Chronic back pain: A case study from practice

Allex is a 54 year old man who is currently 7 in full time employment as an IT trouble shooter. He previously participated in golf, cycling and long distances running as leisure activities and enjoyed keeping fit and active.In 2003 Allex was involved in a road traffic accident when he was knocked of his bicycle by a lorry. He incurred an injury to the cervical spine. Initially he received treatment of medications and outpatient physiotherapy; however, there was no significant relief of his pain and weakness, and in 2005 Allex received a cervical fusion at one level. Despite some improvement in strength, Allex has continued to report neck and upper back pain, headaches and decreased function. He has been referred again for outpatient rehabilitation with a diagnosis of chronic back pain. Upon presentation to you, Allex appeared to hold a negative attitude towards treatment and a sceptical view that it would help. He reported that work was difficult for him as he has to sit for extended periods, and he often experiences headaches at the end of the day. He has reluctantly given up his previous hobbies as he is not able to do them without pain.

Your intervention has been exercise based. Now at 6 weeks following initial presentation, Allex has attended only 3 of 8 scheduled visits (the first, third and seventh) and he is often late when he arrives, which causes disruption to your schedule and waits for your following clients. When he does attend, he often repeats the same information to you about the changes he has had to make in his lifestyle since his original injury, and the activities he has had to give up. He continues to complain that he is experiencing pain though he did recently attempt some running again as the weather was nice and he wanted to be outside, but this increased his pain significantly. He feels that his headaches may be slightly less frequent, though wonders if this is more related to a decreased work load stress rather than your intervention. He reports that the exercises you have prescribed are difficult to do at the suggested frequency due to his busy schedule. The referring physician has asked that you contact her to discuss Allex's progress and your recommendations at this point.
Considering the above information, what factors do you feel are influencing Allex’s engagement in the programme? How would you progress in your approach to Allex?

Within the case study the problems Allex demonstrates following the road traffic accident will be explored as well as strategies that could help him to cope with his chronic disability will be identified. Prior to the accident Allex was a very active man. The study will briefly look at his attitude towards the therapy sessions and the possible reasons influencing his engagement in those sessions. A multidisciplinary approach will be examined that could possibly help to improve Allex’s engagement in the therapy sessions.
Health care professionals use the interpretive model of clinical reasoning in practice as cause and effect phenomenon are not always appropriate when analysing human behaviour (Higgs et al, 1995). The clinical reasoning process requires the clinician to have a sound knowledge base, cognition, meta-cognition, a better understanding of the patient’s perspective of his/her problem, the complexity of the clinical problem as such and the context of the problem (Higgs et al, 1995).Benner (1984), reports experts do not always follow rules but use their intuition and previous experience when taking complex decisions. In the case study a combination of different Interpretive reasoning i.e.. Procedural, Conditional and Interactive reasoning will be used.

Allex’s poor attendance to his scheduled visits to clinic regularly can be considered as symptomatic of his low motivational level. He does not perceive much incentive in changing his present behaviour, Health Belief Model (see Appendix 1) probably because he feels that there is no solution to his suffering and his resultant disability. He seems to be in the Pre contemplation stage in Transtheoretical stages of change behaviour (consisting of five stages, Prochaska, Diclemente and Norcross cited by Ogden, 2000).Allex lacks self efficacy probably due to his suffering for a long time and hence lacks any positive outcome expectancy from therapy sessions which might explain his low motivation towards attending the therapy sessions. And as he lacks determination and will to change, this affects his action plan and action control towards positive outcome. Allex’s family probably is not very supportive and Allex very frequently feels depressed due his inability to participate in social activities as a result of his disability. This further demotivates Alex in any of his endeavour towards positive behavioural change, Health Action Process Approach (See Appendix 2).
So going back, the challenge is to help Allex progress to the Contemplation stage (Transtheoretical stages of change behaviour) next and to work from there but keeping a ‘client centred approach’ (ethical principle of ‘Autonomy’) and interventions aiming to help Allex (ethical principle of ‘Beneficence’) i.e..to teach him coping strategies for him to be able to self manage his problems. The transition can be made easier for Allex by reassuring him that he has the right to have his problems heard and attended to individually (ethical principle of ‘Confidentiality and Justice’) by the health care professionals.

