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
ƒ Physiotherapy (prior to surgery)
ƒ Dec 2002 – Surgery – L4/5 discectomy
Pain
Low back
ƒ Constant aching pain with intermittent stabbing pain with activities
ƒ Worse when sitting or standing for long periods, bending, lifting
ƒ Relieved by lying down, changing position, heat
Left leg
ƒ Constant burning pain particularly over outside of left lower leg and top of left
foot
ƒ Worse at the end of the day
ƒ No relieving factors although better when distracted
ƒ Pins and needles down outside of left leg to foot, numbness over top of foot
ƒ Leg gives way from time to time
ƒ No change in bladder or bowel function
Medications
Current
ƒ oxycodone 5 mg 10-12/day – some relief
ƒ sodium valproate 800 mg/day – not sure if helping
ƒ temazepam 1-2 most nights
Previous
ƒ tramadol, amitriptyline (25 mg nocte) – both gave side effects
Medical history
ƒ Hypertensive – on medication
ƒ Weight gain 15 kgs over last 2 years
Psychosocial history
ƒ Married three children 26, 24, 22 – youngest still at home
ƒ Motor mechanic until discharged from last position, seven years in last
position
ƒ Doesn’t smoke – ceased 10 years ago
ƒ Alcohol – 6-8 cans beer on weekends
ƒ 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
ƒ Mood – irritable, angry, claims not to be depressed
ƒ 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
ƒ Decreased range of movement lumbar spine in all directions
ƒ Pain on extension and rotation to left
ƒ Tenderness in the midline lumbosacral region and paraspinally on the left
lower lumbar levels
Neurological
ƒ Straight leg raise right 75o
left 45o
ƒ Decreased sensation to light touch left leg globally below the knee, more
pronounced over lateral left calf and over foot
ƒ Decreased sensation to pin prick and cool lateral aspect of lower left leg and
over top of foot
ƒ Can stand on heels and toes
ƒ No wasting lower limbs
ƒ Reduced power with dorsiflexion of left large toe
ƒ Knee and ankle jerks present and symmetrical
Investigations
Psych questionnaires
Measures: Compared to RNSH pain clinic sample (percentiles1
for low back/leg
pain)
ƒ Pain (0-10) Ave: 7 (range 5-9): (69th %le)
ƒ Disability (Roland & Morris Questionnaire, 0- 24): 17 (81st %le)
ƒ Depression (Depression Anxiety & Stress Scale – DASS) 31 (84th %le)
ƒ Catastrophising (Pain Response Self-Statement – PRSS, 0-5): 4.3 (90th %le)
ƒ 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
ƒ Small central disc bulge at L3/4
ƒ Left posterolateral disc protrusion at L4/5 appears to impinging left L5 nerve
root
MRI lumbar spine with gadolinium 21 July 2004
ƒ Small central disc bulge at L3/4
ƒ Degenerative changes L3/, L4/5 and L5/S1 facet joints bilaterally
ƒ No nerve root compression or impingement
ƒ 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

WE ACCEPT