Diagnostic Discrimination
Listen to this interview from NPR with a nationally recognized expert on back pain, James Weinstein, D.O. and maybe you'll hear what I heard.
Diagnostic discrimination.
Dr. Weinstein has chronic lower back pain, sometimes so bad that he's not sure if he can make it through his clinical day, yet has not been worked up for it, has not had any imaging studies, and has no diagnosis. His treatment? Ignore it, keep running, change nothing. Dr. Weinstein believes that "hurt does not mean harm." So, just because his back hurts, he can't stand up or perhaps walk, doesn't mean he has harmed himself.
He clings to the outdated notion that 90% of all back pain sufferers will be fine within a few months of the first onset of back pain. What he fails to mention that although this is true, nearly all will still be complaining of back pain and related disability one year later*.
His thinking makes no sense to me. If you spend an afternoon working in your garden and the next morning, your back hurts so bad you cannot stand up straight, you're injured. Period. All movement or activity or exercise that exceeds your body's capacity results in an injury. The only question is how badly are you injured? Injury is the transfer of energy causing an interference of cellular function resulting in physical function decline. If you go to the gym, workout, and hurt the next day, you injured yourself. Two days later, maybe you're fine. In that case, the injury was mild. Get hit by a truck? Big injury.
I say, he's in denial. In fact, when the interviewer asked him why he had not had an x-ray or MRI, or been diagnosed, he said it was probably because he was afraid of what he might find out. Hmmm....I've had a swim or two in that river. Murky, mucky, filled with all sorts of crap that seeps its way into your brain convincing you that you're really swimming in a pristine pool of cool, clear aqua.
Dr. Weinstein does make sense though in his general approach to back pain. He believes that movement is the key to overcoming (although not solving) back pain but what he's missing is an understanding of the consequences of arbitrary movement. His advice is just to grin and bear it. Muscle through it. The result for him? Dr Weinstein has resigned himself to a lifetime of episodic back pain and that's just the way it is. He's just going to have these days when, out of the blue, as if the Back Pain Fairy sprinkled pain dust on him, he's all knotted up and crippled. He has no plan other than to just keep doing what he's been doing. He has no plan on solving his back pain because he doesn't believe it can be solved. Unfortunately, his view is what his patients get as well.
Does it make you wonder if other types of physical problems get this
sort of treatment? This almost medieval, Braveheart approach? Can you
imagine? Sprained ankle? Yeah, sure , run on it! Oh, and that
subluxing shoulder? No problem! Just keep lifting weights! And, oh,
your Achilles Tendon hurts? Sure - sprint! It'll go away!
The answer is no. Other body areas are treated entirely differently than the spine. Back pain sits at the back of the diagnostic bus. Back pain suffers from diagnostic discrimination.
And to prove my point, I'll tackle one of the most common back pain diagnoses that is actually not a diagnosis at all and tell you why clinicians still cling to it as their diagnostic woobie.
But, that's another day. For now, let's bring back pain to the front of the bus.
Make today count.
Doug Kelsey
*Croft, P. R., G. J. Macfarlane, et al. (1998). "Outcome of low back pain in general practice: a prospective study." Bmj 316(7141): 1356-9.











