Referrals from Dr Google
Why Dr Google isn’t always enough.
A colleague of mine in Canberra recently saw a teenage girl whose mother had noticed a curve in her spine. Her mother was worried and took her daughter to her GP. She was diagnosed with a Scoliosis and referred for X-rays. The X-rays suggested the curve was so pronounced she was a candidate for bracing and/or surgery and the GP referred her to Canberra Hospital. Due to the nature of a regional hospital, Canberra didn’t have anyone appropriate to help the girl and sent her away. Unfortunately, they didn’t provide any further referral advice.
As the mother was a client of my colleagues, she asked if she could review her daughter’s situation. My colleague assessed her, read the report, looked at the X-rays and agreed with the findings. Your garden variety Scoliosis* is rarely anything to be concerned about but this girl’s Scoliosis was very pronounced and due to her age, was at risk of progressing with potentially serious side effects. My colleague knew, in this case, her place wasn’t in providing hands-on therapy or exercise advice. The young girl didn’t have any pain. She reassured both the parent and young patient she would look into what the protocol was from this point.
The Mishits
My colleague completed a Google search of her own. The initial hits were private clinics offering exercise therapy from physiotherapists and spinal alignment from chiropractors. Either of these methods, even with the fanciest websites, and expensive treatment programs weren’t offering much for a spinal curve that could impact the long-term health of this young girl. As an Osteopath interested in the evidence behind making decisions in clinic she dug a little deeper and started to search journal articles and systematic reviews about Scoliosis.
Good advice, and therefore opinion, should change as new research enters the fold; exercise, bracing and surgery were all still in the offing but they were used for different grades of Scoliosis. And she was no closer to finding an expert who could help this young girl with her choices.
The Resolution
Many health professionals, especially Osteopaths, often work in isolation. For a whole lot of reasons it can be hard to communicate with other health professionals. It’s called cross-referral.
My colleague rang me to discuss the situation. I followed up her phone call by speaking to a friend who is a paediatrician at the Royal Children’s Hospital in Melbourne. She suggested sending her to a big centre in Sydney to see a paediatric orthopaedic surgeon for assessment and advice. Her advice emphasised consulting a bigger centre as even bona fide specialists are prone to working in isolation. They might have forgotten to keep up with the evidence and then you can be right back where you started.
There are also particular ways to take an X-ray of a Scoliosis that give a more accurate measure of the curve. A big centre will organise this and it may mean this girl is not in as dire situation as her report suggests. That’s worth knowing.
Occasionally, especially when it comes to making decisions about our health, we find ourselves at a loss, and we turn to Google for advice. As magical as Google is, it doesn’t always cough up the best evidence-based advice. There are a lot of people with something to sell, trying to make their living on the WWW.
There are also some amazing people, who have studied a long time and continue to gather the evidence, and question the current dogma in support of what they do. They may not have as much time to construct websites and complete digital marketing strategies that mean they’re ‘top of the pops’ on a Google search. What they do have is more than an opinion. In the case of this young girl, she was best off to navigate the fragile behemoth that is our amazing public health system. My colleague, an Osteopath, has the skills, contacts and strategy to help her navigate the system, interpret the advice and provide reassurance. She will also be there to help rehabilitate her after intervention with movement advice or provide pain relief - should she need it.
My take home point
The health professional you visit, whether it’s your GP, Osteopath, Maternal and Child Health Nurse, Naturopath or Dentist, should be interested in providing advice and treatment based on current best practice, science and research.
Times have changed and will continue to do so. The healthcare/medical sphere is continuing to evolve. As a consumer, it is in your best interest to seek out the professionals that are interested in treating you in this manner because then your healthcare complaint will be managed with the most current information available - NOT ‘this is how we’ve always done it’.
The Osteopaths at Fairfield Osteopathic Clinic are all university trained in their area of expertise. They know their limitations. They have the skills to navigate the healthcare system and will better equip you in your journey. As Osteopaths we also have more time to provide this extra support you require ….. GP’s are VERY busy people.
(1) Epidemiology of adolescent idiopathic scoliosis. Markus Rafael Konieczny, corresponding author Hüsseyin Senyurt, and Rüdiger Krauspe. J Child Orthop. Feb 2013; 7(1): 3–9.
