Week Five Entry- Professional Behaviour/Communication

Situation:
49yr old female was referred to physio for low back pain. She presented to clinic with a very antalgic gait and posture. After the subjective history, it became clear that this lady had complex psychosocial issues going on. Her LBP started just after the death of her husband whom she had been a carer for the previous 4yrs. His care involved lots of heavy lifting and she reported having to lift him off the floor numerous times. She also has two sons. She has a 19yr old who has been diagnosed with mild autism. She also has a 13yr old who she suspects as ADHD and he is currently undergoing testing. The 13yr old has recently been skipping school. The patient has been contacted by the school and they have threatened to take her to court unless his attendance improves. The patient is also illiterate and has received no formal education (both her parents died when she was 2). She is incontinent of urine (urgency, stress and urge incontinence), has regular falls due to her knees giving way and she cannot get up off the floor so has to call for someone to help. She has recently noticed an increase in memory loss, she does not drive and she has no family in Australia.

Task:To provide an assessment and treat this patient, taking into consideration her psychosocial issues and her culture.

Action:
After the subjective assessment I continued with the objective, firstly looking at her posture. During the assessment I was able to place my hands on her with no complaint of pain and place a reasonable amount of pressure while palpating her thoracic and lumbar spine. I then went onto active movements. Every direction caused her pain and she was gasping, wincing, and jerking out of every movement. There was no difference in the type or intensity of the pain between the different movements. To have a closer look at her lower back I asked if she would move over to the plinth. She was then able to bend forward to pick up her bag from the floor and move it without any complaint of pain. She reported she could not lie prone so I did the assessment with the patient in sitting. This time when I placed my hand on her she again displayed non-organic pain behaviours and was wincing, gasping and jerking with only light touch. As I was not able to do any further testing I used this time to consult with my supervisor. He also agreed that this patient had huge psychological component contributing to her pain and that it too would need to be addressed. He also agreed that she should not be transferred to another student as this type of patient would benefit from consistency and would probably feel more comfortable with a senior staff member.

Result:
I returned to the patient and provided her with some reassurance and education about her back pain and the process involved to try and decrease the intensity of the pain. As no “hands on” treatment was appropriate in that session, I provided her with education regarding the use of heat over the area to help relax the muscles and reduce pain. I also explained to her that movement is good for the back and I encouraged her to increase the amount of movement she was doing with general, gentle exercises and stretches.
After this explanation the patient showed good understanding and her mood also seemed to improve. Her pain postures and abnormal gait pattern also was less obvious.

Evaluation:
I think I handled this complex patient well. I listened to what the patient had to say and documented important things but ensured I did not dramatise/catastrophise as this would only heighten the patients’ perception of pain. I maintained a holistic approach by discussing the involvement of social work/psychology with my supervisor. I also was culturally sensitive to the patient.

Strategies:
To continue managing complex patients well, I think I need to be confident in the information and education I am providing them. Also remembering to avoid over complicating the situation and initially just providing education and treating what I see in front of me.