Case of the Month #33: Exploring Patient Stories, Language and Communication

A 52-year-old female who worked as a medical secretary was referred to the pain management service with an eight-year history of neck and shoulder pain. She had recently moved to the area and had previously seen an array of health care professionals in relation to her symptoms, including GPs, physiotherapists, chiropractors, osteopaths, a spinal surgeon and an acupuncturist. 

During the comprehensive joint assessment session with a doctor in Pain Medicine and Clinical Specialist Physiotherapist, this patient shared her story in detail with the team. She explained her pain extended from the centre of her neck across to both shoulders and she reported the whole area felt ‘knotted’. Her pain began when she was decorating her house eight years ago when she noticed sudden onset neck pain and tingling in her right arm. The tingling symptoms settled after a couple of months, but her neck pain had gradually increased in severity since.

• What other information would you like to ask during her initial assessment session with the pain service? 
• What questions could you ask to explore her understanding and beliefs about her pain?
• What would you look for on examination?

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When assessing a patient’s history of pain, it is important to listen to their story, using appropriate open and closed questions to help gather the detail. Using a SOCRATES (Site, Onset, Character, Radiation, Associations, Time course, Exacerbating / relieving factors, Severity) approach to assessment can be helpful.
You may consider asking her the following to explore her beliefs about her pain:

• "What do you think is going on?”
• “When you feel the pain, what is it telling you? What does it mean?”
• “Do you think you could make it worse?”
• “What worries or concerns you most?”
• “What do you think this means for work/activity/the future?"

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The team explored this patient’s story of living with persistent pain, using a biopsychosocial approach. She explained her tingling arm pain settled a few weeks after her pain began but her neck and shoulder pain persisted. She carried on working throughout but explained she took extra care to avoid turning her head and adapted by using her whole body to turn. She explained that she had x-rays and an MRI scan years ago, and she had been told her ‘’Discs had prolapsed’’ and she imagined this to be like the ‘’Jam in the donut squeezed out’’. She anticipated her pain would get worse in the years to come as her discs “Continue to squash and wear out”. 

She had moved to the area to look after her elderly mother a year ago, but she passed away a few months later. She worked full time but also worked in the evenings doing secretarial task for her self-employed husband, who’s business was struggling. She worried about how they would cope financially. She had tried a range of medications, creams and exercises over the years, as well as acupuncture, heat and TENS, without significant benefit. Examination revealed some tenderness over the neck and shoulder area but no abnormal upper limb neurology. Her neck movement was limited by pain.

• What would you consider when formulating a management plan for this patient?