1. 2. Please discuss your hypotheses and supporting evidence (from Dean’s presentation and research) at this stage regarding the presence of nociceptive, neuropathic and/or nociplastic pain types.

Dean’s postoperative clinical presentation was consistent with persistent neuropathic pain of the L5 and S1 nerve roots, due to mechanical sensitivity (no conduction abnormalities) (Smart et al., 2012a, 2012b, 2012c, 2009). This interpretation is supported by the persistent high level of pain, presence of night pain, easing of symptoms with walking (a natural ‘slider exercise’ for the sciatic nerve and aerobic exercise) and symptom reproduction with the SLR and Tinnell tests (Smart et al., 2012a, 2012b, 2012c, 2009; Walsh and Hall, 2009b). Biologically, it is well established that mechanical (e.g. stenosis, bone spurs) and inflammatory (e.g. disc herniation) mechanisms can lead to demyelinization of the proximal nerve root, resulting in an exposed and thus sensitive nerve root, along with activation of the dorsal root ganglion (Saal et al., 1990; Piperno et al., 1997). This sensitization (both mechanical and physiological) of the nervous system has been implicated as a source of persistent pain following lumbar surgery (Piperno et al., 1997; Ulrich et al., 2007). In Dean’s case, the surgery decompressed the nerve root, resulting in a favorable neurological outcome with abolition of weakness, numbness and decreased reflexes.

1. 3. What was your interpretation of Dean’s scores on the FABQ and his perspectives on his current status (e.g. understanding, cognitions, feelings/coping and interest/motivation/self-efficacy) with respect to your management and his prognosis?

With the advent of the ‘yellow-flags’ research (Kendall et al., 1997; Grotle et al., 2006), much attention has been given to fear avoidance, and thresholds have been established in regard to the likelihood of returning to work. It is proposed that FABQ-W scores >34 and FABQ-PA scores >14 are associated with a higher likelihood of not returning to work (Fritz and George, 2002; Burton et al., 1999). In Dean’s case, he exceeded both work and physical activity subscale thresholds, putting him at risk of not returning to work. Given the physical demands of both his truck-driving job and ‘hobby farming’, it seemed reasonable for him to have such high FABQ scores. In addition, Dean experienced persistent pain after surgery, which he reported as being contrary to his expectations. With unexpected pain after surgery, fear increases (Louw et al., 2009; Toyone et al., 2005). It has been shown that surgeons often provide patients with an expectation of little to no pain after surgery (Louw et al., 2009; Toyone et al., 2005), which seems contrary to current evidence and experience (Louw et al., 2014b). Dean seemingly had good attitudes regarding returning to work and function and appeared highly motivated, yet this ‘unexpected’ pain may have increased his FABQ scores as evident in his scores. In line with Dean’s plan of care, the psychosocial issues would feature as a key issue needing to be addressed because it is well established that pain, fear and pain catastrophization may negatively impact motor control (Moseley and Hodges, 2005, 2006; Moseley et al., 2004).

1. 4. What was your interpretation of Dean’s physical examination findings regarding possible sources of ‘symptoms’ and ‘pathology’, and likely ‘contributing factors’ to his activity and participation restrictions?

• • The surgical site/incision
  
• • Altered biomechanics and load on adjacent joints/tissues (spinal levels above and structures below, such as the sacroiliac joints and hips joints)

• • Pain from a sensitive peripheral nerve due to sustained compression, chemical irritation and demyelinization
  
• • Reperfusion hyperalgesia likely associated with increased movement and blood flow which may increase nerve sensitization (Butler, 2000)

In addition, fear-avoidance has been correlated to decreased movement and was likely a significant contributing factor to his limited movement and activity/participation restrictions.

Preoperative neurological deficits and imaging evidence of relevant pathology would have fulfilled contemporary medical criteria for neuropathic pain (Haanpaa et al., 2011; Cruccu et al., 2010; Treede et al., 2008). However, postoperatively, a clinical pattern of ‘neuropathic pain mechanical sensitivity’ was recognized that is important to inform selection of specific treatment strategies.

As recommended in Chapter 4, assessment of Dean’s ‘perspectives’ (i.e. psychosocial status) has included information obtained through both specific questioning in the patient interview and through the use of validated questionnaires. Although understanding patients’ perspectives is important to management (e.g. guiding contextualized therapeutic neuroscience education), questionnaires such as the FABQ provide added quantitative measures with predictive validity for important considerations such as returning to work. Patient perspectives exist along a continuum from positive to negative and are highly individual (Pincus and Morley, 2001). Dean’s high FABQ scores were judged ‘reasonable’, suggesting they may be on the lesser end of a stress continuum and potentially amendable. The judgement that Dean had ‘good attitudes regarding returning to work and function and appeared highly motivated’ illustrates this important attention to positive perspectives that strengthen the prognosis.

Clinical reasoning from the subjective examination is then continued throughout the physical examination, as evident in previous hypotheses regarding nociceptive and peripheral neuropathic pain types being supported through interpretation of physical examination findings. Possible sources of nociception (e.g. spinal joints, sacroiliac joints, hip joints) and potential contributing factors (e.g. altered biomechanics and load) are hypothesized, and patient perspectives (e.g. Dean’s fear-avoidance) are further supported and correlated with decreased physical movement.