Case Analysis for a Patient with a Low Back Pain

Introduction

This case study involves a 45-year-old female patient who had a problem of back pain. The patient said that she had been in the chronic condition for a period of about ten years. As she described the pain, she stated that it was a tightness across the low back which was a constant dull aching. However, she had not undergone any injury on her back. In addition to that, she denied dysfunction, any weaknesses of the lower extremities in her body, changes in the bladder, pin radiation to the extremities of the lower part and no any tingling or numbness of the lower extremities of her body. For a period of about three weeks ago, she had started a workout system with a colleague who is a body builder. The body builder advised her to take Creatine to be able to build body muscles and an antioxidant, Coenzyme Q10. She immediately started taking the medications during the working out moments. Moreover, she also takes Kava in order assist her in lowering her blood pressure for garlic and anxiety. Treatment history of her past include the following: High blood pressure, Type II diabetes from the age of 27 years and Recurrent DVT’s. Some of other treatments are Lisinopril twenty milligram, Glyburide three with breakfast and Coumadin six milligram per day. Back pain is a condition that is common in the world today, the major cause of a low back pain is usually recurrent in a lifetime of an individual which is also unpredictable. Some ten percent of individuals who are above the age of 18 years, in any 1 month, they undergo limitations of work or some other activities due to low back pain. Axial pain is usually described as aching and dull. The pain can be accompanied by mobility’s that are limited and aches in the pelvis and hips. Chronic pain is one of the different types of back pain which continues after healing of the tissues. Chronic pain takes two major categories which include pain with identifiable cause and pain with no any identifiable cause.

 

Findings following reviewing of the medication list

Back pain treatment may range from simple to most complex type of medication. The best route for the treatment is dependent on how long hurting has been disturbing your body, location and severity of your pain. Also if the pain is simply muscular or structural. In most cases, it’s recommended that you start with the conservative treatments then remedies that are home based and finally you may move to a doctor who may assist the patient. Other types of non medical treatments may include: muscle relaxants, anti-depressants, exercise which is usually involves back exercise by a combination of stretching of muscles, exercise on low impact on aerobic and many others . Any type of treatment has some disadvantages, advantages and risks. Hence, the particular problem of the patient in the lower back and the general health will indicate which will be the best pain reliever as indicated, if any.

Chronic pain is accompanied with a greater rate of anxiety and depression. After the healing of the tissue, the pain may continue and there is no any clear causes of the pain. There is variation in the causes of chronic pain. The chronic condition has been identified as the main problem instead of always being a disesase symptom. Hence, the medical specialists for the condition have really grown in numbers. Chronic pain management is usually done by a team of multidisciplinary in order to cater for all types of pain at the same time. This involves thoughts and emotions management, sensation of pain, environment and suffering. This treatments method usually involves physicians who have a foundation in anesthesiology and specialists who have understanding in psychology clinical health. Physiatrists deal with the treatment of conditions that affect movements, focusing on the bones, muscles and nerves.

Significant research has indicated that exercise is an important part in the medication of chronic pain. Mostly, when we undergo chronic pain, we usually avoid many activites in order to avoid pain to start. However, as we know that people undergoing chronic pain, over a given period of time, they gradually become unable to complete many activities that they had been enjoying before, for instance, walking and finding it difficult to do housework activities. Research has significantly shown that exercise can be the best way of treating this worsening pain and the deconditioning, and finally over time, it assists those in the condition to get involved in many activities that they could not get involved before with ease. Hence, engaging in work out programs, is advisable and highly recommended since exercise is an essential daily strategy of managing pain conditions in our body system.

There are different types of exercise recommended that can help manage the chronic pain. Stretching exercise which helps to increase and improve muscle flexibility. Every day, stretching will improve your movement in everyday times. Exercises that involves strengthening. These assists in building up muscles that are strong and stable. For instance, squats. Exercises that involves cardiovascular muscles management. They include, walking, swimming and lifting weights in a gym. Exercising in the mid-morning or early in the afternoon, is highly advisable and try to avoid doing exercises when your muscles may be fatigue. In the morning, your body may not be flexible due to drop in the body temperature. And during a workout, flexibility helps you to have a joint movement, hence you may not be able to perform optimally in the morning hours. You may communicate with your accredited body builder for more advice.

While therapy and treatments are essential in controlling pain, physical exercises and activities can highly improve your life. The less you move the more fatigue and pain you will experience. Being involved in a workout management system is the healthiest way to control the condition. In our case, the patient is undergoing the strength training. Studies have indicated that strength training can assist in treating and reducing depression, as well as even some medications. It involves using of weights that are light and slowly lifting. The ranges of motion should be shortened by taking a bicep curl.

