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‘Pain is not the only problem’: Diagnosis, Part 2

Diagnosing is not something that the clinician performs in order to complete an insurance form. It is not the act of assigning ICD codes; a technicality. Diagnosing is not simply disclosing the name of the problem to the patient; it is not describing ‘what the patient has wrong with them… what they have.’ Diagnosing is not pointing to a chart or a picture with a pencil eraser and placing blame. However, this is the common practice in modern industrialized medicine. Communicating the diagnosis fails to deliver much more than checking a box within the algorithm of insurance-based LBP case-management.

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. In all cases, the clinician should be including diagnostic explanations that are social, economic, cultural, personal, developmental, conditional, religious and environmental. A diagnosis of low back pain (M54.5) with back spasm (M62.830) is incomplete. A complete diagnosis might include lack of exercise (Z72.3), emotional stress with muscle tension (F43.8), hostile work environment (Z56.5), insufficient sleep (F52.12), housing problems (Z59.9), and social fears (F40.10) The complete diagnosis explains the entire patient, not just the symptom.

‘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)

In other words, the diagnosis should be teaching the patient something that they did not already know. A diagnosis of back pain (M54.5) does not teach the patient anything new. However, the clinician can teach the patient about the well documented correlation between her job satisfaction (Z56.6) and LBP. And how her fears about income security if she loses her job (Z56.2) that keep her awake at night (Z72.820) are influencing back pain. Since she is not getting enough exercise (Z72.3) and has gained weight (E66.3) she feels stressed (F43.8) and is avoiding family functions due to social embarrassment (F40.10) that is also contributing to back pain. The relevancy of the diagnosis to the entire patient builds a complete clinical picture that educates the patient. The diagnosis becomes the platform for a course of care to address the entire patient.

Obviously. ‘pain is not the only problem’ when diagnosing the entire patient. A complete diagnosis reassures the patient/athlete that the clinician’s heart and toolbox are vast.

Common lifestyle ICD10 Diagnostic codes:

Fear of being undiagnosed        Z71.1
Fear of injury       F40.233
Fear of falling       F40.248
Emotional stress/bereavement       F43.8
Depression       F32.0
Sleep apnea       G47.30
Insomnia       Z72.820
Insufficient sleep       F51.12
Lack of exercise       Z72.3
Overweight (BMI 25-29)       E66.3
Discriminated feeling       Z60.5
Life management problems       Z73
Social exclusion       Z60.4
Social fears       F40.10
Psychosocial circumstances       Z65.8
Inadequate social skills       Z73.4
Psychological abuse       T76.3
Hostile work place       Z56.5
Employment problems       Z56
Discord with landlord       Z59.2
Housing circumstances       Z59.9
Low income       Z59.6
Contact with health hazards       Z77.128
Smoker       F17.200
Ex-smoker       Z87.891

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
Duplication with permission only

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