Pain Management in End Stage Renal Disease: A Case Study
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This case study focuses on pain management techniques for an older adult diagnosed with end stage renal disease and musculoskeletal pain. The article discusses the pathophysiology, bio-psychological and social impact, pain assessment, and pain management strategies for the patient.
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Running head: CASE STUDY
Pain management
Name of the Student
Name of the University
Author Note
Pain management
Name of the Student
Name of the University
Author Note
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1CASE STUDY
Introduction- Pain management refers to the specialty medicine that has originated
from the need of treating different types of pain namely, spinal, musculoskeletal and
neuropathic pain (Macintyre and Schug 2014). Chronic or end stage kidney disease most
commonly encompasses a range of pathophysiologic mechanisms that are associated with
abnormal functions of the kidney and result in a progressive decline in the rate of glomerular
filtration (Jha et al. 2013). The assignment will elaborate on a case study of an older adult,
diagnosed with end stage renal disease and will provide an insight into the pain management
techniques that can be adopted for treatment.
Case Study- A 78 year old female X (pseudo name) had been admitted to the
nephrology department for her end-stage renal disease and reports signs of poorly controlled
pain, vascular dementia and peripheral vascular disease. The patient had been diagnosed with
ESRD in 2017, and needs dialysis every week for survival. Her family ruled out the option
for a kidney transplant. Although haemodialysis is not a permanent cure for her condition, it
has been considered as an effective strategy in increasing the life span of an affected patient.
The patient has been diagnosed with musculoskeletal pain based on the symptoms reported
such as, stiffness and aching in her legs, sleep disturbances, burning sensation in the lower
limb muscles, and widespread pain that gets worsened with her movement. Furthermore, she
also reported a swelling in the joints after minor movement and stiffness after resting for a
considerable period of time. She was diagnosed with osteoarthritis by blood tests, analysis of
the joint fluids and X-ray imaging. The patient has a body weight of 65 kilograms and was
under the prescribed medication of angiotensin receptor blockers. Assessing her joints during
a physical examination further confirmed the presence of swelling, redness and tenderness.
Pathophysiology- Pain is commonly defined as feelings of distress that are caused due
to the action of some damaged stimuli. It is also referred to an unpleasant, emotional and
sensory experience that is related with potential or actual damage to cells and/or tissues.
Introduction- Pain management refers to the specialty medicine that has originated
from the need of treating different types of pain namely, spinal, musculoskeletal and
neuropathic pain (Macintyre and Schug 2014). Chronic or end stage kidney disease most
commonly encompasses a range of pathophysiologic mechanisms that are associated with
abnormal functions of the kidney and result in a progressive decline in the rate of glomerular
filtration (Jha et al. 2013). The assignment will elaborate on a case study of an older adult,
diagnosed with end stage renal disease and will provide an insight into the pain management
techniques that can be adopted for treatment.
Case Study- A 78 year old female X (pseudo name) had been admitted to the
nephrology department for her end-stage renal disease and reports signs of poorly controlled
pain, vascular dementia and peripheral vascular disease. The patient had been diagnosed with
ESRD in 2017, and needs dialysis every week for survival. Her family ruled out the option
for a kidney transplant. Although haemodialysis is not a permanent cure for her condition, it
has been considered as an effective strategy in increasing the life span of an affected patient.
The patient has been diagnosed with musculoskeletal pain based on the symptoms reported
such as, stiffness and aching in her legs, sleep disturbances, burning sensation in the lower
limb muscles, and widespread pain that gets worsened with her movement. Furthermore, she
also reported a swelling in the joints after minor movement and stiffness after resting for a
considerable period of time. She was diagnosed with osteoarthritis by blood tests, analysis of
the joint fluids and X-ray imaging. The patient has a body weight of 65 kilograms and was
under the prescribed medication of angiotensin receptor blockers. Assessing her joints during
a physical examination further confirmed the presence of swelling, redness and tenderness.
Pathophysiology- Pain is commonly defined as feelings of distress that are caused due
to the action of some damaged stimuli. It is also referred to an unpleasant, emotional and
sensory experience that is related with potential or actual damage to cells and/or tissues.
2CASE STUDY
Musculoskeletal pain are caused due to injury to the joints, bones, tendons, muscles, and
ligaments (Mayer and Bushnell 2015). Although osteoarthritis had earlier been categorised as
a non-inflammatory form of arthritis, there is mounting evidence to suggest that the
inflammation occurs as a result of release of metalloproteinase and cytokines, into the joints.