Creatine is an organic acid which is nitrogenous that is naturally occurring in vertebrates. It helps in recycling of the ATP, mostly in the brain and muscle tissues. It helps muscle cells to increase cell energy production, speeding up of muscle growth and lowering blood sugar levels in the body.  It also improves high-intensity exercise performance such as strengths, muscle endurance and brain performance. In additional to that, creatine may reduce fatigue or tiredness due to creatine supplements. People who combine both creatine and exercise are better in chronic pain management than those who only exercised it. It’s the world’s best effective supplement for increasing mass on the muscles. Over a long period, it also assists in the fibre growth of the muscles by increasing more weights and enhancing performance in the gym. It is the most effective supplement available for muscle building.

Coenzyme Q10 which is also known as ubiquinone serves as an antioxidant that is endogenous. The CoQ10, is found in most living things and is mostly used by our body cells for energy processing and in helping the cells to function properly. As we age, naturally occurring CoQ10 reduces as we age. Other uses of CoQ10 supplements include: helping treat heart failure and high blood pressure, improving symptoms of the chronic pain syndromes and reducing the high level of cholesterols in the body system. Studies shows that individuals who have chronic fatigue syndrome might have inadequate or lack this important antioxidant. As a result, their cells do not function well in the process of food conversion to energy.

Kava, also called Kava Kava is a member of the types of family that is called nightshade and which is native to islands of the South Pacific. It has been used for more than hundred years by pacific Islands as a state of relaxation. Recently, Kava has received a greater attention for its stress-reducing and relaxation properties. However, it has been involved with different health concerns. Studies have shown that Kava lactones may have the following functions on the body: Reduce anxiety, reduce pain sensations and protect neurons from damage. It can be taken as a form of tea, liquid form or powder and capsule. Although Kava can be utilized as a safety measure in the short term, it has been associated with problems of the liver. Hence, it’s advisable to consult a doctor before taking the Kava.

From the previous treatment history of the patient, she was undergoing blood pressure treatment. As a result, back pain can increase or initiate high blood pressure because as the muscles contracts repeatedly, the blood flow is being restricted. Hence there is need to prevent any factor that may initiate increase in her blood pressure such as physical and sensory stress due to back pain. The patient had also been in Recurrent DVT’s which should also be considered while undergoing back pain treatments. The possibilities of having DVT are about eleven percent after the first year and about fourty percent after ten years. Personal risk depends on factors such as how long ago you suffered from it, cause of your first DVT and other factors. This could be managed by achieving a normal weigh and being more active physically. Also checking in with her Doctor as her health status changes, this may help in reducing DVT’s risks.

From the continuation about the historical treatments of the patient: type II diabetes is a problem which is as a result of increase in blood sugar level more than normal. People who have diabetes type II have insulin but their body does not use it. It may be caused by extra weight, genes, too much glucose from the liver, bad communication between cells and other factors. Glyburide is a diabetes medicine for type II diabetes, hence helps in controlling blood sugar level. Coumadin is a medicine that is used to treat any blood clots within the body cells such as DVT. Lisinopril is used to treat high blood pressure in individuals who are aged from 18 years old. It may also be used for other purposes such as improving survival after the heart failure. Hence, past history of the patient on medications should be highly considered as she undergoes back pain management.

Important Additional Information from the Patient

From the above findings, and the patients’ information obtained, there are some additional information that are very essential that may be helpful. The treatment of a primary coordination may depend on the awareness of the physician about the significance of history and physical examination and the patient’s need. This helps in identifying red flags that may show conditions that are more serious. Physical examination should be considered whereby the patient is examined while standing, in lying position and while sitting. Also, the findings should be go hand in hand with a given pathologic process that is known. In addition to that, looking for specific causes that are biomechanical and being in a position to note anatomic generators of the pain where possible.

Other additional information may include: knowing her current DVT condition and if she has been regularly visiting her doctor in order to reduce the risk of DVT recurrent. This should be considered since changes in her health my risk her DVT as a result of managing lower back pain using the workout program. Secondly, goals of a patient. This might be the least asked question, but it is very essential when it comes to treatment prescription. For instance, are you hoping to take a trip on a specific date or play a football? Understanding the goals will help her and the doctor in understanding the course of treatment. Last but not the least, the time the pain is worse either in the morning, evening, at night or afternoon. Does it vary or is it consistent and whether it hurts when she stands, lie down, run, walk or twist?

