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Complicated Patient
771 Plays2 years ago
Josh and Miranda talk through a complicated patient not only from a physiological stand point but from a psychosocial.
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Transcript
Introduction of Complex Patient Case
00:00:08
Speaker
Hi, I'm Josh McDonald. And I'm Brandon Materi, and we are Ham Therapy Academy.
00:00:13
Speaker
We're just having a little different here on this one. We're gonna do a little kind of case study on a patient that we have in my clinic that's a super big challenge. We have a relatively new to hand therapist working with this patient. She and I both treat the patient kind of alternating and it's a really kind of complicated situation and it's just tough to feel like we're making any sense of progress with this patient. So we thought we'd spend some time kind of sharing this and see if maybe you can gain something from it with your caseload.
Patient's Injury and Initial Challenges
00:00:39
Speaker
Yeah. So what, um, what was this patient's injury kind of tell us the history? Yeah, real super quick. Um, patient had a fall at work, um, land on an outstretched hand, had a distal radius fracture that has actually done very well as far as the fracture healing goes, but she began to develop lots and lots of finger pain and stiffness she has since developed. And this was almost a year ago. She came to us at like the nine month mark,
00:01:04
Speaker
because there had been some delay in sending her. She went to a general PT clinic that I know, and they kind of deferred and referred her to me. So she's been
Undiagnosed Pain and Possible CRPS
00:01:11
Speaker
with us for maybe four of the last 12 months since this injury, but has really developed a lot of arm and neck pain that could be described as CRPS, but without the boronia edema, without the hair growth, without the whole pseudomotor stuff. So really more just like this hypersensitive pain thing going on. And so she had a plate
00:01:33
Speaker
Yes, she had ORIF and that went all very well. She had some early problems with pain to her neck and shoulder and has had a total now of eight MRIs and she has bounced from a neurologist to an orthopedic shoulder doctor to a spine doctor.
00:01:52
Speaker
And
Pain Management and Cultural Barriers
00:01:53
Speaker
no one can tell her why she has this significant pain that will start at her neck, radiate all the way down her arm, and why her fingers are in not full extension, but mere full extension and stuck. And she can move them any attempt at passive range of motion or even just like light handling of her hand or arm.
00:02:13
Speaker
has significant pain. She's got nearly full wrist flexion and extension, supination, pronation, and wrist mobility, but her fingers, not so much thumb, but her fingers are stuck and highly painful, as well as her whole neck, shoulder complex are super painful. And did they release her median nerve?
00:02:33
Speaker
No, they did not release median nerve at the time of the surgery. They have not pursued yet options for like a nerve block as if it were a CRPS. They've talked about doing, so someone at one of her MRIs said, one of the doctors said that she was a candidate for a spinal fusion C2 through five because of compression there. She didn't want to sign on to that because they were like, I think that's it, but we'll do the surgery and see if that helps. That's kind of a rough diagnostic procedure to go through. So she is,
00:03:03
Speaker
Kind of at a point where she is just mentally exhausted from all of this. There is a language barrier. She comes with an interpreter because she is from Mexico, and so she only speaks Spanish.
Diagnostic Dilemmas: Psychosocial or Median Nerve?
00:03:11
Speaker
I speak moderate to poor Spanish, and so we still use the translator a lot for communication. But she is at wit's end, and we are trying really hard to ease the tension that she has with the medical system that we become weekly representatives of.
00:03:32
Speaker
Yeah, that sounds like a very tough case. You almost wonder like, are you, like for me, I would always be trying to identify what, what is the cause of this? Is it psychosocial? Is it really a problem with the median nerve? You know, so many times with those distal radius fractures, if the median nerve isn't addressed, then they do present with that weird CRPS type pain or, you know, what is exactly going on or what is, why is this going on for so long, right?
Inconsistent Pain Reactions: Real or Psychosomatic?
00:03:59
Speaker
Yeah, and in our analytical minds in this biomechanical model of hand therapy that relies heavily on biomechanical, wants to check off boxes or cross things off and do this process of elimination and say, you know, is this patient malingering because it's a work based injury? Are they making this up? And I really don't think she is. She has very real responses of pain.
00:04:19
Speaker
it's inconsistent i'll be doing some soft tissue like light touch stuff just desensitization time and be chatting with her and out of no where she'll have a major when response to talk about pain that day so very genuine appearing responses is this a psychosomatic in in that is this something that is.
00:04:38
Speaker
real perception of pain, but not from the sensory receptor level. And it's hard to tell if that's the case. Is it an actual physiological nerve compression at median nerve? Well, she has pain up at the cervical vertebrae. And so we're dealing with this thing where we've been seeing her for a while and we are not after lots of testing and
00:04:58
Speaker
Sometimes provocative testing, sometimes just trialing different things.
