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Difficult patient
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Difficult patient - November 22, 2000 3:44:00 PM
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RookiePT
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Joined: November 21, 2000
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hello everyone. i am a new grad working in private practice. i have been having some recent trouble as of late getting my low back patients to improve, one patient inparticular. He c/o unilateral LBP, worse with sitting and lifting of a chronic nature for 10 years. ROM is WNL, MMT is 5/5. mckenzie extension exercises increase pain. i have seen this patient 12x and have been doing moist heat with estim, ultrasound, and efflurage,but my patient still c/o 9/10 pain. they said this stuff would work when i was in school. does anyone have any suggestions.
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Re: Difficult patient - November 22, 2000 5:29:00 PM
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JoePT
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Joined: November 20, 2002
From: Birmingham,AL
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Hello Rookie. I, too, am a new grad. However I have been lucky to work with some veteran therapists who teach me a lot. Some suggestions that maybe I can offer:
1. I see you are doing effleurage massage to your patient. If a patient has many trigger points, effleurage may not be the solution. Consider petrissage or other deep kneading strokes. Although I do not have experience in it, many therapists use and have great success with myofascial release.
2. Your patient is made worse with sitting or bending. It would seem that McKenzie extension should help. However maybe you are pushing them too far too fast. You may want to consider working in the midranges - perhaps try cat and camel first and then progress to full extension. If not, he may be in the rare category that benefits from Williams flexion.
3. You mentioned you are using ultrasound. However you did not specify whether it was pulsed or continuous and at what intensity. We learned that lower intensities are actually more effective. Your patient has 9/10 pain. It sounds like he may be very inflamed. I don't know how effective it is but you may want to look into trying phonophoresis.
4. Is this patient Worker's Comp or No Fault? This patient can possibly be a malingerer.
5. Have another therapist see the patient for a visit or two. When I have a difficult patient I will have a therapist with advanced training in Strain/counterstrain or craniosacral take a look at this patient.
Hope this helps.
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Re: Difficult patient - November 22, 2000 5:58:00 PM
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JoePT
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From: Birmingham,AL
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Almost forgot, but one more thing you can try. Have you assessed leg length. This patient may have a functional or structural discrepancy. You can determine this with the appropriate palpation tests you learned in school. If there is a discrepancy then try a heel lift. If this is helping, I would then recommend this person get custom made orthotics. I have seen this make a world of difference.
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Re: Difficult patient - November 22, 2000 7:03:00 PM
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mcap
Posts: 652
Joined: February 8, 2000
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Dear Rookie P.T.
I don't know what they told you in school but a patient with Chronic Low Back Pain over ten years is a VERY difficult patient. Don't let anyone tell you otherwise. You may have to be realistic in your goals and expectations.
The first thing is to take a step back! First, does he have any neurological deficit (I assume not becuase of your 5/5 but it isn't clear if you checked myotomes). Second, how much of a functional impact is the pain having. Is he working? Is it ruining his life? How is he coping with the pain? Does he avoid various activities because of fear? This is important information. In a pain management setting he would fill out an Oswestry or similar questionnaire. Has he had X-rays or other imaging?
In terms of treatment, there are a wealth of studies that demonstrate the benefit of aerobic exercise in this population. Work with him to find something he can do, and regularly.
The Richardson, Jull program (see the book) would be a good thing to try as tolerated.
McKenzie may help but you need to work with an experience practicioner to get decent results. You may be trying to extend on a lateral lesion - that will make it worse. Also, many patients can extend in prone but cannot tolerate extension in standing.
It is hard to tell what works without seeing the patient. But you need to look at the big picture. 10 years of pain will probably not go away in a month, probably not in a year!! Your job is to look at the mechanical deficits and address them. Also, to reactivate the patient. If you make your job to cure him completely then you will be frustrated.
If P.T. helped back patients so dramatically, so quickly, there would be no such thing as a Chiropractor. Dr. Sarno wouldn't have such a long list of people who want to see him. We don't have a lot of the answers. However, if we used evidence-based medicine and we apply what we know is a reasonable manor, I think we have so much to offer these patients. But I think that with some low back patients we need to focus on treatment as opposed to "cure."
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Re: Difficult patient - November 22, 2000 7:05:00 PM
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mcap
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Rookie P.T.:
Also.....I recommend looking into courses and taking some of the better ones.
