When Nothing Works

[Nick]

28 year-old client. MVA one-year ago. Multiple interventions, including work hardening, craniosacral, and acupuncture. Severe pain in thoracic spine, freezing cold extremities. Headaches, neck pain, paresthesia in hands, cramping and pain in the calf muscles. Major flexor dominance / heightened startle and withdrawal. Formerly very active, now incapacitated. Recently reported bladder urgency which has me somewhat concerned that there could be a cord compression issue. She has passed out twice reportedly from the severity of pain. I recommended she see her physician again and she told her that she was always going to have pain and is going to refer her to the pain clinic. There is about a 5-year waiting list for the pain clinic here and many of them end up getting referred to me for physiotherapy.

She has zero tolerance for even the gentlest of hands-on input. She has received pain physiology education very well. Wants to resume activity, but finds anything excruciatingly difficult. Crosses the flare up line very readily.

I feel a lot of what we discuss here works extremely well for neurogenic pain of mechanical origin, but what can we do when the nervous system is so revved up that any input is perceived as a threat. I don't know where to go with her. Any suggestions are welcome.

Thanks,

Nick

[Diane]

Yeah.... tough case. How about something like:

1. Look into "old" (pre MVA) history/Rapport building/Pain education
2. Intro to graded exposure/ideomotor corrective movement
3. Simple contact/Start at the feet?

Is she on any anti-neuroiflamm meds (e.g., gabapentin)? They could be helpful.

[nari]

Gabapentin might be useful as a start to calming things down.

I have met many of these super-sensitive folk, and some simply will not let a therapist touch them. With one young woman in particular, I asked if it was OK to place a finger on her neck for about 10 seconds. She agreed. (There had already been ed on pain physiology)
I felt the cringe as soon as I did, but said nothing and ignored the reaction. Gradually it progressed to a flat hand for about 6 seconds. She started to melt a little and reported her feet were beginning to burn. I said that didn't matter.

After about 20 minutes she reported less pain, talked more and made miniscule movements as she sat. From there, she realised I was not going to harm her; and although she still had pain when I last saw her, she understood:

a) it was not her fault
b) this pain was not harmful physically
c) she could do this touching without anyone else
d) only she could escape this sensitivity soup
e) there was no cure from anyone except herself.

and she was doing much more in terms of everyday living. Don't know what happened after that, it was not long before I retired.

During the sessions (3 in all) I said nothing to her, but simply with her. To me that is important.

Hope this helps a bit, Nick. A threat is a threat is a threat - regardless. :)

Nari

[Nick]

Good suggestions, Diane. This is exactly the approach I have taken. We have great rapport and she really trusts me and what I am telling her, but so far her pain is only getting worse. We started with ideomotion from the feet with lots of good characteristics of correction happening. However, within a half hour of any treatment her pain goes through the roof.

Nari, I was intrigued by you saying "there is no cure from anyone bu herself." How do you get this positive message across without making them feel like they are at fault or frustrated by their inability to move beyond it?


Thanks,

Nick

[nari]

Nick, I tend to play things by ear with persistent pain patients.

If they understand that it is their system that is screwed up for reasons which are not yet clearly understood by health professionals, then the next move is for them to get the point that it is their system and they know it better than we do. If they mutter "no I don't" then I try to say that I can help them know it better. Most understand this tactic. From there hopefully we can move towards restoring that loss of authenticity and autonomy.

Mind you, there are those who don't want to know, and don't care about taking some responsibility for themselves. There is nothing anyone can do, then.... is a usual response, with a sigh. The ones who have been tossed around for years by doctors and physical therapists are the hardest to reach.
The ones who have not been dragged through umpteen systems tend to respond well. Those who have chosen not to stay with a PT, for instance, who has them exercising as a mainstay, are more likely to respond well.

And - there are the catastrophic disasters who are interested only in being fixed up by drugs. But they are few.

I think your young woman should do well. Sounds like she hears what you are saying..or not saying.

I should probably amend point (e) - and substitute "resolution". My blue.

Nari

[BB]

Nick,

Please keep us updated. I'll be very interested to hear about her progress.

Nari,

Please keep these gems coming. Despite all you write and offer, I feel as though I've only heard the tip of the iceberg of what you have to say, and what we can learn from your experiences with these people.

[nari]

Cory, thanks for the vote of 'gem' confidence, but I am not sure I can offer much more compared with some of you guys!

However, I am happy to talk about any issues with PPPs which arise. Keep in mind I was probably a frustrated neuropsychologist, so I was much more into the nontangible aspects than most physios. Unfortunately, as well, I did Barrett's course very late in the piece.

Nick, I'd love to hear how you and the young woman progress.

Nari