‘Pain is not the only problem’

Reliable Diagnosis and Predictive Treatment Strategies for Non-Traumatic Musculoskeletal Low Back Pain Disorders. ‘Pain is not the only problem’

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LBP Blog General information

Series Description:
These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.

Dr. Dean Bio:
Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020. www.preformancecxs.org

Specific Episode information:
Article 1. Patient Values: Nothing matters more to the patient than: (1) is it the safest, (2) is it affordable, (3) its effectiveness to restore ADLs and RTP quickly, (4) does the doctor stand behind his/her craft. Western medicine is not exempt from providing customer satisfaction. Did you even ask the patient about their values? READ FULL ARTICLE

Article 2. First Encounter; LBP: The clinician must consider the patient’s values, and ideas about the pain and what it means to them. Maybe the problem is the failure to consider the entire patient. This requires more attention, but at the end of the day, clinicians are building the best possible relationship with their patients and practice, and setting an example of excellence for their colleagues. READ FULL ARTICLE

Article 3. LBP Evidence: The completely normal and usual model of medicine commonly does not meet diagnostic/care Class B RCT standards, asks nothing from patient, does not involve their consent, and does not offer them options such as LBP conservative care. READ FULL ARTICLE

Article 4. Zoom-Out: ‘Zoom-Out’ means that the physician includes a wide-angle-lens approach towards care that focuses primarily on dysfunction associated with the complaint (symptoms felt + changes in ability to do an action), but likely does not explain only the LBP. READ FULL ARTICLE

Article 5. LBP Neural & Motor Contributors: May occur due to intrinsic or acquired mechanical economy; path of least resistance, poor instruction, lack of instruction, occupational or sport demands, or other habits and biases causing LBP. READ FULL ARTICLE

Article 6. LBP Neurological & Immune Contributors: When inflammation is unresolved and tissue repair is unsuccessful, chronic infiltration of inflammatory chemistry persists and destroys the LBP joints (synovosis, panniculosis, athrosis), and joint function. Instability and pain follow. READ FULL ARTICLE

Article 7. LBP Emotional & Behavior Contributors: ‘Expectation Modulation’ describes a fearful patient; a patient may present with guarding, antalgia, fearing certain motions or body positions. These actions should not be casually oversighted, since these actions and shapes describe an entire person consumed by their LBP. READ FULL ARTICLE

Article 8. Define Pain, Part 1: Pain is a story, an idea, an interpretation. Pain can’t be objectively demonstrated. When the clinician touches the area of the patient’s complaint, and the patient says, “Ouch” the origin of the pain is not located at the LBP touch-site. READ FULL ARTICLE

Article 9. Define Pain, Part 2: LBP patients are notoriously blaming themselves for causing their own back pain. Patients, and their doctors are commonly searching for ‘the cause’, the ‘one event’, the ‘incident’ as the mechanism of injury. Pain = bad. READ FULL ARTICLE

Article 10. Afferent Signaling: Not all obvious origins of ‘pain’ are causing pain. This is a huge problem in a clinician’s practice. “Despite the prevalence, no specific cause can be found for almost 85% of the chronic low back pain cases.” READ FULL ARTICLE

Article 11. Afferent Signal Loading, Part 1: Describes the prioritization of a set of sensory signals passing through the ascending peripheral nerves and spinal cord to the brain for interpretation, aka ‘listening.’ ASL is important when interpreting LBP signaling, and more importantly, techniques to ‘hi-jack’ the LBP signal to manage ‘pain.’ READ FULL ARTICLE

Article 12. Dyafferentation: Is the prolonged bombardment of afferent signals to the DRG resulting in habituation of central sensitization and peripheralization of symptoms to muscles and joints. In other words, prolonged local or systemic inflammation can lead to symptomatic response causing irritation or degradation of the nerve sheath, contributing to LBP. READ FULL ARTICLE

Article 13. Kinesiopathology & Spinal Stability, Part 1: Spinal stability requires that the spine have ongoing workloads in a variety of positions and patterns each day, and these workloads must be meaningful and not destructive. These workloads should support a desire to improve spinal stability as a priority. READ FULL ARTICLE

