The multidimensional nature of the pain experience present a management challenge when the multidisciplinary team identify biomedical as well as psychosocial derangements that are amenable to specific treatments. The question becomes a prioritization issue as it is difficult to run both treatments simultaneously. In this case report, after the initial multidisciplinary assessment of this middle aged working man with low back and leg pain, several management approaches were utilized. These approaches included biomedical interventions (nerve blocks and neuroaugmentation) as well as cognitive behavioral therapy. Biomedical management can produce good results but they may also increase patient's reliance on passive approaches and fuel pain behaviors and sometimes fail to provide a solution to a multifaceted pain presentation. On the other hand, cognitive behavioral therapy (CBT) approaches have proven to have successful outcomes but they commonly emphasize on reducing reliance on passive approaches (use of medications and increasing demand for interventions), which sometimes can be contradictory to biomedical management if both are carried out simultaneously. Patients with such presentations still pose a challenge to the multidisciplinary team in deciding on what needs to be addressed first. There are many reports including clinical trials and systematic reviews that support each modality but when it comes to integrated management, the literature is scarce especially in terms of high quality randomized controlled trials.
Case Report History of presenting complaint
In February 1999, Mr.H had a fall while walking up some stairs. He had a tool case in his hand at the time. Following the fall he had right-sided low back pain which he initially did not take much notice of. However, the pain persisted and he was then seen by his GP He was treated with physiotherapy, anti-inflammatories and Tylenol III.
The pain was settling down and two months later when he had a physical examination for medical insurance purposes, he was asked to bend forward which he recalls resulted in a right leg pain. A CT-scan was done on the 5th of March, showing a posterior disc protrusion at the L5/S1 level. Mr.H continued to have increasing pain in the lower back and the right leg and was advised to take time off work on several occasions related to his pain. Due to the continuing report of pain and "numbness" in the right leg he was referred to a neurosurgeon who saw him in July, 1999, and ordered lumbar MRI scan that showed mild focal L5/S1 posteriolateral disc protrusion with slight thecal sac and right S1 nerve root compression. Surgery was not indicated, and was he told that it might not provide any benefit.
Mr.H continued to have pain and continued taking analgesic medications in addition to using a TENS machine. He gradually returned to full time (6 hrs/ day) work by December 1999. He was advised to avoid heavy lifting and prolonged sitting (as when driving for long distances).
He reported a right-sided low back pain, which radiates to the anterior thigh, the right calf and the dorsum of the right foot. He described the pain as continuous with variable intensities. He used the following McGill Pain Questionnaire (MPQ) words to describe his pain: shooting, stabbing, sharp, wrenching, aching, exhausting, radiating, and numb.
On a numerical rating scale (NRS), he reported the following pain intensities:
Intensity during the interview: 10/10
Highest and lowest intensities the week prior to the interview: 6/10 and 10/10
Usual pain intensity: 8/10
He described the following aggravating factors: movement especially lifting and bending, cold and wet weather, sex, and driving.
He described the following to help when he is in pain: warm/hot showers, analgesic medications, hot packs, massage and the TENS unit.
He denies any personal or family history of cancer, report no fever, sweats, bladder or bowel dysfunction or weakness in the lower limbs. He reports some weight gain since he started taking antidepressants.
Mr.H continued full time work in spite of his pain. He is unable to assist with any household activities and tends to overdo activities when he gains pain relief from analgesic medications. He can only drive for a limited period of time. His walking is limited to 100 meters and when not working he spends his time lying flat resting. His ability to play with his children decreased as well.
Prior to the injury he was actively involved in mountain biking, riding and snow skiing all of which he ceased since his injury. He reports waking up at night due to the pain but he can get good sleep on some other nights. He also reports that pain limited his sexual activity.
This was carried out through a clinical interview as well as through the use of psychological pain questionnaires.
Mr.H attributed his depression to the injury he sustained to his finger in 2001, however he mentions that his mood is reasonably stable now. He reports a pain-related disability in terms of limited ability to work, stand, drive, or do house work. His pain prevents him from playing with his children. Pain also limited his sexual activity with his wife and seriously disturbed his sleep. Prior to the fall, he was actively involved in mountain biking, snow skiing and horseback riding all of which are stopped now. His way of managing his pain is through taking medications, physiotherapy exercises, applying hot packs to his back, taking warm showers, use of electrical blanket, use of TENS unit, avoidance of physical activities. Based on the interview and the questionnaires results, Mr.H reports significantly higher pain intensity than the clinic's average. His depression, anxiety and stress scores are less than our clinics average and in fact less than normal which could downplay the importance of these factors in his presentation or could be attributed to his ongoing antidepressant treatment. Based on the SF-36 he reports a better general and mental health than our clinic average. On disability measure, Mr.H shows a significant level of disability that is higher than our clinic mean by one standard deviation. He shows a high level of fear-avoidance beliefs and has low pain self-efficacy beliefs. He scored higher than the clinic average on coping and surprisingly scored lower than average in terms of catastrophising, which may also explain his low depression scores.
In summary, Mr.H present with high pain intensity and significant disability due to his pain. He has significant fear-avoidance behavior and he does not seem to have ongoing depression, anxiety or stress in relation to his presentation but have low self efficacy which may explain his disability level.
Mr.H presents with maladaptive responses to his injury and the subsequent pain with significant fear-avoidance behavior which has lead to activity avoidance and disability. He does not pace his activities to adjust for his pain and his coping skills are passive and rely heavily on resting and taking analgesic medications. His prior history of depression may or may not be related to his current pain presentation.
Given the apparent maladaptive response that Mr.H developed with his pain presentation, we suggest that he participate in a cognitive behavioral therapy program.
- Mohammad, Almajed; Integrating interventional pain therapy and cognitive-behavioral therapy: what comes first?; Internet Journal of Anesthesiology; 2007; Vol. 11; Issue 2.
Reflection Exercise #1
The preceding section contained information
about integrating interventional pain therapy and CBT part I: case example. Write
three case study examples regarding how you might use the content of this section
in your practice.
What are the four psychologic factors of Mr. H’s pain? Record the letter of the correct answer