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Zack
Considering his prior poor response to treatment, did you discuss his expectations and potential concerns about this bout of therapy? Might that have made a difference in your initial approach? Do you feel that your relationship with the patient was negatively impacted after that first visit when he came back flared up? If so, did you address that?
Thanks
AJHunter,
Thanks so much for the post. It sounds like you did a lot of listening during the subjective interview. As you mentioned, she appeared anxious and concerned about her ability to complete her work duties. Did you acknowledge this and verbalize it to her in some way? Or was this more of an observation on your part? If you did acknowledge it, how did she respond?
Thanks
AJIan
I enjoyed reading this. What do you think he is thinking when his pain is increasing and having set-backs? Have you asked?
The 5-6/10 pain may be a nice starting point to consider, however, some patients do not tolerate that intensity. I think you need to find out what intensity they are comfortable with and work in that range.
For me, if I have come to the conclusion that increased pain is not damaging tissue, I’m OK with the patient working into a tolerable amount (their tolerable) of pain. Then what I want to know is if the pain is increasing with the activity or staying the same or possibly decreasing with the activity. That may hep guide me on whether this is too much load or just right for the person. The other thing I want to know is what the response is after the activity. Sometimes this is trial and error, but it should be an informed decision to get started.On a side note, could setting a range for a patient become problematic if the are hypervigilant? What would be an alternative? Thoughts?
Emily
Great post. I have a few questions. What do you think made her say “you probably think I’m psychotic?” What do you think was going on in her head when she was filling out the outcome scores? Rather than say, “no I don’t think your psychotic”, did you consider asking her why she would say that? For me, that would provide me with more information about what she was thinking and allow for a more detailed or targeted explanation.
Last question, why do you think you lost this patient?Clare
Really enjoyed reading your reflection. Do you think your patient’s response to your “style” was based on him expecting to “fix” him? Did you have a conversation about this being a collaborative effort where his input is helpful in making decisions about plan of care? I wonder if this was the first experience he had with a provider that wanted so much information from him, that he took this as you not knowing how to approach his care.
I think it is important to make it clear early on that it will be the 2 of you working together to find the best treatment approach. Especially when the patient has been dealing with pain for 40+ years.
Thoughts?David
Thanks for your post. You mentioned that at a certain point you realized that this was as much a yellow flag case as it was an MSK/neuro case. Looking back at that moment when you realized that, what did that mean for you? Did that change your approach, make you consider new questions or tests?
Your struggle with imaging and patient education won’t be the last, but you will continue to learn from it. What do you think was going on in her mind when you tried to educate her? You said you learned from the experience, how might you approach it differently next time?
AJSarah
Thanks for your reflection. What do you think the patient was apprehensive about? That you were going to make their pain worse, the uncertainty of the exam? Anything other than demonstrating more confidence might help in this situation next time?
You mentioned that he began to relax as you conversed with him. Were there specific things that you shared with him the allowed him to relax or did he just relax from being distracted?
AJ32 year old Hispanic female (ESL) factory worker who complains of right upper trapezius region pain. Insidious onset 1 month ago. Pain is increased at work as her job requires repetitive lifting (3-5#) up to shoulder height for 10-12 hours shifts. The pain is constant and increases in intensity after 30-60 minutes of work. She works 3 days in a row and then has 4 days off. Her shoulder pain “barely” recovers by the time she gets back to work for her 3-day shift. Taking off of work is not an option for financial reasons.
Overhead activity is her only aggravating factor and avoiding overhead activity eases her pain.
Objectively her symptoms are reproduced when placing the upper trapezius on stretch, asking it to contract, elevation of the shoulder overhead and direct palpation to the upper trapezius. There is noticeable scapular dyskinesia with UE elevation. Inferior and posterior capsular tightness of the right GH joint found.
Neuro is negative, cervical quadrants with OP and compression are negative.
After 3 PT visits over 3 weeks, pain is no longer constant, and it takes 3 hours into her shift for the pain to begin.
She goes back to primary care for follow-up and NP-C recommends the patient have cervical MRI and the patient agrees with POC. NP-C has the progress report of the patient’s status in PT.What is your role in this situation? How would you address this situation?
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)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.