“Savasana is my favorite.” – Chester Buckenmaier (mumbled following every yoga session)
Editor-In-Chief, Chester “Trip” Buckenmaier III, MD, COL (ret.), MC, USA
When this editorial charms (or lands with a thud) on the masthead page of the May 2023 edition of US Medicine, Pam and I will be back on the road again. These past few months hanging out in Virginia during Pam’s recovery have been challenging for both of us. We are not used to being this static, physically or existentially. I have been writing extensively during this period, which necessitates a protracted amount of time on my bum (I do my best work with pressure on my brain). This has caused my long-term affair with lower back pain to flare up with a vengeance. I am certainly not alone in this painful condition. Researchers suggest that 8 in 10 Americans will experience back pain at some point in their lives. When I retired from the Army, I noted back pain as an issue during my exit physical review. In response, every corner of my body seemed to be scanned and/or X-rayed. The Army concluded I had the well-used spine of a fifty-something soldier. In short, like so many other humans, I have classic musculoskeletal lower back pain.
Many Americans with this condition fall into the treatment trap of excessive medication (opioids being particularly dangerous) and various invasive procedures involving needles and potions to manage the situation. Some even try surgery, too often, with dubious or even worse outcomes. Patients and providers often select these last resort medical options first, without ever exploring complementary and integrative health (CIH) approaches like acupuncture, meditation, massage, physical therapy or yoga. These non-pharmacologic and noninvasive methods have proven effective in managing musculoskeletal back pain yet are rarely covered by most health insurance plans. Many pain experts (including myself) believe integrative health options should be tried first, when they are most effective, before medications, procedures or surgery. So why do patients usually receive more aggressive, invasive and side-effect-ridden approaches? Money.
I have often lamented in this column the unhealthy fact that medicine in the United States is a business. As such, clinicians in this country are motivated to offer therapies for which they can get remuneration. Most health insurance providers have no problem funding traditional invasive back pain therapies that keep healthcare consumption (pills, needles and knives) up, necessitating expensive health insurance. This vicious medical business circle is fabulously lucrative for a few of the 1% feeding on the healthcare gravy chain. For the past two decades, healthcare lobbying of Congress has increased by 70% to keep the healthcare consumption money-generating juggernaut rolling along.1 One of the reasons I chose federal medicine for my career as a physician was to avoid this seedy underside reality of American medicine. Well, as much as possible.
When confronted with my low back pain flareup, I decided to take a page from my own past. Fortuitously, I have been blessed with some great leaders during my career. One of those inspired leaders was Lt. Gen. Eric Schoomaker, the 42nd surgeon general of the U.S. Army (2007-2011). This was during some of the most challenging times in the Iraq and Afghanistan wars. Under Schoomaker’s direction, while still running a wartime Army medical department, the Army Pain Management Task Force 20103 (PMTF) document was created. This document provided a blueprint for federal medicine to break with the civilian model and explore underutilized integrative medicine approaches in pain management. It was truly groundbreaking in American military medicine. I was honored to be part of the team creating this document. During the task force creation, I was introduced to Schoomaker’s spouse, Audrey Schoomaker. Audrey had her own issues with severe low back pain and had turned to yoga as a solution. Yoga was so successful for Audrey that she became a yoga yogini (Yogi still makes me smile – too many cartoons in my youth.). Audrey worked with the organization I directed, the Defense and Veterans Center for Integrative Pain Management. We accomplished some of the first yoga research involving service members. I learned much from Audrey; her tolerance of my naivety regarding yoga was worthy of an en master.
Since the PMTF effort, I have dabbled with yoga personally, but never seriously and with a condition that I needed to manage. For the past month, I have been using a phone app to practice 20 minutes of yoga and 15 minutes of meditation daily. In addition to significantly improving my back pain, I have discovered my balance has deteriorated substantially (and insidiously) in retirement. I am pleased to report I have also made significant gains in this area. I completed a 5-mile walk just before writing this editorial and experienced little to no back discomfort. I have not been able to walk distances without pain for some time. I recognize that I am an ‘n’ of one, and my experience will not necessarily be the same for others. Nevertheless, more importantly, from my perspective, I am proud to come from federal medicine, where these ideas are being actively explored and implemented. For example, the Whole Health program with the VHA, which emphasizes CIH modalities, must be commended within our system.2 Even if 10% of current back pain patients could be managed conservatively with CIH, consider the advantages of lowered costs and morbidity. I expect a much higher percentage of patients would benefit from this approach.
I think civilian medicine should be taking more significant notice of federal medicine’s move toward more CIH approaches in managing service members, veterans and their families. The suggestions made in the PMTF document are as relative today, two decades later, as when they were established. Schoomaker often commented if we could fix pain management in this country, we would have improved medicine generally. Granted, the pace of change is agonizingly slow, but at least we are finally rolling in a positive direction.
I was pleased to be a part of Schoomaker’s push for CIH within the Department of Defense. It is an important legacy, of which I know both Eric and Audrey are justifiably proud. I also know my comment that savasana is my favorite pose in yoga will make Audrey smile.
- JAMA Health Forum. 2022;3(10):e223801. doi:10.1001/jamahealthforum.2022.3801
- https://www.health.mil/Reference-Center/Presentations/2010/06/08/Defense-and-Veterans-Pain-Management-Initiative – Accessed March 27, 2023.
- https://www.va.gov/WHOLEHEALTH/professional-resources/clinician-tools/cih.asp – Accessed March 27, 2023.
