One of my patients, a 55 year old lady, reported she has had bad pain days since her last visit. She has had annoying and biting back pain in her right lumbar area, and radiating right leg pain with some numbness. Her right sided lumbar pain is flared up by household chores such as washing dishes, taking out the trash, as well as by ADLs such as donning her shoes–all activities that involve leaning forward and bending.
MRI of the lumbar spine showed:
- Advanced lumbar spondylosis. Findings include a moderate sized right subarticular and foraminal disc herniation at L5-S1 causing significant impingement of the traversing right S1 nerve root.
- Small central disc herniation at L4-L5 without mass effect on the nerve roots.
- Left foraminal and far lateral disc herniation at L3-L4 displacing the exiting left L3 nerve root.
HISTORY: Low back pain radiating to left leg. History of lumbar spine surgery at L4-L5 and L5-S1. Two back surgeries and both have helped. Epidural steroid injections never helped she stated.
MEDCATIONS: Depakote from 1500mg hs. Ambien 1mg hs. Neurontin 300mg hs. Vicodin 5/500 mg tid.
INTERVENTIONS: After reviewing her use of her pain meds, we moved on to challenging disabling and pain magnifying thoughts. As she verbalized each thought, I offered her a different way of looking at the situation. That is we “reframed” the negative thoughts.
We talked about coping techniques. We used Cognitive Behavioral Therapy (CBT) strategies to address her anger that flares up when she hurts. We talked about pacing and taking breaks. I demonstrated and had her do some simple back stretches. We talked about self-postural adjustment. The idea is that it’s not either/or move or not move. That is not an option. We discussed her need to stretch her back out regularly as she becomes aware of the strain building in her low back. I emphasized that she would do well to consider taking planned time outs to care for her back.
I also gave the patient a handout with the following coping self statements:
- When my pain flares up, I remind myself that I can adjust my posture and take more breaks. I can stretch.
- I expect up and downs.
- I will always have a back up plan.