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Laura and I are co-treating a very difficult patient, and I would like to post the case and get all brains on deck with any suggestions
PMH: C4-C7 fusion in 2008.
Ulnar Nerve transposition in 2014.
C7-T1 Anterior cervical disc fusion 12/2/2016
CRPS in L ankle in 1983.Patient was previously treated at our clinic for 6 visits in November 2016 prior to his most recent surgery for significant cervical pain, numbness, tingling in B arms (entire arm, no pattern) worse on the left that did not improve, and then he subsequently had the ACDF.
Patient is off work.
Significant history of L arm pain secondary to ulnar nerve pain ever since 2010, and the ulnar nerve transposition made things even worse.
Patient was referred to the clinic earlier than the surgeon normally refers after his most recent surgery due to the fact that the patient had a fall onto his L arm which really flared all his symptoms
Patient recently diagnosed with CRPS of left arm and forearm.
Current complaints: L arm allodynia ( we have it mapped), “dead spot” in middle of palm of left hand, feels like a hole in his hand. Significant muscular pain and tightness in C-spine, L UT and supraspinatus, now having R ulnar nerve pain as well. Significant nerve tension in B UT’s, and L LE ( previous CRPS in L leg).
As you can imagine, this guy is tough.
We currently have him doing the following:
laterality training (GMI protocol) via the orientate app on the iphone 5-10x per day
desnesitzation training with a cotton swab on L arm 3-4x/day
Gentle AROM of cervical spine all directions 4x/day
Gentle pain free nerve glides in R arm and R leg pain free 3x/day
L shoulder flexion with gripping motion as tolerated 3x/day
WALKING PROGRAM – Patient is currently at 17 minutes 1x/dayManual therapy treatment in clinic:
Upper cervical grade II rotations and SB above his previous fusions, gentle distractionProne Thoracic grade II/III several levels below fusion
Current plan:
Recommend psychiatric referral
continue to progress movement, walking program, nerve glides as tolerated
Continue manual in clinic as tolerated
Progress graded motor imagery in 2-3 weeks
Desensitization trainingPlease chime in with any questions or suggestions about the case, I need all brains on deck in order to treat this guy to the best of my ability. Thanks in advance
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Wow Scott. Crazy case. Sounds like this guy’s nervous system is really ramped up. A couple thoughts I had at first in addition to what you have mentioned. I think the aerobic exercise program you have him on is a must. I also thought aquatic therapy could be beneficial. I usually don’t recommend aquatic therapy but for this dude, the tactile stimulation while performing movements could be potentially beneficial. I also thought, wearing a compression shirt under this shirt for some compression reducing neural sensitivity. We do this in children, it could be beneficial for him. Also, when performing nerve glides in the clinic, you could use compression to the proximal arm using a voodoo band or even theraband.
Those were my first thoughts in addition to what you already have going on with him. Let me know your thoughts. I’ll let you know if I have any other thoughts.
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Justin, I think I understand the use of compression in a peds population that responds to tactile stimulation, and for this population I could see how a constant non-noxious form of input might be beneficial to decrease some of the allodynia that he is experiencing, but could you explain the rational for using a tb for compression while also performing the nerve glides?
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The use of compression proximally can reduce the nervous systems perceived threat distally and allow you to move into ranges previously unattainable in a non threatening way. I took a neurodynamic course on medbridge where this technique was used. I have had some success in clinic using this technique; although I have not used it much. Not to say it would work with your guy, but it is something to try if attaining positions for mobilizations is difficult. However, it may be just as beneficial to mobilize elsewhere as we talked about last VOMPTI course.
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I would make sure there is a reason/rationale for any of the nerve glides, even on the opposite side, joint work (even away from the region of pain); I’d focus on pain education; make sure pharmocologically he is taking something to decrease the sensitivity. I love the aerobic exercise, laterality training.
I’d be cautious with nerve glides, other strength/flexibility exercises.
Good luck – embrace a challenging patient
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Scott, for education what sorts of materials have you provided this patient? I think it might be beneficial to show him that TED talk about CRPS that we had watched previously. The video that Eric showed during the course weekend that was from National Geographic and demonstrated the plasticity of the brain’s sensory mapping might also be beneficial to show this patient that these sorts of sx, albeit to a much different magnitude, can happen to anyone.
