Case Study: Managing debilitating back pain

Dr Peter Cox and Mr Joshua Pate

By Dr Peter Cox and Mr Joshua Pate for Australian Doctor
29 March 2016

Sharon, 46, presents to the pain management unit with a six-year history of low back pain after a low-impact twisting injury. She has not had back pain or any injury prior to this.

She describes the pain as a "general ache" across her whole lower back. It is aggravated by walking on the flat, going up and down stairs, and heat. It is eased by paracetamol, rest, lying down and cold.

After trying many passive treatments (including acupuncture, osteopathy and chiropractic), she felt she was "at the end of her rope", and saw her GP for a referral to the local pain management unit.

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Sharon lives with her husband and two adult children.

Examination
Sharon is overweight (BMI 27.5). Her gait has a decreased step length and appears very rigid/protective. She has approximately 50% of typical lumbar spine flexion, extension, rotation and lateral flexion. No abnormalities are found with her reflexes and sensation, but she has some decreased power in her knee extensors. The slump test (box 1) and bilateral straight leg raise test (box 2) are positive (abnormal).

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Sharon has non-specific pain in her low back and reported occasional pain and pins and needles in her legs above her knees. On palpation, she is tender, tight and overactive throughout her paraspinal muscles, worse in the lumbar region.

She scores significantly on her psychological questionnaires for depression, anxiety and stress, reporting family difficulties at home. She states that back pain prevents sleep, and thus she has very poor sleep.

Box 1. SLUMP TEST — to assess if, for example, herniated disc or neural tension are present

  • Seated with hands behind back to achieve a neutral spine
  • Actively slump forward at the thoracic and lumbar spine.
  • If this position does not cause pain, have the patient flex the neck by placing the chin on the chest and then extending one knee as much as possible.
  • If extending the knee causes pain, have the patient extend the neck into neutral. If the patient is still unable to extend the knee due to pain, the test is considered positive.
  • If extending the knee does not cause pain, ask the patient to actively dorsiflex the ankle.
  • If dorsiflexion causes pain, have the patient slightly flex the knee while still dorsiflexing.
  • If their pain is reproduced, the test is considered positive.
  • Repeat for other side.

Box 2. STRAIGHT LEG TEST (Las├ęgue’s sign) — to assess presence of disc herniation (lumbar)

  • Supine without a pillow under head, the hip medially rotated and adducted, and the knee extended.
  • Passively lift the patient’s leg by the posterior ankle while keeping the knee in a fully extended position.
  • The clinician continues to lift the patient’s leg by flexing at the hip until the patient complains of pain or tightness in the back or back of the leg.
  • Repeat with ankle in passive dorsiflexion.
  • If their pain is reproduced, the test is considered positive.
  • Repeat for other side.

Initial investigations
CT of the lumbar spine shows mild spondylitic changes that do not correlate with the patient's symptoms. She saw a surgeon three months ago who said he would not operate.

Further investigations
Sharon is extremely concerned that moving too far or too fast would "cause further damage", so much so, that she stopped working two years ago. She spends most of her day at home watching television and prefers not to leave the house.

Discussion
One in five Australians has chronic pain, and one in five adults with severe or very severe pain also has depression or other mood disorders.1,2

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A mechanism of persistent pain is central sensitisation. The synaptic transfer from the nociceptor terminal to dorsal horn neurones is amplified. Therefore, a sensitised nervous system can present with a range of different neurological symptoms, including pain.3

One aspect of management that is often under-emphasised is the benefits of pain education, recently termed "explaining pain".4

Explaining pain aims to change understanding of the biological processes that underpin pain, emphasising the distinction between nociception and pain. Pain is a protective mechanism and not an indicator of tissue damage.

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This range of educational interventions has been shown to increase pain-related biological knowledge, and decrease catastrophising.4

Early referral to a pain management unit appears to make a significant difference in the time it takes to improve quality of life.5

Treatment plan
After assessments from the team's physiotherapist and clinical psychologist, it was agreed that the best course of treatment for Sharon would be a moderate intensity pain management program. This biopsychosocial program is based on the gold standard principles for persistent pain management.5 The aim is to improve understanding of the neurophysiology of pain, increase activity levels to achieve work/home goals, and use psychological and physical strategies to improve quality of life.

Outcome
Six months after her initial presentation, Sharon has now returned to work two days a week, with a goal of returning to full-time work in the next three months.

She has learnt many psychological and physical skills, and has particularly benefited from pacing up her level of activity in the four-week pain management program. Pacing is a term used to describe how a patient finds a regular rhythm to increase functions, that is, not a stop-start approach.

This multidisciplinary approach is often shown to be successful, as with Sharon.


Dr Peter Cox is a pain physician and Joshua Pate is a physiotherapist at the St George Hospital Pain Management Unit, Sydney, NSW.

Acknowledgement
We thank the patient for her permission to submit this case report. Informed consent was obtained for publication of this case report.

 

This article was originally published in Australian Doctor on 29 March 2016. It was independently written, produced, edited and fact-checked by the Australian Doctor editorial team for our print and digital products.

References

  1. Access Economics. The High Price of Pain: the Economic Impact of Persistent Pain in Australia. MBF Foundation and the Pain Management Research Institute, University of Sydney, 2007.
  2. Australian Bureau of Statistics. Facts at your fingertips: Health, 2011. Characteristics of Bodily Pain in Australia. ABS, Canberra, 2011.
  3. Woolf C. Pain: moving from symptom control toward mechanism-specific pharmacologic management. Annals of Internal Medicine 2004; 140:441-51.
  4. Moseley G, Butler D. Fifteen years of explaining pain: the past, present, and future. Journal of Pain 2015; 16:807-13.
  5. Okifuji A, Ackerlind S. Behavioral medicine approaches to pain. Medical Clinics of North America 2007; 91:44-45.

By Dr Peter Cox and Mr Joshua Pate for Australian Doctor 29 March 2016

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