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Clinical Case Studies

Clinical Case Studies. Developed by Dr. David Hunt. Acute and Chronic Low-Back Pain: Case of Mr. M.B. Setting The Stage. Case of Mr. M.B. Non Specific Mechanical Low Back Pain . 49, Overweight, Married, Self Employed Movie Set Special Effects Technician. Work Factors

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Clinical Case Studies

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  1. Clinical Case Studies Developed by Dr. David Hunt

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

  3. Case of Mr. M.B.Non Specific Mechanical Low Back Pain • 49, Overweight, Married, Self Employed Movie Set Special Effects Technician. • Work Factors • Physically Demanding, Intellectually Challenging • Can Be Dangerous • Can Be Long Hours (12-18hrs / Day) • 6 Figure Income via Contracts

  4. March 2005 – MVA Sitting Unbelted Twisted to Left in Parked Vehicle Forcefully Rear Ended by Drinking Driver in ½ Ton Pick Up(driver fled scene – later got off) 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

  5. 2 days post MVA – 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

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

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

  8. Case of Mr. M.B.Non Specific Mechanical Low Back Pain • 2 days post MVA – Treatment • Education • Non Pharmacological Treatment • Pharmacological Treatment • Goals for the Patient

  9. Case of Mr. M.B.Non Specific Mechanical Low Back Pain • 2 weeks post MVA – Saw F.P. • Continuing to Work With Pain and Stiffness • Unable to Sit for Very Long • Difficulty Sleeping, Feeling Anxious • What Would You Do?… How Would You Treat?

  10. 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. 2 weeks post MVA – Treatment Education Non Pharmacological Treatment Pharmacological Treatment Goals for the Patient Case of Mr. M.B.Non Specific Mechanical Low Back Pain

  15. Case of Mr. M.B.Non Specific Mechanical Low Back Pain • 6 MONTHS POST MVA – 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 – Has Disability Benefits • Feeling Helpless, Hopeless, Avoiding Family and Friends, “Moody” • LB Examination • Protected, Guarded • Sensitive to Light Palpation • Diffuse Tenderness • What Would You Do?… How Would You Treat?

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

  17. 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. 6 MONTHS post MVA – Treatment Education Non Pharmacological Treatment Pharmacological Treatment Goals for the Patient Case of Mr. M.B.Non Specific Mechanical Low Back Pain

  22. Case of Mr. M.B.Mixed Discogenic And Neuropathic Pain • 7 MONTHS POST MVA – 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 • Disability Payments Ceased, High Marital distress • Neuro Intact : Positive Nerve Root Tension on Left • What Would You Do?… How Would You Treat?

  23. 7.5 MONTHS POST MVA – 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

  24. Case of Mr. M.B.Mixed Discogenic And Neuropathic Pain • 8 months post MVA – 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?

  25. Case of Mr. M.B.Mixed Discogenic And Neuropathic Pain • 10 months post MVA. • 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

  26. CASE of MR. M.B.Mixed Discogenic And Neuropathic Pain • 13 months post MVA. • OR Time Opens Up Thursday Before Easter • L4-5 and L5-S1 Discectomies with Bilateral L4-5 and L5-S1 Foramenotomies • Post Op Pain Medication Orders do Not Factor in the High Presurgical Dose of Opiate • Surgeon on Holiday-Covering Surgeon Unaware of Medication History • Patient in Severe Post OP Pain-Accused of Drug Seeking/Addiction • Patient Self discharges AMA at Post Op Day 4 • What Would You Do? How Would You Treat?

  27. 13 MONTHS post MVA – Treatment Education Non Pharmacological Treatment Pharmacological Treatment Goals for the Patient Case of Mr. M.B.Non Specific Mechanical Low Back Pain

  28. Case of Mr. M.B.Failed Back Surgery Syndrome • 15 months post MVA.( 3 MONTHS POST OP ) • Initial Improvement in Leg Pain but Left Leg Pain and Cramps Return • Low Back Pain Worse with Most Activity • Tenderness Localized to Left L4-5 and L5S1 Facet Joint Regions • Facet Region Pain Aggrevated by Combined Extension/Rotation/Left Lateral Flexion • Complaining of More Diffuse Musculoskeletal Pain,A.M. Stiffness,Fatigue and Ongoing Sleep and Mood Disturbance • What Would You Do? How Would You Treat?