Bury (2004) described patients with chronic conditions as ‘Expert Patients’. Chronic conditions however result in loss of self identity/partial identity transformation in sufferers (Asbring, 2000). The diagnosis of a chronic condition and subsequently living with the effects causes major disruption in individuals’ lives. Bury (1982), introduced the term “Biographical disruption” which means life transition, in his work with arthritic patients. Similar disruptions were seen in Chronic Fatigue Syndrome (CFS) and Fibromyalgia patients (Asbring, 2000).Allex’s life transition is due to his long standing pain, headache, decreased function and social impairment. He therefore struggled to get into any biographical flow and continuity in his life (Faircloth et al, 2004). ‘His often repetition of the same information about the changes….(See Appendix A)’– are all reflections of Martin’s Biographical disruptions.

Allex lacks motivation towards therapy sessions due to his past experience (as he had physiotherapy following his injury which did not work), his pain, and his anxiety and depression, Schon (1983), describes ‘reflection in action’ which means the critical appraisal process is undertaken by a clinician when doing data collection or treating a patient, but it can be argued that diagnostic reasoning is sometimes following pattern recognition/ illness scripts (Donaghy et al, 2000),Allex’s often repetition of the same information about the changes he has had to make in his lifestyle since his original injury reflects his depressed state of mind (which further contributes to his lowered motivation towards the therapy sessions), Allex’s self perception and his social issues.

To help Allex, health care professionals can use Principles of Motivational Interviewing (Wagner, 2004) by sharing their own understanding with him of how he feels and also create an environment in which Allex will be able to express his thoughts and feelings adequately, which in turn will help to develop that relationship of trust and understanding. Facilitating a calm and supportive discussion even when Allex is defensive will help Allex to feel that he is understood and accepted. Gradual and cautious attempts than to explore differences in behaviour followed by collaborative working will help to set some achievable goals with Allex, e.g.. probably agreeing with Allex to do exercises only once a day to start with. When Allex has reached a point where he can manage the exercises without pain and within his available time, he can make gradual progression to other aspects of his backcare management routines. Spunt et al(1996), even found in their study in spinal patients, that a videodisc program helps when patients are to decide either to go for spinal surgery or to be managed conservatively. This aids in informed decision making keeping a client centred approach. It can however be argued that the study did not individually randomised patients and the results cannot be compared to other form of information i.e.. education by clinicians. But audiovisual cues could be motivating for Allex as he will be able to see how patients with similar conditions benefited from therapy, in the past. This in turn will influence his informed decision making (to attend therapy sessions) in a positive manner.

Due to the multifaceted nature of chronic pain (with its physical and psychological components), its management requires a multi disciplinary approach. However the concept of multidisciplinary team working can be argued as (Cott, 1997) found that teamworking within a ward situation constitutes a hierarchy of teams (multidisciplinary team and a nursing team) with the multidisciplinary team taking decisions and the nursing team implementing those decisions. A multidisciplinary approach will not only help Allex to take more responsibility for himself but also will help him to regain control of his life, and as it is a collaborative approach it will require patience, permission and persistence on all sides (Sofaer, 1998). Contrary to the strict medical model of patient-doctor relationship previously, Bury (2004) discussed partnership in care as a transfer of power in a therapeutic relationship away from the professional and more towards the client, when using a client-centred approach. The client is encouraged to self manage and make decisions relating to their own care. However he argued that there is a lack of evidence for this power transfer when considering the motivation of the client to make their own decisions, and the will of the professional to allow it to happen.

Guzman et al(2001), Van Tulder et al(2000) and Turner (1996) cited by Daykin (2003), found strong evidence that Cognitive Behavioural Therapy (CBT) helps to improve functions in chronic backache patients and moderate evidence that there is an improvement in pain and this impacts overall superior result in back care management. A review of literature by Reneman et al (2006), even identified a biopsychosocial association of backpain in children over and above the biomedical etiology. The review highlighted that carrying backpacks was not the main cause of back pain in the children but other psychosocial factors were involved. These included activities like a) having jobs outside schools, b) watching television, c)playing computer games. Non specific symptoms like tiredness/ abdominal discomforts/ aggressive or violent behaviour and familial history of back pain, all contributed to vulnerability to back pain in children. However it can be argued that as the study was not a Systematic review so the authors were unsure of the methodologies used for the different studies. The chronicity of Allex’s neck pain has made him overly anxious and depressed over a period of time. As a result of his sufferings he developed some negative attitudes and perceptions. Therefore in Allex’s case, an association of psychological issues to physical disability could be argued.
Due to the chronic nature of Allex’s problems, a functional restoration programme using a cognitive behavioural framework might be beneficial instead of relying just on exercise based intervention. The aims and goals of such programmes would be

