Understanding the Nuance of the Diagnostic Process
Diagnosis noun
a. the art or act of identifying a disease from its signs and symptoms
b. investigation or analysis of the cause or nature of a condition, situation, or problem
c. a statement or conclusion from such an analysis
A patient wants to know five questions when seeking a healthcare professional.
· What is wrong with me?
· How long will it take?
· What can I (the patient) do about it?
· What can you (the healthcare provider) do for me?
· How much will it cost?
The diagnosis determines how the questions will be answered.
The body is an intricate system of systems all interconnected. Trouble in one area can manifest in other areas.
A medical diagnosis is the process of identifying diseases, conditions, or disorders in a person based on their medical history, signs, and symptoms. Medical professionals, such as doctors and healthcare practitioners, use their knowledge of medical science and diagnostic tools to determine the underlying cause of the patient's symptoms. Imaging studies, laboratory tests, and other diagnostic tools often support the diagnosis. A medical diagnosis aims to provide a basis for developing an appropriate treatment plan for the patient's physical health. It is crucial to note that accurate and timely diagnosis is necessary for effective medical intervention and managing health conditions. Sometimes, a diagnosis may be straightforward, while others may require a more complex and thorough investigation. Fortunately, advances in medical technology and research continually improve the accuracy and efficiency of the diagnostic process.
Making the correct diagnosis is crucial to determining accurate treatment strategies.
When patients go to their family doctor or an orthopedic specialist because of a physical ailment, they expect a diagnosis. The assumption that is made after receiving a diagnosis is we now know what to do with the problem; in musculoskeletal and physical medicine, that is often not the case. The better we define the problem, the better we can devise a solution for it. According to the World Health Organization, 90% of all back pain cases are nonspecific low back pain. Non-specific low back pain is a condition without a distinct etiology to explain its associated symptoms. Low back pain is a symptom, not a cause. To provide beneficial treatment, the medical practitioner must dive deeper to unravel the actual cause of the pain. When it comes to non-specific lower back pain (LBP), the lower back is rarely the root cause. It may be the current site of the pain, but it's not always the source of the problem. The pain is usually caused by abnormal motions or loads coming from adjacent or distant areas of the body, which force the lower back to absorb excessive amounts of load until the body says it has had enough, resulting in a pain message. A medical diagnosis sounds fancy and gives the problem a name, but the diagnosis is rarely actionable. For the diagnosis to be actionable, we must dig deeper and ask why.
Start with Why?
The "5 Whys" is a problem-solving technique that involves asking "why" five times to identify the root cause of a problem. It originated from the Toyota Production System and is widely used in various industries. The iterative questioning helps uncover more profound layers of causation beyond the initial symptoms. The goal is to address the underlying issues rather than just the superficial manifestations of a problem, leading to more effective and sustainable solutions.
Asking Why 5 times help to get to the root of the problem.
Digging deeper into the problem, we can identify a movement diagnosis that provides a more specific understanding of the issue. For instance, in the case of low back pain, flexion intolerance is a common presentation. This movement diagnosis is based on pain triggers, i.e., specific motions, postures, and loads that provoke pain. It helps in identifying the mechanical sensitivity and the direction of pain. In MDT (mechanical diagnosis and treatment), our goal is to find both the direction that hurts and the direction that improves the symptoms. While not all pain is mechanical in nature, ruling in or out a mechanical source of the pain is a crucial part of the diagnostic process.
The functional diagnosis is often more actionable the pain generator.
The layer that follows the movement diagnosis is the functional diagnosis. It identifies the areas of the body that may not function properly to absorb and accept force, leading to tissue overload at a distal site. The functional restoration model aims to address activity limitations. The primary objective of modern treatment of musculoskeletal problems is to reactivate patients to restore function while teaching them self-treatment skills to prevent future recurrences. When we improve function, a side effect is reduced pain or discomfort.
Patient evaluation involves taking a detailed history and examining the specific and limited activities, the mechanical nature of the pain, and the patient's functional status. This goal-oriented evaluation helps doctors identify specific functional endpoints of care. Once the painful movement has been identified, the goal is to find a relevant dysfunction that is related to the painful movement. Although the sacroiliac joint is a common area of pain, it is rarely the source. Suppose the lumbar spine cannot move segmentally above, and the hip has inadequate rotation below. In that case, the SIJ is caught in the middle and forced to absorb the extra force it was not designed to handle, resulting in pain or irritation. By focusing away from the site of irritation, we can determine why there is a disruption in the global pattern leading to pain. If we only focus on the painful area, it can be like stirring a hornet’s nest, leading to further irritation.
This is the concept of regional interdependence. Regional interdependence is a concept in healthcare, particularly in the field of rehabilitation, that emphasizes the interconnectedness of different regions or areas of the body and how dysfunction or impairment in one area can affect other seemingly unrelated areas. The body functions as an integrated system, and addressing problems in one region may involve considering and treating related issues in the different areas.
Pain or dysfunction is multifactorial. In most cases there are layers to the problem, not one singular cause.
This concept is often applied in the context of musculoskeletal and movement disorders. For example, pain or dysfunction in the lower back may not only be related to issues in the lumbar spine. Still, it could also be influenced by factors such as hip mobility, pelvic alignment, or even foot mechanics. In such cases, a comprehensive assessment and treatment approach that considers the relationships between different body regions may be more effective than focusing solely on the symptomatic area.
