This morning I reassessed a patient of mine whom I’m going to refer to as “Emma” – and I’d like to share with you some of the background to her presentation initially – and the single most influential factor that shaped her beliefs that she wasn’t “broken.”Emma had presented 8 weeks ago with acute, constant neck pain, and variable right upper limb pain, pins and needles and numbness following a work-related lifting injury sustained one week prior. She also complained of right temporal headaches which seamingly were getting worse each day since the injury.
When I initially assessed her, I was of the opinion she physically demonstrated symptoms consistent with C7 somatic nerve root irritation, but not true radiculopathy. I relayed to her that this would reasonably explain her neck and arms symptoms.Additionally she appeared have significant elements of postural guarding in the form of shoulder shrugging which appeared to be an inadvertent attempt to limit her arms symptoms – unfortunately though loading her upper cervical structures concurrently. I relayed to her that this would explain the cervicogenic headache symptoms she was reporting.
Using simple language, I took a significant amount of time to reassure her as to why her symptoms made sense, how long it typically takes to settle, and help her accept that what she was enduring wasn’t something more sinister than it seemed.I then focused on mapping out essentially what elements she could do about it to gradually overcome same and return to her normal routine including work. I answered any other questions Emma had, before we went through exercises and stretches that were appropriate, as well as pacing and ergonomic strategies to manage her day to day routine.At the end of our consultation Emma angst towards her presentation appeared to have settled significantly, and we mapped out a treatment plan with included short, medium and end stage goals to get her back to full function.
She left my review empowered and understanding what she needed to do.Unfortunately it all went south in an instant when she re-attended her GP for medical certification, and they insisted she get an MRI as she could have disc compression!!The manner with which this was then relayed to Emma reversed all gains we had made in our initial consultation – and the end product she was off for a Neurosurgical review to discuss surgical management.For several weeks thereafter we struggled to make gains with Emma, and she deconditioned significantly – as she was so focused on the language relayed to her by her GP, compounded by speaking to friends and family (whom had “similar injuries”), online research etc.
I reached out to the Neurosurgeon (whom fortunately I knew well) and detailed my history of management with Emma considering all of these factors. The Neurosurgeon attained the MRI and the findings confirmed C7 disc protrusion with potential abutting of same right sided nerve.The Neurosurgeon then took the time to explain and reaffirm everything Emma and I had discussed several weeks prior – that there were no red flags, her symptoms would settle with conservative rehabilitation, and that it was prudent for her to return to normal daily activity including work (within her limits) as soon as possible.This had the identical effect my initial consult had done so previously with Emma 4 weeks prior.
She re-represented to mea week thereafter with significant symptom reduction, greater confidence with pacing and understanding her symptoms, as well as improved focus on the rehabilitation pathway to functional recovery.
Take home message? What we say to patients at initial consultation (especially about imaging) can have more bearing on their rehabilitation outcome than any other factor.The acronym “VOMIT” stands for Victims of Medical Imaging Technology – and in Emma’s case this couldn’t be more true.
For more information on VOMIT refer to Dr Kal Fried’s websites:http://www.kalfried.com.au/VOMIT.php
#painmanagement #paineducation #educationandreassurance #focusonfunction #normalscanfindings #languageiseverything