Nicky's Story - A Pain Management Case Study

Background

Nicky had a below elbow amputation after she lost the use of her right arm in a road traffic accident. Due to a brachial plexus injury, Nicky underwent multiple procedures (including tendon transfers and Targeted Muscle Reinnervation Surgery) in an effort to improve her function and reduce her pain. Nicky came to us having suffered with phantom limb pain for over 20 years. She had tried some graded motor imagery techniques in the past, which had proved beneficial at the time. However, Nicky, by her own admission lacked the time to really dedicate herself to practicing techniques and prioritised other issues above managing her pain. Nicky felt that she was now in a stage of her life where she didn’t want to accept phantom limb pain as part of her daily experience and wanted to dedicate some time to trying to improve her pain experience.

Nicky is extremely active, regularly participating in sporting events and challenges such as swimming the English Channel or undertaking triathlons. Nicky found that she was using sport as a distraction from the pain but was increasingly finding that she would have to rest or withdraw from planned exercise due to severe exacerbations in her pain levels. Nicky would physically curl up in pain several times an hour due to phantom limb pain exacerbations and would remain in that position until the pain passed.

Initial Assessment

At her first appointment, Nicky completed a series of questionnaires designed to explore her pain experience, and participated in a full subjective and physical assessment. Nicky reported that her phantom limb pain was 8/10 on the Visual Analogue Scale, describing it as a gripping and burning pain that started in her elbow and tracked down to her hand with pins and needles, and a twisting session within the hand. Nicky explained that she was experiencing this pain multiple times a day, every day of the week. She had noticed that her pain worsened when she was tired or stressed and had also noted a correlation with the weather, experiencing more severe pain in stormy weather.

On examination, Nicky also had a lot of trigger points around her right shoulder, with increased muscle spasm and shortening of her trapezius muscles. Nicky’s residual limb was cool to touch (which was longstanding) and she displayed a number of compensatory movement patterns when moving her right upper limb. She only had intermittent flickers of activity in her triceps muscles but was able to actively flex her elbow due to a gracilis muscle transfer.

Nicky explained that she took a significant amount of analgesia, but found little benefit or relief in her pain. Nicky took 1800mg gabapentin a day as well as co-codamol, paracetamol and ibuprofen on a daily basis.

Nicky was very keen to engage with a phantom limb pain management programme and identified the following goals:

• To reduce her analgesic requirements
• To decrease her pain score on the Visual Analogue Scale
• To reduce the frequency of her phantom limb pain
• To improve the muscle balance around her shoulder

We then spent some time discussing phantom limb pain and the potential mechanisms for this pain. We spent some time talking about what happens in the brain after an amputation, what the latest evidence base tells us and how this supports the use of a pain management programme (based on a graded motor imagery approach) to help improve her pain experience.

Working together, we devised a treatment programme to target Nicky’s individual problem list. The programme is based on the concept of graded motor imagery, however, we also wanted to include:

• Soft tissue massage and acupuncture to reduce muscle spasm
• Relaxation techniques and sleep hygiene education to reduce stress and improve the sleep cycle
• Education about the different stages of the programme
• Muscle stimulation and exercise to improve muscle balance
• Key graded motor imagery training

Progress

Nicky engaged fully with the programme, embracing the education and principles behind each stage of the programme and practicing techniques at home inbetween face to face sessions. Nicky’s programme comprised of:

• An initial 90 minute assessment
• 6 weeks of twice weekly 90 minute treatment sessions
• A final assessment with maintenance plan and rescue plan

Nicky also has a 6 month and 12 month appointment booked to ensure she has support with maintaining her new skills and managing her pain in the long term. Nicky also has the clinic’s contact details so that she can call or email at any time for further advice or support during this period.

Nicky progressed through the 3 key stages of graded motor imagery over the course of the programme. She started off with some left/right discrimination training using the NOI Recognise app. During our sessions we talked about the evidence base behind this treatment, increased the difficulty of the training and introduced a competitive element (something which suited Nicky well!!). We also combined this with some of the other aspects of the programme including postural training, muscle stimulation and acupuncture.

