This year, as December approached, I decided to make a change to my normal lifestyle for a couple of months. As the quiet time of year drifted into my diary, I decided to travel to Central America, learn Spanish, work with the charity my father is involved with in Nicaragua & write a course that I had been throwing around in my head for a few months.
It has proved a fantastic experience & one that has enabled me to shift my morning training from the gym to the beaches, trails & oceans of my Latin American paradise. Blood flowing to my brain, I then sit, overlooking buena vistas, whilst reading my research papers, liaising with my key collaborators via email, scribbling away in my notepad & constructing presentations on my lap top.
What I have also found over this journey, is that I have spent valuable time building new connections with some fascinating individuals, operating in the spaces that overlap mine & producing work that can only enhance my approach to directing sports performance when I return to the coal face in the coming weeks.
One particular chap, based in Kansas, really caught my attention & we struck up a conversation regarding a book he has been writing over the last seven years.
Dr. Sean Wheeler is one of those guys you wished you had known for years, had the chance to collaborate with, bounce ideas around with & learn from the subsequent conversations.
Even in his emails, a passion for the work he has immersed himself in resonates loudly & his vocabulary is a refreshing music to the ears of those that work in the rehabilitation battlefield.
I can’t wait to read his book, entitled “Uprise” & once you’ve read the interview, Sean kindly agreed to do with me, I think you might understand why.
OF: Please introduce yourself in 10 words or less
SW: Husband, father, regular guy, desperately want my patients better
OF: Please can you tell us a bit about your background in medicine
SW: I finished a primary care residency and spent 6 years in a small Kansas town as a small-town doctor and surgeon, spending half my days in the operating room and half my days in clinic.
This was a mainly agricultural town, in the middle of the United States with a population of about 2,000 people. The closest big city was 4 hours away and, along with the other 2 physicians in town, we took care of everything.
After 6 years I went back to do a sports medicine fellowship and was given an opportunity to help start a pain fellowship. When I finished I was one of the first M.D’s in the U.S. that was board certified in both sports medicine and pain management.
This education, combined with my previous history as a small town doctor led me to become the type of doctor I am. I tend to not take myself very seriously and I take my patients improvement personally
OF: You have recently written a book looking at pain & its presentation, related to low back pain.
Please can you introduce it, tell us about the questions you were looking to answer throughout that process & where the journey of looking into those questions has taken you.
SW: As someone who takes the improvement of their patients personally, spine care ended up being a very frustrating career path for me. I would see people doing exactly what I asked and yet they were still not getting better.
My wife is a physical therapist and with my background in sports medicine, I could see the dramatic advancements the physical therapy world was making in core strengthening, so I felt like I was applying these principles to my patients.
I was a physical therapy snob. I demanded a lot from my physical therapists and I expected a lot in return. Yet, I still had a significant number of people who were not getting the improvement I expected.
The biggest question I had was: why, when you injure the arm or the leg, you can just get back to normal activity and it will improve, but with the back it won’t?
The next question was one that I came across whilst preparing for a lecture. I had read that the discs in the lumbar spine were avascular. This really bothered me. How could the discs be avascular when we move so much through this area?
Movement causes heat and we need blood flow in all the areas that move. The common thought throughout spinal research had been that the discs “just breakdown”. At a certain age, the discs become brittle and in some people they break down and in others they don’t.
I really struggled with this, because it meant that our backs were flawed and I just had a hard time accepting this theory.
The answer came to me in a moment of inspiration that I describe in the book. The discs don’t need blood flow because they aren’t supposed to move. If you sit up straight and hold your shoulders steady and your pelvis steady so neither can move, then attempt to move your low back independently… you can’t.
The muscles of the lower spine don’t move you, they hold you steady when your shoulders or pelvis move. If they don’t, then your discs heat up and without blood flow, the discs break down.
This idea prompted a great deal of understanding that eventually helped me explain the answer of why the back won’t get better by getting back to normal activities.
The back must be stable. And if the muscles that hold it stable get weak (which they can rapidly do with injury), then the hamstrings must take over. When you return to normal activities, the hamstrings continue to stabilize your spine until you figure out how to get the original stabilizers firing correctly.
