During Explain Pain courses we have an exercise during which we critically look at scary sounding diagnoses. We discuss what an individual might be left thinking upon hearing the words, and what appropriate, dethreatening language might be used to correct any misconceptions. The usual suspects are all lined up – Scheuermann’s Disease, frozen shoulder, whiplash, bulging/prolapsed/slipped discs, heel spur and of course, spondylolisthesis.
Dethreatening the ‘diagnosis’ of spondylolisthesis usually starts with a (only half) tongue in cheek apology for the horrible name, an explanation that it is rather common – “sorry, you’re not that special”, and statement that for many people the condition exists without any associated pain at all. For the right person (to whom it might have some relevance or meaning), a quick story about Andre Agassi winning a couple of US Opens with a spondylolisthesis can be thrown in too.
A recent systematic review has provided some powerful, extra ‘educational ammunition’ to help dethreaten this particular diagnosis:
Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis.
“There is no strong or consistent association between SL/IS and LBP in epidemiological studies of the general adult population that would support a hypothesis of causation. It is possible that SL/IS coexist with LBP, and observed effects of surgery and other treatment modalities are primarily due to benign natural history and nonspecific treatment effects. We conclude that traditional surgical practice for the adult general population, in which SL/IS is assumed to be the cause of non-radicular LBP whenever the two coexist, should be reconsidered in light of epidemiological data accumulated in recent decades.”
That’s a strong conclusion, and one that should provide confidence when dethreatening this otherwise danger-increasing label. Of course, dethreatening a diagnosis of spondylolisthesis should also include an appropriate and thorough assessment (with any findings also explained), and discussion and agreement on an appropriate treatment plan as required.
The purpose of dethreatening any diagnosis is not to ignore, belittle or dismiss it, but rather to bring it into the light of a modern understanding of pain – under the ever-increasing power of this spotlight, many diagnostic DIMs can be dramatically deflated.
-Tim Cocks
Andrade NS, Ashton CM, Wray NP, Brown C, Bartanusz V (2015) Systematic review of observational studies reveals no association between low back pain and lumbar spondylolysis with or without isthmic spondylolisthesis. Eur Spine J 24(6) 1289-1295.
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That’s a great post, thank you. Hope this de-threatening approach becomes more widely used!