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Chiropractic, Complexity and Communication
September 5, 2015 by Dr Matthew D. Long
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Chiropractic, Complexity and Communication
September 5, 2015 by Dr Matthew D. Long
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Chiropractic, Complexity and Communication
September 5, 2015 by Dr Matthew D. Long
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The chiropractic profession has always placed an emphasis upon function. Indeed, this focus has always been seen as a strength of the profession - particularly as science struggled to put the diagnosis of spinal disorders into a meaningful context. After all, there has been no end of debate about the reliability and usefulness of orthopaedic testing - and even MRI findings are often called into question. So as we all struggle for certainty there is a very real temptation to classify everything as 'functional' and avoid making a tissue diagnosis altogether. However, by compressing the myriad variables associated with spinal disorders into this hard-to-define construct we lose the subtle variations and differing presentations that typify the patients we see everyday. Not only that, but have we ever thought about the implications of trying to communicate our uniqueness using concepts that are more abstract than concrete? Do others even understand us?
Interestingly, it is not only the chiropractic profession that has decried spinal diagnosis as unreliable. The conventional wisdom amongst many, if not most, of our medical colleagues is that a back pain diagnosis cannot be made in most circumstances. But is this actually true? A recent editorial in the journal Pain Medicine by Michael DePalma (1) stated,
Interestingly, it is not only the chiropractic profession that has decried spinal diagnosis as unreliable. The conventional wisdom amongst many, if not most, of our medical colleagues is that a back pain diagnosis cannot be made in most circumstances. But is this actually true? A recent editorial in the journal Pain Medicine by Michael DePalma (1) stated,
"A postulate that low back pain cannot be diagnosed was published 50 years ago. This assumption was perpetuated for nearly 3 decades before more rigorous studies identified the sources of low back pain (LBP). The medical community’s initial impression that LBP cannot be determined is not correct. Published prevalence estimates with reasonable confidence intervals from three different continents have presented accurate accounts of different structural sources of LBP. The confidence intervals of these published prevalence estimates overlap. Indeed it is now factual that approximately 40%, 30%, and 20% of adults with chronic LBP are suffering from disc, facet joint, and sacroiliac joint related pain, respectively. These proportions change according to patient age with the prevalence of joint pain increasing and disc pain decreasing with advanced age. The medical community can now rest assured that under proper conditions, the source of chronic LBP can be identified. This certainty has far reaching implications."
So what are the implications for chiropractors?
Firstly, it should be said that the world is crying out for better diagnosticians - not better therapists. I would argue that there are relatively few who are truly equipped to triage patients with spinal disorders. To quote just about anyone famous, "If it was easy, everyone would be doing it". Spinal diagnosis requires a depth of knowledge of the contemporary neuroscience and orthopaedic literature, and an ability to think in terms of both pathology and function. I am not suggesting that functional (non-structural) changes are not important - far from it. Indeed, I think that the chiropractic profession is uniquely placed to recognise the duality of pathology and function and straddle both concepts when approaching our patients. This could be our greatest strength. However, I would voice concern that our historical emphasis on purely functional models of spinal health is lopsided and we need to recognise the importance of tissue pathologies also. In this way we can play the very important role of spinal diagnostician, whilst also seeking to identify and address the functional disorders that so often lie beneath. Indeed, the thrust of current research highlights the fact that chronic spinal pain patients exhibit poor proprioceptive abilities at a number of levels. This includes failure of the muscle spindle apparatus, changes in the dorsal horn circuitry and issues of higher processing within the vestibular systems. Furthermore, there is a growing body of evidence to suggest that fundamental changes happen within the cortical circuitry in association with lower back pain. However, we must also appreciate that local spinal tissues will suffer diagnosable injuries as a result, and someone needs to know how to manage them.