These compounds are primarily involved in excessive degradation of the matrix, which in
turn characterises the degeneration of cartilage in osteoarthritis. A fine balance of the water
content present in a healthy cartilage is maintained due to the compressive force that drives
out water, and osmotic and hydrostatic pressure that draw in water (Arden et al. 2014). The
collagen matrix is shows a disorganised state during the onset of the condition, along with a
subsequent decrease in the content of proteoglycan in the cartilage. Increase in water content
occurs due to breakdown of the collagen fibres (Hoff et al. 2013).
Failure of the proteoglycans to exert a protective effect increase susceptibility of the
collagen to get degraded, thereby exacerbating degeneration. Further changes include
thickening and fibrosis of the ligaments present in the joints and damage or wear of the
menisci. Research evidences have also established strong correlation between enhanced
quadriceps strength and reduction of pain (Herrero-Beaumont et al. 2017). Furthermore, a
growing body of evidences have also emphasised on the fact that chronic pain is quite
common in patients with ESRD and creates a virtual impact on different facets of health-
related quality of life (Santoro et al. 2013). There occurs an exponential increase in in the
challenges to treat chronic pain in an ESRD patient, who is on haemodialysis. All of these
changes might have resulted in the onset of osteoarthritis in the patient X, undergoing
haemodialysis for ESRD.
Bio-psychological and social impact- Time and again chronic pain has been
recognised as a main public health issue that produces a significant social and economic
burden on the sufferer and his/her family members. Severe chronic pain has been associated
Musculoskeletal pain are caused due to injury to the joints, bones, tendons, muscles, and
ligaments (Mayer and Bushnell 2015). Although osteoarthritis had earlier been categorised as
a non-inflammatory form of arthritis, there is mounting evidence to suggest that the
inflammation occurs as a result of release of metalloproteinase and cytokines, into the joints.
These compounds are primarily involved in excessive degradation of the matrix, which in
turn characterises the degeneration of cartilage in osteoarthritis. A fine balance of the water
content present in a healthy cartilage is maintained due to the compressive force that drives
out water, and osmotic and hydrostatic pressure that draw in water (Arden et al. 2014). The
collagen matrix is shows a disorganised state during the onset of the condition, along with a
subsequent decrease in the content of proteoglycan in the cartilage. Increase in water content
occurs due to breakdown of the collagen fibres (Hoff et al. 2013).
Failure of the proteoglycans to exert a protective effect increase susceptibility of the
collagen to get degraded, thereby exacerbating degeneration. Further changes include
thickening and fibrosis of the ligaments present in the joints and damage or wear of the
menisci. Research evidences have also established strong correlation between enhanced
quadriceps strength and reduction of pain (Herrero-Beaumont et al. 2017). Furthermore, a
growing body of evidences have also emphasised on the fact that chronic pain is quite
common in patients with ESRD and creates a virtual impact on different facets of health-
related quality of life (Santoro et al. 2013). There occurs an exponential increase in in the
challenges to treat chronic pain in an ESRD patient, who is on haemodialysis. All of these
changes might have resulted in the onset of osteoarthritis in the patient X, undergoing
haemodialysis for ESRD.
Bio-psychological and social impact- Time and again chronic pain has been
recognised as a main public health issue that produces a significant social and economic
burden on the sufferer and his/her family members. Severe chronic pain has been associated
3CASE STUDY
with increased risks of major mental disorders that commonly encompass anxiety, depression
and post-traumatic stress disorder (Turk et al. 2016). With a subsidisation in the pain
symptoms, the stressful response associated with mood alterations also show a marked
reduction. However, in this case scenario, the patient X was found to be constantly stressed
and tense about her health and inability to move. Over time, this stress aggravated her
emotional problem and resulted in the onset of a depressed mood that was characterised by a
reduced self-esteem, fatigue, confused thinking, social isolation and a fear of injury.
Furthermore, another major biological impact created by osteoarthritis is an impairment in
functional mobility (Bunzli et al. 2013). Research evidences have illustrated the fact that
patients with osteoarthritis commonly experience major functional limitations in their hands
and legs compared to individuals without the disease (Neogi 2013).
Additionally, depression also plays a crucial role in modifying the association
between functional mobility and knee pain (Holmes, Christelis and Arnold 2013). In this case
scenario, in addition to suffering from a persistent low mood, the patient X could not move
on her own, without assistance, which in turn can be attributed to the stiffness in her joints
and leg muscles. The subsequent disability also prevented her from participating in activities
of daily living such as, doing household chore, dressing, feeding and fulfilling certain social
roles in the context of the community or family. Behaviour and lifestyle modifications and
several psychosocial attributes have been identified imperative for accommodating to daily
activities and reducing the severity of impairment (Kjeken et al. 2013). However,
osteoarthritis has often been found to create a negative impact on the health outcomes and
daily functioning of affected people, thereby making them travel less distance or use more
transportation.