This idea of “firing correctly”, however, ended up being much more difficult than I had originally thought. The muscles that surround the spine are different than I had ever heard described. The science is already there, but I had never heard it put together in a way that described what was really going on.
The deep muscles of the lumbar spine will not fire correctly if you are hurt or are have bad posture. These muscles are endurance muscles and can never be anything but endurance muscles, which means they fire throughout the day and don’t get hypertrophied when you strengthen them, they just get better blood flow.
However, because they are endurance muscles, they atrophy quickly and take a very long time regain their endurance capabilities. These muscles are strengthened by stabilizing yourself and then stressing this stabilization through movement, not strengthened through movement like other muscles.
When these muscles fatigue, we begin using other muscles to stabilize us, without any warning or signal, making it very difficult to know that you are using them correctly, or incorrectly.
Weakness in the muscles that stabilize the spine leads to weakness in the gluteus muscles because of how we are forced to walk. This leads to instability through the hip, which leads to hip flexor tightness, which leads to hip joint tightness and so on and so on.
What we end up with are patients who hurt in several places, demonstrate weakness in areas that are supposed to be stable, tightness in the muscles that are acting to compensate for this weakness, joint motion that decreases around this area of instability and patients who have poor posture (which is much more than just sitting up straight).
As a profession, we send people to physical therapy whilst they are hurting, use MRI’s as a diagnostic tool, give steroid shots, perform surgery, manipulate along with many other modalities and think that this will get them better so they can ‘get back to normal activities’.
When they do therapy correctly we think that 6 weeks is enough to get endurance strength back. We think that joint immobility and reduced flexibility is just a genetic factor that affects some people.
We accept the idea that we need to treat one area of the spine at a time because we need to find the one area that hurts. Yet through all of these flawed ideas we are surprised to hear that after the last 40 years of treating people with chronic back pain we are not doing a better job.
These fallacies, along with many others are addressed in the book. And it all started with the idea that we need to be stable in certain areas of the body and that this stability is the true problem, not the pain that started it.
OF: How do you hope that the approach to treatment in this field could develop over the next ten years in light of the work you are doing?
SW: I hope to reframe everything that is being done in spinal research. How do we create stability? The entire field has been built upon the flawed idea that discs just break down. We have to go back and change that fundamental belief.
I hope to change musculoskeletal medicine with the idea that there are five other areas in your body that have to be stable and weaken quickly: the neck, shoulders, hips, ankles and feet. Subsequently, when you get an injury that lasts for more than five days, you must not only address the injury, but also address the muscles that stabilize that area.
I hope to change the way we view the chairs our kids sit in. The posture we accept in our children. The fundamental strengthening of our children as they grow to prevent future back pain, neck pain, knee and hip arthritis among other things. There are so many signs of instability that we allow to continue unaddressed because the person does not complain of pain.
Initially, however, I want to change the way the world treats back pain.
We have to view pain as multifactorial, with treatment geared towards finding a period of time that the patient can develop their strength and that the strengthening work should be done in a way that promotes stability, with endurance as the goal.
We want patients who are stable in the important areas, throughout the whole day, with minimal residual pain, with good posture, good flexibility and mobile joints.
When we all start working towards the same goal, I think that this is achievable.
OF: What have been the challenges you have faced in writing your first book?
SW: Pre-conceived notions. Everyone thinks that they know core strengthening and they know how to get back in shape.
This has plagued us so much, that we had to create an entirely new vocabulary as a way to overcome these pre-conceived notions. In explaining these areas of instability I would mention core strengthening and patients’ (as well as professionals’) minds would shut off. They already thought they knew everything about core strengthening.
This is not core strengthening, so we needed a new vocabulary. Consequently, now we call the muscles that stabilize you “Bracing Muscles” and the muscles that move you “Action Muscles”.
When we tell people that they have to do strengthening work, they all talk about getting back to the gym. We tell them that we are not trying to build the strength and size of the muscles, as you do in strength training at a gym but you are trying to build the endurance and blood flow to these bracing muscles through “Circulation Training” that you don’t do at a gym.
