Understanding chronic pain

An elderly patient with chronic pain was finding life miserable. Joan Hester explains how she helped.

Hyacinth was an African-Caribbean woman aged 82 years. She had lived in the UK for 60 years and had four children. She was a factory worker and had retired at 60. Hyacinth's husband died two years ago and she now lived with her daughter.

She sat in a chair watching the television all day, and found it difficult to get up and move about. She had stopped doing the housework and cooking.

Hyacinth woke twice each night and found it hard to go back to sleep.

Life had become an effort and she often wished it would come to an end.

She could not remember how many grandchildren she had.

The physiotherapist had told her to go out for a walk every day, but she felt her back pain was too severe and she had no energy.

Hyacinth's pain had started two years ago in her lower back, but she now complained of pain all over her body.

At onset the pain radiated into her thighs, but it was now worse in her back.

Hyacinth scored 10/10 in the pain severity score. She returned high scores for interference with activities of daily living, walking ability, sleep and enjoyment of life. The pain was made worse by standing, cold, movement and damp weather.

Medical history
Hyacinth had hypertension, controlled with bendroflumethiazide and ramipril, and she took 75mg aspirin daily. Her menopause at 53 years was followed with HRT patches for three years. She was not diabetic, did not smoke or drink and had not had any serious illness.

She took paracetamol only for her pain. Her doctor had recently started her on 25mg amitriptyline in the evening, which she felt helped her to sleep better', but was 'no good for the pain'. She scored 12/21 for anxiety and 14/21 for depression on the hospital anxiety and depression scale.

Examination
On examination she was approximately five foot tall and moderately overweight, with a protuberant abdomen.

Her joints were surprisingly flexible. Her spine was a normal shape for her age, but neck movements were restricted by 20 per cent in lateral flexion. Her hips and knees were mobile with some crepitus of the right knee. Extension of her back was painful, she could not straight leg raise actively, her quadriceps muscles were weak, her ankle jerks were absent, her plantar reflexes were downgoing, with good peripheral pulses, and she had no sensory loss in her feet or legs.

An MRI of her back showed disc degeneration with disc bulges at L2/3, L3/4 and L5/S1 with facet joint arthrosis, but no nerve root compression.

The diagnoses were mechanical low back pain from osteoarthritis and depression.

Hyacinth was referred by her GP to the rheumatology team for the MRI scan, and then to a neurosurgeon who decided she was not a candidate for surgery and referred her to the pain clinic.

It is important to explain to people like Hyacinth why they continue to suffer pain, and to explain the relationship between chronic pain, depression, inactivity, muscle deterioration, deconditioning and more pain.

A spinal model helps to explain the MRI findings and the fact that over 70 per cent of patients will have disc bulges.

A depressed patient may assume that any movement will cause further damage, so it is important to motivate them to walk a little each day, rest afterwards, and to set small goals.

Hyacinth was encouraged to go to church with a friend and to progress to going out to a friend's house for a short while.

Effective advice
This is simple advice but is remarkably effective. The fact that someone has tried to understand the whole person and has explained the relationship between feelings, pain and MRI findings produces a sense of immediate relief.

As Hyacinth was unable to tolerate oral analgesics I suggested a 5mu g/hour buprenorphine seven-day skin patch, explaining how the drug was absorbed and how it would affect her body. This can be titrated to 10 or 20mu g/hour if tolerated.

An information booklet is helpful to give the patient. I highlighted facet joint injections as a possibility.

She had recently started taking amitriptyline, so I emphasised the importance of continuing this.

Hyacinth and her daughter were happy to try the skin patches first and to telephone if the injections or any further treatment were needed.

Ms Hester is a consultant in pain medicine, King's College Hospital and President of the British Pain Society, London

This article was originally published in Paineurope.

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