Mrs P. is a 35 year old mother of two lovely children. During her second pregnancy around four months gestation she developed bilateral lateral hip pain. The pain eased post labour but returned four months later and has never since resolved.
Since mid 2012 her symptoms have gradually worsened and on presenting to physiotherapy she reported constant bilateral lateral hip pain, lower back pain, aching through both thighs and pins and needles throughout the entire leg. Her symptoms were not in a dermatomal distribution and didn't follow a typical clinical pattern for musculoskeletal pain.
Her resting pain levels were often as high as 8/10 and most aggravated in side lying. Mrs P. was unable to find a position of comfort for her pain. Despite her high pain levels Mrs P. tried to complete her normal daily tasks as best as possible, all the while struggling to manage her pain. In time this became very taxing and impacted on her emotional well being, sleep, and ability to complete her role as both a working-mother and wife.
Past treatment had involved a short period of manual therapy around the hips and pelvis with an Osteopath (providing short term relief) and a pilates program focussing on pelvic stability and core strength (which she felt was making her symptoms worse).
A recent CT lumbar spine reported on mild lumbar spondylosis and broad based central disc protrusion at the level of L5/S1. These results didn't seem to correlate with the presenting symptoms.
The physical examination
At the conclusion of the subjective examination I was perplexed by the onset, nature and behaviour of Mrs P's symptoms and was yet to generate a list of possible hypotheses which could be investigated further in the physical examination.
Instead I had to just look at it all, with no particular pattern or reasoning, purely to be open minded about what I might find and not allow myself to be limited by pattern-recognition. The response to manual therapy was atypical for back pain and the increased pain after pilates made me wonder if compression/stabilisation was not what she needed to get better. Both these suspicions were clarified further in the physical examination.
- Standing posture - increased muscle activity in gluteus maximus, TFL and vastus lateralis.
- Single leg stance - increased pain bilaterally and was worse with all muscle augmentations and slightly better with therapist pressure over the hips.
- ASLR was heavy and painful bilaterally, again worse with muscle activation and better with lateral hip compression.
- SLR limited at 30 degrees bilaterally and eased with cervical flexion.
- Prone knee bend 40 degrees knee flexion P2 and ease with cervical extension.
- Unable to prone straight leg raise due to pain over the lateral hips.
- Hypersensitive to light touch throughout the lumbopelvic region.
- Pain with sacral PA and post thigh thrust but no increased movement.
- Didn't look at lumbar AROM Day 1.
- Neurological examination was unremarkable.
- And that is an all over the place assessment of SIJ, hip, lx and neurodynamics and not enough of anything to clear an area nor enough to clearly implicate an area..... and it left me stumped.
So I was considering altered neurodynamics, overactivity and excessive force closure through the pelvic girdle and yet there was an inability to load transfer... the pieces didn't fit.
Day 1 treatment was lumbar rotation stretches and knee hip flexion stretches (don't ask me why I chose that - I think I was worried about flaring her up with further manual therapy). Both exercises and the excessive assessment aggravated her symptoms significantly.
The fact is I didn't complete my assessment thoroughly enough due to severity and unknown irritability and because I wasn't being lead by a list of hypotheses, I was simply running through a range of tests. To my detriment, by the end of day 1 I was no closer to developing a hypothesis.
And despite not having a clear answer for Mrs P. (which I honestly explained to her) and despite being terribly sore following our assessment, she returned more confident and positive that at least I was trying hard to find a solution. One thing I knew I could offer was a systematic assessment of the lumbopelvic region and we agreed to start with that and just see what we found.
Day 2... start again...
- Every test above was exactly the same, which confirmed that the abnormal response was at least consistent and reliable for this patient.
- Lumbar active range of movement (new) revealed restricted flexion to mid shins, extension to end of range and lateral flexion to mid thigh (P2). This didn't provide too much more information or clarity to the problem.
- The mini treatment was what started to link the asterisks.
- Day 2 mini treatment and treatment involved GR III - left sided PA over L23 L34 L45 with the aim of desensiting the lumbar spine to palpation. On reassessment flexion increased to floor, lateral flexion to knees, SLS was painfree, PPT and sacral thrust painfree and ASLR less painful. That is to say, they all changed and with only a small amount of generalised desensitising treatment.
And this confirmed one thing for me..... assess and treat the spine!
After completing my masters degree the one thing I knew was my responsibility as a primary care practitioner is to assess and treat the spine. I didn't do this day 1 and like others prior to me, I missed the underlying driving mechanism.
So the initial phase of treatment involved gently increasing the grade of lumbar mobilisation and focussing on desensitising the lumbar spine, gradually increasing range of movement, and monitoring the effect and nature of change across a range of asterisk signs.
