Imagine just for one day, we swap professional roles. I am the client and you are the chiropractor…
I come to you with a problem. I have low back pain. You perform an extensive examination on me and come to the unfortunate realization that you were not able to reproduce ANY of my symptoms of stiffness and pain in my lower back. Believe it or not, this happens far more often than expected. How would you convince me that the treatment you are about to provide will have any positive effects? I may assume one or two things:
- You haven’t adequately assessed my “threshold point” and
- My subjective awareness of symptoms does not match your clinical competency in reproducing my symptoms.
Let me say that these two points are fairly normal to consider!
If I cannot reproduce your symptoms in the clinic at the particular point in time you consult with me, then three things can be done:
- Provide a short term treatment (chiropractic, laser, massage or any other modality) aimed at addressing the “functional” flaws or neuromuscular impairments that were present during the examination, to determine if this opens the window for symptom resolution
- Provide a long-term intervention (exercise, self-guided rehabilitation, psychotherapy, symptom modification etc.) OR
- Change my strategy as to HOW, WHEN and WHERE I assess you!
In the video below, I discuss in more detail the changes in symptoms that may occur at the level of your spine using an anatomical model:
If we look back at point 1), we really cannot determine if symptoms resolved as we could NOT REPRODUCE THEM DURING THE EXAMINATION. All that any clinician could do is provide a treatment based on examination findings alone. In the absence of symptom reproduction, we are coerced to make a clinical based assumption that an improved short-term outcome (ROM, Strength, mobility) will correlate to an improvement of your symptoms – AT THAT SPECIFIC POINT IN TIME.
It is only a clinician’s wish that a short-term input aimed at addressing the “functional” flaws or neuromuscular impairments would drastically affect both perceptual-cognitive-emotional (pain) responses that are in direct response to improvements in range of motion (ROM) and strength output. In other words, improvements in strength and/or ROM, directly after treatment, may not improve your symptoms.
If the short-term outcome (ROM, strength, mobility) is not sufficient enough to improve your symptoms, this leaves me with points 2) and 3). By providing a long-term intervention plan, whether it be sitting less and moving more, engaging in mindfulness/psychotherapy-based exercises or committing to a self-guided rehabilitation plan that we can offer for just $60 per month. The paradox becomes that you will learn to document the subjectiveness (frequency of symptoms) and have regular visits at The Chiro Hub to be assessed for the improvements in functional outcome measures and determine if symptoms lesson during the times I am not in your presence (remember we could not reproduce symptoms in clinic).
Furthermore, meaningful task analysis involves analysing your daily occupational and biomechanical demands and determining ways to optimize your movements, whether it would be to help you constrain unhelpful provocative movements or re-introduce/re-educate different ways you can move to offload the symptoms you experience which cannot be elucidated in clinic. Remember I am only with you for 30 minutes to an hour out of all the other 168 hours present during the week.
Finally, the long-term intervention also requires the assessment of your immune/endocrine 24hr assays (referral is needed). Immune and endocrine fluctuations may alter metabolism and our muscles require optimal levels of glucose, oxygen and ATP to carry out activities of daily living. Sufficient amounts of these are needed when there are shifts in circadian rhythms, and times during which work/occupational/sporting/exercise demands are high. Therefore, symptoms may only be apparent during times of high demand and low energy bioavailability. Of course, this can be further complicated in those with undiagnosed anaemias, of which there are plenty. Read more about anaemia here. From a biomechanical perspective the intervertebral disc is not a static, isolated, stupid piece of bone and cartilage, but rather a dynamic, living organism that is constantly being regulated by our nervous, endocrine and immune systems. Differential pressures across the disc are diurnal and constantly changing. Having diurnal bouts of low back pain towards the end of the day illustrates the approximation of the intervertebral joints leading to facet-related pain, especially bending backwards. For those with diurnal variations in pain and stiffness when arising in the morning, I would suggest replacing early morning routines with 20-30 minutes of exercise, whether it be routine stretching, walking or mind-fullness for 2 weeks and determine the effects that has. Morning back pain, which is relieved by taking a shower, could be due to the following reasons:
- Immobility reduces blood flow to the disc with increased hydrostatic pressure that is exerted against the outer annulus in the presence of the radial disc tear, OR
- A mismatch between intended movement during the first hour upon waking and the perception of where your body is in space.
