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14 Articles in Volume 18, Issue #2
Ask the Expert: Is there evidence to prescribe cyclobenzaprine long-term?
Challenging the Chronic Pain Personality Profile
Designer Peptide May Prevent Chemo-Induced Neuropathy
Inside the Cancer Pain Research Consortium
Intrathecal Drug Therapy for Cancer-Related Pain
Managing Cancer Pain in an Era of Modern Oncology
Mapping Complex Pain: A Case Study
Medication Overuse Headache: Inaccurate and Overdiagnosed
Pain and Fall Risk in the Elderly
Reporting Quality of Care in Cancer Pain Management
Sharing the Risk: An Update to DEA & Doctors Working Together
The Intensifying Conflict Between Opioid Control and Pain Control
Two Mobile Apps Aim to Target Patient Compliance & Safety
Why Prescribers Need to Adopt Abuse-Deterrent Opioids

Mapping Complex Pain: A Case Study

Visualizing complicated chronic pain conditions may help to align treatment approaches with multiple comorbidities. The author uses an intricate case study to propose an assessment and treatment model.

Premise

The “fog of war” has become one of the most widely used military metaphors for dealing with the uncertainties faced by a commander in the battlefield. It likely resonates with practitioners treating complex pain syndromes, such as fibromyalgia or perhaps patients in intensive care units. The term has been widely attributed to Carl von Clausewitz, although he never used the exact term itself. In his words, “war is the realm of uncertainty; three quarters of the factors on which action is based are wrapped in a fog of greater or lesser uncertainty.”1

Use of the term “fog” further implies that increased information may clear the mists and reveal the path forward. This common interpretation, however, may provide a disservice, both in the military arena 2 and in medicine. Upon further review, there is often adequate intelligence; what is lacking is a way to harvest and view existing information.

The traditional approach to documenting pain and medical conditions may be to blame. Typical methods involve rating pain via a one-dimensional visual analog scale and, on occasion, adding a second dimension of time.3  With multiple issues or comorbidities, practitioners may simply list the conditions, or, better yet, plot them over an outline of the human body.

However, addressing complaints of pain individually, rather than as a whole, directs patient care along a linear trajectory, with several ensuing disadvantages. First, the approach often ignores a patient’s own perspective on the relative importance of their symptoms. Second, it ignores the psychic satisfaction in conquering a selected easier problem early on. Finally, and most seriously, this method may tangle inter-related problems, making it harder to contextualize the issues at stake. A treatment team may ultimately find itself in an endless war of attrition punctuated by sporadic guerilla-like attacks on select problems, as the patient sinks into a morass of unrelieved pain.

This paper proposes a new way of mapping complex health issues encompassing not only pain but also a patient’s subjective functioning in society. The methodology uses three variables:

  • pain/discomfort
  • commitment needed
  • life impact.

The variable pain/discomfort is self-explanatory. Commitment needed refers to the time, effort, or other resources needed for improvement (eg, taking a pill involves far less effort than physiotherapy). Life impact reflects the patient’s estimation of how much a medical condition affects his or her daily functioning. The sample case presented below inspired this approach.

Case Study

A 64-year-old woman diagnosed with fibromyalgia, chronic low back pain, hypertension, Type 2 diabetes, and vertigo. presented to a residential multimodal setting for complex pains, opiate dependence, and increasing isolative behaviors.4 She served as the chief communication officer of a high tech company and worked primarily from a home office. She had been physically active much of her life, including international travel. During the past couple of years, however, she had decreased her work and charitable obligations to the point of becoming homebound. She cited agoraphobia as a further reason for dropping these activities, and also ceased ongoing physical therapy and aquatherapy. The patient denied present tobacco, alcohol, or drug use. Her sister had a history consistent with fibromyalgia and multiple chemical sensitivity.

Assessment

The patient self-reported her primary pains on a 10-point scale by life impact as follows, starting with four musculoskeletal pains, which may be reviewed in tandem with Figure 1 and Table I:

  • bilateral hip pains: life impact ranked 6 out of 10
  • lumbar pains: life impact ranked 7 out of 10. Note: radiology was notable for degenerative changes in the sacroiliac joints, grade 1 anterolisthesis, and moderate-severe multilevel facet arthropathy. The patient found relief with lumbar epidural and facet steroid injections every four to five months, with the most recent injection occurring three months prior. She also reported some relief with yoga, but had dropped the practice several years ago. Lidocaine patches helped as well. She had sacroiliac joints pain with a life impact ranking of 4 to 9 out of 10 and gluteal trigger points ranking 4 to 7 out of 10.
  • upper back pains/upper trapezius pains: life impact ranked 7 out of 10. Of note, a couple years prior, the patient experienced pain relief through dry needling of the rhomboids, but the symptoms had returned gradually.
  • shifting musculoskeletal (fibromyalgia) pains, appearing in areas ranging from the gastrocnemius to gluteals to the deltoids: life impact 6 out of 10.

