Case Study with Relevant Psychosocial, Cultural and Ethical Considerations

Case study
Trigger 1 “Jeff”  Part A
3,000 word written case study on the management of chiropractic patient (from selected trigger case) with a focus on relevant psychosocial, cultural and ethical considerations
Case History
A 44 Year Old Male Teacher with intermittent non-specific low back pain. No associated leg symptoms.
3 year recurring history following a fall at work, worse over last 6 months.
No red flags present
MRI (3 months ago) NAD – (nothing abnormal detected)
Had x10 physio sessions (manual treatment) through insurance – no effect
Yellow flags present, see below
Social history
2 children (10 and 7)
Currently going through a divorce with wife
Normally plays football (5 a side – non-competitive) weekly but not attended for 8 weeks due to low back pain
Occupational History
Been a teacher for 10 years, 6 months ago promoted to head of geography “very stressful, too high a work load”
Had the last 3 weeks off work “work being unsupportive”
Part B
Jeff scored as high risk on the STarT Back Tool
Jeff scored 60 out of 70 on the Bournemouth Questionnaire
Jeff states he has no confidence in ability to carry out his ADLs including football and work
Jeff does not feel that he will get better and that nothing will help “maybe surgery”
Jeff is very worried about his back “serious damage”
Although the MRI was normal a “bulging Disc” was shown “this is serious!”
The physiotherapist told him it is “a disc bulge” and that he shouldn’t bend forward or do any sports at the minute “should I stop forever?” “Exercise is not safe, cause’s further damage”
In addition Jeff states – “making me blue” “bit depressed”
Has suffered over the last 5 years with mild depression and anxiety.
Jeff states his sleep is now being affected by “everything”.
Patients states “cant carry on like this, what’s the point, no one cares”
Jeff denies suicidal thoughts
Part C
You have been treating Jeff x4 per week over the last 2 weeks
Jeff initially states feeling better following sessions “feels like someone cared and listened for the first time”. He also feels more “confident” in his back. His Bournemouth questionnaire is now 40/70.
However at week 3 Jeff has a flare up “lifting a box at work” and his symptoms and mindset return to his original presentation. He states he has lost his motivation for your management plan and Jeff’s GP has referred him for “chronic pain management” at a local hospital.
You now feel emotionally drained and do not look forward to seeing Jeff. You start to feel that Jeff is exaggerating his pain and worry if your beliefs will impact the therapeutic relationship and outcome.
 
Key points

• Relationship between anxiety and depression
• Fear
• Catastrophizing
• Bournemouth questionnaire
• Bulging disc
• Patient expectation
• Imagining
• Reassure the patient
• Screening Tool, how effective
• When we think a referral is required, To whom
• How to meet patient’s expectation
• Doctor patient relationship
• Placebo
• Trust between patient and Chiro
• Lifestyle
• Jeff should definitely return to work
• Red flags and yellow flags
• What is the epidemiology
• ICE (idea, concerns and expectation)
• Effective listening and communication
• patient education -use of simple language with the patient – the difference between advice and information
• use of words
• Shared decision on the care plan – The patient is an active decision maker
• Confidence
• What do you recommend Jeff should do, what kind of exercise