There are some basic foundations that can provide an understanding of the problems and then the development of an effective treatment program. These basics are built on an underpinning of compassion, understanding, and completeness.
Knowledge of differential diagnosis is important. The famous Harvard physician Dr. William Osler made an astute observation that most physician's live by. "You see what you know, and you find what your look for." In other words, you have to know what can go wrong to identify it, and you have to look for it, or you won't find it if it is present. The caregiver [treatment provider] has to know the spectrum of what causes pain or symptoms and how to identify it. This defines both the science and the art of medicine.
A patient can present with leg pain. The differential can include nerve pain, muscle pain, referral (sclerotomal) pain, spinal cord pain, and even poor circulation, or a blood clot. If the physician doesn't think of the possibility of a blood clot, this could be a significant error. Even if the therapist had never had the experience of seeing a particular disorder, but has digested a significant amount of literature, he or she will be prepared to identify it. A physician has to be "on their toes" to be aware of possible misleading symptoms and have a good differential diagnosis.
Diagnostic proficiency comes through experience and a thorough history and physical examination. A complete history of the problems is essential. "Any family history of back disorders or even of non-spine-related issues, such as ulcerative colitis?" Some back problems stem from related diseases and may need to be treated differently. Psoriasis (a common skin disorder) has associated spinal problems and has a different treatment protocol. It is also important to discover if there are any legal issues, such as automobile accidents or work history, and who may be at fault. Legal issues can shade results of the history and need special types of treatment.
A good review of the individual's general health is important. Through a good history and nothing else, 80% of the diagnoses of low back and leg pain can be ascertained.
The physical exam needs to be complete, and the skill of the examiner is very important. There are some very subtle "shades of gray" that can shed light between various disorders. The diagnostician may need to identify the difference between a plus-2 and plus-1 reflex, sometimes a slight difference, but this may give an important clue to cause of the pain. The skill to perform a great exam takes experience, attention to detail, and time. The examiner needs to be thorough.
A patient just came into the office that had leg pain and aching for six weeks. This patient also happened to be a chiropractor and was thinking nerve pain, as we also assumed by the symptoms. Some parts of the exam demonstrated possible nerve root pain, but the patient also had no pulse in the affected leg! It turns out he had a blood clot in the artery in his leg. A simple matter of not being thorough and checking pulses would have missed this very important diagnosis.
The second skill set is the ability to decide what further tests (if any) would be applicable to complement and confirm the initial impression (presumed diagnosis). Not just the ability to order the right tests but the ability to thoroughly interpret these test tests results is important. Occasionally, the interpreter (for example, a radiologist), not knowing all the clinical information, may not know how to interpret the results. Some of the information gleaned from the tests can lie in a gray area.
The investigations that image the spine are:
Tests like EMGs that look at nerve function can be helpful in shedding some light on the diagnosis.
The third skill necessary and most important is taking the care and responsibility to educate the patient about their basic illness. Patients need to have the information demystified in a manner that is basic and understandable. This knowledge must be conveyed to the patient in a comprehendible manner with visual aids if necessary. If a patient cannot understand and grasp the problem, then the treatment will be less effective, and the patient's expectations for success will be murky. The mystery and fear of disabling low back pain can be significant. Education removes this mystery and eliminates fear of the unknown.
Treatment Protocol Technique
The fourth skill of a caregiver is the art and ability to develop a treatment protocol that is reasonable, effective, and appropriate for the patient. This cannot be a cookbook technique. The approach and even the personality of the therapist and patient have to be taken into consideration. This may include different types of physical therapy, chiropractic, activity modification, medication, injection, alternative therapy, massage, and even surgery when needed.
Treatment needs to be cost effective as medical care is very expensive and escalating yearly. The knowledge of well-qualified specialists to refer to for further diagnostic testing or treatment is important. A good spine expert can often be like a quarterback. He or she looks at the defense (diagnosis), calls the plays (treatment), and then passes or hands off to another health care provider for the necessary tests or care.
Donald S. Corenman, MD, DC is a practicing orthopaedic spine surgeon and chiropractor in Vail, CO and the author of Everything You Wanted to Know About The Back, a consumer's guide to the diagnosis and treatment of lower back pain. Click here for more information about the book.