Being Specifically Non-Specific in Clinical Practice
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There is a time and a place for specificity, especially when there are clear, significant and debilitating injuries involving structural changes to our Patients. However, much of the time, especially with pain with an insidious onset (seemingly out of nowhere) often it is very difficult to be certain about what is structurally causing the pain, even with our best diagnostic imaging.
This is made much more difficult by the fact that Pain is an extremely complex Neurological and Psychological experience that is an output of the Central Nervous System based on the input of our ‘noxious stimulus detectors’ or ‘nociceptors’ in our Peripheral Nervous System. However, Clinicians are placed in a tricky position where Patients often seek their expertise in order to get a clear Diagnosis.
Recently there has been an increase in the use of the term ‘Non-Specific’ in the research. It has been used directly for Low Back Pain (Non-Specific Low Back Pain — NSLBP) (Koes, Van Tulder et al. 2010, Maher, Underwood et al. 2017) or the words “Non-Specific” haven’t directly been used and instead the Diagnoses have been non-specific in nature:
- Rotator Cuff Related Shoulder Pain (RCRSP) (Bury, West et al. 2016, Lewis 2016) for shoulder pain that appears to be rotator cuff related (…duh),
- Athletic Groin Pain (Hölmich, Phillips et al. 2016) for groin pain specifically in athletic populations (further (and more specifically) sub-grouped into Adductor-, Illiopsoas-, Inguinal-, and Pubic-Related Groin Pain).
- Plantar Heel Pain (Irving, Cook et al. 2006)
However, this concept of non-structural and semi-/non-specific regional diagnosis has been around for a little while now, albeit with other descriptive words attached to the diagnosis such as ‘Syndrome’ or ‘-algia’.
- Patellofemoral Pain Syndrome (Waryasz and McDermott 2008, Lankhorst, Bierma-Zeinstra et al. 2012) for the anterior knee,
- Greater Trochanteric Pain Syndrome (Williams and Cohen 2009) for lateral hip pain,
- Lateral Epicondylalgia (Bisset, Paungmali et al. 2005) (aka “Tennis Elbow” or Lateral Elbow Tendinopathy,)
- Metatarsalgia (Espinosa, Maceira et al. 2008), or foot pain around the metatarsals.
It’s important to note here that simply telling Patients “you have Non Specific Low Back Pain” or “you have Rotator Cuff Related Shoulder Pain” without further context is not very nice. A Patient in pain might get defensive if told their very painful and disabling low back pain is “non-specific”, they may feel as though you are belittling their (quite specific) pain experience. One must also be aware of the nocebic nature of words such as ‘syndrome’, Patients intuitively associate it with long-term disability rather than by its true scientific meaning of ‘a group of symptoms which consistently occur together’.
Although it seems odd to call a painful condition “non-specific” there’s a good reason why it is being utilised in the research. It is reserved for the following conditions where it is very difficult to accurately point to a specific structure (bone, tendon, cartilage, ligament, nerve etc.) and say “THAT is the cause of the pain”.
Some structures, such as tendons and muscles, are very good at telling us where there is a problem, anyone who has had a cranky Achilles Tendon or a Hamstring Strain can attest to that. Then there are some structural complexes such as the Patellofemoral Joint, Cervical Spine, Lumbar Spine, Hip Joint and many more (especially nerves) that have vague referral patterns, making it very hard to:
- Differentiate which body region is referring the pain, and
2. Figure out what exactly is causing the pain in that body region.
Some of these regions don’t require us to know the specific structure in order to manage the injury any differently. This is the key message from the research, for example, a Patient with insidious onset Low Back Pain who has had all the nasty stuff ruled out on assessment might be told by their Clinician:
“You have low back pain but nothing particularly nasty is going on based on your assessment so there’s no need for alarm or for further investigations (MRI etc). I can’t be 100% sure what exactly is causing the Pain however it won’t change the management, it’s very common and should self-resolve with time…” and then the Patient is further provided with some guidance around NS-LBP, I’ve written about this here.
Note the de-threatening nature of the language in that paragraph. Words we use with Patients are important, they form the Narrative or story that the Patient takes away and can change their pain experience. Nocebic Narratives are when negative language influences a Patients pain negatively, sticks and stones may break their bones but words can prolong pain and therefore increase healthcare burden.
Sometimes we have to be specific
Of course, sometimes Specificity matters.
No Clinician would refer a young footballer with an MRI-confirmed ACL Rupture with an associated bucket handle tear of a medial meniscus to their Orthopaedic Surgeon with a referral saying “Thanks for seeing this Patient who has Tibiofemoral Related Knee Pain”, or labelling a patient who just felt a pop in their anterior elbow near their distal biceps tendon doing a pull-up with “Anterior Elbow Related Pain”.
Specificity will matter in diagnosis of acute and/or traumatic injuries where there is potential for significant structural changes that directly impact on the Patients function, particularly those that may require surgical or specialist medical management.
Smart Cookies and Science/Health Communication
Musculoskeletal Clinicians are a bunch of smart cookies, students often need to be in the top 5–10% academically to enter relevant university courses. Some of Clinicians have multiple degrees with tens of thousands in Higher-Education Loan debt and have since spent many tens of thousands of dollars on continuing education.