The fact that depression in the patient X influenced the relationship between her
functional mobility and knee pain is further illustrated by low mood and poor self-esteem due
with increased risks of major mental disorders that commonly encompass anxiety, depression
and post-traumatic stress disorder (Turk et al. 2016). With a subsidisation in the pain
symptoms, the stressful response associated with mood alterations also show a marked
reduction. However, in this case scenario, the patient X was found to be constantly stressed
and tense about her health and inability to move. Over time, this stress aggravated her
emotional problem and resulted in the onset of a depressed mood that was characterised by a
reduced self-esteem, fatigue, confused thinking, social isolation and a fear of injury.
Furthermore, another major biological impact created by osteoarthritis is an impairment in
functional mobility (Bunzli et al. 2013). Research evidences have illustrated the fact that
patients with osteoarthritis commonly experience major functional limitations in their hands
and legs compared to individuals without the disease (Neogi 2013).
Additionally, depression also plays a crucial role in modifying the association
between functional mobility and knee pain (Holmes, Christelis and Arnold 2013). In this case
scenario, in addition to suffering from a persistent low mood, the patient X could not move
on her own, without assistance, which in turn can be attributed to the stiffness in her joints
and leg muscles. The subsequent disability also prevented her from participating in activities
of daily living such as, doing household chore, dressing, feeding and fulfilling certain social
roles in the context of the community or family. Behaviour and lifestyle modifications and
several psychosocial attributes have been identified imperative for accommodating to daily
activities and reducing the severity of impairment (Kjeken et al. 2013). However,
osteoarthritis has often been found to create a negative impact on the health outcomes and
daily functioning of affected people, thereby making them travel less distance or use more
transportation.
The fact that depression in the patient X influenced the relationship between her
functional mobility and knee pain is further illustrated by low mood and poor self-esteem due
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4CASE STUDY
to inability to walk at a rapid speed or rise from a chair or bed, without assistance
(Abdulmonem et al. 2014). All of these factors have been identified central in limiting the
participation of the affected people in different social roles. Thus, the subsequent limitations
that occurred as a result of being diagnosed with osteoarthritis prevented the patient X in
taking part in social activities and also contributed to poor quality of life.
Pain assessment- Chronic pain is most commonly the major complaint reported by
patients diagnosed with osteoarthritis and ESRD, thereby making evaluation of pain a
fundamental requisite in assessing the health outcomes. In spite of the fact that pain is a
subjective experience, management of the condition requires certain objective standards that
are related to care. Pain is most commonly categorised into acute and chronic subtypes
depending on the continuum of duration. An analysis of the patient suggested that she was
suffering from chronic pain since it intensified and worsened over time and was found to
persist for long time period. The initial pain assessment was conducted with the adoption of
the WILDA approach that primarily focuses on words for describing pain, its location,
intensity, alleviating or aggravating condition and the duration (Dansie and Turk 2013). The
patient was asked certain questions like, “Tell me about the pain”, or “How would you
describe your pain”.
Close attention was given to the patient narrative and few words were identified from
her account as ‘burning’, ‘aching’, ‘miserable’, ‘unbearable’ and ‘sharp’. Following the
universal scale of 0-10 for clinically assessing the pain made X give her pain a score of 9 that
was associated with severe pain intensity, as perceived by her. The self-reporting
Multidimensional Pain Inventory (MPI) was also used with the aim of assessing the pain
interference and intensity, in addition to the psychological state of the patient (Choi et al.
2013). Responses provided by X for the 52 items present across three domains and 12
different subscales suggested that the patient was dysfunctional, and perceived severity of her
to inability to walk at a rapid speed or rise from a chair or bed, without assistance
(Abdulmonem et al. 2014). All of these factors have been identified central in limiting the
participation of the affected people in different social roles. Thus, the subsequent limitations
that occurred as a result of being diagnosed with osteoarthritis prevented the patient X in
taking part in social activities and also contributed to poor quality of life.
