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Please see the following attachments and answer the questions at the end of the case.
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Hey Jeff,
Great case. There’s been so much attention to accurately categorize our patients (movement deficit, radic, instability) that I wish the article made some mention of that for their subjects.
1. Based on the subjective findings, what are your immediate differentials?
I’d be interested where in the posterior L LE her pain refers.. Lower lumbar radic, Lower lumbar facet referral, Lower lumbar clinical instability. Disc doesn’t make my top list d/t painful sleeping prone, which should improve discogenic sxs.
2. Based on the objective findings, are there any other tests that you would have performed?
H & I testing for the quadrant, PIT or active paraspinal contraction with UPAs, Slump or SLR with UE extension activating abdominals, Seated picking up object from floor (though probably wouldn’t push this matter), and I’d be interested in which direction the car hit her from… on the front L? Would that push her into L SB and Ext, making her fearful of moving that direction?
3. What is your primary hypothesis?
Lower lumbar facet referral rises on my list d/t painful flexion quadrant R in addition to extension quadrant L
4. What interventions would you have performed on the first day?
** Education: Getting to know her belief system and what she feels is still the problem / what has been successful aside from opioids. Discuss reality that any “damage” likely healed by now, so we need to find the root cause and give her tools for independent management strategies. Her goals will be important.. does she even want to return to higher activity level, or is getting around the house enough?
She could probably benefit form the Explain Pain YouTube video as homework!
* Manual: What kind has she received in the past? Could be worthwhile, given your article, to provide a TS manip (or mid-grade mob).
* Exercise: Your exam shows that A/PROM hip flexion is normal… can we have her perform “bending” tasks from the bottom up? Maybe supine DKTC or Seated Cat (trunk rounding) with arms supported on knees? I’d be really interested in helping her really “map” out what she’s capable of.. it sounds like no one has ever guided her through movement after the accident, and she feels totally reliant on other people to keep her going.
5. Would this be a patient you would perform manual therapy with, or would you keep your interventions all active? If you did any manual therapy, which technique would you choose?
I’d include it to begin a few f/u sessions, if she felt like these were particularly helpful in the past. Her fear levels are so high (actually refusing to attempt to pick up an object from the floor) that I’d be hesitant to throw her into the ring of pure active focus right off the bat. The article shows good improvement in FABQ scores after manual tx to TS, so I don’t see a particular reason not to unless she demonstrates any yellow/ red flags not listed here.
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Based on the subjective what is your immediate differentials?
– Lumbar facet dysfunction
– Lumbar radiculopathy
– Lumbar discogenic pain
– Lumbar DJD?Does she sit or stand for work? Does working increase her sx?
Based on the objective findings are there any other tests that you would have performed?
– Slump (more provocative if inconclusive SLR?)
– H&I testing
– endurance testing?
– Prone instability testing; vertical compression test
– DTR’s
– Interesting that she has WNL lspine flex but refused to attempt to pick an object off the groundWhat is your primary hypothesis?
– Lumbar facet dysfunction w/ catastrophization
– especially if she feels that her pain has increased because of insurance cutting off her opioidsWhat interventions would you have performed on the first day?
Education: addressing her yellow flags, describe to her the importance of continued movement and activity. Express to her that the tissues affected during the MVA have healed by now and we are not damaging them by moving. Additionally I would educated on setting up work ergonomics standing or sitting.
Due to increased fear of movement I would start w/ simple supine exercises LTR’s, SKTCWould this be a patient you would perform manual therapy with, or would you keep your interventions all active? If you did any manual therapy, which techniques would you choose?
Erik I think you make a great point in attempting to identify if she received any manual therapy in the past and their effect on her symptoms.
I would perform MT with this patient explaining to her its role in treatment. I would explain to her these techniques are meant to give you some relief so that you can perform exercises/activities in an attempt to promote independence and active exercises. Based on the information I would perform slidelying flex/rot mobs to Lspine Gr I-IIAfter reading the article I would consider Tspine manipulations but probably not on day 1 due to her yellow flags that I would like to continue to address during subsequent visits.
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Erik and Matt, I really like your takes on patient education.
