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  • The Perfect Pain Patient?

    So I recently was a Clinical instructor for a DPT student rotating through my clinic. She was excellent, and made me realize how far we had come as a profession in the 8 years since I had graduated. It left me with no doubt that the APTA had made the right decision in moving toward a clinical doctorate.

    Anyway, I was doing my best to help her and inculcate in her the principles of EBP, the use of Clinical Prediction rules, and classification of patients with the available tools to help their outcomes. Also, I was busy trying to dispel the many myths that PT schools still place in our students' heads, like: posture and pain being correlated, over-reliance on biomechanics and "dysfunction" to explain painful problems, lack of pain physiology education, and the unwillingess to provide a lot of manual care (especially manipulation - the use of which places me in the minority here, I realize).

    I want to say "THANKS" to Barrett, Diane, and Nari, without whom many of these myths would still be in my head as well.

    Anyway, a few weeks ago, we had what I would call the perfect pain patient.
    She was in many ways prototypical: mid 40s female, a few traumas here and there (motor vehicle and slip/fall) many, many episodes of acute on chronic pain in neck and low back with radiation to some limbs at various points. Had been through multiple rounds of PT, Chiro, PM&R, Pain Managment, etc, etc for years and years.

    After a history (during which I could feel my student become overwhelmed) the patient began to set some groundrules for us, her caregivers. I am paraphrasing here, so bear with me: she said that she didn't want to get any stretching exercises, because she had done a lot of those, and she was more flexible, but still had pain. She didn't want to do any walking on the treadmill, because it just made her sweaty AND painful. She didn't want any strength exercises, becuase she was stronger, but still had pain. She didn't want "the cracking, like the chiropractor" because it only gave her temporary relief, and became less and less effective as time went on. She didn't want the epidural steroid injections anymore, either because they hurt to get them, and didn't seem to change anything. She said she had had tons of MRIs, Xrays, CT Scans, and such things, and asked me if the "arthritis and disk problems" found on such studies could ever be "fixed" by anyone, or would she have to live with her pain forever?

    She even said that she was tired of people (she mentioned the physiatrist specifically) telling her she was better because she could reach further down toward her toes (as in bending forward), do more repetitions of exercises, or walk longer on the treadmill. She said people were ignoring her PAIN, and that is what she wanted help with!

    A few years ago, I would have groaned and felt I did not have much to offer this patient. However, I feel the recent advances in neurobiology and pain education research give us a lot of directions to go in to help a patient like this.
    I silently wished for a videocamera and a blank consent form, as I feel what she had to say has a lot of value for those of us in Physical Therapy.

    Before I tell anyone what approach I took, I wanted to get everyone's feedback on this so far.
    And also, what would you do?

    Yes, I fully expect my question to be answered with more questions...
    J
    Jason Silvernail DPT, DSc, FAAOMPT
    Board-Certified in Orthopedic Physical Therapy
    Fellowship-Trained in Orthopedic Manual Therapy

    Certified Strength and Conditioning Specialist


    The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

  • #2
    Jason,

    Perfect pain post!!

    Perfect example of where we go wrong sometimes with the idiosyncracies of managing pain. We do tend to ignore pain in the sense that we can "measure" it, treat offending 'causes', real or imaginary, and still discover with surprise that it's there, despite traditional approaches which "work" for some patients.

    Approach? My first instinct is Simple Contact..she sounds ideal for it. Criteria? Quite likely an abnormal neurodynamic...

    I might let Barrett answer that one...

    But, in the days of pre-Simple Contact, I would have:

    Looked at Yellow Flags, for the purpose of possibly understanding why she is in this situation....may not be relevant, but often is.

    Tested for Slump, SLR, ULNT1,2,3,4. Likely to be positive.

    Treat with the testing procedures...carefully...
    AND, simultaneously:
    Educate++ on the origin of this pain, its physiology and behaviour under various circumstances (eg, when lying down, trying to sleep)
    Especially emphasise that this pain cannot HARM her, physically.

    Do a Moseley test (I think that is around somewhere on the BB, if not, can post it) to test the level of understanding as the result of education. This is for her benefit, not mine.

    Tell her to go and do whatever she wants to do - and that is anything at all -and help her get there. (However, if she aims to go climbing Mt Rainier, I would encourage a more realistic goal).

    See her only once a week or fortnight, giving her food for thought and time to digest, without 'interference' from me.

