Mr Jones Persistent Pain Case Study

 Presenting Condition

Mr Jones is a 45 year old male who has persistent low back pain for 5 years.

He reports:

  • Pain radiating from the centre of his spine up to mid thoracic spine VAS 6-7/10 constantly
  • The pain intermittently radiates down both buttocks into mid posterior and anterior thighs VAS 8/10
  • Sleep disturbed total of 4-5 hours on a good night. Takes an hour nap after work.


Aggravating factors:

  • Walking more 10 minutes
  • Sitting more 30 minutes
  • Lumbar flexion and extension
  • Driving longer than 20 minutes
  • Lifting and carrying any weight
  • Having sex 


Easing factors:

  • Side lying
  • Intermittent walking / sitting
  • Taking medication

24 Hour Pattern

Am-

Wakes up pain 7/10 takes him a while to get going, takes his pain killers and allows him to get ready doesn't eat breakfast everymorning as it is difficult to to face due to the pain

Goes to work by car 30 minute drive and parks next to the office door pain is aggravated again 6/10 due to the drive.

Sits at his desk all morning taking 1 coffee break. He moves around in his chair as he is uncomfortable, and finds it difficult to concentrate and focus on his work due to the pain and the pain medication. 

PM 

He has his lunch from the canteen which is a 3 minute walk away and sits with his colleagues for 25 minutes before returning to his desk. Pain is 7/10 normally. 

He spends the rest of the afternoon either at his desk, on the phone to clients or in meetings with project teams and management. 

He finishes work and drives home, by this point he is 8-9/10 VAS

He then spends 1-1.5 hours in bed as he is exhausted by the pain and hasn't slept well. He also finds that the medication make him feel sleepy. 

His wife cooks dinner and they have together as a family. He then spends the rest of the evening watching television. He finished his evening off by having a cup of tea and checking social media on his phone in bed before he goes to sleep. 

He wakes up at 2 - 3am most nights and gets up and sometimes goes on the internet or goes downstairs. He usually gets back to sleep for another couple of hours and gets up at 7am for work. 

On a weekend he spends 2 hours napping and tends to stay in and around the house. His wife does the shopping, cooking and cleaning (she also works full time), as these tasks flare up Mr Jone's pain. 

History of Presenting Condition

Mr Jones was at work one day 5 years ago when he reached across his desk to pick up a box of documents and he ‘felt his back go’ he finished work early and spent the rest of the day at home in pain.


Mr Jones saw his General Practitioner (GP) the day after who prescribed him Co-codamol 30/500mg and ibuprofen 400mg with a 3 day course of diazepam for the muscle spasm.


Mr Jones spent the week in bed taking his medication as prescribed by the GP with little affect, each time he got up he would be in a lot of pain and since had developed right posterior leg pain.


This worried him therefore presented at Accident and Emergency Department (ED) where a doctor assessed him and diagnosed him with a potential right L5/S1 nerve root (no red flag symptoms) due to a possible ‘slipped disc’. He prescribed him a starting dose of amitriptyline alongside his co-codamol and ibuprofen and referred him back to his GP for further management and Physiotherapy.


Mr Jones had to wait over a week for an appointment with his GP due to the weekend and short staffing in the practice. In the meantime he continued with his bed rest in side lying as this was the only relief he could get.


When he finally saw his GP, he saw a locum doctor who was new to the practice where he became more frustrated with explaining his history once again. The GP gave him a prescription for continuing the amitriptyline and increased his dose of analgesia to Tramadol with Naproxen. She also referred him to Physiotherapy and gave him a sheet of stretching exercises, to which he discarded as he couldn’t contemplate starting them when walking was bad enough.


4 weeks later and Mr Jones is still off work sick and has started Physiotherapy. They have given him another sheet of exercises (to which he still doesn’t do) and is becoming more and more sedentary for fear of aggravating his back pain. The Physiotherapist then refers him into the back pain group 4 weeks later (the physiotherapist then rotates to a different area). Mr Jones attends the 1st session and then does not attend any further session.


His pain is a little better as he can now walk around for short periods of time but is still unable to perform house hold duties such as ironing and washing the dishes and hoovering, driving is difficult and any static position standing or sitting aggravates his pain.
Mr Jones represents at his GP and is sent to the orthopaedic spinal team for a review. The GP also requests an MRI scan.

