Untold Physio Stories – A Pain Science Education Breakthrough

welcome to untold physio stories a
podcast that informs and educates by connecting you to rehab industry leaders
who share their candid successes and failures in business and
practice welcome back to untold physio stories
I’m one of your hosts Dr. E with modern manual therapy, EDGE mobility system and
the eclectic approach my new co-host Dr. Dana Palmer of Modern Rehab Mastery
mentoring is filling in for Dr. Andrew Rothschild. And Andrew some time
will be back whenever his schedule frees up but for now you guys should
enjoy Dana’s story that she gave me a little preview of. So you have a story
for us right? I do it’s um it’s a it’s a little bit of a fail story we in the
Modern Patient Education with Andrew we’ve been talking a lot about pain
science and words matter and and how you talk to your patients about
persistent pain and it sort of reminded me of this story I had with a patient I
saw a few months ago. She was in maybe her early 60s. She came to me about four
or five months after a greater tuberosity fracture. She had fallen she’d
slipped on ice that was on her steps and fallen. She was put a sling for six weeks.
She had no PT up to this point but she did have pain management and they
injected her shoulder which was no effect. She comes to me and she’s in a
lot of pain, she’s very frustrated and emotional, why she’s still in pain about
why she hasn’t seen PT yet, why her doctor didn’t refer her or mention PT
yet. She’s rating her pain at a constant ten on ten, no no give there. After a long
conversation about the pain scale I got her to budge and say nine out of ten at
rest and ten at a ten with any movement that’s I could that’s all she would give
me. I’m already thinking this is a patient that would be difficult. Yeah and
she’s she was very emotional, very anxious afraid, she had a lot of
stiffness and pain in her elbow and wrist as well because even once the
sling was gone she sort of just braced her arm against her body. The exam was
really difficult she didn’t want to move at all she was very emotional.
I couldn’t get a lot out of her she was very hyper sensitive to light touch over
her traps all the way down to her elbow. We did a lot of talking about how that
is a you know not a normal reaction to light touch and how she’s just
sensitized with that. So initially there was very little I could do with
her so we started with some desensitization. We did light touch
different strokes I taught her husband how to do it with her at home. We did
isometrics to just sort of get her activating some muscles and and and we
did range of motion on the contralateral side and then I had her visualize moving
her sore side each time she was focused on we would do one thing and she’d say
yes but it still hurts why does this still hurt this isn’t normal.
I’ve I have a high pain tolerance I’ve had a lot of pain in my life this
is different. And I sort of had to dial her back from that each time as you know in
a higher volume clinic I get maybe 15 to 20 minutes with this person each session
and she required a lot of one-on-one and a lot of hands-on I couldn’t really
leave her to do anything because she wouldn’t do it or it would hurt too much
or whatever. So finally after a few weeks of this and some pain science I used
Greg Lehman’s cup analogy we talked about all the other factors that could be
contributing to her pain because now at this point she’s five and a half or more
months after her fracture which has you know been healed and and we talked about
tissue healing times and what’s normal for bones and normal for tissues. And she
was sort of buying into that a lot she wasn’t sleeping much because she was in
pain but also because she was afraid is how long as my arm gonna hurt? Is
it always gonna hurt? So she’d get very little sleep at night. She was very
focused on the incident she couldn’t even walk past her stairs and look at
them without thinking about it never mind walk down them she thought why
wasn’t the ice cleared? Why didn’t I step differently? Why did I
go out that morning? And she was just focused on this months later she
couldn’t stop thinking about it so I spent a lot of time telling her
your bone has healed it’s been five six months you’re fine this is you know she
had had other pain man and her regular physician tell her not
so much it’s in her head but it’s a little bit there’s no reason for her to
be hurting you’re fine there’s no reason and so I had to really
tread lightly because she what she needed for me was to be heard. And like
yes I’m experiencing this pain, yes it is real at the same time I’m trying to work
through how she can manage it. I ended up finding her some cognitive behavioral
therapy resources that she could go to locally and I talked to her about the
benefits of that with persistent pain. I think that came across as you need
therapy unfortunately, She she said she was gonna I know she said she was gonna
look into it you know each time we talked about the, hey look you can move
this much further now and or you can do this. One time she handed me a gift and
she reached out and handed it to me with her sore arm and she had more movement
than I had ever seen in the clinic and she didn’t even think about it and I
don’t think she was faking it I think it’s because she wasn’t thinking about
it. She wasn’t thinking I’m moving the arm. She’s like here I want to give you this. Did you mention that?
Yeah that I did I said look how far you just reached out and and she was oh yeah
well and it was sort of like well now it’s hurting and now it’s gonna be sore.