The idea of regional interdependence highlights the need for healthcare professionals to take a holistic and integrated approach when evaluating and treating patients. It encourages them to look beyond the site of pain or dysfunction and consider the entire kinetic chain or functional unit. This approach can lead to more accurate diagnoses and targeted interventions, ultimately improving patient outcomes.
When you find the “Key Link” most other things fall into place.
The term function can have various meanings depending on the context. However, in its simplest form, function refers to what is significant to an individual and whether they possess the necessary prerequisites to perform a meaningful task or activity. Every movement requires a specific joint capacity to execute it. For instance, a baseball pitcher needs a higher level of rotational capacity in their throwing arm compared to an average recreational athlete.
MRI arthrogram of the shoulder showing the capsular space.
Joints are the spaces between adjacent bones or bone and cartilage that form a movable connection. These spaces are known as joint spaces and are dynamic physical capacities that can expand, contract, or be sustained. They are also a trainable quality of the human biological system. Joint space is critical in determining joint function, a crucial determinant of movement ability. Absolute joint function is a fundamental capacity, and it is essential to understand function and dysfunction from a performance standpoint.
Functional joints refer to those that display no capsular barriers on movement potential. They allow the athlete's nervous system to organize its internal space to move and navigate through external space effectively and efficiently. They work as system amplifiers, enabling the athlete's ability to move and navigate.
On the other hand, when joints become dysfunctional, the athlete's nervous system's ability to move and navigate through external space is disrupted, leading to compensation as an inevitable consequence. Therefore, understanding the concept of joint function is crucial for performance practitioners.
“The clinical picture correlates better as a rule with the changes in function than with the structural pathology. Very frequently, indeed, pathological changes do not manifest themselves so long as the function is not impaired. On the other hand, changes in function by themselves may cause very marked clinical changes in the absence of any (structural) pathology. “ Karel Lewit
While utilizing the concept of regional interdependence, we also need to address the system's individual components. If the individual parts are not functioning correctly, they will be challenged to integrate into the system as a whole. The time frame of how long the issue has been going on matters. If the disruption is acute, the regional interdependence approach may be all the system needs to start functioning correctly again. In chronic cases where tissue changes have occurred, a holistic approach can be beneficial but insufficient to address the altered tissue. In most scenarios, both approaches are necessary. Specific training needs to be done at a local level, but there also needs to be global training done to ensure the new local changes are integrated back into the system as a whole. It does no good to make tissue changes if the brain does not know how to use them in desired movements or activities.
Finally, we can obtain a more precise understanding of the issue by conducting a tissue diagnosis. Each tissue in our body has its unique load profile, which requires specific inputs to bring about the necessary changes in function. The most common exercise recommendation in conventional physical therapy clinics is to perform three sets of ten repetitions. This approach may effectively increase the recruitment of slow-twitch fibers with repeated efforts not to failure. However, if your goal is to enhance the load-bearing capacity of the connective tissue in your shoulder, the load profile of the exercises might not match the tissue, and it may fail to bring about the desired change.
When a patient seeks the help of a healthcare provider, they are essentially “renting” the doctor's brain. The doctor has a level of expertise that the average person does not have. Thus, they seek guidance from someone more skilled. The word “doctor” is derived from the Latin docco, which means “to teach.” But the word “teacher,” as well as the word “learning,” means different things to many people. There seems to be agreement that if more citizens had more knowledge and the will to act in certain areas, we would have healthier communities. Karel Lewit (a Czech neurologist) defines rehabilitation as showing patients what they can do for themselves.
Self help works to a point, but in certain cases we need to find someone with more knowledge to intervene. Doctors guide the patient to the correct solution.
We must clearly define the problem before finding an effective solution. The more specific we can be with our diagnosis, the clearer we can be with the intervention, leading to more efficient results. In medicine, we have poorly defined outcome measures, which leads to generic treatments and mediocre results. Ill-defined problems lead to ill-conceived solutions. In healthcare, being specific means gathering all the necessary information, analyzing it thoroughly, and providing a clear and concise plan of action for the patient. This process requires a higher level of thinking from healthcare practitioners, as they must consider all the possible scenarios and outcomes before making a decision. However, the benefits of being specific are numerous. Patients receive a more accurate diagnosis, a better understanding of their condition, and a clear direction for managing their health. This, in turn, leads to better health outcomes and a higher level of patient satisfaction. Therefore, healthcare practitioners must prioritize being specific in their approach to patient care.
There are different levels of diagnosis. The medical diagnosis in musculoskeletal medicine (without sinister red flags or disease) is only essential for insurance purposes and is not particularly actionable. A movement diagnosis helps to narrow things down further, identifying mechanical sensitivities and directions of preference. The functional diagnosis works in parallel with the movement diagnosis to help elucidate areas that may not be painful but are not moving in an ideal way. The tissue-specific diagnosis allows us to prioritize the type of tissue that is not behaving correctly and disrupting the movement efficiency. To provide beneficial treatment, the medical practitioner must dive deeper to unravel the actual cause of the pain or dysfunction.