Pain assessment- Chronic pain is most commonly the major complaint reported by
patients diagnosed with osteoarthritis and ESRD, thereby making evaluation of pain a
fundamental requisite in assessing the health outcomes. In spite of the fact that pain is a
subjective experience, management of the condition requires certain objective standards that
are related to care. Pain is most commonly categorised into acute and chronic subtypes
depending on the continuum of duration. An analysis of the patient suggested that she was
suffering from chronic pain since it intensified and worsened over time and was found to
persist for long time period. The initial pain assessment was conducted with the adoption of
the WILDA approach that primarily focuses on words for describing pain, its location,
intensity, alleviating or aggravating condition and the duration (Dansie and Turk 2013). The
patient was asked certain questions like, “Tell me about the pain”, or “How would you
describe your pain”.
Close attention was given to the patient narrative and few words were identified from
her account as ‘burning’, ‘aching’, ‘miserable’, ‘unbearable’ and ‘sharp’. Following the
universal scale of 0-10 for clinically assessing the pain made X give her pain a score of 9 that
was associated with severe pain intensity, as perceived by her. The self-reporting
Multidimensional Pain Inventory (MPI) was also used with the aim of assessing the pain
interference and intensity, in addition to the psychological state of the patient (Choi et al.
2013). Responses provided by X for the 52 items present across three domains and 12
different subscales suggested that the patient was dysfunctional, and perceived severity of her
5CASE STUDY
pain as high. Furthermore, she also reported that the osteoarthritic pain directly interfered
with her life, and resulted in severe psychological distress, by reducing her activities. In order
to gain a sound understanding of the pain severity, she was also asked to mark the pain areas
on a human figure outline (Barbero et al. 2015). X circled areas around her knees and legs,
thereby confirming severe osteoarthritis.
Pain management- Owing to the complex nature of pain, there are a plethora of
therapies, medications and mind-body techniques that effectively help in management of
pain. The mainstay pharmacologic treatment for osteoarthritis include administration of
acetaminophen (Moore and Hersh 2013). However, taking cues from trials that elaborated on
the fact that acetaminophen exerts short-term effects on pain, the patient was prescribed
diclofenac, a non-steroidal anti-inflammatory drug (van Walsem et al. 2015). The drug has
been found effective in reducing presence of substances in the human body that lead to
inflammation and pain. Furthermore, its efficacy in treatment of osteoarthritis supported its
administration upon the patient. In addition, the patient was cautioned about the adverse
impacts of diclofenac that include an elevation in blood pressure, and/or gastrointestinal
bleeding (Malfait and Schnitzer 2013). 50 mg diclofenac was administered twice a day for
managing the osteoarthritic pain symptoms.
In addition, intra-articular corticosteroid injection was also used for treating the
osteoarthritic pain. This provided short-term relief from the unbearable pain, and has also
proved its efficacy in trials that focused on treatment of knee pain. The patient was also
warned of possible flare-up in symptoms within 24 hours of medication administration.
Efforts were also taken to implement appropriate alternative and complementary medicine for
treating osteoarthritis of the knees. Glucosamine and chondroitin are the most commonly
used supplements that help in pain management. A combined administration of both have
already been proved effective by different studies in the treatment of severe knee
pain as high. Furthermore, she also reported that the osteoarthritic pain directly interfered
with her life, and resulted in severe psychological distress, by reducing her activities. In order
to gain a sound understanding of the pain severity, she was also asked to mark the pain areas
on a human figure outline (Barbero et al. 2015). X circled areas around her knees and legs,
thereby confirming severe osteoarthritis.
Pain management- Owing to the complex nature of pain, there are a plethora of
therapies, medications and mind-body techniques that effectively help in management of
pain. The mainstay pharmacologic treatment for osteoarthritis include administration of
acetaminophen (Moore and Hersh 2013). However, taking cues from trials that elaborated on
the fact that acetaminophen exerts short-term effects on pain, the patient was prescribed
diclofenac, a non-steroidal anti-inflammatory drug (van Walsem et al. 2015). The drug has
been found effective in reducing presence of substances in the human body that lead to
inflammation and pain. Furthermore, its efficacy in treatment of osteoarthritis supported its
administration upon the patient. In addition, the patient was cautioned about the adverse
impacts of diclofenac that include an elevation in blood pressure, and/or gastrointestinal
bleeding (Malfait and Schnitzer 2013). 50 mg diclofenac was administered twice a day for
managing the osteoarthritic pain symptoms.
In addition, intra-articular corticosteroid injection was also used for treating the
osteoarthritic pain. This provided short-term relief from the unbearable pain, and has also
proved its efficacy in trials that focused on treatment of knee pain. The patient was also
warned of possible flare-up in symptoms within 24 hours of medication administration.
