S-I was referred a patient, Miss B, with an acute exacerbation of chronic low back pain. She was in a car crash in 1988 and from that time onwards she has been in constant pain, at the neck, shoulder and low back. She was initially involved in a compensation claim and has been off work since that time receiving a disability pension.
From the first moment I met her I knew she would be a tough patient. Miss B is only 44 years old, yet she walked into the treatment room with a WZF! I think now that this is in an attempt to display her sickness, especially seeing as she didn’t use it correctly. My first question to Miss B was ‘can you show me exactly where your pain is’…her response was ‘L4/L5.’ I couldn’t believe it! Throughout the assessment, many more yellow flags became apparent. She had underlined x-ray findings for me (degeneration at L4/L5, arthritic changes), she was on such a cocktail of pain meds she was unable to drive and had had numerous hospitalizations with CLBP.
In my first treatment session I tried a bit of everything. No movements of the back were relieving whatsoever, even gravity eliminated PT induced. I then tried IFT therapy with a heat pack but even this was aggravating. TENS also had the same effect. I then tried some grade II mobilizations to achieve a pain gate effect. Miss B had to sit in a special pregnancy chair as prone lying was out of the question. Doing these gentle mobilizations turned out to be disastrous. Miss B became so sweaty and was in so much pain she almost threw up. This shook me a fair bit, so I decided to leave her with just gentle pelvic floor contractions. (Even these tugged at her low back). It seemed hopeless.
T-my task was to provide appropriate treatment at her next session.
A-I realized that the above treatments I tried were not the right things for her. I had already recognized that Miss B’s pain was dominated/maintained by psychological factors and so my treatment really should have been directed at her thoughts/feelings and beliefs. So I decided to research pain in an effort to best describe it to her and decrease its threat value.
I re-read the book ‘explain pain’ and summarized what I thought was most important on 2 A4 pages. I booked an hour appointment for her next session and the first half of that we spent just talking about chronic pain and explaining her x-rays. The next half of the session we brainstormed a graduated exercise program. Miss B’s goal is to get back into pilates. Thus we made an 8 day program that encouraged gently re-entry into some basic moves…starting in sitting, moving to side-lie and then on day 7-8, into crook lying (to perform Miss B’s goal of leg slides). On day 8, she made another appointment to see me, and assuming everything goes to plan, we are aiming to start a graduated walking program.
R- Initially Miss B didn’t seem too won over by me. I think I was bit nervous because I didn’t want her to think I was suggesting she was making the pain. (Which she wasn’t…she was DEFINITELY in pain, it almost made her throw up! It’s just that the way she thinks and feels is sustaining this pain). After a while though I eased into it. Miss B seemed to be particularly open to the idea of increased sensitivity. (Having more ‘sensors’ in her low back and a lower threshold for them to fire). She understood the analogy of a car alarm that used to go off normally, and that now goes off when just a bird lands on it. This means that hurting doesn’t mean you are causing re-injury; rather it’s just a throwback to a state of heightened sensitivity.
Miss B left feeling quite excited and ready to take part in her graduated program.
E- I’m beginning to realize that with many patients, what you say can be SO MUCH more valuable to the person than what you do with your hands. It’s amazing, and probably the best tool we have.
STRENGTHS:
-Good preparation. The session would not have been successful otherwise!
-Incorporating Miss B’s goal into the graduated program. This enabled her to get on board with the idea…which I’m sure seemed very foreign to start with.
-Building a good rapport with Miss B, which was essential in order to get her to believe in what I was saying.
-Picking up on what Miss B responded to (pain hypersensitivity), I could then use this throughout the session to keep her on track.
WEAKNESSES:
-I was nervous to start with. I didn’t want Miss B to think I was saying she was making her pain up. My nervousness probably made it even worse to start with! I think next time I’ll practice my spiel on someone first so that I’m more comfortable with how to word things.
-Until I got into the flow of things, my talking may have seemed a bit rehearsed (I had written down all my important points on paper). Hopefully it becomes more natural with practice!
S- Good preparation
- Practice first on somebody I know
- Build a good rapport
- When describing complex concepts, create simple analogy’s to aid understanding
- Find out patient goals and use them to create a meaningful treatment
- Remember to treat what you identify as the cause of the problem
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