Clinical Case Studies Developed by Dr. David Hunt

2 Objectives When working with patients with acute then chronic pain you will be able to:  Identify the condition of non-specific mechanical low back pain  List assessment tools that may be useful (10 available)  Explain the importance of a pain management strategy  Develop an Action Plan for treatment

Acute and Chronic Low-Back Pain: Case of Mr. M.B. Setting The Stage

4 Objectives When working with patients with acute then chronic pain you will be able to:  Identify the condition of non-specific mechanical low back pain  List assessment tools that may be useful (10 available)  Explain the importance of a pain management strategy  Develop an Action Plan for treatment

5  49, Overweight, Married, Self Employed Movie Set Special Effects Technician.  March 2005 – fell off ladder at home › Landed and twisted to left › No Head Injury › Shortly Developed Burning Non Radiating Pain in Neck, Mid Back and Low Back Case of Mr. M.B. Non Specific Mechanical Low Back Pain

6  2 days post Injury – Saw F.P. › Burning Pain and Stiffness at Injury Sites › Moderate Restricted ROM, Muscle Tenderness and Spasm › Has to Work because of Deadlines and Lucrative Contract Case of Mr. M.B. Non Specific Mechanical Low Back Pain

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9  2 days post accident – Treatment › Education › Non Pharmacological Treatment › Pharmacological Treatment › Goals for the Patient Case of Mr. M.B. Non Specific Mechanical Low Back Pain

10  2 weeks post injury – Saw F.P. › Continuing to Work With Pain and Stiffness › Unable to Sit for Very Long › Difficulty Sleeping, Feeling Anxious  What Tools might you use here? Case of Mr. M.B. Non Specific Mechanical Low Back Pain

11 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

12 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

13 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

14 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

15  2 weeks post Injury – Treatment › Education › Non Pharmacological Treatment › Pharmacological Treatment › Goals for the Patient Case of Mr. M.B. Non Specific Mechanical Low Back Pain

16 Case of Mr. MB Non Specific Mechanical Low Back Pain  Between 2 weeks and 6 months from Injury  Patient lost to followup  Had been trying other treatment modalities including chiropractic, rest and massage therapy  Chiropractor concerned because his pain is no longer relieved by his treatment and he is having some other symptoms.

17  6 MONTHS POST Injury – F.P. › Daily Severe Low Back Pain … “11/10” › LBP Aggravated by Activity › Pain No Longer Relieved by Chiro › Stopped Work as Soon as Contract Ended – had been on EI › Feeling Helpless, Hopeless, Avoiding Family and Friends, “Moody” › LB Examination o Protected, Guarded o Sensitive to Light Palpation o Diffuse Tenderness › What tools might you use at this exam? Case of Mr. M.B. Non Specific Mechanical Low Back Pain

18 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

19 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

20 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

21 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

22 Case of Mr. M.B. Non Specific Mechanical Low Back Pain

23  6 MONTHS post injury – Treatment › Education › Non Pharmacological Treatment › Pharmacological Treatment › Goals for the Patient Case of Mr. M.B. Non Specific Mechanical Low Back Pain

24  7 MONTHS POST Injury – F.P. › Fell Asleep in Small Loveseat in Hyperflexed Lumbar Position for Several Hours › Awoke in Severe Low Back Pain and Mixed Left L5 + S1 Nerve Root Pain to the Foot › Pain Worse with BM’s › “Can’t Sleep”, Angry and Irritable › EI Payments Ceased, High Marital distress › Neuro Intact : Positive Nerve Root Tension on Left › What Would You Do?… How Would You Treat? Case of Mr. M.B. Mixed Discogenic And Neuropathic Pain

25  7.5 MONTHS POST Injury – F.P. › Private MRI Lumbosacral Spine › AT L4-5 › Moderate Central Disc Herniation which narrows the Left Neural Foramina and Compresses both L-5 Nerve Roots › AT L5-S1 › Moderate Central Disc Herniation with Possible Compromise of both L5 Nerve Roots › Moderate Bilateral L5S1 Facet Joint Degenerative Changes What Would You Do?…How Would You Treat? Case of Mr. M.B. Mixed Discogenic And Neuropathic Pain

26  8 months post Injury – F.P. › Requiring More and More Opiate for Only Partial Relief of Back and Leg Pain › Current Dose-HMContin 9mgm Q8h:HM-IR 8mgm/24hr Having Back Muscle Spasms and Calf Cramps › Started Drinking Alcohol and Smoking Pot for the Pain and Insomnia › Anxious and Depressed-Catastrophizing › Back and Lower Extremity Exam Unchanged On urgent list to see Neurosurgeon › What Would You Do?… How Would You Treat? Case of Mr. M.B. Mixed Discogenic And Neuropathic Pain

27  10 months post Injury › Assessed by the Neurosurgeon › Exam:  Positive Nerve Root Tension Signs with Crossover  Mild Sensory Deficits in Distal Left L5 and S1  Severe Pain Not Responding to Conservative Therapy  Imaging Correlates with Clinical › Recommends Surgery Case of Mr. M.B. Mixed Discogenic And Neuropathic Pain

28 Questions

29 Objectives When working with patients with acute then chronic pain you will be able to:  Identify the condition of non-specific mechanical low back pain  List assessment tools that may be useful (10 available)  Explain the importance of a pain management strategy  Develop an Action Plan for treatment