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.
Much of the clinician’s attention regarding a low back pain complaint is directed to the site of pain, then looking for diagnostic features to explain the pain, then prescribing a course of care (‘treatment plan’), then doing back-office work, and getting paid. All of that appears to be the completely normal and usual model in the clinician’s office; however, that model is all wrong.
It isn’t a doctor-patient relationship, it is a patient-doctor relationship. Patients seek help because they have a problem that they can’t solve on their own. The patient brings the complaint to the doctor, not the other way around… the patient is in charge, the patient is the consumer. The doctor agrees to service the complaint by providing supervision and care to meet the patient’s needs: expectations on effectiveness (safety, side effects, NNT), efficiency (value, time, costs, referral visits), patient engagement/education, number of return visits, course of care perceptions, and bias. Does the patient believe that your recommended course of care is just; is it sufficient, warranted, and essential.
A primary diagnosis for LBP is likely due to abnormal movement patterns associated with the symptomatic area but not specifically at the symptomatic area; Symptomatic Compensation to Associated Dysfunction (SCAD, Dean 2016). The human body is primarily two things: (1) a ‘task machine’ that acts to produce and manage mechanical work, (2) a ‘chemistry machine’ that acts to manage myriad reactions of decomposition, synthesis, combustion, etc. in order to help the task machine function. With diagnosis, the best place to start is with a functional evaluation: mechanical and chemical. Which operations of the entire person are not working properly?
In the case of a 34-year-old right-handed single tennis player with low back pain on the right side, and upon functional evaluation (seen by looking at videos on her phone), appears to be facing the net directly instead of the classic side-ways stance during her forehand swing, forcing her into too much right-sided rotation, and producing ‘learned’ spinal instability. You can’t see this with orthopedic exams, and definitely not on an MRI. Remember, EVERYTHING you need to know, diagnostically, is in the patient presentation and history. Do you have the skill set to do this kind of evaluation? Drugs are not going to fix her swing. Blaming disc height isn’t doing to fix her swing. Correcting the swing fixes her swing, and BEGINS to address her back pain, since there may be other factors involved with her swing, stance, and other problems. And, in all cases drugs will never prevent re-exacerbation.
Since we are agreeing to not focus on pain in these articles, but rather on the mechanical/chemical contributors to the entire patient experience that includes LBP, let’s build-out another layer to offer the patient’s best possible outcomes by utilizing the best available current evidence. This evidence should focus on the parameters of the patients’ values and not on the ‘sale-ability’ of a specific type of treatment, since a reductionist approach is likely to fail at the expense of the patient. The evidence should: (1) meet (at least) Class B RCT standards, (2) offer patient education, (3) be based primarily on an at-home or remotely supported active-care, (4) encourage patient accountability, (5) involve changes to lifestyle, sport, and intrapersonal contributors.
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 conservative care. It does not fully explain NNT, risks, likelihood of no benefit, and what will happen if the symptoms are not corrected satisfactorily. The completely normal and usual model of medicine does not respect the waste of patient time and expense; delays in meeting patient expectations, and prescribing without asking and respecting patient values. The completely normal and usual model of medicine is a cookbook, an old cookbook with a lot of missing ingredients.
The medicine of today is not a cookbook; it is a dynamically evolving interchange between researchers, artists, critical thinkers and dreamers. I wanted to find a one-visit solution for any kind of chronic or acute non-traumatic LBP at low cost, so I went on that journey and found my answer. Along the journey I learned a lot about the practice of medicine that disturbed me because it wasn’t directed towards patient values. Advocate for your patients by listening to their story, because ‘pain is not the only problem.’
LBP Blog General information
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
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