Death of the Diagnosis (As We Know It)

Badges of Despair

I can vividly remember my differential diagnosis professor stating that his class was THE most important class we would take, there may have been many professors that made this same claim. But his reasoning was sound, appropriate treatment can only be administered once the practitioner has narrowed down the issue at hand. This is and always will be true.

With the principle of proper diagnosis preceding treatment it would only make sense that we must properly label each patient with the appropriate ICD 10 classification. Then and only then should the practitioner administer treatment, then the insurance company recognizes the codes input by my staff and then the practitioner gets paid. That’s the way it works, right?

Oh by the way, the patient is feeling better…at least for now.

As a society, now more than ever, we wear labels of illness and injury as a soldier would wear a medal of commendation. We attach these labels to our treatments and prescriptions. You’ve got your Prilosec for your acid reflux, or your Pendalol for your chronic migraines, maybe you have to do your glute bridges in order to wake up those sleepy glutes, and let’s not forget that you can never, ever, under any circumstance bend over again due to your herniated lumbar disc. 

Labels cross societal and cultural lines, you may be diagnosed with biliary colic in the U.S., but in China you may told that you have excess Yang. That may lead you to have your gallbladder removed in the West whereas you’ll be prescribed an herbal concoction along with some Qi-Gong in the East. Diagnosis is the language of health care, but the language has become damning and most practitioners are operating with little to no awareness issue at hand.

The diagnosis of illness, pathology and pain is just not that cut and dry. That is why a proper diagnosis should always be considered a ‘working diagnosis’. A working diagnosis entertains the thought that there may be multiple aspects to the chief complaint as well as multiple possibilities and could include a laundry list of comorbidities.

Find Your Waze

The more we learn about all aspects of the human body, the more worrisome the idea of labeling pathology becomes. When exploring the idea of epigenetics, we find that we may not just be a preset code of of A’s, G’s, T’s and C’s, Instead our genetics may work similarly to the algorithm in an app like Waze. Waze might be called ADHD version of Google maps. Waze takes data from other users and various sources to constantly update the route to your desired destination. Whether Waze tries to direct you around a traffic jam or you decide that you would like to take a more scenic route, Waze (or more appropriately the Waze algorithm) will re-direct you as efficiently as possible. This may be similar to how our genetic expression plays out. We have a somewhat predetermined destination that is largely comprised of your maternal and paternal ancestors genetic input over a few generations that has finally been distilled down you…all 46 beautiful chromosomes of you. As we go through life our dietary choices, emotional traumas, physical stress, sleep, etc… all reroute our genetic expression until we are left at a destination that we may not recognize at all. 

How does this apply to diagnostic labels?

Well, we now need to consider a scenario such as this.

Likely Story

Mr. Smith goes to see Dr. White because he has been experiencing low back pain for the past two weeks that has not eased up. Dr. White orders x-rays and determines that Mr. Smith has some degeneration of his lumbar spine and is dealing with a bulging or herniated disc. Dr. White, being the 21st century physician he is, prescribes some NSAIDs and muscle relaxers, suggests that Mr. Smith rest for 1-2 weeks and warns Mr. Smith that he should be very careful when bending through his back and he should definitely not be lifting weights or anything of that nature. Mr. Smith is happy to get his bag of pills but he is not so happy that he was told that he should stop working out. Mr. Smith begrudgingly decides that Dr. White is probably right, he reasons that working at a desk most of the day doesn’t really demand too much of him so why continue to lift weights or workout vigorously at all and risk re-injuring his low back? 

Fast forward 5 years, Mr. Smith has put on a few pounds and is wanting to start working out again, so he joins a local gym and hires a personal trainer. Mr. Smith is paired up with Johnny Squats, Johnny thinks he can really help Mr. Smith and they start working out twice a week. On their third session Johnny programs some light back squats for Mr. Smith, Mr. Smith let’s Johnny know that he ‘has a bad back’ and that he would rather not do the squats. Johnny soothes Mr. Smith’s worries with some big words and a flash of his own monstrous quads. Well on the second set, you guessed it, Mr. Smith feels a ‘pop’ and has instantaneous low back pain. 

