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This past week, I evaled a pt with referral of lumbar radiculopathy. After I had gotten well into the subjective portion of the exam, the pt nonchalantly mentioned that she was to have lumbar surgery in March. She was near ecstatic to be going through this procedure as she describes her frustrations with finding anything to relieve her pain. She mentioned that the MD had told her that her presentation was not “severe enough” or have the “typical pattern” to require surgery. Her understanding of why she now would receive surgery is because she started having pain down her leg. When I asked why she was at PT or what she wanted to get out of it, she stated that she would like to strengthen before surgery.
Now, since I knew the pt was going to receive surgery,I expected most of her neuro tests to be positive during the objective exam. To my surprise I found intact sensation, myotomes, reflexes, (-) SLR and (-) slump tests. The pt was extremely fear avoidant and would grimace and moan with all lumbar movements. She visibly appeared pained and kept glancing around as if she was extremely nervous. I encouraged this pt to try some simple exercises and explained how I did not want to exacerbate any of her symptoms and that we would start small in order to strengthen.
What struck me most about this pt encounter was how excited this pt was to go through surgery. She even stated, “I can’t wait until this surgery. I just know I’ll feel so much better.” My gut twisted as she said this, knowing that she very well could come out of surgery with the same, if not more pain, especially because her neuro tests were negative. In this situation, I lightly educated her regarding the negative tests, but avoided questioning the surgery as I did not want to lose rapport. Going forward, I’m not sure that I’ll be able to dispel any of her beliefs so I have decided to go the route of trying to decrease her fear and gain some lumbar ROM and LE strength prior to surgery. She has many psychosocial components to address, but fear is definitely the most limiting – at the first follow-up the pt asked me what time it was toward the end of the session. When I told her we were 45 minutes in she started to ask if she could leave but stopped herself. I asked her if she was scared to do more and she said yes. I think her acknowledgement of fear is a great first step and hopefully her ability to recognize it and desire to fight it will help her recover.
I would love to hear others thoughts or experiences with situations like this and if anyone has any advice or thoughts about treatment.
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