Transcript The Effects of Anger on Treatment and Appraisal of Chronic

Often Missed Treatable Co-Morbidities in Patients with
Treatment Resistant Chronic Pain: Case Studies
Janice J. Montbriand, University of Northern British Columbia
Dr. M. Montbriand MD, Lakeshore Medical Clinic, Regina, Sk
Abstract
AIM: To present several often missed comorbidities in patients with treatment-resistant
chronic pain through case studies in a general
medical practice, and to highlight the need for
further investigation in these areas. Due to recent
advances, some contributing co-morbidities in
chronic pain are becoming more detectable,
leading to management. METHODS: Sleep
apnea, Bipolar disorder, and occult vitamin
deficiencies were investigated in patients with
treatment-resistant chronic pain in a general
medical practice. Bipolar disorder was measured
with The Mood Disorder Questionnaire and
detailed current and retrospective interviews.
Pernicious anemia is virtually non- existent in
Canada due to folic acid supplementation in flour,
leading to undiagnosed cases of leg pain related to
vitamin levels. Testing B12 and 25-OH Vitamin D
levels could be helpful in treatment. Sleep apnea
was investigated using in-home nocturnal
oximetry. Case studies and possible treatments are
presented. RESULTS: A proportion of cases with
treatment-resistant chronic pain showed missed
diagnoses of either BP, vitamin deficiencies and/or
sleep apnea, and some patients have improved
with treatment. CONCLUSIONS: Bipolar
spectrum, vitamin deficiencies and sleep apnea
may be over-represented in patients with
treatment-resistant chronic pain in general
practice. Knowledge of these diagnoses may
substantially change the recommended treatment,
and benefit may be derived from altered treatment
in these subgroups. Further research is warranted.
Methods
Bipolar Disorder
 Vitamin D levels were measured
using 25-Hydroxyvitamin D levels and
B12 levels by standard lab tests.
 In-home oximetry was done, using a a
Simed S100E Pulse Oximeter and a
laptop with a continuously recording
serial interface program.
 The Mood Disorder Questionnaire
(MDQ) is a short self-report measure,
designed to screen for present and past
hypomanic episodes, with a sensitivity of
75% and a specificity of 90%
(Dunner, 2003). Semi-structured
interviewing was necessary to trigger
recollection.
The Leeds Assessment of neuropathic
Signs and Symptoms (S-LANNS) is a
short self-report questionnaire with a 75%
specificity and 74% sensitivity (Bennet,
Smith, Torrance & Potter, 2005).
 The aim of this poster is to highlight some
co-morbidities that affect patients with
chronic pain, and their treatments. It is
hoped that this will increase awareness of
these comorbidities and lead to improved
treatment for these patients.
Introduction
 Chronic pain produces suffering,
disability, and financial hardship.
 10% of Canadians over the age of fifteen
experience chronic pain (Government of
Canada, 2004).
 Much of chronic pain is of undefinable
origin.
 Opioid therapy is useful in only half of
all cases and reduces pain by only 2050% (Bates, 2005).
 There is a defined subgroup of patients
with chronic pain that is particularly
treatment-resistant.
 Because of the multifaceted nature of
chronic pain, comorbid problems can
stall progress if ignored.
• Bipolar disorder (BD) type II has recently
been shown to be vastly under-detected
(Allilaire et al., 2001). The atypical
presentation of patients with chronic pain
may further add to this problem.
• Taking on too much and overspending is
unlikely in cases of pain and poverty. Some
patients have admitted to energy episodes,
but were in too much pain to act out.
• Mixed state symptoms (anger, irritability,
poor concentration, and insomnia) may be
interpreted as part of the chronic pain.
Irritated/agitated depression suggests a
mixed state; this, however, may be
misinterpreted as anxiety and/or depression.
• When these factors were taken into
account, we found a noticeable presence of
BD in patients with treatment-resistant
chronic pain in our clinic.
Sleep Apnea
Vitamin D
• Vitamin D deficiency is common in the
general population and linked to certain
chronic pain disorders.
• Patients with back pain and low vitamin
D levels can decrease their pain with
supplementation (Faraj & Mutarai, 2003).
Aim
Vitamin B12
• It has been our experience that the
combination of Vitamin D
supplementation and muscle-based
treatments is much more effective than
vitamin D supplementation alone.
Case 1
 This is the case of a 47-year-old lady
with a complex history, including severe
leg pains in childhood which spread to
include her her back, right shoulder and
right arm. She did not take supplements
except during pregnancy when her pains
seemed to improve. Her condition was
complicated by mild right
femoroacetabular syndrome and right
shoulder capsulitis.
