I am 100% behind pursuing evidence-based information. I believe it is the perception and assumptions around research that need to be tweaked. For example, I was at a conference and the statement was made, ‘if you provide treatment that is not evidenced based (meaning not researched) that is unethical.’ There are couple of problems with that statement. First there are areas of health that have not been fully researched. There are people who have health problems in those areas. They need to be able to seek help from providers, and have the providers try to help them without the fear of being accused that they are unethical because someone has not yet researched that area.
Second there are areas that have been extensively researched and yet there are still unanswered questions. My topic, back pain, is a good example of that. There has been a lot of research about back pain. Yet it is widely accepted in medicine that the cause of back pain is unknown for most people who have back pain.
I am a kinesiologist and a physical therapist and I have been practicing for over 34 for years. For the past 20 I have spent over 3 hours on most of my patient evaluations, doing a deep dive into their mechanics, range of motion, strength and motor control. It is crystal clear to me what the underlying cause of back pain is for most people
When I take the steps to try and share that information, I have often met resistance, with questions like, ‘where is your research?’ Ironically that was often during my attempts to share this idea to encourage research.
I am a sole practitioner. This research is going to take the collaboration of multiple universities, and internationally, because back pain is the number one cause of disability in the world and has been for the past 30 years, likely because the cause of back pain has been unknown. There is a need to coordinate trials, to gather baseline information, to study the patterns I found, refine that, and move forward.
Meanwhile there are millions of people suffering in pain. Fortunately, the underlying cause of back pain is basic. I could take five people to a stage and they could talk about the positions and activities that bring their pain on. We could then look at their range of motion. By the end it would be crystal clear to the audience what the cause of back pain is. The underlying cause of back pain is basic and easy to demonstrate.
As a refresher from our early conversation, the cause of back pain is that people have limitations in the range of motion needed for the positions and activities that bring the pain on. When people do those activities anyway the back pays for it and that causes the back pain. Pain is how the back lets us know there is a problem.
Experience is an idea that has taken the back seat to research. An illustration of the importance of experience is, ‘I am standing at the door of a plane, I don’t ask if there has been research to prove that I need a parachute, I take the parachute.’ Similarly, if someone has glass in the bottom of their foot, I don’t wait for research to take it out. Fortunately, life provides us with much experience so we can make good decisions for ourselves.
Considering that the cause of back pain is basic, that we have experience on our side and that there are licensed physiotherapists around the world, we could take steps now to identify the cause of back pain for many people, and that would be huge. We can also take the next, more difficult, step of working to improve those mechanics. It will not be easy or perfect, however we cannot stay where we are with hundreds of millions of people suffering.
We know that it will take research years to do trials, collect and analyze data and we eagerly await their information to make needed adjustments to better serve people.
In number 3 of what I wish someone told before I got started, I have used research as my example of a current idea that can provide resistance to sharing a new idea. If I had known there would be resistance, I would have been better prepared. I would have been more flexible and would have made more plans of how to share this information. It would have saved me time and money on effort that was not helpful. This idea is very easy to demonstrate and extremely important, I was naïve. I had no idea that it would be difficult to share.
I will say that, with respect to research things have improved, before I started there was one study on range of motion and it had been done years before. There is more research on range of motion.
However, the big idea of being able to identify the cause of back pain, should not be met first with resistance.
4.) Before I started, I wish someone had told me about people and platforms that could readily help me share my message. For example, this interview with Authority Magazine on A Big Idea that Might Change the World. This topic is perfect to help me share information that I need to share for people who need that information, whether they are suffering, or whether they can reach out to help people who are suffering. The follow up questions are perfect they are definitely the questions that I need to answer. I am grateful to Authority Magazine for the opportunity that this interview provides.
I also found Chris Winfield and Jen Gottlieb who have a PR agency. I have seen them give and then give more, to help people with a message reach the people who need that message. I am extraordinarily grateful for their help.
I wish I had known about these people and this platform before I started, it would have saved time and energy and I might have been able to help people sooner.
5.) Before I started, I wish that someone had told me that if I have an idea, I know it is right, and I have the perseverance and the support of my family, that is all I need. I will make it through the fact that it is hard, that I will get in my own way, and that there will be resistance, and I will find people and platforms that will help me share this information, so that maybe one day this big idea might change the world.
Can you share with our readers what you think are the most important “success habits” or “success mindsets”?
I believe a positive mindset is important, failure is an opportunity to grow, perseverance plays a big role in success and you should envision yourself accomplishing your goals.
Some very well known VCs read this column. If you had 60 seconds to make a pitch to a VC, what would you say? He or she might just see this if we tag them 🙂
Back pain is the number one cause of disability in the world. Informing the world of the cause of back pain is going to be a significant game changer.
There are numerous opportunities as this long overdue shift takes place.
A few examples include:
- Facilitate the ability of physical therapists to help: Fund or start PT clinics that schedule the patient to be fully evaluated to identify if there are mechanical limitations related to the pain. This directly contributes to alleviating the back pain epidemic.
- Hire and train a PT for your self-insured business: Have an in-house PT who can fully evaluate your employees and address the cause of their pain to help them reclaim their lives and be more productive.
- Build effective technology highways: Technology will help significantly as education and information will need to be shared globally effectively impact the epidemic.
- Develop implementation strategies. Middle- and lower-income countries are going to require help as their back pain numbers are projected to rise over the next few decades. These efforts will help people reclaim their lives and contribute to their communities.
Identifying and treating the cause of back pain will reduce the overall cost of back pain both financially and to society on numerous levels.
Currently those who are self-insured are well positioned to make this shift. @warrenbuffet @berkshirehathaway @jpmorgan @jeffbezos
I look forward to collaborating with you on this historic project.
Contact me for more information.
How can our readers follow you on social media?
Instagram: @cathymahonpt
This page has a series of 5 videos with the instructions on how to record/track pain
Website: cathymahon.com
The website has the resources including, the book and a video library with videos that: demonstrate the recommended measurements and demonstrates steps for telemedicine.
Facebook: www.facebook.com/CathyMahonPhyscialTherapyLLC
LinkedIn: cathy-mahon-physical-therapy-llc
Twitter: @cathymahonpt
Thank you so much for joining us. This was very inspirational.
SLAP: Cathy Mahon’s Big Idea That Might Change The World was originally published in Authority Magazine on Medium, where people are continuing the conversation by highlighting and responding to this story.
