A Review of Clinical Reasoning in Spine Pain® (CRISP®)

CRISP®
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The establishment of a working diagnosis identifying the key factors contributing to the patient’s pain, disability and suffering experience allows the practitioner to make clinical decisions about the best management strategy. That is, as with all areas of medicine, the treatment plan is based on the diagnosis.

Within the context of the CRISP® protocols there are certain treatment approaches that are recommended for each potential contributing factor. Specifics regarding this can be found in Chapters 9, 10 and 11 in Volume I of the CRISP® books and in Chapters 5, 6 and 7 of Volume II of the CRISP® books. However, it is not simply the application of therapeutic techniques that provides benefit to the patient. The communication context is also critically important to obtaining a good outcome.

Regardless of the diagnosis and the clinical decisions regarding management, it is essential to monitor the results of the approach, using formal outcome assessment tools as well as relationship-centered communication. Expertly applied diagnostic and therapeutic methodology is irrelevant if it does not result in an improved quality of life for the patient.

The CRISP® protocols involve the practitioner asking the Three Essential Questions of Diagnosis:

Do the presenting symptoms reflect a visceral disorder, or a serious or potentially life?
Where is the pain coming from?
What is happening with this person as a whole that would cause the pain experience to develop and persist?

Diagnostic question #1 considers traditional “red flag” conditions such as cancer, infection, fracture and cauda equina syndrome as well as other medical conditions that can produce pain in the spine such as gastrointestinal, genitourinary and neurological disorders.

Diagnostic question #2 considers the possible presence of four clinical entities that can produce pain:

Disc derangement
Joint dysfunction
Radiculopathy
Myofascial trigger points

Diagnostic question #3 considers mechanical, neurophysiological and psychological perpetuating factors such as:

To understand and appropriately apply the CRISP® protocols, certain important things must be understood:

The purpose of CRISP® is to provide a means by which the spine practitioner can apply an evidence-based approach to the evaluation of the patient in order to arrive at a diagnosis.

This process considers not only the individual clinical entities that may be present but the whole patient. As stated earlier, it is a whole human being who is having a pain, disability and suffering experience that brings him or her to the practitioner. Effective application of the CRISP® protocols requires this whole-person context.

In any given patient, one or more (usually more) of these factors contributes to the overall clinical picture, and there is often great interaction between the factors. Therefore, in most patients a multimodal approach is required. There are a number of general approaches that are applicable to all patients, as well as specific approaches that are designed to address the individual elements that make up the diagnosis.

It is also important to reiterate that the various pain generating and perpetuating factors listed above are inextricably linked. In other words, while the biological, psychological and social factors are discussed individually in this book series for learning purposes, it is essential for the practitioner to think and act in terms of the patient and the spine related disorder that he or she is experiencing being an integrated whole.

Asking and answering the three questions of diagnosis, and applying therapeutic approaches that address the relevant factors, is what makes up the mechanics of the CRISP® protocols. However, it must be realized that the real value of CRISP® comes in the whole, rather than the sum of its parts. That is, the most important application of CRISP® is in its context.

Dynamic and passive instability	Nociceptive system sensitization
Oculomotor dysfunction	Fear
Catastrophizing	Passive coping
Low self-efficacy	Depression
Anxiety	Hypervigilance for symptoms
Cognitive fusion	Perceived injustice