After two treatments, Mrs P. reported that her pain was 30% better, less constant, there were no symptoms in the legs, and she was able to fall asleep in side lying. A good improvement given the chronicity and severity of her symptoms.
And from there it just continued to improve.
After six weeks (of weekly reviews) Mrs P reported that she was 50% better overall. Her goals for further treatment were to be able to walk without pain, sleep without pain and complete normal activities of daily living. When further questioned what was the limiting factor to these activities improving, she responded "I'm worried about becoming paranoid about the pain and being hypervigilant about what I can and can't do".
This isn't something we often hear our patients say and immediately demonstrates a level of trust to confide such fears in me, and also a level of self-reflection about the barriers to recovery. And so I responded "We have outcome measures which can evaluate the way you conceptualise and think about your problem. Would you be interested in completing them to see if we can understand these worries a bit further?"
After further review of the literature I realised that many of the standard outcome measures I implement with patients to evaluate and measure pain and disability don't have the capacity to evaluate the psychological aspects of my patient's problem.
In this case specifically, Mrs P. had verbally indicated her fear towards exercise and movement, her fear towards therapy and her fear towards her activities of daily living (ADLS) aggravating her pain.
I used the following three outcome measures to evaluate her fear-avoidance, kinesiophobia and pain catastrophization. All are separate components of the cognitive aspects of the 'psycho' part of the biopsychosocial model for pain.
- Fear-Avoidance Beliefs Questionnaire (FABQ)
- Fear-avoidance about physical activity 11/30
- fear-avoidance about work 2/66
- Overall score 13/96, which was well below the cut off score of > 13 for the physical activity component and > 34 for the work component.
- Pain Catastrophizing Scale (PCS-EN)
- Overall score of 12/52 which is well below the cut off rate of >30.
- Further psychometric properties of the PCS-EN can be found in the user manual.
- Tampa Scale for Kinesiophobia
- Overall score of 44/68 which is above the cut off score of 37.
It was evident from these three different cognitive measures that Mrs P. had a high level of kinesiophobia related to her chronic pain.
Kinesiophobia is defined as “an irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury” (Kori et al., 1990).
To delve further into the results of the Tampa Scale for Kinesiophobia questionnaire we highlighted the statements which she had marked as agree/strongly agree and discussed each sentence individually. The following topics would drawn from the questionnaire and used to tailor a pain-education session to educate Mrs P. about her pain and belief system.
- "I'm afraid that I might injure myself if I exercise."
- "If I were to try overcome it, my pain would increase."
- "Pain always means I have injured my body."
- "I am afraid that I might injure myself accidentally."
- "Simply being careful that I do not make any unnecessary movements is the safest thing I can do to prevent my pain from worsening."
- "Pain lets me know when to stop exercising so that I don't injure myself."
Changes in treatment direction.
Based on the information gained from these questionnaires both myself and the patient were empowered with the tools we needed to educate and re-conceptualise Mrs P's. knowledge and beliefs about her pain.
Further to our in-room discussions, I recommended for Mrs P. to read parts 1, 2, and 4 of explain pain which reinforced and expanded on our conversations.
After breaking down and re-conceptualising the cognitive component of her pain, Mrs P. has returned to a functional rehabilitation program at her local gym 3-4 days a week and begun to exposure herself to ADLs which previously aggravated her pain. All of this has been achieved without further aggravation in her symptoms. Surprised by her level of capability, Mrs P. has been encouraged and more confident to try new movements and activities. This in turn has lead to an overflow to the emotional/affected aspects of her chronic pain problem, and lead to improvements in her sleep, mood, happiness and relationships with loved ones.
In no means have we cured Mrs P. of her pain, but her level of pain and associated disability has significantly reduced to the level that she can cope more independently. It was important to remember that we weren't looking for a quick fix or cure, more we were hunting for the reasons behind treatment failing in the past. And after long and open discussions with my patient decided to explore the 'psychological' component held within the 'biopsychosocial' model for patient-centred care. It was empowering experience for both of us.
Mrs P. continues to receive manual therapy every 10-14 days and has progressed steadily at the gym, all the while we continue to be open to discuss and address the cognitive/affective aspects of her condition. Ten weeks after beginning treatment, Mrs P. is 70% better in her pain levels, disability and level of function. We are both very happy with this improvement.
I learnt that there are ways we can measure and evaluate our patient's belief systems and help them to reconceptualise their pain. Mrs P. learnt that knowledge can help overcome fear of movement and that it is imperative we address the way we think as well as the way we move. A positive step forward in the journey of recovery from a difficult, long-term chronic lower back pain problem.