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Why Everyone Should Know the Evidence

The opinion expressed in this blog entry is entirely my own, and should read as agitated.

The last time I checked, ridiculing a patient for their correct, evidence-informed approach to care is not in the ‘caring for a patient’ playbook. With this preface in mind, please enjoy (and maybe learn from) my rant:

The patient that is the subject of this blog is a 37 year-old Female, mother of a 3 year old daughter that disrupts mom’s sleep significantly every night, from a quality and quantity perspective. She is employed in a profession that demands long periods of standing throughout the day. This woman has scoliosis (curvature of the spine) and flat feet – both are structural/physiological presentations that complicate her existing condition: Low Back Pain.

Low back pain is poorly treated and understood all over the world. Science is helping clinicians like myself diagnose, and treat back pain more efficiently (Note: I treat low back pain more than any other musculoskeletal condition and have a strong track record for helping my patients recover). Evidence continues to point to variables that never used to be considered important in the management of back pain. These variables include, but are not limited to:

  • Stress
  • Lifestyle – including exercise habits
  • Sleep Quality & Quantity
  • Job satisfaction

Evidence points to managing the above mentioned variables in helping patients recover from back pain. Evidence also identifies which therapy techniques have stronger evidence than others, including:

  • Spinal Manipulation
  • Massage Therapy
  • Exercise
  • Education
  • And, in persistent, chronic back pain, a multimodal approach to care including the above mentioned techniques, with or without medicine.

Evidence also explains that we don’t need advanced diagnostics to diagnose and treat back pain, unless the patient is not responding to care or if there is a concern for more sinister causes of the back pain.

Now, let’s review the case:

This patient presented to my office in August with a history of chronic back pain that has not responded to previous forms of therapy. After only a five treatments, this patient was, and I quote the patient, “feeling her best in years” by mid September. This, by any measure, was and is a success. However, with mounting stress due to job dissatisfaction, lack of sleep, and stress, her back pain returned. Due to previous success, similar methods of treatment were utilized, including:

  • Spinal Manipulation
  • Education
  • Exercise prescription
  • Laser Therapy
  • Soft Tissue Therapy
  • Ongoing discussions to deal with sleep habits, stress management

Unfortunately, she did not respond as favourably as she did in August/September. So, following the direction of the ‘Evidence-Informed Back Pain Management’ playbook, I recommended the patient do the following:

  • Rule out anything worrisome by getting x-rays
  • Add massage therapy to her care plan
  • Consider adding medicine for the short term to help alleviate pain
  • Hire a sleep trainer to assist her daughter in better sleep habits, so the entire family can get a better quality and quantity of sleep.

So, on my advice, this patient booked a visit with her family physician and presented all of the above information. The doctor then responded in the following way:

  1. Agreed with me that her back pain is mechanical in nature, but, just in case, ordered x-rays.
  2. Agreed with me that the patient should add massage therapy to her care plan and gave her a referral note so the patient can reclaim her massage therapy expenses from her insurer.
  3. Then told the patient that she’s been “wasting her money” on “that guy” (referring to me)
  4. Provided a referral for “physiotherapy”, but did not direct her to a specific practitioner or give advice on which “techniques” or “therapy” should be included in her treatment.

So, what do we make of this situation? Obviously, this doctor is a case in contradiction. On one hand, the doctor agreed with my recommendations of including advanced diagnostic methods and expanding the conservative care to a multimodal approach (or just did what the patient requested), but on the other hand, ridiculed the patient for “wasting her money” seeing me. Well, which is it? – agree with the model of care provided by the referring chiropractor, or feel that it’s been a waste of money? And, this wouldn’t bother me so much if it hadn’t affected the patient, but it did. The patient was distressed by her doctor’s point of view and the doctor’s lack of further direction. And, it wouldn’t bother me so much if I hadn’t heard this type of story so many times. What also frustrates me is the “referral to physiotherapy”, as if to suggest the patient isn’t already engaged in “physical therapy” under my care. Patients need direction, not ridicule and vague suggestions on what to do. Physiotherapy, like Chiropractic, are professions – they are not therapy techniques. Telling a patient to do “physiotherapy” does not provide any information as to what the patient should be doing. As you may be aware, there is a huge variance in physical therapy techniques, ranging from archaic methods that include heat and cold application and modalities like TENS and ultrasound. Modern, advanced techniques often include manual therapy, spinal manipulation, exercise, soft tissue therapy, and education. And, all of these types of therapy can be delivered by physiotherapists, chiropractors, osteopaths, athletic trainers, etc. These techniques are not exclusive to a profession. It would be akin to saying that the treatment for a bacterial infection is going to a medical doctor. It isn’t. The treatment of a bacterial infection is taking an antibiotic. Well, if the infection is in the gums, your dentist can prescribe the medicine, and there would be no need to go to a medical doctor. My point is this: we have evidence for how to manage patients’ conditions – and the evidence makes no mention of which professional should deliver the treatment, so long as the patient receives excellent, proper care. And, let’s not forget that the word ‘care’ is integral to looking after patients’ health and lives. Ridiculing their correct approaches to care because you’re biased against a certain profession is unjust and, well, being a bad doctor. Maybe she just had a bad day. But, well, that’s a lousy excuse too.

I’ll keep you updated on this case, because I’m intent on helping this patient recover – just as intent as I am in helping YOU recover.

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