January Journal Club Case

[sewhitta]

Referral: sciatica, right
60 yr old male physician (OB-GYN)
Subjective asterisks:
Chief Complaint:
• Gradual onset of stabbing & aching R buttock pain, lumbar stiffness and constant lateral lower leg numbness 3 mo ago. Patient states he woke up one morning and couldn’t move.
• Symptoms now are constant
• Pain is worse in the buttock
• No apparent pain in the low back, just c/o stiffness
• Attributes to prolonged sitting at computer researching 3 months ago during a busy time at work.
• Aggs: Immediately when sitting <5 mins; walking >1 hr; fwd bending; rising from a chair; rolling in bed.
• Eases: Walking <1 hr, lying down and when relaxed
• Activity Level: Walks for exercise daily for 1-2 hours
Functional Outcome Measure:
• ODI score = 15/50, 30% – Moderate disability
• FABQ : PA= 10; Work= 7
PMH:
• L5-S1 microdiscectomy in 1993, again in 1997
• L5-S1 laminectomy & fusion in 1998
• No prior physical therapy
• No back problems since last surgery

Patient comments and beliefs:
• “Right side sciatic pain that has led to lower back, SIJ pain and stiffness
• “I can feel my disc rubbing on that nerve where I had my surgery, the way it did before”.
• “My lateral leg is numb, in the L5 dermatome.”
• “I’m thinking I might need to go back to my surgeon to get another MRI to see what’s going on in there and if I need another surgery”
• “I don’t really notice it when I’m performing surgery because I’m focused on what I’m doing”

Hypothesis: L4-5 disc w/ radiculopathy
Differential List: L4-5, L5-S1 somatic/facet, Glute min referral, QL referral, SIJ, Hip, Piriformis

• Observation:
– Decreased lumbar lordosis, increased kyphosis
– protective behavior sit to stand from waiting room, walk through clinic and sitting in chair in exam room (tense, leaning back and sliding down in chair)
– Demeanor: relaxed, joking
• Sit to stand: aberrant, lack of trunk & hip flexion, UE assist
• Standing Lumbar Active Mobility:
– Standing forward bend: aberrant; lack of lumbar flexion; breath holding; Gower’s sign on return; painful catch
– Extension & side bending: Hypomobile but pain-free
• Neural Exam: Slump (-); Prone knee flexion (-); Myotomes & dermatomes normal; decreased reflex response throughout bilaterally; SLR (hamstring tightness apparent B) increased back pain but no change w/ cervical mobility
• Clearing Exam: Hip (-); SI cluster (-);
• Special Tests: Alternating ASLR test (-); Piriformis stretch (tight – “feels good”); Prone ASLR – poor timing and activation of gluteal’s and multifidus (assessed with palpation)
• Joint Mobility: PA pressure: L5-S1 (hypomobile); L4-5, L3-4 (painful); R side lumbar opening technique increased lower leg symptoms.
• Repeated Motion Testing: Standing L/S flexion (excessive bracing but did not worsen); prone press up & lying prone (decreased symptoms in buttock, lower leg numbness remained)
• Palpation: tightness and TTP to Right glute min, glute med, piriformis and QL (referred to buttock)

Discussion questions:
1. Based on this information, how would you classify this low back pain patient?
2. What additional information, if any, would you need to classify this patient?
3. What “Phase of Degeneration” do you suspect this patient is experiencing?
4. Do the patient’s comments raise any concerns for you? Would these comments change your approach to how you educate and treat this patient? If so, how?

Article question:
1. In the Clinical Assessment, the therapist utilized principles to “building therapeutic alliance”, such as expressing empathy, open and reflective questioning and communication, summarizing, identifying discrepancies, setting goals, and supporting self-efficacy. I think we can all agree that the ability to effectively execute these principles is what separates a good clinician from a great clinician. I feel I struggle with asking open and reflective questions that encourages the patient to be more introspective with their condition, and encouraging self efficacy can be challenging. What are some strategies or dialogue you have used, or feel would be effective, to facilitating open and reflective questioning and encourage self-efficacy.

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[Nick Law]

Sean,

Thanks for the thorough and detailed post.

I definitely think that the combination of the patients comments, surgical history, and profession give you substantial amounts of information that alter your treatment of him. In my experience, physicians, and especially surgeons (as in this case), can sometimes (though not always) be difficult to treat as they view their bodies through a more exclusive pathoanatomical model, a model they are very familiar and versed with, and with which pathoanatomical correction (i.e., surgery) is the answer.

