Physiotherapy Interventions for People With Complex and Enduring Health Condition

Where the patient is being assessed:
The Persistent Physical Symptoms Service
Name: Joanna Sykes
Age: 47
Diagnosis
Persistent Lower Back Pain
Reason for Referral and History of Present Condition:
· LBP began 14 years ago when she bent forward and lifted her baby out of the cot. Immediate pain and struggled to straighten up. Had to ask a neighbour to help until her husband came home from work. Later the same day, the pain travelled into her leg and down into her foot, which also went numb. “Very scary experience”. Her husband called 999 for an ambulance when her foot went numb. Seen in A&E, given strong painkillers and set home. GP advised rest and sent for an urgent MRI. MRI showed a “Slipped Disc” at L4/5 and she was referred to Newcastle RVI for Lumbar discectomy surgery. Pt describes this as a very frightening experience due to the risks of surgery. She didn’t understand how a disc could slip and why some of it would therefore need to be removed: “if one disc could slip out, could the others slip out as well”?
· After this, very little pain in her back until her second episode of lower back pain two years later when leaning forward and lifting shopping out of the boot of her car. Slight radiation of symptoms into left buttock and thigh. Anxious that “another disc had slipped out” and would need surgery again. Complete bed rest for about ten days and within this time, her pain slowly settled.
· After this episode, she reports having around 1-2 episodes of LBP per year, which settled with approx. 1-2 weeks of bed rest
· Each episode has gotten progressively worse
· 2-3 years ago, pain gradually became more constant with flare-ups becoming more and more regular. “Never a day without pain in my back, the only variable is how much it hurts”. She worries that her spine is weak and unstable, that her spine is not properly aligned, that more discs are slipping out and that she will likely “end up in a wheelchair”.
· Pt does recognise that the increase in pain coincides with her husband’s diagnosis of fibromyalgia and her Fathers deteriorating health/memory.
· Very anxious regarding her prognosis and worried that “there might be something else going on” that has been missed

Past medical History including any previous admission to hospital:
· Migraine (started in early teens – one migraine per month on average but getting more frequent and intense over the past 2-3 years)
· Episodic lower back pain for 14 years, occasionally with left leg pain. Has been to A&E on several occasions over the years, always discharged same day with pain killers.
· Lumbar Discectomy at L5/4, 14 years ago – 5/7 stay in hospital followed by outpatient physio. Found the whole experience very frightening
· History of depression and anxiety
· Smoker – approx. 20 per day
· Slightly overweight

Drug History:
· Amitriptyline: 75 mg, once per day
· Over the counter paracetamol and ibuprofen (takes maximum dose every day)
Social History:
· Lives with husband who was diagnosed with fibromyalgia 2 years ago (currently signed off sick from work due to flare-up)
· Has 2 children aged 16 and 14
· Has an elderly Father with early signs of possible dementia (although not formally diagnosed) who lives nearby. Pt helps with housework, cooking and shopping most days because “he can’t manage on his own”. Pt’s mother died 15 years ago of lung cancer. No other family
· Doesn’t get out much and does not have any friends – she has lost touch with most of her friends over the years, blames her pain for this
· Works part-time in Tesco on the tills – does not like her job and feels “they could do more” to support her with her ongoing pain.

Education / Work History
· Left school at 18 with seven GCSE’s and two A-Levels. Did an apprenticeship in hairdressing and worked as a hairdresser full-time until her first child was born 16 year ago – describes this job as “the best job in the world”.
· Came out of work to raise her family. Tried to go back to hairdressing 12 years ago, but stopped after 3 months due to back pain flare-ups and worsening migraines – being on feet and leaning over people to cut hair made pain worse
· Stay-at-home Mum for the next 5 years, then began working in Tesco. Initially liked the job, but feels “it has changed” and now strongly dislikes her job. Due to the amount of time she has had off sick due to her pain, she does not think she would be able to get a different joband reports being “too old” for a career change

Treatment/intervention including Physiotherapy/AHP
· Investigations
o MRI Head 17 years ago: NAD (no action)
o MRI Lx 14 years ago: Disk herniation at L3/4 and L4/5, mild spondylosis at L3, L4 and L5 (had surgery and physio – see PMH)
o X-ray Lx 11 years ago: mild spondylosis and possible disk degeneration at multiple levels (referred to physio)
o MRI Lx 9 years ago: Disc dehydration and degeneration at L3/4. Annular Fissure at L2/3 (referred to physio)
o US scan left shoulder 7 years ago: Small tear in supraspinatus tendon (no surgery required – referred to physio)
o X-ray Cx 5 years ago: moderate spondylosis at multiple levels. Loss of normal curvature of the spine (referred to physio)
o MRI head 9/12 ago: NAD (referred to PPSS)
· Previous Interventions
o Several courses of physiotherapy over the years – feels that it doesn’t help anymore and is now “a complete waste of time”
o Acupuncture: helps a little at the time, but pain always returns once the course of treatment finishes (can’t afford to have acupuncture over the long-term)
o Pilates, Yoga and Tai Chi: All aggravate back and/or migraine pain
o Massage: helps for a few days, but pain always comes back
o Walking club: group walked “too far and for too long” – aggravated pain

Any previous or current involvement with other services (if applicable)
· None

Home Environmental Subjective Assessment (but not to include solutions to any issues)
· Not carried out
Brief: A written essay entitled 'A Critical Case Discussion of the Physiotherapy Management of a Person with a Long Term Condition'. Your assignment is to be based on a case study. You are to choose from 1 of 5 case studies that have been written for you.
Word Count: 2000
Learning Outcomes: Your 2000 assignment is based on the intended Learning Outcomes for this module. These are:
LO1. Critically review current physiotherapy interventions for people with complex and enduring health conditions.
LO2. Demonstrate critical awareness of psychosocial factors that might influence practice when working with people with complex and enduring health conditions.
LO3. Critically evaluate strategies aimed at supporting individuals, families and carers in the management of complex and enduring health conditions.
Referencing: Use Harvard Referencing style when citing your sources within your written work
Appendices: You are to include your chosen case study as an Appendix to your assignment (this will not be included in the 2000 word count). You should refer to your case study within your assignment
Marking Criteria: