Throughout my last prac in the outpatient setting i saw various examples of how different people and demographics respond to pain and how this can both positively and negatively influence their prognosis.
One example is a middle-aged male patient i saw following a lower limb muscle excision. This patient arrived in the outpatient clinic pushed in a wheelchair by his wife (the car being parked approx 50m away). This immediately drew my attention as the patient's inpatient notes stated that he was WBAT and should be progressed as quickly as possible (and was now 2 weeks out of surgery). Throughout the entire subjective and objective examination it was clear that the patient was not comfortable with the notion of pain and was doing everything in his power to avoid it. He refused to roll up his pants by himself or take his shoes and socks off because he "couldnt" and any his range of movement of initial examination was a total of 5degrees and was 10/10 pain in both directions which increased above 10/10 when i did it passively. These pain scores were very surprising to me as he pulled very few faces and didnt make any painful noise whilst moving, just casually stated it was maximum pain. Also, since the surgery he had not touched to foot down on the floor and spent the last week at home sitting down and keeping the leg as still as possible.
Getting to the point though, his unwillingness to comply with the movement program supplied by myself or the surgeon, because they were painful, were negatively affecting his progrosis as he had started to develop marked ankle joint stiffness. Also with this type or surgery, movement is required very quickly to avoid the fascial structures and scar tissue from adhering to each other and preventing movement long-term. So instead of a 4-6week complete healing period with minimal strength loses, he was looking at a significantly greater rehab period.
Following the initial treatment, i spoke in depth with various other members of staff about possible treatment strategies for this patient. We all came to the agreement that a very upfront and abrupt manner was needed when dealing with this patient. He needed to understand the consequences of his unwillingness to comply with our advice and that regaining movement needs to happen regardless of 1/10 pain or 10/10 pain.
I am unable to comment on the outcome of this patient since it was my last week on placement but i have heard that various different staff members have attempted to treat and educate this patient with varying degrees success.
So in conclusion, a patients response to pain can greatly affect the outcome of their rehabilitation program. Compared to the other post about the elderly generation doing too much activity with pain and hence causing detriment to their condition, there are some who cannot cope with pain and see it as BAD BAD BAD. Our manner and styles of education need to be changed dramatically in relation to the type of patient being dealt with.
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I had a patient similar to this, and I went in there thinking I was going to fix all his pain with all the hands on techniques we have learnt, but soon realised that wasn`t going to work at all. In the end i realised with patients like this that chronic pain is something far beyond simple. And also treatment of these people largely involves education and self-management, because your hands on techniques either make them worse, or they start to depend on physio and never actually take control of their problem. And you also end up being part psychologist to these people because they start pouring out all their life problems, and although it is not our place to treat this, we can still be available to listen. But I learnt how important it is to educate them on how chronic pain and fear of movement are a vicious cycle that needs to be broken. Very interesting cases.
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