Recommendations for managing patient’s medications

For physical and exercise and activity, the following are the recommendations:

  1. Advise the patient that she should stay physically active which is beneficial.
  2. Structural program me exercise should be considered and offered to the patient:
  • It should involve eight sessions as a maximum period of two weeks
  • Involve her in an exercise that is being supervised in a group of about ten individuals.
  • If a group program me is not working to the patient, a one to one program me that is being supervised should be considered.
  • The following may be recommended for exercise program me:
  • Stretching
  • Strengthening of the muscles
  • Control of postural
  • Activates on aerobic
  • Instructions on movement

Most patients who may be suffering from low back pain, usually improve over a given period of time irrespective of treatment. The patient and clinicians should consider non pharmacologic medication that includes exercise, acupuncture, rehabilitation that is multidisciplinary, relaxation that is progressive, exercise that is motor control and behavioral therapy that is cognitive.

For education, information and preferences for patient, the following are recommended:

  1. Give the patient adequate information and advise in order to promote their low back pain self-management
  2. Provide education advice that may involve information on the nature off low back pain that is not specific and encourage the patient to remain active by continuing with normal activities.
  • Take into consideration the patients’ preferences and expectations while taking into account treatments that are recommended. But the recommendation and responses should not be used as a prediction for a treatment.

For a combined physiological and physical medication program me; for a period of one hundred hours over a time period of eight weeks, for patients who: have undergone at least treatment that is less intensive and have a high level of psychological distress. Combined physiological and physical medication program me should involve a behavioral approach that is cognitive. Some of other non-pharmacological therapies that are electrotherapy modalities may include: Offering laser therapy is not recommended, do not offer therapy that is interferential and traction. Also avoid offering lumbar supports and therapeutic ultrasounds.

For procedures that might be invasive, avoid offering injections of substances that are therapeutic into the back for a low back pain that is non-specific. Moreover, it is advisable to offer a course that involves acupuncture needling which may comprise up to ten sessions maximum for a time period of twelve weeks. It is also recommended to provide a course that will include manual therapy that may comprise up to a nine sessions for a period of twelve weeks maximum.

Components for educating the patient

Patient education is a system by which professionals who have specialized in health, and others channel information to patients and other individuals that might be taking care of her that it may improve their health status and behavior positively. Education may be undertaken by a healthy professional that have knowledge about appropriate education on patients education and communication, training education which is always found in the training of health professionals. The most appropriate tools for patient education are responsibility that includes skill building, group effort which is also important and each and every member of the patient’s team that are involved in the health care.

There is need to use patient education in order to help the patient to understand and learn more on her pain and what to go about it. Providing an intensive education to the patient will highly contribute into her recovery in an effective way. This can mean a discussion that may involve a special class, health professional, information’s that is written in form of booklets or some other formats that may include videos. It may include: avoiding worry and going back to normal activities. Remaining active and ways to restrain from future back pains. In addition to that, education sessions that are longer than 12 weeks, providing information that is written that will involve in person education should be included.

Sessions for in-person patient education should also be involved. They may last atleast one or two hours as they undergo their daily care. This may help the patient to appreciate and have individual understanding of  the information provided regarding patient education on low back pain management. The message should be well understood by the patient, and it should create a positive change concerning low back pain. Some of the recommended written materials may include: educational materials about back pain. This will highly contribute in decreasing the risk of the disorder progression toward disability due to low back pain.

Competences of the patient education can be assessed by considering the following factors: By using technology in appropriate and effective way. Be current in the field of back pain and ensure that you continue to advance in education effectively. Also, ensure that you provide evidence-based, accurate and competent care to the patient. Focusing on a centered relationship care with the patient and her families. Be sensitive to the culture of the patient and being open to a different society.

In summary, the importance and value of a patient education can be said to be : It will help the patient to be in a position to comply and be motivated to get well. Patient is more likely to provide a positive response their treatment plan. Increased and improved understanding of disease and medical condition. Informed consent whereby the patient will feel that have information that they mostly needed. It also provides enhanced understanding of means and methods to be able to manage different aspects of medical conditions and patient is most likely to refer her friends and feel much satisfied.

Medical Prescription

A prescription is a program involving a health care that is being implemented in the form of instructions by a  physician or practinioner that are qualified which govern the individual patient plan of care. Both acute and low back pain are being treated by a wide range of medications.

They involve over the counter aspirin and acetaminophen. Also prescription opiods like hydrocodone and morphine.

  1. NSAIDs

Non-steroidal anti-inflammatory drugs or NSAID’s for instance, Advil,Nuprin helps with pain management by reducing any inflammation and pain which is a common component of many types of back pain. They are the most prescribed mediciens in the world. There are different subdivisions of NSAIDs medicine types, each having different properties and side effects. Over the counter, they include ketoprofen and naproxen sodium which are fairly inexpensive.

