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‘Pain is not the only problem’: Diagnosis, Part 1

Diagnosis equals Evidence. Consider these three divisions of clinical diagnosis: (1) ‘diagnostic possibility’, (2) ‘diagnostic probability’, and (3) ‘diagnostic pathology.’ If a diagnosis is provided by a top surgeon, the patient will get a surgically-related diagnosis. If the patient is diagnosed by a top sports chiropractor, the patient will get a motor function-related diagnosis. Optimally, the various 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.’ Physicians should be practicing ‘across cultures’, instead of battling it out to prove themselves right. This causes confusion and problems for patients that seek out ‘opinions.’ Medicine is not a territory to defend.

‘Diagnostic possibility’ offers no direct proof, and is non-compelling. Diagnostic possibility is described as: ‘chance, feasible, potential, conceivable, might, and bet.’ Diagnostic possibility is reductionist; it makes no effort to rule out other diagnoses, and only addresses symptoms, such as ‘pain.’ Diagnostic possibility commonly includes theoretical explanations such as pinched nerve, disc herniation, disc degeneration, subluxation, or cord compression. Diagnostic possibility does not offer other multi-system explanations or co-morbidities, and does not offer chemical, neuro-immuno, social, economic, motor, nor function explanations. Diagnostic possibility offers the weakest treatment plan since no known cause is understood. It is the cookbook approach, based mainly on practice bias, for whatever reason. It is equal to kicking the tires without looking under the hood.

“Making a conscientious effort to base clinical decisions on research that is most likely to be free form bias, and using interventions most likely to improve how long or well patients live.” (Ebel, 2019)

‘Diagnostic probability’ offers some direct and convincing proof. Diagnostic probability is described as: likely, reasonable, expected, and uncertain. Diagnostic probability is based on findings related to symptoms, imaging, labs, tests, etc. and attempts to use these findings to explain the symptoms (but not the problem), yet the multi-system explanations are absent. Diagnostic probability considers patient presentation with a commonality or frequency within the population. Diagnostic probability offers a more specific treatment plan, but this can be dangerous if surgery is recommended, since the diagnosis is still presumed and not proven. It is equal to looking under the hood without turning on the engine.

‘Diagnostic pathology’ offers direct and compelling proof by identifying (all) specific lesions, disease, or motor function insufficiencies, and offers a variety of working/differential diagnoses. Diagnostic pathology considers the input from all physicians on the patient’s team. Diagnostic pathology is evidence-based, identifies current best practices, and includes a complete multi-system explanation; “the whole patient approach.” (Dean, 2016, ~Fardon, et. al., 2014) Diagnostic pathology can treat the problem directly since it very well understood by the physician and by research. It is equal to turning on the engine and taking the car out for a spin.

To be fair to the discipline, clinical decision making can involve complicated statistical analysis, significance, p-value, prevalence, probability, and the like. However, the clinician’s attention may produce better outcomes by taking a new look at LBP diagnosing as recommended in these articles.

‘Diagnosis’ definition: The way the physician characterizes the most complete and likely explanation to describe and explain the complex of problems and symptoms being experienced by the patient. (Dean, 2016) ‘Diagnostic Evidence’ definition: Credible, robust, expert articles that argue in favor of a diagnosis without personal bias or attitudes, nor plausibility. (Dean, 2016) The physician does not assert a professional opinion that certain objective findings could in theory, and without other prevailing evidence, support a rationale to conclude one specific diagnosis; all diagnoses are considered: working diagnosis, differential diagnosis, and complete diagnosis. Complete diagnosis means that the physician has charted all of the patient’s medical conditions, currently presenting and historical. The number one co-morbidity to LBP is smoking, so this should be included in the chart notes (Z72.0 tobacco use, Z77.22 second-hand smoke exposure) and a treatment plan should be prescribed.

How does the diagnostic process work in your office? Do you have a list of your favorite diagnostic codes? How many diagnostic system codes do you commonly chart… 1-3? How many total diagnostic codes do you chart for your average LBP patient… 1-3? What kind of evidence do you use to evaluate your LBP patients… is it always plain film first? How much evidence do you gather for your final diagnoses… is it a routine? Do you chart and code anything/everything from the patient’s Problem List? Do you chart anything that is not LBP related? (Z71.1 fear due to being undiagnosed) Are you charting pain as the primary diagnosis? Did you ask the patient for their ideas about their LBP?

In all cases, a diagnosis should never be made only because the physician offers a treatment plan for it, or “… exclusively to determine need for care.” (Globe,, 2015)

Acquiring diagnostic evidence takes time, but not much more time than a thorough history. 90% of the diagnosis is already in the history, and the clinician is already being paid to take the history. Clinician’s diagnostic habits and protocols may be oversimplifying the diagnosis as only pain; however, ‘pain is not the only problem.’

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.

© Copyright 2021 SpineSync, Forester Dean, DC
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