For this week’s patient encounter reflection, I wanted to bring up a patient that I have recently started treating who helped me understand the role we can play in our patient’s care when we take the time to advocate for them outside of usual PT care. This patient is a 60 y.o. Male who originally presented with an increase in low back pain after shoveling snow in his driveway last January. Over the next few days, his back pain began to travel to the L side and eventually began traveling down his posterior L thigh and calf. Over a period of two months, the pain did not seem to improve and he began experiencing numbness and tingling down that same pathway towards the ankle. Objective examination revealed extension intolerance and limited range of motion into both extension and L SB of the lumbar spine. His neuro screen was (+) for diminished sensation along L4,5 with myotomal weakness into ankle DF, eversion, and PF and hyporeflexia at the Achilles tendon. Lumbar spine was hypomobile for PAIVMs at L3-S1 and SLR test was (+) for reproduction of posterior thigh and calf symptoms with structural differentiation. Subjectively and objectively, the patient displayed signs/symptoms most consistent with a diagnosis of L5, S1 radiculopathy secondary to foraminal stenosis.
Initial treatment for the patient focused on flexion-biased exercises, neurodynamic mobility, and lumbar spine mobility in order to reduce symptoms before progressing towards extension-biased movements. The patient initially did quite well and saw a great reduction in symptoms. However, after trying to move furniture one day at the end of July, he re-aggravated all of his symptoms from the L side of his back down to his lower calf. From here, his symptoms began to get progressively worse to the point where it became difficult for him to walk without the use of a rollator. For reasons unknown to me, one of his other providers decided to send him in to receive an injection in the SIJ to relieve his symptoms. After this did not improve any of his symptoms, he was sent in for another injection into the hip to serve as a diagnostic measure to determine if this was the source of his pain, despite all signs pointing to the lumbar spine as the source. By the time I began seeing him last month, he was continuing to see a decline in function, progressive increase in pain, and had developed atrophy in his L LE.
As a new grad clinician, I think one of the most challenging aspects of care is learning how to properly and effectively advocate for our patients when we notice that they are slipping through the cracks of the healthcare system. As I reflected on this patient encounter, I thought back to some advice I had received regarding the role we play as advocates and the tendency for young clinicians to be reluctant to stand up for their patients. I can definitely think back to some instances as a full-time student where I could’ve done more to help patients get better care or just simply provided them with encouragement for a second opinion when the care they were receiving didn’t add up. For this particular patient, he had an upcoming appointment with a spine specialist and so I decided to take the opportunity to reach out to that Dr. before his appointment to share what I had been seeing in the clinic and where I thought his symptoms were coming from.
Thankfully, my message was well received and the current plan for the patient is to receive another injection into the lower lumbar spine and to continue with PT. As I reflect further on this encounter, I can’t help but think that maybe if this communication had happened earlier, then all those injections and debilitating increase in symptoms could’ve been avoided. I definitely know that I won’t think twice before advocating for my patients to ensure they get the care they need and avoid this type of situation. As I feel patient advocacy is a skill that I still have a lot of room for improvement in, I’m curious to ask the group what kind of experiences they have had or seen with patient advocacy? In what ways do you think we could improve upon the way in which we advocate for our patients?