Help

[CFSupport]

I am seeing a patient who has endured laminectomie to combat spinal stenosis and disc degeneration......I am kinesiologist and this patient has been referred to me by his physio. I've been working with the individual for about 2.5 months and have helped him improve his strength, balance, and tolerance to standing and sitting.

His (and my) major concern however is the absence of improvment in his right leg. He's says the leg always feels hot, and when walking it feels like he's in water. He also says that without his complete concentraion he could lose control and fall......whats going on here?

[gcoe]

Hmm…tricky. A few things come to mind:

1. He is quite likely to have chronic pain syndrome in which case he could be experiencing dysaesthesias (an unpleasant abnormal sensation, whether spontaneous or evoked) which could account for the hot feelings and the watery feelings in the leg. If they aren’t unpleasant then the term used is paraesthesia but it is much the same. Dysesthesias and paraesthesias can be quite florid and bizarre.

2. Does the lack of concentration actually result in him falling or does he feel like he will but doesn't actually? If he does fall does the leg collapse and can this collapse be accounted for by weakness in the antigravity muscles of the leg? What is his proprioception in the leg like? – if that is affected could that account for his loss of control He could be having to compensate by relying on his vision and vestibular systems for balance if his leg isn’t giving him proprioception. Is there any reasoning you can do around this to clarify the problem?

3. Failing that an alternative hypothesis is that all the symptoms may be part of a somatoform disorder (Psychiatric disorder) he has developed alongside his musculoskeletal problem. Somatoform disorders come in lots of variations but basically they are characterised experiencing physical symptoms which can’t be explained by medical examination. If so it is not uncommon for patients to be distressed in other ways as well so perhaps you could consider how he seems to have coped with his problem, his surgery and his recovery.

this needs and expert diagnosis. I think it might be time to get an opinion from a pain specialist – possibly a multidisciplinary pain team assessment would be best. They might be able to help work out what is going on. If by chance there is a psychiatric issue they could refer your patient on after ruling out a pain syndrome. That might be better than approaching a psychiatrist first off, as that could well be quite demoralising and alienating for your patient. Are you in a metropolitan city? – that is usually where you can locate chronic pain teams at large hospitals.


All the best with sorting this out.

[CFSupport]

Thank you so much for the amount of thought you put into this. Your second hypothesis is intriguing. I do think he is relying on his senses to maintain his balance and co-ordination. Is there a vaildated protcol i can follow to test proprioception of the legs. I tested and retested his ability to maintain a squat posture at 90 degrees... his tolerance went from 17-25 second (after 2.5 months) so his strength and endurance is improving.

My reccomendation to his case manager was that he see a neuromuscular specialist. Unfortunatly I live in a remote community in Northern Canada. The town has 9000 people 1 physio (who has a 300 person waitlist) and a few inexperienced overbooked physicians.....I am the only kinesiologist in town and although i want to help this individual i am discouraged and feeling unqualified for the case.

I truly belive that patient wants to get better..... although i could hardly rule out psychological factors as it is outside my scope of practice.

Hmm…tricky. A few things come to mind:

1. He is quite likely to have chronic pain syndrome in which case he could be experiencing dysaesthesias (an unpleasant abnormal sensation, whether spontaneous or evoked) which could account for the hot feelings and the watery feelings in the leg. If they aren’t unpleasant then the term used is paraesthesia but it is much the same. Dysesthesias and paraesthesias can be quite florid and bizarre.

2. Does the lack of concentration actually result in him falling or does he feel like he will but doesn't actually? If he does fall does the leg collapse and can this collapse be accounted for by weakness in the antigravity muscles of the leg? What is his proprioception in the leg like? – if that is affected could that account for his loss of control He could be having to compensate by relying on his vision and vestibular systems for balance if his leg isn’t giving him proprioception. Is there any reasoning you can do around this to clarify the problem?

3. Failing that an alternative hypothesis is that all the symptoms may be part of a somatoform disorder (Psychiatric disorder) he has developed alongside his musculoskeletal problem. Somatoform disorders come in lots of variations but basically they are characterised experiencing physical symptoms which can’t be explained by medical examination. If so it is not uncommon for patients to be distressed in other ways as well so perhaps you could consider how he seems to have coped with his problem, his surgery and his recovery.

this needs and expert diagnosis. I think it might be time to get an opinion from a pain specialist – possibly a multidisciplinary pain team assessment would be best. They might be able to help work out what is going on. If by chance there is a psychiatric issue they could refer your patient on after ruling out a pain syndrome. That might be better than approaching a psychiatrist first off, as that could well be quite demoralising and alienating for your patient. Are you in a metropolitan city? – that is usually where you can locate chronic pain teams at large hospitals.


All the best with sorting this out.

[gcoe]

You are welcome

Proprioceptive testing is more of an art than a science to be honest, so aren’t lots of validated tests out there. This testing also gets into the whole area of balance testing so gets quite complex Referring him to a physiotherapist with a neurological background might be able to help with more extensive testing of proprioception. A quick screening test you could do is the Rhomberg test:

Neuroexam.com - Romberg Test
Romberg's test - Wikipedia, the free encyclopedia
However this test doesn’t distinguish between proprioceptive or vestibular loss. To do that you can also repeat the test on a foam squab – the foam disables proprioception so forces the patient to rely on vision and vestibular information. If he is markedly worse with eyes closed on a foam squab than with eyes closed on a firm surface then that is suggestive of a vestibular problem than a proprioceptive problem.

You could also repeat the test standing on one leg – not a standardised test but that would really emphasise the defective leg.
given the geography it might be a bit hard orgnanising a referral. However eve if this is hard to organise given the situation of having such problems with balance in standing and walking with these sorts of symptoms at this stage sounds a bit concerning. So if you can refer him to your nearest town with a pain team that may be really helpful.

Just with the psychiatric idea – remember this is all just conjecture on my part. However I should say that if this is the case the issue is not to do with psychological motivation. Such patients genuinely want to get better. It is more of a case of they have got themselves in trouble and don’t know how to get out the situation. As a management rule it is often considered acceptable practice to treat them as if it is a physical problem and carry on with supportive rehab reinforcing positive improvements etc. However it is best if his management is supervised by an appropriate mental health professional (psychiatrist, rehab doctor or clinical psychologist). Otherwise if he hits snags along the way the rehab may get frustrating for all concerned.

It sounds like he is making some gains with strengthening under your care which is great. However to be honest I do think it sounds like your patient may be in the s*%t and really needs some specialist help at this stage, even if it is just to rule concerning things out or to provide some direction for continued recovery.

[CFSupport]

Thanks, i am going to contact his physio (the physio) and investigate her comfort level with advanced neuro-physiotherapy. I am also going to ask for her support in my reccomendation that the insurance company spring for a trip out to see some serioius specialists. Thanks again for your help, i have a good relationship with the patient and he was impressed he was benifiting from the knowledge and experience of a physio all the way in NZ!! You've been very helpful, thanks again.