* Very few humans on this planet have ‘perfect’ alignment. Millions of people have Scoliosis (1) - a sideways curvature of the spine - with no undue stress or strain placed on any part of our bony structure, or the muscles and ligaments that attach to it.
Extra information
The Internet is an amazing resource, full of information and misinformation. This is a great link that questions the value of opinion: http://theconversation.com/no-youre-not-entitled-to-your-opinion-9978
You can't take a picture of your pain.
by Mark Cooper
It may surprise you to know that two out of every three people you meet today walking your local streets of Northcote, Fairfield or Alphington will have some kind of abnormality of their spine, be it bony change, disc bulge or spinal curve, and they will have absolutely NO PAIN!
That's right folks, they are getting on with their inner-north-hipster-cold drip coffee culture lives totally oblivious to the changes in their low backs. I hear you ask "How can this be?"
These changes are, for the most part, a normal process of ageing and the body is very good at adapting. What the research boffins know is that without a doubt MRI, CT scan and X-ray results DO NOT predict the amount of pain you will be in or even that you will experience pain at all.
I outright avoid sending people for scans. There is a time and a place to order them, especially if there are serious indicators, however, there is an ever growing issue regarding the amount of medical imaging being ordered across all facets of health care. But I'll focus on my niche area - LOW BACK PAIN.
A systematic review and meta-analysis (that is the bees knees of research thoroughness) was done on imaging strategies for low back pain in 2009 and published in the Lancet Journal (that's a seriously good place to land your research study). The findings were as follows:
"Lumbar imaging for low back pain without indications of serious underlying conditions DOES NOT (my emphasis) improve clinical outcomes. Therefore, clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low back pain and without features suggesting a serious underlying condition." (1)
Have you heard the one about the man with low back pain who walks into the Osteopath/Chiropractor/Physiotherapists' clinic? From the history and examination there is no indication of anything sinister. Three treatments later with no change to the patient's pain experience, he is starting to get concerned and lose faith in the practitioner's ability to help him. The practitioners ego is taking a battering so they need to bump up their authority with the words "better get a scan" and "this doesn't look good". Low and behold the scan report has some big foreign words in it. Words like osteophytes, foraminal encroachment, decreased lumbar lordosis - could it be any worse? This confirms the patient's fears and they immediately start to feel negative about their prospects of making a full recovery. Their mind starts racing with black cloud scenarios like, "I'm going to have to stop running, I'm only 45 and how am I going to play with my kids?" Crotchety Uncle Brian appears in his mind, fast asleep in his wheelchair at Christmas after his third back surgery, drooling from the mix of codeine and alcohol in his system. Often all the practitioner has to offer is "I told you so - it's bad - you're going to need to see me a lot in the future." The patient is disempowered from every angle.
There are real dangers of associating findings on an X-ray to a patient's experience of pain. Pain is complicated (ouch, there is that word again). It hurts my brain how complex pain is, no wonder patients and practitioners across the board avoid explaining it properly. Pain is a process driven by the brain and negative reinforcement of a patient's pain may be extremely detrimental to their recovery.
Scans can also be used against you in a massive sales pitch from dodgy practitioners. Treatment plans will usually involve 'straightening' your spine with manipulation three times a week for six months and 'oh, could you pay for that up front'. Other practitioners might show you how to strengthen your core in any number of ways - most of them will be expensive and involve you handing all sorts of power over to them.
The best evidence suggests that most cases of serious low back pain resolves within weeks. A bit of reassurance, good advice and pain relief from a competent practitioner might help and leading an active, healthy lifestyle should be the primary prescription going forward.
At Fairfield Osteopathic Clinic we are always cautious when ordering scans for patients. Even when patients present with scans (that we didn't order) we try to use positive language to explain the results and findings, as the pictures of your insides do not reflect the way someone is feeling on the outside. Remember you can't take a picture of your pain.
1. Dr Roger Chou MD, Rongwei Fu PhD , John A Carrino MD, Prof Richard A Deyo MD - The Lancet, Volume 373, Issue 9662, Pages 463 - 472, 7 February 2009