We see it all the time, especially over social media. Success story after success story. We see blog posts and facebook status updates detailing how a patient was miraculously cured of a chronic ailment in a single session because the practitioner was able to find what no one else was able to see. Often times when questioned about the assessment and treatment method employed to help such patient the inevitable response is usually “you must take my course to find out”. This blog post will be in direct contrast to that. This will be a quick case summery of a failed treatment of a patient I thought I could “fix”. We learn more from our failures than we do our successes so here’s hoping I’ve learned something from this.
About 2 months ago a new assessment came my way, referred to me by the Physiatrist in the clinic I work at. He was a 27 year old male with a chronic history of idiopathic low back pain. He walked into my office and I literally thought he was a neurological patient due to the sever antalgic and shuffling gait pattern. He was so far laterally shifted that he was losing balance while walking. In all honesty, once I realized he was a back pain patient I started salivating,..”this will be a great success story” I thought to myself. The more acute they are, the more of an instantaneous change I can usually make. It’s the chronic low grade back pain patients that take more time to see results. He explained to me that he has had multiple instances of his back going “out” on him over the past 5 years, but usually got better in a few days. This time was different in that he was in severe pain for over 2 weeks before seeing me.
Here is a bullet form list of what his exam findings were:
- Severe lateral shift (pictures below…don’t worry, I got permission before posting this)
- SLR of 20 degrees on right
- +ve crossed SLR with pain only into the contralateral side of the low back
- Absent right S1 reflex
- Dermatomes within normal limits
- No complaints of bowel or bladder signs, but had pain down to the right heel
- Lumbar flexion to 20% of normal…couldn’t get his hands past his upper thighs
- Lumbar extension to about 40% of normal
- Basically all lumbar movement was classified as a DP (dysfunctional and painful)
Most other standard testing was not done due to the aggressive nature of his pain. At this point my diagnosis was in keeping with a severe right L5-S1 disc herniation compressing the L5 nerve root. He was already under medical management for this so I didn’t deem it prudent to send him for medical follow up. We started treatment with the idea of de-facilitating his sympathetic response. He was pretty wound up (understandably) so my clinical judgement lead me to work on crook lying diaphragmatic breathing, which did help slightly. For the first 1-2 sessions he couldn’t stay in any one position for more than 2-3 minutes before he had to move…suffice to say he was a challenge to treat. What he did respond to was aggressive lumbar traction in side lying. I had to use everything I had to traction his lumbar spine, which was exhausting for me but abolished his pain when maximum force was used. I basically just did this for another session or two, but results did not last at all. He would get off my bed as shifted as ever and in the same amount of pain as when he walked in. Many things were tried with him such as soft tissue release to his paraspinals and sciatic nerve pathway, thoracic spine manipulation, cervical traction, lumbar spine unloading tape jobs, side glides with over pressure, and many forms of self traction. He would always feel better after treatment, but the shift did not change and the results were very temporary. This was unacceptable to me. This client was talking time out of his busy day to see me and paying good money for my care…he should get at least some benefit from each session.
Homework consisted on breathing exercises, side glides in standing, crook lying core contractions, and self traction exercises of various degrees.
I treated him for 8 sessions using pain science education, traction and every type of self care exercise I could think of. With some initial progress but not enough, when he came in for his final session with me even worse than he had been before, I decided to throw in the towel and refer him back to our Physiatrist. At that point he was taking 12 percocets a day (!!!) and couldn’t work (even from home). The hard part was that he had no hard neuro signs and when we told him to go to the ER, they gave him pain meds and told him to come back if he had signs of cauda equina syndrome. He was stuck in limbo…too much pain to achieve therapeutic benefit and not enough to warrant a surgical opinion. He was given an MRI, which did show a large right sided disc herniation compressing the L5 nerve root. On a side note, it’s patients like these the remind me that imaging findings DO matter some of the time in that his pain was directly correlated to what his MRI showed. This is undeniable to all the pain science people out there. This was a young man who desperately wanted to get better. He did everything that was asked of him and more. He just wanted to get back to work and resume his life. I can safely say this was a patient that kept me up at night thinking how else I could help him.
Our Physiatrist sent him to a pain clinic for injections in his back. The first one he had worked well and he achieved an 80% reduction in pan, but he went back for a second round the next day for more shots, which actually made him worse ($hit!). He was in agony again and back to square one. We are waiting for his symptoms to calm down a little before re-starting rehab and he is in line for a surgical opinion (finally).
This was written to remind you that there are just some patients we can’t help, despite doing everything we can. There is a tendency in the rehab/exercise social media setting to glorify outcomes, which I think make us as rehab professionals feel like we should be able to cure everyone who walks through our doors. As much as we want to, this is just not possible. But never stop trying and continually elevate your game to help as many people as possible. But also know that throwing in the towel is nothing to be ashamed of, as I feel It shows professional responsibility and a patient centred model of care. If I couldn’t help him, I wanted to find someone or something that could. I feel like I would enjoy reading this type of post if nothing else but to remind me that clinicians all over the place are working hard and not always getting the results they want. If you are struggling with some patients, seek out others for advice. Personally, I spoke over the phone with my friend and trusted colleague Erson Religioso about this case and he gave me some excellent advice. I went on a rehab group message forum to get suggestions from such people and Craig Liebenson. Just reach out and ask for help. It will serve both you and the patient well.
Here are the pictures of my patient so you can get a sense of how shifted he was:
If you have any questions about this case (I know I didn’t give too many details) or any suggestions please do let me know. I think sharing troubling cases like this makes for an excellent learning opportunity and I hope you do too.
Thanks for reading