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‘Pain is not the only problem’: 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. A diagnosis of low back pain, sciatica, lumbago, disc disorder, or piriformis syndrome is a generalized ‘superficial’ diagnosis that suits the requirement of diagnosis, although it rarely characterizes the more important underlying problems. A diagnosis must completely explain the entire patient, not simply the experiences of discomfort. The diagnosis should primarily explain ADL insufficiencies, sports activity deficits, hobby and leisure obstacles, and other struggles with usual enjoyment and mental wellness. The diagnosis should not be an offhand guess; a short-cut to begin treatment.

The diagnosis must describe a real biological or biomechanical problem based on scientific research, not based on popularity such as ‘piriformis syndrome’ or ‘sciatica’. The diagnosis should not be an over-simplified attempt to explain the complexity of the patient’s experience, instead to describe: (1) symptoms, (2) ADL insufficiencies, (3) employment problems, (4) inability to do sports, hobbies, and daily enjoyment, (5) emotionality: organic and experiential, (6) attention to personal values and expectations.

The diagnosis should include contributions of lifestyle choice and circumstance. Lifestyle choices and circumstances should be addressed by the clinician during the explanation of the diagnosis so that the patient understands the influential connections. A diagnosis of ‘sciatica’ might explain the symptoms, but does not address the causes for the distribution of pain down the back of the leg. Simply blaming a pinched nerve is not scientific nor accurate. A diagnosis that only addresses pain is borderline malpractice.

The diagnosis should never be used exclusively to determine a need for care (Globe, et. al. 2015). Instead, the diagnosis should define the Course of Care to resolve the complex patient experience: (1) address symptoms, (2) re-establish ADLs and minimize further disability, (3) return to work, (4) accessibility to sports, hobbies, and daily enjoyment, (5) improve outlook and emotionality, (6) minimize further disability and fear of recurrence, (7) provide excellence in patient outcomes and satisfaction.

The action of diagnosing must address the insufficiencies of the patient and the clinician. Patient insufficiencies include (1) Habituation: no cognitive mapping; “I’m too lazy”, (2) Ambivalence: no cognitive mapping, doubting, “It will pass”, (3) Exemption: no cognitive mapping, denial, “It won’t happen to me”, (4) Preference: includes cognitive mapping, biases, convenience, “Therapy is inconvenient”, (5) Reference: includes cognitive mapping, pattern copying, non-professional approach, “I will figure something out myself”… reasons to neglect acquiring a diagnosis.

Clinical insufficiencies include (1) absent final or working diagnosis, (2) wrong or incomplete final or working diagnosis, (3) absent differential diagnosis, (4) absent patient education and Report of Findings (ROF), (5) absent management plan or Course of Care, (6) wrong or incomplete management plan or Course of Care. A clinician that begins treatment without a complete diagnosis (that has been explained to the patient) is in every violation of medical care.

Clinical insufficiencies are devastating to case management since referral and treatment intervention are prescribed without the foundational support of a complete diagnosis. Gold-standards are over looked, science is ignored, current research is unincorporated, conservatism is overlooked, and yet patient care proceeds.

85% of LBP patients experience depression (Sheng, et. al. 2017.) A diagnosis of low back pain without a diagnosis of depression does not completely address the patient experience, and does not incorporate a Course of Care to manage the patient’s depression. The diagnosis must describe every real biological or biomechanical problem based on scientific research, not just pain, since ‘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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