There you are, as a clinician, with a patient’s eyes glaring at you for a reason. WHY do they hurt? It made me uncomfortable in my early years, but later, I learned that sharing your ‘probable’ diagnosis is essential. As a chiropractor, we are trained to nail down the diagnosis. Our teachers drilled and graded us on right and wrong. But in a clinical setting, a precise musculoskeletal diagnosis can be challenging because of the number of anatomical tissues related to a painful spine motion segment. However, painful people want answers and solutions to their pain. Luckily, there are a finite number of tissues that can be sore.
Sometimes you must go with your gut and awkwardly lean into a definititve diagnosis for the patient even when you have doubt. JF
Over my years of practice, I have learned much about what is most important to patients. Mostly they want a professional opinion on the problem and solution; explaining the dynamics of their pain with conventional models could not cut it, so I got to work on models with more realism and, importantly, with an annulus and a nucleus. And before offering a solution, one must understand the problem. And conveying this to a patient means delivering the best patient education possible, but what is patient education? What does that mean?
Levelling Up Patient Education
Over the years, patient education has evolved. Pamphlets or printed handouts used to be the go-to media to provide patients. Although, more recently, videos appear to be popular with clinicians often resorting to YouTube for resources. In a recent publication in Clinical Rehabilitation 1, ‘comprehensive patient education’ included a series of videos and a spine model demonstration to match individual needs. The time dedicated to this comprehensive approach included interactive slide shows and hand drawings of the nervous system involving four one-hour sessions over four weeks for a total of four hours.
With low back pain as the leading cause of disability worldwide and a common complaint to clinicians, delivering timely patient education is critically important. An hour of patient education is unrealistic for many.
One of the reasons I decided to develop a better patient education spine model is that I knew I needed to be timely, helpful and cost-effective. Patient pain education needs to be optimized in a busy clinical setting and specific for each patient encounter. Initially, I wanted a model that moved as I wanted to show a patient the movements that often cause ongoing pain triggers to the disc(s) or facet joints.
Take, for instance, an individual pain patient with axial low back pain (no leg pain) with their repeated pain pattern triggered from getting out of a chair after a period of sitting. Over my years of practice, I have learned that this is often related to a spinal motion segment that moves a little too much and rubs the wrong way—not allowing the biology to heal. Sitting (in conventional seats) rounds the lower back, flattening the lordotic curve and placing end-range flexion to the vertebrae and disc of the lumbar spine. And if someone has a disc that has lost a little bit of height from an earlier injury, the motion segment will sag a little and creep towards further end-range misalignment. This misalignment is often not seen with conventional x-ray or recumbent MRI because the misalignment is too small to visualize dynamically. When someone gets up from this end-range flexion loading, the shift to standing aggravates the end-range tissues transiently, rubbing the tissues in an irritating way. It often causes these people to remain in a slightly stooped position for some time, and after a few steps, they can straighten up in less pain. The nociceptive source is often from an open fissure or the shearing of the vertebra to aggravate a facet joint. I have found that demonstrating to a patient a probable ‘why’ helps the patient understand the solutions to alleviate. In this instance, I often give them better-sitting strategies, incorporating offloading and better posture. This is usually married with a hip-hinging technique to load the biology differently and allow healing to take place.
Developing a better patient education model that can dynamically show these movements and the suggested strategies fuels compliance and understanding for the patient. When patients can see the movements that cause their symptoms, they are much more motivated to make the movement that can help. A 3d model with an annulus and a nucleus, which is what I worked to develop, has been very helpful to me and hundreds of other clinicians.
Addressing the bio, with a dynamic model, in the biopsychosocial model of back pain is what I wanted to step up.