hen I was in my residency, much of the basis of my clinical reasoning and assessment was based on pathoanatomical diagnosis. I would try to determine if the source of low back pain was a herniated disc, spinal stenosis, a combination, or something else entirely. Towards the end of my residency, I was introduced to the advancements of pain science research by Dr. E at The Manual Therapist. It was freeing in some ways. I didn't have to try so hard to diagnose each patient and look for the evidence-backed treatment options. My evaluations became standardized and based partially off repeated motions. I altered my treatment based off patient response and didn't necessarily have to follow the "rules" of anatomy. Instead, my evaluation and treatment focused more on the nervous system and altering the threat level.
One of the arguments against a system like this centers around the issue of repetitive microtrauama. Sahrmann has built her Movement Impairment Syndromes (MIS) theory off the belief that repetitive microtrauma and prolonged postures via abnormal movement patterns are responsible for developing abnormal bone growth (via Wolff's Law), degeneration, and then pain. With the development of pain science research, we have learned that there is no correlation between abnormal anatomical findings in imaging and pain. In fact, no long-term study has found repeated motions to directly cause abnormal bone formation. That being said, we must remember certain diagnoses which are directly associated with repetitive microtrauma. For example, spondylolistheses and stress fractures. Now I did discuss last week that spondylolistheses can be found in asymptomatic individuals, but there are cases where they are associated with significant medical problems. Likewise, should a stress fracture not be dealt with in a timely manner, it could lead to bigger issues.
So how should we consider pathology? With research pointing more and more towards dismissing pathological findings on imaging, the tendency is to move towards a system completely devoid of it. While this is tempting (as it is easier), there are certain conditions that we should be aware for potential relevance. Now it is not necessary to have imaging to support these conclusions, but instead we should use patient presentation and response to dictate our management. Should a patient with low back/LE pain and/or N&T present with bowel and bladder issues or saddle anesthesia, refer the patient to imaging. In general, if you are not making progress with a patient after a month of treatment they should be referred back to the doctor. There are certain conditions that mandate being aware of pathology and for that reason alone, we shouldn't be so quick to abandon them.
-Dr. Chris Fox, PT, DPT. OCS
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