    I wouldn't touch vertebrae or muscle. Soft tissue work (especially the kind that Diane does) may help in my attempt to talk to her CNS.

    Question: What sort of language does she use when describing her pain?

    More later


    Nari

    Comment


    • #3
      Does her pain change with movement and positioning?
      "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

      Comment


      • #4
        Thanks for posting this Jason, and you're welcome for earlier provision of any bits of virtual conversation that you may have read/felt that came to you from me.

        Isn't it classic that all her practitioners declared her better by measuring some observable thing about her, but ignored her complaint? (Sound of me ripping out my hair.)

        Kierkegaard said, "The majority of men are subjective towards themselves and objective towards all others - terribly objective sometimes - but the real task is in fact to be objective towards oneself and subjective toward all others." I think that's awfully good advice for therapists. Time to enter the woman's "movie" or narrative with her, and start to look for clues with some attentive resonance (see Cells and Stars for what that is).

        Simple contact, like Nari said, would be a great tool, something she could work on herself.

        Unlike Barrett, who finds it a nice way to hold a boundary between himself and his patients, I've found that on the contrary, it ends up opening up people and their stories quite rapidly, moreso and faster sometimes than I feel I have the capacity right now (winter) to handle. So I use it sparingly for people, saving it for ones who I could describe exactly the way you've described your gal.
        Diane
        www.dermoneuromodulation.com
        SensibleSolutionsPhysiotherapy
        HumanAntiGravitySuit blog
        Neurotonics PT Teamblog
        Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
        Canadian Physiotherapy Association Pain Science Division Facebook page
        @PainPhysiosCan
        WCPT PhysiotherapyPainNetwork on Facebook
        @WCPTPTPN
        Neuroscience and Pain Science for Manual PTs Facebook page

        @dfjpt
        SomaSimple on Facebook
        @somasimple

        "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

        “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

        “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

        "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

        "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

        Comment


        • #5
          What color car is she driving? Okay, just kidding.

          The physiologic signature of neural irritation is sympathetic dominance, so I'm wondering whether or not your patient is commonly cold. This might be related to her breathing pattern as well.

          I'm also wondering about the resting posture of her legs when she lies supine. What you see in the photo linked below is what I look at. When the nervous tissue is pulled tautly (for lack of a better term), what you might find is relative internal rotation and/or adduction in the hips, usually the more symptomatic side is easily seen to be more adducted and the toes point toward the ceiling. This is derived from Breig's work published in "Spine" a few years ago. The second link demonstrates the position more commonly seen in right sided pain.

          http://www.flickr.com/tools/uploader...e?ids=79939335,


          http://www.flickr.com/tools/uploader...e?ids=79940389,
          Barrett L. Dorko

          Comment


          • #6
            (Barrett, any chance you could post the pictures again?.. all I get is a sign-up sheet for flickr.)
            Diane
            www.dermoneuromodulation.com
            SensibleSolutionsPhysiotherapy
            HumanAntiGravitySuit blog
            Neurotonics PT Teamblog
            Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
            Canadian Physiotherapy Association Pain Science Division Facebook page
            @PainPhysiosCan
            WCPT PhysiotherapyPainNetwork on Facebook
            @WCPTPTPN
            Neuroscience and Pain Science for Manual PTs Facebook page

            @dfjpt
            SomaSimple on Facebook
            @somasimple

            "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

            “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

            “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

            "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

            "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

            Comment


            • #7
              Try this:

              http://www.flickr.com/photos/35469288@N00/79939335/

              And then this:

              http://www.flickr.com/photos/35469288@N00/79940389/

              I don't know if these will work for you or not. As they say in the Army (and Jason will know about this), such things are beyond my pay grade.
              Attached Files
              Last edited by bernard; 01-01-2006, 11:00 AM. Reason: added pictures
              Barrett L. Dorko

              Comment


              • #8
                (Much better, thank you!)
                Diane
                www.dermoneuromodulation.com
                SensibleSolutionsPhysiotherapy
                HumanAntiGravitySuit blog
                Neurotonics PT Teamblog
                Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                Canadian Physiotherapy Association Pain Science Division Facebook page
                @PainPhysiosCan
                WCPT PhysiotherapyPainNetwork on Facebook
                @WCPTPTPN
                Neuroscience and Pain Science for Manual PTs Facebook page

                @dfjpt
                SomaSimple on Facebook
                @somasimple

                "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                Comment


                • #9
                  Hi Jason,

                  She said she had had tons of MRIs, Xrays, CT Scans, and such things, and asked me if the "arthritis and disk problems" found on such studies could ever be "fixed" by anyone, or would she have to live with her pain forever?
                  I always look out for comments like this because they offer a glimpse into the belief system of the patient regarding their pain that I think it is very important to address.