I would definitely be educated this patient regarding the NEGATIVE findings (negative slump, SLR, myotomes, dermatomes, reflexes) that point away from a serious neurological injury that would require surgery. I am not 100% sure how I would classify this patient; certainly flexion movements are painful, however at his age I think it is less likely that it is a true disc injury; my suspicion is that it is myofascially related, driven and support by unhealthy beliefs and maladaptive central changes.

Although aspects of his profession may indeed make aspects of treatment more difficult, there are certainly advantages to treating a patient with the knowledge and intellect that he has. I would leverage his background understanding in going deep with him regarding pain mechanisms and the disconnect between MRI findings and pain/functional loss.

[omikutin]

Thanks for sharing Sean. His symptoms sounds like a discal presentation but MOI doesn’t correlate. Nick brings up a good point on educating him on the negative presentation of the neural exams. As well, you said he doesn’t experience pain while performing surgery. Is he standing during the whole procedure? Did he get an MRI or is he still contemplating?

I like this article’s quote: “CFT combines a functional behavioral approach of normalizing provocative postures and movements while discouraging pain behaviors, with cognitive reconceptualization of the NSCLBP problem.” O’Sullivan also mentions how flexion based movements activated higher levels of muscle activation. Have you tried to have him “relax” into lumbar flexion? (I’m thinking of the video we saw during Mark Jone’s lecture). If you get better results with lumbar flexion after “relaxing into it” then I’m thinking more along the lines of maladaptive CNS.

Open ended questions are difficult sometimes. Sometimes I have to politely interrupt. Something that is helping me is to repeat what they said to make sure I’m understanding exactly what they’re saying. Then I would ask further questions if I misunderstand and help facilitate the conversation towards pertinent information. It’s a game I’m learning. If you found something that works for you, I’d love to hear it.

[sewhitta]

I think you guys bring up good points and I have tried some of your suggestions. I did try and highlight his negative neuro exam and the poor correlation of radiological findings during the first visit. The second visit was all focused on muscle relaxation and addressing his maladaptive movements, which as helpful; however, he was a bit resistant and very convinced that is damage to this spine. Nick, I appreciate your approach of using his education and background as leverage. That’s a good point. I think it could be beneficial to educate someone like him on the disadvantages of implementing only a single dimension such as a pathoanatomical approach. It may be worthwhile to highlight the fact that just treating the pathology, without addressing the mechanism driving the pathology, is most certainly a mistake and will only result in a repeated “fat lip” to tissues in his spine.
Oksana, to make my question a little more – when I think of reflective questioning, I’m thinking more along the lines of asking questions that facilitates reflection by the patient on their condition. What questions can we ask that can turn on a light bulb in the patient’s head, to get them to really think about physical, psychological and social factors in their life that could be driving their symptoms? This is something I am trying to get better at.
I think it is possible this patient could have painful or damaged tissue with an inflammatory process present even though he does present with maladaptive behaviors. His symptoms are very localized. I guess what I struggle with is educating a patient like this, who I believe could have a present inflammatory process, which presents with maladaptive movements and fear that are feeding into his pain cycle, without eliciting more fear in his mind. This guy knows something is not right in his low back and although he is fearful of another surgery, it occurs to me that he would go through with it if his surgeon recommended it. That’s the last thing I want for him. He has fear, back beliefs and maladaptive movements present that could be making it worse, but it’s not just all in his head. So, I’m struggling with convincing this patient that physical therapy is the correct approach for him and educating him on the mechanism of his symptoms. In my head, I’m thinking his L5-S1 segment is not moving because it’s been fused and that has caused his L4-5 region to develop some instability and irritation. But I don’t want to tell him he has an unstable or irritated segment because he may equate that to “I’ll need surgery on that too”.
Speaking of the mechanism, I feel he definitely has some weaknesses in his spine and could benefit from strengthening, but I have a hard time determining what caused his flare up. Could it simply be prolonged sitting at a computer doing research? What do you guys think?

[Nick Law]

Sean,

Glad your computer finally decided to let you post.

I resonate with you in regards to the difficulty of managing patients who you think truly have a an active, nociceptive injury, and yet whose pain is also driven by all kinds of maladaptive behaviors and beliefs, central sensitization.

The more I consider the situation and what I might say, the more aware I become of my uncertainty. I still think it would be very smart to help him understand the true biology behind pain and the truth of central sensitization; I would want him to understand that at the end of the day pain is the response of the BRAIN to several factors, and that tissue damage does not correlate 1:1 pain. “Explain pain” has some great examples to illustrate this that you could review or have him read. I would not flat out deny to him the possibility of structural damage, however I would educate him on the natural strength and resiliency of the spine, his negative findings, and the high likelihood of central changes that have occurred.

In summary, I don’t think you can or should try to convince him that there is no structural damage/nociception, however I would educate him on the multifaceted nature of pain and likely central maladaptations, as well as his own maladaptive beliefs and behaviors.

