What is integrative diagnosis? How is it different than other tools?
Dr. Nottoli: From a big picture standpoint it is a system for complete diagnosis and conservative management of musculoskeletal conditions. Essentially everything that we do in our scope of practice whether you're a PT or a DC or even licensed massage therapist. That’s essentially what you're going to see coming in your door, conservative musculoskeletal problems. It’s got detailed procedures and tests for everything you do in your offices from the history, to the functional testing, to the palpation of adhesions, to the communication, to the management of the patient. Everything is built in that robust system.
Noah: It sounds like a protocol that will give you great results. Is it an algorithm or cookie cutter approach?
Dr. Nottoli: We're trying to get it streamlined to where it's more digestible for a younger practitioner or a student to have more reliable testing, have more reliable treatment, have more reliable diagnosis, but patients are complex and musculoskeletal problems are complex. A lot of individuality and personal experience goes into the training in order to make any profession more diligent and focused.
Professional athletics is an easy analogy for somebody to get. If you're a high school basketball player and you’re great you're still not beating Jordan when he was your age. There's a big experience and time component to the training. Everything is built into the system to help you become more and more streamlined and effective. It’s not cookie cutter because nothing in life works that way, but it gives you tools to determine what the diagnosis is, to determine what step they're on as far as conservative treatment, and what the priority is so you know where to start.
Noah: I know a lot of this information is proprietary and there’s a lot of competition in the marketplace, but can you kind of walk us through one of the algorithms?
Dr. Nottoli: A common misconception among doctors in all fields, especially chiropractors, is that when you graduate or when you take one course you’re automatically a master at it and you never have to take it again. You’re proficient and on to the next thing so to speak. That's not how this system is built, it's built to make you a masterful practitioner and then you just build on that skill and sharpen the saw all the time. That's the long game. The short game part of the question is you have to have an idea of what the patient is actually coming in with so ID teaches practitioners how to interpret data points with history.
Data points like the gender, the age, the quality of the pain, symptom location, symptom intensity, what’s provocative, what's palliative, what's loaded, what's unloaded and what feels better. If they are a good candidate to start treatment. It will give you a good differential. When you know how to answer those questions you can interpret the data. Everything the patient says means something and it's our responsibility to figure it out.
The history is one part of the equation and can get you a long way. Then there is the testing component where you assess what’s going on. A case comes in and you're suspecting a local problem. A knee or an ankle and after the history you're not suspecting that it's global so you’ll assess and test that local tissue in that local joint and see what the status is of that area. If everything makes sense with what the patient told you and what you're testing then you have a complete idea what the diagnosis is.
What usually happens is that your exam doesn't answer your questions or it's not reverse compatible then you start looking above and below that area and testing that and seeing what else is involved. It’s a huge list and a lot to do. It’s complex. Learning is an ongoing process where you learn and refine that so that you don’t leave anything to chance and making sure they get the right treatment.
Noah: It seems like this system helps you figure out exactly what’s going on with a person. What evidence and research is behind ID?
Dr. Nottoli: It's a synthesis of the research that provides evidence for clinical decisions. The research guides clinical judgment, but it doesn't dictate practice. Essentially it's a clinical training program, not a research training program so we use the research that's out there to determine if what we're doing makes sense. We look at the research and ask if it objectively meets the criteria we have for the patient. The pain score, the outcomes, the functional mobility outcomes and a bunch of other assessment forms. The goal is to improve ADL's and there is a significant amount of research out there that helps guide that.
Noah: What are you utilizing to determine that this is the most effective approach?
Dr. Nottoli: Dr. Brady is completely objective with all this. If a research paper comes out tomorrow that says the straight leg raise is garbage. We review it and make sure it's correct and then change it right away. Actually straight leg test is a good example as it shows very good reliability. It shows that you can use handheld inclinometers to get consistent reliable results. It’s poor at determining the differential diagnosis between a disc herniation and low back pain.
It’s one of the problems with research. The research subjects are put into categories that aren’t tissue and pathology specific. You can’t test one part at the exclusion of every other part. When you take apart each one of those SLR research papers you can find that it point’s us in the right direction and that it is a reliable test consistently. It also tests for neural tension. We previously thought that it was hamstring stiffness, but now research shows that the hamstrings aren't activated with SLR.