He grabs his phone and starts dialing Dr. White’s number as he leaves the gym. Dr. White gets Mr. Smith in and decides that since Mr. Smith is in so much pain that an MRI should be done before they move forward with anything else. The MRI results show multiple levels of herniations and moderate degeneration. Dr. White suggests surgery, Mr. Smith is abrasive to the idea of back surgery, but ultimately he can’t stand the pain so he is put on the schedule to under the knife. 

Demand Greatness

So from that long story, which may be a very familiar one, we have to ask a few questions.

Did Mr. Smith ever really have a bad back?

Does ANYONE ever really have a bad back?

Did Mr. Smith self-manifest his MRI results, whether from a sedentary lifestyle after his initial diagnosis or even weirder yet, from epigenetic changes due to emotional, mental and lifestyle alterations put in motion after his first bout with LBP?

Basically, we are left with the chick or egg scenarios of…was it Mr. Smith’s back that did him in or the label that he bought in to? Obviously this is a hypothetical scenario, but this is an extremely common drama that is played out every day. These questions are very challenging to answer for most people, even though they should still be asked. Especially when making major lifestyle changes or deciding on invasive interventions. As science advances it is my presumption that we will be looking more and more in to things like quantum mechanics, epigenetic cueing and pain neuroscience.

So how can physicians and patients help with this issue as it stands right now?

Physicians: Simply put, tell the patient the truth. Physicians are rarely 100% sure of what the driver of a certain pathology or pain is, but we can surround the issue with plausible agents, we might also call this a working diagnosis (wink*). As a physician you may think this leaves this patient with ambiguity which then causes more distress as they turn to Dr. Google to find out what ‘label’ they have. Here is where diagnostics, not necessarily diagnoses, become absolutely crucial. Proper examination, imaging and testing lead to precise, powerful and timely treatment. When a practitioner can provide care that is targeted at a specific solution without the harm of labeling the person, the results will always be improved.

In addition to the proper diagnostics and treatment, communication is such a large part of the biopsychosocial aspect of treatment that we cannot underestimate it’s importance. Humans are robust organisms, reminding patients that they are not fragile and that in fact they are Anti-Fragile can be very empowering. As Dr. Greg Lehman says…

“be a movement optimist”

… replace ‘movement’ in that quote with human and you cover the entire spectrum of illness and pain.

Patients: Do not settle for a label and a shotgun approach to care. Instead, demand explanation, education and efficacious treatment. The patient is ultimately a consumer and consumers drive a capitalist system…and if you are under any illusion that our medical system is not of capitalist roots then I can firmly give you the real label of delusional. The patient drives the quality of care, so be your own advocate and DEMAND GREATNESS.

 

 

 

 

 

 

 

 

 

 

The de-evolution of human movement and how pain can save us all.

" Life imitates art..."

Wall-E-mart People

Wall-E-mart People

I can't remember if I cried during the end of Wall-E, but I definitely shed a tear at the cold realization that the scene depicted above is almost a reality.

As a society we are overweight, we lack proper nutrition and we live in a movement desert, and many people believe that we are becoming less intelligent as well. Damn, what a pleasant picture. I tend to disagree with the last sentiment. I think that we are becoming less knowledgeable in the classic sense, but we are far better at assimilating mass amounts of data. This is an evolved trait due to the shear amount of information put in front of our faces everyday. Now, some of us are better at uploading this data, filing it appropriately and then being able to still make logical or sometimes just common-sense decisions. As a whole we are not becoming less intelligent, we are just evolving to think and process differently.

As our brains evolve we will lose certain aspects of humanity, this is inevitable. It is a common presumption that if you are a more analytical and logical thinker that you are probably a bit less emotional, at least when it comes to decision making. As the human species continues to assimilate massive amounts of information on a daily basis, it could be postulated that there will be less energy available for emotional based responses, creative thinking, imagination and perhaps less actual emotion overall. You heard it here first, we are becoming Vulcans. 

'V' is for very nice bangs.

'V' is for very nice bangs.

