I recently had an experience with a teenager, a little similar to V’s (pt with CRPS), though my pt didn't have a diagnosis and her pain was much less extreme:
My pt had been complaining about pain in every joint, all the time. Walking, standing, sitting, horse riding all hurt, though she was not functionally limited by her pain. She had had numerous investigations (imaging, rheumatological, orthopaedic etc) which had all turned up clear. However, via google (a most trusted medical expert!), the pt had self-diagnosed arthritis..
A thorough physio Ax showed some global deconditioning, mild joint hypermobility, some reduced muscle length and poor muscular control of loaded joints. But nothing particularly stood out as an obvious reason for her pain. I explained that poor muscular control may place undue stress on the passive structures and perhaps this may cause pain. Whilst the teenager was unimpressed with my explanation, mum was happy for us to intervene however we saw fit. The plan was for weekly land-based strength/cardio sessions and hydro sessions for 12 weeks, at which time we would re-evaluate.
The first session was a disaster! The pt complained that everything hurt too much and that every action I asked her to do caused more pain. I acknowledged her pain, but explained that some increased pain was to be expected in the beginning and thus it might be best if we didn’t think about the pain, but focused on completing the exercises accurately, just to see if they might have some benefit long time.. At the next session Mum decided not to observe. I didn’t ask about pain, just directed the pt and did all the exercises along side her. We chatted about school, her friends etc and soon enough the session was over without a single complaint! Our sessions continued in this way and the patient even suggested some progressions along the way!
In my final week, I did another assessment to measure any gains. The pt stated that her pain was much the same as before we had started the program. However, when I was able to objectively show her how far she had come (improved strength and cardio endurance), she was actually really pleased with herself. And when I asked if the pt was willing to continue the program she was very enthusiastic about it, surmising she might like to join her local gym when her physio program was completed!
Whilst we still don’t know if the pain has an anatomical/pathological source, and whilst we certainly did not rid this young patient of pain, I feel that the intervention had a positive effect on her self-esteem and future health behaviours. I realised that whilst pain is an important clinical indicator, focussing on it can be very detrimental to the goals of an intervention! Also, I now appreciate that assess/intervene/reassess is not always relevant to a single session – it often takes much longer to see gains which the patient can appreciate and that sometimes we need to point out these improvements.
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It's definately an eye opening experience. I found that distraction helped when treating a pt with crps too. Another treatment technique that the physio used was imagery. For example this pt had decreased knee extension so everyday she had to do 5 active knee extension exercises and 5 thinking exercises where she had to imagine straightening her knee or look at my leg straightening and not hers. It was difficult to see which exercises had helped as they were used in conjuction and I only saw her twice and little gain was made.
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