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Like Scott said, I have been co-treating this patient and I cannot stress enough how important the psychiatric referral will be for him. The more that he tells us about his life events and how they coincide with periods of increased pain or injury, this may be one of (if not THE) most important component of treatment. He was hesitant at first to the idea, but seems to be coming around now after this past session.
I don’t want to underestimate the power of manual therapy for this patient either, for both addressing the physical tightness around his cervicothoracic region and hypomobility in both upper cervical and thoracic regions, as well as provide opportunity to discuss pain education, importance of consistent walking program, progressive movement with left arm, and rationale for our other treatments. It has definitely installed more trust from him in us that we are listening to his story and what he believes is helpful for his pain.
I like the ideas of tactile stimulation that you guys have suggested, including the compression shirt and aquatic therapy. I think stressing to him the importance of using his arm for functional tasks will be key for him, like using his left arm for automatic motor patterns like light switches, buttoning shirts, arm swing during gait. He’s a PE teacher and former baseball coach, therefore we might be able to find familiar or automatic movements associated with either that he could practice to assist with plasticity and cortical re-organization.
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http://channel.nationalgeographic.com/brain-games/videos/rubber-hand-experience/
Another pain video post – requested
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I’d love to again have people share specific examples of “Explain Pain” strategies, analogies, metaphors, stories, approaches that have worked and not worked with this patient and similar.
Read through the 10 Key concepts posted by David Butler and think about ways to address some of these concepts.
https://noijam.com/2017/03/03/supercharging-explain-pain/
Post some thoughts.
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I have been seeing a lot of patients following MVAs and have been practicing pain science education with graded exposure. The #1, #2, #4, and #8 concepts Butler posted are things I regularly address with patients. I explain that what the patient is experiencing is a normal response following a car accident and that it is the body’s way of trying to protect itself, however sometimes it can be a little overprotective (like a helicopter parent, or crazy girlfriend, etc.). What we are going to do is retrain your body that not all movement is bad or warrants a protective response. We will do this by slowing adding non-painful motion back to this system starting with small non-weightbearing motion all the way back to walking and/or sport. That way we let it knows things are going to be okay without sounding the alarm.
What works for others? How would you change my spiel?
For reference:
1: Pain is always normal, personal, and real.
2: There are danger sensors, not pain sensors.
4: Pain depends on the balance of danger and safety.
8: Bioplastic… pain can change
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Erik
I think you’re on the right track but how do you (or others) deal with the next level of questions or comments from patients:
-I think I need an MRI (from those pts experiencing pain but have had no trauma involved or indications that diagnostics are warranted)
-I think I need to see x specialist (ortho, neuro…etc when you “know” he or she has a basic degenerative or musculoskeletal issue that is straight forward)
-I need a chiropractor (because that helped a friend/family member)
-I need surgery (on heaven knows what structure…)
-I need more pain medication…no one understands how bad this hurts
-YOU don’t understand what I’m going through..!There will be a lot more but how have you or will you deal with these statements from your patients? Please realize we all have a little “crazy” in us, especially when we’re in pain or are dealing w/psychosocial issues. How you deal with the patient in front of you at the first time these questions/comments come up will shape your relationship w/your patient, the amount of respect you gain from them and the overall outcome of the case. Good to be prepared.
pls share your thoughts.-
For the patient that tells me “You don’t understand what I am going through” I will say, “you’re right I can not experience what you are feeling, but I want to help you feel better and this is how I think we can accomplish that…”. With patients that I recognize with irritable symptoms or with fear avoidance behaviors I try to gain trust by letting them know that they are the experts on their own body, they’ve lived with it their whole life. I want them to communicate with me their pain or the reservations so that I can cease an ineffective treatment or let them know that what they are feeling is the goal of the selected treatment. With the latter of those 2 goals it is always helpful to let the patient know what to expect with a selected treatment prior to initiating it.
Those first 2 visits are tricky things with patients. If I don’t nail those down trust is hard to gain. I have seen quite a few patients recently that come in on day one stating they need imaging or a specialist or their chiro. I have found a lot of success with explaining that MRI/x-ray is a picture and doesn’t show movement which is when most patient’s hurt. I also explain the false positives shown with imaging and I feel like this helps with most patients. The expense of an MRI is also sometimes enough to gain some buy-in for PT over imaging/surgery. It is not my first option, but it is definitely something that works well with certain folks. I have noticed some that still have that look about them that says exactly what you already brought up, “but that study or image is not me”. This is something I have struggled in finding an effective response for and I would love to hear what others have done in similar situations.
