Pathoanatomy vs Psychosocial: Back to the Future?

The debate between "diagnosis" vs "no diagnosis", and the "pathoanatomic diagnosis" vs "psychosocial"  approaches to the assessment and management of pain is prominent in social media circles. Sides are chosen, battle lines are drawn and shots are fired in a battle that is fought between colleagues from within- and between professions. Many enter the battle without fully understanding the concepts of diagnosis, central sensitisation and psychosocial modifiers and how they are all related. Some steadfastly defend their position for other reasons.

Like anything in healthcare, nothing is ever black and white, and if we choose a side and take up arms against the perceived enemy, the biggest casualty ends up being our patients. 

Flavio Bonnet from the Agence EBP provided the forum for a discussion on this topic  between myself and Dr Mark Laslett. In a live social media event, we discussed the relationship between patho-anatomic diagnosis and psychosocial factors in our respective areas of low back pain (Mark) and shoulder pain (myself). The discussion streamed live on Facebook, Twitter and Instagram from Christchurch, New Zealand on 18th March 2019 with the event viewed by more than 7,500 people from around the world.

In this series, I provide a summary of the main points from the key topics in our discussion:
1. Is it possible to make a diagnosis?
2. Does the pathoanatomic approach ignore the psychosocial aspect of the pain experience?
3. What do you say to colleagues who say that diagnosis does not change treatment?
4. How does imaging relate to diagnosis?
 
You can also watch a video recording of the full discussion by clicking on the link below.  
Link to video on Twitter: https://twitter.com/marklaslett_NZ/status/1107733389300240384

---

PART 1. Is it possible to make a diagnosis?

Download a more detailed summary of this section here:

PART 1: Is it possible to make a diagnosis?

 A summary of discussion points on this topic is provided below. To download a more detailed transcript on this topic, click on the file link below. 

SUMMARY:

• Diagnosis is a 3-part process that includes identifying the source, cause and modifiers of pain.
• An important part of the diagnostic process is to exclude serious medical conditions, or conditions that required different management. It is just as important to know what the patient "hasn't" got. 
• It is important that all members of the primary health care team speak a common diagnostic language and use agreed, evidence-informed management pathways. 
• Lumbar spine: for some patients a specific diagnosis is possible. But you don’t always need a specific diagnosis.
• Shoulder: In most cases a specific diagnosis is not possible using clinical tests alone. A staged approach is best, using clinical classification, followed by imaging if this is required to inform further management.

---

PART 2: Does the pathoanatomic approach ignore the psychosocial aspect of the pain experience?

Download a more detailed summary of this section here:

PART 2: Psychosocial Factors

In Part 2 we discuss the relationship between pathoanatomy, central sensitisation and psychosocial factors, and look specifically at:

1. Differences in central sensitisation and psychosocial factors in low back pain vs the shoulder
2. How do psychosocial factors influence diagnosis
   
3. What takes precedence for treatment: psychosocial factors or pathoanatomy?
   

SUMMARY:

• Central sensitisation and psychosocial factors are modifiers of pain, not a cause of pain.
• Persistent pain does not always mean ‘central sensitisation’.
• Persistent pain may reflect persistent pathology.
• It is possible to reach a pathoanatomic diagnosis in someone with significant psychosocial modifiers:
  • but they may confound pathoanatomic diagnosis
  • it (diagnosis) must be carefully worded and communicated to the patient.
• Pathoanatomy would take priority for management in serious injuries such as unstable fractures or dislocations.
• Significant psychosocial factors should be prioritised early in treatment as they may present a barrier to recovery

---

PART 3: Does diagnosis change treatment?

Download a more detailed summary of this section here :

PART 3: Does Diagnosis Change Treatment?

In Part 3 we discuss whether we need a diagnosis in order to treat a patient effectively and, if so, what types of diagnoses are helpful in guiding management?

SUMMARY:

• Diagnostic process is important to exclude serious pathology in primary care settings. These pathologies influence treatment (cancer, rheumatoid arthritis etc).
• Diagnosis does change treatment for many conditions.
• Many acute LBP conditions may not need a specific diagnosis and can be managed with guideline-based care. However, if the patient is not progressing “diagnosis” becomes more important.
• Diagnosis is important in traumatic shoulder injuries to identify conditions that require early surgical management (e.g complete subscapularis tear) or when it will alter prognosis.  
• A specific diagnosis is not required when it doesn’t alter management or prognosis. E.g subacromial bursitis, supraspinatus tendinopathy, atraumatic partial-thickness, or small, full-thickness tear.

PART 4: How does imaging relate to diagnosis?

Download a more detailed summary of this section here (includes references):

How does imaging relate to diagnosis?

In Part 4 we discuss where imaging fits in the diagnostic process, who should we be imaging and how to interpret the results in the context of a high prevalence of findings in asymptomatic populations. 

SUMMARY:

• Clinical examination is the start point from which you decide if imaging is even necessary.
• The high prevalence of asymptomatic findings on imaging means you cannot make a diagnosis of symptomatic pathology based on imaging alone.
• Don’t treat the imaging, but equally, don’t write off imaging findings as ‘asymptomatic’ if the clinical picture fits.
• Some imaging findings DO give us a diagnosis and are useful.
• Imaging or surgical visualisation as a reference standard in diagnostic research tells you nothing about whether the ‘structure’ is symptomatic. 

---

Questions from Social Media:

Specific vs "Non-Specific" Pain

Download a summary of this section here:

Specific vs Non-Specific Pain

SUMMARY:

• Diagnosis of "non-specific" pain is appropriate only if you have excluded clinically significant entities. 
• It may not be possible, or necessary to achieve a specific diagnosis for some patients. For these patients symptom-based approaches to treatment are appropriate. 
• We cannot make a 'specific' diagnosis of most shoulder pathologies using clinical tests alone. Imaging is required in some cases to confirm/exclude certain conditions.
• Shoulder conditions can be clinically classified:
  • ​STIFF  SHOULDER
  • UNSTABLE SHOULDER
  • ROTATOR CUFF
  • ACROMIOCLAVICULAR JOINT
• Where specific management exists for specific conditions, we are doing the patient a disservice by ending the diagnosis process prematurely and assigning the label "non-specific" pain. 
• Making a 'specific' diagnosis is about manipulating probabilities based on the known prevalence of specific conditions in specific populations, combined with supportive clinical data. 

---

How Do You Manage Psychosocial Factors in the Clinical Setting?

​Download a summary of this section here:

Managing Psychosocial Factors

SUMMARY:

How do you interpret the results of randomised controlled trials when they include such a wide spectrum of patients?

Download a summary of this section here:

Interpreting Randomised Trials

SUMMARY:

• RCTs provide an average (mean) value of change in the outcome of interest.
• Average values may mask true treatment effects in some individuals.
• Systematic reviews are 'averages of averages'.
• Be careful interpreting RCT's looking at outcomes of interventions for patients with 'subacromial impingement'.

Do you use manual therapy in the treatment of shoulder and low back pain?

Download a summary of this section here:

Manual therapy for shoulder & LBP

SUMMARY:

• Manual therapy is relevant for shoulder pain and low back pain, including acute conditions if not contraindicated.​
• In LBP, manual therapy in the form of acute lateral shift correction is essential. 
  
• When used, care must be taken not to impart unrealistic expectations of manual therapy that might create dependence. 
  
• When used in the context of short-term symptom modification, combined with education and progressive exercise, it is an appropriate modality for shoulder pain.
  
• Technique selection is guided by symptom modification and how each technique influences patient-specific impairments.