Week 1

Situation
Patient A was referred to the Bentley outpatient hospital by the pain clinic with request for a graduated exercise program for ongoing and progressive lower back and right hip pain secondary to osteoarthritis and fibromyalgia. Patient A is on the disability pension and had an extensive medical history of depression, sleeping difficulties, vertigo, tinnitus, left upper limb lymphodema post left mastectomy in 2002, chronic ongoing pain over the left scapular region and narrowing of the c5/c6 resulting in a progressive right radiculopathy for the past fifteen years. Patient A underwent facet joint injections for her chronic lower back pain one year ago with no success. She is on numerous medications and regularly takes antinflammatories for her back and hip pain however has never previously recieved physiotherapy services. During the subjective assessement patient A described herself as an obssessive personality. She lives independently in a one storey house and recieves help for domestic activities from her daughter. She explained recent difficulties with her daily cleaning and vacuming regime as her daughter has returned to full time work, and her pain levels do not enable her to do the daily cleaning. Patient A has relatively low activity levels outside of her cleaning regime, she stopped gardening one year ago and only takes occasional 20 minute walks outside. Patient A explained the only two things that helped ease her pain was a forward supported sitting position with her arms fixed and heat. Objectively, i could not find a preferential movement direction during the active range of motion assessement. All movement was painful. Patient A had a slow waddling gait and a slight right trendelenburg. Sit to stand and stand to sit was slow and difficult with alot of assistance from her upper limbs and very poor quadricept control. Patient A also had difficulty moving in and out of supine as she could not move through sidelying due to her hip pain. I did not perform an accessory or passive physiological intervertebral assessement.
Task
To educate my patient on pain management techniques and discuss the goals and intentions of a graded exercise program. I then needed to choose an appropriate starting point for the mobility program in which the patient would be challenged but would not cause her pain levels to sky rocket.
Actions
I started off by educating my patient on different methods of handling her pain. I explained that it is better to take lots of breaks throughout the day rather than taking a bust boom approach and doing too much and then needing to rest for two days, i wanted her to take regular breaks before her pain peaked. I advised use of a heat pack throughout the day and as her pain levels would usually increase mid day and throughout the afternoon, i suggested she break the day up with a hot shower. Patient A was concerned that "her leg joints were stiffening up and she was not getting enough exercise" as she could not walk on days when the pain was bad. I suggested an unloaded mobility routine she could do when the pain was restricting. I adviced foot pumps, active knee extension and hip flexion in sitting. I then needed to device a mobility program for her lower back pain. This was particularly difficult as all movement caused her pain to jump straight to a 7-8/10. I finally decided to put my patient in crook lying where she could do gentle lumbar rotation, flexion and pelvic tilts.
Results
Patient A agreed that she needed to break up her daily activities with more regular breaks howver she was concerned that it would be difficult not to let her pain peak as some days the pain would go straight to a 9/10 as soon as she commenced activity or before she had even started. Patient A was very happy with the seated lower limb exercises and responded well to the light lumbar mobility exercises in crook lying. She then informed me that it would be impossible to perform the lumbar exercises on her bed as it is a water bed and her couch is too small to lie on so she did not have anywhere in the house to perform the exercises.
Evaluation
I decided that i would somehow need to give my patient a means of objectively monitoring her pain scores and her breaks so that she could ensure her pain did not reach a peak throughout her daily activity. Patient A and myself her both happy with the alternative to walking when the pain was bad, as seated lower limb range of motion exercises would enable her to sustain lower limb flexibility without further increasing her pain. I did however have a conflict with the lumbar exercises. I knew the floor was not an option as patient A was currently unable to get down and back up from the floor. The only option i had was to change the position she performed the exercises in. I decided to adapt the lumbar flexion, rotation and pelvic tilts to a seated position. This required further feedback and correction of body position, however it was relatively pain free for my patient and she was still getting the same benefits from the exercise.
Strategies
1: I used a two point pain discrimination rule where by Patient A was only allowed to carry out activity or exercise if her pain was below or equal to 5/10. Once the pain got to 7/10 she needed to sit down, have a rest and apply heat if necessary untill the pain dropped back to a 5/10. This strategy will enable my patient to monitor her pain scores and stop her from letting the pain peak during activity.
2: Have the flexibility to adapt my exercises as necessary. This may mean a change of body position or a change of equipment. It is important that i make the exercises easy and accessible to the patient, otherwise they will not be performed.