Evidencebased
11-11-2006, 11:36 PM
Hey SS,
I do a bit of private work as an activation therapist for a company that deals with chronic disability cases in hopes of getting to return them to work. I meet with the clients for 1 hour a week and my job is essentially working with failed LBP cases whereby I go in and do a 1 on 1 session with them doing Stu McGill and Hodges/Richardson/Hides exercise protocols.
This particular patient I had today was unlike any other I've seen. 28 YO Male, with ULQ, LLQ adbominal pain which began 1.5 years ago while twisting at work. He's had all imaging and lab work done under the sun (MRI, US, CT, Xray, CBC, hormone levels, etc...) showing no overt pathology. Doctor after doctor cannot come up with a diagnosis and it is called right now a "deep tissue injury" :confused: Every type of intervention thus far has failed (massage, acupuncture, meds, psychotherapy, holistic medicine, deep breathing exercises,). I'm pretty much the last stand before they ship him off into a pain clinic with older individuals with phatom limb pain, etc. He's has a lot of anxiety, upset over a lack of control and is his doctors tell him he has to be resigned to living his life in pain.
PHYSICAL OBSERVATIONS
The patient cannot lie on his left side, so the only position where he gets any relief is laying on his right side and has his hips flexed to 90 degrees. When he is upright he flexes at the back as straightening upright is tremendously discomforting. His left arm is in a sling like position across his abdomen at all times. The pain is located as a square patch, approximately 1cm lateral to the umbilicus that extends 3 inches superiorly, inferiorly and laterally. I took a fine piece of cottom and was brushing his abdomen and he was getting lots of pain in that rectangular zone, none from the other side. His pain was also recreated by gently pushing on the left side of his back, approximately at the T-L region a little laterally, about where the longissimus part of the erectors attaches, the serratus posterior inferior and proximal attachment of QL.
There is no associated G-I, G-U findings in lab reports or during the history. Systems review is unremarkable.
As a therapist, the company strictly wants me to stick to my role doing exercises. I demonstrated to him 'abdominal hollowing' and he tried it and almost fell out of the couch due to pain. I don't think exercises is going to help this guy out, at least not at this point in his condition. He needs to neuromodulation and I'm willing to try some stuff out with him during our hour together to see if I can help him besides the exercises.
How to I approach this case trying to modulate his pain given the fact that the symptomatic side appears to be allodynia? He looks to have central sensitization/deafferentiation going on. When I gently palpated the opposite side (R) there was a threshold (early) which created pain on the L side. I figure I'll work on the non-painful side first, but even this is tricky. Since global movements originate in the trunk, and its his anterior trunk which is the problem, I'm a little confused at how to approach this, even working on distant sites.
I don't have much background with CRPS, so I don't know if this is a good differential (the x-rays did not show any focal osteoporosis, but that isn't the most sensitive test for bone density anyways) I have no access to modalities, so my hands and education is all I've got. I would very much appreciate your feedback in dealing with this complex case.
Sincerely,
Marc.
I do a bit of private work as an activation therapist for a company that deals with chronic disability cases in hopes of getting to return them to work. I meet with the clients for 1 hour a week and my job is essentially working with failed LBP cases whereby I go in and do a 1 on 1 session with them doing Stu McGill and Hodges/Richardson/Hides exercise protocols.
This particular patient I had today was unlike any other I've seen. 28 YO Male, with ULQ, LLQ adbominal pain which began 1.5 years ago while twisting at work. He's had all imaging and lab work done under the sun (MRI, US, CT, Xray, CBC, hormone levels, etc...) showing no overt pathology. Doctor after doctor cannot come up with a diagnosis and it is called right now a "deep tissue injury" :confused: Every type of intervention thus far has failed (massage, acupuncture, meds, psychotherapy, holistic medicine, deep breathing exercises,). I'm pretty much the last stand before they ship him off into a pain clinic with older individuals with phatom limb pain, etc. He's has a lot of anxiety, upset over a lack of control and is his doctors tell him he has to be resigned to living his life in pain.
PHYSICAL OBSERVATIONS
The patient cannot lie on his left side, so the only position where he gets any relief is laying on his right side and has his hips flexed to 90 degrees. When he is upright he flexes at the back as straightening upright is tremendously discomforting. His left arm is in a sling like position across his abdomen at all times. The pain is located as a square patch, approximately 1cm lateral to the umbilicus that extends 3 inches superiorly, inferiorly and laterally. I took a fine piece of cottom and was brushing his abdomen and he was getting lots of pain in that rectangular zone, none from the other side. His pain was also recreated by gently pushing on the left side of his back, approximately at the T-L region a little laterally, about where the longissimus part of the erectors attaches, the serratus posterior inferior and proximal attachment of QL.
There is no associated G-I, G-U findings in lab reports or during the history. Systems review is unremarkable.
As a therapist, the company strictly wants me to stick to my role doing exercises. I demonstrated to him 'abdominal hollowing' and he tried it and almost fell out of the couch due to pain. I don't think exercises is going to help this guy out, at least not at this point in his condition. He needs to neuromodulation and I'm willing to try some stuff out with him during our hour together to see if I can help him besides the exercises.
How to I approach this case trying to modulate his pain given the fact that the symptomatic side appears to be allodynia? He looks to have central sensitization/deafferentiation going on. When I gently palpated the opposite side (R) there was a threshold (early) which created pain on the L side. I figure I'll work on the non-painful side first, but even this is tricky. Since global movements originate in the trunk, and its his anterior trunk which is the problem, I'm a little confused at how to approach this, even working on distant sites.
I don't have much background with CRPS, so I don't know if this is a good differential (the x-rays did not show any focal osteoporosis, but that isn't the most sensitive test for bone density anyways) I have no access to modalities, so my hands and education is all I've got. I would very much appreciate your feedback in dealing with this complex case.
Sincerely,
Marc.