Ethnic lady grimacing in pain

Has your back pain been properly assessed? In this case study from Chartered Physiotherapist and BackCare Professional, Nick Sinfield, we take a look at how best practice in patient-centred care can make all the difference when it comes to your back pain recovery.

Mrs E was a 36 year old graphic designer. She experienced a sudden stab of pain in her lower back when leaning into her newborn daughter’s cot. Her GP prescribed painkillers, but things got progressively worse over the next few months. Sometimes the pain was so bad she could hardly walk and had to use her daughters buddy as a walking frame.

Most episodes of back pain resolve spontaneously, though we may use medication to make your back pain recovery more comfortable. However, in around 20% of cases, the pain persists long term and symptomatic relief is simply not enough.

As the pain became chronic she became very anxious about her back pain recovery. She would anticipate pain in every move, bracing herself every time she went to pick up her daughter. Her anxiety about her back made her pain worse, while the fear about carrying her daughter compounded her anxiety because she worried that she wasn’t the mother she wanted to be.

The body is naturally robust and resilient, but stress primes the nervous system to respond differently. The tendency towards anxiety and fear of movement can predict long term pain and disability.

Following her deterioration the GP asked her to complete the STarT Back Screening Tool, where she was shown to be a high-risk candidate for developing persistent pain. She was subsequently referred to a physiotherapist specialising in psychologically-informed physiotherapy – providing a comprehensive biopsychosocial assessment and management plan in order to enhance her physical and functional status.

Although most back pain spontaneously resolves, around 20% of cases do not. The most consistently evidenced predictors of long-term pain and disability are psychological factors.

The STarT Back Screening Tool is used to check if a patient is at risk of developing long-term pain and disability so that they can be referred for appropriate treatment. This targeted approach has been shown to significantly reduce pain, disability, depression and time-of-work in high risk cases.

Back Pain Recovery Workbook

This therapeutic process is based on using a standardized model where Mrs E received a psychological and physical low back pain treatment programme. Each programme is individualised in order to provide the necessary self-management skills for long term back pain recovery whilst continuously setting functional patient goals. The therapeutic focus covers low intensity cognitive behavioural therapy (CBT) for back pain, relaxation and breathing, postural education and exercise programmes consisting of strengthening, stretching and general functional exercises. She was provided with a Back Pain Personal Health Plan workbook consisting of all the educational materials supplied in the programme.

The pain management programme addresses physical fitness and functioning as well as negative thinking habits and emotional stress. The patient is taught how to take back control of their health by targeting the common factors that feed into their back pain condition.

Mrs E completed the ‘Numerical Pain Rating Scale’ (which measures pain) and the ‘Patient Specific Functional Scale’ (PSFS; measures disability) before and after the programme. Following the programme Mrs E achieved significant functional improvements – her average pain score dropped from 8.0 to 3.3 and her disability score was down from 9 to 4.

The patient-centred healthcare professional welcomes the patient into a collaborative process whereby their own goals become part of the clinical outcomes – for example, the PSFS assessment asks the patient to nominate specific personally-important activities that have been limited by their pain.

At the time of discharge she was less anxious, more positive about her future back pain recovery, no longer taking painkillers, returned to swimming, started Pilates classes and performs back stretches every day. One year after the last session, she was contacted again in order to check on her progress. She reported a continued improvement and was expecting her second child.

‘Yellow flags’ have been effectively disarmed and the patient is no longer taking pain medication. New healthy practices are adopted as part of self management and back pain recovery. Best practice in pain management emphasises empowerment and enablement with a return to normal functioning and even growth towards new levels of functioning.

Mrs E is convinced psychological factors played an important part of her ongoing pain, this therapeutic approach provided reassurance and education in order for her to become more active. These findings demonstrate the benefit of patient pathways which provide a biopsychosocial approach, patient-centred management plan and self-management educational materials for improving the functional recovery of patients suffering from low back pain.

Pain management goes beyond passive medical treatments and helps you see how your fitness and wellbeing affects your back pain. You can then take charge of your own back pain recovery and begin to get your life back.

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