Pain Management

Pain Management Case Study: Mr Jones Frank Jones is a 48 year old man presenting with low back and left leg pain. History Mr Jone was working as a motor mechanic when lifting a heavy piece of machinery weighing 35 kg (77 lb) on 5 March 2002. He felt something “give” and had immediate onset of pain in the low back. He was seen by his local doctor and given antinflammatory medications and told to take 3 days off work. There was no neurological deficit and X rays of his lumbar spine failed to find any abnormality. He requested several more days off work and then returned to work one week after the injury. Any lifting caused an increase in his pain and after consultation with his local doctor he was placed on light duties. He returned to work and was given office duties but his boss made it clear that he was not welcome at work if he could not return to what he was doing before. He was very dissatisfied doing paperwork. Eight weeks later his pain had largely resolved and he was cleared by his local doctor and allowed to return to normal duties. Three months later when he bent over to pick up his tool box he experienced pain in his back and a shooting pain down his left leg. He returned to the local doctor who requested a CT scan. This showed a left posterolateral L4/5 disc protrusion that was impinging on the left L5 nerve root. He was refered to an orthopaedic surgeon who advised an L4/5 discectomy. Following surgery, he had good relief of the leg pain although not the back pain and despite attempts to return to work found it impossible to carry on. He was dismissed from his job at the mechanical workshop six months later. He now spends much of his time at home and twelve months following surgery began to experience constant burning pain in the left leg below the knee. He now has continuing pain in the low back and left leg. Mr Frank Jones - Case Study: Assessment PAIN5002: Introduction to Pain Management © University of Sydney All rights reserved Previous intervention ? Physiotherapy (prior to surgery) ? Dec 2002 - Surgery – L4/5 discectomy Pain Low back ? Constant aching pain with intermittent stabbing pain with activities ? Worse when sitting or standing for long periods, bending, lifting ? Relieved by lying down, changing position, heat Left leg ? Constant burning pain particularly over outside of left lower leg and top of left foot ? Worse at the end of the day ? No relieving factors although better when distracted ? Pins and needles down outside of left leg to foot, numbness over top of foot ? Leg gives way from time to time ? No change in bladder or bowel function Medications Current ? oxycodone 5 mg 10-12/day – some relief ? sodium valproate 800 mg/day – not sure if helping ? temazepam 1-2 most nights Previous ? tramadol, amitriptyline (25 mg nocte) – both gave side effects Medical history ? Hypertensive - on medication ? Weight gain 15 kgs over last 2 years Psychosocial history ? Married three children 26, 24, 22 – youngest still at home ? Motor mechanic until discharged from last position, seven years in last position ? Doesn’t smoke – ceased 10 years ago ? Alcohol – 6-8 cans beer on weekends ? Sleep – better with temazepam but still woken by pain PAIN5002: Pain Mechanisms and Contributors Assessment: Case Study – Mr Frank Jones © University of Sydney All rights reserved ? Mood – irritable, angry, claims not to be depressed ? Activities – spends most of time at home, watches TV, “potters” in back shed, can’t do housework or gardening, mowing the lawn, occasionally walks around the block, sees friends at club from time to time but can’t stay too long Examination Musculoskeletal ? Decreased range of movement lumbar spine in all directions ? Pain on extension and rotation to left ? Tenderness in the midline lumbosacral region and paraspinally on the left lower lumbar levels Neurological ? Straight leg raise right 75o left 45o ? Decreased sensation to light touch left leg globally below the knee, more pronounced over lateral left calf and over foot ? Decreased sensation to pin prick and cool lateral aspect of lower left leg and over top of foot ? Can stand on heels and toes ? No wasting lower limbs ? Reduced power with dorsiflexion of left large toe ? Knee and ankle jerks present and symmetrical Investigations Psych questionnaires Measures: Compared to RNSH pain clinic sample (percentiles1 for low back/leg pain) ? Pain (0-10) Ave: 7 (range 5-9): (69th %le) ? Disability (Roland & Morris Questionnaire, 0- 24): 17 (81st %le) ? Depression (Depression Anxiety & Stress Scale – DASS) 31 (84th %le) ? Catastrophising (Pain Response Self-Statement – PRSS, 0-5): 4.3 (90th %le) ? Self-Efficacy Beliefs (Pain Self-Efficacy Questionniare, 0-60): 14 (24th %le) 1 A percentile is a value on a scale indicating the percent of the sample that is equal or below it. For example, a score at the 75th percentile is equal to or higher than 75% of all the scores in the sample. Note, however, in the Pain Self-Efficacy Questionniare higher scores = greater confidence to manage pain. Mr Frank Jones - Case Study: Assessment PAIN5002: Introduction to Pain Management © University of Sydney All rights reserved CT scan lumbosacral spine 16 Sept 2002 ? Small central disc bulge at L3/4 ? Left posterolateral disc protrusion at L4/5 appears to impinging left L5 nerve root MRI lumbar spine with gadolinium 21 July 2004 ? Small central disc bulge at L3/4 ? Degenerative changes L3/, L4/5 and L5/S1 facet joints bilaterally ? No nerve root compression or impingement ? Enhancement around left L5 and S1 nerve roots suggestive of epidural fibrosis For this assignment you need to complete a prescribed case review. You can access the case study by clicking on the following link: - Mr Frank Jones Case Study.pdf Please use the following questions to provide a structure for discussing your essay. The word count for this assignment is approximately 3000 words. Given the total word count for your written assignment, this equates to approximately 750 words per question. However, you may find that you use more or less words depending on the question posed. What precipitating events are important in contributing to the experience of pain? What underlying processes may be triggered by these precipitating events? What mechanisms or other factors would you need to consider as part of the ongoing experience of pain? What are possible implications of the involvement of these mechanisms and contributors for management? Marking Criteria: Case Review: Demonstrates analytical thinking and ability to synthesise and integrate understanding Demonstrates application of theory to practice Demonstrated ability to source relevant and up to date information and resources Relevant literature is used to support and develop argument and/or justify conclusions Appropriate and consistent referencing style is used For referencing, use the Harvard style