The unique assessment that doctors should be ordering for musculoskeletal pain

When you present to your doctor with a health problem of any kind, they will likely either directly perform or refer you out for some form of testing. This is so common that it would be unusual if it wasn't done.

According to a 2018 Centers for Disease Control (CDC) report, an examination, screen, lab test, or imaging study was conducted or ordered at 80% of office-based physician visits. And for a good reason, these investigations help doctors make objective decisions regarding patient care.

There's a saying in medicine that you can't treat what you don't understand.

You can't speculate whether someone has anemia, strep throat, or an underactive thyroid. You must test for it to make informed decisions regarding the most effective treatment.

The same goes for musculoskeletal pain. Proper diagnosis is necessary to apply the best available treatment and establish a reliable prognosis.

However, the tests we use to diagnose these conditions are less cut and dry than those we use for other problems.

Currently, the standard means of assessment for musculoskeletal disorders include diagnostic imaging and orthopedic testing. These investigations are designed to identify the anatomical structure causing symptoms and formulate treatment based on these findings. Unfortunately, most of these approaches don't find what they seek.

Unbeknownst to many, a fundamental failing of diagnostic imaging for musculoskeletal pain is its inability to consistently relate pathology to symptoms. What we used to deem as abnormal findings on X-ray and MRI are actually found in a sizable number of individuals who have never had symptoms. People may be told, for instance, that they have degenerative disc disease of their spine, a partial tear of their rotator cuff, or a bone spur in their heel, when in fact, these findings are innocent bystanders that aren't related to their symptoms.

The same goes for orthopedic testing. These commonly used tests are wrought with false positives and often tell us very little about the source of symptoms. Because of this, very few orthopedic tests are able to make a diagnosis on their own.

To base management upon these investigations alone has been seriously questioned in recent years. Thankfully there is a better option, one that can provide more helpful information regarding diagnosis, treatment, and prognosis.

This option is a McKenzie Method assessment.

A McKenzie Method assessment includes a detailed history and structured examination consisting of repeated movements and sustained positions. By noting the effect these mechanical loads have on a patient's pain, we can obtain a unique window into their pain generator that cannot be achieved through other forms of testing. This information allows McKenzie Method clinicians to classify patients into mutually exclusive subgroups based on specific patterns or characteristics of pain behavior attained through assessment.

Most conventional diagnoses, accurate or not, often don't tell the clinician what needs to be done to correct it. A McKenzie Method classification, on the other hand, directly influences and drives the management strategy. Essentially, the McKenzie Method is a diagnostic and treatment approach all in one.

A particular presentation leads to a specific classification with a precise treatment strategy and a predictable response to management.

For example, a McKenzie Method assessment can reveal if a patient with back, neck, or extremity pain has a directional preference, defined as rapid and lasting improvements in symptoms, motion, and function as a result of performing a very precise movement. Once a directional preference is established, treatment consists of the patient moving into their preferred direction while temporarily avoiding provocative movements and activities. Research has demonstrated a high likelihood of a successful outcome when this patient subgroup is treated this way.

Just as important, the assessment can reveal if a patient does not have a directional preference. These patients may still be classified into another McKenzie Method subgroup and managed in a way that is specific to their classification, leading to the most effective outcome for that individual.

We know that 75-80% of patients with musculoskeletal pain in the back, neck, and extremities can be classified in this manner. Another valuable component of the McKenzie Method is that management is rooted in self-treatment, freeing the patient from dependency on passive interventions. This lends itself well to long-term self-management and prevention of recurrences.

The information gained through assessment is also beneficial if a patient does not fit the criteria for a McKenzie Method classification. These individuals have shown to be better candidates for MRIs, injections, and surgery than the general population of patients with musculoskeletal pain. Therefore, the assessment helps to improve the selection criteria for these more invasive investigations and procedures.

The McKenzie Method also boasts excellent inter-tester reliability, meaning there is consistency between adequately trained clinicians. In the traditional model, it wouldn't be uncommon for a patient with shoulder pain to receive a diagnosis of bursitis from one provider, impingement from another, and rotator cuff tendonitis from a third. In the McKenzie Method, there is a strong likelihood that the same conclusion would be reached if multiple providers assessed the same patient.

These features make the McKenzie Method uniquely suited to bypass some of the previously mentioned shortcomings of traditional diagnostic methods for musculoskeletal pain.

This is extremely important since musculoskeletal pain is highly prevalent in our society and one of the more common reasons why patients consult healthcare providers. According to a study from the Journal of General Internal Medicine, musculoskeletal complaints account for 10% to 15% of all visits to primary care physicians, who then must determine how to manage these patients best.

By shifting their diagnostic paradigm and referring patients for this unique and highly effective assessment, doctors will be able to receive information that helps them make sound decisions on the diagnosis, treatment, and overall management of their patients with musculoskeletal pain.

Dr. Jordan Duncan was born and raised in Kitsap County and graduated from the University of Western States in 2011 with a Doctor of Chiropractic Degree. He practices at Silverdale Sport and Spine. He is one of a small handful of chiropractors in Washington state to be credentialed in the McKenzie Method.

This article originally appeared on Kitsap Sun: The assessment that doctors should order for musculoskeletal pain