Dr David McGrath

Spine Physician

MB BS (Hons) FAFOM, RACP, FAFMM
Master of Pain Medicine

What's Wrong With My Back?

The answer to this question depends on who is asking; sufferer or doctor. This is so, because the answer is validated by the reference frame which makes sense of the diagnosis. A patient may accept "a torn muscle" as a diagnosis if their knowledge base encompasses "muscle" and "torn". To a doctor "non specific backache" is more valid if other possibilities have not yet been excluded. A doctor would know that pain can arise from blood vessels, ligaments, joint capsules, bone, muscle, intervetebral discs, extra cellular matrix and in fact every tissue which has an interactional connection with pain neurons (capable of encoding for pain).

Knowing this complexity a doctor will often give a diagnosis acceptable to the patient. This can usually be done without compromising treatment and management.

A problem arises when the outcome of treatment is poor or less than expected. A patient may now feel let down and lose faith in their doctor. Thorough doctors may couch the diagnosis in probability terms such as "the most likely diagnosis is". This allows for a correction at a later date if the condition does not behave as expected or more data comes to light through investigations.

For patients the issue is rarely the diagnosis, but the outcome. The connection between diagnosis (defined as "through knowledge") and outcome depends on clinical science. There may be differences in treatment and outcome between "non specific back pain" and "disc pain" in which case the diagnosis becomes much more important than an explanation designed to satisfy a patient or doctor.

Diagnosis or explanations can be divided into two main categories. There is a component category which seeks to assign the problem to a part. There are many examples- a broken bone, sprained ligament, torn muscle are a few. There is another category which assigns the difficulty to an altered or disturbed relationship. Scoliosis or bent spine is an example. This label implies the postural geometry is incorrect. This category quickly extends to the idea of faults in movements between postures. That is, the patterning may be faulty. Patterns may be faulty under specific or general conditions. A person may always bend over incorrectly (general) or only when using a broom (specific).

There is a large divide between these two types of explanations.

If we accept a component diagnosis, treatment is naturally directed at or through that component. A "weak muscle" is strengthened. A "tight ligament" is stretched. A broken bone is rested and splinted. Well and good. However,

What if the tight ligament arose through poor sitting posture? Correction of the ligament length would be undermined by the recurring pattern of sitting thereby making treatment superfluous and unsuccessful. In other words the diagnosis is incorrect in the sense of no-value.

Some doctors adopt the perspective of diagnosis AND cause. From this position, the "short ligament" is the diagnosis and the poor posture in sitting is the cause. This world view leads to divergent treatment behaviour. A treatment approach might stretch a ligament (diagnosis focus) while changing the chair (cause focus). Success may depend on the relative emphasis on these two aspects of the problem. In a clear example of a broken bone, there may be no value in looking at cause if there was a one-off traumatic event. A headache produced by repeat head banging may need only a tablet with the cessation of the causative behaviour. Overall this approach is very useful, provided equal consideration is given to both with the right proportion of intervention.

Does the "cause AND diagnosis" approach always work? A lot depends on the accuracy of diagnosis and cause and connection between the two. In the head banging example, the sufferer might have a brain tumour leading to the abnormal behaviour and headache, in which case neither the tablet nor change in behaviour will lead to a satisfactory outcome. That is, the cause OR diagnosis may be wrong OR there is no physiological connection between the two if correct. Returning to the chair example; the patient may have a short ligament (true) and sit poorly (true) and yet there is no connection between the two. A focus on both will fail. The true cause of the short ligament remains (without intervention) and the change in sitting becomes irrelevant.

To recapitulate, we have seen that there are two types of diagnosis:

1. Component focus statements (back, neck, disc, muscle etc)

2. Structural arrangement statements (poor posture, poor chair, poor movement skill)

A focus on diagnosis is often destined to failure because an ongoing cause is neglected. This leads to the diagnosis AND cause approach which is useful but dependant on:

1. Diagnosis and Cause Accuracy

2. The Strength of Connection between the two

Let's look more closely at Cause. We live multi-dimensional lives. We are able to interact simultaneously and sequentially in multiple domains. For example we can drive a car, listen to the radio and think about the future. This can occur while we digest our breakfast and readjust our circadian rhythm for the day. This is superimposed upon a monthly menstruation and seasonal cycle. Our body may also be adjusting to a recently acquired virus and a change in temperature. The list goes on. I wonder if a single cause truly exists for anything. There always seems to a lesser convergent input playing a role in the development of dysfunction. If this is the case, cause will always be diverse but perhaps rank able into major and minor. The development of pneumonia might be due to underlying immune weakness (major), inadequate clothing (major), exposure to pathogenic bacteria (major), stress and anxiety (minor). There may be inputs to those causes as well. An underlying cancer may be responsible for the immune weakness. The cancer itself may have historical roots in a toxic chemical.

Most often the full complement of causal factors cannot be identified or interventionally modified.

