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19 and 16, and a daughter aged 11. Separated from her husband for
four years, she looks after the children by herself, apart from every
On examination, Joni was very guarded when moving in any direction
second weekend when her ex-husband has the younger two children.
and held herself very rigidly throughout the consultation. She winced
Joni has had low back pain for the past eight weeks and was referred
when she did move, and said that she felt as though her spine was
by her GP, due to a failure to improve. The pain had started after she
going to break. She asked if she could lie down on the bed two or
had done some ‘spring cleaning’ at home: she was lifting the couch
when she felt her back ‘go’. She took some Panadol on and off for
Lumbar extension, lateral fl exion and rotation were all limited to one-
the fi rst few days and then saw a massage therapist on three or four
quarter range, with extension being the most painful. Joni was most
occasions over a three-week period. Joni said that she felt better
reluctant to fl ex her spine, moving her hands only one-third of the
for a few hours after the massage, but then the pain returned. She
way down her thighs. All lumbar spine movements produced back
then consulted her GP, who said that she might have strained her
pain alone. Neurological examination was unremarkable.
discs and prescribed Celebrex. Joni was very concerned about the possibility of a disc injury; her aunt had had a back problem requiring
Joni was very painful on palpation through the whole lumbar spine.
two occasions of spinal surgery, after which she was never pain-free.
There was considerable spasm through both paraspinal groups of muscles. Deep muscle contractions were very diffi cult to ascertain
Joni’s pain slowly worsened and she started taking two Panadeine
due to this spasm, but there was obviously signifi cant global muscle
Extra (15 mg codeine) tablets, 2–3 times per day. On a number of
involvement. She found it diffi cult to stand on either leg alone due to
occasions, she had taken four tablets at night due to an inability
to sleep. She felt bad doing this, as she normally tried to avoid medications as much as possible.
ANALYSIS AND TREATMENT
Joni described pain across her whole lumbar spine, equal right and
Given such a history and presentation, as her therapist what would
left side, rating it as a constant 6/10, with intermittent sharp pains
you be thinking? Why does she still have pain? How do you think she
on movement of up to 10/10. She described intermittent bilateral
posterior upper leg pain to the level of her knees up to 3/10.
What you may have noticed as you read through this case was
The pain at night prevented Joni from sleeping well. The back pain
a number of features that suggested that this was more than
built up during the day at work, proportional to the time that she
just a soft-tissue strain to the lumbar spine. As noted above, a
spent sitting. She tried to get up and move around, but her job was
biopsychosocial understanding of pain demands that a holistic
mostly sedentary—she worked four days a week in human resources
view be taken. Joni identifi ed worries about her situation, and her
at a middle management level—requiring her to sit at her desk and
medication use was erratic, even dangerous. The last eight weeks
develop protocol statements. When she was not at her desk, Joni
had seemingly taken their toll on her, and life seemed somewhat
attended meetings in the company boardroom, usually lasting for 2–3
hours with only a short break halfway through. Her pain was always
There are a number of simple pain questionnaires that are becoming
more frequently used to evaluate the psychosocial presentation
Joni thought her pain was making her lose concentration and
of patients in pain. Physiotherapists working with compensable
affecting her ability to perform her job, which was quite stressful
patients would be aware of some of them, as there is increasing
(although she normally enjoyed the challenge). She had been in her
requirement from funding bodies to use them. The questionnaires
current role for only eight months and was concerned because she
are used to identify certain features of patient beliefs, mood
had already taken a total of 12 days off work due to her pain. At that
and other cognitive factors associated with increased disability.
time, she wasn’t sure whether she would be able to continue.
Identifi cation of these factors is important because there is now extensive evidence that it is the psychosocial variables that are
Joni had no relevant history of injury or illness. Indeed, she wondered
the more important risk factors for patients who will continue into
if her current level of pain was normal for an injury, given she had
July 2013 23
Journal of Orthodontics, Vol. 34, 2007, 6–11M. A. Hain, L. P. Longman, E. A. Field, J. E. HarrisonLiverpool University Dental Hospital, Liverpool, UKNatural rubber latex (NRL) allergy can have potentially serious consequences, and reports of orthodontic patients reacting toNRL have increased significantly over recent years. It is therefore important for the orthodontist to know how to managepa
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