Summer is coming to a close and the Holidays will be upon us soon, so we are back to a standard profile for the HWR Newsletter.

First we have an insightful article on Four Common Types of Back Pain from Physician Dr. Gerard DeGregoris III through Medical Editor Dr Steven Mandel. We hope to follow up with an article compiling your experiences responding to lower back pain. Send your note today to Richard Gray, Editor, at rgray@fjmc.org.

Then Wealth Editor Gary Smith reminds us about the wisdom of Concentrated Investing based on his personal experiences and his broad investment reading.
 
Please do not miss the overt and underlying messages of all these articles that FJMC continues to be a place that we need to be participating in with our financial support as well as our time.

Be sure to be in touch with Richard Gray, Editor, at rgray@fjmc.org with your articles, comments, appreciation and critiques. Each issue is brought to you by your editorial staff that includes:

• Richard Gray (Editor in Chief)
• Steven Mandel MD (Medical Editor)
• Gary Smith (Wealth Editor)
• Mark Druy (Publisher)

This HWR was sent out on , at approximately 9:30 PM (Eastern and prior to Shabbat).

Almost everyone experiences back pain at some point in their life.  Back pain can range from a mild annoyance to a career (or even life) ending problem.  But how do we know what is causing our back pain?  And what can we do to ameliorate it?  And how do we effectively communicate with a physician about our back pain?  One important step is to discern between several commonly reported types of pain:  axial back pain, referred pain, radiating pain, and tenderness.  Patients who can articulate which of these patterns best describe their pain have the best chance of helping their physician make a diagnosis efficiently.
 
As an interventional pain specialist, the most common back pain complaints that my patients report are complaints of axial back pain.  These symptoms are usually only located in the back (and occasionally the buttocks), but do not extend below the bottom of the buttocks (the "gluteal fold").  Common causes of axial back pain include sprains and strains (commonly caused by over-exertion or lifting something heavy), lumbar spondylosis  (a type of osteoarthritis), and intervetebral disc degeneration (a naturally occurring process that is part of normal aging)  
 
Referred pain is more difficult to describe, and your medical doctor can help you identify it.  This occurs when the painful symptom is felt in a spot that is different from where the pathology is located.  An extreme example is when someone who is having a heart attack feels pain in their left arm.  The mechanisms of referred pain are controversial and probably different for different types of pain.  Often times muscular back pain is associated with referred pain, whereby palpation at one site causes pain at a different site in the back.  This is one of the characteristics often seen with myofascial back pain.  
 
Radiating pain is similar to referred pain, but in the context of back pain it usually refers to pain that starts in the back or buttocks and is felt to be "running" down one or both legs.  This is very commonly reported as sciatica, or lumbar radiculopathy.  It can be associated with numbness (anesthesia), a feeling of pins and needles (paresthesia), or increased sensitivity to touch (hyperesthesia).   These symptoms usually suggest that one or more of the spinal nerves are irritated, either from stretch, osteoarthritis, a disc bulge or herniation, or other causes.  The exact pattern of the radiating pain will help the physician determine which nerve roots are likely affected.
 
Tenderness is important to discern from other types of pain because it usually implies that at least part of the problem is located at the site of tenderness.  This is especially helpful when ruling out radiating pain syndromes such as sciatica.  Tenderness is commonly reported with sprains or strains, spondylosis, and myofascial pain.  If leg pain is due to sciatica, however, then there should not be leg tenderness over the painful area.
 
Understanding these common pain descriptors will help the savvy patient effectively communicate with the physician and may facilitate diagnosis and treatment of back pain.  One important note, however, is that back pain is frequently multifactorial, and may have certain characteristics from several different categories.  In these cases, a thorough history and physical, combined with imaging and expert consultation where appropriate will usually yield one or more diagnoses.  

Dr. Gerard DeGregoris III is the Co-Founder and Chief Executive Officer of Park Avenue Spine and Pain in Midtown Manhattan.  He has been selected as a "Rising Star" by Super Doctors in the New York Times and is a Clinical Assistant Professor at Hofstra Northwell School of Medicine.  Prospective patients may call 212 535 3505 or FAX 212 535 3505 to schedule an appointment.