In the musculoskeletal area we have the same problem. There are multiple inputs creating multiple changes. It is still not clear the difference between age-related changes and other types such as healing or pathological. It is this confusion which leads to loss of utility in respect of the "component diagnosis". Are degenerate changes within the spine related to age, injury, disease or simple healing? In general we know these changes do not predict pain and disability. If there is no correlation between such structural changes and disability, how can they be legitimately used as a diagnosis? It would not be surprising to learn that interventions aimed at deranged parts have a very poor success record. Surgery, manipulation, strengthening, and stretching all intervene at the component level consistent with a stated or implied component diagnosis.

Where does that lead us? Multiple causes leads to painful and non painful parts and difficulty distinguishing between them.

Perhaps there is an answer in the second type of diagnosis? These are statements about relationship. What if cause and diagnosis merged into another concept leading us past the difficulty of identifying multi cause and relevant pathology? As complex systems, we are continually changing our structural configurations consistent with the environment. Every component has a structural limit which if exceeded could be viewed as the problem. A constant pain implies some part is constantly under excess stress. As we move we change the relationship between our parts which can be monitored by our conscious reflection and observation. By establishing a painless or comfortable set of movements and relationship we have obviated the difficult task of establishing a "true diagnosis" and "true cause". Both of these concepts might be incorporated into a process which has the added benefit of being a treatment as well. Component strain and its causes are dealt with simultaneously. A n interaction focus deals with cause and component effects simultaneously. All causal inputs are covered (even if not identified) as the final result of component coherence is achieved by design. All painful components are rendered non painful by the same reasoning.

Let's look at some examples.

1. You have a "bad back" translates under the new diagnosis as "your set of comfortable movements and postures is small". In the first diagnosis the focus is on intervention to both the back and possibly any identified causes. Welcome to the land of confusion. Which bit of the back is crook? And what are the ongoing causes?

In the second formulation the focus is on capacity. Capacity is domain specific. What are the situations which are comfortable and uncomfortable? We will need to explore and extrapolate from similar presentations.

2. You have "rotator cuff tears" versus "there is difficulty with abduction of the glenohumeral joint". In the first there is a focus on a tear leading to surgery, for instance. In the second, other directions of movement could be explored leading to non painful routines and recovery of the tear.

Why is this different than Exercise?

It all comes down to the diagnosis. An exercise is generated from a diagnosis, stated or otherwise. There is no purpose in stretching or strengthening unless there is an assumption of tightness or weakness. How accurate is that assumption? In addition, are the causes of tightness and weakness being addressed? If not the situation is likely to be perpetuated.

Okay. We are getting close. We have seen that a structural diagnosis may be flawed and causes may be missed. We have seen that there is another type of diagnosis which is a statement about relationship. Relationship can refer to internal components or internal /external components. Relationship can be relatively static or dynamic. It can be historical and contemporary. Does this make our task easier or harder? Are we substituting one problem with another? How would we construct this diagnostic process? Do we have an idea about usual relationship and therefore a grasp of aberrant disorder? How many types of relationship are there? All of these questions and more may need answering if we are to replace a time tested method of cause-structural fault concept with something better.

Maybe it is not as hard as first it appears. Perhaps the body has subroutines which arrange into larger time and space routines giving the appearance of immense complexity. There may be simple power and factorial relations between these routines creating our diversity. If that is the case, each base routine can be trialed in much the same way as a vocabulary is learned and practiced.

I did some calculations on spinal movement. There are 79 basic movements for each spinal segment. Now there are 25 joints in the spine. If each joint was independent there would be 10 raised to 46 power combinations. This is not likely given joint dependencies. I discovered 9 possible relationships between the joints creating only 711 possible one step moves. This is a much more manageable number. Mastery of an even smaller number is likely to abolish a lot of suffering. The pelvis and shoulder girdle only slightly increase the numbers. It is still manageable.

The focus and diagnosis can now be restated. What spinal movements (of the 711) are competent and by inference which ones are incompetent and creating disabilities. Can the incompetent pathways be trained to competence or will they need to be quarantined out of life? Perhaps training will decide both.

Does this seem surprising? Life is a dynamic relationship, not a static entity that can be labeled. Without explicit recognition of this fact we will struggle in the wrong reference frame misdiagnosing painful disability and perpetuating the problem.

Perhaps some analogies will assist in understanding this problem. (See metaphors and insight section). For now, let's consider simple situations. Music capacity requires the ability to play notes, scales and chords. If there is a deficiency there will be different effects, depending on the music being attempted. The poor sounding music could be explained by "the difficult piece" which compares with cause in this essay, the abnormal notes (diagnosis), or from the new perspective the inability to play a specific chord. In other words the lack of skill in creating the "C minor" note is the primary difficulty, not the music or inappropriate substitute sound. Regardless of the number of causes which are found (difficult pieces of music) or the number of bad notes which are identified (component diagnosis) the problem will persist until C minor is achieved or all music containing such a note are avoided.

Consider the game of tennis. There are a number of basic strokes such as forehand, backhand, smash and volley. A player who lacks one of these strokes will win/lose depending on the opposition and the need for the missing stroke. The opposition in this case is the "cause" of the "diagnosis" win/lose. In both analogies we could draw the conclusion that a focus on the cause or diagnosis will not rectify the problem. Trying harder would be futile and frustrating. The dynamic fault needs to be recognised.

Spinal problems can be viewed from the same perspective. A lack of spinal skill (one of 711) will create situational causes and damaged components.

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