Red Flags - Guide to Identifying Serious Pathology of the Spine.pdf
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First published 2006
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Foreword
I have always believed that every patient who goes to
see their doctor wants to know the following:
•
Doctor, what’s wrong with me?
•
Doctor, how long is it going to take to get better?
•
Doctor, is there anything that I can do to help it get
better?
•
Doctor, is there anything that you can do or give me
to help it?
The order of importance to each individual may alter
slightly, but for most, a reassuring answer to the first
question is always somewhere near the top. Implicit
here is a simple desire to know whether there is some-
thing seriously wrong. It is often the most important
starting point for a successful treatment outcome.
Perhaps clinicians need to think about this more,
because without a thorough understanding and without
reassurance, the patient’s progress is likely to be ham-
pered by feelings of uncertainty and insecurity. Would
you go back to work, comply with a series of exercises
ix
FOREWORD
or take a prescribed medicine if you still had an uneasy
inkling that something was badly wrong or something
had been missed?
A great many patients, acute and chronic, report that
they have not been listened to fully, not examined fully
and not been reassured or had an adequate explanation
of their symptoms. Many people with benign pain com-
plaints remain burdened by uncertainty and hence are
unable to recover in any meaningful way. The title of an
old but very important article by Nortin Hadler always
rings in my ears: ‘If you have to prove you are ill, you
can’t get well’ (Hadler 1996). The main message for me
is: ‘Top-down before bottom-up’, which simply means
that for every clinical encounter undertaken it is the
clinician’s responsibility to reassure the patient (top-
down), before embarking on the ‘physical’ (bottom-up)
recovery pathway.
In my daily dealings with patients I frequently hear
about pain that comes on for no reason and often quite
severely, about pain that keeps the patient awake at
night, that gets rapidly worse and pain that the patient
thinks is something serious. Patients are naturally
worried; after all, worry is what often drives their help-
seeking behaviour.
I strongly believe that in order to be successful all
good therapists need to be far more explicit here. At the
end of every first session with all my patients I state/ask
the following: ‘It is important before moving on with
treatment/rehabilitation that you feel comfortable that
I have listened to all your problems, all your concerns
and examined you fully. I need you to feel reassured
x
FOREWORD
about what is wrong and the recovery process. Do you
have any concerns?’.
You simply cannot ask this question if you are not
confident, if you do not know.
Having up-to-date ‘Red Flag’ knowledge is essential
for clinician confidence and in turn for patient confi-
dence – every therapist or doctor should be able to say
to every patient seen that they been through a check list
of features that signifies a serious disorder and the need
for further investigation.
This book is so important and so timely as we start
to learn more and more about the importance of
clinician–patient interactions. Reassurance is a pain
killer, and you cannot give reassurance if you are unsure!
This is a book that every clinician should have a per-
sonal copy of and continue to refer to throughout their
whole professional life.
Louis Gifford
Reference
Hadler N M 1996 If you have to prove you are ill, you can’t
get well. The object lesson of fibromyalgia. Spine 21(20):
2397–2400
xi
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