When patients talk about quitting after their 6 weeks of therapy, we talk about “180 in 180”. Which means a 180 degree turn in 180 days which tells them that we need 6 months of strengthening to get the endurance back in these muscles.
All of this new vocabulary is meant to change the conversation in a subtle way so that people can understand. The other words in our vocabulary have to do with the way we view our bodies.
We are a finely tuned instrument that can easily fall out of tune. When out of tune, we are unable to play our life-song. We are not who we were meant to be, we can not reach our potential. This concept we call “Body Guitar” which is the name of the company and “Tune Me” is the process of getting this instrument back in tune.
What you should know is that I don’t describe a particular exercise program or method in the book, only concepts. What I am hoping is that what we know now becomes much more refined over the years. I do believe, however, that the concepts and the vocabulary are timeless.
OF: Who have been some of the key collaborators in the project & how have they been able to contribute?
SW: Steve Cranford and his marketing and artistic team at Whisper have been incredible to work with. I tell him that this whole concept would never be anything but an idea in a Kansas City doctor’s head without them.
The vocabulary we use they came up with, whilst the illustrations in the book, which are incredible and will probably become staples of every back pain practitioners’ office in the world, were developed through their minds’ eyes.
I had the ideas, but had a very poor idea of how to explain it to people who were not medical professionals. Take this interview for example. This explanation is for medical people. This is completely different than how I would explain this book to someone who is not in the medical field.
Steve and his team have helped me to understand that and it has transformed the book as a result.
OF: Is this book the end of the journey or just a starting point? Is there more to come from Dr. Sean Wheeler’s literary career?
SW: I have plans for a book about the neck and shoulder, which is even more complicated than the back. In addition, I am still working on the same concepts for a foot and ankle book.
Hopefully those will be completed in the next several years.
OF: Who has inspired you throughout your career & why?
SW: Well, my wife and kids inspire me to be a better man.
Professionally I had a partner in the small town in Kansas who asked me “is this about you or the patient?”. This has become a mantra for me. A way to overcome my ego and place the emphasis where it should be.
The other person that inspired me was a doctor named Adam Arrendondo, who taught me during my fellowship and who always told me to keep it simple when treating pain.
While I may have gone off the tracks and made it not simple, my approach to treating pain with procedures remains very simple. Get people out of pain so we can do the strengthening. Put out the fire any way you can, so that you can start rebuilding the house.
OF: If you were able to meet your 16 year old self & offer him one piece of advice, what would it be?
SW: I would probably try to pass some winning lottery numbers on to him. That, or I would tell him to stay as a quarterback.
I played receiver in college, but in high school I switched from quarterback to receiver because my older brothers, who I idolized, played that position.
That said, my 16 year old self would very likely not have listened to me. Not unless I gave him winning lottery numbers first to prove my powers of prediction!
OF: For anyone looking to get into medicine as a career or to specialize in the area of pain medicine, what advice would you give them?
SW: I would tell them that the patients are the hardest, because they have been hurting for a long time and are probably not sleeping. Your patients are going to expect you to take all of their pain away and you have to temper their expectation. Have compassion for them. It is not an easy road that they are on.
I would tell them to surround themselves with partners, co-workers and others who share your passion and compassion. They will make you look better.
I would tell them to never put themselves in a position where a slow month means they can’t pay their bills. Get a simple car and a simple house - make sure the person sitting in your exam room is someone that you care about getting better, not someone you need to conduct procedures on to support your lavish lifestyle.
OF: For anyone reading this that wants to know more about you, your book & your work in general, where can they go for more information?
SW: The book UPRISE comes out in late February/early March of 2015, but you can find lots of information at the website www.bodyguitar.com
Sean, thank you for taking the time to answer the questions I’ve put to you. I really am looking forward to picking up a copy of “Uprise” in the coming weeks & hope that we will get the chance to collaborate in the future.
In my opinion, your approach to your adopted passion is one that is much needed in the sports medicine field & would provide huge compliment to a multi-disciplinary team operating on the same wavelength immeasurably.