                  I had a very similar patient to this recently and I started where I gather you started, with education, specifically addressing her beliefs and mythconceptions (unfortunately she had even been told she would simply be managing her pain forever). After our very long talk I could see in her face and body a sense of relief and softening. She came three times and is doing fine now.

                  It's probably no surprise that I would use SC also, though I would want the same questions asked by Jon and Barrett answered before I started.

                  Like Diane I also find that it is a very rapid way of opening people up. It seems that as you provide a environment for authentic physical expression then authentic emotional/mental expression emerges also (never of the Barnes type though). However I am not so interested in the particular content, only that it allows them to become aware of things in their life they may desire to change (stressful commitments, habits, situations etc). Like Nari, I prefer if this happens without interference -I'm not trained to do much more than that anyway.

                  I can't wait to hear your approach.

                  Luke
                  Last edited by Luke Rickards; 01-01-2006, 02:20 AM.
                  Luke Rickards
                  Osteopath

                  Comment


                  • #10
                    Hi Luke

                    I wasn't referring to psychosocial history in particular re the use of the word "interfering" - but rather avoiding a verbal or tactile "interference" with her plans and goals to get herself better.

                    If therapists would occasionally butt out of the "I have to do something physical" line of thinking, and hand the ball over to the patient's court...it might be surprising what happens. Of course this can only happen with pain ed., passed on at the current level of understanding.

                    Something that haunts me post- Nanaimo is the notion of PTs 'doing nothing'...but what they do when they do nothing is extraordinary.

                    Jason...tell us your management plan soon...

                    Nari

                    Comment


                    • #11
                      Nari,

                      I know you weren't. I am talking about the same thing.

                      Luke
                      Last edited by Luke Rickards; 01-01-2006, 11:04 AM.
                      Luke Rickards
                      Osteopath

                      Comment


                      • #12
                        Ok... I misunderstood the sequence of your last paragraph.

                        Nari

                        PS - a disgusting day in Sydney and Canberra today?...why don't we live in the Northern Hemisphere???

                        Comment


                        • #13
                          44'C!!! Ppphhew. I agree, though there is a slight sea breeze at Bondi.
                          Last edited by Luke Rickards; 01-01-2006, 11:04 AM.
                          Luke Rickards
                          Osteopath

                          Comment


                          • #14
                            Well, I've only seen her once, so probably cannot post a case-study type of thing for anyone, but here goes:

                            Questions first:
                            -She was sympathetic dominant, one of the things I have trained my student to look for. The student picked it up as well. Definitely a shallow breather, but didn't ask about being cold frequently. (forgive me, I'm a beginner)
                            - She did have an IR'd LE on her painful side
                            -She did have neurodynamic issues on SLR B and in ULNT on her painful side

                            Approach:
                            - PAIN EDUCATION. I had my student work with her for about 45 min, while I handled the rest of the caseload that morning, b/c she had so much to learn from this patient
                            - Diaphragmatic breathing and an overview of how the autonomic state can impact the pain experience.
                            - Discussion of using her toes as a "dial" to dial down her pain by moving more into ER through breathing/relaxation
                            - Brief overview of ideomotor motion and how to go about starting it
                            - She worked on the beginning stages of the deep neck flexor activation exercise
                            -She said she had a really busy holiday, but would get back to me when it was all done. I hope to see her again.

                            Ideas? Feedback?


                            J
                            Jason Silvernail DPT, DSc, FAAOMPT
                            Board-Certified in Orthopedic Physical Therapy
                            Fellowship-Trained in Orthopedic Manual Therapy

                            Certified Strength and Conditioning Specialist


                            The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                            Comment


                            • #15
                              Jason,

                              a few queries:

                              What is your reasoning for teaching deep neck flexor exercise?

                              Try neurodynamic movements (as per Shacklock et al), unilaterally and bilaterally? If the pain disappears, it enhances the education process; a perfect example of the nature of pain.

                              She certainly has criteria for an abnormal neurodynamic.

                              Good luck. (I don't know why that is such a common phrase - luck hasn't much to do with it!)

                              Nari

                              Comment

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