Figure 1. A traditional diagram of the patient’s primary pain points. The diagram does not account for other issues, such as obesity, dizziness, agoraphobia, or insomnia, some of which ranked higher in the patient’s priorities.

Further questioning yielded four additional non-pain issues potentially contributing to the patient’s decline:

  • obesity: due to its social impact, the patient viewed obesity at a life impact of 10 out of 10.
  • agoraphobia: the patient cited a fear of being outdoors, especially in crowds, and rated this at 8 out of 10 in terms of life impact. She cited agoraphobia as a reason for canceling social and therapeutic appointments.
  • dizziness (diagnosed with benign paroxysmal positional vertigo): although dizziness limited the patient’s ability to exercise, she reported that prophylaxis with meclizine lowered life impact to 2 out of 10 and therefore did not pursue potentially therapeutic Epley maneuvers.
  • insomnia: life impact ranked 4 out of 10.

The physical exam was notable for obesity and multiple trigger points in the bilateral upper trapezius, right rhomboids, bilateral deltoids, bilateral gluteals, and bilateral gastrocnemius. There was moderate tenderness over the bilateral greater trochanters. The patient walked stiffly with small steps and a somewhat wide base. Her gait smoothened slightly after a few steps, but her posture remained stooped with 30 to 35 degrees flexion at the waist and 25 degrees at the knees.

Medications

The patient had tried multiple medications over the previous five years, including: pregabalin, meclizine, quetiapine, buprenorphine/naloxone (for transitioning off opioids), metformin, hydrochlorothiazide, lamotrigine, metoprolol, and pramipexole. Supplements included melatonin, cholecalciferol, and levomefolic acid.

Mapping the Patient’s Pain for Improved Care

Given the obvious difficulty in following the patient’s pain issues through a mere list, a pain map was created using the aforementioned three variables: pain/discomfort, commitment needed, and life impact. The patient’s major pain issues were rated and tabulated along these three dimensions using a 0-10 scale (See Table I). Only when plotted graphically (see Figure 2) did meaningful patterns emerge.

Figure 2. A visual representation of the multiple medical issues presented in the sample patient before treatment. Each circle represents a different issue (musculoskeletal pains are bolded), with size indicating the life impact variable. The horizontal axis plots the commitment needed variable (in terms of time and other resources), while and the Y-axis plots the pain/discomfort variable.

Aligning Treatment to a Map

While this paper focuses on physical pains, it should be noted that the treatment team spanned many disciplines, including primary care, psychiatry, neurology, physical therapy and physical medicine. Because of the prominence of obesity on the pain map, shown in Figure 2, treatment approach from the outset emphasized weight loss through food substitutions, meal timing, decreased intake, and exercise. Further motivation came from recent scientific insights into the relationship between obesity and chronic pain.5,6 In one month, the patient lost 30 lbs, leading to tapering of diabetes and hypertension medications (metformin and metoprolol were stopped; the beta-blocker decreased).

For the first four pain conditions, primarily musculoskeletal, issues, the patient underwent physiotherapy and yoga coupled with trigger point injections (upper trapezius; gluteal and lumbar, bilateral deltoids) and two rounds of bilateral hip bursitis injection. In parallel, she underwent counseling, including cognitive behavioral treatment. The patient initially encountered pain flares and almost withdrew from the program (necessitating an evening course of injections gluteal/lumbar, and hip injections). Occasionally new pains would emerge: for instance, bilateral deltoid pains consistent with trigger points, headaches, and restless legs syndrome. Over time, she reported less pain, and her posture straightened while her gait became more balanced.

Treating the patient’s agoraphobia, which had greatly increased her isolation, was prioritized. To this end, the care team explored relaxation and outdoor virtual reality scenarios.7-10 Her toleration of several outdoor simulations, including garden scapes, undersea excursions, and even roller coaster rides, helped to eliminate agoraphobia as a limiting factor. Thereafter, the patient trialed real-world excursions starting with five-minute local walks, building up to ambulating 3 miles during a 3.5-hour mall excursion.

Due to ongoing dizziness (initially a lower priority as it was fairly well controlled with medicine), the patient agreed to undergo vestibular restoration maneuvers. Insomnia was addressed indirectly through tactics undertaken for other conditions, including exercise and mindfulness, as well as ongoing quetiapine therapy.

Visualizing Progress

Figure 3 plots the patient’s status after one month of treatment. Progress is indicated graphically by circles representing pain issues that shrink and descend toward the bottom left of the chart. All of the patient’s musculoskeletal pains shrank toward the zero point. The life impact of obesity, however, remained high despite substantial weight loss (30 lbs). Agoraphobia virtually vanished from the map, but the patient’s life-impact score for dizziness rose significantly due to interference with her increasingly active lifestyle. (The increased score for her ongoing dizziness illustrates how the relative ratings may underestimate overall absolute progress).

