Here’s part 1 of my recently submitted assignment. Hope you enjoy and get something out of it. Feedback of course is always welcome! Part 2 will follow in a week.
A clinical perspective of pain management for Low Back Pain: A case study
Low back pain (LBP) remains a prevalent health burden according to epidemiological data with an increasing length in years lived with disability and an increasing financial burden globally. Many people living with persistent pain can face societal stigmatization resulting in social exclusion, mental health problems, chronic disease, and weight disorders. Persistent pain is referred to as a multi-dimensional experience, and as such is a particularly enigmatic phenomenon. The following case study reviews a video vignette of a female with low back pain. It is the aim of this assignment to identify (through a biopsychosocial paradigm) how an understanding of previous experiences has contributed and possibly perpetuated her current behaviour. The assignment will attempt to address the main concerns, clinically appropriate intervention and appropriate referral to members of the interdisciplinary team (IDT).
Low back pain (LBP) remains a prevalent health burden according to epidemiological data with an increasing length in years lived with disability (Vos et al., 2012) and an increasing financial burden globally (Hoy et al., 2012). Many people living with persistent pain can face societal stigmatization resulting in social exclusion, mental health problems, chronic disease, and weight disorders (De Ruddere, Bosmans, Crombez, & Goubert, 2016). Persistent pain is referred to as a multi-dimensional experience (Melzack, 2001), and as such is a particularly enigmatic phenomenon (Eriksen, Kerry, Mumford, Lie, & Anjum, 2013). Traditional medical treatments continuing to be advocated in the treatment of persistent pain, often with no reduction in pain outcomes .
This creates a cycle, exemplified by the quote “Pain is an ideal habitat for worry to flourish” (Eccleston & Crombez, 2007, p. 234). Common clinical practices for LBP continue to emphasise attention to the pathological nature of the tissue as a direct cause of pain (Butler & Moseley, 2003; Louw & Puentedura, 2013). Unfortunately, due to the limitations of a biomedical approach, people and symptoms are often seen but not heard.
Eccleston & Crombez, (2007) state, “one can view the person with chronic pain as an active problem solving agent, one who despite failure and disappointment continues searching for solutions.” (p. 234). Healthcare continues to resort to diagnostic procedures such as the use of imaging to identify pathology with the intention that “fixing” the pathology will remove the pain. This is still common practice despite the extensive imaging evidence that identifies similar pathology in a wide age range of asymptomatic populations (Brinjikji et al., 2015). It is becoming more evident that psychosocial factors play a crucial role in the development of LBP .
More recent discussion in the research literature identify LBP as part of a group of enigmatic phenomena classed as medically unexplained symptoms (Eriksen et al., 2013). Chronic conditions such as Non-Specific Low Back Pain (NSLBP) or Fibromyalgia fall into this group of conditions due to poor correlative and causal links particularly in their aetiology. NSLBP shows poor correlative and causal links demonstrated by pain and pathology seen on MRI, a lack of clarity linking pathophysiological factors, and suspected mechanical factors such as posture, lifting, carrying, pushing and pulling (Balagué et al., 2012).
This further demonstrates the paradoxical presentation of LBP and the multiple possibilities that clinical interpretation can present. This can be appropriately illustrated by the image below, (see figure 1) that presents as a mereological fallacy of blindfolded people placed around an elephant asked to describe the specific parts.
The following case study reviews a video vignette of a female with low back pain. The intention is to deliver a clinically reasoned approach based upon why the patient presented to me in that way at that time with a means of identifying the most appropriate method of intervention. I aim to identify (through a biopsychosocial paradigm) the main concerns, including how a traditional understanding of pain has contributed and perpetuated her current behaviour, select appropriate outcome measures, reason clinically appropriate intervention and (if required) make appropriate referral to members of the interdisciplinary team (IDT).
The patient is a 49-year-old female with a history of LBP. She is married and lives with her husband and two children. She works full time as a teaching aid and her husband is a full time mechanic. The vignette commences with the patient sitting in the waiting room on her mobile phone. She looks up somewhat concerned or possibly agitated before she is asked to come into the clinic room. She sits down tentatively in the chair opposite the health professional.
The patient appears fatigued and dishevelled. She reports an insidious onset of back pain, unable to recall how it developed. She vaguely suggests that it may have occurred from “hanging out the laundry” and that it “came on one morning.” There is no report of trauma and no indication of red flags or neurological involvement. It appears from the video that she has experienced back pain in the past.
The main concerns – how it is affecting her life
- Her back pain has recently become worse and she is finding “important” activities such as kneeling and bending to talk to the children increasingly difficult.
