Subjective Examination

Jack is a 22-year-old man who presented with a 7-year history of progressively disabling chronic central low back pain. Jack’s symptoms began gradually when he was 15 years of age while he was undergoing intensive football (soccer) training. He had tried to manage the pain by doing a lot of core stability exercises, as advised by his physiotherapist. However, 6 months after this time, when he was 16 years of age, he experienced a ‘major’ episode of pain at training, whereby his back ‘spasmed’ and he was carried off the field. He reported his pain was 10/10 and ‘frightening’. At this time, he was playing at an elite level and was aiming for a professional contract.

Jack went to see his general practitioner, who referred him for a magnetic resonance imaging (MRI) scan, which he stated had found a number of ‘damaged discs and bulges’. He was referred to an orthopaedic surgeon who, after reviewing the MRI, told him that he had the ‘back of a 70-year-old’. He also told Jack that he would have to stop playing football and might need to have a spinal fusion, whereby they would have to ‘operate through his stomach’. He was further told this operation could prevent him from having children in the future and ‘all this [other] scary stuff’. As a young man of 16 years, Jack described how this frightened him and that he feared for his future. Jack denied any contextual life stressors around the time of this severe pain episode.

Based on this advice, Jack ceased playing football, left school and started a manual job. Since that major episode of pain, he reported that ‘his back was never the same again – it is always tense and doesn’t relax’. He further reported that over the subsequent years, his back pain had slowly become more intense and disabling. A year prior to the first consultation, Jack ceased doing manual work due to the high levels of pain he experienced and instead took a desk job. However, because his pain was aggravated by sitting, he had now been out of work for 3 months due to his back pain. He was currently spending his time at home, lying down or going for walks.

Jack had trialled various passive interventions (mobilization, manipulation, massage and acupuncture), which he reported only gave him short-term relief. He noted that having his girlfriend walk on his back with heels had given him the most relief, as had massage and heat. He had undertaken no self-management strategies.

Pain Characteristics

Jack stated that he experienced constant tension in his back which increased when he maintained upright postures, such as sitting and standing. He reported a deep, gnawing pain in his lower back that increased during the day, and he also reported a severe, sharp pain when he flexed, extended or rotated his back. He rated his gnawing pain as 9/10 and his sharp pain as 9/10 on a numerical pain rating scale. He described a positive relationship between the level of ‘tension’ in his back and his pain. That is, when one increased, so did the other. Jack denied any leg pain or neurological symptoms (see Fig. 24.1).

MRI Scans

MRI scans (Fig. 24.2) conducted when he was 16 and then repeated when he was 21 years of age confirmed his reports of multi-level disc degeneration in the lower lumbar spine. Disc bulges were noted at L4/L5 and L5/S1, and multiple levels of disc fissures and Schmorl’s nodes were visible at T12 and L1. There was no sign of nerve compression.

Örebro Screening Questionnaire

The score recorded for the Örebro Screening Questionnaire was 132, indicating that Jack was at high risk for chronicity (Boersma and Linton, 2005; WorkSafe Victoria, 2016).

Of particular note were the high scores recorded for the following questions:

1. 1. In the past 3 months, on average, how bad was your pain on a 0–10 scale? (10/10)
   
2. 2. Based on all things you do to cope, or deal with your pain, on an average day, how much are you able to decrease it? (I can’t decrease it at all, 10/10)
   
3. 3. How tense or anxious have you felt in the past week? (as tense and anxious as I have felt, 8/10)
   
4. 4. How much have you been bothered by feeling depressed in the past week? (extremely, 7/10)
   
5. 5. In your view, how large is the risk that your current pain may become persistent? (high risk, 10/10)
   
6. 6. In your estimation, what are the chances that you will be able to work in 6 months? (no chance, 1/10)
   
7. 7. An increase in pain is an indication that I should stop what I’m doing until the pain decreases (completely, 9/10).

Reasoning Question:

1. 1. Can you please briefly outline what you considered were the key findings and related hypotheses immediately following the subjective examination? In particular, can you comment on how you planned to test these hypotheses, especially in relation to the dominant ‘pain types’ you hypothesized?

Answer to Reasoning Question:

At the end of the interview, it was very clear to me that Jack was in big trouble. He was a young man who was reporting high levels of pain, and he was very disabled, distressed, fearful and pain-vigilant, with no active coping strategies to manage his pain. His distress levels appeared to be proportionate to his circumstances. He believed his back pain was due to his spine being damaged, as advised by the orthopaedic surgeon based on his MRI, and he held little hope for this to change.