In any case I think her doctor told her you know go to PT for four weeks and
come back and see me and so she did and when she went back he ordered an MRI
which found a rotator cuff tear and he also ordered a CT because I guess he’s
thinking like this this long after and you know the x-rays showed healed. Turns
out not only was her fracture not healed it was displaced so she. And she needs
surgery mm-hmm. So she calls to tell me and cancel her
other visits and she was very sweet about it she wasn’t upset and like you
told me I was fine. Which I was that’s what I was thinking.
Right you could have been that could have gone really wrong. I could’ve gotten an earful. But I think that I spent so
much time with her she told me you’ve talked to me more and spent more time
with me than anyone else she really latched on to me even the first couple
even in your super busy caseload, Right? Like she even with that caseload and isn’t
that a sad state of affairs that I’m told that even you know getting 20
minutes with her I’m told oh you spend more
time with me. So I think we had a really strong therapeutic alliance and she
trusted me. You know so in the end it worked out good and she just wanted to
let me know cuz I think she felt too – that I was working so hard for her I would
want to know the solution – like hey what was this after all this she’s
crazy high level of pain. I don’t think you know that’s very well it wasn’t
healed fracture that still doesn’t explain constant ten out of ten no
matter what and all the emotion that goes along with it you know I think
those factors did still come into play you know she couldn’t even look at her
stairs. Yeah that’s there’s no easy solution for
that I mean someone who’s that traumatized essentially but CBT. But she does
need therapy she absolutely does. share she knows only does there’s such a stigma
associated with that and that’s no one wants to admit that not for pain, exactly
and so going forward I worried that she’ll you know not carry put as much
weight into the things we talked about and I think that she bought into because
she’s like oh no no it actually was still broken that it wasn’t all that
other stuff none of that matters. You know maybe she you know what maybe like
having that validation of the CT and the MRI also she had rotator cuff tear and
getting all this repaired maybe she feels a hundred percent better. So I was
thinking that too – like maybe this will be the thing like oh that’s all it was and
now if I’ve had surgery to fix me mm-hmm my air quotes fix me then you know you
know and I hope so and I you know I I don’t know how that’ll turn out because
I think also sometimes people with that high sensitivity and pain
catastrophizing don’t do well with surgery. no no and they’re coming out of
that not to mention she already hasn’t been moving her arm very much for five
to six months going for surgery with basically a tight capsule yeah yeah you
don’t think she’d be receptive to the study that Andrew reviewed recently on the
Journal of Common Sense that showed that placebo shoulder surgery did just as
well as, she probably wouldn’t have been receptive to that that. No, maybe
well she’d say for someone else but my CT shows I’ve got a piece of bone
floating here cause everyone’s special right? It’s not me I’m not the
20% person or the 10% we talked about that in our our chat last night with a
Modern Pain Education group and you know like 70 percent of people are gonna be
fine or whatever stat you want to show . But everyone always thinks, but I’m the 30% because everyone’s special
yeah well that’s, I mean I hope you find out
an update I know that um you’re going out with your co-workers so
maybe they’ll be able to tell you an update. Yeah I you know I’d like to kind
of hear how that ended up with her I think what it taught me was generally as
a clinician I try not to say in definites to talk in definites you know in
absolutes, it could be this it could be that. Because we don’t know you know even
imaging doesn’t tell us really exactly what’s going on but in this one instance
I was so sure I’m like you’re five months out you’re totally fine let’s
just talk this out of you, let’s just modify our thoughts, yeah just like that.
Yeah I’m just gonna talk it right out of you in twenty minutes yep, And that 20
minutes a couple times a week was this totally over do all your ruminating
thoughts you have. Exactly day in and day out even at night, Boy, someone like that I
just I feel for her you know, yeah she’s such a sweet lady
you know she’s bringing me gifts and and she was very grateful for the time I
spent with her. mm-hmm, If any of you guys out there actually have any studies cuz
Dana and I were wondering about this earlier today too you know. It was she
like this prior to her injury like a kind of
Debbie Downer that we were talking about or does does something that strong
traumatize someone to the point where they have the high fear avoidance only
afterward? I mean I haven’t I don’t know if I’ve ever read a study like that and
you haven’t either right? I do know that certain things like the best
predictor of a good outcome after total knee operation is not like strength a
range of motions one of things I always asked my course is at strength is range
of motion people I was guessing things like that prior function but it’s level
fear voidance prior to the surgery. So I think it’s been looked at in other
things you know maybe post for post-ops but yeah I mean I just everyone kind of
knows someone who’s in generally negative and what
and to that person when they finally get injured? Alright, it’s a chicken or the
egg yeah over the weekend in El Paso someone
actually told me it’s you know that’s a ridiculous question because like God
he’s like God made the chicken, God made a bunch of eggs and they hatched. That makes sense it makes sense
I’ve never heard it that way. So anyway thanks for coming and filling in for Andrew
again you’re a regular now. Make sure to subscribe, if you’d like this, rate of
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