Nicky then moved on to relaxation techniques and meditation scripts, techniques which fit in well with the second stage of graded motor imagery: Implicit motor imagery. We spent time visualising the phantom limb, discussing the position of the hand, the textures, the pressure areas and many other factors to ensure that Nicky had really embodied her phantom limb.

The final stage of the programme used the Neuromotus augmented reality programme; allowing Nicky to visualise her limb on the screen and control it for movement. In conjunction with this, we used magazines, NOI cards and other visual stimuli to practice visualising moving the phantom limb in to different positions whilst providing constant education, advice and tips about how to practice this at home.

Each week, Nicky would have some techniques to practice at home. Between us we made an achievable plan that fitted into her lifestyle and suited Nicky’s interests. She also kept a diary so that she could identify any changes in her pain experience.

Outcome Measures

At regular intervals, we undertake outcome measures so that we can see if there is any change or improvement in our patient’s pain experience. We also monitored Nicky’s goals and wellbeing at regular intervals. The results were as follows:

Brief Pain Inventory

This valid and reliable outcome measure is used to assess the severity of pain and its impact on daily functions. It can be used for both acute and chronic pain states and provides an objective measure of pain.

This score shows the improvements that the programme has made on Nicky’s quality of life to date. Of particular significance is the fact that Nicky’s analgesic requirements have significantly reduced (in line with GP advice) and continue to reduce. Despite this, Nicky’s overall pain experience has continued to improve with a reduced impact on her quality of life.

It is important to stress that Nicky has not yet finished the programme and is continuing to incorporate these techniques into her daily routine so further improvement may occur in the coming months.

Pain Self Efficacy Questionnaire

This simple questionnaire assesses the confidence of individuals with chronic pain in their ability to participate in activity. A lower score (<20) indicates the individual is more focused on pain and this needs to be addressed before increasing activity levels. A higher score (>40) indicates the patient is likely to respond well to a regime that incorporates physical activity.

There has been a significant improvement in Nicky’s self-efficacy, with a noticeable reduction in activity restriction as a consequence of pain.

Hospital Anxiety and Depression Score

Major amputation is associated with high rates of anxiety and depression; both of which can exacerbate chronic pain states. Anxiety often precedes depression and is poorly recognised in depression-only questionnaires. The HADS is a valid and reliable outcome measure that detects changes in mood through the measure of non-physical symptoms and manifestations. It is easy and quick to use and can prompt referral to relevant health professionals.

Over the course of the core treatment sessions, Nicky’s anxiety and depression levels have significantly reduced. At the start of treatment, Nicky’s anxiety levels were considered to be abnormal and her depression levels to be considered borderline abnormal. Both levels have now significantly reduced and are considered to be in normal range. This is likely attributable to an improved sleep pattern, a reduction in stress, and an improved quality of life due to a reduction in perceived pain levels.

Visual Analogue Scale

This is a pain rating scale that runs from 0 to 10 – 0 being no pain and 10 being the worst pain imaginable. We asked Nicky to give her average pain rating at her initial assessment and at the end of her core treatment:

As you can see, Nicky’s average pain intensity score has reduced from 8/10 to 5/10, however, Nicky was keen to point out that the frequency of her pain had reduced significantly so the amount of time that she was experiencing phantom limb pain, in her opinion, had reduced by over 50%.

Summary

Nicky has not yet come to the end of her pain management programme, but within a few months, she has already significantly reduced her pain experience, significantly reduced her analgesia and seen an improvement in her overall wellbeing. Nicky is empowered to continue to practice the techniques that she has learnt and will continue to receive support from the team as she works through more of the long-term pain management strategies. Nicky suffered with phantom limb pain for over 20 years and whilst she still has some pain, it has significantly reduced, she feels empowered to manage her own pain, and she is continuing to notice improvements in her quality of life. Nicky sums up her experience perfectly in her own words in the video below.