- She is having trouble sleeping, which affects her at work as it makes her tired and “scratchy” (this is highlighted a number of times throughout the vignette).
- Concerned about gaining weight.
- Worried she will end up like her mother who had crippling back pain.
Self diagnosis – What she thinks is going on
- Has not seen any other professional for this episode as previously she was told by a physiotherapist to strengthen her core muscles.
- Unsure of what is going on in her back, could be a broken bone, cancer, degeneration or perhaps a disc is out. She acknowledges that she has to strengthen her core.
Coping strategies – How is she coping?
- Drinking and smoking more.
- Sitting and lying down more.
- Avoiding bending and lifting.
- Stoical (she just puts up with it because she has to keep moving).
Work – how it is affecting her work?
- Not doing as much as she used to.
- Changed where she stores things to make it easier for access.
- Sitting more rather than bending over.
- Finds she is more irritable.
- Stoical (she pushes through).
- Concerned that she may not be able to carry on at work and have to give it up (emphasis on giving up work would be bad).
Social support – what do friends and family think?
- Friends and family concerned as she normally has a high pain threshold.
- Avoids telling friends and family about her pain as she feels they are getting fed up.
The main outcome to address
The patient in this case study has identified real concern about the nature of her back pain, aspects of her working life that are becoming increasingly problematic and restrictive and feelings of guilt and isolation as she is unable to engage with her family. She appears to present with a stoical nature that is reflected in her comments and how her friends and family view her.
Particular movements are limiting her ability to fulfil her work role, she displays catastrophic fears and concerns about what might be going on in her back, there is a need for diagnosis likely for confirmation or disconfirmation of her concerns, with a request to obtain this through diagnostic imaging. Finally, she highlights (on a number of occasions) her lack of sleep becoming a real hindrance to her daily activity.
It is apparent that the patient presents with some concerns about what might be going on in her back that would suggest a need for diagnostic imaging, yet evidence demonstrates that x-ray provides poor prognostic value and correlative links to pain and pathology .
The initial aim is to provide her with reassurance about her main concerns, addressing the beliefs she has about her back, and providing her with adaptations and alternative strategies that she can adopt whilst at work (This is discussed in the intervention section).
Other members of the Inter-Disciplinary Team
Due to the multitude of concerns identified the patient would benefit from seeing an occupational therapist to address work related issues with her employer and to follow a graded exposure program pertinent to her work activities. A referral to a psychologist would help to address her current coping mechanisms (her “push through” nature), help with her sleep issues and also strategies on managing her stress. In terms of my physiotherapy approach, I would aim to address her beliefs and behaviour towards back pain, her reluctance to engage in exercise also safety and avoidance behaviours towards activity and movement. The patient may also benefit from speaking to a nutritionist to address her concerns about gaining weight.
We will leave it there for part 1 and resume next week for part 2 which will include assessment and also intervention.
Thanks all for having a read
Balagué, F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2012). Non-specific low back pain. The Lancet, 379(9814), 482–491. http://doi.org/10.1016/S0140-6736(11)60610-7
Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., … Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American Journal Of Neuroradiology, 36(4). http://doi.org/10.3174/ajnr.A4173
Costa, L. D. C. M., Maher, C. G., McAuley, J. H., Hancock, M. J., & Smeets, R. J. E. M. (2011). Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain. European Journal of Pain, 15(2), 213–219. http://doi.org/10.1016/j.ejpain.2010.06.014
Craske, M. G., Treanor, M., Conway, C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23.
