Page 220 Guide to Pain Management in Low-Resource Settings

208 Mathew O.B. Olaogun and Andreas Kopf

the attention he received, and he left with the hope of to Nigeria, after about 10 weeks, he was free of pain
becoming pain free afterwards. In a phone contact lat- but still had movement restrictions. His condition
er his condition was reviewed. He was radiant on the has been stable since then. His local doctor (his son)
phone. He expressed gratitude and stated that he has saw him with a radiant smile—pain free during walk-
been feeling a lot better. He has been rigorously carry- ing and without any symptoms in his back and thigh.
ing out the exercises prescribed and has been obeying Papa returned to his work immediately and still ob-
the prophylactic instructions without any exacerbation serves the midday practice of lying supine for 30 min-
of the waist pain. Given that this is not the case in many utes at his office.
patients with the same pain syndrome, this news was Th is case report illustrates not a typical “non-
very encouraging for the therapists as well. specifi c back pain patient” but a “specifi c pain” due to
functional spinal stenosis caused by spondylolisthesis.
Case report 2 While conservative techniques are desirable, nonphar-
macological techniques are recommended, such as ex-
A 71-year-old pharmacist (Papa) had been on conser- ercise therapy, behavioral therapy, and education on
vative management for back pain for about 3 years. Th e the care of the back and on compliance with the use of
regime of treatment, aside from the earlier, occasional, rehabilitation aids. Otherwise, specifi c interventions,
analgesics, had been back extension exercises, spinal including surgery like the one described above, can
manual treatments, thermotherapy, and education on bring long-lasting relief from back pain. Diff erentiating
the care of the back. Th ough a pharmacist, Papa had between nonspecifi c back pain (which is very frequent)
not resorted to symptomatic use of medication for his and specifi c back pain (which is rare) is crucial to avoid
chronic back pain. Sometimes pain would radiate to making nonspecifi c back pain worse with intervention-
the posterior thigh, which may be “referred pain” from al techniques and analgesics, and to avoid unnecessary
the facet joints or the iliosacral joint. suff ering in patients with specifi c back pain needing lo-
A signifi cant achievement in the course of treat- cal—and sometimes invasive—therapy as well as anal-
ment was that his pain usually subsided lying down in gesics to improve.
either a supine or prone position. Papa was therefore
advised to have a table in his offi ce in an adjacent por- Why is chronic back pain
tion of his offi ce. He was advised to lie on the table at
so important?
his midday break from work for continuous decompres-
sion of intradiskal pressure. He complied very well. Chronic nonspecifi c back pain is very common. Few
However, back pain was preventing Papa from of us never have back pain; most people have periodic
walking very far. He was advised to use a lumbar cor- back pain and some have chronic back pain. Chronic
set (appropriate for patients with instability who do not back pain is mostly located in the lumbosacral and pos-
have access to stabilizing surgery) and elbow crutches terior neck region.
for partial weightbearing on the lumbar and lumbosa- In industrialized countries, low back pain
cral joints. Th e orthesis and the walking aid eliminated (LBP) is the most common cause of activity limitation
his back and posterior thigh pain. However, he started in persons younger than 45 years. It is defi ned as pain
going out less as he became anxious about using the in the low back that persists longer than 12 weeks.
walking aid and orthosis, purely for cosmetic reasons. Although acute LBP has a favorable prognosis, the ef-
He confessed that he had often felt embarrassed by fect of chronic LBP and its related disability on soci-
people staring at him or asking him about the walking ety is tremendous. For example, approximately 80%
aids. He complained and felt that more could still be of Americans experience LBP during their lifetime.
achieved to stop his pain without the use of the corset An estimated 15–20% develop protracted pain, and
and elbow crutches. approximately 2–8% have chronic pain. Every year,
In late 2006, his children invited him to go 3–4% of the population is temporarily disabled, and
abroad for medical treatment. Besides initial medica- 1% of the working-age population is disabled totally
tion, after diagnosis of lumbar instability with consid- and permanently, because of LBP. It is estimated that
erable spondylolisthesis, he underwent surgery for spi- the costs of LBP approach $30 billion annually in the
nal fusion at the level of L4/L5. When he came back United States.