Advice on difficult case

[PT2Bee]

Hello everyone, as the title states I had an eval that has stumped me and apparently every other healthcare practitioner this pt has seen.

Pt was initially injured years ago when someone he was carrying a heavy object with unexpectedly let go, which put the whole force of the object on the pt. The pt said the force felt "straight down", so this leads me to believe it was similar to a compression/crush type injury. Pt said his tailbone was extremely sore and the next morning he woke up and one of his legs was numb from tailbone to knee. Xrays, MRIs, basically everything has been negative for vertebral fx, spinal cord injury and nerve damage. Pt has been in excruciating pain for decades. Pt said he fell 3 years ago which increased symptoms.

Lumbar, SIJ and coccyx were all hypomobile with sig increase in symptoms. Worked on him for about half hr trying joint mobs and STM, nothing relieved his symptoms. He walks with sig forward flexed posture. Pt has been to almost every doctor you can think of and has had exploratory surgery. Nothing.

Bottom line: I'm stumped. Anyone seen anything like this?

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[jblil]

Unilateral symptoms of numbness & excruciating pain + walking with forward-flexed posture: for me, all this points to nerve involvement, possibly because of a decreased intervertebral foramen. How was his Lasegue test? You mention that he has no spinal cord injury, but did he have a nerve conduction velocity test done?

 

[jesspt]

Nocioception is neither necessary or sufficient to create pain.

 

[Fiveoboy11]

Hello everyone, as the title states I had an eval that has stumped me and apparently every other healthcare practitioner this pt has seen.

Pt was initially injured years ago when someone he was carrying a heavy object with unexpectedly let go, which put the whole force of the object on the pt. The pt said the force felt "straight down", so this leads me to believe it was similar to a compression/crush type injury. Pt said his tailbone was extremely sore and the next morning he woke up and one of his legs was numb from tailbone to knee. Xrays, MRIs, basically everything has been negative for vertebral fx, spinal cord injury and nerve damage. Pt has been in excruciating pain for decades. Pt said he fell 3 years ago which increased symptoms.

Lumbar, SIJ and coccyx were all hypomobile with sig increase in symptoms. Worked on him for about half hr trying joint mobs and STM, nothing relieved his symptoms. He walks with sig forward flexed posture. Pt has been to almost every doctor you can think of and has had exploratory surgery. Nothing.

Bottom line: I'm stumped. Anyone seen anything like this?

Just wondering if this individual has any mental conditions diagnosed or that you're suspicious of? Any secondary gain issues? Do you think he is "playing" you? Normal sensation/myotome/DTRs? He walks slumped, can he lay prone, POE, prone press up, etc? Does he walk to his car "normal"? What's his explanation why he walks slumped? Do you think aquatic might help him? Does he still have/get N/T? If not I'm not surprised at all by no findings on imaging or exploratory surgery. As you know many people have pain without findings on imaging and many with findings have no symptoms. If he still gets parenthesis could it be some type of trigger point referral? Is he on medications? Maybe he has some type of hypersensitivity or his original injury was very traumatizing?

 

[PT2Bee]

Just wondering if this individual has any mental conditions diagnosed or that you're suspicious of? Any secondary gain issues? Do you think he is "playing" you? Normal sensation/myotome/DTRs? He walks slumped, can he lay prone, POE, prone press up, etc? Does he walk to his car "normal"? What's his explanation why he walks slumped? Do you think aquatic might help him? Does he still have/get N/T? If not I'm not surprised at all by no findings on imaging or exploratory surgery. As you know many people have pain without findings on imaging and many with findings have no symptoms. If he still gets parenthesis could it be some type of trigger point referral? Is he on medications? Maybe he has some type of hypersensitivity or his original injury was very traumatizing?

Thanks for the replies

No mental conditions I'm aware of. Strength decreased bilaterally. The only positions he could tolerate were sitting or sidelying for short periods of time. Sit to stand transfer was dicey too, enough to make me feel nervous for him to do it independently at home. He says it hurts his tailbone a ton to transfer from sit to stand. He is having an EMG and will most likely have the results by our next apt. Funny you say that about walking to his car, I was wondering how he drives and I got distracted and forgot to ask that question, go figure. He's on a litany of medications including muscle relaxants. I'm wondering if his coccyx was somehow damaged by the initial injury and it wasn't caught and has been referring symptoms and causing compensatory changes. I'm not sure what he would have to gain from playing me because it's been 25 years since the injury. If nothing is found from the EMG I think I am just going to refer him to a pelvic floor pt who is better qualified to take a closer look at pelvic floor and the coccyx because at this point I think he needs something more specified than OP. The entire apt he was saying how he was disappointed that no one ever payed attention the the coccyx and thanked me numerous times for even exploring it. Don't know what to think.

 

[Azimuthal]

Has he seen a pain doc, been through a pain course/ class?

