A Missed Diagnosis or Incorrect Treatment Plan?

Oncology. Cardiology. Obstetrics. Urology.Gastroenterology. Hematology.

Would you be open to the possibility of a practitioner beginning appropriate treatment for a diagnosis, yet the diagnosis is incorrect? Or forming an accurate diagnosis followed by incorrect or incomplete treatment for that diagnosis? Now, even though most of us are not quite “up to speed” with respect to all current or modern medicines or therapies within these fields (if you are, why are you reading this?!), imagine the plethora of negative ramifications of either scenario in any medical field. Let’s not even consider a missed diagnosis coupled with incorrect treatment for the diagnosis!

You may have noticed that I omitted the field of orthopedics from the list above; you know, that little area of medicine assessing and treating the musculoskeletal system, including but not limited to surgeons who replace and and repair knees, hips and shoulders, and physical therapists that rehabilitate them. The same healthcare providers deal with back pain and vertebral/disc derangement every day, predictably facilitating thousands of people back to active pain-free lives every month. What happens if they miss a diagnosis or treat inaccurately or incompletely? Or both? 

If you were having back pain (maybe from doing dentistry with less-than-ideal posture every day. I know, you can’t even imagine how bad that would be, right?!) and you wanted the pain to go away and to find out what could be done to keep the pain away. You would expect the physical therapist and/or the orthopedist to:

• Listen to your history
• Complete a thorough exam
• Evaluate the signs, symptoms and history collectively
• Form a working diagnosis
• Treat accordingly
• Assess and re-assess during treatment for possible necessary “course corrections”

Would you be open to the possibility that some physical therapists could perform different examinations (maybe more thorough) than other therapists? And that some could have different ways to assess and form a diagnosis? And even different treatment plans? And different treatment modalities? Was their formal education that different? Or do some seek out high-level post-graduate education that separates them from others, resulting in more thorough examinations, systematic assessments, accurate diagnosis, and predictable treatment?

And some patients don’t know that difference. Until they do (hopefully)... like me. I like to stay pretty active by running, cycling, swimming, hiking, etc. on a fairly regular basis. Needless to say, I have encountered some pain, inflammation and tightness many times in the past.

And just like you and your patients, I play through it, slightly altering form or flow while taking anti-inflammatories until one day it’s just gone. 

And sometimes, also just like you, I still do the run when friends are in town, or still play softball and run the bases harder than I should, or go on a long bike ride even when it’s hurting pretty bad. I might have even played two hours of “bubble soccer” with a pretty tight and painful back one day. And when I did, I had some of the scariest pain that I have had in a while (yep, that’s me with my horizontal. One of many, many times that day). So bad that I found a physical therapist who was close to my house and could get me in within a couple of days. Sound familiar?

It seemed like she heard my story, although she was really focused on making sure all of the lines were properly filled out on her exam sheet so that the more senior/owner therapist would not reprimand her. Her exam was pretty quick, as was her diagnosis. I assumed that it was just a typical “SI joint” patient that must always have some “piriformis issues” and collateral “gluteuss medius” pain. I was actually relieved that I was a typical patient and that her diagnosis and treatment plan were so simple. There was hope and I was excited to be healthy again. I did my strengthening exercises and stretches religiously and went to my appointments at least two times a week ... for two months. I was frustrated and my hope started to wither. I happened to be traveling to Portland and had dinner with a dentist friend of mine, who happens to be married to a physical therapist.

He listened to my story differently. He asked different questions. He was respectful of the other practitioner but eloquently questioned the diagnosis. And if the diagnosis was wrong, the treatment I was having was wrong, although would have been very appropriate for that diagnosis (sacroiliac joint dysfunction). So he asked if he could evaluate me. Heck yes!!  His exam was different. He looked at different things. He had me do some stretches and movements and asked what I was feeling. Did it get better? Did it get worse? Did it stay the same?  He suggested that I try something different for just a couple of days and see what happens. I noticed a difference in a day.

I happened to be traveling later that week to my home town, where my sister lives and just happens to be a physical therapist, you know, the one who you don’t want to bother from long distance when you are in constant excruciating pain. Yes, the one who wants to cause you pain when she finds out what has been going on and that you didn’t call). So, after listening very carefully to my story, she asked me some questions, did an evaluation, had me try some movements and stretches and asked more questions. It was like a repeat of what my friend in Portland had done. Almost exactly!!

So, I wanted the same experience and care when I returned home to Arizona. How could I find someone like that? Why were they the same, yet different from my first physical therapist?  Were there more like them?  They had both become very passionate and committed to treating patients differently, something that they learned after their formal education. They took time out of the office. It was not inexpensive. It made sense to them. This particular continuum has a website listing other practitioners in the U.S. and around the world who have taken the courses. And on the website, I read this about the philosophy:

The clinician takes clues from the history about the effects of specific loading strategies on symptoms. During the history, the clinician begins to formulate a differential diagnosis. First, is it a problem with a mechanical influence, a medical influence, a biopsychosocial influence or any combination of the above? Second, if mechanical, which of the syndromes is likely the diagnosis: derangement, dysfunction, posture or “other?” The physical examination which includes a series of loading strategies confirms or refutes the postulated diagnosis.

Benefits

• Scientific Basis
• Early Prognosis
• Prevention of recurrence

Almost eerie how familiar that sounds, right? It actually made me feel proud about my dental background and the work I do today, with patients, and dentists and teams.

Would you believe that when I got home I found someone who had also done the training and who was also passionate about and trusted the process? I was not surprised, but still excited that he listened carefully to my story, did the same thorough evaluation, systematically came up with a treatment plan that he felt should predictably make me feel better and that I should be able to remain pain-free without needing to see him on a regular basis.

As I write this article, I am two weeks into the new stretches, exercises and treatment. I have seen him or one of the other trained therapists in this practice only four times so far. I feel better in the last two weeks than I have in the past six months. I have hope. I am excited to be healthy again. My friend in Portland is different. My sister is different. My therapist in Arizona is different. If you are reading this, you are different. And you should be proud.

In the next article, I will review with you some steps that you can take on a regular basis so that your patients continue to tell their own version of my story. 

Kevin Kwiecien, D.M.D., M.S., Spear Faculty and Contributing Author