This begs the question – Is the reproduction of symptoms at the time of which you visit, a complete determinant for both a short and long-term treatment plan? So far, with points 1) and 2) covered, the answer is NO! So continue reading…
The last point is one we can perform in the clinic but requires the HOW, WHEN and WHERE principle of analysis to determine the threshold point for the expression of your symptoms.
Firstly, let’s start with the HOW and WHERE!
This is where my expertise is able to determine the “breaking point” so to speak.
In the past few years, there has been a shift away from orthopaedics to biotensegrity and isolated to dynamic systems. As stated in the British Journal of Sports Medicine, “diagnosis or reproduction of symptoms to determine ‘tissue in lesion’ diagnosis is a complex dynamic integrative process with multiple interacting variables which is funnelled/converted into a simplified yes/no decision by the use of special (orthopaedic) tests”. Unless you have a bicep tendon rupture or rotator cuff rupture, or grade 2 ankle sprain, isolated systems and orthopaedic/special tests alone, do not provide much information in patients who have vague, ill-defined pain and stiffness that cannot be re-produced in a clinic. Instead of assessing your elbow on the table, I might have you positioned in a yoga type format or position that stresses other sub-units that feed into the elbow to determine reproduction of symptoms. The WHERE essentially highlights examining away from a typical clinicians or doctor’s office into a more functional relevant environment.
The next question – HOW?
Firstly, I need to determine the relevance of testing you in a fresh versus fatigued state.
As noted in my video, I can induce pre-conditioned stimulation/fatigue via 3 mechanisms in the clinic.
- Static (increasing time duration) x incremental loads x different time constraints
- Dynamic repetitive movements x incremental loads x different time constraints
- Dynamic movements under acceleration/deceleration x different time constraints
Note: All these can be performed at neutral vs end range and in combination with the alteration in personal, task and environmental constraints
Eg. performing repetitive forward bends with a box to elicit low back pain
- Engage in meaningful task (bike, treadmill, rower, step up boxes) to combine with different energy systems (ATP-PC system, anaerobic and aerobic systems)
- Eg: Performing multiple step ups on box for 5 minutes to elicit knee pain
- Mental fatigue and dual task when loading joint of interest
- E.g Holding a kettlebell above the head whilst walking backwards, counting down from 100 in 3s to zero, to determine if neck pain comes on)
These pre-conditioned fatigue or stimulation tasks enhance the examination to be more functionally relevant and tax the bodily systems, as well as provide an environment that allows more specificity .
WHEN? Due to diurnal variations in energy metabolism, fluid shifts, cognition, etc., I must asses you at the time at which you perceive stiffness and pain. Referring to the graph (see video above), I would like to assess you in the morning if morning stiffness is when you feel symptoms. Note that this graph is a very common finding across many low back pain patients.
Is symptom reproduction important? If symptoms are a poor reflective of overall health, then whether or not it can be reproduced in the clinic may not be all that important. It is about providing an intervention based on examination findings and clinical history, addressing psychosocial aspects and if possible, determining whether pre-conditioned fatigue and or stimulation is necessary before proceeding to examination-based tests to elucidate symptoms.
Remember the next time you visit a clinician’s office (chiropractor/osteopath/physiotherapist), ask yourself – Are you being assessed under specific conditions, constraints, task demands, movement actions/relevance and meaningfulness? Or are you just another victim to the squared room, allowing for dictatorship to determine what is conceived to be relevant and important to you? This, to me, is already sub-consciously constraining your movement options, rendering it very difficult to reproduce symptoms or explain the reason you booked in for your appointment or walked in the door in the first place.
Something to think about!
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