 

[Fiveoboy11]

Thanks for the replies

No mental conditions I'm aware of. Strength decreased bilaterally. The only positions he could tolerate were sitting or sidelying for short periods of time. Sit to stand transfer was dicey too, enough to make me feel nervous for him to do it independently at home. He says it hurts his tailbone a ton to transfer from sit to stand. He is having an EMG and will most likely have the results by our next apt. Funny you say that about walking to his car, I was wondering how he drives and I got distracted and forgot to ask that question, go figure. He's on a litany of medications including muscle relaxants. I'm wondering if his coccyx was somehow damaged by the initial injury and it wasn't caught and has been referring symptoms and causing compensatory changes. I'm not sure what he would have to gain from playing me because it's been 25 years since the injury. If nothing is found from the EMG I think I am just going to refer him to a pelvic floor pt who is better qualified to take a closer look at pelvic floor and the coccyx because at this point I think he needs something more specified than OP. The entire apt he was saying how he was disappointed that no one ever payed attention the the coccyx and thanked me numerous times for even exploring it. Don't know what to think.

Sounds like you're on top of it and doing a good job to me. So many issues here probably. I wonder if he "believes" in you. Or I wonder if he's interpreted past dealings with healthcare providers as being pawners. But then again maybe he'd get attached to you or something if you kept him on your caseload? I wonder how compliant he's been in the past with recommendations? Did he lay in bed for a year after his initial injury? Did the referring physician promise to "do something else" if "PT doesn't work"? What's his attitude towards physical therapy, does he think it's going to help/harm/indifferent? Weakness as you know could be d/t pain + relative immobility over extended period of time. Sounds like maybe he's afraid to move, as in fear avoidance behavior or failure to recover from the injury as the average person would then the onset of hypersensitivity. At this point, even if the original injury was isolated to the tailbone, it doesn't sound like it is anymore. So, I don't know that primarily isolated treatment would be the way to go, but maybe I'm wrong. Some people have very poor coping when an injury happens to them and they can't deal with it and move on and so it gets far worse in time than it would have in the average person (who would've simply resumed ADL's as tolerated, and walked). I honestly doubt he's had a "missed" diagnosis of some isolated problem. Sorry so much rambling and I know you're aware of all these things...

 

[jesspt]

Thanks for the replies

No mental conditions I'm aware of. Strength decreased bilaterally. The only positions he could tolerate were sitting or sidelying for short periods of time. Sit to stand transfer was dicey too, enough to make me feel nervous for him to do it independently at home. He says it hurts his tailbone a ton to transfer from sit to stand. He is having an EMG and will most likely have the results by our next apt. Funny you say that about walking to his car, I was wondering how he drives and I got distracted and forgot to ask that question, go figure. He's on a litany of medications including muscle relaxants. I'm wondering if his coccyx was somehow damaged by the initial injury and it wasn't caught and has been referring symptoms and causing compensatory changes. I'm not sure what he would have to gain from playing me because it's been 25 years since the injury. If nothing is found from the EMG I think I am just going to refer him to a pelvic floor pt who is better qualified to take a closer look at pelvic floor and the coccyx because at this point I think he needs something more specified than OP. The entire apt he was saying how he was disappointed that no one ever payed attention the the coccyx and thanked me numerous times for even exploring it. Don't know what to think.

"When the Primary Complaint is Pain, the Treatment of Pain Should be Primary"
~ Barrett Dorko PT

You seem to be looking for "things" to treat. Pain is an output of the brain - how about starting there?

If you're going to help this patient, I think you're going to need to brush up on some therapeutic neuroscience education, or some work from Butler and Mosely.

 

[Moose A Moose]

Sounds like neuropathy/radiculopathy. When was the last time your patient went for an MRI? If its been years, I'd say it's time for a follow-up.

Referral for limbo-sacral/pelvic OMT wouldn't hurt either

 

[jesspt]

Things to consider:
How accurate do you think you assessment of SIJ and coccyx mobility is considering that the sacrococcygeal joint is ankylosed and the SIJ is usually ankylosed in males in our mid-fifties?

If he has pain all the time, do you think looking at ways that he positions himself to drive his car will be particularly fruitful?

Recommendations:

Give him this questionnaire - The Central Sensitization Index. Look here to learn more about cut off scores for patients whose pain is being contributed to by Central Sensitization. Look at the attached to better understand what Central Sensitization is.

Consider providing him some YouTube resources re: pain science education if you are unfamiliar. If you are unfamiliar, you should watch them too. Here are a few to start with:

• 5 Minute Primer on Pain
• Why Things Hurt

 

[PT2Bee]

Thanks for the responses everyone. I do have the Why Do I Hurt book by Louw so I will bring that in with me tomorrow. I have a feeling I'll have to tackle the "so do you think it's just all in my head?!" mindset with this one. It seems more and more likely that he's just been in this hypersensitive/alarm state for the past decade and he perceives everything to hurt. I'll update you all in a week or so!