1. Based on the subjective findings, what are your immediate differentials?
– Acute on Chronic/degenerative discogenic (L4/5, L5/S1)
– Acute on Chronic/degenerative facet (left lumbar)
– Myofascial referral from lumbar musculature (lumbar multifidus, erector spinae, QL)2. Based on the objective findings, are there any other tests that you would have performed?
– Common positions at work?
– Dermatome
– Seated compression
– Traction
– Slump
– Prone torsion test
– Prone press up
– SIJ cluster
– FABQ
– T/S screen3.What is your primary hypothesis?
-Acute on chronic left lumbar facet pathology
4. What interventions would you have performed on the first day?
– Education for positions of comfort at home and at work (right side-lying with pillow under hips, knees to chest)
– Gentile active ROM exercises (forward table slides, quadruped rock backs, knees to chest supine)
– Introduce chronic pain talk (but not too much)5. Would this be a patient you would perform manual therapy with, or would you keep your interventions all active? If you did any manual therapy, which technique would you choose?
– I would start with manual to try to gap the left lumbar segments in side lying
– Maybe light massage for soft tissue restrictions / giving non-painful input to brain to lumbar region
– Potentially manual traction
– I feel like this patient could very easily not tolerate manual interventions in which I would switch to mostly active interventions – starting in gravity minimal positions. -
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Hi everyone. I think my biggest question and topic I wanted to bring up is where do we think this person lies on the biopsychosocial aspect of things? It’s obvious that this needs to be addressed but I wonder how much and its implications for her plan of care? I feel like I’d go down this road hard, but I don’t necessarily know if that is most appropriate. Erik (if I am going to assume) would maybe do mostly education? Cam nation maybe a little less?! Jeff, I’m curious as how much of those yellow flags were noted via just general questioning or did you intentionally spend time on these topics trying to get a better understanding of her beliefs and overall biopsychosocial status? Did you feel good about the information you got from her? Where would you classify her psychosocial risk status (low, medium, high)? How much of ths played into how you conducted your examination and eventually treatment/POC? (sorry for all the questions)
The reason I bring this up is after reading this article: Listening is therapy: Patient interviewing from a pain science perspective (Physiotherapy theory and practice, 2016) It made me wonder if I read this prior to evaluating a patient like yours would it have changed the way my interview, examination, and treatment? The paper discusses the importance of screening those yellow flags, identifying those psychosocial barriers, and how steering your examination and treatment should be highly driven by your subjective from a pain science/education standpoint.
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Thanks Casey
Do any of the findings/”impairments” matter when the biopyschosocial components seems to superseed any accuracy for those objective findings?
How would you modify your communication, exam, and treatment direction when the biopsychosocial/fear components is the primary diagnosis?
Looking forward to a great DISCUSSION at Journal Club – ideally about how to change treatment planning/communication for this high fear patients.
Thanks
Eric
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1. Based on the subjective findings, what are your immediate differentials?
– Stenosis (L uni or central)
– facet referral on L
– lumbar myofascial referaal
– L inta/extra articular hip referral
– possibly disc/SIJ referral but less likely2. Based on the objective findings, are there any other tests that you would have performed?
– SIJ cluster to rule out differential
– paraspinal palpation
– dermatomes
– FABQ?
– varying heights willing to pick up object (if she’s willing to do lumbar flexion during APR)
– any improvement in pain with intra-abdominal contraction?
– hip strength?3. What is your primary hypothesis?
– facet referral of L lumbar spine without radiculopathy4. What interventions would you have performed on the first day?
– education regarding fear avoidance, continued movement, length of time to expect “tissue damage” if MOI was so long ago, analogies if appropriate (i.e. car alarm leaf vs burglar)
– possible gapping mobilization based on response – general L lumbar if she seems comfortable with this
– Exercises to work on gapping the L side, possibly some light activation drills based on strength levels found5. Would this be a patient you would perform manual therapy with, or would you keep your interventions all active? If you did any manual therapy, which technique would you choose?
