Let’s take a look at your X-Ray: A Case Story

It was his 3rd visit in for his back pain, but it was the first time I had seen him. I ask how he’s feeling that day.

“I’m hurting, not much different since last time. I’ve had back pain for 5 years, it’s gotten worse in the last 3. I had an X-ray by a gastroenterologist done a few years ago and she saw my spine on the image. She asked if I had back pain.  I said ‘yes, yes I do.’ She said she could tell, because my lower vertebrae were fused together, L4 or 5 or something. She said I’d have back pain for the rest of my life because of it. I’m about a 5-6/10 pain today.”

It was the same story he’s told to every practitioner, over and over again. I know because

I read the same thing from doing a chart review and reading his evaluation documentation. I listened. I want to hear what patients think about themselves and their body. I also enjoy cataloging the things they say and how they describe their conditions… it’s either out of curiosity or fascination with what is internalized by people and how they are communicated to.

Anyway, the above statements are not that uncommon. So I perform a movement assessment with no change in symptoms. Have him perform his HEP motions to make sure he understands them (prone press-ups, McKenzie style). No change in symptoms.

Follow me along with what happens next. I force-progress the press-up to include patient over-pressure.  (That’s where the patient sags and lets out air at the top of a press-up, increasing the pressure.) No change. He then asks “Will this ever get better? Will I have to live with pain?” Excellent question.  This is what I need, he is open to hearing what I will say, he is feeling lost, he wants answers, and he is inviting in dialogue. Enter pain neuroscience education.

Truth be told I did a very quick poor job in describing it. I told him that “pain is a feeling.  Since it is a feeling, and not something I can show him, that it will depends on how he… feels.” Crap. I started in the middle. I usually like to start with what a nerve is and that it has an on/off switch. We then interpret the mix and patterns of on/off signals coming from body parts. Then it usually goes something like this:

“So, everything in your body that you can sense comes from a nerve. No nerve, no feeling, no movement (not totally true, but it serves a point). So you are feeling your back because a nerve has been stimulated. Now it is up to your brain to interpret that stimulation. For example: if you feel a tickle on your upper arm while you are in spooky woods, you would likely be startled. If you felt that same tickle between-the-sheets with your lover, you would have a different feeling.  Same stimulation on the skin.  Different re-action.” and so on describing context, etc…

But I started in the middle… I paused to see if there would be resistance. He said “No, I get it.” Ok. Good so far. I asked him to get up. I went to look in the EMR to see if we had imaging of his back from a recent X-Ray. (One benefit of working in a large Hospital HMO system). We did, of course we did… there is seemingly always an X-Ray before a referral to PT.

I pulled it up so we both could see. If there was fusing I wanted to see it. Anterior view. Lateral view. Beautiful disc space. Straight alignment. Looked completely typical. (Shout-out to my ODU DPT program for teaching us radiology, at least the basics.) I pointed out these features, admit that I cannot find any significant apparent change… everything looks good. I scroll over and highlight the Radiologists Impression: “No abnormal findings”

“Hmm.” He said.

I did not plan that. It just happened.

We go back to the plinth, I palpate around the paraspinals, make a few comments like “It’s sore out here, out in the muscles” (pointing out the pain is not in the spinal column.) We then did a set of press-ups again with PT over-pressure, again, McKenzie style.

He stood up.

“I feel great.     No pain.    I haven’t felt this good in 5 years.”

Holy crap that can’t be. He walked around the clinic 3 times. 0/10 pain. Shook hands, then set one appointment for next week.

What was that about?

Three things could have occurred. The McKenzie force progression, the neuroscience education, or the visual patient education.

While I have seen force progressions work amazingly in the past, I am a novice McKenzie practitioner. I have little experience with the forces used. I did not give exceptional pain science education…

This is a case of rephrasing a patient’s body. We had a medium that people believe in: Written words in an EMR along with X-Ray images.

We had just changed his above story…

We had a combined visual and auditory placebo (albeit unplanned). I showed an image of his back with explanation that it looked good. And showed him, in writing, that the radiologist wrote, officially: “No abnormal findings.”

Patient education can be a powerful tool.  Same with pain neuroscience education.  The words are a powerful placebo intervention.  I mean that in the most honest way possible. While telling someone about how their body works, how the nervous system is there to protect them with pain responses and how sometimes things can go wrong… we are basically using placebo. Or at least our words are physiologically working like a placebo does…

Now, I a not performing blinded research. There were indeed multiple variables involved in the care of this man. But I cannot shake the idea that seeing his official medical status as normal was the key factor.

Conversations can change physical feelings. We know it happens. We know people are swayed and influenced by context, by words, by visual in-puts…

Either way, an amazing experience for all involved.

Matt D

PS: Upon next visit, patient reported “I’ve felt good all week.”


5 thoughts on “Let’s take a look at your X-Ray: A Case Story

  1. Pingback: The Thousand Word Image | PTbraintrust

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