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Managing Lizzie Berry - Coggle Diagram

- - - - Gradual onset during first pregnancy (4–5 years ago)
      - Obstetric history: Emergency c-section (first child). Vaginal birth (second child)
      - Depression: Diagnosed ~7 years ago; recent exacerbation post-second birth
      - Anxiety: Emerged postnatally after second child
      - Medications (as of April 2025): Lorazepam (for anxiety), Citalopram (antidepressant), Naproxen & Paracetamol (pain relief)
  - - - High levels of pain-related fear avoidance
      - Depression, anxiety, social withdrawal
      - Low motivation and catastrophising (e.g., “stabbed in the back,” believes she cannot return to previous activities)
      - Past disengagement from physiotherapy and feelings of hopelessness
- - - - Main Complaint: Chronic low back pain, worsening over the last 6 months.
      - Pain Quality & Intensity: Continuous 12/10 pain, described as a “bad, very painful ache” and “like being stabbed in the back”.
      - Pain Distribution: Primarily low back, some discomfort in right buttock. No radicular symptoms (no leg pain, no pins and needles).
      - Onset & History: Gradual onset during first pregnancy (~4–5 years ago); worsened postpartum and after caring for second child.
      - Aggravating Factors: Lifting children (especially 6-month-old), twisting, prolonged sitting, all movements.
      - Easing Factors: Rest helps temporarily but leads to stiffness.
      - Functional Impact: Unable to walk child to school, difficulty with day-to-day parenting, inactive during the day, unable to engage in previous hobbies (e.g., pilates, hiking).
      - Psychological: Tearful, anxious, reports low motivation, feelings of failure, social withdrawal, difficulty sleeping, poor diet. Reports ongoing depression (on citalopram) and new anxiety since second child.
      - Medical History: Emergency c-section (1st child), vaginal birth (2nd child), past physiotherapy (limited engagement), currently taking naproxen, paracetamol, lorazepam, and citalopram.
      - Red Flag History: One episode of lower limb weakness and urinary symptoms leading to A&E visit (resolved). Recent MRI shows degenerative changes but no nerve impingement.
      - Goals: Walk eldest to school, return to pilates and walking, engage more with her children and daily life.
  - - - Gait/Posture:
      - Guarded, slow, stiff gait
      - Kyphosed seated posture with protracted glenohumeral joints
      - Pain-related facial expressions
      - Palpation:
      - Pain present on grade one palpation from L1–S1, including surrounding musculature
      - Lumbar Range of Motion (ROM):
      - Significantly limited in all planes; approximately ¼ normal range due to pain
      - Neurological:
      - Dermatomes & Myotomes: Normal (lower limbs)
      - Reflexes: Normal and present (lower limbs)
      - Special Tests:
      - Slump test: Not tolerated due to pain
      - Straight Leg Raise (SLR): Not completed – discomfort in supine position
      - Functional Tolerance:
      - Poor sitting tolerance
      - Difficulty engaging in objective physical assessment due to high pain and emotional distress
  - - - Oswestry Disability Index (ODI): To quantify back pain-related disability
      - Tampa Scale of Kinesiophobia (TSK): To assess fear-avoidance behaviours
      - PHQ-9 / GAD-7: For screening and monitoring depression/anxiety severity
      - Pain Catastrophizing Scale (PCS): To assess thoughts and feelings related to pain
      - Goal Attainment Scaling (GAS): To personalise goals (e.g., walking child to school)
  - - - Cultural, Psychological, and Communication Factors
      - Psychological:
      - High emotional distress, tearful during sessions, poor coping mechanisms, difficulty engaging with treatment
      - History of depression and current anxiety impacting pain perception, motivation, and compliance
      - Fear of movement and re-injury influencing avoidance behaviour
      - Communication:
      - Open and articulate when emotionally regulated; easily overwhelmed
      - Demonstrates willingness to engage with therapy when supported
      - Requires empathetic, paced communication with space for emotional expression
      - Cultural/Social:
      - Social isolation due to partner working away and difficulty managing two young children
      - Strong desire to fulfil parenting role but feeling unable, affecting self-worth
- - - - MRI: Mild disc protrusion at L4/L5; degenerative changes at L4/L5 and L5/S1; no nerve root impingement
        
        High pain report disproportionate to imaging findings
        
        Clear psychosocial contributors to chronicity
  - - - Lumbar facet joint arthropathy MRI evidence of facet joint degeneration; localised lumbar tenderness
      - Central sensitisation Pain 12/10 continuously, disproportionate to objective findings; allodynia; poor pain modulation
      - Postnatal mechanical instability History of pregnancy, C-section, reduced activity postpartum, weakened core muscles
      - Persistent somatic symptom disorder Somatic focus, functional limitations, co-existing anxiety/depression
  - - - Functional impact: Severely reduced mobility; difficulty with childcare
      - MRI findings: Mild disc pathology without nerve impingement
      - Psychosocial signs: Fear avoidance, anxiety, catastrophising
      - Previous A&E attendance: Suggests acute flare or fear of serious pathology
  - - - NICE Guidelines (NG59): Emphasise biopsychosocial approach in management of chronic low back pain, encourage physical activity, psychological support, and avoiding over-medicalisation
      - NHS Clinical Knowledge Summaries (CKS): Encourage patient education, reassurance, goal setting, and gradual return to activity for chronic back pain
      - Central Sensitisation & Chronic Pain Literature: Explains disproportionate pain perception, importance of multi-modal therapy (e.g., Butler & Moseley, 2013)