My patients pain hasn t gone away An injured worker case study

Transcription

1 My patients pain hasn t gone away An injured worker case study Dr Kevin Sleigh Learning outcomes Increase awareness of persistent pain (PP) Increase knowledge of recognition of PP How to manage early signs of PP When to refer Ongoing management 1

2 Case study discussion Mr S is a 34 year old Works as a storeman Presents with low back pain following some awkward manual handling at work the day before Mr S is a 34 year old storeman who presents to you with low back pain following some awkward manual handling at work the day before which he had been directed to do, despite his misgivings that it might hurt his back. Case study Physical examination Some tenderness right lower back laterally. Painful and restricted spinal movements. No neurological signs in the legs. Pain management Nurofen Plus has done little to alleviate his pain overnight. He says he is unable to work. Movement hurts, rest helps. 2

3 Case study You diagnose a muscle strain and begin treatment with Panadeine Forte, referral to physiotherapy and certify him unfit for work for a week. Over the following weeks despite the best efforts of you and the physio, Mr S fails to improve. You are finding yourself extending his certificate week after week and you are beginning to doubt your clinical judgement in the original diagnosis and management you will just give it a bit more time. Case study Mr S is worried there is something more serious wrong, the physio is frustrated but continues treatment and you decide to get an MRI because you want to make sure you are not missing anything. The WorkCover Insurer has organised for Mr S to be examined by an orthopaedic surgeon next month. This has upset Mr S as he thinks he is not being believed that he has pain. It is now 6 weeks since you first saw Mr S. 3

4 Case study MRI shows some minor disc bulging at multiple levels and nothing else this eases your mind. However, Mr S is anxious about his pain he has heard that disc bulges are painful. Your examination now is no different from first presentation. The physio agrees his treatment is not helping and you cease it. Mr S has been away from work for nearly 10 weeks now and you are feeling more and more frustrated. Case study The IME examination went ahead but you have no knowledge of the outcome. You are being pestered for information from the employer and insurer with phone calls and demands for a medical report. This certainly has not gone the way you expected it to! My patients pain hasn t gone away what now? 4

5 Persistent pain Pain which has persisted beyond the expected time of injury healing Need to be aware of it and when you think your patient s pain should have resolved Trust your clinical judgement Ask the question early rather than late Be aware of some early warning signs Has bio psycho social determinants Use validated tools STarT Back Screening tool (validated for lower back pain) Orebro Brief Pain Inventory PEG DASS21 K10 5

6 Practical strategies Start the conversation early Consider the whole person not just the symptom Avoid over investigation, particularly invasive procedures or imaging where red flags have been ruled out Set realistic activity goals including return to work Timely intervention is key Useful questions to ask What goals have you set around getting back to your usual activities? What progress have you made toward these goals in the last 6 weeks? What s been stopping you? How are you addressing this? What are you doing by yourself to manage your pain? 6

7 Practical strategies Allow patients to make the necessary lifestyle, behavioural and attitudinal shifts to ensure they can effectively manage their pain and optimise their change of remaining active and independent. Engage a co ordinated, co located multidisciplinary team (e.g. Network Pain Programs). Network Pain Programs Aim to help patients injured in workplace or transport accidents to manage their persistent pain, and increase their independence at home, work and in the community. Network Pain Programs Faster access to Pain Management Programs Comprehensive assessment (multidisciplinary) Comprehensive reports 6 12 week programs individual and group Links with other specialised services (psychiatrists, exercise physiologists, dieticians) 7

8 Professional development resources The following RACGP QI and CPD accredited e learning modules are available: a) Persistent Pain in the General Practice setting b) The Role of the GP in return to work including certification c) The Health Benefits of Safe Work Access the modules from the following websites: Other useful resources General Resources on the role of the GP, health benefits of work, talking about a return to work conversation starters, info on invoices, payments and policies Certificate of Capacity Resources include Medical Director and Best Practice user guides, FAQs, certificate guide and examples Services Network Pain Management Program Return to Work Case Conferencing Occupational Rehabilitation providers E-therapy 8

9 Further resources Printed For Patients and Clinicians: Australian Pain Society (2013) Take Control of Pain, Readers Digest control of pain / Butler DS and Moseley, GL (2003) Explain Pain 2 nd Ed (paperback, e book and audiobook, also available in Dutch, Spanish and Portuguese, Noigroup Publications, Adelaide Nicholas, M, Molloy, A, Tonkin, L and Beeston, L (2011) Manage your Pain 3 rd edition, ABC Books, Melbourne (paperback and e book) your pain 3rd edition Siddall, P, McCabe and Murray R (2014) The Pain Book. Hammond Care (paperback and e book also the spinal cord injury pain book) managment/the pain book Further resources Online For Patients and Clinicians: TedX: (good patient related explanation of neuropathic pain) Understanding pain clip (BrainMan): (good patient related explanation of persistent pain from the Hunter) Australian Pain Society: Health Networks, Department of Health, WA: Austin Health top 12 pain tips for consumers: NSW Agency for Clinical innovation, NSW Health: pain Mainly for Clinicians: International Association for the Study of Pain: pain.org National Pain Strategy: national pain strategy/national pain strategy (good reference and aspirational document) 9

10 Contact information WorkSafe: TAC: Provider Support: 10