– I would consider doing a gapping mobilization if I felt it was appropriate based on how our conversation was going. If she’s bought in, the info in the sheet indicates that it could give her relief. If she appears too fear avoidant/cautious/anxious, then it would not be appropriate and you could give her variations of exercises to work on gapping on her own.I think the majority of my eval day would be education although. Exercise and manual would come second to this on the first day because likely this person has not been moving due to fear for several years. Some education/pain neuroscience would be most beneficial for her most likely, especially if we only had 15-30 mins after the eval with her. I’ll be interested to see where you took this and if we all would have treated her similarly/differently.
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Despite the fact that this patient demonstrated hypervigilance, fear avoidant behavior, and catastrophization, at the initial evaluation she had fairly consistent impairments that either reproduced her symptoms and or alleviated symptoms. She was definitely in need of education with a limited objective exam, but the objective information gathered allowed for consistent assess re-assess.
The patient education for this patient needs an approach that addresses her current state of hypervigilance, her fear of falling into an “exacerbation” phase and what the meaning of her pain is when she is in an “exacerbation” phase. However, along with this education, additional patient buy-in and functional improvements could be achieved with this type of patient by addressing her consistent impairments and making immediate changes/long term changes.How might you go about explaining the “exacerbation” phase to her that helps decrease her current hypervigilance? Understand that this patient has concerns about missing work and losing her job when she does “have to take time off of work” due to pain.
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I agree with AJ. She stated she didn’t want to bend to pick up something off the floor when asked but then she did a squat and forward flexion. I would of started my education at that moment while being sensitive to her beliefs about bending. Again, I don’t think her obj exam necessarily completely validated a hypersensitive/catastrophic presentation due to the patterning therefore I would of discussed the natural history of low back pain and that her exacerbation’s are not necessarily uncommon. Looking forward to a more in-depth discussion at lunch.
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I meant to post this article as well and pose additional questions.
How might this relate to this case (ie: unable to get meds she thinks she needs and or being a victim of accidents years ago) -
Jeff – I thought you did a great job presenting a multi-faceted case stimulating newer discussion.
When I picture this patient in front of me, the first thing I’d want to do is have her explain to me why she thinks she’s still in pain 12 years later. I think I’d be more effective at combatting her belief system… if I knew what exactly it was. To me, this is the crux of her self-limiting behavior, and I know I can weave in counter points if I know where the holes of her arguments are.
People are unhappy when their version of perceived reality differs from actual reality, and this person feels as though her life drastically changed from the moment a drunk driver collided with her car 12 years ago. I’d first and foremost demonstrate active listening with empathy. From there, it could be a good strategy to just show her all of the things she can do and begin to match current objective reality with her own sense of what she’s capable of. Rapport would be paramount, and it’ll be important to gradually gain information about what a typical day looks like in her world, her social support system, and her motivation factors.
By building a comprehensive picture for the patient, pain acceptance can gradually occur as her perceived reality begins to better match objective reality, and the injustice she clings to can gradually fade.
I have a 56yo mother, who was the captain of her tennis team before a competitor fell into her in the changing room and tore her ACL. My patient was/is furious, and suspects that this was on purpose.. This was her first actual injury, and it was evident her interpretation of Pain is extremely superficial and elementary (pain vs no pain, rather than a spectrum). She entered my office 6 weeks post-op (no PT) and was steadfast in her belief that, if she experiences pain, it means she’s tearing her ACL reconstruction.
My first 2 sessions with her were entirely listening to her reiterate how she’s furious she even has to be in PT instead of competing. All I did was accept and listen (Actually, I was gathering information). Her constructs of Pain, injury, perception of injustice, and her own interpretation of her prognosis were all poorly founded. The next 3 weeks were my turn, where I was able to systematically attack her beliefs with 1) education 2) goal setting 3) turning a negative into a positive.
My goal setting included both short and long-term goals. Short term goals were between-session goals that she was meant to obtain with her HEP (like demonstrate a steady quad set for 10 seconds, or achieve full active knee extension). Long term goals were my duty, like weight bear without crutches, walk, and move in bed without dragging her limb with her arms. The point of this was to show her that she was improving by participating in my plan (she knew her plan had failed — she came to me in bad shape 6 weeks post-op).