A great book on Low Back Pain is Dr. Gordon Waddell's Back Pain Revolution. It will help to put things into perspective!!
mcap
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Re: Difficult patient - November 23, 2000 4:15:00 AM
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JoePT
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Joined: November 20, 2002
From: Birmingham,AL
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Mcap has a very good idea about taking continuing education courses. I have yet to take a course myself. My clinical director insists we begin with Barnes' Myofascial 1 course. They also recommend the Travell seminar series.
RookiePT, I just saw a course in Advance magazine that might interest you, "Managing Challenging Back Patients" by BodyWorks Physical Therapy. I bet you would benefit from it. Anybody else have other suggestions for courses??
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Re: Difficult patient - November 26, 2000 9:58:00 AM
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mcap
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Dear new PTs:
You must make up your own minds and develop your own philosophy. I will not comment on the particular courses you were considering.
I will say though, that it is time for PTs to develop more independence when it comes to what they learn and from who. If you are interested in a course, then read some of the background information first. Check Medline to see if there are ANY studies, at all, that attest to claims of efficacy. Think about the background theory. If it doesn't make sense to you then you should write the group offering the course and ask for clarification.
This may seem like troublesome and extreme advice but I can tell you....There is a lot of continuing education out there that has no scientific basis. Many of the techniques offered have never been tested.
If the method hasn't been proven but the intervention is based on what you feel to be rational and sound theory then you should consider it.
You can gain invaliable insights simply by reading. For the spine, I recommend Waddell's book and Bogduk's Book, Clinical Anatomy of the Lumbar Spine and Sacrum.
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Re: Difficult patient - November 26, 2000 10:00:00 AM
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mcap
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And also.....
Don't forget to check Cinhal as well as Medline [IMG]http://www.rehabedge.com/forums/smile.gif[/IMG]
mcap
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Re: Difficult patient - November 26, 2000 4:01:00 PM
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JoePT
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From: Birmingham,AL
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Good idea....I never thought of researching the courses before I signed up. The tendency is to go with the best looking ad i.e. Craniosacral (the man holding the little baby) or Osteoporosis with Sara Meeks (the woman holding the spine and smiling). Although my personal favorite is the Maitland kangaroo.
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Re: Difficult patient - November 27, 2000 7:28:00 AM
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edilling
Posts: 139
Joined: January 10, 2000
From: pullman,wa,usa
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Rookie,
First, a small correction- extension exercises are not "McKenzie extension". Robin McKenzie developed an evaluation and treatment system involving treatment into ALL ranges of movement depending on diagnosis.(his books are available at OPTP.com or the McKenzie website- [URL=http://www.mckenziemdt.org/)]www.mckenziemdt.org/)[/URL] A better understanding of why and how and when to extend a patient will up your success rate dramatically.
On to your patient--
You mentioned his condition was chronic for 10yr. Has it been relativly constant? Can we assume that it has hurt but a recent exacerbation aggravated it (I doubt he has been in 9/10 pain 10yr). What exacerbated it?(lifting, falling, flexion strain, extension strain) If ROM is WNL how does extension cause pain?(there may be a block in extension at some segments) Are his symptoms constant, radiating, aching, burning...?
I have just raised some questions for you to consider and would love to help you think them through. Please respond with a little more detail of this patients history so that the forum may better guide you in your treatment choices.
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Re: Difficult patient - November 27, 2000 5:08:00 PM
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RookiePT
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Joined: November 21, 2000
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hey joePT, thanks for the great advice!!!!!
i tried petrissage today on my patient and the effects where felt immediately. his pain dropped almost instantly to 6/10. i also checked my ultrasound settings, and to my dismay i was using pulsed instead of continuous. i changed the setting and my patients pain dropped to 4/10. i don't know why i didnt think of this sooner thank for all the help.
as far as continuing education courses i signed up from that one entitled managing difficult back patients in california.( any body want to come along). i also asked my clinical director she suggested sharon-weiselfish. has anybody heard of her or taken any of her courses??