Efforts were also taken to implement appropriate alternative and complementary medicine for
treating osteoarthritis of the knees. Glucosamine and chondroitin are the most commonly
used supplements that help in pain management. A combined administration of both have
already been proved effective by different studies in the treatment of severe knee
6CASE STUDY
osteoarthritis (Fransen et al. 2014). Both of these are essential components of the cartilage
and stimulate the body to produce more cartilage. In addition, efforts were also taken to
implement certain non-pharmacological interventions such as exercise and moderate physical
activity.
Moderate exercise has many a times proved its effectiveness with respect to
management of pain and functionality in people suffering from osteoarthritis in the hips and
the knees (Messier et al. 2013). Conducting these exercise at least thrice a week might help in
managing the severe pain that X is currently suffering from. Providing clear advice to the
patient and making the exercise activities enjoyable would prove beneficial in the long run.
Furthermore, she also needs to be reassured about the significance of doing exercise. Other
nonpharmacological interventions that can be applied in this scenario include gait, functional,
and balance training for addressing the impairment of balance, position sense, and strength,
with the aim of reducing falls (Liao et al. 2013).
Spirituality is crucial in pain management because the condition is associated with
meaningless and endless suffering (Siddall, Lovell and MacLeod 2015). Spiritual issues in
this case were related to feelings of guilt, anger and despair. The patient was allowed to seek
support form a spiritual leader to manage her distress. The ethical principles of beneficence,
autonomy, nonmaleficence and justice guided the entire pain management process (Gatchel et
al. 2014). The patient’s valid consent were taken before administering any of the
interventions. This demonstrated a respect towards her decision making skills and values.
Furthermore, efforts were also taken not to inflict intentional or careless harm, in addition to
taking positive steps to help her. With an increase in the trend in medical use of NSAIDs and
opioid medications, there is a need to consult government officials for ensuring that efforts to
curb abuse of drugs are not impeding the patient’s right to pain management. Gaining a sound
knowledge of litigation that is relevant to pain management will also help in informed clinical
osteoarthritis (Fransen et al. 2014). Both of these are essential components of the cartilage
and stimulate the body to produce more cartilage. In addition, efforts were also taken to
implement certain non-pharmacological interventions such as exercise and moderate physical
activity.
Moderate exercise has many a times proved its effectiveness with respect to
management of pain and functionality in people suffering from osteoarthritis in the hips and
the knees (Messier et al. 2013). Conducting these exercise at least thrice a week might help in
managing the severe pain that X is currently suffering from. Providing clear advice to the
patient and making the exercise activities enjoyable would prove beneficial in the long run.
Furthermore, she also needs to be reassured about the significance of doing exercise. Other
nonpharmacological interventions that can be applied in this scenario include gait, functional,
and balance training for addressing the impairment of balance, position sense, and strength,
with the aim of reducing falls (Liao et al. 2013).
Spirituality is crucial in pain management because the condition is associated with
meaningless and endless suffering (Siddall, Lovell and MacLeod 2015). Spiritual issues in
this case were related to feelings of guilt, anger and despair. The patient was allowed to seek
support form a spiritual leader to manage her distress. The ethical principles of beneficence,
autonomy, nonmaleficence and justice guided the entire pain management process (Gatchel et
al. 2014). The patient’s valid consent were taken before administering any of the
interventions. This demonstrated a respect towards her decision making skills and values.
Furthermore, efforts were also taken not to inflict intentional or careless harm, in addition to
taking positive steps to help her. With an increase in the trend in medical use of NSAIDs and
opioid medications, there is a need to consult government officials for ensuring that efforts to
curb abuse of drugs are not impeding the patient’s right to pain management. Gaining a sound
knowledge of litigation that is relevant to pain management will also help in informed clinical
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7CASE STUDY
decision making (Manjiani et al. 2014). Moreover, a rigid generalizations would lead to
cultural stereotyping and serious inaccuracies. Thus, the fact that the patient’s experience of
pain will manifest in behavioural and emotional responses, particular to her personal history,
and culture, will also be taken into consideration.
Conclusion- Pain management is the branch of medicine that employs an
interdisciplinary approach in order to reduce the suffering and improve the overall health and
quality of life of patients living with chronic pain. Conducting a blood test of the ESRD
patient X ruled out other potential reasons for joint pain like rheumatoid arthritis, and helped
in diagnosing osteoarthritis. Osteoarthritis, the condition reported by the patient suffering
from ESRD was primarily characterised due to breakdown of the bone and joint cartilage,
thereby leading to stiffness and joint pain. Hence, the implementation of appropriate
pharmacological, alternative and nonpharmacological interventions, in accordance to the
cultural and legal aspects of the client was an essential step in pain management.
decision making (Manjiani et al. 2014). Moreover, a rigid generalizations would lead to
cultural stereotyping and serious inaccuracies. Thus, the fact that the patient’s experience of
pain will manifest in behavioural and emotional responses, particular to her personal history,
and culture, will also be taken into consideration.
