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PPP Management How to help PPP patients.

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Old 02-05-2006, 04:51 PM   #1
christophb
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Default A Break Down...

Ok, just kidding, but I have a few challenging patients in the clinic and would like a little perspective on one

She is 73 y/o, has had chronic pain for years, failed/minimal success with chronic pain clinic in 1990 (was there for LE CRPS). Pretty tough hx in general (husband murdered) and was in PT for chronic LBP prior to July of 2005 when she fell down stairs and fx right humerus, no surgery because she needed heart surgery first. She was placed in a nursing home until October when she had a CABG x 4. She had no cardiac rehab and was sent home. She had home PT for the shoulder, the home PT "mashed" on the shoulder and made it slightly better (over the course of a few months). During our sessions she describes every slight sensation of pain she experiences and reports during gentle palpation that, "it hurts bad where you just punched me in the shoulder” I have tried education RE pain/brain etc, but she says, "they tried that in the pain clinic and it didn't work” During SC she feels relaxed, but there is no carry over to her daily life /gentle skin stretch causes her to dig up all sorts of pains (central px?). I guess my question is not so much what I do (or maybe it is), but when do I stop trying? This is perhaps a little cynical, but I'm sensing she is also getting a little annoyed with me when I try to offer he another option for pain relief than "mashing" on the shoulder. From past experience when the patient-client relationship breaks down (it wasn't very good to start with), it is very difficult to get it back.

Any thoughts?

Chris
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Old 02-05-2006, 04:56 PM   #2
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Any cognitive issues? Abuse issues? Substance abuse issues? Sounds like there are seething and roiling emotional undercurrents.
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Last edited by Diane; 02-05-2006 at 05:13 PM.
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Old 02-05-2006, 05:09 PM   #3
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Chris,

I'm glad this isn't my patient and I feel certain you're doing all the right stuff, whatever that means.

I'm reminded of an exchange on Seinfeld between George and Jerry that went like this:

George (Rightous and Loud) "I'm going to go down there and tell her exactly what I think of her and then I'm going to get my money back!"

Jerry (shaking his head matter-of-factly) "You're a dead man."

George (limply as he plops on the couch) "I know."
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Old 02-05-2006, 07:21 PM   #4
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Diane, there are some emotional under currents as far as I can gather. She also has quite a bit of fear/activity avoidance (resistant to education like superman to bullets). She is on oxycodone/mm relaxors. Trying to wean herself off of them but gets huge flare-ups in pain.


Barrett, yeah, I'm dead

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Old 02-05-2006, 10:56 PM   #5
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Chris,

It sounds like she has more yellow flags than a battleship in quarantine.

Why is she in the clinic? Was it her doctor's suggestion?

Can you determine what she wants from you other than mashing the shoulder in order to cause more pain? Seems like the lady is continuing to punish herself for some misdemeanour years ago - a common 'victim' nonconscious ploy.
If she has seen a social worker/psychologist in the past with not much success, it is unlikely you will be able to do much.
However, if she were mine, I'd keep her going but not do anything; I'd look for her narrative, and if a glimmer appears, and a chink in her armour...then look at physical things. She is expecting more pain and failure, so anything you try will end up vindicating her beliefs.

I would persist for 2-3 sessions; if the headbanging was still unchanged....give her time out and see her again in a month.

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Old 03-05-2006, 01:15 AM   #6
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Chris,
Why has she come to you? What does she want to do? Maybe getting her focussed on some functional activities might reveal more about her pain state. She could just be using you for social contact, someone to complain to.

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Old 03-05-2006, 03:11 AM   #7
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Eric, I think she was sent to me from an ortho doc (called him up and all he said was "there is nothing surgical we can do," not like I was asking).

Thanks for the suggestions Nari, I honestly don't know if I’m patient enough to wait for a window of opportunity (this may sound bad, but really, it's tough to make it through a session with her). It could be that our personalities are not compatible? I am on the verge of suggesting she find another therapist.

This has been a good experience to observe my ego rambling on about how I'm supposed to fix everyone that walks through the door.

Chris
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Old 03-05-2006, 04:25 AM   #8
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Chris

So she has been 'dumped' by the ortho- the story of so many complex pain people. Not that he could do anything either, I suspect.

However, despite those words, you should not feel at all obliged to see her if you deem it inappropriate; ie, if she rejects all offers of help/care from you.
She may be looking for a magic cure without input from herself; and she may have no concept that it is up to her to improve, with assistance. Education does not help everyone - their narrative reveals their reluctance to take onboard that improvement is up to themselves; at least the kick-start ignition bit.
Personality incompatibility certainly comes into it.

I had one woman with RA scream and cry at me because all she wanted was massage and US. She stormed out of the room with amazing strength and function; she positively barrel-gunned herself out the door.
I am quite sure she found someone to comply with her wants.

Good luck. And...no guilt!!

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Old 03-05-2006, 04:29 AM   #9
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This seems to relate to the thread about professionals being unnecessary. What do we "do" when we realize there is nothing we can do? What happens when even our knowledge is not enough to help?

I'd start with her statement that "they tried that in pain clinic and it didn't work." Wake-up call: it is not about them trying; it is about them attempting to share something with you to teach you how you can help yourself.

Just heard a great line from George Orwell on TV:
"In an age of universal deceit, telling the truth is a revolutionary act."


I don't really think we're unnecessary, but I do think we need to focus more on promoting responsibility and self-efficacy rather than on fixing people. Pain is not something that can be fixed! Therefore, no need for a stuffed toolbox. My suggestion is to do nothing. Make her do it herself. Let her pay you to witness it - or not. Her choice. Depends on what she needs. You've lost your placebo power. Any chance you can empower her? Even if it's to rail against PT. Sounds like she been defeated by a tough life. Not much wonder she'd upregulate her sensitivity. It's a hostile world.

Sorry for rambling

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Old 03-05-2006, 05:37 AM   #10
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Well, good for the ortho for deciding to back off.
Sounds like she's in a life she doesn't like.. I wouldn't say she's in the wrong hands, though, Chris... even though it sounds like she needs to lean toward counselling more than she needs to lean on PT..
I like Nari's outline of a (um..) treatment plan. Anyone you can refer her on to?
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