[Laura Thornton]

1. I agree with you Sean. My first train of thought is to classify this patient in the clinical instability category. Key subjective/objective asterisks: previous lumbar fusion at L5-S1, no hypomobility noted within L4-5 or L3-4, just pain; aberrant flexion and return from flexion; pain with transitional movements, (+) prone ASLR. Tests you could perform to confirm/support this hypothesis: vertical compression test, H & I testing, and prone instability test.

I also think there is a maladaptive component with his case and seems like he has a one-dimensional view on his condition. These statements are pretty concerning to me:
• “Right side sciatic pain that has led to lower back, SIJ pain and stiffness
• “I can feel my disc rubbing on that nerve where I had my surgery, the way it did before”.
• “My lateral leg is numb, in the L5 dermatome.”

It sounds like he already has made conclusions about what is happening. He is an educated, medical professional who is probably not going to be swayed easily in changing his opinions. At least not right away. He also seems to me to be the perfect pain analogy of the “lion following you around”, where patients have this pain as the overarching, single, separate entity that has no relationship to how you move, it will just always be there until we have surgery to take it away.

I really attempt to dive into what was going on in the patient’s life around the time when the pain starts. Changes in exercise, changes in work environment, changes in home environment, changes in diet, changes in driving habits, all that could have had an effect on their movement patterns. Sitting for long periods of time could have certainly affected him, but what about his sitting posture and environment. Did he stay rotated towards one side versus the other? Is he a leg crosser? What about this has changed from the initial onset?

In my (short) experience, patients have appreciated taking part and collaborating with problem solving. Just as well, they appreciate us concentrating on their specific goals. What does he feel that he can get out of physical therapy? What brought him to seek out a physical therapist initially? What does he want to be able to get back to? Maybe not trying to change his beliefs right away, but working with him gradually to show how he can move OR changing one thing at a time about his movements in daily life. Once he can see the value that you can provide in a functional, movement sense, then start talking with him again about his beliefs as irritability and pain reduce.

[omikutin]

Sean, I have the same struggle. There is obviously something there that caused pain receptors to activate. The main thing we can do is treat what we see. I found an article looking at forward head posture corrective exercises in the management of lumbosacral radiclopathy RCT. You mentioned earlier he had forward head. This is something you can present to him and it might be helpful? You’re more than welcome to check it out.

I used the narrow search strategy- golden. “low back pain radiculopathy”

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[ABengtsson]

Already a lot of great points made.
How has he reacted to some of the assess/re-assessments regarding his syx? Was he able to make the connections b/w your initial findings, education and outcome of treatments so far?
Also, this might be a completely wrong approach, depending on his personality, but have you tried printing out and article or two reg all this stuff and just given it to him to read?
It seems like he might be interested and if he’s open to changing his opinion, just sharing that as a side note may help too. Just a thought.
I’ve been surprised quite a few times by how much some pts are open to different ideas. Often times when I least expected it.

[Laura Thornton]

Great presentation today Sean. I have a hard time reflecting on these types of patients and as to what kinds of things I could have done differently. I appreciate how much you are trying to find the best approach for him and looking into both research and expert opinion on the matter. This is a challenging case for not only the presentation but the patient-clinician relationship.

I really liked how the article broke down the cognitive functional training stages, but I have found in clinical practice that it’s not cut and dry. Each stage overlaps with each other with incorporating functional movements, managing fluctuations, and changing pain perceptions. It’s not so much a linear process, but a continuous cycle between introducing functional tasks and reflection on pain education and decreasing fear.

Could you send us the powerpoint slide that talked about your resident process? I though that was brilliant. As well, did you get a chance to watch the video in the O-Sullivan article in the cognitive training stage? I can’t seem to find it online.

[sewhitta]

Laura – Absolutely! thanks for the kind words. I’ve been called a lot of things in my day, but brilliant has not been on the list.

I totally agree with you. Aspects definitely overlap and it’s never straight forward. I’ve recently had a couple patient’s last week that were more appropriate for this study. Individuals that have had a lot of psychosocial issue that nearly cleaned out a box of tissues during the interview. A lot more challenging to say the least. I definitely focused initially on Phase I (Cognitive Training), but I’ve found that it takes a long time to change beliefs, so you have to move on to something else and begin functional training while educating.

So I tried to find the video as well. I copied and paste the youtube link, but it was no longer up. Have you been shown the “white board” videos. I imagine it was the same if not very similar.
The link below is “Understanding Pain (Whiteboard Medical Animation)”
https://www.youtube.com/watch?v=ksNfgE3pVBw

If you decide to use this with a patient, please post something and let us know how the patient received it.

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