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One thing I have come to realize after treating a couple patients this year with a larger psychosocial piece is that you can’t expect people to understand pain in two visits. Understanding pain is a hard concept and it takes time. You have to layer in pain education with other treatments as they gain trust in you as their practitioner.
That’s why the first several visits are crucial for patients to believe that you understand them, you are listening, and you have compassion for them and their story. Even indirect things like eye contact, body language, and gentle handling skills are huge. I try to make a point to pay close attention, let them speak, and then say something along the lines of “I can’t imagine what you’re going through, it takes courage to show up here and continue to try and get better, and I am going to try with all my power to help.”
Assess, treat, reassess is a core concept that we use, but those who have a big fear component and poor coping strategy, I like to use it to decrease fear of the untreatable and to give back a sense of control.
I also use Lorimer’s snake bite story quite commonly to tie in how the brain uses memories, emotions, and environments to perceive a threat/non-threat. I like to point out the optimistic view of the human body being adaptable and learned, because that what makes us so much better than machines, and as much as our body has become sensitive, it can do the opposite and change back the other way.
It’s a tough conversation to have when the patients who are adamant that they require an unnecessary MRI, surgery, or further referral. I like to keep in mind that the patient has right to make the best informed decision on their care. It’s important to acknowledge their concerns, lay out all the indications for further referral, and explaining how they fit/don’t fit in these indications. This would include what the MRI, surgery, or referral would NOT provide or show, and with a benefit/cost ratio, give them my opinion on whether they should or should not. Relate all the current research we know on unnecessary referrals back to their situations so they have the facts and can be part of the decision making process.
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Erik
I like your statement referring to the MRI as a “picture” producing a static image of the pt vs looking at them from a function and movement perspective. Another analogy I provide is to inform patients that many people have “positive” findings on MRI that may or may not be linked to their symptoms as well as even if they have a positive finding, their course of care will still most likely be the least invasive/aggressive/expensive approach…which is PT anyway. So many pts perceive MRI results will finally provide a hard answer of what the underlying problem is. what they do not understand is that those test results will many times make things less clear when the findings do not correlate with signs/symptoms and overall intervention. -
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Scott
I think you’ve hit the nail on the head in your statement that the pt “perceives therex flares his condition” because his perception is his reality. This is a really tough sell whether it is the pt who is glued to modalities, manual therapy….etc when it comes to passive vs active treatment. The education on pain science is one discussion which it sounds like you’ve at least approached w/him. The discussion about active vs passive treatment and participation in it is best had as early as possible when you are building relationships and overall expectations with a patient. You can focus on different things based on the patient and how you feel he will respond. First, you should educate him on the need to ultimately be an active participant in his healing and overall health maintenance. You should be used as a TOOL to direct the progression of healing but he has to learn to find ways for management of his body and symptoms because those symptoms may (and probably will) be present to some degree when he is not in the clinic and after d/c. D/c typically happens when the pt becomes independent in managing his care…the goal is never consistent treatment w/o the ability to reach goals of self management. I describe pt’s bodies like vehicles….if you do not personally maintain them through oil changes, tire rotation, etc, they will eventually break down. Most of us don’t live with a mechanic who will perform work for/on us every day. The pt will need to be the person maintaining the vehicle eventually. The final thing you could point out is that either the referral source or insurance company (and you) may/will eventually see a plateau of progress and d/c to an independent HEP will become necessary (or d/c to goals being met and he will still need to know how to manage bouts of returning symptoms). the PT’s job is to ensure the pt is ready for this time of taking on his own care. -
Hey Scott or Laura, any updates with this patient?
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Scott, did these other pain areas correlate with life events like his current symptoms?
And do you know any of the doctors that he has consulted with so far, whether that be his PCP or the surgeons? Maybe reaching out to them to ask what their thoughts are on psychological counseling and whether they had any recommendations on who or where that might be most appropriate. Couldn’t hurt to have someone else potentially on your side.
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