The results of the scan are posted to Mr Jones:


L3/4 Broadbased disc with disc dehydration, facet hypertrophy with mild foraminal narrowing bilaterally
L4/5 Broadbased disc, modic changes type 2 with facet hypertrophy and mild foraminal narrowing bilaterally
L5/S1 Broadbased disc with disc dehydration, modic changes type 2 with foraminal norrowing bilaterally, mild disc protrusion with possible right L5 nerve root irritation.
Impression: Degenerative disc disease noted as above with evidence of spondylosis deformans. Mild Disc protrusion with possible right sides L5 nerve root irritation.


Worried about the meaning of his scan results he went straight to the internet to search for answers. He was worried as he came across lots of people who had similar symptoms and had to have emergency surgery and related his scan to descriptions of a ‘crumbling spine and flattened discs with bone rubbing on bone.


He made another appointment with his GP to discuss the results whilst waiting for the Orthopaedic appointment who tried to reassure him about the results and explained his results in a similar term to those he had seen on the internet.


Mr Jones finally received his Orthopaedic appointment 4 weeks later, the registrar then explained his results to him and explained there were 3 options he could take:

  • Try Physiotherapy
  • Try and Injection
  • Try surgery to open up the exiting foramina to relieve pressure on the nerve


Mr Jones opted for the injection as he had tried physiotherapy before and this hadn’t worked and was worried about the thought of surgery.
In the meantime Mr Jone’s work have called him in to discuss options for returning to work as he has been off sick for 5 months. His work are good and give him full pay for 6 months while he is off which then reduces to ½ for the following 6 months. Mr Jones agrees to go back to work but within 2 weeks he is really struggling.


The date for his injection comes around and he is hopeful that with this he should be back to normal. Unfortunately he gets 1 day of good relief from his pain and the pain is back to normal. He attends the Orthopaedic clinic for a follow appointment and they agree to try surgery, but with a Physiotherapy referral to help manage the pain while he is on the waiting list, which is 3 months. He attends Physiotherapy and tries a course of acupuncture for 6 weeks and some exercises. He finds the acupuncture helps for a day or so and then the pain returns.


Mr Jones has his surgery which goes without any complication and is discharged the same day and referred back to physiotherapy for his post-operative rehabilitation.


Mr Jones attends 2 1:1 physiotherapy session and is then placed in the post-operative back rehabilitation class for 6 weeks and is discharged back to orthopaedic clinic.He is worried about getting back to work as he has now been off sick for a 3rd time (once for the initial injury, secondly for the injection and now again for the surgery).


He feels the pain in his leg is a little better but is still a dull ache and his low back pain is still bad. He then attends his Orthopaedic surgery follow up clinic and is discharged, from their point of view the surgery went well and he now just needs to recover and build up back to full fitness.


Over the next 12 months Mr Jones struggles with pain and activity, he has put weight on and has become low in mood. His relationship with his wife isn’t the same as they can’t go out and enjoy the activities they use to and they struggle to have sex due to Mr Jone’s pain. He has stopped socialising with his friends as he is unable to stand in the pub or go out running, cycling or playing golf with them.


He has been managing his pain with his GP increasing his analgesia getting as much done as he can after they have taken affect and resting and taking a nap after work. He has tried seeing a chiropractor and private physiotherapist which have both involved manual therapy, TENS, Megapulse, acupuncture and exercises which he finds too uncomfortable to do. All of which haven’t really made any difference.
He has been for a second orthopaedic opinion at a different hospital. He has had a repeat MRI scan which shows nothing new other than scar tissue at the site of the operation, so they have tried more spinal injections, of which help for a short period and wear off.
The orthopaedic doctors run out of treatments to try for Mr Jones and refers him to the Pain Management Team. Where he sees you.

Social History

  • Graphic Designer full time
  • Previously enjoyed running, cycling, swimming and golf, has completed triathlons 1 year previous to onset of back pain.
  • Married with 1 child (15 year old boy)
  • Lives in 3 bedroom house with toilet / bathroom upstairs
  • Driver

Drug History

  • Naproxen
  • Paracetamol (PRN)
  • Amitriptyline
  • Fentanly Patches
  • Oromorph (PRN)
  • Citaolpram

Past Medical History

  • Microdiscetomy 4 years ago
  • Spinal injections