During my musculoskeletal outpatient placement I had a patient who presented with a three month history of constant 7/10 back pain that is aggravated by even the simplest of actions such as walking or sit to stand. While completing a detailed subjective examination I was told about this patient’s long standing history of depression, multiple personality disorder and suicide attempts that have required numerous admissions to mental health units across
In terms of the impact of her back pain on her life, the patient reported that most days she would walk for about 10 minutes before her pain was so bad that she would take a morphine tablet and sleep for a couple of hours. The patient was under the care of multiple teams of doctors and had had a number of investigations to rule out more sinister causes of this lower back pain; however no clear diagnosis had been made.
After completing my subjective I felt quite overwhelmed by the amount of information and the severity of this patient’s problem. I was really not confident about how to approach assessment and treatment for a patient with such severe pain and irritability. I discussed what I had found with my supervisor and that I felt that Physiotherapy may not be appropriate for this patient. We agreed that it was still worth completing a modified objective assessment to try and get as much of a picture as possible.
Objectively I found a tight, hypomobile Lx spine and poor habitual sitting postures. This was treated with STM, gentle PAIVMS and education about posture and the use of heat for muscular pain.
The patient reported that they while her pain had not really changed with the treatment she felt that she was doing something proactive about trying to help it, which is something that she found hard with her other conditions. After discussing this with my supervisor I can see that while we may not be able to alter many aspects that contribute to the patient’s problem, it is possible that we can help the patient both with hands on treatment and providing an opportunity for developing self management of contributing factors like posture and exercise habits. I feel this experience has allowed me to more clearly see that while the patient can have many issues in their life, we can have a role in changing those factors within our control.
2 comments:
I had a similar patient Brett and i too pondered how to manage the situation. I don't believe we have had enough training in managing these situations. After just completing a placement at Graylands i saw how complex patients' problems can be. I think the interview we did in second year provided some insight but it does not quite prepare us. We can only treat how we have been trained and i think our training presently is inadequate for dealing with mental health.
I also had a fairly similar situation on my msc prac in terms of being overwhelmed and not knowing how to approach a highly irritable patient on medication (although my patient did not have quite the same severity of Hx of depression ect..)
I agree with Mat in that we are taught about 'Yellow Flags' and know how to recognise them, but when faced with a real life patient, we are still feel overwhemled!
I think you handled it really well by continuing with an objective assessment. I think for some patients, they become reassured when you find something wrong, and have a plan on how to treat and manage it. (We would all get worried about not knowing why we are in pain)
I also learnt that by remaining extremely positive, and not appearing overwhelmed, can have a massive influence on the patients wellbeing! As you mentioned Brett, its an amazing realisation when you feel like you have had a positive influence on someone life, especially with a History like this patient had!
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