We can’t always explain the test results. Sometimes when the leg goes up and it stops early and they don’t have symptoms. It can’t explain a disc herniation. That can’t be explained. That's not hamstring stiffness which leads us to why we palpate, treat, find, or look for nerve entrapment. It could be an adhesion around a sciatic nerve. In the absence of disc herniation, in the absence of hamstring stiffness we need a differential diagnosis. There are surgical articles that show theirs an adhesion around the sciatic nerve.
It responds well to care and patients have excellent outcomes. The amount of pain reduction, the functional test scores, the outcome scores and the narcotic use going down to nothing. It’s not like surgery in terms of recovery. It’s a conservative treatment that can be used before surgery becomes an option.
Noah: How you’ve created this musculoskeletal algorithm and have synthesized all the tests is impressive. How does ID compare to other systems that are out there?
Dr. Nottoli: ID essentially teaches the provider what we should have learned in school. ID is the only system that I found after all the training and searching that says what the diagnosis is first. After that we can have a conversation about what treatment best fits the patient but until we get the complete diagnosis we're not talking about treatment, we're not talking about techniques. That's the biggest distinction. A lot of things don’t have assessment. There is a big disconnect with students and also physicians. We’re ingrained early on that it's all about what technique you do. It’s not about us as providers it's about the patient first and foremost.
The treatment doesn’t matter until we know what the diagnosis is.
Noah: The idea is if you're treating the right area and the right dysfunction of the tissue you're going to get better results, whereas if you've only got one tool you may not be helping people.
Dr. Nottoli: A shotgun approach can be less effective and eventually it piles up and you start asking yourself hard questions like why aren’t they getting better. That’s why I think it’s important for the profession as a whole right now. Because if more chiropractors and chiropractic students have these diagnostic skills they're going to get better outcomes and build more public trust. The next steps for a chiropractic student or chiropractor who recognizes that their diagnostic skills could be improved then ID is the right diagnostic approach for them.
If you love conservative musculoskeletal care and you got into this profession to help patients and give them the best outcomes and be the best doctor you can be then this is how you do it. Dr. Brady is incredible at synthesizing this information and putting it together to be able to train other providers with this information.
If you want to get really good results and really patient-centered results that are truly objective. He’s going through the information, the research data all the time. When you’re in clinical practice you don’t have time for that. He is constantly changing and improving this system, he’s only married to the truth and he's really the only person that I found that to be able to-do that as well as he does. He has a really unique skill set.
For many of us we get into a system and just start supporting the system at the expense of the patient outcomes. We're so married to the system that it’s difficult to be objective, it’s difficult to integrate the latest research and figure out where it fits in.
Noah: It sounds like this process is ever evolving. What is the investment of time and finances to get good at a system like this?
Dr. Nottoli: The more I put into it, the more I get out of it. It was not so long ago that I was in your shoes and I was scared. I really thought I had it figured out and thought I could diagnose and treat patients with all the skills and tools I had from what we were taught in school. Then I started asking myself “where do I apply each one of these treatments?” So I started reading all of the textbooks to figure out how to assess this patient and to figure out where to apply this treatment.
The further I would dig the more I would recognize that I have no idea what I'm doing and I have no idea how to help this patient. How can I confidently tell them that I have their best interest in mind if they're going to see right through me. That’s what drove me into this. It has answered all those questions and it was a system that already had those tools in place. It just made sense to. The more work I put in, the more time I spent immersing myself in it really payed off.
The better results you get, the quicker your practice grows and everything in life gets better.
You can sign up for the online portal for $24. Then you can attend one of the seminars. We really try and make each one of them digestible. We hone in on the testing, the diagnosis, and the treatment and it’s very hands on. So start small and then gradually expose yourself to more and they will show you how to build the practice of your dreams.
Writing with originality, generosity, compassion and purpose, Dr. Noah Volz imparts valuable lessons in an entertaining, engaging and snappy way―backed by a wealth of experience. As an author, chiropractor, and entrepreneur, he has started and run multiple companies and has been the host of the DC2Be Revolution YouTube channel and podcast.