Conclusion- Pain management is the branch of medicine that employs an
interdisciplinary approach in order to reduce the suffering and improve the overall health and
quality of life of patients living with chronic pain. Conducting a blood test of the ESRD
patient X ruled out other potential reasons for joint pain like rheumatoid arthritis, and helped
in diagnosing osteoarthritis. Osteoarthritis, the condition reported by the patient suffering
from ESRD was primarily characterised due to breakdown of the bone and joint cartilage,
thereby leading to stiffness and joint pain. Hence, the implementation of appropriate
pharmacological, alternative and nonpharmacological interventions, in accordance to the
cultural and legal aspects of the client was an essential step in pain management.
8CASE STUDY
References
Abdulmonem, A., Hanan, A., Elaf, A., Haneen, T. and Jenan, A., 2014. The prevalence of
musculoskeletal pain & its associated factors among female Saudi school teachers. Pakistan
journal of medical sciences, 30(6), p.1191.
Arden, N., Blanco, F., Cooper, C., Guermazi, A., Hayashi, D., Hunter, D., Javaid, M.K.,
Rannou, F., Roemer, F. and Reginster, J.Y., 2014. Atlas of osteoarthritis. Springer Healthcare
Limited.
Barbero, M., Moresi, F., Leoni, D., Gatti, R., Egloff, M. and Falla, D., 2015. Test–retest
reliability of pain extent and pain location using a novel method for pain drawing
analysis. European Journal of Pain, 19(8), pp.1129-1138.
Bunzli, S., Watkins, R., Smith, A., Schütze, R. and O’sullivan, P., 2013. Lives on hold: a
qualitative synthesis exploring the experience of chronic low-back pain. The Clinical journal
of pain, 29(10), pp.907-916.
Choi, Y., Mayer, T.G., Williams, M. and Gatchel, R.J., 2013. The clinical utility of the
Multidimensional Pain Inventory (MPI) in characterizing chronic disabling occupational
musculoskeletal disorders. Journal of occupational rehabilitation, 23(2), pp.239-247.
Dansie, E.J. and Turk, D.C., 2013. Assessment of patients with chronic pain. British journal
of anaesthesia, 111(1), pp.19-25.
Fransen, M., Agaliotis, M., Nairn, L., Votrubec, M., Bridgett, L., Su, S., Jan, S., March, L.,
Edmonds, J., Norton, R. and Woodward, M., 2014. Glucosamine and chondroitin for knee
osteoarthritis: a double-blind randomised placebo-controlled clinical trial evaluating single
and combination regimens. Annals of the rheumatic diseases, pp.annrheumdis-2013.
References
Abdulmonem, A., Hanan, A., Elaf, A., Haneen, T. and Jenan, A., 2014. The prevalence of
musculoskeletal pain & its associated factors among female Saudi school teachers. Pakistan
journal of medical sciences, 30(6), p.1191.
Arden, N., Blanco, F., Cooper, C., Guermazi, A., Hayashi, D., Hunter, D., Javaid, M.K.,
Rannou, F., Roemer, F. and Reginster, J.Y., 2014. Atlas of osteoarthritis. Springer Healthcare
Limited.
Barbero, M., Moresi, F., Leoni, D., Gatti, R., Egloff, M. and Falla, D., 2015. Test–retest
reliability of pain extent and pain location using a novel method for pain drawing
analysis. European Journal of Pain, 19(8), pp.1129-1138.
Bunzli, S., Watkins, R., Smith, A., Schütze, R. and O’sullivan, P., 2013. Lives on hold: a
qualitative synthesis exploring the experience of chronic low-back pain. The Clinical journal
of pain, 29(10), pp.907-916.
Choi, Y., Mayer, T.G., Williams, M. and Gatchel, R.J., 2013. The clinical utility of the
Multidimensional Pain Inventory (MPI) in characterizing chronic disabling occupational
musculoskeletal disorders. Journal of occupational rehabilitation, 23(2), pp.239-247.
Dansie, E.J. and Turk, D.C., 2013. Assessment of patients with chronic pain. British journal
of anaesthesia, 111(1), pp.19-25.
Fransen, M., Agaliotis, M., Nairn, L., Votrubec, M., Bridgett, L., Su, S., Jan, S., March, L.,
Edmonds, J., Norton, R. and Woodward, M., 2014. Glucosamine and chondroitin for knee
osteoarthritis: a double-blind randomised placebo-controlled clinical trial evaluating single
and combination regimens. Annals of the rheumatic diseases, pp.annrheumdis-2013.