NSAIDs table for short term use( less than two weeks ) for mild to moderate LBP.

Type Drug(Brand) Related indications for LPB Dosage Comments/Side effects
                                                           Non Selective NSAIDs
Salicylates Aspirin(Generic) Acute Pain,

OA/RA

Acute pain: 32A. 1000 mg. 6 to 4 hours. Contraindications: peptic ulcer disease, pregnancy, cardiac surgery, bleeding disorder, epilepsy and psychlatric disordes.
Salicylate Diflunisal (Generic,Dolobid) Acute or Chronic pain. QA/RA Acute pain 1000 mg in the first time. 500 mg for every 8 to 12 hrs  
Phenylacetic Acid Diclofenac sodium(Voltaren SR, Voltaren, Voltaren XR) Acute pain,

RA/QA

50 mg . Max: 200mg/d  
Indoleacetic Acids Etodolac (Ultradol,generic) Acute pain, RA/QA Acute pain: 200 to 400 mg for every 6 to 8 hrs.  
Indoleacetic Acid Indomethacin(Indocin,generic) QA/RA 25mg tid or mid; max, 200 mg/d  
Indoleacetic Acid Tolmetin (Toletin,generic) QA/RA 400 mg tid; max dose: 1,800 mg/d  
Indoleacetic Acid Sulindac (Clinoril, generic) RA/QA 150 mg tid or mid with food. Max dose, 400 mg/d  
Oxicams Meloxicam(Mobic and generic) QA/RA 7.5-15 mg. Once per day. Max; 15 mg/d  
Oxicams Piroxicam (Feldene,generic) QA/RA Twenty mg per day  
Napthylkanoes Nabumetone(Relafen,generic) QA/RA 1000 mg/d per day. Max, 1800 mg/d  
                                                        Selective NSAIDs
COX-2. Selective inhibitors Celebrex Acute pain. QA/RA 100-200mg bid, it’s dependednt on the indication. Use with caution for patients with cardiac disease and hypertension.
  1. Muscle Relaxants

These are groups of medications which are used to treat severe LBP that is severe and mild . They usually work by hindering neuronal of the central polysynaptic events that affect the skeletal muscles indirectly. They are divided into two types that is antispastic and antispasmodic.

Muscle Relaxants as adjunctive Treatment of mild to severe Acute LBP

Type Drug(Brand)  Usual Dosage Comments/Side effects
Benzodiazepine

 

Alprazolam(Xanax,Xanax XR and generic) 0.25 to 1 mg tid . Use with caution with patients who have addiction history.
Clonazepam (Klonopin,generic) 0.1 to 1 mg bid
Dalmane (Flurazepam) 30 mg per day
Diazepam (Valium,generic) Muscle relaxant:

2.5 to 10 mg qid to tid as needed

Benzodiazepine

 

Hydroxyzine(Vistaril,generic) 800 mg tid to qid as needed  
Nonbenzodiazepine Cyclobenzaprine(generic,Flexeril) 5 to 10 mg tid as needed. Contraindications may include: congestive heart failure,disturbances that may involve heart block conductions and hyperthyroidism.
Carisoprodol (generic, soma) 250 to 350 mg Withdrawal, drug dependence and abuse.
Tizanadine(generic and Zanaflex) 8 mg for every six to eight hrs as needed. Max: 36mg/d Use with caution with patients who are renal impairment and hepatic
Antispatstic Dantrolene (generic, Dantrium) 25 to 100 mg tid Contraindications may include: diseases related with active hepatitis, with caution to those patients who have a history of liver dysfunction, muscle weakness and impaired cardiac.
  • Anti-depressants

These are commonly utilized for diagnosis of psychiatric, however there is evidence that they benefit adjunctive analgesics for syndromes that are related with pain. SSRIs, SNRIs and TCAs have been used in the following table.

Antidepressants as Adjunctive Treatment for Neuropathic LBP

Drug Name (Brand) LBP related indication Usual Dosage Comments/Side effects
                                        Tricyclic   Antidepressants
                                       Antidepressants
Amitriptyline (Elavi,generic) Chronic pain(off label) 25 to 100 mg per day . Longest history of use that is related with chronic pain; doses for curing pain less than a dose for treating depression. Use with caution in elderly
Desipramine (Norpramin,generic) Postherpetic neuralgia (Off label) 25 to 150 mg daily
                                                            SSRIs
Duloxetine(Cymbalta) Chronic Musculoskeletal pain; neuropathic pain  30 to 60 mg daily Not recommended with patients with hepatic impairments

In Conclusion, the patient should be highly monitored through follow up on medication, workout program and educational  programs in order to improve her  condition.

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