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Old 18-08-2004, 12:17 PM   #1
jim hardie
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Wouldn't mind your opinions on this. 55 year old lady is ref with neck pain, when she sits down and tells me her story I want to go to university and throttle lecturers, GPs, orthopods, physios and just about everybody she has come into contact with. I will try to put chronolgical list of points.
24 year old ...neck pain diag cervical spondylosis, car crash whiplash collar 6months ,2kids.... backpain discectomy x2... bilat hip pain diag widespread oa walking stick... duaghter anorexic marrioge breakdown shoulder pain..bursitis, bilat arm pain..tennis elbow..health board supply electric wheelchair, physical therapy, osteo manip, chronic pain management which includes acup, facet inject, 21 years of mismanagement. now on max dose of nsaids and tricyclics. as she is siting talking to me I am thinking Butler, Moseley, Gifford, Stevens etc , should I put my hands on her and why? will information really help her? sorry its abit long but I hear things are quiet. ps its still raining in Scotland maybe thats the problem!
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Old 18-08-2004, 01:16 PM   #2
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Hello Jim!

It is quiet because the olympics are on, and our leading light on the forum Bernard is holidaying, and maybe it is the dark of the moon - I'm not sure.

Seriously, I know how you feel. There are people I see who have had extremely rough experiences with health professionals for years; and it is probably due to the best of intentions being played out, with not much notice taklen of the patient and her story, from the beginning.
With your patient, I gather she was 24 when the MVA occurred, and do you have details of that event? Rear-ended, side on, etc?

I am a bit confused about ages and dates; can you clarify her age and the other dates?
Wearing a collar for so long sounds horrific, if there were no fractures or major instability concerns; given that 21 years ago, there was not the understanding of the importance of early functional mobility, it is probably easy to look back in hindsight and think of mismanagment issues, but if you were practising in 1983, clinical practice was quite different.
Rest was the all-cure - bed rest for back pain up to three weeks, collars were used left right and centre for the mildest symptoms of neck pain; and surgeons did many operations on spines, up to six on the one patient.
At least, that was the rough picture in some Australian centres.

I would not do anything physical to her - sounds like she has been assaulted (strong word, but appropriate at times) too much by health professionals. If you haven't already, listen to whatever she wants to tell you of her story; she will probably appreciate a good listener.

She has more yellow flags than a fleet of ships in quarantine (nautically, a yellow flag on the stern mast means "Danger - do not come aboard") and these need to be addressed by yourself or someone else.

It sounds as though she has central sensitivity, strong fear of movement, probably of health professionals as well, and is ruled by her pain experiences. What have you read of Gifford, Moseley (Lorimer)and Butler? there is a wealth of info in their papers and books on just this kind of person. If you can access Moseley's work through Pub Med or similar, he has some excellent advice.

If you can supply some more details, we will have a go at helping, but it is not easy on the net, it is very non-three dimensional!

If you want to try hands-on, let her talk at the same time, steer clear of her hot spots (neck, arms) and just do old fashioned, slow massage-style movement on her back, with her lying on her side. People can feel very vulnerable lying prone(can't see) or supine (exposed).

Good luck and keep in touch.


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Old 18-08-2004, 03:32 PM   #3
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Jim,

dilemma indeed .......I used to try and intervene with these things single handedly and got totally burnt out .......However these issues are ubiquitous as we are medicalising social distress ......The language of pain is used to seek help and bodily dysfunctions are often a way of receiving help . I believe centralised physiological explanations are probably helpful but miss the cultural and social narrative .
I have onlyjust got hold of TheCulture of Pain by David Morris but its a must read for anyone who deals in poorly understood problems ie 90% of GP patient referrals ......
I find I am much better now at dealing with these problems . I had the worst case ever yesterday and my student sat with her mouth open listening to a series of stories that would make your hair curl ......Why these patients are referred to Orthopaedic clinics is totally beyond me... Equally insane is trying to put someone who has whole body pain and shakes like someone who has advanced Parkinsons disease on a treadmill .......It was interesting that some words and gestures I used turned off the tremor totally and others landed like exocets reigniting the whole defensive postural response .......
One thing in our own profession would be to make 'mental' health issues compulsory in training and to look at the reality of conditons presenting to GPs in particular ......epidemic of somatoform disorders/anxiety /depression and chronic pain... However admitting this does not make your career path in Physio easy -- it derails it .....
One thing that we do have is the ability to touch and listen ..Equally we should use this skill sparingly for our own health ..There is nothing most drs like better than to get people out of the clinic as they simply do not have anything to offer .......I will let you have Nathans Touch and Emotion in Manual Therapy (promise !!) this saved me spending a fortune on mechanical fix it courses which simply don't addrress the reality you describe ........

ian
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Old 19-08-2004, 12:57 AM   #4
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ian
Sounds like that book is well worth a look at. I'll nosey around for it, too.

Does it surprise you that in our relatively closeted lives, that there are huge numbers of people 'out there' with disastrous/dysfunctional emotional lives? Makes you wonder at times, which world we live in.