Crombez, G., Eccleston, C., Damme, S. Van, Vlaeyen, J. W. S., & Karoly, P. (2012). The fear avoidance model of chronic pain: the next generation. Clin J Pain, 28, 475–483. http://doi.org/10.1097/AJP.0b013e3182385392
De Ruddere, L., Bosmans, M., Crombez, G., & Goubert, L. (2016). Patients are socially excluded when their pain has no medical explanation. The Journal of Pain, 17(9), 1028–1035. http://doi.org/10.1016/j.jpain.2016.06.005
Deyo, R. a, Jarvik, J. G., & Chou, R. (2014). Low back pain in primary care. Bmj, 349(July), 1–6. http://doi.org/10.1136/bmj.g4266
Deyo, R. a, Mirza, S. K., Turner, J. a, & Martin, B. I. (2009). Overtreating chronic back pain: time to back off? Journal of the American Board of Family Medicine : JABFM, 22(1), 62–68. http://doi.org/10.3122/jabfm.2009.01.080102
Downie, A., Williams, C. M., Henschke, N., Hancock, M. J., Ostelo, R. W. J. G., de Vet, H. C. W., … Maher, C. G. (2013). Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ (Clinical Research Ed.), 347(January), f7095. http://doi.org/10.1136/bmj.f7095
Eccleston, C., & Crombez, G. (2007). Worry and chronic pain : A misdirected problem solving model. Pain, 132(3), 233–236. http://doi.org/10.1016/j.pain.2007.09.014
Eriksen, T. E., Kerry, R., Mumford, S., Lie, S. A. N., & Anjum, R. L. (2013). At the borders of medical reasoning: aetiological and ontological challenges of medically unexplained symptoms. Philosophy, Ethics, and Humanities in Medicine : PEHM, 8(1), 11. http://doi.org/10.1186/1747-5341-8-11
Flynn, T. W. (2011). Appropriate Use of Diagnostic Imaging in Low Back Pain – A Reminder That Unnecessary Imaging May Do as Much Harm as Good. Journal of Orthopaedic and Sports Physical Therapy, 41(11), 838–846. http://doi.org/10.2519/jospt.2011.3618
Hoy, D., Bain, C., Williams, G., March, L., Brooks, P., Blyth, F., … Buchbinder, R. (2012). A systematic review of the global prevalence of low back pain. Arthritis and Rheumatism, 64(6), 2028–2037. http://doi.org/10.1002/art.34347
Karel, Y. H. J. M., Verkerk, K., Endenburg, S., Metselaar, S., & Verhagen, A. P. (2015). Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis. European Journal of Internal Medicine, 26(8), 585–595. http://doi.org/10.1016/j.ejim.2015.06.018
Leeuw, M., Goossens, M. E. J. B., van Breukelen, G. J. P., Boersma, K., & Vlaeyen, J. W. S. (2007). Measuring Perceived Harmfulness of Physical Activities in Patients With Chronic Low Back Pain: The Photograph Series of Daily Activities-Short Electronic Version. Journal of Pain, 8(11), 840–849. http://doi.org/10.1016/j.jpain.2007.05.013
Leeuw, M., Goossens, M. E. J. B., van Breukelen, G. J. P., de Jong, J. R., Heuts, P. H. T. G., Smeets, R. J. E. M., … Vlaeyen, J. W. S. (2008). Exposure in vivo versus operant graded activity in chronic low back pain patients: Results of a randomized controlled trial. Pain, 138(1), 192–207. http://doi.org/10.1016/j.pain.2007.12.009
Louw, A., Zimney, K., Puentedura, E. J., & Diener, I. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice, 3985(August), 1–24. http://doi.org/10.1080/09593985.2016.1194646
Melzack, R. (2001). Pain and the neuromatrix in the brain. Journal of Dental Education, 65(12), 1378–1382.
Pitsoe, V., & Maila, M. (2013). Re-thinking Teacher Professional Development through Schön’s Reflective Practice and Situated Learning Lenses. Mediterranean Journal of Social Sciences, 4(3), 211–218. http://doi.org/10.5901/mjss.2013.v4n3p211
Ramond, A., Bouton, C., Richard, I., Roquelaure, Y., Baufreton, C., Legrand, E., & Huez, J. F. (2011). Psychosocial risk factors for chronic low back pain in primary care-a systematic review. Family Practice. http://doi.org/10.1093/fampra/cmq072
Southall, D. (2013). The patient’s use of metaphor within a palliative care setting: Theory, function and efficacy. A narrative literature review. Palliative Medicine, 27(4), 304–313. http://doi.org/10.1177/0269216312451948
Stewart, M. (2015). The assumption dilemma : do healthcare professionals have the teaching skills to meet the demands of therapeutic neuroscience education ?, 13(1), 40–42.
Stewart, M. A. (2014). The road to pain reconceptualization: Do metaphors help or hinder the journey? J Acupunct Assoc Chart Physiotherapists, (36). Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=amed&AN=0180670&site=ehost-live
Tardiff, H., Blanchard, M., Fenwick, N., Blissett, C., & Eagar, K. (2015). Electronic Persistent Pain Outcomes Collaboration National Report 2014. Australian Health Services Research Insitute, (University of Wollongong). Retrieved from https://www.noca.ie/wp-content/uploads/2015/11/IHFD-National-Report-2014-Online-Version.pdf
Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., … Moradi-Lakeh, M. (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. The Lancet, 380(9859), 2163–2196. http://doi.org/10.1016/S0140-6736(12)61729-2
Vlaeyen, J. W., Morley, S., Linton, S. J., Boersma, K., & de Jong, J. (2012). Essential guide to treatment. In J. W. Vlaeyen, S. Morley, S. J. Linton, K. Boersma & J. de Jong (Eds.), Pain-related Fear: Exposure-based treatment for chronic pain. Seattle: IASP Press.
Leave a Reply