LBP fear avoidance pt (lumbar weekend)

[ABengtsson]

I figured since Aaron mentioned this pt during the course, I’d give you guys a little more background information, especially because I was able to implement some of those strategies he talked about with a couple of other pts and it works really well with certain people.

Pt is a 63 y/o sedentary and overweight female with traumatic onset of LBP and neck pain approximately 8 weeks ago. She tried to sit down in her chair at work, but the chair rolled and she sat down on the floor instead. She described immediate pain in lumbosacral area from impact and pain in neck, stating she “jarred” her neck. She came in approximately 4 weeks ago and was very kinesiophobic from the beginning, so I spent a lot of time on education during every visit so far. She kept emphasizing (a lot) that she had never had a serious injury/pain/LBP before and repeatedly expressed concern that she’d be in pain for the rest of her life. I always asked her why she thought that and she just answered “I don’t know, but I never had anything like this…”; the way she talked about her LBP in particular was right along the lines of what Aaron was talking about in regards to people thinking that the back is this mysterious/fragile thing. So lots and lots of neurophysiology/pain science conversations and I tried to make her tell me during every visit how she was doing better so she’d come to the conclusion that her back is in fact getting better on her own. It worked pretty well temporarily, but she kept falling back into that cycle saying that she never had anything like this etc. etc., despite the fact that she noticed herself that she was getting better. Very interesting in the sense that she was able to quantify her improvement based on specific performances in ADLs, but she still had this fear avoidance belief system.

Objectives:
Both C-sp and L-sp AROM was severely decreased and painful in all directions during the IE, again high kinesiophobia and catastrophizing.
(+) hypomobility and pain in lower C-sp/CTJ/upper and mid T-sp
(+) hypo and pain in craniocervical spine and intermittent HA (onset coinciding with trauma)
(+) SIJ provocation tests (tested 5/6 – didn’t do gaenslen’s due to irritability and frankly, I’m not sure if she would’ve even let me attempt it, or been able to get into that position even without pain)
(-) radic syx in UE and LE
(-) Slump and ULNTT (median)

Posture:
Increased lumbar lordosis (c ant pelvic tilt), thoracic kyphosis, FHP (worse at IE – improved quickly) – both in sitting and standing.
When sitting she was in an exaggerated upright posture and stated that she felt like she had to sit this way, “because that’s what everybody always says you have to do to protect your back”.

The first couple of weeks I didn’t really touch her low back much and just had her do a lot of gentle therex (pelvic tilts post>ant, LTRs, supine marching etc.) within the pain-free ROM. I usually spent the entire 30 minutes during every visit on education while she was doing therex or when I was working on her neck. Very repetitive, just trying to phrase it in all possible ways and making her explain it back to me. Mostly stuff like “moving below the pain threshold to let the body know it’s ok to move and get out of pain response/guarding etc.”.
I did do some mobilizations/STM/stretching in cervical area and she regained cervical ROM pretty quickly. I started at the C-sp for a few reasons
– she said C-sp syx affected her more in ADLs/work (sitting in front of 2 screens all day, having to turn head a lot)
– L-sp already appeared hypermobile (but then again who knows), but was very tender to palpation and any mobilizations (all PPIVMS, PAIVMS in all positions/directions I could think of)
– manual work really helped to get buy in with her and calm her down quite a bit, gave me some extra time to focus on education (she also has a hard time focusing and staying on track)
– she was always fascinated by the fact that somebody can move her neck and figure out what some segments don’t move as well etc.

I think the mechanical aspects improved pretty quickly, and even though she improved overall, she still exhibited a lot of those fear avoidance and catastrophizing behaviors. Also, during one of the later visits I talked to her about how much pain she is still having and she said this morning it was a 100/10, before I finished the question (I usually end that question with “10 being that you have to go to the ER immediately). When I finished that part she said 10/10. I asked her whether she called 911, or went to the ER (much to the amusement of one of my colleagues) and she said she just moved around a little, took a hot shower and it was a 3/10.
Another part of this was her difficulty with focusing etc. At the beginning I taught her how to transfer on the table (in bed) and how to get form SL to sitting to avoid pain. She was able to demonstrate c good form right from the beginning, but unless I reminded her somehow, she’d always forgot to do it and would go from sitting on the EOB to long sitting to just going straight to supine, using all abs/hip FLXs (causing her quite a bit of pain). Same thing in reverse supine-sit. She told me that sometimes when she remembers using the correct form she’d notice a huge difference in regards to pain etc. Generally with movement, she’d always try to tighten her core up (sometimes observable distention of abdomen) and usually would hold her breath. Again, tried a lot of ed and she’d be able to repeat it back/explain it to me, just didn’t implement it very often.

When I saw her with Aaron, he spent quite a bit of time talking to her about everything he mentioned yesterday (just a lot more detailed) and very similar to O’Sullivan’s conversation with that pt in the video that Mark Jones showed.

As he mentioned Aaron used that wrist analogy and made the pt try it too (moving wrist with mm contracted vs. relaxed) and lead her to come to her own conclusions. I really think that the way Aaron phrased certain things and made the pt come to her own conclusions, really helped her understand some of those things.
Aaron got her to really relax her core and especially lumbothoracic paraspinals and then made her go through lumbar AROM -> huge increase in range and decrease in pain.

Another thing that happened when I saw her c Aaron was that she came in c a new syx (sharp pain in L mid-thorax area, worse c deep inhale, got better when her son was “rubbing it”, but was painful again when he stopped) – increased tone in L lumbothoracic paraspinals and TTP L to T7 area. I went into mobility testing etc. thinking some type of rib involvement causing mm guarding/spasm, but Aaron thought it would be better to address her overall posture/EXT/movement/hypertonicity etc. first (and it def was). After Aaron got her to move more relaxed and with decreased to no pain, she never mentioned her new syx again.
Afterwards we had her go through some of the initial therex, with an increased focus on relaxing everything. She immediately noted decrease in pain with movements.

