OA07 What is effective pain management: an illustrative case report?
Authors: de Villiers Elsje , Shenker Nicholas 
Published: September 2022

Abstract

Introduction/Background
Pain is a sensory and emotional experience perceived in terms of tissue damage and expressed in terms of altered behaviour. Chronic, medically unexplained pain is complex, disabling and common. It is important to rule out medical or modifiable causes, but most tests will not result in significant changes in management nor prognosis.
Attempting rehabilitation before the patient narrative has been fully explained usually leads to a lack of progress. Sleep deprivation is important to acknowledge and restorative sleep has analgesic and fatigue-improving properties. Prior mood disturbances may alter management, particularly if bereavement or post-traumatic memories are present. Adverse childhood events occur more frequently than expected in this population. Somatisation and personality disorders will need expert evaluation and management. Significant anxiety and depression should be managed independent of pain report.
Physical rehabilitation is effective in restoring function which can lead to a recovery of identity and workplace productivity. Altering health beliefs and cognition can be important as part of this process. Exercise prescriptions and access to support during this process are also important. Analgesic medications usually have little to offer other than side effects, but can be used to bridge difficult times, particularly if patient expectations align with their use. Strong opioids should not be started, unless no other options are available, and always with a time- and dose-limit, preferably less than 50mg daily of morphine equivalent for less than 3 months.
We present the case of a young gentleman of working age with chronic back pain who underwent effective pain management to restore good function including a full return to work, improvement in his mood, sleep, physical function and quality of life.

Description/Method
43 year old manager working as a Risk Manager developed back pain without trauma that affected all three segments. There was no morning stiffness, night pain nor gelling history. His pain was worse on exercise and when standing. The pain was intrusive and affecting his quality of life, to the extent that he could not attend work. Time away from the workplace was adding stress and affecting his mood and, intermittently, his sleep. There was no history of night sweats, weight loss, loss of appetite, significant leg pain nor numbness in his feet nor saddle area. There was no loss of control in his bowel nor urine habit.
His blood tests (FBC, LFT, Creat, ESR, CRP, vitamin D, ESR, CRP) were normal. An MRI scan of his whole spine showed minor degenerative disc changes but no significant bone changes nor neural compression.
His medications were sertraline 50mg once daily, meloxicam 7.5mg once daily and omeprazole 20mg once daily.
The pain management programme teaches self-management approaches to patients experiencing chronic pain. It is delivered by a physiotherapist, an occupational therapist, a nurse and a clinical psychologist. Its aim is to help patients to maintain or increase their physical functioning and to regain their sense of control in the context of their life. In turn, patients may improve in their well-being and their quality of life, despite their chronic pain. The programme runs for twelve days with patients attending as out-patients, four days a week for three weeks. Reviews take place at one month, six months and one year following this.

Discussion/Results
Table 1 outlines the improvement in his outcomes. Self-efficacy scores rose first with associated drops in catastrophisation and kinesiophobia. Anxiety and depression scores also dropped after the first 6 weeks. Pain significantly reduced along with improvements in quality of life and return to full employment 6 months later.

Key learning points/Conclusion
Patients with chronic pain have significant disability, poor quality of life and are not economically productive. Pain management programmes are well evidenced to restore function and improve quality of life. Pain scores typically drop later and full employment can be regained, thus suggesting a cost-effectiveness of such programmes for a population.