Clinical Case Studies

Developed by Dr. David Hunt

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

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

www.pspbc.ca
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

4
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
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

5
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
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

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 accident 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 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?

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

15
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.

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

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

22
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
6 MONTHS post injury Treatment
Education
Non Pharmacological Treatment
Pharmacological Treatment
Goals for the Patient

23
Case of Mr. M.B.
Mixed Discogenic And Neuropathic Pain
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 BMs
Cant 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?

24
Case of Mr. M.B.
Mixed Discogenic And Neuropathic Pain
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?

25
Case of Mr. M.B.
Mixed Discogenic And Neuropathic Pain
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?

26
 Case of Mr. M.B.
Mixed Discogenic And Neuropathic Pain
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

27
Questions

28
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

29