Don’t forget to reply with your experience and questions. Possible treatment options range from conventional medicine to acupuncture to laser therapy to surgery. And, how have you been helped by PT’s and OT’s and things like pilates, reformer, exercise and nutrition? Back problems are endemic in our society and the morbidity of back problems is pervasive. Let’s help each other.

It is so difficult to beat the market over the long term.  Short term we can get very lucky but the greater the risk the less likely you will beat the market over the long term. 
 
How many of us attended the Berkshire Hathaway annual meeting?  For the past 30 years I have been a proponent of the Warren Buffet investing philosophy.  Historically Berkshire has been the top performer in 100 Baggers.  What this means is returns of 100 to 1 from 1962 to 2016
 
His stock which in effect has been a mutual fund of many of the top companies in the world, BRK.A and BRK.B, has risen18,000 fold which means 10,000 dollars in investment in 1965 turned into 180 million dollars 50 years later vs just 1.1 million invested in the S&P 500.  I learned of two important factors to get that kind of performance.
 
Do not own too many stocks- Diversify and do not own to many of the same type of stocks.  Focus your best ideas and concentrate on them.  I recommend the book which came out last year called “Concentrated Investing”.  When you look to buy stocks to fit this idea try not to chase prices of stocks. Patience is very important. Trying to buy most of the world dominating stocks during low periods of the market can be very rewarding.  You will be handsomely rewarded by holding them for a long time. I have been able to put my children thru college with this type of safe investing. These are companies that increase their dividends every year by 15-25 %.  Companies included in this category are all companies owned by Berkshire.
 
Johnson and Johnson J&J, Home Depot, Coke, Geico, American Express, Constellation Brands, Nike, Iron Mountain, Bank of America, Carmax, Burlington Northern, Glaxo Smith Kline, Moody’s, and many more. There are other world dominators that Berkshire does not own but I think you get the idea.  The great investors focus on their best ideas.  They do not spread themselves too thin.  The book mentioned above also includes more formal research that supports the idea that focus is a way to beat the market.
 
Leave your stocks alone- Once you have determined thru research that you want to own a stock, make sure it is one you want to own for the long haul.  This is to me by far the best way to save for your child’s college education. Great stocks almost always perform great.  Those mentioned above are some examples. 
 
There is a great story that goes with this idea, told by Raffaele Rocco in Omaha at one of Berkshire's annual meeting.   There was a king who wanted to repay someone for saving his daughter.  The man said you do not have to pay but the king persisted.  So the man said give me 1 grain of rice and double it each day for 30 days.  So the king agreed.  Within 30 days the king’s silo was empty.  He had paid over 30 billion grains of rice.
 
This story gives 2 very important lessons.  The 1st is obvious, the power of compounding. The 2nd is a little subtler.  On the 29th day working backwards the king paid 500 million pieces of grain and on the 28th day he paid 250 million pieces. What this means is returns on back end investments are back loaded.  The biggest returns on any dividend paying investment will really take off as time goes by.  This is a beautiful way of investing and it works so well. It stands the test of time.
 
I hope this wealth tip has some impact on your thinking and might help you to think seriously about how you invest.  Great for grandchildren and for your kids.  For further discussion please refer to your investment advisor or I would be more than happy to have a conversation if you would like an opinion. Email me at gsmith@fjmc.org or better at foundationjl@gmail.com along with your interest in becoming a Foundation Fellow to support FJMC and this institution behind this newsletter.

This issue is prepared by a bunch of guys who are continuing to GIVE BACK to FJMC.  We invite you to also give back to FJMC through your participation and most importantly through donations supporting FJMC as Friends of FJMC.  Participate by clicking on “Become a Friend of FJMC” on www.FJMC.org or contact Gary Smith at gsmith@fjmc.org.

Send your comments to Richard Gray at rgray@fjmc.org.  We want to hear from you. HWR is a publication of the FJMC.

We hope that you enjoyed this issue and will consider sharing with other members of your club, family, and friends.  Ask them to opt-in and receive this newsletter.  We are building a nice following and appreciate your support.  We are looking for guest writers; if interested please contact with Richard or Gary. If you're receiving this from a friend forwarding you the newsletter, you’ll need to ‘opt-in’ to receive this newsletter.  To opt-in, and receive this bi-weekly publication, click on the following link, and provide us with your email address: https://fjmc.org/civicrm/mailing/subscribe?reset=1&gid=1302.