This topic contains 6 replies, has 2 voices, and was last updated by Matthew Ellerbrock November 30, 2018 at 1:55 pm.
November 27, 2018 at 2:33 pm #3088
First order: 24 year old male (6 foot, 176 lb)
Location: Low back across beltline, down left leg posterior and anterior thigh
Quality: ache stiff low back occasionally sharp, the left leg symptoms are tingly numb
Intensity: 3.5 now, 4 avg, and 7 worst
Prov: sit on hard surface is the worst, working on hands knees doing projects, standing still for longer than 15 mins, extension of low back, laying on stomach
Pall: moving, walking, laying on back and twisting at waist
Onset: longer than 2 years, possible back injury while playing basketball had an extension injury
Course: constant now, but getting worse the past few months
Recreation: do it yourselfer, home projects construction type, basketball
No treatment, no imaging prior to our consultation
Strength and DTR normal lower extremity
SLR R 85 pulling to the knee mild with pos DF
SLR L 82 pull to knee mild with pos DF
SHF R 1/2 finger, medial thigh pulling mild
SHF L full medial thigh pulling mild
QLF 10012 no symptoms
KHE bil 12 inches with stretch anterior hip
SLPF palms on ground no symptoms (feels good)
DX: Possible pars defect lumbar spine, possible disc derangement with nerve root compromise, Adhesion noted R multifidi III L3-5, Longis L3L2 III, L L5S1 Multif III, L3 Longis III
Ordered plain films and they came back negative but the patient was not able to get the actual films for me to see yet. Should be here this week.
The patient is not super excited about going to a doctor for anything but his fiancee made him promise to get his back fixed because she is a super good woman apparently and doesn’t want a broken down 24 year old husband. One challenge in this case already is get him to understand how serious this is at this point. From a communication stand point I am on this, I just mention it as a side note.
Two treatments in and the patient reports feeling better for a day or two post treatment, but notes two odd things: 1. he is worse on the weekends and on monday almost every week. 2. He also cannot stay in bed very long as those days he tries to sleep in and is miserable and has to get up.
So a tuesday friday treatment his QLF went from 40 % to 90% and we have a little party as he ‘kinda’ feels better too. But then the weekend came and he was super sore yet. I explained the mechanism of the pain is most likely the disc and its still early.
So a couple questions~ He has really good motion and while its early, I am thinking pathology. He denies any provocative activity on the weekend.
My question is we have six more appointments scheduled and we are really doing great on the functional front. He has a huge deductible and doesnt want to get an MRI. I have changed my mind a lot and have pushed for an MRI so a patient ‘gets’ the big deal that it is. Is it wrong to tell him to show up and let us work the system and ultimately decide in a few weeks how to proceed?
I feel this is the best place for him to be, but if his movement gets to 100% and adhesion is gone, strength is good we really only have pathology left?November 27, 2018 at 3:32 pm #4740
This is a cool case, because you get to deal with the different flavors of communication. I agree his disc pathology is a big portion of symptoms, and needs to be imaged.
In the ROF videos part 1 and 2 videos in the communication section, Bill talks about having a magic wand to remove reducible blocks. If you were to remove all of the adhesion, and make him stronger what percentage of this kid’s problem do you think is irreducible block?
If it were me, and his irreducible pathology seemed to be at least 40-50% of the diagnosis, I would tie that to his symptoms and function, and also my rapport with him. If there is room to build more rapport and he doesn’t want to get the MRI right away, I would still put the request in with the imaging facility to get the ball rolling, and work on him for a couple more visits. “No matter what all of the adhesion has to be fixed. You also need this picture so we can see how bad your discs are damaged. When we fix all of the adhesion, it will be time to get the picture. It’s best if we do that now.” I would then continue to bring up this nasty disc injury and hop on the whiteboard until we were close to MMI. At least then he has been gearing up for it and hopefully has realized that he’s not all the way better because there’s more going on. At that point if he is resistent, then you have that discussion about how his deductible has nothing to do with the fact that he needs the picture, that neither of you want to participate in a failure, etc. The problem with this scenario is you give him leverage to believe that he has some case control. You don’t need to compromise with him. I would just ask him, “What do you think you need for your low back to be better?”
You could also go the opposite way and do a hard stop. “You have a disc injury, and it’s a big deal. The most important thing we do right now is get the MRI. I’m recommending against any further treatment whatsoever until we have this picture.”