9CASE STUDY
Gatchel, R.J., McGeary, D.D., McGeary, C.A. and Lippe, B., 2014. Interdisciplinary chronic
pain management: past, present, and future. American Psychologist, 69(2), p.119.
Herrero-Beaumont, G., Roman-Blas, J.A., Bruyère, O., Cooper, C., Kanis, J., Maggi, S.,
Rizzoli, R. and Reginster, J.Y., 2017. Clinical settings in knee osteoarthritis: Pathophysiology
guides treatment. Maturitas, 96, pp.54-57.
Hoff, P., Buttgereit, F., Burmester, G.R., Jakstadt, M., Gaber, T., Andreas, K., Matziolis, G.,
Perka, C. and Röhner, E., 2013. Osteoarthritis synovial fluid activates pro-inflammatory
cytokines in primary human chondrocytes. International orthopaedics, 37(1), pp.145-151.
Holmes, A., Christelis, N. and Arnold, C., 2013. Depression and chronic pain. The Medical
Journal of Australia, 199(6), pp.17-20.
Jha, V., Garcia-Garcia, G., Iseki, K., Li, Z., Naicker, S., Plattner, B., Saran, R., Wang,
A.Y.M. and Yang, C.W., 2013. Chronic kidney disease: global dimension and
perspectives. The Lancet, 382(9888), pp.260-272.
Kjeken, I., Darre, S., Slatkowsky-Cristensen, B., Hermann, M., Nilsen, T., Eriksen, C.S. and
Nossum, R., 2013. Self-management strategies to support performance of daily activities in
hand osteoarthritis. Scandinavian journal of occupational therapy, 20(1), pp.29-36.
Liao, C.D., Liou, T.H., Huang, Y.Y. and Huang, Y.C., 2013. Effects of balance training on
functional outcome after total knee replacement in patients with knee osteoarthritis: a
randomized controlled trial. Clinical rehabilitation, 27(8), pp.697-709.
Macintyre, P.E. and Schug, S.A., 2014. Acute pain management: a practical guide. Crc
Press.
Malfait, A.M. and Schnitzer, T.J., 2013. Towards a mechanism-based approach to pain
management in osteoarthritis. Nature Reviews Rheumatology, 9(11), p.654.
Gatchel, R.J., McGeary, D.D., McGeary, C.A. and Lippe, B., 2014. Interdisciplinary chronic
pain management: past, present, and future. American Psychologist, 69(2), p.119.
Herrero-Beaumont, G., Roman-Blas, J.A., Bruyère, O., Cooper, C., Kanis, J., Maggi, S.,
Rizzoli, R. and Reginster, J.Y., 2017. Clinical settings in knee osteoarthritis: Pathophysiology
guides treatment. Maturitas, 96, pp.54-57.
Hoff, P., Buttgereit, F., Burmester, G.R., Jakstadt, M., Gaber, T., Andreas, K., Matziolis, G.,
Perka, C. and Röhner, E., 2013. Osteoarthritis synovial fluid activates pro-inflammatory
cytokines in primary human chondrocytes. International orthopaedics, 37(1), pp.145-151.
Holmes, A., Christelis, N. and Arnold, C., 2013. Depression and chronic pain. The Medical
Journal of Australia, 199(6), pp.17-20.
Jha, V., Garcia-Garcia, G., Iseki, K., Li, Z., Naicker, S., Plattner, B., Saran, R., Wang,
A.Y.M. and Yang, C.W., 2013. Chronic kidney disease: global dimension and
perspectives. The Lancet, 382(9888), pp.260-272.
Kjeken, I., Darre, S., Slatkowsky-Cristensen, B., Hermann, M., Nilsen, T., Eriksen, C.S. and
Nossum, R., 2013. Self-management strategies to support performance of daily activities in
hand osteoarthritis. Scandinavian journal of occupational therapy, 20(1), pp.29-36.
Liao, C.D., Liou, T.H., Huang, Y.Y. and Huang, Y.C., 2013. Effects of balance training on
functional outcome after total knee replacement in patients with knee osteoarthritis: a
randomized controlled trial. Clinical rehabilitation, 27(8), pp.697-709.
Macintyre, P.E. and Schug, S.A., 2014. Acute pain management: a practical guide. Crc
Press.
Malfait, A.M. and Schnitzer, T.J., 2013. Towards a mechanism-based approach to pain
management in osteoarthritis. Nature Reviews Rheumatology, 9(11), p.654.
