Last week, I did a blog based on a podcast I listened to about whether or not you need a Medical Diagnosis (before treating a patient). Check it out here: https://www.fourleg.com/Blog?b=577
So, while I was listening to the podcast and writing up the blog, I thought of innumerable patients and cases. So, this blog is about them!
This was the wife of a cousin (sorry, this is a human case) that approached me at a community function to ask me about her back pain. She had radiating leg pain, to the point that she wasn’t able to walk without a walker. She was moving a bit better, but was worried about the pain and whether or not the physio she was seeing was doing the right things or not.
The short history is that she had gotten up out of one of those Adirondack Chairs (they sit low, knees are high… but generally, you sit in them on a deck, drinking cocktails, while at a cottage somewhere), and had immediate back pain that radiated down her leg. She went to the doctor, was referred for an x-ray, and was subsequently told that she had degenerative discs and a pinched nerve. She was then referred to physio.
She was devastated! “How could the physio correct the degenerative disc? That was permanent!”
So, I gave her my 14-year-old-girl speech about inflamed nerves. (See here: https://www.fourleg.com/Blog?b=454 )
She listened intently, and as a former junior high vice principal, she understood the analogy perhaps better than most!
She thanked me, with renewed hope, that all that was needed to be accomplished was to shut up the 14-year-old girl living in her back, and her posse of ‘girl-gang’ residing in her spine and brain that were perpetuating the ‘over reaction’ to a little pinch!
I further told her, “You had those degenerative discs years before you sat down in that chair! There is no reason to believe that this is a permanent conditions. Nothing in your back has changed except that a nerve got inflamed and is now still overreacting.”
In this case, the Medical Diagnosis didn’t change treatment and was in fact detrimental to recovery.
A client drove from another city to come see me. Her dog had been diagnosed with lumbosacral disc disease. She was devasted. This was a high energy border collie, and while the owner had come to terms with the fact that her dog wouldn’t be able to compete in sports, she was simply hoping that she could be functional and pain-free enough to enjoy life and maybe play around a wee bit at being more than a couch potato.
So, my assessment was my typical assessment… evaluate all things biomechanical and structural. I don’t even remember, I might have found an SIJ dysfunction (they can typically interfere with lumbosacral junction ‘happiness’), and I may have found L7 or L6 pain on palpation. Really, it doesn’t matter, because I would have mobilized what I found to be painful, and mobilized L7 regardless of what I found.
Treatment has included shockwave, laser, acupuncture, PEMF, and mobilizations when the patient comes IN to clinic (once a month or somewhat less frequently, depending on time of year and road conditions). Home program has included tail pulls and ‘pelvic tilt’ exercises.
And what has happened? Well, this little dog can play in both agility and flyball. Not competitive, but for fun! She has been fantastic! If she is sore afterwards, then the owner knows what to do in regards to tail pulls or short term NSAIDS as required. The owner no longer panics when she sees a bit of a ‘rounded back’. She has tools to manage this!
Perhaps most importantly, the dog is still having fun! The dog has outings! The dog gets to play the games it loves! I call this a success story.
Does this dog need fancy imaging? No. Does it even need a radiograph to confirm it? Not necessarily. Many lumbosacral disc disease cases don’t show anything on x-ray anyways. A practical / presumptive diagnosis tends to be all that needed. Evaluate. Make a physical diagnosis. Try some treatment. Evaluate the results. Regroup if necessary. Continue on and/or progress as needed!
This is an ‘ugly’ case. This time I saw a dog, a previous patient at the clinic, but new to me. It’s regular therapist was on vacation, and the owners were very concerned about a new development. The dog was lame on a front leg.
There had been a history of cancer, but for the life of me, while typing this up right now, I can’t remember where.
I started, as I always do: History, and then I evaluate everything ‘neuromusculoskeletal’. No joint pain. No tendon pain. No muscle pain. No spine pain. Full range of motion. Non-weight bearing lame. Occasionally lifting the leg up as if experiencing pain. Tremendous atrophy of the triceps.
This was an case where I then sat back and had that tough conversation. And “tough”, because I CAN’T make this diagnosis, but I NEED to get the owners to somewhere that can, and I need to give them enough information to get them to take prompt action and tell them my concerns in a compassionate way.
I am very consistent with how I phrase my thoughts on cases such as this. Here’s how THIS conversation went.
“I can’t tell you what this is exactly, but I can tell you what it’s NOT based on my exam. This isn’t a joint issue, or a spine issue, or a muscle or tendon issue. I do think it’s a nerve issue, but not from a typical cause (i.e. pinched nerve from a degenerative disc or disc herniation). What I cannot rule out is a tumour or some other weird nerve problem. I think you would be best to go back to your vet in order to get a consult with the neurologist and/or do some testing. I’ll write them a note, so that they know what I’m thinking, which might help speed up the process.”
Sadly, it turned out to be a nerve tumour. However, as happened in this case, and what typically happens, is that the owners called back to update us and THANKED US for guiding them in the right direction.
So, here’s a case where a MEDICAL DIAGNOSIS is necessary before any treatment decisions can be made!
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So, there you go. Putting this all into perspective clinically. Let me know your thoughts!