Page 219 Guide to Pain Management in Low-Resource Settings

Chapter 27

Chronic Nonspecifi c Back Pain

Mathew O.B. Olaogun and Andreas Kopf

Case report 1 raising in supine position) is negative. He can perform
an abdominal curl (sitting up from the supine position)
A 27-year-old chemical engineer who has had back without pain. With the patient prone, Ely’s test (hip ex-
pain for about the past 10 years was referred for phys- tension with a straight knee) is negative, and back ex-
iotherapy. He reported with a recent radiograph, which tension does not elicit pain. Th us, there is no evidence
showed no serious pathology aside from straightening of of disk herniation, facet-joint osteoarthritis, or lumbar
the lumbar lordosis. Pain is constant but is relieved with spinal stenosis.
rest; it radiates in a nonradicular pattern into the upper Th e patient is rather disappointed that the
limb. Th e patient has taken a series of periodic medica- doctor does not prescribe a strong pain killer or pro-
tions, particularly analgesics, with no lasting modulation pose a surgical intervention. He is not really taken
of pain. Th e back pain is often exacerbated in attempts with the extensive explanations on the structure and
to get up from a lying position to a sitting position, and pathomechanics of the spine. Th e education of the pa-
often the patient has experienced pain around the waist. tient involves using a plastic model to demonstrate
On questioning, the patient complains that carrying correct lifting techniques (not exceeding 70% of body
heavy loads has damaged his spine. He had the fi rst epi- weight) and correct sitting posture, while at the same
sode of acute pain at the age of about 16, when he car- time explaining the extraordinary functional reserves
ried a 50-kg keg of water (about 100% or more of his of the spinal column. Th e patient is advised to use a
body weight at that time). Th e pain subsided after taking portable back support for his car and for chairs with
medication, but he has not been completely free of the poor ergonomic design, but to avoid extended rest and
pain since then. Th e pain has been undulating in intensi- not look after himself too much. When leaving the con-
ty, and he has continued to live with it, but he has seen a sultation room, the patient—as could be seen—was
doctor occasionally for medication. Now he explains that not fully convinced, and nobody expected to see him
he has come to the teaching hospital in Ile-Ife, Lagos, Ni- again. Interestingly, he came back a few days later for
geria, to have his pain treated “once and for all,” and, he his scheduled “education consultation” and was now
says, “even it requires surgery.” less demanding about invasive procedures but was ask-
On examination, the pain is axial around L3– ing for more advice on the etiology and the prevention
L5, not referred and nonradicular. Th e X-ray shows of back pain. He seemed to have a high motivation for
no degenerative disk disease. When he lies supine on a changing his attitudes and behavior, with an overall
table there is no pain, and Lasègue’s sign (straight leg positive approach to the future. He was satisfi ed after

Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. No responsibility is assumed by IASP 207
for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or
ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent
verifi cation of diagnoses and drug dosages. Th e mention of specifi c pharmaceutical products and any medical procedure does not imply endorsement or
recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.