The clinician’s qualifications and scope of practice will determine the recommended LBP treatment. This can be a problem if the patient prefers a type of care that is not within the clinician’s scope of practice, for example, a patient that prefers conservative or non-invasive care. This can also be a problem for the patient if the clinician’s toolbox is limited or biased towards certain types of treatments, for example, treatments that can be done only by the clinician and billed by the clinician. “Clinicians are ‘content experts’; enthusiasts for whatever content they are an expert in (i.e., spine surgeon), whereas the medical conservative is enthusiastic only for that which has proven to promote health…content experts become a synonym for devotion to the prevailing model or theory.” (Mandrola et. al., 2019)
The Medical Conservative approach: “We oppose medical progress, and the accumulation of private wealth that accompanies it, when it occurs under the pretext of ‘science’, without meaningful improvement in patient outcomes.” (Mandrola, et.al., 2019)
Another problem occurs when the clinician fails to discuss or recommend conservative options that are provided outside of their office, or that conservative options exist. The clinician should provide optimism towards out-of-office cross-culture conservative options by other skilled physicians and specialists on a referral basis, especially when risk, cost, and treatment duration can be reduced.
Before LBP treatment can be prescribed there must be significant quality reporting on its efficacy. The treatment must have high marks for effectiveness, with least consequence to the patient, including accessibility and cost. A treatment should not be prescribed simply because it exists, or if it is the clinician’s treatment of choice. Treatment should address everything involved with current patient care, not just focusing on a specific lesion; the care should be designed as a plan, including patient education and choice. A prescription for epidural injection is not a treatment ‘plan’ for LBP.
Clinicians should include cross-culture care and treatment models with high efficacy, at low risk and cost. It is uncommon for a medical doctor to prescribe coordinated chiropractic care, acupuncture, Chinese medicine, or naturopathic care; however, the inverse is not true. “Conservative chiropractic care for non-traumatic & non-specific LBP, and LBP surgical failure can be resolved in as little as one treatment at low cost.” (Dean, 2016). A LBP treatment plan that only addresses patient symptoms should be considered borderline malpractice.
“The physician has minimal knowledge of muscle and movement function. Anatomy and the physical exam are not a major part of practice. Not only is the physician knowledge limited in these areas, but there is also limited appreciation for the importance of movement and the role of contributing systems… endocrine, nervous, cardiovascular, pulmonary, integumentary, and musculoskeletal. Few physicians were interested in the specifics of the movement disorder and were more interested in the nervous system lesion itself and what type of medication could be used to alleviate symptoms. Conservative treatment, reducing the need for drugs and surgery is cost saving and optimizing the human experience.” (Sahrmann, 2017)
Any clinician’s treatment prescription is restricted to: (1) the scope of practice within the office, (2) the clinician’s biases about care, (3) the clinician’s schedule, (4) the clinician’s biases about referral to cross-culture practices, (4) the clinician’s ability and willingness to provide on-going care monitoring, and (5) the clinician’s scope of knowledge regarding whole-body system health. “In the absence of evidence from well designed and conducted RCTs, clinical practice has been largely driven by personal preference, experience, and anecdote.” (Cousins, et.al., 2018)
A patient’s treatment options are therefore limited to one type of care recommended within the office, likely invasive, that is convenient for the clinician’s schedule, ability to provide ongoing monitoring, and limited to treating only symptoms. ‘Invasive’ treatments include: injections, surgeries, drugs, and coercion. ‘Invasive’ is not only defined by the type of treatment, it is defined by the attitudes of the clinician. A treatment plan should be chosen at the discretion and approval of a well-informed patient, not forced on them. Treatments are invasive if there is a likelihood of drug addiction, and when the addiction is not monitored nor addressed by the clinician. Treatments are invasive when the clinician is insensitive and disrespectful regarding the needs of the patient to function safely in their everyday life while under the influence of pain drugs; the patient can’t drive, perform certain work duties, care for children, make important decisions, functionally relate… the drug creates worse problems than the LBP, and likely endangers the patient.
The act of treating patients is a pursuit to provide sustainable coordinated medicine, not to be a hero. Conservative care should be the gold-standard for non-specific, non-traumatic LBP. Patients should be informed about the severity of the risks involved with invasive types of care, and the likelihood that the invasive care may actually manage the problem, since ‘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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