Traditional Diagnostic Methods

Understand at the outset, that medical science's understanding of the causes of back pain is so limited that there, to this day, is no agreed-upon method of diagnosing a structural abnormality of the spine despite two extensive reviews in the medical literature. In fact, the following list of conditions can all be managed by The O'Connor Technique (tm) because they all can be associated with and attributed to intervertebral degenerative disc disease because they are simply different descriptions of the same physical phenomenon either by being accurate representations of the same underlying condition or incorrect, misdiagnoses, of the same entity.

So, review the below listing of diagnoses and see if your back pain, neck pain, or backache has been described or diagnosed in those terms. If so, then The O'Connor Technique (tm) has a very reasonable probability of helping you and well worth the effort to explore to the fullest because there is no better method of determining the source of back pain, neck pain, or spinal pain than what is offered in this webbook's FREE diagnostic methodology.

Alternatively, when a patient presents with back pain to a chiropractor or physician, the most commonly ordered diagnostic imaging study is a spinal, plain film, X-Ray series. This usually amounts to long-axis side views, front to back views, and oblique views oftentimes focusing on the specific area of pain or the Lumbar region by virtue of its statistical probability of being the site of an abnormal finding. They cost Medicare $50; but, for everyone else, they can cost 2-3 times as much. Even more disconcerting is the amount of radiation to which the patient is exposed in light of how little they contribute to elaborating the cause of back pain.

People have a need to know how much radiation they will be exposed when "the routine X-Rays" are taken in an Emergency Room, the Chiropractor's office, or when ordered by a physician. Undergoing a three view lumbosacral spine study is equivalent to having a Chest X-Ray study done every day for at least three years! This is one of the major reasons why a person should think twice before allowing themselves to be X-irradiated. A lot of people dispense with the risk by saying that we are always being exposed to radiation from natural sources. That is true, but there is a "natural" rate of cancer, too. Not only are you being forced to take your risks of getting cancer simply by choosing to live on this planet; but now when some other people on the planet want to make money off of you by increasing the amount of radiation you are exposed to by hundreds of times higher doses, I tend to get infuriated. Add to that, the doses calculated were probably measured with reasonably new equipment. Many facilities have purchased the old machines without image enhancing capability; and the doses are much higher. Evidently, the fact of radiation-induced genetic damage and its ability to cause cancer has escaped the educations of those people who down-play the 400 mRads of radiation to the female gonads and bone marrow entailed in every medically unjustified study they accomplish.

True, the cells of the body have a capacity to repair the genetic damage induced by radiation, however, that capacity has been evolutionarily designed to deal with background levels of radiation, not the logarithmic excesses to which some would have them exposed. Justification for the use of X-Rays (including CAT scans) exists, but it is limited by a few considerations which are pertinent to a patients decision to consent to an X-Ray procedure. Swedish investigators concluded that one might expect to find X-Ray evidence of a diagnosis not indicated by the physical exam in only one of every 2,500 adults under age 50 with low back pain. Many X-Ray findings are unrelated to symptoms of back pain and are found just as often in asymptomatic individuals.

If the first back pain episode started when a patient is over 50 years old or as a teenage athlete with activities strenuous to the Lumbar spine (i.e. gymnastics, wrestling, etc.) the yield of a plain film X-Ray study may justify the expense and radiation risk, especially if there has been a history of steroid use, a reasonable suspicion of ankylosing spondylosis, prior history of cancer, weight loss, bowel or bladder incontinence, a history of substance (drug or alcohol) abuse, significant trauma, failure to improve with conservative therapy within 4-5 weeks (The O'Connor Technique constitutes conservative therapy), or motor neuron deficits.

A condition that usually first affects athletic young people causing them to seek medical attention is called spondylolisthesis, which is a often a congenital (present since birth) defect or traumatic fracture of vertebral pedicles (the pars interarticularis--the bridge-like bones that join the front portion of the vertebral bones with the back portion). When the segments are separated, it is called spondylolysis. Either can be painful or simply found incidentally during an X-Ray done for other reasons. That reality makes it a confusing problem to indict as the source of pain and also difficult to manage. This condition, however, is decidedly a statistical minority.

I mention this specific condition here because if you are one of the few people who have this condition I cannot be sure The O'Connor Technique (tm) will be helpful. I doubt that it would be harmful because, in that event, the pain would not be helped by the technique and those patients would reasonably stop practicing it. In the worst case scenario, it might increase the pain, and logic would dictate that you would stop doing what hurts before any serious damage could be done. For more information on this condition especially as it relates to sports, go to the SPORTS Section of this book.