It is an understatement to say that many Musculoskeletal Clinicians know a lot about the musculoskeletal system and are extremely passionate about what they know and are even more passionate about helping the Patient. Therefore, in the process of trying to simultaneously help the Patient whilst also demonstrating their expertise (to be believed or gain credibility or sometimes just to stroke their own Ego) it is very natural to resort to ‘regurgitation of knowledge’.
Communicating Science is difficult. There are entire tertiary degrees just on Science Communication. It is a skill and an art. It is the greatest challenge to a Clinician to have comprehensive understanding on specific things yet have the ability to convey these complex concepts to the general public at a very simple and clear level.
Many less experienced Clinicians fear that by communicating things so simply they will not be able to demonstrate their education and experience to the Patient and also fear losing credibility without confidently identifying a specific cause for the Patients pain.
Saying “I Don’t Know” is OK
Patients often want a Diagnosis. It’s a skill and an art to convey Credibility and Reassurance to a Patient whilst saying “I don’t know”. However this is where the Patients needs can be met without telling them “what is going on”. The number one reason Patients seek Healthcare services is to rule OUT nasty conditions or ‘Red Flags’ as we call them. Patients are often very satisfied and have faith in their Clinician if they hear “Well I don’t know what it is but I can tell you that it’s highly unlikely to be X, Y and Z” rather than “I don’t know”, especially if they’ve been on the diagnostic journey with their Clinician and have seen their “working out”.
Reassurance is a potent tool in a Clinicians toolbox, which can only be effective following a thorough examination (subjective and objective).
There are many more ways a Clinician can earn Credibility with their Patients.
Gaining Credibility
Here are some tips that might help a Clinician to gain credibility with their Patient without providing a Specific Diagnosis:
- Be thorough — basically just do a good job, have a thorough subjective examination followed by a thorough physical examination.
- Be a good listener — utilise active listening techniques, let them tell their story in their own words.
- Be nice — be caring, use empathy, Clinicians should put themselves in the Patients shoes.
- Be transparent — “show your working out”, remember that? Clinicians were once made to demonstrate their ‘working out’ in maths exams in school, they should do the same thing with the Patient and think out loud or verbalise their ideas during the assessment such as what has been ruled out and why? A Clinician should take their Patient on a ‘Diagnostic Journey’ with them (a part of ‘Patient-Centred Care’).
- Be good looking — Be well groomed. Dress like a Registered Healthcare Professional. Have a shave, have a haircut.
- (Optional) Smile, have a laugh — Not all of us have a ‘funny bone’ but in the right moments (ie, not when you’re delivering a nasty diagnosis) actually have a laugh with the Patients, make a joke every now and then, having a laugh is not only very therapeutic but is one of the best ways to demonstrate a connection with people, it is disarming and can actually contribute greatly to the confidence the Patient has in their Clinician. ‘The Science of Laughter’ is a fantastic episode of The Infinite Monkey Cage podcast if you have further interest in how ‘Laughter can be the best Medicine’.
Did you enjoy this blog or learn something new that will help you with your clinical practise?
Are you a patient and has this helped you in some way?
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References
Bisset, L., et al. (2005). “A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia.” British journal of sports medicine 39(7): 411–422.
Bonfim, I., et al. (2021). “‘Your spine is so worn out’-the influence of clinical diagnosis on beliefs in patients with non-specific chronic low back pain-a qualitative study’.” Brazilian Journal of Physical Therapy 25(6): 811–818.
Bury, J., et al. (2016). “Effectiveness of scapula-focused approaches in patients with rotator cuff related shoulder pain: a systematic review and meta-analysis.” Manual therapy 25: 35–42.
Espinosa, N., et al. (2008). “Current concept review: metatarsalgia.” Foot & ankle international 29(8): 871–879.
Hölmich, P., et al. (2016). “Athletic groin pain: a systematic review of surgical diagnoses, investigations and treatment.” British journal of sports medicine 50(19): 1181–1186.
Irving, D. B., et al. (2006). “Factors associated with chronic plantar heel pain: a systematic review.” Journal of Science and Medicine in Sport 9(1–2): 11–22.
Koes, B. W., et al. (2010). “An updated overview of clinical guidelines for the management of non-specific low back pain in primary care.” European Spine Journal 19(12): 2075–2094.
Lankhorst, N. E., et al. (2012). “Risk factors for patellofemoral pain syndrome: a systematic review.” journal of orthopaedic & sports physical therapy 42(2): 81–94.
Lewis, J. (2016). “Rotator cuff related shoulder pain: assessment, management and uncertainties.” Manual therapy 23: 57–68.
Maher, C., et al. (2017). “Non-specific low back pain.” The Lancet 389(10070): 736–747.
Waryasz, G. R. and A. Y. McDermott (2008). “Patellofemoral pain syndrome (PFPS): a systematic review of anatomy and potential risk factors.” Dynamic medicine 7(1): 1–14.
Williams, B. S. and S. P. Cohen (2009). “Greater trochanteric pain syndrome: a review of anatomy, diagnosis and treatment.” Anesthesia & Analgesia 108(5): 1662–1670.