• Pacing helps to break the overactivity- underactivity cycle (Shorland, 1998). Birkholtz et al (2004), reveals not to have enough evidence that links time contingency to activity pacing. For Allex however it can be argued that teaching (Pacing technique) could be beneficial to integrate exercises to his daily activities.
• Relaxation exercises (McCaffery, 1983) help to alleviate stress, reduces muscle tension and facilitates sleep which in turn helps to relief chronic pain (Shorland, 1998). Relaxation physiologically helps in the release of endorphins which acts as a natural analgesic for the body (Louie, 2004). Allex evidenced stress symptoms which subjectively can be argued by his repetition of previous information and his complaints of pain and headache, during therapy sessions. Therefore teaching Allex relaxation techniques could be beneficial although the practice of guided relaxation was found to have no statistically significant physiological effect in COPD patients, except for oxygen saturation (Louie, 2004).

Goal setting: Siegert et al (2004), reports goal setting in rehabilitation to be a dynamic and collaborative process. Involving Allex and his family in the goal setting process for the therapy sessions might be beneficial. Emmons, added a component of ‘emotion’ to goal setting and as Allex is depressed so setting up initially some pleasurable goals will set the scene for future realistic goals. Allex’s lowered confidence level and impaired social relationship due to his disability affects the goal setting process (Deci and Ryan’s self determination model cited by Siegert et al, 2004). Karniol and Ross emphasised the impact of past experience in present goal setting. Allex’s past physical fitness could be argued as a hurdle for his present realistic goal setting. Barnes and Ward states ideally when doing goal setting, the goals should be SMART (Specific, Measurable, Achievable, Realistic and Time specific) goals. In order to provide objectivity and to be able to measure outcome of interventions, SMART goals with Allex can be agreed upon which could be short term, medium term or long term. Goal setting will eventually increase Allex’s optimal level of activity, will reduce pain behaviour, will help planned gradual increments in activity and reinforcement of achievements’ (Shorland, 1998). However Pain et al (2004), argues that it is not the setting up of short term goals that works effectively all the time, but strategies of anger management as priority sometimes work better, although their work was with a Paratelic motivated athlete. However an association can be seen with young and active individuals who have become recently disabled.Allex’s anger subjectively can be argued due to his pain, his disability and his suffering for a prolonged period which prevents him from doing his job, his leisure activities and probably affects his family life.

Cognitive therapy to identify and modify maladaptive thinking processes and coping strategies (Shorland, 1998). This is achieved by patient education individually or in a group. Goodwin et al(2005), found a positive effect in disabled young people who attended summer camps in a segregated group of disabled youths by: not feeling alone, found new identity of self and also identified new levels of independence although it can be argued that the findings to be applicable to context only as the groups had few non disabled people too (thus was not a segregated group completely). Allex might benefit from attending group sessions with other chronic backpain patients, empowering him with information about his condition and teaching him some of the coping strategies will specifically help him to come out of the stressed situation and to be more compliant with his therapy regimen.

In conclusion,Allex’s inability to engage in therapy sessions can be considered multifactorial when an appropriate clinical reasoning framework is used by healthcare professionals whilst analysing physical and psychosocial issues involving his engagement.Allex’s motivational level affecting his attendance in the therapy sessions is presented with an overview of the biographical disruption/ life transition, he was in. The strategy of motivational interview discussed that could help Allex to be more compliant with his therapy sessions. It is proposed towards the end that a multidisciplinary Cognitive Behavioural Therapy (CBT) approach will not only help Allex to engage in the therapy sessions but also will help him to cope and self manage his problems (especially his chronic pain and functional limitation) better.

References for the case study:
? Asbring P (2000) Chronic illness- a disruption in life: identity –transformation among women with chronic fatigue syndrome and fibromyalgia. Journal of Advanced Nursing. 34 (3), 312-319.
? Becker (1974) cited by Ogden (2000) Health beliefs. Textbook of health Psychology (2nd edition). Open University Press.
? Benner P (1984) From novice to expert.Dreyfus model applied to nursing.28-37.
? Birkholtz M, Aylwin L and Harman RM (2004) Activity Pacing in Chronic Pain Management: One aim, but which method? Part two: National Activity Pacing Survey. British Journal Of Occupational Therapy. 67(11), 481-487.
? Bury M (2004) Researching patient- professional interactions. Journal of Health Services Research & Policy.9 (1), 48-54.
? Cott C (1997) “We decide, you carry it out”. A social network analysis of multidisciplinary long term care teams. Social Sciences Medicine. 45(9), 1411-1421.
? Donaghy ME and Morss K (2000) Guided reflection: A reflection to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice. 16, 3- 14.
? Faircloth CA, Boylstein C, Rittman M, Young ME and Gubrium J (2004) Sudden illness and biographical flow in narratives of stroke recovery. Sociology of health and illness.26(2), 242-261.
? Goodwin DL and Staples K (2005) The meaning of summer camp experience to youths with Disabilities. Adapted Physical Activity Quarterly. 22 (2), 160-78.