The next time she came in she looked way better than I’d ever seen her – overall, looking happier, better movement, not kinesiophobic. Stating that we’d fixed her. The odd thing was that she contributed her significant improvement to the manual I did with her (I probably did way too much, making her think that she needed it more than she did), so I spent a lot of time on ed on what Aaron talked about the previous visit and how the improvement stems more from a change in how she moves. Also tried to improve her self-efficacy etc.

Just thought I’d give you guys the background on her, because I think she’s a great example. The day after I saw her with Aaron, I saw another pt who is similar in some regards (I’ll write about him in a week or two – very interesting case as well) and saw a lot of improvements with him as well. Haven’t seen him since, so I don’t know yet whether it made a difference.

Hope this helps.

[Michael McMurray]

Great take home points here.

We are typically part of the problem versus the solution with these folks.

“Weak core”, unstable spine”, “Hypermobility”, “Hypomobility”.

Patient with high fear/anxiety become more hyper vigilant with everything that we say, waiting for the most fearful phase to twist into a pain memory which requires challenging efforts to change.

Some great things I read – were: Showing her, not telling her that she can control her pain by moving better (transitional movements); getting cognitive change through her own awareness; especially relaxation and movement to decrease her fear of pain/re injury.

Manual Therapy in these cases – think neurophysiological effects more that anything bio mechanical you think you may be doing; and definitely how you explain Manual Therapy rationale.

Our language probably more important than the specific technique

Great post – more discussion hopefully with similar cases – more next OMPTS Weekend as well

[Nick Law]

Recognizing the psychological and erroneous belief components of patients pain in cases of chronic LBP is something I am growing in appreciating the importance of, and yet I still feel very ill-equipped to manage these patients. I am sure the next OMPTS will give us additional tools in helping work with these patients. I am also excited for Rusty Smith’s course in the spring on the biopsychosocial approach in managing patients with spinal instability.

I have yet to read it, however the O’Sullivan crew just published an article in PTJ on Cognitive Functional Therapy for Chronic Disabling Low Back Pain (see attached). I am sure it contains a lot of pearls. The appendix also looks to be especially helpful.

[Laura Thornton]

Thanks for posting this article and about the patient case. I appreciate breaking down the intervention into distinct stages because there can be so much to cover with these patients and it’s a little daunting on how to approach this type of intervention. Can’t wait to learn even more.

[ABengtsson]

Another follow-up regarding aforementioned pt:

She has cont to improve significantly since I saw her with Aaron, both in her functional limitations and perception (self-efficacy, fearfulness).

She is still very focused on the fact that she never had anything like this before, but with the understanding that she won’t have pain forever, which is probably the most significant improvement as compared to a few weeks ago. She still has minor limitations in C/S AROM and PAMs (C4-5 only).

The other day I talked to her about how she improved her movement patterns, motor control and habits and how, at this point, that is a lot more important than any manual intervention. I also talked to her about D/C planning and she was still a little nervous about stopping right away, so we decided to decrease frequency just to follow up for 3-4 weeks (I believe we have 3 visits over the next 4 weeks). She said she was 96% better, but when we talked about D/C, she was still very fearful about possible re-exacerbations, although not nearly as fearful as she used to be.

Seeing how that was a nice example of how it can work, I figured I’ll share a story about another pt (I mentioned in my first post here).

Quick overview, this guys has had 4 L/S including laminectomies, discectomies and fusion of 2 levels. He’s been in PT on/off for 3 years and has seen the majority of PTs at our clinic.
As I mentioned above, I had the same conversations with him as I did with the pt I saw with Aaron. His L/S AROM was pretty much normal in sitting and he could move without increase in “baseline pain”, in every direction. As soon as he stands though, his AROM is maybe 10% in all directions, if that. As soon as he started moving, his entire trunk started shaking and he had a hard time moving back to neutral; also reported sig increase in pain.
The second to last visit, I spent close to an hour talking to him about pain science and everything that Aaron talked to that other pt about (relaxing trunk/core etc). It was kind of a perfect situation, because I saw that first pt with Aaron just the day before. I got him to figure out why he has more pain with AROM in standing, as compared to sitting and got him to come to his own conclusions. He even figured out how to adjust himself and move differently in standing and he increased his pain-free L/S AROM significantly (hands below knees in FLX).
I was really excited to see him again to see how/if he improved and I was hoping for the same, or a similar outcome as with that other pt.
He cx/NS the next 2 visits so I didn’t see him for another 2-3 weeks. When I saw hime again, he was still in a lot of pain and seemed to move even worse.
The interesting part was that he was able to repeat everything we had talked about verbatim, even how he was able to move better during the last visit, taking control of his pain/importance of improving his own movement etc. etc. etc. etc., but followed up immediately with “I need to find somebody to fix me”. It was another 50 min visit with a lot more conversation/education, but at that point it was pretty clear that regardless of what I told him (or all the other PTs for that matter) and what he learned, it wasn’t going to change his outlook.
He told me how he already tried pain management and psych therapy (depression, anxiety, PTSD – deployment, several near death experiences) and that it did not help him at all. He was even able to recite the neurophys of pain modulation and connection to depression etc., but apparently did not make that connection.

Hope it helps to have an example of where all that stuff does not end up helping.

In conclusion, I fully agree with Nick… can’t wait to learn more about this during the next courses. It also showed me again how little preparation I got for these situations in my curriculum.

[Author]

Posts