Article 14. Kinesiopathology & Gamma Gain, Part 2: (coming soon)

Article 15. Explaining Pain: Neither event-based LBP trauma nor LBP pathogenesis can explain emotional pain, like that of grieving; pain that feels ‘loud’, amplified, and crushing. Neither can they explain mis-matched pain, intermittent pain, and pain with no historical or clinical basis. READ FULL ARTICLE

Article 16. Afferent Signal Loading, part 2: In grad school they taught us that different kinds of pain can describe different kinds of low back injuries, and while that might be true in theory, I found to be less helpful in practice. I found that regardless of the patient’s description of the LBP it was not helpful in determining the diagnosis. READ FULL ARTICLE

Article 17. Sub-threshold Micro-trauma: With enough repeated and unresolved acute spikes of tissue injury, the LBP patient/athlete will begin to experience symptoms, and experience repeated failures to control the movement pattern. In many cases the early warning signs are disregarded, and the patient/athlete persists with the assaulting activity. READ FULL ARTICLE

Article 18. Diagnosis, Part 1: Optimally, the various LBP diagnoses from various physicians should land sufficiently on the same dime, but this is rare. Physicians with specific backgrounds and expertise commonly practice ‘within their wheelhouse.’ READ FULL ARTICLE

Article 19. Spinal Stability, Part 2: It appears that ‘spinal stability’ has unstable definitions. However, it is prudent and essential to (1) agree on the role of spinal stability, and (2) agree on the spinal stability contributors. This way, spinal stability can be understood, evaluated, diagnosed and corrected. READ FULL ARTICLE

Article 20. Spinal Stability, Part 3: Surgical consulting, as a first-line of LBP case-management, attempts to correct a picture of a spine, and not the function of a spine. Protecting the patient’s QOL standards should insist on employing a rigorous conservative-care approach specifically to establish spinal stability. READ FULL ARTICLE

Article 21. First Encounter, Part 2: The patient’s framework is different than the doctor’s framework on the first encounter. The patient wants the doctor to be on time, to make them feel comfortable, to be professional, and make a positive connection. READ FULL ARTICLE

Article 22. First Encounter Checklist: LBP flare-ups can come from curious places. This is a list of uncommon findings from my clinical experience. READ FULL ARTICLE

Article 23. Sagittality: Is defined as the chronic central activation of sagittal plane motor mechanisms to accomplish daily activities, resulting in soft & hard tissue injury, and plastic changes (osseous, neural, motor) that support primarily sagittal plane movement patterns. READ FULL ARTICLE

Article 24. Advanced Imaging, Part 1: Advanced Imaging is the prevailing scientific evidence that has a power like no other form of diagnostic importance. It is complex, impressive, imposing, and definitive within the medical culture. But advanced imaging is also elusive, contingent, relative, imperfect, and its diagnostic value is not well understood. READ FULL ARTICLE

Article 25. Advanced Imaging, Part 2: Classical advanced imaging interpretation includes the usual organic LBP suspects; however, in this list I have omitted disc herniation classifications and spinal cord impingement due to lack of evidence. READ FULL ARTICLE

Article 26. Pinched Nerve & Bulging Disc Nonsense: Arguments for the assertion that ‘disc herniation’ causes low back pain is unsupported by the evidence. Neither disc herniation nor spinal ‘compression’ contribute to non-traumatic LBP in more than 90% of cases. The hypothesis that a bulging disc is the cause for back pain or radicular pain is nonsense. READ FULL ARTICLE

Article 27. Pain Is Not The Only Problem: Lumbar Degenerative Disk Disease Article: This article reiterates many of the points I have been arguing for years. I found it searching for published evidence that spinal and nerve compression causing LBP “is a real thing.” READ FULL ARTICLE

Article 28. Diagnosis, Part 2: Diagnosing is much more than matching the history and the findings with an accurate description of the patient/athlete’s problem. Diagnosing should expose and explain the experience of the entire patient with a sound medical explanation. READ FULL ARTICLE

