Grappling with diagnostic reasoning and treatment

Research has established that health practitioners are unable to rely on tissue based diagnoses and justify the effects of manual therapy on mobility or tissue lengthening. There is a realisation that patients need a psychosocial approach alongside biomedical intervention. This has led to the development of several models for diagnostic reasoning and treatment by manual therapists. I’ll just discuss a few models here. It’s a challenge to osteopaths to really think about their diagnostic reasoning and treatment methods in light of current evidence. It’s something all the manual therapy professions are grappling with. 

Osteopaths reasoning

Osteopath, Eyal Lederman has developed a process based approach aiming at identifying and supporting the patient’s recovery processes rather than trying to influence biomechanics. The patient’s symptoms are identified as being in either the repair, adaptation or symptomatic recovery process or more than one of these processes. Treatment is then applied depending which phase the patient is in. 

Osteopath Fryer identifies the pain process – acute or chronic and neuropathic, nociceptive, central sensitisation or mixed. Manual therapy or psychosocial education are applied as the primary focus of treatment depending on the dominant process. 

Both of these osteopathic models focus on the patient’s presenting condition and process recognition. They do not include contextual, lifestyle and social factors such as sleep hygiene, physical conditioning, lifestyle, work and relationship satisfaction. Both models retain the focus of the practitioner as expert rather than a collaborative, patient-centred, values-based approach. They also do not emphasise active treatment and increasing self-efficacy as much as other professions. 

Chiropractic reasoning

Chiropractor, Newell proposes a Contextually Aided Recovery model from a chiropractic perspective. Touch, verbal cues and environmental cues are utilised as powerful stimulants for analgesia, and immune and motor modulation – maximising the use of placebo. 

Physiotherapy reasoning

Cognitive Functional Therapy has been developed by physiotherapists. This approach uses a wide range of biomechanical and psychosocial evidence to inform an individualised narrative-based treatment process. Patient-centred treatment processes include education, graded exposure, exercise and minimal hands-on treatment tailored to the patient’s values and goals. The aim is to reduce pain-related fear, catastrophizing and disability and change movement behaviour. Pain education aims to reduce fears and improve understanding and physical performance. The aims of treatment are to make sense of the pain through education and behaviour change, exposure with control through graded exposure techniques and lifestyle change aimed at achieving goals. 

There are many positive and different elements to each of these models.  Next week we will look at some of the objections to various elements of these models and then in the 4th week we will use an osteopathic perspective to provide a biopsychosocial osteopathic model for diagnostic reasoning and treatment for people with chronic pain. 

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