Turning a negative into a positive was something I “prescribed” on my own agenda by flipping the script. Whenever she described her own reality as down, hopeless, and unjust, I would explain to her that she’s getting expert attention to her physical well-being so she can be a better competitor post-op than she was with her previous training program (which was just a stair climber 5x/ week, anyway). Her competitive nature, which in part fueled her feelings of anger, became a tool I used as we train for her big return to the court.
She started to actually love coming to PT, as her reality went from one where she was forced off the court to one where she was focused on training to become an even stronger competitor. Her tx session subj report became more detailed and no longer her only indication of success or progress.
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Erik I think you make a great point about determining the patients beliefs and why they think they’re in pain and using that as critical information that you can utilize to hopefully chip away at those negative thoughts and turn them into positives. Unfortunately sometimes we do not have the patients who come in and say I hurt for these reasons, instead they say something along the lines of “everything hurts and I don’t know why” and they’re obviously there for us to fix them. As mentioned in Journal club pointing out disparities in their complaints and how they are actually functioning in front of us would be a great place to start with some of those patients.
I recently discharged a 50y/o female who was involved in an MVA 4/8/18. She had been seen by another therapist at my clinic fairly consistently for about 5 months for concussion symptoms as well as neck and low back pain until I started seeing her. At this point to my knowledge their treatment consisted of concussion rehab, dry needling, and manual therapy to her neck and back with min-mod improvements.
She had been out of PT for about a month prior to our evaluation together at the end of October and she presented with complaints of constant neck and back symptoms. Similar to the case presented in journal club she did demonstrate what appeared to be mechanical symptoms that I felt could be treated with manual therapy, exercise, and education. I believe this is where I made my first mistake, I did not properly identify the potential yellow flags associated with this case including the duration of time she had been in PT prior w/ complaints of similar symptoms and the fact that her therapy was being covered as part of her settlement following the MVA. Being a new clinician I figured I could fix all her problems with my hands on treatment – (mistake number 2.) We did a combination of mobilizations and manipulations to her C/S and T/S with good short term improvements. She appeared to be getting better but would come in subsequent visits expressing that she felt the same noting no sustainable change long-term. She kept reporting that she felt that her body was 80 and was letting her down and she could not do what she wanted to do on a day-to-day basis. This went on for about 6 weeks before I realized there needed to be a shift in POC.
In early January, I spent a large majority of the session educating her on pain science. I explained to her that the tissues impacted during her MVA have all but healed by this point and her system was most likely in a repetitive hypersensitive state in patient friendly terms (alarm system on high alert and a leaf blowing across sets if off). She appeared encouraged by the shift in POC as I encouraged progressive increase in cardiovascular exercise and a completely hands off approach to care. Subsequent visits she performed a circuit of cardiovascular exercises centered around a treadmill walk (one of her goals), total gym for time, and bike riding. During these visits I did not perform formal pain science education instead pointed out what she was able to do pain free and continue to encourage her participation in her desired activities. We recently discharged her at the beginning of the month, but I definitely feel that I could do it over I would have handled this situation at lot differently now being more aware of the yellow flags that were present during initial evaluation and incorporating more biopsychosocial treatment earlier on in treatment.
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After listening to the last journal club and talking to co-workers, I realized that I do not have a very good approach towards managing a predominately biopsychosocial case. I typically try to fit everyone into a biomechanical category/pathology and treat from there. For example, I thought Jeff’s case was primarily facet driven when reading the case. However, I was missing a huge biopsychosocial component. Because of this I researched and found an article to provide a framework when evaluating, managing, and treating someone with disabling low back pain. The article is titled, “Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain” by Peter O’Sullivan. When a patient presents with a huge biopsychosocial component and chronic pain, the style and focus of my PT interview and intervention needs to change away from a biomechanical approach, but rather towards a cognitive functional therapy approach in my opinion after reading this article. I created an outline of this article that I can use in clinic. It highlights the multidimensional factors associated with low back pain including the modifiable and non-modifiable factors for influencing pain and behavior. But more importantly this gives me a framework for interviewing, assessing, and managing an individual that I might encounter with chronic disabling low back pain. This article also gives three patient case examples on Cognitive Functional Therapy which I thought were helpful.
