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‘Pain is not the only problem’: Treatment Part 2

Prescribing a treatment plan is more of an art than a science. There is significant research available to describe our many attempts to observe and report patterns in treatment success. Scientific research looks for patterns of correlation and causation among treatments, then compares them against each other searching for the music in the noise. However, the results are commonly insufficient enough to proclaim victory. Therefore, prescribing might be best described as an ART; “an application of human creative skill and imagination … acquired through practice.” (

According to Dean, 2016:

Treatment definition: the manner in which someone behaves or deals with someone or something; conduct. In the clinic, treatment often implies a therapeutic application; the administration of care on behalf of the patient’s well-being. Since patients are individually unique, each prescription of care should be individualized… the treatment becomes an art.

Treatment Plan definition: a proposal for a manner of behavior, conduct or therapy on behalf of the patient’s well-being. In the clinic, treatment plans begin with a discussion of the Report of Findings (ROF), then the clinician proposes a Plan for the administration of care. Treatment Plans are customized to meet the individual needs of the patient, their values and expectations. Since no two patients are alike, the Plan comes an art.

Course of Care definition: a proposal for the entire duration of the treatment plan that includes resolution of the Problem List using an agreed strategy involving primarily patient contributions, along with the clinician’s ongoing conservative coordinated-care advice, with a personal & professional warranty that the best outcomes will be made possible with the most economy of the patient’s time and finances, and at least risk to the patient.

Coordinated Care definition: the physician’s ardent commitment to expedite patient healing by respecting and involving cross-culture care with optimism.

Treatment Reasoning should represent One Standard of Care (OSC.) Treatment reasoning should never change when considering patient: social economics, ethnicity or skin color, religious or spiritual beliefs, gender or sexual identifiers, fear, bias, prejudice, preference, mood, or clinician’s personal financial gain.

How many patients would you treat using a specific treatment strategy or plan (TS) without realizing your predicted outcomes (PO) and expected patient satisfaction (PS) before you would abandon that treatment or plan?

(x)TS ≠ [PO + PS] = NNT; Number Needed to Treat.

When the NNT is lower, the occurrence of benefit is high. The NNT for statins is commonly around 300; for every 300 patients on the statin drug, only one gets satisfactory results, the other 299 pay for the drug and take it every day without satisfactory results. Treatment reasoning includes a NNT with patient satisfaction determined at 12 months. Therefore, if an epidural injection is prescribed to treat LBP, the patient should be informed that the NNT is ∞ (infinity); patient satisfaction for epidural injection is 0% at 12 months (Weinstein et. al. 2016.)

A well-organized treatment plan is a billable service, so there is no need for the clinician to take short-cuts. E&M coding allows for 10-50 minutes, or more if consulting or review of records is required. A well-organized treatment plan should include: (1) a brief conversation with the patient to discuss the ROF, (2) a brief conversation with hand-outs to discuss an anti-inflammatory low-histamine diet (AILHD), (3) a hand-written flow chart that maps the Course of Care, (4) a list (costs and stores) for therapy or nutrition supplies, (5) a time-line of expected recovery with mile-stones, (6) access to self-help content (clinician’s YouTube channel or website, handouts), (7) direct access to the doctor for troubleshooting (email, cell phone, text, message center, blog board, online chat, etc.) The clinician makes it clear that there is never an option to abandon the patient’s care.

If the clinician is unprepared to promise long-lasting resolution of the patient’s LBP and associated FMP (at low cost and low risk), the clinician should refer the patient to a capable local practice that is getting excellent results with high marks for patient satisfaction (or to a virtual platform.)

Finally, a reminder that the treatment plan is a proposal; the patient is not required to accept it. Clinicians should be prepared to modify the proposal until it suits the patient. The patient should not be coerced into the clinician’s preferred treatment plan, nor shamed or scared into a certain treatment. Clinicians should include other cross-culture care clinicians in the treatment plan. LBP is notoriously self-resolving with minimal monitored conservative care, especially with lifestyle, diet, and smoking changes… 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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