Clinical reasoning in spine pain

Clinical reasoning in spine pain (CRISP) is an evidence based approach for the evaluation and management of spinal pain conditions. It sorts out the multitude of theories and methods, leaving only the most practical and relevant treatment options. This approach combines and utilizes effective techniques from a variety of therapeutic disciplines. Most importantly, there is the recognition of the need for patient education and self-management strategies.

The Current Model Could Benefit From Some Improvements

There are several reasons why a new model is necessary. First, costs for the treatment of spine pain have been rising for decades. Recent estimates are as high as $87 billion/year. The  increase in cost can be attributed to unnecessary imaging studies and premature utilization of invasive procedures. Also, there are many chiropractic and physical therapy clinics that tend to treat more than necessary. CRISP advocates to treat as little as possible during acute pain. Instead, patient education in regards to movements, posture, stretches and exercises are encouraged.

Next, there are too many specialized fields that don’t communicate. The treatment a patient receives is often determined by the type of practitioner he or she sees, rather than by the specific needs of the patient. For example, a chiropractor may only perform spinal manipulations. Physical therapists may only use generic strengthening protocols. Pain management specialists typically only prescribe medications or injections.

CRISP is effective and efficient because of its integrated approach, incorporating multiple therapeutic options. However, treatment is not applied until a key detailed history is taken and a battery of orthopedic tests are utilized. It is understood that no single test can determine an exact diagnosis. However, a clear clinical picture can start to be appreciated once proper questions are answered and appropriate testing is performed. This can minimize imaging costs and ensure a correct course of treatment from the start.

Recommended Treatment Methods

The tissues most likely to be pain generators are discs, nerves, joints and muscle. For disc pain, either McKenzie protocols are utilized or some form of traction/decompression. In treating nerve pain, NSAID’s and or steroids are usually recommended in the acute stage, followed immediately by decompression and nerve mobilization techniques(Neurodynamics). Spinal manipulation is the treatment of choice for joint pain and especially joint fixations. Most commonly, joint and muscle pain coincide, making it appropriate to apply soft tissue techniques in conjunction with spinal manipulation. These soft tissue techniques may include myofascial release, trigger point therapy, and one of the various modes of stretching. Passive therapies such as interferential, heat, ice, etc. are utilized for acute muscle spasms, strains, and inflammation.

Pain Related Factors

The most common component of chronic back pain is dynamic instability. This instability coupled with poor posture and movement patterns is also a risk factor for recurring back and neck pain. For these chronic and recurring conditions, patients are educated on the importance of strengthening. Without exercise, muscles weaken and the joints, tendons, and ligaments accumulate more stresses. This is why functional rehabilitation, posture correction and ergonomic training are heavily emphasized.

Finally, the biopsychosocial model is also considered when working with spine pain. This is because 50% of chronic pain sufferers also have an underlying psychological component that exacerbates the pain experience. Some examples of this are fear avoidance, catastrophizing, passive coping, depression and even nociceptive system sensitization (hypersensitive pain experience). Listening to and developing a healing relationship with patients is often necessary when dealing with chronic pain. In these instances, yoga, mindfulness meditation and even acupuncture can be appropriate courses of treatment.

One final benefit of the CRISP model is that it offers individualized care and proper guidance. There is no one set strategy that will work for all the varieties of spine pain. However, this is what many people are promised when encountered with the large number of products and services available. With the help of a primary spine practitioner, patients can be educated on which products may help and what to absolutely avoid.

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