I guess my question would be, what is it that you think he needs? Is it that he is money focused instead of problem focused and solution oriented? Is it that he is still deciding to trust you and needs more exposure to the process?
Asking questions to get him to become solution oriented is what I would do here. When people are stuck on price, then it comes down to just making a decision.November 28, 2018 at 9:56 am #4741
I guess my question would be, what is it that you think he needs?
My initial communication is that this is a big deal and that while his fiancee is making him come in, its not ‘normal’ to have this much back pain at his young age.. He agrees and is making his appointments, but it may be just personality but he grumbles about the process, making me think he isnt getting it. I agree and said no one wants to be hurt or in pain, but you have to be responsible for yourself and get it fixed.
Is it that he is money focused instead of problem focused and solution oriented?
He came in awhile back for a shoulder injury and at that time he stopped coming after being 90% better due to money.
Is it that he is still deciding to trust you and needs more exposure to the process?
He seems to trust the process (he had good results on his shoulder) and while the MRI would be great, my fear is that if he sees what he is up against he may just give up and realize if I cannot fix all of it lets just get surgery, etc. … That is where my communication needs to be ready to counter that process, even tougher when he passes all the tests and has minimal adhesion.November 28, 2018 at 10:45 am #4742
Seth Schultz, DCParticipant
One thing you can do is go back to your first order data and ask him about his provocative. Wait and let him answer those questions, even if it takes 30 seconds. He needs to hear himself say that. That information can always be used to your advantage. Most times patients are so focused on still being in pain they forget where they were.
To go back to the initial post “1. he is worse on the weekends and on monday almost every week. 2. He also cannot stay in bed very long as those days he tries to sleep in and is miserable and has to get up.” Even though he may not be doing anything provocative, if he’s adding any sort of excess load to his spine it’s creating inflammation and flaring him up. He’s probably more active during the weekend and may not be aware of the stresses he’s adding to his back. I would really drill down on his typical weekend and see if there’s anything you can tease out.
So a tuesday friday treatment his QLF went from 40 % to 90% and we have a little party as he ‘kinda’ feels better too. But then the weekend came and he was super sore yet. I explained the mechanism of the pain is most likely the disc and its still early. That’s a massive jump in function. Unloading the spine that much that quick could create some temporary instability as those tissues have not moved that well in years. Let him know when you have big jumps like that, he’s probably going to be sore as his back needs time to accommodate to the new function you’ve given him. He’s young so his disc are more than likely really well hydrated, so if he does have a disc derangement any sort of inflammatory state will cause him to be sore.
Is it wrong to tell him to show up and let us work the system and ultimately decide in a few weeks how to proceed? Absolutely not, you are his best option. Disc injuries take time to heal and he needs to know that. You’d be doing him a disservice if you didn’t continue treatment. 24 is young for surgery and you know what the other end of that looks like. He’ll be back in your office anyways. It’d be worth it to show him that picture as well. You are going to fight like hell to keep him out of surgery by keeping his adhesion gone, maintaining full functional testing, and strengthening the surrounding tissues.November 28, 2018 at 5:19 pm #4743
I agree with Seth regarding points of communication. To answer your question, I would get him the image. His opinion on wanting the image is irrelevant to the fact that he needs it. You’re doing your job by getting exactly what he needs. It’s up to him to follow through with it, because his health depends on it. Facts over feelings.
In a coaching call a couple years back I was talking with Bill about how often to image. I remember him saying that 20% of the time, an MRI should come back negative for any major findings. If I’m not certain we’re getting a picture at the beginning of care, I definitely know by visit 4 if symptoms and function aren’t matching up. If you think pathology is the hang up with symptoms, and function is improving, I would put the request in.November 29, 2018 at 12:16 pm #4744
Seth Schultz, DCParticipant
Exactly what Drew said. This guy is young and if you can catch a significant pathology early that’s top level doctoring. Something you know he won’t get anywhere else.November 30, 2018 at 1:55 pm #4745
Thanks to you all, great advice. I saw him this morning. His added that his worst complaint is standing in church.
I said a healthy back doesnt hurt when you stand in church, and your 24, I know you want a healthy back, right?”
“We can make your back healthy but its not quick and its not cheap, is that ok?”
We agree to finish the first 8 appts then see where he is pain wise, then he is good with MRI. So sorta a deal and meeting him where he is at.
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