Hi guys. I’ve just started musculoskeletal outpatients and last week I had a challenging patient. I was asked to assess a 50 year old man with a referral from his case manager (workers compensation) asking to give home exercise program for his lumbar spine and education regarding his condition. The first assessment was quite challenging for me. When I asked the first question “as far as you are concerned what your main problem is at this stage?” he answered me “my case manager wants me to go back to work, but I don’t think I am able to. I want to get the disable pension, but they won’t give me because they know that I play tennis regularly for more then 2 hours...”.This start already took me out of track and the yellow flags came into my mind. In summary, the history showed an insidious low back stiffness (no pain), aggravated with sustained flexion and after tennis (>3hs) eased with standing and walking. The patient hasn’t been working for 11 years, but now is very active overall and thinks that the reason of his problem is degeneration and what will help him is “manipulation and stretches as he sees the physio do on the football players on TV”. He had previous treatments which he believes didn’t change his condition. He already mentioned that he doesn’t do home exercises given by the physios. The physical examination showed good general AROM with mild contra lateral Lx pain on OP in combined extension and sideflexion; several segments of Lx stiff on PAIVMs and PPIVMs and poor standing and sitting posture. My first intervention was AP mobilization on stiff segments of Lx which reduced the mild pain on combined active extension and sideflexion, general mobility Lx exercises and education regarding alternate sitting and standing positions. I reinforced and that the manual therapy will give him a temporary relief and the importance the mobility exercises to have better results. I also mentioned that in a medium to long term we would start some posture corrections. When I finished the session I asked if he was happy with that, he said “yes, that’s great! What about that stretch/massage that I see on TV?”. I said that from my assessment findings I didn’t think it was necessary and his condition would be better managed with active exercises, posture correction and some changes during his ADLs and this will hopefully help on his quality of life.
Now I don’t know if I should keep the hands on treatment or only manage his condition. There is only a little pain response on his active movements and the patient is quite active. I am afraid that it will reinforce his beliefs that only passive treatment will help him. I also not sure if I should contact his case manager and say that I think that he is physically able to work, but in a different position, may be doing lighter activities, even though he clearly showed that he is not interested on that.
Any ideas would be appreciated.
Caroline
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Hey Caroline. I would definitely talk to your supervisor about this one. Given he has been referred from his case manager I would assume that you would be required to communicate with that person just as you would with a GP referral. The treatment vs management question is tricky. Even though he is restricted on PPIVM/PAIVM Ax that wouldn't be my main focus of treatment. Given the yellow flags and his attitude/beliefs education would be essential. I would be thinking along the lines of a few PAIVMs initially to loosen up with the main bulk of treatment being postural retraining. From what you've said this man isn't particularly disabled and probably should be working. Just because he doesn't want to work doesn't mean he should be receiving compo for a resolved problem. I would think that your findings should be communicated to his case manager. There probably is some specific protocol with regards to this so run it by your supervisor. Good luck, Anna
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