Now, what does all this speculation have to do with movement and pain? First, let us define the de-evolution of human movement. For thousands of years humans have been evolving in all sorts of fantastic physical ways. Bipedal movement. The ability to sweat, allowing for long bouts of endurance. Fine motor skills allowing for advanced tool development, writing and art. At the same time that fine motor skill was being developed it is thought , that as a species, we experienced a huge leap forward in cerebral development. This could possibly be due dietary changes or attributed to the freedom of time that was allowed by things like advanced tool making and the efficiency in daily life that came with these innovations. This free time allowed for more time for deep thought, but mainly thoughts that developed our conscious mind. 

As far as we know, we are the only species on the planet that contemplates our own existence. This is very unique, and this unique scenario brings about a very interesting theory that the human brain and the human body have evolved to be not one entity but instead two separate organisms. This makes sense when you think about how we talk to ourselves, how often do we hear people talk about 'their body'? Well if it's YOUR body, shouldn't it just be you? Why is it always possessive when speaking our thinking about it? Deep, huh?

You whipper-snappers can Google this later.

You whipper-snappers can Google this later.

So, let's say that the body and the brain are two separate entities. In my opinion the brains job, from an evolutionary standpoint is to make processes as efficient as possible. Processes involving everything from pattern recognition, speech, vision, complex thought and movement. We think in patterns to speed processes, we perceive the world as we see fit in order to process information more effectively and in an ideal world we move as efficiently as possible in order to conserve energy. This superb conservation of energy is beneficial to the organism as a whole, but what if the brain is conserving energy so it can selfishly use all the glucose for cognition??? Conjures images from my Saturday mornings as a kid.

tmnt_villains_krang.jpg

So if the brain needs more energy on a daily basis because we are constantly bombarding it with information to process, that means that that trade-off is to down regulate other energy consuming task such as movement.

There is a lot of hype these days about sitting being the new smoking. I won't completely affirm that, what I will agree with is that a sedentary lifestyle will definitely detract from one's health. But what if our lack of movement and subsequent up-regulation of cerebral processing is just evolution? 

The main weakness in this argument is that if the body becomes unhealthy, then the brain will ultimately die, right? Absolutely true, at least at the current level of science and technology. Without going all singularity on you, the field of research exploring the prolongation of human life through advances in nanotechnology, AI and other advances in science, is growing extremely rapidly. So, even though it may seem far-fetched to think that our own brain is slowly killing us for it's own evolution, it can't be ruled out.

I've come for your telomeres...

I've come for your telomeres...

 

At the same time that I throw this crazy theory out there, it's very interesting that there is such a cult following to all things 'Paleo', 'Primal' and anything that gets us more in touch with our caveman ancestry, even though the jury is still out on the validity of a lot of these theories.

As man has tended to do throughout the age of human cognition, we intervene when and where we can. What if this return to our primal ancestry is an intervention to not be bested by our cerebral counterpart, sounds f$%!ing crazy, right? Well, let's take a look at one more theory.

As our society has become more sedentary, one thing that we cannot deny is an increase in PAIN. Yep, just overall pain. There is such a pain epidemic that we have had to start labeling things that we don't even understand such as fibromyalgia, complex regional pain syndrome, and chronic pain syndrome. Now, I won't go into the details on how our oh-so smart society has generally tried to treat these things...cough,cough...pop a pill and figure out how to handle the side-effects of said drug later, which is usually treated by another magical pill. Probably another evil plot by the cerebrum to take us out, or maybe just the cerebrums at Pfizer. Why are we all in so much damn pain? You may say, well we are in pain because we eat like shit, move like shit and really we think like shit too. All of these reasons are true, but what if there is another aspect to the pain epidemic?

As I mentioned earlier, when we tend to become more analytical, logical and data driven (and no this is not called being 'being left-brained' anymore, check out this link for more info on that...Neil deGrasse Tyson Stomps Notion of Left vs. Right Brain ), we also tend to lose some of our emotional intelligence. One thing that has come to the forefront of pain science in the past few years is the strong link between chronic pain patterns and our emotional responses to that pain and the beliefs surrounding it. Let's put on our theorizing helmets again...is it possible then that that our body is fighting cerebral override by maintaining a focus on itself in the most powerful and painful way possible? It is now widely thought that most chronic pain is patterned in the brain, or simply put there can be pain when no injury or pathology exists any longer. What if the body is creating more noxious stimuli, nociception, in order to shift our conscious mind back to the body? 

