Case Scenario Severe Chronic Pain

A patient presents with overwhelming severe pain:

Creating a space of calm and confidence in the face of a storm of pain is difficult. Referring a patient to a website in this situation will not work, but your toolbox will come in handy.

Give the patient a chance to express their pain. Allow them time to talk. Not being heard ramps up anxiety. 

If time is limited, warn the patient that a repeat consult will be needed but assure them that in the meantime a short term of adequate analgesia will be provided. The aim is to lower the patient’s anxiety and stress levels early on in the consultation. 

A directed examination to exclude serious pathology can be performed relatively quickly with enough practice. The core back examination is an essential tool when examining lower back pain and can be done in as little as 3 to 5 minutes. In patients who are less mobile, this will take longer. 

Ensure there are no red flags:

Back pain red flags #Backpain

Assessing wide spread joint pain can take as little as 3 minutes:  3 minute GALS assessment 

Suspected Fibromyalgia can be diagnosed more efficiently with a questionnaire, rather than using trigger point examination. Widespread Pain Index.

Once serious pathology has been excluded, if the patient is able, hand the patient questionnaires, explaining it will help in their management. If they find it too difficult, I have one of my medical office assistants help the patients with the forms:

Brief Pain Inventory

 PHQ-9 and GAD 7 

Engaging a patient in severe pain is difficult. I demonstrate paced breathing in my office. The first video in Step 2 has a short 3 minute demonstration video. 

Providing the patient with simple Recovery Poses for severe pain can be useful, even in widespread pain. Qi-Gong can be easier to manage and there are short 10 to 13 minute exercises on the Daily Program

Prior to the patient leaving the office, a Care Plan can be established as part of partnership care.

He has no red flags. Full Core Back Exam has been normal. A Care Plan can be Established.

Hope heals. The most important treatment is the first week of treatment. There needs to be an understanding that decreasing overwhelming pain requires a diligent and disciplined recovery back program which means the person with pain may require support from support person(s).

I believe overwhelming pain often requires using medications . Obviously this has to be assessed individually. I have used Amitryptaline low doses, Cyclobenzaprine low dose at night – 5mg usually, or opioids in low doses at night, or, if indicated, more often.