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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.
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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.


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.


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.

Last updated on: April 23, 2018
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The Intensifying Conflict Between Opioid Control and Pain Control