The paradigm for managing spine-related conditions continues to evolve. Models that proved highly effective in health care when dealing with infection or significant trauma have continued to show limitations when applied to nonemergency neuromusculoskeletal (NMS) conditions. Ongoing research shows the limitations of oral medication, injection therapy, and spinal surgery. This is not to say these are unreasonable treatments, but suggests that they should be applied judiciously and only after or in conjunction with conservative clinical care—“the right treatment, for the right person, at the right time.” We are now seeing written policy codifying the needs to attempt conservative care prior to more invasive measure such as opioids and surgery.^1,2 This shift in public and policy maker awareness has been heightened because of the current opioid epidemic (and rising disability) and has shown efficacy in emphasizing conservative management.^3,4 Opioids are recommended for only select patients for a limited duration of time.⁵

This chapter will outline a clinical framework (CF) that emphasizes self-efficacy and patient involvement in health care. It is one that centers around the informed and educated patient and it should not be lost that education pervades every aspect of care from history, to in-office active care and home care recommendations (see Chapter 13). Contemporary clinicians will do this using evidenced-influenced decision-making with a focus on patient-centered care and functional gains. Individualized goal setting, consideration of biopsychosocial (BPS) factors, and a focus on an outcomes-based strategy are some of the hallmarks. The steps outlined in this chapter are reinforced in the chapters that follow in this section (Chapters 38 and 39). The framework that follows will guide clinicians from history and initial assessment, through clinical thought process, patient education, progressing active exercise, and discharge to self-care.

The CF will guide our process and at the same time be more formless than a protocol. The framework will serve as guardrails and waypoints for clinical assessment and intervention. Eighty percent of our patients will follow the scalable principles of modern BPS care outlined in the second part of this chapter. These scalable principles involve steps to address overprotection and under-preparation via reassurance and reactivation. At the same time, the CF recognizes that each condition and each individual is unique. When dealing with a dynamic system, like the human being, living in a dynamic environment, a precision approach which adapts to the individual by consistently probing for responsiveness will be needed to “tune” our approach approximately 20% of the time.

The CF has several hallmarks. It is patient centered, evidence influenced, recognizes the BPS model, scalable, and individualized in an agile manner—when necessary—in its delivery (Fig. 37.1). To do this effectively, one must begin by building trust and confidence in the process (Fig. 37.2). It is recommended that the clinician begin with empathetic listening as it leads to better quality care.^6,7 Using empathy, a skilled clinician can demonstrate understanding of the patient’s statements, probe for more information, and build confidence through motivational interviewing.^8,9 With empathetic listening and motivational interviewing, the doctor-patient relationship strengthens. Once the patient feels they’ve been heard, and that they’ve been understood, trust both in the doctor and in the process grows. This lays the framework for the final piece of history taking and doctor-patient conversation, reassurance including education, and empowerment of the patient. Laying the groundwork that change is possible, growth can occur, and this is within the control of the patient is essential for driving toward autonomy and clinical success. These ideas just need to be offered or touched upon at this point as they will be enforced and solidified later through the assessment and clinical audit process (CAP).

For clinical care to be patient centered, we can think of the patient being the spoke of the wheel with the care team of clinician, trainer, coach, and other health care specialist as the spokes on the wheel. It may also be helpful to take a moment to recognize methods that are not patient centered:

Evidence-influenced (or informed) care is often described as a tripod, a balance of the best available research, clinician experience, and patient beliefs and values. Without each of these three legs, there is no way the stool would stand. Sackett, the godfather of the evidence-based movement, says, “Clinical expertise should be informed but not replaced by evidence.”¹⁰ Those who overemphasize one aspect of this at the expense of the others do their patients a disservice. The bulleted text is an example of overemphasis of clinician experience and attitudes. Similarly, some take peer-reviewed published research to the same extreme. They believe if it has not been proven and published, it cannot be true or effective. Although the authors believe that understanding the best available research is essential, there are clearly cases within conservative NMS care where a more artistic approach is required. Perhaps the manual medicine pioneer, Karel Lewit said it best, “We work at the acceptable level of uncertainty.” This quote has such eloquence because it clearly implies that being uninformed is not acceptable, but that proceeding with certainty is something typically seen in sophomoric clinicians and simple cases. Uncertainty and humility go hand in hand. Knowing that one does not know places the clinician in the best position to passionately pursue evidence to help inform patient care and strive to reach a patient’s goals with approaches that can produce sustainable, resilient outcomes (see Chapter 1). We should expect uncertainty as the rule rather than the exception and to overcome it, the clinician will be most successful when balancing the tripod with best evidence, clinician experience, and patient values.