Jeff, looking back at your journal club case, I feel like the interview strategy proposed in this article could provide a framework for managing that challenging patient.
Erik, I really liked how you managed the patient’s pain beliefs and other emotional/social factors that were associated with her injury.
Jeff, is / has the patient being seen by someone for her PTSD? That’s awesome that you blocked off time for her to read the pain book. How do you think you could change her belief about pain?
Matt, I feel like I have done something similar in clinic. I always want to be hands-on, especially after our weekend courses to practice techniques. However, a hands-on approach might not always be best and may encourage dependence like Jeff stated. I liked how you switched your focus in clinic towards her goals of walking while also addressing her pain.
Any thoughts on the article I posted?
For someone like me who has a difficult time talking about emotions, I thought this article was helpful to give me some guidance towards opening up a potentially giant/scary biopsychosocial door.
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Hi all!
Reading through your patient case examples got me thinking of where my current frustrations lie with where I think I miss with some of my patients. I get stuck in this realm of patient A walks in and it’s time to use my PT knowledge and fill in the blanks: subjective, objective, PT diagnosis and give them 3 exercises. Bam, I’m done. I just vomited my knowledge onto this person, they now know all the tissues, movements and structures that are at fault and are educated on how we are going to address and rehabilitate them. However, what I fail to recognize is maybe I just did more harm them good. Maybe I just added more yellow to their system. For a patient who has seen multiple different health care providers, who’s life has been defined by pain for X amount of time, did I just medicalize a pyschosocial persisting pain problem? I probably just created more fear by informing them of the structure that is at fault, the muscle that isn’t working appropriately, and their awful posture. Probably things they’ve heard a million times and I am another provider amplifying their pain beliefs. I think forgetting to ask these open-ended cognitive and emotional questions is where I am doing a disservice to my patients and where I miss my opportunity to truly assess and evaluate their yellow flags and ultimately knowing where the focus of my treatment should be. So thanks Cam for that article, table 2 will be extremely useful to me!
I took this quote from a book I am reading “Remember, pretty much every assumed dysfunction, (posture, tightness, weakness, structure, degeneration) can exist in people without pain” And I think sometimes as health care providers we can drive this train, blaming the impairments which we are trained to find, to believe these factors are the causation of their pain which may be faulty thinking and hindering their recovery. I want to be better at screening for these yellow flags, identifying patients (using the appropriate tools and skillful patient interviewing) who need more pain science education and step away from the biomedical explanations and treatment I tend to lean towards.
I wanted to ask people what are your go-to pain education strategies. I’ve found that examples or analogs are the best way for me to understand and educate my patients when the majority of what they need is pain education. My go to lately is pain is an alarm (stole this by the way) analog. I’ve found it to be helpful to get some of my points across and drive my agenda, especially with patients with high fear of movement. Below is one I’ve found to be successful for me.
My patient education tends to be something along the lines of this: Pain is an alarm (house alarm, smoke alarm, alarm clock, whatever)… its purpose is to alert you of potential danger, or motivate you to take action. However, the magnitude or number of alarms going off doesn’t always equate to the level of action or protection need, it’s not a direct correlation. When there is an insult to our system our bodies often go into overamplification of protection mode. For example, when we break a bone our body makes extra bone or when we burn our skin we produce extra skin scar tissue and sometimes that process goes overboard, like some people getting keloid scars. Pain can do the same thing; our bodies and our brain can have an overreaction and almost becomes better at producing it. So, what started off as a “oh s*** meter” which was helpful and potentially necessary at the time, now is continuing to alert you however is no longer helpful and has become its own problem.
Sorry for the rant, I love this stuff!
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I like to describe not so much the What but the Why to patients who have higher, more irritable, or persistent pain without acute injury. I’ve found success explaining the function of nerves, as you have Casey, and their role as vigilant body guards to alert us about potential danger. “Potential” is a key word here. That means it’s in part reliant on the nerve (and the person’s) PERCEPTION of what could be harmful. When “the system” is overactive, our body’s car alarm begins to turn on even against the brush of a leaf. (Possibly stolen analog).
Check out the attached article for a great example of this, which I’ll sometimes describe to patients.
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