Discrepancies Between Physical, Radiologic Findings and Physical Limitations

This case study highlights discrepancies between physical and radiologic findings and physical limitations in a patient with cervical and lumbar pain complaints.

MP is a 61-year-old female patient with multilevel degenerative disc disease. Prior to her diagnosis, she was physically active and exercised vigorously.  She has developed increasing major joint pain, including severe upper and lower back discomfort.  Pain in the cervical and lumbar spine is her worst complaint. 

She is currently prescribed opioid medication (low to moderate use) and receives interventional treatment. She also receives mental health treatment for her chronic pain issues.  Although she frequently complains of increased pain during her clinic appointments, she does report that her treatments have been helpful.  Magnetic resonance imaging (MRI) of the spine was performed, and the results of the study were discussed with the patient: We diagnosed the patient with degenerative disc disease with associated spinal stenosis.

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Since that time, however, her clinical presentation has worsened and she now considers herself completely disabled.  She uses an assistive device for ambulation and demonstrates pain behavior that is often disproportionate to her radiologic findings. 

MP’s condition was noted to worsen significantly once she was presented with the degenerative changes on her MRI.  She now demonstrates guarding on movement and ambulation. Her physical activity is limited to such an extent that she is now beginning to demonstrate general muscle weakness and worsening physical stability.  

MP does not require financial assistance for her disability. She is not interested in receiving additional pain medication. However, a profound change in pain behavior demonstrated by the patient following the recent review of her radiographic reports is evident. Although there has been progression of her degenerative condition, the severity of change demonstrated by this patient does not correlate well with her findings on radiographic examination. 

Although MP does not appear to be attention seeking, her physical response to being informed of worsening of her degenerative disc condition on MRI is compelling. Her MRI findings appear to have been the trigger for what is now seen as an exaggerated pain behavior. This was only observed after the last MRI results were reviewed with the patient. She had not demonstrated this type of behavior before.

She continues with interventional treatment and oral opioid and non-opioid medication, both of which are reported to be helpful. Although present, her MRI findings were not extensive; however, her disability behavior is significant. 

Have you experienced a similar situation in your clinic? How often do you see significant discrepancies between physical/radiologic findings and physical limitations in your patients with pain complaints?  How would you manage this patient’s increasing disability?  Share your experiences in the Comments section below. Mr Pacheco will be available to provide insight and feedback to your comments in this moderated forum.