Firstly, it should be said that the world is crying out for better diagnosticians - not better therapists. I would argue that there are relatively few who are truly equipped to triage patients with spinal disorders. To quote just about anyone famous, "If it was easy, everyone would be doing it". Spinal diagnosis requires a depth of knowledge of the contemporary neuroscience and orthopaedic literature, and an ability to think in terms of both pathology and function. I am not suggesting that functional (non-structural) changes are not important - far from it. Indeed, I think that the chiropractic profession is uniquely placed to recognise the duality of pathology and function and straddle both concepts when approaching our patients. This could be our greatest strength. However, I would voice concern that our historical emphasis on purely functional models of spinal health is lopsided and we need to recognise the importance of tissue pathologies also. In this way we can play the very important role of spinal diagnostician, whilst also seeking to identify and address the functional disorders that so often lie beneath. Indeed, the thrust of current research highlights the fact that chronic spinal pain patients exhibit poor proprioceptive abilities at a number of levels. This includes failure of the muscle spindle apparatus, changes in the dorsal horn circuitry and issues of higher processing within the vestibular systems. Furthermore, there is a growing body of evidence to suggest that fundamental changes happen within the cortical circuitry in association with lower back pain. However, we must also appreciate that local spinal tissues will suffer diagnosable injuries as a result, and someone needs to know how to manage them.
'If it was easy, everyone would be doing it.'
This brings me to my second thought. If chiropractors were to take centre stage in the role of spinal expert, we would require a strong and easily understood message. In truth, we have done a poor job of explaining our skills and unique approach to others, particularly to our medical colleagues. Indeed, we frequently fall into the perennial trap that authors Chip and Dan Heath call "The Curse of Knowledge" (2). This simply means that once we understand something, we find if very hard to remember what it was like not knowing it. As such, when we try to explain our idea we inevitably do so using terms and concepts that are beyond the audience. In other words, we assume too much and our message is too complex.
According to Chip and Dan Heath successful communicators have a number of key attributes that allow their message to cut through the 'noise' of our world, and resonate with our often-disinterested audience. In essence, they employ messages that are simple, concrete and credible.
According to Chip and Dan Heath successful communicators have a number of key attributes that allow their message to cut through the 'noise' of our world, and resonate with our often-disinterested audience. In essence, they employ messages that are simple, concrete and credible.
"What makes something 'concrete'? If you can examine something with your senses, it's concrete. A V8 engine is concrete. 'High performance' is abstract... Concrete language helps people, especially novices, understand new concepts. Abstraction is the luxury of the expert. If you've got to teach an idea to a room full of people, and you aren't certain what they know, concreteness is the only safe language."
Terms like "joint dysfunction" or "aberrant spinal biomechanics" may mean something to chiropractors, but they sound like jargon to the average medical practitioner. Even concepts such as "spinal instability" require further explanation. We should reflect upon the fact that medical practitioners think in terms of pathology, not function, so you must give them pathology if you want them to understand. I would therefore encourage chiropractors to become familiar with the latest literature on spinal disorders and learn how to communicate this first. Then, having gained some measure of understanding and common ground, it is possible to discuss some of the more complex ideas of spinal stability and health that form the heart and soul of chiropractic practice. But such concepts will only be understood when they rest upon a firm foundation of diagnostic excellence.
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. DePalma, M. J. (2015). Diagnostic Nihilism Toward Low Back Pain: What Once Was Accepted, Should No Longer Be. Pain Medicine (Malden, Mass), n/a–n/a. http://doi.org/10.1111/pme.12850
2. Heath C, Heath D. (2007). Made to Stick - Why Some Ideas Survive and Others Die. Page 20. Random House. New York.
1. DePalma, M. J. (2015). Diagnostic Nihilism Toward Low Back Pain: What Once Was Accepted, Should No Longer Be. Pain Medicine (Malden, Mass), n/a–n/a. http://doi.org/10.1111/pme.12850
2. Heath C, Heath D. (2007). Made to Stick - Why Some Ideas Survive and Others Die. Page 20. Random House. New York.