? Guzman J, Esmail R et al (2001) cited by Daykin A (2003) Literature review. Unpublished work.
? Higgs J and Jones M (1995) Clinical reasoning. Clinical Reasoning in the
Health Professions. Pp 3-23. Oxford Butterworth-Heinemann.
? Louie SWS (2004) The effects of guided imagery relaxation in people with COPD. Occupational Therapy International.11(3), 145-159.
? McCaffery (1983) Pain Therapies Pain Principles, Practice and Patients (3rd edition). Cheltenham: Stanley Thornes (Publishers) Ltd.
? Pain M and Kerr JH (2004) Extreme risk taker who wants to continue taking part in high risk sports after serious injury. British Journal of Sports Medicine 38, 337-339.
? Prochaska, Diclemente and Norcross cited by Ogden (2000) Health beliefs. Textbook of health Psychology (2nd edition). Open University Press.
? Reneman MF, Poels BJJ, Geertzen JHB and Dijkstra PU (2006) Back pain and backpacks in children: Biomedical or biopsychosocial model? Disability and Rehabilitation.28 (20),1293- 1297.
? Schwarzer cited by Ogden (2000) Health beliefs. Textbook of health Psychology (2nd edition). Open University Press.
? Schon cited by Donaghy ME and Morss K (2000) Guided reflection: A reflection to facilitate and assess reflective practice within the discipline of physiotherapy. Physiotherapy Theory and Practice. 16, 3- 14.
? Shorland S (1998) Management of Chronic pain following whiplash injuries. Topical Issues in Pain 2 (1st edition). Cornwall: CNS Press Ltd.
? Siegert RJ and Taylor WJ (2003) Theoretical aspects of goal- setting and motivation in rehabilitation. Disability and rehabilitation.26(1), 1-8.
? Sofaer B (1998) Pain Principles, Practice and Patients (3rd edition). Cheltenham:Stanley Thornes (Publishers) Ltd.
? Spunt BS, Deyo RA, Taylor VM, Leek KM, Goldberg HI and Mulley AG (1996) An interactive videodisc program for low back pain patients Health Education Research Theory & Research 11(4), 535-541.
Wagner C (2004) Motivational Interviewing and Rehabilitation Counseling Practice. Rehabilitation Counseling Bulletin 47(3), 152-161
Appendix 1:
Health Belief model:
-Developed initially by Rosenstock (1966) and further by Becker and colleagues throughout 1970s and 1980.
Core beliefs:
• Susceptibility to illness (example: ‘my chances of getting lung cancer are high’).
• The severity of illness (example: ‘lung cancer is a serious illness’).
• The costs involved in carrying out the behaviour (e.g. ‘stopping smoking will make me irritable’).
• The benefits involved in carrying out the behaviour (e.g.. ‘stopping smoking will save me money).
• Cues to action, which may be internal (e.g.. symptoms of breathlessness) or external (e.g. information in the form of health education leaflets).
So risks/ benefits appraisal and cues to action than result in Health Behaviour (I will stop smoking).

Appendix 2: (Health Action Process Approach).
- Social Cognition model of motivation developed by Schwarzer (1992).
- Stages of HAPA:
a) Decision making/ motivational stage.
Components of it:
? Self efficacy: ‘I am confident that I can stop smoking’.
? Outcome expectancies: ‘Stopping smoking will improve my health’. It has a subset of social outcome expectancies (e.g. ‘Other people want me to quit smoking’).
? Threat appraisal: ‘I will get lung cancer if I continue smoking’.
b) Action/ Maintenance stage.
Components of it:
? Cognitive (Volitional): Shows determination/ person’s will.
a) Action plans: ‘If offered a cigarette when I am trying not to smoke I will imagine what the tar would do to my lungs’.
b) Action control: ‘I can survive being offered a cigarette by reminding myself that I am a non- smoker’.
? Situational factor:
a) Social support: The existence of friends who encourage non- smoking.
b) Absence of situational barrier: The financial support to join an exercise club.
- HAPA bridges the gap between intention and behaviour.
- Criticisms of the HAPA:
Less rational factors like emotions are neglected.
What role do social and environmental factors play?
Do the cognitive states really exists or are created by the theorists?