The Irritable Patient

I am currently doing Musculoskeletal Outpatients placement and am currently treating to a patient with high irritability. Patient A was driving and got T-boned by a truck in December 2007, sustaining an undisplaced fracture of the posterior aspect of the right twelfth rib.

Patient A presented with right sided mid-back pain which was described as sharp and stabbing which was aggravated by normal basal breathing, bed mobility, trunk movements in all directions, right or left shoulder movements, walking and prolonged standing. On initial assessment, the pain was reproduced with all trunk movements, especially to the left (opening up on the right), and the patient was extremely TOP and quite swollen over the lower Thoracic spine and surrounding soft tissues. When questioned about pain coverage, the patient said that he had been taking Tramadol up until 4 days prior to this session, and he had gone off them because he had began to suffer form hallucinations. The patient was unable to get into the prone position on the plinth due to pain so, much of the assessment was conducted in supported sitting with the patient leaning forward on the plinth. I soon realized that this patient was quite irritable and would not tolerate a great deal of manual therapy.

After consulting with my supervisor I decided to manage this patient with the following plan:
1. Education regarding –
- Going to GP for advice on pain cover
- The importance of gentle active movements as pain allows to maintain/improve mobility of joints and muscles in the affected area
- The importance of deep breathing exercises as pain allows
2. Gentle soft tissue massage of surrounding structures (not directly over rib 12) to help mobilize the swelling and reduce some of the over-activity of the surrounding guarding muscles (patient was in supported sitting)
3. A HEP was provided which included gentle active movements, deep breathing exercises, shoulder and trunk AROM exercises for him to do in his swimming pool

Although I did not perform a great deal of manual therapy, I felt that this was a successful session in that the patient received a lot of education and reassurance, which seemed to put his mind at ease, and also some swelling management to aid the healing process. If anyone else has any ideas how to manage a patient in a similar situation, it would be great to get some more ideas.