Article 29. Diagnosis, Part 3: Clinically, the requirement to diagnose can be an administrative headache. It would be easier to skip the process altogether and move on to the treatment, since the patient isn’t usually interested in the diagnosis anyway. READ FULL ARTICLE

Article 30. Report of Findings: In brief, the Report of Findings (ROF) communicates diagnostic discovery and the recommended treatment plan to the patient. The ROF is a verbal conversation that explains the characterization of the diagnosis, and the treatment indications. READ FULL ARTICLE

Article 31. Treatment, Part 1: The clinician’s qualifications and scope of practice will determine the recommended LBP treatment. This can be a problem if the patient prefers a type of care that is not within the clinician’s scope of practice, for example, a patient that prefers conservative or non-invasive care. READ FULL ARTICLE

Article 32. Treatment, Part 2: Prescribing a treatment plan is more of an art than a science. There is significant research available to describe our many attempts to observe and report patterns in treatment success. READ FULL ARTICLE

Article 33. Epidural Injection: Epidural injection is commonly prescribed for LBP even before conservative care is offered. A first-line of care for non-specific LBP should never be an invasive prescription with poor performance and poor patient satisfaction. READ FULL ARTICLE

Article 34. Phases of Healing, Part 1: An updated Phases of Healing model (5-POH) demonstrates how the clinician can direct a more accurate Course of Care by understanding the presentation of the LBP injury within the Phases of Healing model. READ FULL ARTICLE

Article 35. Phases of Healing, Part 2: The inflammatory response is a key healing process since it initiates the tissue repair process; however, chronic systemic inflammation (CSI) will interfere with healing. The clinician must also prescribe diet and lifestyle re-habituation skills to reduce or eliminate CSI, while reinforcing its influence on persistent low back pain. READ FULL ARTICLE

Article 36. Sub-threshold Micro-trauma, Part 2: All of these circumstances describe the threshold at which the patient/athlete can’t suffer any more. It is the responsibility of the clinician to explain STMT, and how it will be treated. READ FULL ARTICLE

Article 37. Game Day: A visit to the doctor’s office is no different than an athlete seeking guidance from their coach. Clinicians are coaches… so are doctors and physicians… coaches with guidance, with optimism, and with solutions. READ FULL ARTICLE

Article 38. Game Day Plan: Team coaches do not get superior performance from the team unless there is a Game Plan that the entire team understands, supports and implements. Team coaches use ‘plays’ that work, and discard ‘plays’ that do not work since points are in jeopardy. When clinicians use LBP ‘plays’ that do not work, patients are being pointed in the wrong direction and can’t win. READ FULL ARTICLE

Article 39. LBP Lifestyle Co-contributors: Since patient lifestyle choices are the commonest contributor to LBP, it is prudent for the clinician to discuss co-contributors as well as FMP within the Report of Findings. READ FULL ARTICLE

Article 40. Sympathetic Lifestyle: The sympathetically amplified lifestyle describes a frustrated patient struggling to secure peace and sanity. When sympathetic amplification occurs alongside LBP, patient communication and treatment are nearly impossible. READ FULL ARTICLE

Article 41. Parasympathetic Lifestyle: The parasympathetic lifestyle explores better health outcomes by practicing a lifestyle that is within the scope of improved health, and respect for the limitations of the human body. READ FULL ARTICLE

Article 42. Course of Care: Historically, patients have been ‘taught’ to rely on their doctor to remedy their health problems; doctors are Gods that ‘do no harm.’ Historically, doctors have been ‘trained’ to represent superiority; paragons of medicine and the apotheosis of the health-sciences. READ FULL ARTICLE

Article 43. Refresh: The usual medical model is struggling with failed attempts to treat LBP, in fact surgical failures continue even in the age of modern medicine and advanced technology. Why? Because they didn’t read my blog, ‘Pain is not the only problem.’ READ FULL ARTICLE

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