This is a different post for me, a little less evidence-based and fact-filled and a little more reflective on lessons from the past. I was recently reminded of a patient that from three years ago that presented with severe low back pain that was preventing her from walking. I began the subjective examination with the same format as I would any new evaluation but in the end, there was one particularly important question that unravelled her story... asking why?
The subjective examination or patient interview is, in my mind, an incredibly important part of patient assessment. It's at this point in time that we try understand what problem brought the patient to us, what possible reasons underlie their struggles and how we might be able to help. In the biopsychosocial model for pain, it is really important to understand the person, their pain and how they live with their pain before trying to look at the physical contributing mechanisms. There are so many questions to ask that assist in clarifying and differentiating between different clinical patterns. Probably one that I've begun to use more and more is why?
- What brings you to Physical Therapy?
- Why did you come now?
- What do you think is the main problem?
- Why have you come to that conclusion?
- What do you expect I can offer you to help?
These are some of the phases of thinking I progressively go through with each client. I generally wouldn't ask these is such a blunt or direct way but I am thinking along those lines.
So back to my patient, a 49 year old female, who came in on a Saturday morning with severe lower back pain that spread across her lower back in a banding pattern. She told me there was no referred pain to the legs and denied any accompanying neurological symptoms. Her pain had gradually built over the last 2 months and now she wasn't able to walk. She felt her core strength was poor and came to see if Physiotherapy or Pilates might be able to help.
This is how some (not all) of the questioning went from here...
I began trying to understand the impairment a little bit more:
Q: I'm interested to know more about your pain. Is it constant or does it come and go?
A: It comes and goes.
Q: When is it worse or better?
A: It is good in the morning and gets gradually worse as the day progresses.
Q: Does it wake you in the night?
Q: Is there anything you can do to ease your pain in the afternoons?
A: I'm not sure what to do but moving around does help?
From this, as I recall, I thought I was dealing with a mechanical problem (over inflammatory) although it didn't seem that clear. There weren't any red flags jumping out at me and after questioning about her general health, I wasn't too concerned about sinister pathology.
So I jumped to a different thought process around her limited level of function:
Q: You said you can't walk - is it the pain that is limiting you?
A: Originally no, but now yes.
Q: What do you mean by that?
A: I stopped walking before the pain began.
Q: When was that and why?
A: Just over two months ago.
Q: Was there a particular reason?
A: I had to put my dog down and I've just been so upset that I can't face going outside where we used to go walking.
Asking why unravelling a large 'social and affective' component to her pain.
It was at this point that my thoughts around the driving mechanism of her pain were questioned. The patient was also very upset recounting her story and I didn't want to pry more than what was needed. So I asked just a few more clarifying questions.
Q: I'm really sorry to hear about the loss of your dog. I can see how difficult that has been for you. I just want to ask a few more questions before we move onto our assessment if thats ok?
Q: When you mentioned before that you thought your core was weak, what did you mean by that and why do you think that?
A: Because most people said my back would hurt if my core was weak.
Q: Do you think it is?
A: I'm not sure. I used to walk everyday and feel fit but now I feel out of shape.
Q: Ok, well let's look at some physical tests and see what we find and relate that back to the pain you have today.
The objective examination - where to begin?
The first part of the objective assessment involved me observing her walking and her standing posture. With her top lifted and tucked into her bra I was able to see both her stomach and lower back. Two things became very evident.
- She was sucking in her upper abdominal wall and breathing apically.
- Her paraspinals were bilaterally engaged when she stood quietly and when she walked, there was little variation in their level of engagement and basically not trunk rotation.
I then asked to bend forward the best she could (which stopped just above the knees and was limited by tightness across her lower back) and could see that there was minimal segmental spinal flexion or relaxation of the paraspinal muscles.
Q: It seems like you're holding in your stomach, is there a reason why?
A: Because my back hurts so I am trying to engage my core to support it.
1. Education about normal breathing and not holding in the abdominal wall.
2. In supine crook lying practicing normal diaphragmatic breathing and relaxation of the abdominal wall.
3. In supine crook lying practicing lumbar rotation to both sides focussing on letting go and getting movement from each level of the spine.
On standing her pain had reduced significantly and she was able to bend forward to the level of mid shins with minimal lower back pain.
I think its important to educate our patients why treatments change the way we move and in this particular case, she needed to know that holding her stomach in was the problem not the solution. We discussed how loosing her dog had changed her activity patterns and how the stress of this loss was changing the way she breathed. She agree completely and was relieved to feel that her pain could be reduced with something as simple as breathing.
Coming back to the patient described above, she had fallen into a viscous cycle:
- The pain of personal loss.
- A disruption in her fitness routine.
- An avoidance of going out walking.
- Stress and anxiety changing the way she breathed.
- Unaware that the change in activity and breathing could change the way her body responded to movement.
- Adopting the therapeutic beliefs of others without clarifying if they related to her problem around her core being weak.
- These beliefs further amplifying the breathing problems and gripping postures.
- Becoming worried that the pain meant something was injured and without a clear moment in time for onset, assuming it might be something sinister.
- Then further avoiding activity in the thought that it might make the pain worse.
Asking why isn't always easy. When you put the onus back on the patient to try get them to problem solve their own issue it has the potential of coming across as not knowing the answer. That's not true and when I ask why, I am literally just curious to find out more information and dig a little deeper. If this ever seemed like the case however I might begin by saying "It sounds like the problem you're having is this.... and I'd like to know more about your thoughts as to why that might be the case?"
I'm sure we've all seen a similar fear-avoidance spiral before and not all patients that I ask why to have fear avoidance, but it was a good example for when we need to clarify what the patient means and is experiencing before making a judgement on their physical presentation. I hope it reminds you to dig a little deeper next time the pieces don't add up and if you'd like to read more about kinesiophobia and fear-avoidance, we've previously written about these on the Rayner & Smale blog.