 

[jesspt]

Thanks for the responses everyone. I do have the Why Do I Hurt book by Louw so I will bring that in with me tomorrow. I have a feeling I'll have to tackle the "so do you think it's just all in my head?!" mindset with this one. It seems more and more likely that he's just been in this hypersensitive/alarm state for the past decade and he perceives everything to hurt. I'll update you all in a week or so!

Any update?

 

[noyceguy]

Hello everyone, as the title states I had an eval that has stumped me and apparently every other healthcare practitioner this pt has seen.

Pt was initially injured years ago when someone he was carrying a heavy object with unexpectedly let go, which put the whole force of the object on the pt. The pt said the force felt "straight down", so this leads me to believe it was similar to a compression/crush type injury. Pt said his tailbone was extremely sore and the next morning he woke up and one of his legs was numb from tailbone to knee. Xrays, MRIs, basically everything has been negative for vertebral fx, spinal cord injury and nerve damage. Pt has been in excruciating pain for decades. Pt said he fell 3 years ago which increased symptoms.

Lumbar, SIJ and coccyx were all hypomobile with sig increase in symptoms. Worked on him for about half hr trying joint mobs and STM, nothing relieved his symptoms. He walks with sig forward flexed posture. Pt has been to almost every doctor you can think of and has had exploratory surgery. Nothing.

Bottom line: I'm stumped. Anyone seen anything like this?

Chronic pain patients are a treatment black hole. Don't spend a lot of time trying to figure out what is wrong with this patient. Give him a good HEP and send him to pain medicine and treat the next patient, who you may be able to actually help.

 

[PT2Bee]

So update, last apt pt told me he was basically coming to PT for his social security benefits. Gave him the option of referring to pelvic health pt to further explore any coccyx involvement. Immediately declined stating he was uncomfortable and didn't want anyone near that area. Gave him the central sensitization questionnaire and he was pretty pissed because he though I presumed he was faking his pain. Explained what it really meant and seemed to understand more. Basically he doesn't want to try anything outside of the box and doesn't believe PT will help. So I'm doing the best I can with ther ex as he only tolerates sidelying... I expect him to drop off the schedule in a few weeks.

 

[jesspt]

Chronic pain patients are a treatment black hole. Don't spend a lot of time trying to figure out what is wrong with this patient. Give him a good HEP and send him to pain medicine and treat the next patient, who you may be able to actually help.

What's a good HEP for a patient that says that "everything hurts."?

 

[jesspt]

So update, last apt pt told me he was basically coming to PT for his social security benefits. Gave him the option of referring to pelvic health pt to further explore any coccyx involvement. Immediately declined stating he was uncomfortable and didn't want anyone near that area. Gave him the central sensitization questionnaire and he was pretty pissed because he though I presumed he was faking his pain. Explained what it really meant and seemed to understand more. Basically he doesn't want to try anything outside of the box and doesn't believe PT will help. So I'm doing the best I can with ther ex as he only tolerates sidelying... I expect him to drop off the schedule in a few weeks.

So, did his score exceed the cutoff?

And, if you're not changing his symptoms positively, why don't you d/c him or refer to another healthcare professional?

 

[PT2Bee]

So, did his score exceed the cutoff?

And, if you're not changing his symptoms positively, why don't you d/c him or refer to another healthcare professional?

Nope.

He refuses to be referred. Honestly, he's been to every healthcare provider you can name and he says he's sick of being shuffled around with no results. I can get that. EMG results came back as negative for nerve damage. I think he's hoping for a quick cure or answer and if that doesn't come he gets frustrated easily. I feel like 2 visits of PT isn't really giving it a fair shot, but he was getting slightly combative after discussing the EMG (not with me specifically, just the situation in general and how he can't get SS benefits). I'm sure discharge will happen within the next visit or 2 as I am not able to offer him more than STM and table exercises, which offer minimal short term relief.

 

[PTAwesome]

Chronic pain patients are a treatment black hole. Don't spend a lot of time trying to figure out what is wrong with this patient. Give him a good HEP and send him to pain medicine and treat the next patient, who you may be able to actually help.

I don't have much to add to this conversation, but as a chronic pain patient who was helped exponentially by the diligent effort and education provided by physical therapists who cared to keep trying, I take great issue with your advice and hope that others will not take it as direction on how to practice as PTs/PTAs nor as a barometer of what chronic pain patients can expect from their PTs/PTAs as they seek help.

 

[Andeve33]

I don't have much to add to this conversation, but as a chronic pain patient who was helped exponentially by the diligent effort and education provided by physical therapists who cared to keep trying, I take great issue with your advice and hope that others will not take it as direction on how to practice as PTs/PTAs nor as a barometer of what chronic pain patients can expect from their PTs/PTAs as they seek help.

Totally agree with you!