My back still hurts, is therapy a waste of time?

[Farisshd]

For this reflection journal post, I am choosing to reflect on continued encounters with the same lumbosacral radiculopathy patient from my last post. In that post, I focused on our discussion regarding her x-ray results reviewed with her pain management doctor. For this post, I’d like to reflect on her limited progress over her plan of care. Since our conversation, the patient has had progress measures, displaying improved tolerance and available range of motion in all planes, and improvements in LE strength measures. She continues to have periods of centralization with gapping and distraction, but these windows seem to fade following her session within a few hours. The patient has clear improvements in gait and movement quality with decreased rumination on pain in her sessions. However, she recently called in and stated that she feels the therapy is only leading to temporary relief, clearly frustrated that she continues to experience pain on a day-to-day basis. She was asking for advice if the therapy is helping her or if she is wasting our time and hers by coming.
As the therapist, I share in her frustrations relating to continued pain and inability to attain long term centralization. However, I am encouraged by the improved exercise tolerance, the recurring centralization with treatments, and the decreased impairment reflected on outcome measures. A lot of the appointment time is spent reassuring the patient and working to calm anxieties related to expected prognosis, insurance approvals, imaging results, and recurrent radicular pain, but the patient always leaves endorsing that she is reassured and almost always with decreased pain than on arrival. I have worked with the patient to learn self-gapping over a rolled pillow, trunk shift correction for improved gapping and postural education, and comfortable positions to reduce pain, as well as core NMR and slow progression of in clinic exercises. I expressed to the patient all of the positive aspects that I see with her progress and encouraged her to continue the therapy.
Unfortunately, the patient is unable to “take a day off” of caring for her 21-month-old granddaughter, as she is the primary caregiver and has no assistance during work hours. Expectedly, the constant bending, lifting, carrying, and getting up and down from the floor, along with long car rides on trips to multiple clinicians in other cities, have led to frequent exacerbations of her symptoms. I plan to make a shift in the focus of education to target these caregiving activities and positions. I’m hoping that mindfulness throughout her day to limit painful positions and pain provoking positions, and to use improved movement patterns in these daily activities will decrease the frequency and intensity of her exacerbations and allow continued progress. With my patient’s mindset, I recognize that I must take care to avoid making her feel fragile or overly cautious with movement.
Although the patient’s pain severity and irritability level were initially extremely limiting, I think I could have done a better job to incorporate simulation of childcare activities and specifically addressing these positions and movements earlier in the care plan. I plan to have the patient take part in the development of specific tasks and activities to simulate in the clinic to improve buy in, increase engagement, and further improve her level of function outside of the clinic.
Any thoughts or ideas from your patient interactions that may be helpful would be appreciated!

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