Sometimes, I just don’t know. Okay?
“If the MRI didn’t show anything, then why is my back so painful?”
Diagnostic testing doesn’t quite add up, orthopedic/mechanical testing is inconclusive, and impairments don’t correlate with the degree of pain and functional limitation.
Sure - think outside of the box. Is this patient struggling with anxiety? Do they want to be off the field? Have they consulted Metzger Wickersham?
Am I missing something, worse yet, something obvious? Is my focus off? My mind is racing, searching the archives in the hopes of churning up some test or piece of evidence. Exactly how long do I sit there in the dust and ashes of clinical prediction rules? Where’s that elusive fact or technique that's the sun to burn away the fog?
What am I going to do with you? Well. ... First....We're gonna...
Patients and PTs like to know what's happening, but how much exactly do we need to know? “Non-specific” low back pain is a term universally recognized in the medical field. If experts investing loads of time and funding into peer-reviewed research aren’t afraid to admit when they’re uncertain, why should the common therapist?
While knowing the exact mechanism or injured tissue (i.e. herniated disc) can help guide treatment, merely knowing rarely guarantees a good or bad outcome. The actual tissue injured in a joint is far less important than knowing what movement(s) can effect lasting improvement. Patients don't like that, but it's the truth.
What if PTs were eager to explain why they're uncertain? What if PTs weren’t afraid of losing 4 units or being “shown up” by another therapist with a different perspective? Far worse things can happen, you know, like the rote application of the same ineffective treatment and the loss of respect for our profession.
There’s a fine line between speaking with confidence and speaking fables. We can all easily come up with fancy medical terms and string them together in a circle. I’ve helped many people to make incredible recovery, but certainly not everybody. I’m getting better at being okay with that.
When will be the day that I'll arrive as a seasoned therapist? Never. I’ll do all that’s in my power to learn and schedule more than 15-minute time slots for patient evaluations. The number of books above our desks and letters behind our names do not earn us infinite wisdom. Or less time to listen.
I won’t always guarantee great outcomes, but I will shoot for truth, to the best of my ability.