Handling Stress with Non-responsive Patients
00:05:01
Speaker
She'll have what we call splinter skills. Well, she'll be able to do something. Something's great. She can do stress loading through a brush at the tabletop really well. She'll talk about, hey, I can scrub the walls. This is too easy. But then when I ask her to pick up foam cubes, she says, I can't do that. It's too painful, and I can't manage that. Really light foam cubes where we're not reaching at all. So splinter skills, and it's been very hard to identify how are we going to help her
00:05:26
Speaker
whether it's on an individual diagnostic level or just in general, how are we going to help you play with your grandkids better kind of thing? Yeah, and I think when you have patients like these that you can't figure out or you don't know, right? Because we can't explain everything, even though we like to try, right? We want to understand everything. Sometimes we can't. And I think even as a practitioner, these patients can be exhausting, right? Because you're trying everything and they're still not
00:05:52
Speaker
getting better or they're not responding to what would traditionally work. So I guess my question
Cultural Influences on Therapy Perception
00:05:57
Speaker
is for you is how do you manage that, I don't know if you want to say stress level on yourself with these patients? And that's something that's a great question because I'm really working on that with my staff member that's dealing, like every Friday, we'll debrief on this patient because I saw the Monday she sees them Thursday.
00:06:17
Speaker
And I'll say, you have to not internalize that. And you have to say, we're trying, we're doing the best we can. Are we doing everything we possibly could? If that's the case, we're still trying, but I need to not let that go home with me and not let that become a point where like, I'm frustrated that I can't solve this, or I'm frustrated at the patient because they're not
00:06:40
Speaker
playing along, right? Like they're not getting fixed and that's their fault. Sometimes we don't have the answers. This patient also has social and family tubs pulling her away from solutions we may be presenting. She's from Mexico, so she has family members telling her like,
00:06:56
Speaker
the american medical system is failing you and i kinda think it is you need to go back to mexico and use their medical system she said therapy mexico would be better wouldn't be uncomfortable be painful like this is all this is horrible and worse and and i kinda know that the mexican therapy system and i don't think it's.
00:07:13
Speaker
As good as a kind of a personal bias on my part but she has the social and cultural talks pulling her away and so it's very layered thing that's kind of what i told her new grad this this therapist is. We have to see this through layers there's not one thing that is the problem.
00:07:30
Speaker
Let's say it's a CRPS ish kind of thing. That's one layer. The cultural thing is another layer. The work thing is another layer. The medical systems kicking her can down the curb and saying, go see a spine doctor, he'll fix you. Go see a shoulder doctor, he'll fix you. It's not my problem with someone else's.
Validating Pain and Multidisciplinary Team Involvement
00:07:45
Speaker
These are all layers that affect this and I can't fix all of them. I maybe can't even fix any of them except
00:07:51
Speaker
helping her to just try to do one more thing positively today just try to maybe even i'm just the positive light in her day when she comes in and i'm in a good mood and i'm trying to get her smile and laugh a couple of times maybe that's what i what what helps her use her hand more functionally down the road yeah and i think um
00:08:11
Speaker
With those tough patients, it's always really important to validate what they're feeling, right? Like you never want to make them feel like they're crazy for having this pain or that, you know, it's something that they've done wrong. I really feel like validating the patient can be very helpful. And then talking to them about, telling them that I know your pain is real, but also making sure they have the right people as part of their team, right? Do they need to be seeing a psychologist, a psychiatrist, a pain management doctor, getting some of those other people on board that,
00:08:40
Speaker
can maybe help manage the long-term pain aspect of it.
00:08:44
Speaker
Yeah, yeah, and this lady has a team of over a dozen doctors and specialists and pain clinics. I don't believe she has psychiatry yet, or psychology in either case. We've recommended for that, and I don't think that's something she pursued. I don't know if it's for, if she forgot to pursue it, if it's something she chose not to do because it may not be as culturally relevant for her. That's not something that's common within that population to go pursue. So yeah, we've tried that, but you're right. Not validating it and saying, I understand you're in pain.
00:09:14
Speaker
because like telling your significant other in an argument, you just calm down. That never actually works. And so telling a patient, it's in your head.
00:09:23
Speaker
even if it is in their head, that doesn't make it better. So validating and saying, I understand you're in pain. Not the therapy talk of, I know that you think you're in pain, but validating, I understand you're in pain and we're here to help you and get you as much function as you can. Just trying to help the patient do
Conclusion: Emotional Well-being in Complex Cases
00:09:39
Speaker
something positive on the back end of this. We don't have solutions and answers just yet, but it's interesting to go through with the staff member and say like, how are you gonna manage this patient and how are you going to see
00:09:52
Speaker
like a positive outcome for yourself in this because that's something as therapists that we tend to internalize too. Yeah, definitely. I think taking care of the staff and the patient, right? Something we do as owners and when running clinics. Yeah. So not necessarily integrate resolutions, not one of our posts that gives you all kinds of solutions and answers and stuff, but still kind of a good thing to hear a discussion of on difficult patients because man, we all have a couple at least on our, on our schedules, right? Yeah, definitely. All right.
00:10:23
Speaker
A job early there. Sorry. That's okay. I was doing a little info at hand therapy academy thing, but that's okay. Here we go. All right.