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Fashionably misdiagnosed for 35 years

PainSci » bibliography » Taylor et al 2017
Tags: sciatica, pain, structuralism, politics, radiculopathy, leg, back pain, pain problems, spine, buttocks, hip, herniation, limbs, neuropathy, biomechanical vulnerability

Four pages on PainSci cite Taylor 2017: 1. The Complete Guide to Trigger Points & Myofascial Pain2. 38 Surprising Causes of Pain3. Reluctantly Reconsidering RESTORE4. Misdiagnosed for 35 years

PainSci notes on Taylor 2017:

This paper tells the story of a patient who had “sciatica” for thirty-five years and was misdiagnosed many times until finally getting not only a definitive diagnosis but a cure. He had a narrowed artery (arterial stenosis causing “claudication,” the pain of impaired circulation). That’s it! Not even a difficult diagnosis in the end, really. There were some pretty glaring clues there that got ignored by a lot of people who should have known better.

Not only was he misdiagnosed many times over more than three decades, he was misdiagnosed fashionably: that is, each misdiagnosis neatly fit a paradigm in physical therapy, better than it fit his symptoms. This carried on right up to and including the present day fascination with psychosocial factors and sensitization (which served him no better than any of the other paradigms had).

Interestingly, the patient’s belief that something ‘was actually wrong’ had remained with him throughout the journey. This, of course, had been explained away to him (more recently) by current research and evidence-based thinking on central sensitization and pain.

Just fascinating. The authors thoughtfully explore the implications of this rather shameful episode (definitely aimed at pros, some jargon, but readable enough for anyone — and behind a paywall, unfortunately). The bottom line? Good diagnostic skills are never out of fashion. Or shouldn’t be, anyway!

There are criticisms of this paper from a couple of my favourite experts and writers, pointing out in a letter to the journal that one of the “fashionable” paradigms impugned here, the biopsyschosocial model, “includes the considerations [the “bio” part] that eventually cured the patient’s pain.” I like the criticism and I like the authors’ response — I see only healthy debate here

Accuracy disclaimer: It’s always possible that a case study like this has been misrepresented to make a point. Maybe it didn’t really go down this way. But based on my own professional, I think things like this definitely do happen (and based on my personal experience, I know they do). I am referring both to fashionable misdiagnosis in general, and to problematic overemphasis on psychosocial factors and sensitization in particular. The omission of the “bio” from the “biopsychosocial” model should not happen in theory, but it certainly does in practice.

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

The current move in physical therapy toward the biopsychosocial management of chronic pain has led some interpreters to call for a less hands-on approach, as awareness of central sensitization leads to specific management trends and a move away from pathoanatomical considerations. The authors of this Viewpoint suggest that no approach, no matter how vocal and evangelistic its followers, would likely be any more certain than what preceded it. This Viewpoint poses the question, why, when we (as a profession) appear (according to the new physical therapy gurus) to have been so wrong before, do we appear to believe that we are right this time?

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