Trog Blog #6: A diagnosis of exclusion–a double edged sword

If you have been reading, or listening, to any recent research in PT then you know that things are changing. Maybe ACLs can heal without surgery. Most meniscus pathologies don’t do better with surgery compared to conservative care. Rotator cuff tears are extremely common and don’t necessarily need surgery. Lumbar disc issues are common and also might not need surgery. The list goes on.

But it does leave the lowly-PT with fewer tools than we already had. At least back in the day, when you had pain bending your back, you could blame the disc and move on. Or the painful arc was a positive sign for rotator cuff problems and you knew what to do. Recently, everything is more nebulous. A lot of research is suggesting that painful conditions may be “non-specific”--meaning the link between a structural/tissue issue and someone’s pain experience is extremely tenuous.

Before you knew which direction to go. Now you don’t even know which way is up. Even more so, it leaves you wondering what-the-hell to do when patient’s ask the tough questions:

“What’s wrong with my back?”

Your patient definitely has back pain. Has had it for 10 years.

You’ve ruled out all red-flags. Nothing seems to be amiss. So you know that it’s safe to treat them and their prognosis is fair.

Classically, this is looking like a disc. But you know that recent evidence suggests that isn’t a very accurate diagnosis. Plus, they’ve done extension-based treatment (exercises for the disc) with only moderate success.

So it’s probably more of a “flexion intolerance”. But you also know that sometimes people get better with injections or even surgery. Should you refer? But this is classic non-specific low back pain. You know that they benefit from movement & other conservative measures.

Your patient keeps asking you what’s wrong with their back. You know referring for imaging in the absence of red-flags is a no-no, because it will likely increase the chance of unnecessary interventions. But they really want to know what is going on.

You don’t know what is going on. You also know that no-one can really “know what is going on” in a situation like this. You’ve ruled out every other possible cause, so it’s clearly a case of non-specific low back pain.

But your patient keeps pestering you.

See what I mean? Nebulous and stressful. Emphasis on the stressful. Because to be a good, evidence-based clinician in this case you have to accept the fact that there isn’t an answer for the question your patient keeps asking. You just have a diagnosis of exclusion to give them.

Good.

Think about it: people seek care for things they can’t manage. Or things that really threaten their identity. You don’t go to the doctor for a routine head cold. But you might if it’s been around for 16 weeks. Or if it’s changed enough that you’re worried you have lung cancer. Or it prevents you from playing the tuba, and you sure love the tuba.

So de-threaten their back pain. Decouple it from their identity. And a really good way to do that is to say “you don’t have the scary stuff, which means you have a pretty good prognosis of this not preventing you from doing what is important to you”.

I’ll be honest, this is a hard one. For everyone, not just newbies. It effectively takes the basis of your entire education (the biomedical/pathoanatomical model) and flips it on its head. But it also doesn’t mean that the pathoanatomical model is WRONG all the time, it’s just less RIGHT than you thought. Because sometimes people do need surgery and injections and medication. And now, it’s a lot more murky as to when & who need those things.

The clinical pearl? Embrace the murky, nebulous, nuanced, shades of gray, uncertain, frustrating, unknowns of the clinical world. Use your diagnosis of exclusion constructively to arm your patient with the knowledge that they don’t need to fear the big-scary stuff and that they have a positive prognosis to return to what they want to do.

Wield your double-edged sword valiantly… and don’t live in caves…

^ actual footage of YOU about to explain imaging findings to a patient with chronic back pain.

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