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This past week I evaled a patient with the referral of low back and leg pain. Upon seeing this referral my first thought went to a hypothesis of lumbar radiculopathy or some degree of radicular pain. I received the body chart completed by the patient and was slightly surprised to see that the calf was circled, but no part of the lumbar spine was colored in. The medical screening form had a massive amount of information written on it, not only in designated areas, but scribbled in the margins as well.
As I brought the pt back, I started to ask him about his body chart/symptoms. He dove into his PMH and switched back and forth between topics, hardly finishing one thought before starting another. This ranged from explaining that he sustained a head on collision with a car as a child to the multiple concussions he’s had, to the issue with his back and leg being entirely “nerve related” and coming from the disc. He expressed frustration with his medical treatment and had with him an entire book bag full of medical records. He has been dealing with these symptoms for over 15-20 years with little relief and with the biggest challenge being sleep.
After listening to this patient try to explain everything that has been going on, I had a great deal of sympathy for him. I also realized that there was going to be a huge psychosocial component to his care. The most unfortunate part about this eval for me was that I did an extensive neuro screen (reflexes, sensation, myotomes, slump and SLR) and every component came back negative. After finishing this part of the exam, I took a moment to gather my thoughts about how to explain this to the patient. I ended up going the route of saying that my neuro tests were all negative, which was a good thing and meant that if he did have nerve involvement it had not affected these components. I received no response to this explanation.
The second difficult part came when I began lumbar PAs. As I assessed the central PA at L5 and unilateral L sided PA at L5-S1, the pt said he could feel his symptoms so I asked where and he said “down in the disc”. If you’re an office fan, I believe I had a Jim Halpert look up “at the camera” moment when the patient said this. He continued to say that when I pushed down he could “feel the disc pushing on the nerve”.
Clearly, I am going to have to approach this pt’s care carefully in order to gently counteract his obviously strong beliefs about his condition. I know that I may not even be able to change his thoughts, and it could be better to educate where I can, get him stronger and show him change through reassessments instead of words. This pt brings a LOT of different factors to the table: multiple traumas causing memory loss (car accidents, falls, motorcycle accidents), being a vet, 20+ years of chronic pain, and poor healthcare experience. Navigating all these factors is going to be challenging, but hopefully I’ll be able to nudge him in the right direction through gentle education and treatment.
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