 Patient was in considerable pain, and had
been capable of little work. Her shoulder
was steroid- injected at initial visit. Most of
her remaining problems were muscular.
Vitamin D levels were found to be 8
nmol/L (normal range=25-250). She was
started on Osteoforte Vitamin D, 50,000
units every five days for the first three
months, switching to weekly thereafter.
Muscle areas that were very tense on initial
visit softened up after six weeks.
Improvements were then made easily with
very little massage and trigger injection.
She now feels greatly improved and is
presently working six hours per day.
• Sleep disturbance is very common in
patients with chronic pain, and appears to
aggravate both pain and fatigue. Normal
subjects deprived of deep sleep will develop
fatigue with musculoskeletal tenderness and
pain (Moldofsky et al., 1975).
• Multiple nocturnal hypoxic episodes are
common in chronic pain and often represent
Periodic Breathing. (Sergi et al, 1999).
Periodic Breathing can be a mild form of
sleep apnea or a form of brain dysfunction
(Gold et al, 2004). Frank sleep apnea has
been documented in rheumatoid arthritis,
male fibromyalgia, and morning-exacerbated
chronic daily headaches. Obesity is also a
risk factor for sleep apnea.
Case 2
• This is the case of a 53-year-old patient
with longstanding chronic pain in the upper
and lower back, interstitial cystitis, and
pelvic pain. Prior therapies had been
ineffective or short-lived. She had a positive
family history of depression and on detailed
questioning, she gave a history of hypomanic
episodes and a positive MDQ. During one
observed mixed state, she was agitated,
irritable, depressed and had insomnia. In this
state, she painted her bedroom in one day
and spent the next few days in bed
recovering. Another episode caused a
significant increase in muscle tightness and
pain. Her Bipolar condition had to be
addressed with medication to obtain
substantial improvement in her condition.
• Co-morbid with the pain was long-standing
fatigue and non-restorative sleep. Oximetry
demonstrated numerous hypoxic spells per
hour; further testing confirmed sleep apnea
and CPAP has improved fatigue and sleep.
• B12 deficiency leads to numbness, fatigue,and
pain.
• Certain populations are susceptible to effects of
B12 deficiency, such as patients with diabetes or
multiple sclerosis.
• Since the introduction of folic acid into flour in
Canada, pernicious anemia has becomes a late
finding, meaning B12 deficiencies are often missed.
• A recent review of clinical studies using B12 in
diabetic neuropathy suggests beneficial effects on
pain and paresthesias (Sun, Lai & Lu, 2005).
Metformin, used by patients with diabetes, can lower
B12 levels.
Case Three
• This is the case of a 59-year-old patient without
diabetes, with neuropathic quality bilateral arm pain
and numbness. Her neuropathic pain levels were
extremely high, with a score of 24/24 on the SLANNS scale. Cervical x-rays showed mild
degenerative changes. She did have a positive
response to cervical traction.
• She had mild anemia, which was not macrocytic.
B12 levels were found to be 74 pmol/L (N=132-857).
She was started on B12 supplementation, 1000mcg
subcutaneously for three doses in a two week period,
followed by oral supplementation. Following
supplementation, arm pains disappeared with very
little physiotherapy.
Summary and Further Observations
•
Occult Vitamin B12 deficiencies can lead to
continued disability. Patients with diabetes seem
particularly prone to this, and one unreported subject
with chronic pain and marginal B12 levels responded
well to B12 supplementation.
• Vitamin D deficiency is extremely common, and
tends to present with regional muscle problems.
Fibromyalgia has not been shown to respond to
supplementation. A study has demonstrated benefit in
patients with back pain, and there are responsive cases
documented with post-laminectomy syndrome.
• Bipolar spectrum presented in a surprising number
of patients with treatment-resistant chronic pain, and
may form a subgroup of Dennis Turk’s
dysfunctional” subgroup . The presentation of BD is
often atypical and requires careful questioning.
• Nocturnal oxygen desaturations are frequent in
patients with treatment-resistant chronic pain, and
were seen in three out of six subjects tested. Mild
forms of sleep apnea are often categorized as a form
of periodic breathing disorder. CPAP, sleep hygiene,
and cognitive behavioural programs have been shown
to help. There appear to be ties with the sleep
disordered breathing seen in PTSD; these cases could
respond to PTSD treatments as well.