Another situation in which an X-Ray examination may reveal the source of pain is in the presence of pain that is constant, not improved by lying down, or does not respond to bed rest. These findings suggest a systemic disease or cancer. By "constant" it is meant that the pain stays largely the same regardless of what one does to try to alleviate it. Discogenic pain usually is reduced by lying down and returns when a person tries to get back up. If the pain were caused by cancer, no matter what one does, the pain of the tumor encroaching upon a nerve will not reduce in severity.

The other two most common diagnostic modalities used in the evaluation of back pain are the CAT Scan (Computerized Axial Tomography a.k.a. CT Scan) and the NMRI (Nuclear Mass Resonance Imaging a.k.a. NMR).

The CAT Scan is basically an X-Ray machine hooked up to a computer that takes lots of X-Rays, pools the information into one picture and gives an X-Ray cross-sectional slice-through- the-body. Because different tissues of the body allow X-Rays to pass more freely, those tissues with major differences in density can be differentiated from each other and not just bones are outlined. Its two largest draw-backs are the amount of radiation to which the patient is exposed and the limited resolution--especially in the neck region. To get some idea of how old the technology is, it was developed by money from The Beatles rock group. Since there are a lot of the machines still around and they have been paid off already, they can sell the images cheaper. But not even The Beatles can solve the radiation problem--it is even worse than that of the standard spine series. The problems of both cost and radiation can be somewhat mitigated by asking the physician ordering the study to limit it to just the painful area. Unless there is a compelling reason to irradiate the entire Lumbar region, you may reasonably request that the study be limited to just the painful area (which you can demonstrate to the radiologist). This way, if the pain is localized to one or two disc units your probability of seeing what is wrong by just examining those discs stands to be much more productive with respect to cost and radiation exposure.

CAT scans were once the best means of seeing into the spinal anatomy; but the NMRI is its higher-resolution competitor. The most accurate picture of the spine, especially the intervertebral disc structures, and least dangerous, is the NMRI (Nuclear Mass Resonance Imaging). It is about twice as expensive as the CAT Scan, but the resolution is much better without exposure to radiation. It actually is an amazing device. Patients are placed in a large magnetic field, and the manner in which the atoms of the body vibrate in that magnetic field differs from tissue to tissue and the difference can be detected with sensors. So, one gets a picture of the internal muscles, bones, cartilage, and other soft tissues. Whereas the plain X-Ray only sees the bones, with an NMRI device, the displaced disc material can actually be seen; and the position of it relative to the vertebral bodies and, more important, the spinal nerves can be determined.

The draw back here is the cost. It is a relatively new technology and expensive. If you are paying for it, you are looking at upwards of a thousand dollar bill. That's a pretty hefty sum, and it is very difficult to get a doctor to order one because they are hassled and intimidated by HMO's, administrators, or third party payers' refusal to pay. Or worse, the managed-care doctor himself (when your health care dollars are paid to him and capitated in advance) can have become reluctant to spend his "own" money on you. The conflict of interest inherent in capitation warrants an entire book; but, suffice it to say, that, if you are in a capitated care plan, this book is probably the only way in which your back will be made to get better. When anyone is getting paid more by delivering less care to your back, it will probably get better on its own before they do anything that can realistically be expected to alter the outcome.

The most common justification they give for not ordering any expensive modality is that at any given time, probably 20% of "normal" thirty-year-olds who undergo an imaging study (CT, myelogram or NMRI) can be shown to have asymptomatic evidence of herniated discs. This statistic is then often misused to justify a belief that the finding of an herniated disc on an imaging study is not equated with pain. I fervently disagree. The presence of a herniated disc on an imaging study constitutes irrefutable evidence that the patient has suffered an injury to the disc system; and the burden of proof, then, rests upon the physician to prove that the disc is not responsible for the pain's origin. Until that is done, the disc should be considered the most likely source until it is proven that such is not the case. Admittedly, this advice deviates markedly from the current approach to back pain management; yet I am convinced that, as the reader completes their understanding of The O'Connor Technique (tm), they will logically conclude that it exposes a fundamental inadequacy in the current "academic" approach to this human problem.

The finding that a substantial percentage of asymptomatic people are usually found with evidence of a herniated disc simply establishes the reality that far greater numbers of people (than currently believed) could be suffering from disc disease. These people simply may not have had the diagnosis made previously. That doesn't mean that they don't have disc herniations, it just means that they don't have symptoms at the time of the study. Any time a "scientific" study establishes the statistically significant presence of undiagnosed disease, it is equally probable that the explanation rests in a failure of the diagnosticians to have previously elaborated the disease through adequate histories and physical examinations.

Many patients may have unconsciously, unknowingly, or coincidentally accommodated to the problem by limiting their activity, become so accustomed to the pain and limitations of movement that they no longer accept or perceive it as abnormal, stopped complaining about it to themselves or their physician's, or the area has become scarred down and physiologically, spontaneously, stabilized. Denying the significance of a disc herniation does not, however, make it go away or provide assurance that it will not again become symptomatic later.

