Medical
Motivational Interviewing
Motivational interviewing is a patient counseling technique with wide applicability in healthcare.
Extensively developed in working with patients with substance abuse disorders the method also useful for patients with chronic conditions such as diabetes. It’s applicable in patients where behavior change is an important part of treatment.
In this patient, we will try to understand her values and the barriers that she perceives to following through with the treatment plan. By framing the discussion in terms of her values, reaching goals that are relevant to her, partnering for change, and offering specific simple solutions to potential barriers. Even a short session with a patient can result in meaningful steps.
Physical Therapy Treatment Perspectives
Ava tries four different physical therapy approaches to help treat her pain.
Abdominal stabilization
The directions for this physical therapy exercise dictate that while supine, raise your hands in the air so they are perpendicular to your body. Pull in your lower abdominal muscles and while raising your hips, bring your arms downward. Hold for five seconds. Repeat five times, while breathing normally.
Spine realignment
The directions for this physical therapy exercise dictate to lean forward slightly, then tilt your hips backwards to align your spine with your center of gravity. This will help avoid putting excess strain on the pubic symphysis.
Sitting to Standing
The directions for this physical therapy exercise dictate that to keep your knees shoulder-width apart, and your back straight, exhale as you stand from the sitting position.
Hip Abductor Strengthening
The directions for this physical therapy exercise dictate to sit down, put your fist or a rolled towel or exercise ball between your knees. Squeeze your knees together. Hold for five seconds, then repeat five times.
Clinical Psychology
Treatment Perspectives
Pain Psycho-Education
- Biopsychosocial model: the experience of pain is multi-factorial
- Gate Control Model of Pain
- Pain Triggers
- Pain-coping strategies
Managing Pain Triggers: Stress and Pain
- Problem-focused coping versus emotion-focused coping
- Emotion-focused coping strategies
- Relaxation techniques
- Cognitive therapy
- Distraction
Behavioral Strategies and Sleep
- Pacing
- Behavioral activation
Coping
- Problem-focused coping
- Appropriate when stressor can be changed/impacted
- Emotion-focused coping
- Appropriate when stressor is outside of individuals control
- Examples:
- Chronic pain/disease process, other people’s behaviors, traffic, weather, economy, etc.
- Focus is on regulating self’s response to stressor
- Thoughts, emotions, and behaviors
- Emotion-focused coping examples
- Cognitive therapy
- Pacing
- Behavioral activation
- Relaxation training
Available Resources
- Assess available resources
- Review access to healthcare
- Social support
- Positive social support
- Negative social support
Pharmacy
Medication Pregnancy Rating A
Example: Acetaminophen
Controlled studies in women fail to demonstrate a risk to the fetus in the first trimester (and there is no evidence of a risk in later trimester), and the possibility of fetal harm appears remote.
Medication Pregnancy Rating B
Examples: Benadryl, Zantac
Either animal-reproduction studies have not demonstrated a fetal risk but there are no controlled studies in pregnant women or animal-reproduction studies have shown an adverse effect (other than a decrease in fertility) that was not confirmed in controlled studies in women in the first trimester (and there is no evidence of a risk in later trimesters).
Medication Pregnancy Rating C
Examples: NSAIDs, Morphine, Oxycodone, Codeine
Either studies in animals have revealed adverse effects on the fetus (teratogenic or embryocidal or other) and there are no controlled studies in women or studies in women and animals are not available. Drugs should only be given if the potential benefit justifies the potential risk to the fetus.
Medication Pregnancy Rating D
Examples: Topamax, Klonopin, Xanax
There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective).
Medication Pregnancy Rating X
Examples: Depakote
Medications in this category should be discussed with the patient’s obstetrician. Studies in animals or human beings have demonstrated fetal abnormalities or there is evidence of fetal risk based on human experience or both, and the risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is contraindicated in women who are or may become pregnant.
Test Your Knowledge: Pharmacological Treatment
Which of the following medications is most appropriate for pregnant patients experiencing musculoskeletal pain?
Summary
- Acetaminophen is usually the safest choice
- Suggest non-pharmacologic interventions for management of low back pain in pregnancy
- I.E. physical medicine and rehabilitation methods
- Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used from the time of the first missed menstrual cycle up until the beginning of the third trimester.
Rehabilitation
Education
Activity modifications:
- Bed mobility
- Roll in bed with knees together
- Getting out of bed, roll with knees together, bring hips to 90 degrees and roll from laying position to sitting position
- Sit to stand activities
- Keep knees together when getting up or sitting on a chair
- Transfers (in-out of a car or other vehicle)
- When getting into a car, sit first then swing legs in, keeping knees together
- Walking
- Take smaller steps
Avoidance of:
- Active stretching
- Squatting
- Sitting cross legged
- Breath stroke
- Walking for exercise
- Sitting on soft or low sofas/chairs
- If possible, avoid stairs
- Pulling up from laying on the back
Reference
Depledge J, McNair PJ, Keal-Smith C, et al. Management of symphysis pubis dysfunction during pregnancy using exercise and pelvic support belts. Phys Ther. 2005; 85:1290-1300.
Interventional Treatment
Interventional options exist, but are not warranted at this time.
