Low Back Pain With a Side of Anxiety

[David Brown]

I recently had a 30 y/o female low to moderate complexity patient with low back pain and peripheral pain traveling down her L posterior leg to the level of the foot. Going into the exam, my main goal was to examine the relationship between the low back and the peripheral symptoms and to differentiate if there was a peripheral nerve entrapment (in the piriformis) or a radicular pain. As soon as the exam began I was able to pick up that the patient was very anxious and she was fidgeting and shaking her leg while in the chair and went on to talk for about 10-15 minutes about how her symptoms began, how it felt at different parts of the day and how it was impacting her life. During this discussion, I would interject questions to clarify certain aspects of the timeline but I otherwise let her talk. It started to become confusing to me about how her symptoms would come and go in an unpredictable fashion; the severity of her symptoms would vary widely, sometimes only in her foot, sometimes her hamstring and foot, etc. She did mention since the onset of her pain around 5 months ago, the only time she had full abolishment of her pain was when she started to workout at her local gym around a month performing non-specific exercises targeting lower quarter strength (squats, DLs, lunges) as well and walking on an inclined treadmill (all for general health). She said once the semester began two weeks ago she had to stop going to the gym because of time constraints and her symptoms returned with a vengeance becoming more painful than it had ever been.
The patient is a nursing student under a lot of stress and is having to stand for 12 hour clinicals, which is provoking to her sx and this causes further stress for her emotionally. I began to realize that this was becoming just as much a yellow flag case as it was a MSK/neuro case. The patient luckily had a good understanding of the anatomy that is involved in the areas of her symptoms so my education about what was going on was easier for her to understand. The subjective exam itself took over 30 min which is the longest it has taken me since I was in my first clinical rotation in PT school. She had many questions including showing me X-Ray imaging that she claimed showed disc herniations at the level of her pain which she was convinced that this was the driver of her pain. I tried to have the conversation of “what you see on imaging doesn’t always correlate with your pain and disability. Everyone at the age of 30 probably has some degree of disc protrusion”. She seemed upset by that answer and went on to ask “Well this is where my pain is, how can it not be related?” I had a hard time navigating this conversation as the patient was clearly stressed and was not open to my commentary on the imaging. I have taken time since this encounter to think about and learn from this and potentially try to navigate a similar situation better in the future.
As I began my objective exam (this patient had fairly minimal irritability), a few of my tests did reproduce her sx, while others she had to focus and think for a while to decide if what I did caused her pain. To me this was another yellow flag in that she wasn’t sure if she was hurting or not. I explained to her that she is having to contemplate for 10-15 seconds as to whether or not what I did provoked sx, it probably didn’t. By the end of the exam, I concluded she did have some radicular pain without a radiculopathy ((-) neuro exam). I discussed some exercises and nerve gliders for her to perform as well as encouraged her to return to the gym as clearly that helped her symptoms. I also spent time educating her on her pain and how the emotional stress and perseverance of her symptoms can exacerbate the pain which she was open to hearing and agreed to. I have learned many lessons in this encounter as how to better steer the conversation using more closed ended questions when I sense the patient is anxious and has been perseverating for a long time, especially when they have a medical background.

[Sarah Frunzi]

David,

In my experience that I have had so far, patients that have a medical background can be some of the most challenging patients to treat because of their level of knowledge of the human body as well, which can sometimes be helpful or a hindrance. I commend you for addressing her MRI results and something I have found helpful when getting the response like you did with, “well this is where my pain is,” is that I acknowledge that while many are asymptomatic and normal imaging findings, they can sometimes be cause symptoms and that the tests we will do in the examination will provide more clarity on the current episode. I also note we will provide the tools they needs to manage their symptoms independently. I also appreciate that you encouraged her to return to the gym where she found relief, most likely physically AND mentally. I encourage you to continue to have that listening ear and calming presence with her, because like you had mentioned, her stress of being a nursing student, during Covid times no less, is mostly likely very taxing – mentally, physically and emotionally. I love to incorporate diaphragmatic breathing with patients that demonstrate high levels of anxiety. When paired with exercises, as a mindfulness practice, or as an exercise alone, I have found some patients are open to this and are willing to try it. This may be a beneficial tool for her while on clinical rotations when stress and anxiety begin to run high. Keep up the good work David!

[David Brown]

Thanks so much Sarah! You provided a great amount of insight that I will try to incorporate in future sessions with this patient. She did mention the mental relief she got from going to the gym, which is why I reiterated the importance of that. If you remove the stress reliever from your life, add low back pain to the mix, that is enough to cripple anyone!

[AJ Lievre]

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?
AJ

[David Brown]

AJ,

At the moment of realization that this was a yellow flag case, I immediately tried to shift my dialogue away from talking about the anatomy of the back and the potential structures at fault. I shot myself in the foot a little bit as I had already gone down this path with her so I tried to shift the conversation towards dealing with anxiety and stress through getting more sleep, continuing her exercise regiment that she had already stated made her sx feel better, and even talked about some pretty hikes she could do on the weekend. I was reluctant to perform any more special tests as I feared this would continue to confirm in her mind that there was indeed something “wrong” with her that needed to be “fixed”.
In terms of the education with imaging, I tried to navigate this subject as best I could but I felt like the message she got from me was that what was on the radiograph was not driving her pain (I could be wrong but this was the body language I received). I didn’t intend for this to be the message, but more so that to not always hang your hat on what you see with imaging and that there is a lot we can do with PT and in our personal lives to influence our symptoms. I took away from this that I still need to practice how I navigate these conversations and although we have discussed this in PT school and in the cervical course series, when talking to a actual patient who has emotional implications in conjunction to what they are feeling and what they are seeing, it becomes far more of a challenge.

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