Drinking From the Firehose of PNE

[ebusch19]

I had an eval with a persistent pain patient a few weeks ago and thought we had a good connection after the first two visits, but she ended up canceling the rest of her visits and wanted to go back to her MD. When she called, she stated that she wanted to check back in with her MD about her pain and if she would return she would come back to working with me. She came in with a 20-year history of back pain that had been worsening within the past year. It originally started after working on her patio and being in a bent over position for a sustained period and since then gets flare-ups about 2x/year, but this past year it has already happened about 4x. The most recent occurrence began after vacuuming and she reported pain in her low back that radiates to the left low back. She has had xray imaging which was clear and her doctor started her on steroids which has been helping a little. During the eval she kept using verbiage that indicated she had a lot of fear avoidance beliefs. She told me she considers herself to be a person with a “bad back” and has avoided movements since the most recent flare up in her back. She also told me she feels like she needs to “reset” every morning by sitting down before starting the day to prevent her pain. She used to be very active previously before covid but since has not been as active and has gained some weight.

I think hearing her say all those things and knowing she has persistent pain, my thoughts for treatment went straight to pain science education. During the exam, she presented with a more stenotic/facet arthropathy type presentation where extension bothered her pain more than flexion and had hesitancy with movement. She was also very hesitant about me pressing along her back and around the muscles. I kept thinking she would be the perfect candidate for PNE and tried to start incorporating it during the first visit, talking about the alarm system and tried talking about how the brain stores memories similar to a talk from Lorimer Mosley. She seemed on board with it at the time and I had planned to incorporate it during the second visit. At the second visit, I was excited to work with her and gave her the Tampa Scale of Kinesiophobia and as soon as she completed it, she was like “you probably think I’m psychotic”. I tried to reassure her I did not, but she did score high on it (52/68). I really tried that session to incorporate exercises with PNE and reassure her that it’s okay to move, but everything we were doing seemed to bother her pain.

Looking back on the treatment sessions, I could tell that she seemed a little skeptical of everything I was saying and was not 100% bought into it. I remember listening to Adriaan Louw’s presentation and even this past weekend with AJ, that if the pt is not open to learning more about their pain, then PNE is likely not going to be as affective. I should have asked more questions to get a better idea if she was open to it from the beginning before diving into it. She probably thought she was drinking from the firehose of PNE with all the talk and the outcome measure. I definitely learned a lot from this experience and will ask pts in the future how they feel about learning more about their pain. I would be curious to know if others have had something similar happen to them or ways they like to incorporate PNE with their patients.

[AJ Lievre]

Emily
Great post. I have a few questions. What do you think made her say “you probably think I’m psychotic?” What do you think was going on in her head when she was filling out the outcome scores? Rather than say, “no I don’t think your psychotic”, did you consider asking her why she would say that? For me, that would provide me with more information about what she was thinking and allow for a more detailed or targeted explanation.
Last question, why do you think you lost this patient?

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