Jack reported that his pain was relatively constant, with mechanical provocation on bending and twisting activities. He was highly guarded and protective of these movements. He had been out of work for 3 months, and he had minimal expectations of returning to work. He didn’t know whether physiotherapy could help this time because it hadn’t in the past, but he was desperate to try anything.

There was one clear discrepancy in his story. On the one hand, he reported that he was constantly protecting his back for fear of doing harm; however, on the other hand, the only thing that gave him relief was massage, self-manipulation and heat that relaxed his muscles. It was thus deemed important to investigate this relationship in the physical examination. Finally, based on the interview, it sounded like Jack had high levels of sensitization of local spinal structures, with pain amplification due to his lack of pain control and his high levels of vigilance, fear, distress and inactivity (O’Sullivan et al., 2014; Rabey et al., 2016).

Therefore, the aims of the physical examination were as follows:

1. 1. Ascertain exactly where his symptoms were located.
   
2. 2. Determine his level of tissue sensitivity to palpation and pain responses to movement.
   
3. 3. Determine his levels of resting trunk muscle tension and body posture by observation and palpation in his pain-provocative postures (sitting, standing and lying).
   
4. 4. Examine his movement-control strategies during provocative tasks (bending, lifting and rolling) and his thoughts and beliefs in relation to this.
   
5. 5. Explore the relationship between Jack’s muscle ‘tension’ and his protective behaviours in relation to his provocative postures (sitting and standing) and feared movements (load transfer, bending and rolling). This was deemed critical to determine whether his protective behaviours were provocative of his pain.
   
6. 6. Conduct a series of postural and movement-guided behavioural experiments to determine the following:
   
   
   
   • • Whether he could normalize his movement patterns
     
   • • Whether his pain was influenced by his levels of muscle tension
     
   • • Whether his pain was modifiable/controllable by doing so
   
   
7. 7. Use these guided behavioural experiments to encourage Jack to reflect on the relationship between his beliefs, behaviours and pain experiences.

Reasoning Question:

1. 2. Were you surprised that the onset of back pain at such an early age had such a dramatic effect on Jack’s life given the apparent lack of external stressors?

Answer to Reasoning Question:

No – sadly, there are many cases such as Jack’s where negative interactions with healthcare practitioners reinforce catastrophic beliefs and provocative behaviours that leave people with no control strategies and, consequently, disabled and distressed. This notion of the health system actually driving disability, largely due to the misinterpretation of imaging results and the reinforcement of avoidance and protective behaviours, has been reported previously in the literature (Lin et al., 2013).

Perhaps if Jack had taken a different clinical path that instead ‘dethreatened’ his pain, that is, provided him with an evidence-based understanding of his pain, as well as active pain-coping strategies, all with a view to Jack returning to his valued activities, he likely would have avoided years of unnecessary suffering.

Clinical Reasoning Commentary:

Two interesting aspects to the clinician’s reasoning are apparent in these responses. First, the clinician has clearly encountered many similar cases previously and recognizes the ‘pattern’ encapsulating typical key clinical findings, particularly those indicating that the patient has adopted catastrophic beliefs and fear-based understandings of the pain largely borne of the structurally focussed biomedical approach to musculoskeletal diagnosis and management (see Chapter 2). Counterproductive guarded back postures and avoidant actions are the natural result of these maladaptive thoughts, as the patient seeks to protect the back structures and follow typical health professional advice accordingly. However, the clinician here, despite having seen this pattern many times previously, remains open-minded, which allows for the detection of the ‘clear discrepancy’ that the pain best responds to interventions designed to relax the back muscles (e.g. massage, heat) and move the spine (e.g. self-manipulation, walking). It is apparent how this ‘discrepancy’ has influenced the clinician’s determination of the physical examination aims.

The other interesting aspect of the clinician’s reasoning evident in these answers is how the list of seven aims flowing from the patient interview demonstrate the planning process, whereby hypotheses regarding movement patterns formulated in the patient interview will be tested through the physical examination. Elements of guided self-management, especially the ‘correction’ of counterproductive beliefs and understandings underpinning Jack’s protective/guarded postures and movements, are planned to evaluate their effect and inform further management. The physical examination and management phases of the clinical session are essentially planned to be executed concurrently, albeit in a modifiable and individualized fashion if unexpected/atypical responses from the patient arise.

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