Over 20+ years I had spent studying the spine literature I found that, while a lot of great work was done in this field, no single treatment was found to be most valuable to patients suffering from Spine Related Disorders (SRDs). I concluded that this was because, first, SRDs are multifactorial in etiology and mechanism and, second, each patient experiences a SRD in his or her own unique way. I therefore concluded that a multi-modal approach that can be individualized to address the unique diagnostic features in each patient and that focuses on the practitioner getting to know the patient as an individual is needed for this complex and often confusing group of disorders.


Through my study I came to realize that there are a number of individual diagnostic and treatment approaches that are beneficial in addressing specific aspects of the SRD experience. But the randomized, controlled trials in the field generally show that each approach, when randomly applied to groups of patients without regard for diagnosis or individualization, contributes relatively little to the overall picture. This has led to many researchers and clinicians to conclude that nearly every diagnostic and treatment approach was nearly, or completely, worthless!

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I decided to see it differently. It seems that the fact that each individual approach contributes a small amount means that a combination of approaches might add up to “contributing a lot”. More importantly, the key to effectiveness is figuring out in each individual patient what combination of approaches is most important for that person’s problem.


Moreover, it became apparent that a focus on “treating pain” was misguided because what we are “treating” is an individual human being who is suffering due to pain and its resulting distress that comes from disability, fear and uncertainty.

The logical conclusion was that any diagnostic and management approach that is going to be helpful has to involve the following features:

The recognition of the multifactorial nature of SRDs.

The recognition that for most of the contributing factors there is no single diagnostic test that definitively and objectively demonstrates its presence. Therefore a comfort level with “gray areas” was necessary to effectively help patients with SRDs.

The recognition that it is not a spine that is seeking our help, it is an individual human being who is having a pain, disability and suffering experience.

The recognition that while there are several treatments that have been shown to be beneficial in the treatment of SRDs (and many others that have not), it is the communication context in which the treatment is applied that determines the degree to which the patient benefits.

Therefore, an integrated approach is needed that allows the clinician to consider all of the possible contributing factors in each individual patient to arrive at a diagnosis that is relevant to each patient.

As I further studied the literature I realized that there was no single study or group of studies that provided a definitive approach to SRDs. However, I discovered that there was a great deal of information from high-quality scientists that allowed me to develop an integrated approach that included all of the features listed above. This resulted in the CRISP® protocols.

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Specifics About Clinical Reasoning in Spine Pain® (CRISP®)