This lady does need teamwork, as it is a huge load for one person.
Mental health education is becoming more and more of a 'must' for physios.
OTs cover a lot of ground in this respect - why not us??


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Old 19-08-2004, 11:14 PM   #5
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Hi all!
Im afraid the health profession is more or less,rather than helping them!
making pain patients .
Jim,what is her expectations by visiting you!Do you think you Can fullfill her expectations!
RIN
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Old 20-08-2004, 10:35 AM   #6
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Hi Folks really appreciate your interest, makes me feel personally less frustrated and consequetially more attuned to helping clients, have had a few D.Fens moments lately ( Michael Douglas abandoning his car in the middle of the motorway, good scene ,crap film )
This particular pt was coplaining of non-specific neck pain aged 24 went through wind screen of car 1 year later, nasty scar on neck, 6 months in collar within next 5 years had 2 discectomies in lumbar spine, life started to fall apart ,medicalization +++ Diagnosis like Tennis elbow, frozen shoulder, oa etc etc, on the subject of her expectations the first thjing she said was " I dont think you can help me " I spent the next hour listening and gently trying to debrief ie you dont have tennis elbow these are just names invented by the gurus . When I asked the GP who ref her what her expectations were of me in ref this woman she replied that I might have some new exercise and if not she would send her to the osteopath. This lady had spent two weeks at a residetail osteopathic clinic paid for by the insurance and was now terrified of any" hands on"! I will spend some time on breathing pattern and try the side lying non threat approach try to build some trust, to be honest though still have some issues about my expectations , what should I aim to achieve ? would appreciate any comments.

Jim
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Old 20-08-2004, 12:07 PM   #7
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Jim , from my experience with some therapists (personal treatment) and a lot of reading to make sense of what happened (and also exposure to a vast quantity of similar cases at a pain clinic)I would offer a few things....
I went on a brilliant course called Therapeutic Encounter with David Riley head of the Glasgow Homeopathic hospital recently .......He constantly talked about changing patterns and how consultations can cause shifts in patterns .......I believe Melzacks model helps the rational thinkers to accept how things may work or may change whole complex multisystem issues (have a look at the Glasgow Homeopathic website there are resources on consultation skills etc )
Have a look at this http://www.umassmed.edu/cfm/srp/
Practically if you are a single handed practioner and WANT to try and do something and she is open there is always hope .......Its like the nervous system taking highways of entrenched grooves when there are highways and byways off the motorway ........Biomedicine is stuck in the motorway between Perth and Inverness, outside we have the delights of Weem,Aberfeldy,Loch Tay Dunkeld and a whole host of nice galleries and hills to explore .......Being in chronic pain hones the perceptive field to looking at caravans on the A9 -- trouble is the drivers of the caravans are often the therapists and Drs!
Now then ..... I would say explore the narrative ......you have all these things going on , things done , things that were not too helpful ......Get her to accept that pain is the problem and that ongoing pain is a really common difficult problem .......Introduce her to www.painsupport.co.uk and have a look at basic issues re pain gate .......explain why the vigorous hands on caused wind up and made pain worse ......Have a look at issues to do with sensitivity and how the body 'armour' reinforces messages to the brain that it is always under threat
I would go along the path of driving school analogy -- you do a bit set a bit of homework, practice and if there is any progress you do a bit more..if no headway in a few sessions or you don't connect at all multidisciplinary pain managment best long term option but this can take years to arrange ......
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Old 20-08-2004, 12:45 PM   #8
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Jim

Expectations - ideally they are mutual, so try to determine what *her* expectations are. She may not even be able to verbalise them; she may need help and some empowering (dreadful word, but her self-esteem is probably in her boots).
Try to find out from her one goal, that she would like to achieve. If she says: 'to relieve my pain', steer her onto one thing she would like to be able to do, one thing above all the rest. Then, if she realises that you will assist her to achieve this one goal, regardless of obstacles, she can focus on something other than her pain.
She needs to understand there are no magic wands!
Contact her GP if you can, and explain what you are doing, and that there are no 'exercises' that will help at present, but state what you feel you can help her with, ie small functional goals.
Measure her RR, which is probably high, and aim to establish some breathing control to reduce the rate.
If you decide to do some movements, make them hers - ie active. Try to achieve breath control while she does something simple, such as moving one arm somewhere (avoid abd at this stage) and perhaps bending her knee. Slow stuff, as though moving through oil. She may find it better to sit in a comfortable chair, rather than lie down.
Music can be helpful.
The gist of this approach is to allow her to find out that some movements hurt, but she can do them (Hopefully)

If she can find a single goal to work towards, then focus on the functional movements needed for that. It's OK to assist very lightly, but she has to be the prime mover.

Assure her that you will not 'mobilise' or 'strengthen' or 'stretch' anything until she feels ready. Lots of patients have fixed ideas about what physios do, and those ideas often revolve around increasing pain, and, unfortunately, bullying.

In other words, forget you are a physio for a while, gain her confidence and trust (very important); if three sessions later you haven't laid a hand on her, it doesn't matter. We work with our brains, not just our hands.
(Though Diane, another poster on the forum does splendid work with her hands!)

Aim to be a safe friend for her.


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