My solution for the pain epidemic.

My solution for the pain epidemic.

For more great info on pain science, check out greg lehman's website...

Greg Lehman

...also this keeps me from having to site like a thousand research articles.

When we are talking about energy systems and efficiency, we know for a fact that the most efficient way for the brain and the body to accomplish a task is usually to reduce the task to an unconscious level. Take driving for example, say you have been driving for 10 or more years, you can very easily shift gears, change lanes and ,God save us all, probably text all at the same time. The ability of the brain to shift tasks to an unconscious level makes the toll much lower from a cognition and energy standpoint.

What if in an effort to reduce energy consumption, the brain has completely put movement on auto-pilot. Most movement is already automatic, for example walking, breathing and almost everything once we become proficient. What if this is the problem?

For hundreds of years yogis, martial artists and other movement practitioners have been assuring that humans bring INTENTION to their movements. Once again...

WISDOM for the WIN

The lack of intention through a daily movement practice is almost non-existent in most of North American culture. What's even scarier is a complete lack of ATTENTION to movement as well. Sounds like we could all be brought on to the next episode of Maury for a 'Movement Intervention'. Pain to the rescue.

"DNA testing reveals that you are turning into a blob that moves like shit, but THE BABY IS NOT YOURS!

"DNA testing reveals that you are turning into a blob that moves like shit, but THE BABY IS NOT YOURS!

In my office I usually see people who are poor adapters to pain. They are dealing with pain that probably should have went away as the initial injury or insult diminished but for some reason it did not. As hard as this is for people to grasp I really try to get my patients to look at their pain or injury as an opportunity. An opportunity to improve their overall quality of life, because it is far more likely that QOL led to their pain more so than picking that sock up off the ground last Tuesday. 

By the way sock are evil. It's proven by their murderous ways, why do you think you always end up with only one sock out of the pair. #sockicide

Here is where it all comes full circle...the body creates pain so the brain pays attention to it, the brain doesn't want to pay attention (he likes the step-father you always wanted). So the body starts yelling at the brain through more pain. Eventually the brain starts to lose it's shit, and here come the emotions; stress, anxiety, worry, fear, depression, etc... Finally it's time for intervention. This could be a drug, this could be a surgery, hopefully it's something far less invasive, maybe it's just getting the brain and the body to sit down and have a conversation. 

Now, before all of my pain neuroscience colleagues come out of the woodwork wanting to cut off my manhood with their synaptic pruning sheers, I get that this is completely backwards to how we would explain most chronic pain. We tend to think that the brain is patterning pain in order to get us to move differently or more often. What if that's not the case. What if our conscious mind is stuck in the middle of chess match between our brain and our body?

So maybe pain is just what we need, just what we need in order to make change.

So how do we stop this de-evolution.

One of the first things we assess and work on in our clinic is breathing. Breathing is unique in that it is the only human function that can be regulated by your autonomic nervous system and conscious thought. Breathing is vital to physiologic function, stabilization of the body but also diverting conscious thought back to the body and away from the site of pain. As simple as this sounds it is extremely effective, and there is a lot of research being done on correlation between breathing, pain and performance. There are a lot of other areas of our life that we must bolster in order to ensure that we are taking steps in the right direction, but I'll save that for another blog.

So maybe in the end pain is the hero, the hero that is a literal pain in the ass.

There are a lot of IFS and MAYBES here, but it's always good to think about things in a different perspective. If you are terrified that you brain is taking over your body like a parasite, the good news is all you need to do is just take a few deep breaths and you'll be okay.

Until next time...

Question everything...seek YOUR truth.

Eyes, Scoliosis and Golf?

Your eyes rule the roost when it comes to neuromechanical function. Learn how your eyes may be inhibiting your golf swing, contributing to scoliosis and much more.

Here's an interesting article looking at the correlation between juvenile spinal curvature and eye dysfunction.

Visual Deficiency and Scoliosis

As always, question everything and always seek the truth.