The event that caused the herniation also could be so distant in time that a recollection of the event is difficult; but it is these very types of patients who probably constitute the population of persons who (seemingly inexplicably) are immobilized by pain when the already herniated disc only requires a relatively small amount of force to push it into a painful configuration. These are the type of patients who give a history to their doctor that they were simply taking out the trash or sneezing when suddenly they were immobilized by pain. The doctor feels the area, finds muscle spasm and assuming that the force described could not have been sufficient to cause a herniation, then erroneously concludes that the source of the pain is a pulled muscle--which is now in spasm. They then conclude that no imaging study is necessary with that diagnosis and elect the cheapest and easiest strategy: "conservative management" (which is no more than what we physicians call "benign neglect") relying upon the assumption that within two months most of these patients will again be pain-free.

You may find it difficult to obtain an NMRI if your doctor's compensation is capitated by your insurance or health care program because the doctor is now spending his money. This whole movement in medicine called "managed care" is the worst of all systems from a quality point of view because an inescapable conflict of interest is designed into it. If your doctor is paid up front to take care of you, when it comes to ordering an expensive study or sending you to a specialist--the money comes out of his pocket. As perverse as it may seem, human nature being what it is, don't expect your doctor under that type of system to do anything but the cheapest management possible unless he is a Saint. The most important factor influencing his decision appears to be how much risk he is willing to take with your well-being yet still not get sued.

This book is not the ideal forum to expose the particulars about how bad the basic philosophy of these HMO's, Kaiser-like plans, or capitated programs truly are because that's another entire book that belongs more in the horror stories section of the book store. But it is appropriate to address the motivations of those persons charged with the responsibility of your health because, when it comes to the costs relegated to back pain, those paying for the care do not want to spend any more money than is absolutely necessary. It seems that everyone is jumping on the "get-it-done-cheaper-at-any-cost-band-wagon" and, those that don't climb aboard of their own volition, are being economically drummed out of the practice of medicine by the administrators and business people who are reaping enormous profits from this scam (right now, their "take" averages 12% of the health care budget in any market they can capture). It is accurate to say here, that if the "bean-counters," whether at a governmental or corporate level, can persuade a doctor not to order an expensive test, they can take that money and give it to themselves. So, more often than ever before, beneficial (and even essential) diagnostic information is not obtained because someone along the line is willing to play the odds such that, by withholding any particular procedure or diagnostic test, they can stumble along without it (regardless of the excess pain and prolongation of ignorance that such a strategy entails) so long as they are willing to sustain the reality of your not getting better, staying in pain longer than necessary, or suing them.

An excellent example of this mentality is represented by a recent case known to me. JM is a physical laborer who sustained a fall and has never been able to alleviate the back pain subsequent to that trauma. Two years after the injury, he presented with obvious clinical symptoms of disc prolapse with possible spinal nerve root involvement at the clinic where I practice. I attempted and then taught him some self-administered extension MANEUVERS to see if he would benefit, but he not only achieved no obvious relief, but he had to stop doing them because they hurt more.

The degree of pain involved and the potential presence of nerve root impingement indicated that the safest and most prudent course would be to acquire an NMRI to make certain that he could mobilize the spine by without risking additional nerve damage. When I ordered the NMRI, a nurse with absolutely no knowledge of the specific patient or back pain in general refused the imaging study and insisted that he go to an orthopedist specialist for consultation. Because the local Medicaid managed-care organization refused to pay local orthopedists a reasonable compensation for their work, he was sent to the University where he was seen by a student doctor. Without knowing whether the patient had a partial extrusion that could reasonably be expected to be made worse by extension exercises (a risk I was unwilling to take in light of the fact that extension was so painful), he ordered physical therapy with extension exercises before determining the extent of the protruded disc material with an NMRI. This was done in the presence of the fact that in my consultation request I informed the doctor that previous extension-type physical therapy attempts had met with a worsening of the condition.

It seems now-a-days, that economics are the most influential determinant with regard to whether an NMRI is "necessary." An NMRI costs about $1,000.00. The physical therapy costs $60 a week. If he's hurt by the exercises, it helps convince a physician that the fellow has a real problem--the pain and neurological function gets worse. Then, only after his condition gets worse or no better will some other strategy be tried. The problem with this scenario is that JM unnecessarily must be put through weeks of pain before being "allowed" the imaging modality and risk suffering a permanent neurological deficit when treated by an exercise instructor who has no true knowledge of the injury's extent. In fact, even the doctor doesn't know it because he failed to obtain the "road map" NMRI. So, I was forced to stand by and watch this man's future ability to walk jeopardized because money wouldn't be spent by a nurse (who's job is to refuse services) and the doctors within this system were willing to proceed with a demonstrably dangerous plan from a perspective of elective ignorance. The frequency with which this occurs is so great that it defies description; however, I present it so that the reader will at least be forewarned about the current state of affairs in medical management decisions and be better prepared to deal with it.

