.....but why?

This is Lucy. We’ll see her a few times as we progress through this programme…...

She’s come in with right-sided low back pain……

Write down all the questions that you would ask in your Case History (sorry, I know you learned all this stuff before, but the reason for doing this will become clear....

Don’t proceed until you’ve written them down!

So, she tells us that the pain possibly came on after digging in the garden recently, but she’s not sure.

She has had it occasionally in the past

She has a history of surgery to the right knee: a menisectomy

There was nothing else of note in the history

Give yourself a point if you listed these questions in your case history.

Question: ‘What do you think caused your problem?

Question: ‘Have you had it before’?

Question: ‘Have you had any operations in the past’

Did you score 3/3?

(You’ll have asked her lots of other questions, of course)!

Write down any comments or thoughts......

After scoring yourself and writing a comment, carry on: 

Now you are going to examine Lucy.

Write down each item in your examination process of a patient with back pain (again apologies, I know that you were taught this as an undergraduate. I'm not trying to replace your education. I'm just trying to remind you of something....)

When you have written everything that you would do, then carry on…..

Examination process:

Standing:

• Postural examination
• Palpation of pelvis and hips
• Flexion/extension and side bends
• Can the patient stand on tip-toe and on their heels?
• Can they squat down and get up again?
• Can they stand on one foot?

Sitting

• Motion palpation of whole spine
• Can they lift both arms above their head?
• Reflex tests: arms and legs
• Blood pressure test. Pulse taking.

Supine:

• SLR, Thomas and Patrick Fabere. Knee and ankle ROM
• Strength Sensation tests on legs
• Clonus and Babinski.
• Toe extensor strength tests
• Abdominal palpation – tenderness anywhere?

Additional tests:

• Urinalysis and weigh the patient

1. Of course, everyone’s examination routine is different. But was there anything from the list above that you missed out?

Did you examine everything? Yes/No. Note to self:

Back to our patient, Lucy…..

Let’s say that you examined everything (and you should, within reason)….

You would have found the following:

1. The right sacro-iliac was somewhat tender to palpation

2. The right knee limited her ability to squat comfortably, and it was painful when she tried to squat. The knee was somewhat stiff and her right quads were slightly weak on resisted testing. Her one-foot balance was not quite so good on the right foot as the left.

3. The right lower abdominal quadrant was tender to palpation

Given the above findings, what what do you think is causing her back pain? What might the diagnosis be?

Write your diagnosis down (It's really important that you write it down for the learning process.

When you have written your diagnosis above, then proceed….

How about this?

Right sacro-iliac strain, possibly due to mechanical overload as a result of right knee OA (subsequent to menisectomy). Differential diagnosis: right sacroiliitis secondary to possible intra-pelvic issue.

Our diagnosis should include:

1. The pain producing tissue (in this case the right SI joint)

2. Why the tissue has become painful (mechanical overload from the stiff knee)

3. Anything else that we should consider/monitor (the ipsilateral lower abdominal tenderness might be an issue).

In other words we need to answer the ‘why’ question!

Have a look at the diagnosis that you wrote down. Did it include any of the following words/phrases?

….’due to’….

….’as a result of….

….’as a consequence of’….

….’secondary to’….

Can you re-write your diagnosis in a way that includes any of these phrases? Write it down now.

If you are unable to answer the ‘why’ question, you will be unable to come up with a treatment plan that makes sense (which is what we are going to do next, of course)!

The Management Plan

Write down what your treatment plan would be for Lucy:

Did having an answer to the ‘why’ question make this easier? How so?

Is it possible to come up with a treatment plan if the ‘why’ question hasn’t been answered?

Pearls of wisdom:

• Chiropractors should always look at the whole of the patient. Top to bottom, front and back! Inside and out! This will enable us to understand more completely what is going on with the patient.

• We should always have the words because or due to, or as a consequence of in our diagnosis.

Homework:

• Look at your last 10 new patient files. Read the diagnoses that you have given. How many of them fit the criteria above?

• Rewrite the diagnoses of those that do not fit the criteria above. Will that change your management of that patient?

• Make sure that future diagnoses do have ‘because’ in them.

• Remind yourself that if you don’t have ‘because’ in the diagnosis, you do not fully understand what is going on, and you will be unable to properly explain to the patient how you can help them.