When LBP patients come to the doctor’s office, they make one of two statements, “When I…. I feel pain”, or, “I feel pain…. when I.” Both statements disclose a feeling of pain, and a description of a function that is associated with the pain, but possibly not the cause of the pain; rather an association with an insufficiency of some kind. The pain is not causing the insufficiency, so it can be ignored while the functional ‘problem’ is explored.
Functional insufficiency has been already discussed as a presentation of spinal instability, and many other contributors. Not yet discussed are the topics of undiagnosed/misdiagnosed patients, and untreated/mistreated patients. The undiagnosed category includes patients that have not sought out care (many equally valid reasons), patients ‘stuck in the system’, and patients in the wrong doctor’s office. Misdiagnosed patients worry me the most because a doctor has likely ‘sold’ them on a diagnosis that ensures a reason to start treatment, and the doctor can sign them up for treatment within their office today. Misdiagnosis includes: (1) hastily diagnosing without a complete clinical picture (rushed, “possibly” category), (2) pressuring the patient without discussing the clinical reasoning for the diagnosis, (3) incomplete diagnosis that focuses on the clinician’s ‘favorite’ diagnosis, and (4) scaring the patient. In all cases, the doctor should never hold up a picture and blame everything on: disc herniation or protrusion, a pinched nerve, spinal canal stenosis, degenerative changes, or subluxation. Pictures can’t demonstrate non-traumatic low back function, or for that matter ‘pain’, ever.
“Despite the prevalence, no specific cause can be found for almost 85% of chronic low back pain cases.” (Steele, et. al., 2014)
What are your attitudes at the first encounter? “Growing body of research showing that interventions designed to enhance positive adjustment can benefit patients suffering from persistent pain… we need to pay more attention to the role that positive adjustment factors, such as optimism, play in the pain experience… focus on their strengths, sources of resilience, … Best Possible Self.” (Keefe and Wren, 2013)
This is a list of suggestions for a patient first encounter: (1) create a strong projected desire and ability to treat the patient quickly at low cost, (2) ask for and listen to the patient’s expectations and psycho-social limitations, (3) inquire about patient knowledge of the human anatomy and function (~LBP), (4) patient self-sense of historical experiences with activity/sports, (5) offer access for ‘anytime’ support, and (6) don’t rush anything.
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. The patient wants the doctor to factor in everything that is important to resolve their LBP, make an accurate and complete diagnosis, explain the diagnosis, and offer treatment options that meet their personal values. The patient wants to see confidence in the doctor and a promise to treat them with good care, and get better quickly. The doctor’s framework is different, since the practice is a business; it is likely based on volume and billability. The doctor must practice within the confines of 3rd party payer demands and restrictions. The doctor gets over-booked, gets behind, gets stressed, and takes short-cuts at the first encounter. The doctor utilizes personal bias and a cook-book approach to care, diagnosing from a list of favorites, and rushes the diagnosis explanation. The doctor does not offer or administer a Report of Findings. Patients are not offered treatment options. Patient risk increases, trust is lost, and without any promise or guaranty. The patient is kept ‘in the cycle’ of endless re-visits to pay overhead… what I call “kicking the can of health care.”
On the first encounter, the clinician should be asking broad, non-specific ‘yes-no’ questions to first rule out 911/red flag concerns and to save time. There are excellent intake forms backed by significant research that can aid the clinician’s efficiency by simply scanning the form. The clinician should be sure to discuss any overlooked everyday-type movement deficits. Explain how improper footwear and postures are choices and not disease. Explain how smoking, alcohol and diet prevents healing.
The first encounter physical exam should include basic non-orthopedic physical test. These tests should be listed and performed in order with a pass-fail check box. This exam should take no more than 5-7 minutes. If the patient fails the spinal stability skills (performed first on the list), stop the physical exam, prescribe spinal stability re-education for 3-4 weeks, then have the patient come back. On the follow-up, re-test the spinal stability skills. If the patient passes, continue to perform the remainder of the physical exam. If the patient passes the spinal stability exam, the pain will have likely diminished or resolved anyway. If the patient is experiencing a critical level of LBP pain, read all of the articles in this series.
Which treatment milestones do you use to determine patient outcomes? I use these improvement milestones in my practice: motor, symptoms, ADL/RTP, hobby/interests resumed, social re-integration, emotionality/depression/optimism, specific personal goals, and of course I ask the patient, “Did I meet your expectations?” It is during the first encounter that the clinician can do the best work, 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
© Copyright 2021 SpineSync, Forester Dean, DC
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