My solution was to send a letter to his lawyer, outlining the problem, and to the doctor reminding him that extension exercises were already unsuccessfully attempted and persisting with them presented the potential for further harm. In that way, the entity that chooses not to do the proper imaging study will have a legal "sword of Damocles" hanging over its head (rather than mine). You see, when capitated health plans deny services, the legal liability for that decision still remains with the physician unless he makes a good-faith effort to protect the interests of his patient. I protected my patient while at the same time transferring liability away from myself. If the other physician is so arrogant as to persist with his plan to proceed blindly, he would be the one to end up in court explaining his methods to a jury. My ethics won't allow me to violate the trust engendered in the physician's precept primum non noicere (first do no harm) nor ignore the published guidelines that justify an imaging study if the patient has gone greater than six weeks without alleviation of symptoms. However, health plans are not governed by that creed and can choose to ignore any given M.D.'s orders. Their interest is in acquiring wealth regardless of patient's additional suffering or risk. The reality is that these machinations exist so far beyond the understanding of the patient that the administrators can get away with just about anything. They act upon the assumption that their decisions will not be legally questioned until it can be proven, afterwards, that they caused damage. Even in the presence of damage, it is very hard to prove that they actually caused the damage, so it behooves the patient to become sufficiently educated to manage their own back problem through the system, to prevent irrevocable damage. I designed this book for laypersons because they must be able to make their own diagnosis.

Don't mistake my loyalties, most physicians I have met are hard-working, humanitarians with altruistic goals and genuine concern for the welfare of their patients. However, as hard as it may be to believe, (because doctors are sometimes seen as "all-powerful") they are often victims of forces beyond their control. In that instance, few of them are martyrs enough to suffer in your stead. All too often, they, by their own experience with "the system" have become complacent and unwilling to stand up for their patients' well-being let alone their own.

Here's how it works. If a particular capitated program's cost-control officer looks at the statistics and sees a particular physician is ordering too many NMRI's, he will be either intimidated into ceasing this practice (by volumes of additional paperwork, "guideline" educational seminars, demands for specialty referrals, or "de-credentialed" if he persists. These capitated plans and HMO's usually have clauses in their contracts that allow them to remove a doctor from their provider lists "without cause." To even the best doctors, this can mean being put out of business. It is a modern form of corporate "Black-Listing;" and it especially happens to doctors who "cause trouble" when they protest decisions of the health care plan not to approve expensive procedures. If you suspect you are suffering this situation, don't attack your doctor, write a certified letter to the healthcare plan demanding an alternative decision. By demanding that they put in writing the specific criteria they are using to deny you that service and indicating that any future pain, suffering, or disability resulting from a failure to adequately diagnose the problem, you intend to hold the persons making the decision liable for damages because, inherent in the act of refusing legitimate diagnostic or therapeutic modalities, they are practicing medicine without a license.

If your back pain is not getting better and, after practicing The O'Connor Technique (tm) enough to convince yourself that you have given it an adequate opportunity to work, you feel that having an anatomical image of the problem will make the definitive diagnosis, and you are paying for it yourself (or have a doctor that is paid up-front by your health care plan that refuses to order the study), there may be a compromise. You can reduce the cost by specifically asking your doctor to order just a limited study of the area in question. Usually, the painful area of the spine only involves a few segments and, after you have lived with the pain for a while, it is not too difficult to determine where the specific area of the spinal pain is located. It is unnecessary to image the entire spine when only a small area is actually affected by pain. So, if you want the best imaging study to determine if a disc is herniated, a limited NMRI may be the best option. By reading on, you will be given a means to localize the site of the problem if an NMRI or CAT Scan becomes necessary.

However, the greater purpose of this book is to teach the reader how to make their own back better. In large part, that must include figuring out, for yourself, without great expense, what is actually wrong. The following describes how you can do it yourself because, in fact, you are the best person to do it. No doctor known to me is aware of this method, nor is it, to my knowledge, described in the medical literature (and believe me, I am well-read in the field of back pain); so, up until now, patients have really been left to their own devices, anyway. So, at worst, the situation hasn't changed with the advent of this book. At best, the reader has every reason to believe that they, themselves, can be made competent enough to figure out if they have a disc problem and remedy it by a few simple movements.

Further Reading:

Damage / Pain Scenerio
Traditional Diagnostic Methods
Self Diagnosing your Disc
Documenting your disc

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