Pain Management
Clinical Case Studies
Learning Session 2
Developed by Dr. David Hunt
Presenter’s name here
Location here
Date here
www.pspbc.ca
Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
2
Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
3
Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
4
Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
5
Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
6
Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
7
$1,540.18
$160.00
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
 49, Overweight, Married, Self Employed Movie Set
Special Effects Technician.
 March 2005 – fell off ladder at home
› Landed and twisted to left
› No Head Injury
› Shortly Developed Burning Non Radiating Pain in
Neck, Mid Back and Low Back
8
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
 2 days post accident – Saw F.P.
› Burning Pain and Stiffness at Injury Sites
› Moderate Restricted ROM, Muscle Tenderness
and Spasm
› Has to Work because of Deadlines and Lucrative
Contract
› 00100
9
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
10
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
 2 weeks post injury – Saw F.P.
› Continuing to Work With Pain and Stiffness
› Unable to Sit for Very Long
› Difficulty Sleeping, Feeling Anxious
 00100 even if visit more than 20 min
11
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
12
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
13
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
14
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
 6 MONTHS POST injury – F.P.
› Daily Severe Low Back Pain … “11/10”
› LBP Aggravated by Activity
› Pain No Longer Relieved by Chiro
› Stopped Work as Soon as Contract Ended – Has
Disability Benefits
› Feeling Helpless, Hopeless, Avoiding Family and
Friends, “Moody”
› 00100 even if visit more than 20 minutes
15
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
16
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
17
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
18
Case of Mr. M.B.
Non Specific Mechanical Low Back Pain
19
Case of Mr. M.B.
Mixed Discogenic And Neuropathic Pain
 7 MONTHS POST INJURY – F.P.
› Fell Asleep in Small Loveseat in Hyperflexed Lumbar
Position for Several Hours
› Awoke in Severe Low Back Pain and Mixed Left L5 +
S1 Nerve Root Pain to the Foot
› Pain Worse with BM’s
› “Can’t Sleep”, Angry and Irritable, anxiety and
depression worse
› Disability Payments Ceased, High Marital distress
› Neuro Intact : Positive Nerve Root Tension on Left
› 00100 even if more than 20 minutes
20
Case of Mr. M.B.
Mixed Discogenic And Neuropathic Pain
 8 months post INJURY – F.P.
› Requiring More and More Opiate for Only Partial Relief of
Back and Leg Pain
› Current Dose-HMContin 9mgm Q8h:HM-IR 8mgm/24hr
Having Back Muscle Spasms and Calf Cramps
› Started Drinking Alcohol and Smoking Pot for the Pain and
Insomnia
› Anxious and Depressed-Catastrophizing – referred for
MH&A counselor
› Back and Lower Extremity Exam Unchanged On urgent list
to see Neurosurgeon
› 00100
21
Case of Mr. M.B.
Mixed Discogenic And Neuropathic Pain
 10 months post INJURY.
› Assessed by the Neurosurgeon
› Exam:
 Positive Nerve Root Tension Signs with Crossover
 Mild Sensory Deficits in Distal Left L5 and S1
 Severe Pain Not Responding to Conservative
Therapy
 Imaging Correlates with Clinical
› Recommends Surgery
› 00100
22
CASE of MR. M.B.
Mixed Discogenic And Neuropathic Pain
 13 months post Injury.
› L4-5 and L5-S1 Discectomies with Bilateral L4-5 and L5-S1
Foramenotomies
› Post Op Pain Medication Orders do Not Factor in the High
Presurgical Dose of Opiate
› Surgeon on Holiday-Covering Surgeon Unaware of Medication
History
› Patient in Severe Post OP Pain-Accused of Drug
Seeking/Addiction
› Depression/Anxiety continuing
› Patient Self discharges AMA at Post Op Day 4
› 15300 (now 50 yrs old)
23
Questions
24