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10CASE STUDY
Manjiani, D., Paul, D.B., Kunnumpurath, S., Kaye, A.D. and Vadivelu, N., 2014. Availability
and utilization of opioids for pain management: global issues. The Ochsner Journal, 14(2),
pp.208-215.
Mayer, E.A. and Bushnell, M.C., 2015. Functional pain syndromes: presentation and
pathophysiology. Lippincott Williams & Wilkins.
Messier, S.P., Mihalko, S.L., Legault, C., Miller, G.D., Nicklas, B.J., DeVita, P., Beavers,
D.P., Hunter, D.J., Lyles, M.F., Eckstein, F. and Williamson, J.D., 2013. Effects of intensive
diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight
and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. Jama, 310(12),
pp.1263-1273.
Moore, P.A. and Hersh, E.V., 2013. Combining ibuprofen and acetaminophen for acute pain
management after third-molar extractions: translating clinical research to dental practice. The
Journal of the American Dental Association, 144(8), pp.898-908.
Neogi, T., 2013. The epidemiology and impact of pain in osteoarthritis. Osteoarthritis and
Cartilage, 21(9), pp.1145-1153.
Santoro, D., Satta, E., Messina, S., Costantino, G., Savica, V. and Bellinghieri, G., 2013. Pain
in end-stage renal disease: a frequent and neglected clinical problem. Clin Nephrol, 79(Suppl
1), pp.S2-S11.
Siddall, P.J., Lovell, M. and MacLeod, R., 2015. Spirituality: what is its role in pain
medicine?. Pain Medicine, 16(1), pp.51-60.
Turk, D.C., Fillingim, R.B., Ohrbach, R. and Patel, K.V., 2016. Assessment of psychosocial
and functional impact of chronic pain. The Journal of Pain, 17(9), pp.T21-T49.
Manjiani, D., Paul, D.B., Kunnumpurath, S., Kaye, A.D. and Vadivelu, N., 2014. Availability
and utilization of opioids for pain management: global issues. The Ochsner Journal, 14(2),
pp.208-215.
Mayer, E.A. and Bushnell, M.C., 2015. Functional pain syndromes: presentation and
pathophysiology. Lippincott Williams & Wilkins.
Messier, S.P., Mihalko, S.L., Legault, C., Miller, G.D., Nicklas, B.J., DeVita, P., Beavers,
D.P., Hunter, D.J., Lyles, M.F., Eckstein, F. and Williamson, J.D., 2013. Effects of intensive
diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight
and obese adults with knee osteoarthritis: the IDEA randomized clinical trial. Jama, 310(12),
pp.1263-1273.
Moore, P.A. and Hersh, E.V., 2013. Combining ibuprofen and acetaminophen for acute pain
management after third-molar extractions: translating clinical research to dental practice. The
Journal of the American Dental Association, 144(8), pp.898-908.
Neogi, T., 2013. The epidemiology and impact of pain in osteoarthritis. Osteoarthritis and
Cartilage, 21(9), pp.1145-1153.
Santoro, D., Satta, E., Messina, S., Costantino, G., Savica, V. and Bellinghieri, G., 2013. Pain
in end-stage renal disease: a frequent and neglected clinical problem. Clin Nephrol, 79(Suppl
1), pp.S2-S11.
Siddall, P.J., Lovell, M. and MacLeod, R., 2015. Spirituality: what is its role in pain
medicine?. Pain Medicine, 16(1), pp.51-60.
Turk, D.C., Fillingim, R.B., Ohrbach, R. and Patel, K.V., 2016. Assessment of psychosocial
and functional impact of chronic pain. The Journal of Pain, 17(9), pp.T21-T49.
11CASE STUDY
van Walsem, A., Pandhi, S., Nixon, R.M., Guyot, P., Karabis, A. and Moore, R.A., 2015.
Relative benefit-risk comparing diclofenac to other traditional non-steroidal anti-
inflammatory drugs and cyclooxygenase-2 inhibitors in patients with osteoarthritis or
rheumatoid arthritis: a network meta-analysis. Arthritis research & therapy, 17(1), p.66.
van Walsem, A., Pandhi, S., Nixon, R.M., Guyot, P., Karabis, A. and Moore, R.A., 2015.
Relative benefit-risk comparing diclofenac to other traditional non-steroidal anti-
inflammatory drugs and cyclooxygenase-2 inhibitors in patients with osteoarthritis or
rheumatoid arthritis: a network meta-analysis. Arthritis research & therapy, 17(1), p.66.
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