While discussing the evidence and efforts to further back pain research by the Lancet, in his critique Lorimer Moseley keenly points out that, “Education is universally recommended as a first line treatment for acute and persistent back pain but it attracts little attention.”¹¹ Education should be layered throughout the CF; it should begin in the history with the way questions are framed and the thoughtful exploration by the clinician. The second part of this chapter addresses the education in more detail as do Chapters 13, 14, 15, 16. It should continue in the report of findings with explanation of why diagnostic examinations are being ordered or at what point in care they would be appropriate. Further it continues as reassurance regarding active interventions and continues throughout the exploration of movement and appropriate self-care strategies.

The framework also includes promoting self-efficacy through early active interventions and emphasizes patient-specific functional goals (Table 37.1). In the McKenzie method, the early application of self-directed strategies for patients creates valuable self-attribution. The key factors of clinical success are having an internal locus of control, a growth mind-set, and grit (Fig. 37.3). Those who believe they have control (internal locus of control) and autonomy have better health care outcomes^12,13 (see Chapter 17). It has been shown that having control, or even the illusion of control, has an impact on mind-set, which can be important for helping a patient remain optimistic during a difficult time.¹⁴ Being able to overcome adversity, such as an injury, is best accomplished with grit, which is a combination of both passion (think: goals and motivation creating a consistent direction) and perseverance (think: resiliency and longevity of effort even during tough times).¹⁵ The resilient mind-set is focused on building activity tolerance rather than a reactive process focused on palliative measures. This is the sustainable answer to our modern disability epidemic (see also Chapter 38).

Part of early active intervention is recognizing the impact of psychosocial factors in clinical care. Even in a case, which is predominantly biologically driven, psychological factors such as patient attitudes, beliefs, fears, worries, and past experiences need to be considered (see Chapters 1, 3, 7, and 13). Social factors such as support structure, financial need/concern, work situation, community behavioral nudges, and living arrangements must also be considered (see Chapter 1). When contemplating psychosocial factors, a balanced approach must be applied. Regretfully, many NMS clinicians fail to recognize and appreciate the notable impact that psychosocial factors have on their patient’s condition. At the other extreme, those familiar with these factors can mistakenly place an outsized importance on them failing to appreciate the biologic and anatomic components of the patient’s condition. Looking at these examples more specifically on one side, we may have the clinician who, while well meaning, provides iatrogenic words to the patient. This can be in the form a structural diagnosis
the patient takes too seriously (the bulging disc) or the seemingly eloquent functional diagnosis (inhibited gluteals impairing gait) that the patient fails to understand or gain control of. The other example would be a nihilistic application of pain science, where the clinician deemphasizes the physical reality of the pain, and presents only a top-down central neurologic approach that the patients fails to grasp and appreciate. The authors strongly suggest a moderate and eclectic approach—one where the clinician strives to identify and value psychosocial considerations, but aims to apply their expertise in biology and neurology leveraging these factors to create psychosocial change rather than falling into the trap of becoming an “arm chair psychologist.” Guidance as to the relative importance of peripheral nociception or central mediated pain can include the fact that acute injuries tend to have larger contributions from peripheral nociceptive input and chronic issues tend to have a larger representation from the output of central sensitization. For cases where the psychosocial components are primary and they need to be addressed directly, referral to appropriate specialists and creation of a multidisciplinary care team is likely the most prudent approach.

Specific functional goals are mutually determined by the patient and the clinician; they represent the patient’s tasks and activities, and are objectively measurable. Goals should be SMART: Specific, Measurable, Attainable, Relevant/Relatable, Time bound. This allows tracking during reassessment periodically throughout care to remind the patient of their goals and progress to date. Other specific functional outcomes tools can be used such as the Patient-Specific Functional Scale (PSFS), which is the most individualized of the outcome assessment tools.^16,17 Other tools were discussed in Chapter 8 that, using reliable, valid, and sensitive measures, help us track impairment, patient activities, and participation in work. Functional goals should relate more to activities and participation than to impairments¹⁸ (see Chapter 38). However, short or intermediate goals might include the impairments. For continued clinical success, it is important that periodic goal revision is performed by the clinician and the patient.

As the CF has many important aspects, questions often arise about how to apply it to clinical cases. The next section will walk you through some common questions and clinical challenges.