The Best Treatment Begins With a Precise Diagnosis

December 10, 2011

In their excellent book about health care reform entitled “The Innovator’s Prescription”, Christiansen, et al provide some very practical insight into the challenge of diagnosing and treating low back and neck pain. The authors describe three sequential eras or phases of medicine: Intuitive, Empirical, and Precision medicine.

Three Eras of Medicine

Intuitive Medicine involves highly trained professionals who solve medical problems using intuitive experimentation. They primarily select their treatment based on their own personal experience and that of their mentors.

We move into an Empirical Medicine era when we start to collect data, especially from randomized clinical trials that typically focus on how best to treat the average patient with a particular symptom. Today’s academics, clinical leaders, and policymakers strive to bring clinicians out of the Intuitive phase into what is felt to be this much superior Evidence-Based era.

However, it is in the Precision Medicine era where diseases are diagnosed much more precisely. These authors define “a precision diagnosis” in a very specific way: one that identifies a predictably effective, standardized treatment that addresses the cause of the problem and not just the symptom. Notice that this definition does not require a patho-anatomic diagnosis be made.

Limitations of a Patho-Anatomic Diagnosis

But seeking a patho-anatomic diagnosis for low back and neck pain is the priority for most clinicians, but one can be made for only 15% of patients. However, even when one can make a precise anatomic diagnosis, i.e. a painful herniated disc, it still falls short of Christiansen’s definition for precision because the treatment for a herniated disc is far from standardized since some require surgery while others do not.  There is great variation in the number of treatments prescribed, again depending on who you see, with most not producing predictably good outcomes.

Meanwhile, in the 85% in whom we are unable to make an anatomic diagnosis, the key question becomes: can we somehow still find a way to directly address and correct the underlying cause?

Moving Into the “Precision Diagnosis” Era in Spine Care

Yes!  We can be precise in our diagnosis in most cases…..if we appreciate the high value of making a quality mechanical diagnosis.  That is exactly what has happened over the past 30 years, thanks to the work of Robin McKenzie, a physical therapist from New Zealand. Using his methods of clinical assessment, we can mechanically characterize the underlying pain source that provides a “mechanical diagnosis” which usually has a very specific, standardized treatment. Using these methods, many studies document predictably effective treatment of the underlying cause, without needing to know its anatomic identity.

This form of care is called Mechanical Diagnosis & Therapy.  To learn more about it, go to and also read my other blog posts (scroll down).


4 Responses to “The Best Treatment Begins With a Precise Diagnosis”

  1. […] to the existence of low-cost, low-price technologies provide important background for one such low-cost diagnostic technology and innovation that is transforming how back and neck pain patients are evaluated, diagnosed, and treated. Instead […]

  2. […] key to producing these benefits is better diagnostics, specifically by reliably identifying valid subgroups for which there are standardized, predictably […]

  3. […] LBP subgroups, most based on clusters of clinical findings. One with considerable support is the “derangement” subgroup in whom “pain centralization” and a “directional preference” are reliably elicited during a […]

  4. […] would LBP be any different? The prime example are those who are found to have a directional preference. Their pain centralizes and abolishes and recovery is typically fairly fast and quite predictable, […]

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