multiple sites of pain

In my first week of musculo out pts i had a pt referred from a regional hospital for chronic LBP. On subjective Ax, this was only a piece of the puzzle with pain down the (R) leg to her foot, severe cervical/thoracic pain and a recent shoulder reconstruction causing pain and AROM limitations. Most of the subjective questioning was open and the pt reported that most of the pain was from the cervical/throacic region. These were the most prominent symptoms so activities that brought these on were detailed, while she seemed to dismiss her LBP. On checking with my tutor, due to the LBP referral, this must be the focus of Ax and Rx, and if the other areas need Rx a further referral is needed.

When i returned to my pt and informed her that her LBP must be the focus of this Rx, she accepted this and gave me more details on her low back pain. During the objective Ax and Rx there was no further mention of any Cx or Tx pain, and her shoulder was holding up well. It seemed that as I put my focus on the LBP, so did she and any other pain seemed insignificant. As Rx was on the lumbar spine, post Rx she had greater range and less pain in this area.

This was interesting as the lumbar pain was insignificant at initial Ax, then was the main complaint when she was told it had to be. She also reported that her pain had been worse since she had time off work to recover. I believe as she was not at work she spent most of the day concerned with her pain, while at work she would be pre occupied. Prior to this encounter i didnt realise the effect of focussing on pain and the reinforcing effect it can have. I think for future encounters it will be worthwhile even encorporating some distracting activites in the home exercise programme.