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Re: Difficult patient - November 28, 2000 5:10:00 PM
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JoePT
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Joined: November 20, 2002
From: Birmingham,AL
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Rook,
Good to hear of your success with this patient. However, I did not expect 1 such treatment to cut his pain level in half. I am wondering if anyone else found this odd?? Such a response should lead you to question if this patient is indeed a malingerer. Here are 2 things to try:
1. The HOOVER TEST. See Hoppenfeld page 258. This test readily identifies the malingerer.
2. Waddell Testing. A little cumbersome but effective nonetheless.
I am almost certain that one if not both are positive with your patient.
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Re: Difficult patient - November 28, 2000 7:11:00 PM
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edilling
Posts: 139
Joined: January 10, 2000
From: pullman,wa,usa
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Rookie
While I may be wrong- it sounds from these postings that you are asking "what can I do to this patient". I believe the more appropriate question you should ask is "what is wrong with this patient and how can I positively affect these impairments with the tools I know?"
Why ultrasound for a patient who has chronic back pain? All of the literature states that there are no more than temporary effects to chronic pain. It wastes time, money and fosters a dependent attitude in the patient.
Why Petrisage over efflurage? How are the therapeutic effects different? Why not High Volt Pulsed Current or Interferrential current or Russian Stim? Why use heat vs ice?
Nearly every intern that I work with makes the same mistake that it appears you are making. Applying treatment before determining what it is you are treating. After you have determined what it is you are treating (muscle spasms for instance) How can you effect this impairment? (gentle movement in an unweighted position, HVPC to break the pain/spasm cycle, ice to slow pain input, grade 1-2 mobilizations to mediate pain by facilitating type II mechanoreceptors...) Then choose the best tools based on evidence and experience.
Please clarify this patients history and presentation so that the form may better assist you in choosing treatment.
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Re: Difficult patient - November 29, 2000 3:07:00 AM
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mcap
Posts: 652
Joined: February 8, 2000
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Dear Rookie:
I have to ask this question first....Are you the Bobcat????
If you aren't then I must say this. READ, READ, READ. It is obvious that you have a lot of questions about the low back (as we all should). But taking one course is not likely to answer most of them.
JOE!!!!
Waddell's signs are NOT used to find malingerers!!!!! It is used to find non-organic pain and they should be used carefully and correctly. Someone with non-organic pain is NOT malingering and the pain they feel is real. They have been misused and misinterpreted.
mcap
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Re: Difficult patient - November 29, 2000 5:11:00 PM
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RookiePT
Posts: 11
Joined: November 21, 2000
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sorry, i am not the bobcat. he does sound like a interesting fellow.
i had one of my co-workers look at my difficult patient. he introduced me to a new term, FOS(full of **** ) in reference to my patient. he then gave me a lesson on malingerers. are all no-fault and workers comp patients "FOS"??
edilling, thanks for the response and advice. in answer to your question about ultrasound i thought it was suppose to help, and how else am i gonna get that 3rd or 4th billing code the boss expects?
and to whoever suggested the course by kevin wilk, let me throw this one out there for discussion. he is a good instructor, knows his stuff about the shoulder and knee. but doesnt he work for healthsouth in birmingham, alabama. isnt that weird?????
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Re: Difficult patient - November 29, 2000 6:12:00 PM
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mcap
Posts: 652
Joined: February 8, 2000
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Rookie:
It is difficult to work with medical/legal patients and worker's compensation patients but try not to get too jaded. There are some malingerers out there but the research seems to suggest that it is less than we think.
It could very well be that the effect of litigation or worker's comp status has a subconscious or indirect effect. These patients definitely do worse but they are not all actively "faking" it.
mcap
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Re: Difficult patient - November 30, 2000 10:58:00 AM
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Barrett
Posts: 967
Joined: July 28, 1999
From: Cuyahoga Falls, Ohio
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A few days ago on this thread Joe PT (who has no personal email address) said that his clinical instructor was "insisting" he take the Barnes course.
I've just done an unpublished essay entitled "Not in Kansas Anymore" about the Barnes courses and I'd love to get this clinical instructor's opinion of this work in progress.
I'll need Joe PT to help me with some contact info, so I thought I'd try here.
Are you still there Joe?
------------------
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Re: Difficult patient - November 30, 2000 4:54:00 PM
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JoePT
Posts: 0
Joined: November 20, 2002
From: Birmingham,AL
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Barrett,
It is not my clinical instructor who requires us to take this course but rather my director. Due to this fact, I cannot give you this person's name. I do not want to jeopardize my job.
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