Figure 3. Improvement noted after one month of treatment. The solid circles labeled A-G represent the patient’s pains before treatment, while the corresponding open circles labeled A'-G' represent the patient’s pain after treatment. Six issues were markedly improved, including all musculoskeletal pains (bold outlines), shrinking toward the bottom left. After losing 30 lbs, the patient still perceived obesity as a primary challenge. Arrows indicate that two other issues (dizziness and insomnia), despite any real change, now loomed relatively larger in the patient’s mind. While their relative increase underestimates overall progress, their status motivates future interventions.

 

Further refinements may be made to this model. For instance, the addition of arrows between circles (or color-coded circles) may help visualize causal links, with the caveat that too many interconnections might resemble a tangled web. The treatment team shared the map with the patient, using annotations and planned interventions on each circle, which proved helpful in guiding her progress.

Discussion & Recommendations

To the author’s knowledge, this is the first published attempt to map health and pain using anatomical, psychological, and societal dimensions. Three important general elements emerge in reviewing this case.

First, the patient’s priorities may turn out quite differently from prima facie assumptions. During open-ended inquiry, the patient admitted quite surprisingly to the treatment team that obesity impacted her life more than pain; her 50-lb increase over a two-year period had accompanied her increased isolation. This revelation led to emphasizing weight loss from the outset. The success noted herein highlighted the need to rate “life impact” rather than using traditional pain scales alone. In providing this type of valuable input, the patient became part of the care team. It is worth noting that divergences between patient and practitioner perspectives in mapping issues may in themselves prove informative. For instance, a patient might consider his or her back pain successfully controlled with opioids, until the treatment team potentially points out deleterious side effects impacting other aspects of life quality.

Second, being able to visualize the entire “battlefield” facilitates the search for creative, unifying solutions. In this case, the map led to the use of virtual reality for tackling both agoraphobia and fibromyalgia.

This holistic approach contrasts with traditional, linear assessment, which often places “the biggest problems at the top and smaller problems underneath. When there are too many small problems to consider, a horizontal line may be drawn, beneath which healthcare providers might not tread.”11 As a result, problems deemed “minor” may be ignored, only to resurface as even larger stumbling blocks in the long term.

Third, in the course of solving one issue, another pain symptom or problem may surface to replace it. By addressing existing and emerging pains, a treatment team may have to gradually strip away different layers of pain and associated conditions. While sometimes frustrating, this process can often yield more successful outcomes.

Tracking Progress

The use of numeric scales may facilitate monitoring progress quantitatively. In the clinical setting presented (see Figure 4), a statistically significant decrease was noted with treatment for pain/discomfort and life impact variables but not for the commitment needed variable. Despite marked improvement, therefore, there remained a need for ongoing commitment and vigilance to augment or even maintain progress. The ability to track such changes may be useful in research as well.

Figure 4. Note that pain/discomfort and life impact have dropped considerably, while ongoing commitment needed appears little changed. Statistical testing confirmed these results. (Paired, 1-tailed t-tests: commitment needed t = 0.79, p = 0.228; pain/discomfort t = 5.00, p = 0.001; life impact t = 2.58, p = 0.0183). Thus, despite marked improvement, a need for ongoing vigilance and treatment remained.

Potentially, a one-number index could be created using a combination of all three variables. The simplest such index could be as simple as direct summation across all issues as follows:

Index Score = ∑ (pain/discomfort + commitment neededlife impact)

In this case study involving eight conditions, a simple index score could range from 0 to 240 (8 pain issues x 3 dimensions x 10 points = 240). In this regard, the sample patient’s index score started at 146 and, over the course of treatment, dropped to 81. A caveat is that, even with a successful program, a patient’s minor problems could increase in relative size and thus lead to underestimating overall progress. However, this circumstance could motivate future interventions, and highlight the primary importance of pain mapping presented herein as a way to facilitate communication between the patient and treatment team.

Another obvious refinement to this complex pain map for research purposes could allow patients to provide ranges of scores (potentially with graphical markers indicating ranges). Different healthcare settings could also experiment with alternate variables.

Practicalities

Overall, this mapping process requires the ability of a patient to reliably provide feedback regarding his or her pain and its functional impact. While initially requiring more time, the approach may save time in the long term. In a rushed clinical setting, however, even crude hand-drawn pain maps at the bedside may provide a fairly immediate perspective and feedback. Many patients with chronic pain conditions are familiar with giving pain estimates; an evaluation of pain/discomfort provides a good starting point, priming discussion regarding more in-depth inquiries about commitment needed and life impact.

The methodology lends itself to complex conditions ranging from opioid detoxification to failed back syndrome to fibromyalgia. Often, sufferers of such conditions liken their multiple medical, functional, and societal issues to tangled knots, uncertain which issue to tackle first. This model may allow for initiating symptomatic pain care even while the search for a potential unifying cause proceeds.

Conclusion

Mapping complex pain and health conditions in the manner described may help make visible the invisible, and enable detection of patterns to guide effective, long-term treatment. This approach promotes examination of individual factors, as well as the psychological and societal dimension of a patient’s quality of life. Sequential maps may allow healthcare providers to follow changes in a patient’s condition over time. Reliance on patient input may further boost patient commitment and compliance.

Last updated on: April 12, 2019
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