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| History vs. Technology - How a Physical Therapist can make a Proper Diagnosis |
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by Matthew Goodemote MPT, Dip MDT - September 1, 2010
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I recently finished reading two books, Blink andOutliers, by an author named Malcolm Gladwell. If you get a chance, I highly recommend these books. What I especially like is that the author takes a topic we think we know about and dissects in a way that points to a new perspective that we may find hard to believe until we read the proof he offers. In Blink, for example, one of the chapters is about how most people think that the more we know about something; the more likely we are going to make a good decision about what to do. But it actually turns out that in most cases the opposite is true. We know “in the blink of an eye" what we need to do and this decision is usually better than one we may make after debating all the possibilities. Gladwell provides lot of examples, far too many to share with you today, but reading this particular chapter leads me to talk about an issue in my line of work where this is particularly true, diagnosis of back pain.
Every week I talk to frustrated and discouraged patients whose back pain just doesn't seem to get any better, or it does improve some, but it lingers on. And then there is the plethora of horror stories about people we know who have had surgery or other procedures that have not gone as well as hoped. So you may expect that someone like me who has spent years talking to patients with back pain, some with severe disabilities resulting from it, you may expect that I have seen and heard a lot more stories about people who have been unable to get better. But the truth is, my career has been filled with the opposite. I have met with far more success than failure. I would say that at least 90% of the people I know with back pain found relief. In other words, for every 10 back pain patients I see, 9 find relief. This is not an unusual scenario. Research on the spine routinely points to this level of success. The truth is that most people with back pain, even debilitating pain, get better.
So why doesn't everyone get better? I think the answer is multiple combinations of reasons, but for the purpose of this article, let me point out one that stands out and that connects to Gladwell’s chapter on decision-making and information: the disadvantage of "too much information." The most common belief nowadays is that with all the fancy equipment, MRIs, CT scans, nerve conduction test, X-rays, etc, we should be able to "see" what is wrong with the patient and help them get to the right people to help them find relief. In addition to all the technology, we have we have the patient who has the symptoms and one or more medical professionals who know about the body and who can steer us through the confusion. With all this information, diagnosis should be a snap, right?
Theoretically yes, but not all of medical professionals may agree on the origin of the problem. We have some who think the muscles are the main source, others who believe it is degeneration, still others who blame arthritis. A lot of people believe that the discs in the back are the main culprits, while others think that the alignment of the spine is the source of people’s pain. All of these beliefs are fairly common in the medical profession, and they plus many other are the actual reasons for some people's back pain. But more testing does not clear up the confusion, it adds to it.
For example, a patient wakes up one morning with severe low back pain. He goes to the doctor and is told that he has a muscle strain/pull. The doctor then sends the patient to a chiropractor who tells the patient that the problems is mostly because the spinal alignment is off and needs to be adjusted.
After a while, the patient still has some pain and is advised to go to a specialist, where an MRI is ordered and the patient finds out that he has a herniated disc, several degenerated discs, and a bit of scoliosis. The specialist sends the patient to a physical therapist, who discovers that the patient has a leg length difference and tells the patient that this is the real problem.
I do not intend to paint any one branch of the medical profession as better as or worse than any other, nor do I think that one diagnosis is superior to any other. However, more information is not always helpful. In this completely fictitious example, my point is that in the course of a few weeks this imaginary patient sees several well-intentioned clinicians and instead of just back pain, he now has:
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Muscle Pull
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Alignment issues
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Herniated Discs
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Degenerated Discs
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Scoliosis
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Leg length differences.
This is just a simple example about how several pieces of information actually lead to more confusion than assistance. And let me remind you that 9 out of 10 people get better, despite the diagnosis.
Not the normal uplifting message so far??
Let me say this: the point of this article this is help people realize that what matters most is a good history of the medical problem. In order to have an accurate diagnosis ALL the pieces must fit together. So let me give you another quick example, this time of a case in which a good history made all the difference.
Years ago, I had a patient in Baltimore with low back pain. She had been to another physical therapist before coming to see me. She was told that she had a leg length difference and that this was the reason for her back pain. Her history included when the pain started, which was few months earlier while at work. She told me that she was a receptionist and sat at her desk almost 8 hours per day. In fact, she confessed that after her hour commute home, she most often grabbed a quick meal that she ate while sitting in front of her TV, which she did for 2-3 hours each night before going to bed. Notice that the majority of time she was sitting. How in the world could it possibly matter if one leg was slightly longer than another? The key was the history. The history did not match what the tests had shown so the test was NOT relevant.
I have had similar cases where the patient came to me with a diagnosis for a muscle pull. But history revealed that the patient woke up with a "pulled" muscle. A pulled muscle requires a considerable force and we name the size of the "pull" by grading it depending on the severity. I have never seen a pulled muscle in any part of the body that a patient woke up with other than the spine. Think for a second and try to remember a time when you pulled your stomach muscles sleeping one night. It doesn't happen very often, nor does a pulled back muscle.
More common is the diagnosis that degeneration is the cause of someone's pain, but recent debate about degeneration has broken out in the spine community, because it is starting to look like this may not be true. This means that a person with back pain and has degeneration may not have back pain BECAUSE of degeneration. But as soon as the MRI results show that, the treatment for degeneration starts. Unfortunately, this is the problem. We sometimes treat the wrong thing, because too much information distorts the truth and prevents us from matching what the patient tells us to what the technology verifies for us.
I am not suggesting that one should not get testing, I highly recommend it. What I am suggesting is that the technology must be translated and more importantly it MUST match your history. So a patient with a numb big toe, with pain down the leg and in the lower back area that has muscle weakness along the L-5 nerve root and corresponding pain and motion loss can rest assured when the MRI says their problems is from the herniated disc at L-5 - S-1. In other words, when the history points to the same thing as the MRI or other tests, you can rest assured that is the problem. When the history points one way and the technology points in another direction, trust the history! When you are trying to put the puzzle pieces together, always start with the obvious. The obvious needs no technology, just you and a skilled clinician!
Matthew Goodemote is the founder and owner of Community Physical Therapy & Wellness in Gloversville, NY. He has degrees in Exercise Science, Health Science, Physical Therapy, and he is one of just over 250 in the world with a Diploma from the McKenzie International Spine Institute. Matthew is recognized as an expert in the fields of Physical Therapy, orthopedics, spinal disorders, sports medicine, and wellness. He is routinely called upon to offer tips and suggestions relating to health and wellness. His unique approach makes him a highly sought after expert at different ends of the media spectrum. He has received requests to participate in studies for scientific journals, and to write articles for trade magazines and popular press magazines such as Fitness to offer proven recommendations that stand the test of time. More of Matt’s blogs can be found at http://www.matthewgoodemote.com/blog/.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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