  29. 15 months post MVA. - TREATMENT Education Non-Pharmacological Pharmacological Goals Case of Mr. M.B.Failed Back Surgery Syndrome

  30. LEARNING OBJECTIVES Using Case Studies Discuss Issues Around Opiates, Addiction, and Chronic Pain

  31. Opiates, Addiction And Chronic Pain • Have You ever Felt Uncomfortable or Uneasy When a Patient with Severe Chronic Pain Requests Increasingly High Doses of an Opioid? • Yes… • No..

  32. Can you explain why you feel uncomfortable?

  33. Opiates, Addiction And Chronic Pain I am uncomfortable because: • I am never sure if the patient really has pain as bad as they claim. • I have no way of knowing if the opioids are actually relieving the pain…is “taking the edge off” enough to justify the doses? • I am worried the patient is abusing or misusing them. • I am worried about a College Review. • I do not generally worry about any of these potential problems.

  34. Case of Reverend R.G. • 48, Married • Failed Back Surgery Syndrome • With Right Sciatica Post- Op. Scarring • Minister ½ Time • Stable Dose Medication • Low ORT Score

  35. Case of Reverend R.G. cont’d Medications: • HM Contin 9 mgm q8h • HMIR. 2-4mgm q6-8h PRN • ( average 12mgm / 24hrs ) • Gabapentin 900mgm q8h • Nortryptaline 40 mgmqhs • Celexa 20 mg O.D.

  36. Case of Reverend R.G. cont’d • Gentle Exercise Program 20-30mins – 5/7Days • Denies Significant Mood or Sleep Problems • No Nausea, Sedation, Sweating or Constipation • Recent Random Urine Test Negative for Drugs of Abuse Question: Any concerns?

  37. Rev.R.G.Stopped all Hydromorphone 3 months Earlier Continued to Refill Rx – “Just in Case of a Flareup” Kept Remaining Drug in Bathroom Drawer 14 Year Son,Acting Out,Moody,Suddenly Failling at School,Seemed to have More Money… What would YOU Do? How would YOU Treat? Case of Reverend R.G. cont’d

  38. Drug Misuse / Diversion • If the Patient is Misusing / Diverting, Don’t Expect to Always Catch on Right Away • No Matter how Smart We Are, We Can and Will be Fooled by a Professional Drug-Seeker • With Careful Observation, Careful Prescribing Practices and Careful Documentation Over Time, all Drug Misusers Will Eventually Slip Up

  39. Case of Mr. G.H. • 54, Married, Carpenter • Builds Movie Sets- “Workaholic” • Mixed Chronic Nociceptive and Neuropathic Pain to Left Chest / Abdomen from Crush Injury 1996 • Pain Report 3-5 /10 to 10/10 • Spontaneous Electric pain – “zingers” • Allodynia, Hyperalgesia, Sensory Changes • Marked Muscle Spasm when Flared

  40. Case of Mr. G.H. cont’d Medications: • Meslon 80mgm in divided dose / 24 hrs • Morph. IR10-20mgm for break through • 40 mgm / 24 hours • Gabapentin 800mgm 8h – 2400mg / 24 hours • Not Tolerate TCA’s or SNRI’s Stable Medication Dosing for 7 Years Able to Work Full Time By Pacing his Activities

  41. Case of Mr. G.H. cont’d • 2008 Life Events • Bilateral Carpal Tunnel Surgery • Off Work for Several Months • Father ill  Died in Toronto • Aunt had Cardiac Arrest at Fathers Funeral • Marital Disharmony • Wife had Nervous Breakdown • Financial Pressure Increased • Took on Heavier Work – Movie Set on a Mountain

  42. Case of Mr. G.H. cont’d January 2009 escalation in medications • Meslon 80mgm / 24hrs to 160mgm / 24hrs • Morph.IR 40mgm / 24hrs to 80mgm / 24hrs • Asking for Meds Early • Left Meds in Toronto – “Sister can’t Find Them” • Random Urine Screen - • Positive for: Cocaine, Marijuana, Opiates

  43. Case of Mr. G.H. cont’d • What would you do?

  44. Concurrent Pain & Addiction • Both pain and addiction can co-exist in the same patient • This does not always preclude the use of opioid therapy, but does require more attention (and time): • more controlled assessment • more controlled prescribing • more controlled monitoring

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