Current medical history and information at the first visit
The patient is a 35-year-old woman who has been working as a caregiver. When she was in her 20s, she developed low back pain due to the physical burdens and frequent night shifts, which caused her to take two leaves of absence. After she was transferred to a department that did not require night shifts, she managed her low back pain by receiving massages and walking.
When she was 33 years old, she became the chief of the department. Due to her increased workload, her neck, shoulder, and back pain returned. Additionally, she did not get along with her boss and became depressed. An industrial physician, who was concerned about her pain and depression, referred her to a psychosomatic medicine clinic. At the clinic, a physician did not prescribe any medication and told her that she did not need to continue visiting the clinic. Thus, the industrial physician referred her to our tertiary pain management hospital.
During the first visit to our hospital, she stated, “I have heavy pain in my low back and shoulder.” She also mentioned that regular exercise relieved her pain, so she went to the gym and walked with a friend. She cried and complained about her workload and the boss. She did not have suicidal ideation and had a good appetite. She said that “Why do I have to work so hard?” but she also said that “I enjoy working and living for the work.” She suffered from sleep disturbance. She woke at 7 a.m. and fell asleep at 3 a.m. She took loxoprofen (60 mg) and clotiazepam (5 mg) once a week.
Outcome measure at the first visit
At the first visit, the patient completed six questionnaires to assess her condition. First, the Numerical Rating Scale (NRS), ranging from 0 (no pain) to 10 (worst pain imaginable) was used to evaluate the worst, least, and average pain severity over the past 24 hours as well as the current pain severity. Second, the Pain Disability Assessment Scale (PDAS) [16] was used to assess the degree of pain-related disability. The PDAS ranges from 0 to 60, with higher scores indicating a greater degree of pain-related disability. Third, the Pain Catastrophizing Scale (PCS) [17, 18] was used to measure catastrophic thinking in relation to pain. The PCS ranges from 0 to 52, with higher scores indicating greater levels of catastrophizing. Fourth, the Pain Self-Efficacy Questionnaire (PSEQ) [19, 20] was used to assess the confidence in performing activities despite the level of pain. The PSEQ ranges from 0 to 60, with higher scores indicating greater perceived self-efficacy. Fifth, the Athens Insomnia Scale (AIS) [21, 22] was used to evaluate the intensity of sleep disturbance. The AIS ranges from 0 to 24, with higher scores indicating a greater degree of sleep disturbance. Finally, the Hospital Anxiety and Depression Scale (HADS) [23, 24] was used to assess the degree of anxiety and depression. The HADS-Anxiety and HADS-Depression subscales range from 0 to 21, respectively, with higher scores indicating greater levels of anxiety and depression.
During the first visit, her NRS scores were 2 (worst), 0 (least), 5 (average), and 2 (current), while the scores for the other five scales were as follows: PDAS (8); PCS (28); PSEQ (39); AIS (6); HADS-Anxiety (11); and HADS-Depression (5) (see Table 1). These scores indicated that she felt anxiety and had mild catastrophic thinking, but did not experience as much pain severity, pain-related disability, insomnia, and depression.
Table 1
The outcome scores at each visit
| At the first visit | Six months after the first visit | At the final visit |
NRS (worst: 0–10) | 2 | 7 | 3 |
NRS (least: 0–10) | 0 | 0 | 0 |
NRS (average: 0–10) | 5 | 5 | 2 |
NRS (current: 0–10) | 2 | 6 | 2 |
PDAS (0–60) | 8 | 10 | 13 |
PCS (0–52) | 28 | 15 | 13 |
PSEQ (0–60) | 39 | 42 | 38 |
AIS (0–24) | 6 | 8 | 7 |
HADS-Anxiety (0–21) | 11 | 6 | 8 |
HADS-Depression (0–21) | 5 | 3 | 6 |
Note: NRS, Numerical Rating Scale; PDAS, Pain Disability Assessment Scale; PCS, Pain Catastrophizing Scale; PSEQ, Pain Self-Efficacy Questionnaire; AIS, Athens Insomnia Scale; HADS, Hospital Anxiety and Depression Scale. |
Psychotherapy
Since her low back and shoulder pain included no specific pathology, we decided to intervene with psychotherapy and physiotherapy. Prior to such therapies, the industrial physician took her a leave of absence because of her pain and depression. It is important to note that these therapies were performed simultaneously, and physiotherapy included patient education, stretching instruction, and strength training. In addition, she had been prescribed loxoprofen (tablet: 60 mg, tape: 100mg) by the industrial physician during the psychotherapy. She only took loxoprofen when her pain flared up.
The psychotherapy consisted of CBT for nine months, for a total of 19 sessions. Initially, we decided to intervene in sleep disturbance to improve not only such disturbance, but also pain-related disability and depression. After she was instructed on sleep hygiene and relaxation, she completed a sleep diary (Fig. 1). According to this diary, her sleep efficiency was 82.5%, and the wake-up and bed times differed every day. In this regard, she stated, “I want to sleep after I do everything that I want to do that day.” Accordingly, she went to the gym, completed take-home work, and watched recorded television programs at midnight. A psychologist recommended that she should regulate her wake-up and bed times. Based on the sleep diary, her average sleep time was six hours. Thus, she decided to go to bed at 12:15 a.m. and wake up at 6:45 a.m.
She attempted to perform sleep restriction and stimulus control. However, it was difficult for her to go to bed at 12:15 a.m. because she did not want to stop doing the activities at night. Consequently, she and the psychologist discussed how to spend her daytime hours. For example, she agreed to go to the gym earlier in the day and watch her recorded television programs in the morning. When adjusting her schedule, she looked back on the work and realized that her late hours at work as well as the excessive workload exacerbated her pain. In order to change her working style, she was taught activity pacing, after which she applied it to her housework or other activities. Due to these efforts, she was able to go to bed and wake up at the same time every day. Eventually, her sleep efficacy increased to 85.2% (Fig. 2).
During the psychotherapy, she returned to work and was transferred to a different department. Although this new department included a high physical workload, she no longer had to deal with her former boss. However, her overactivity and sleep disturbance returned, after which she stated, “It is difficult for me to use activity pacing at work.” The psychologist then asked her to identify the automatic thoughts that led to her overactivity. In this regard, she often thought, “I have to do this and that” and “I must do them perfectly.” In some instances, she even performed her colleague’s work.
Subsequently, she and the psychologist used cognitive restructuring to transform the automatic thought of “I have to do this and that” into a well-balanced thought. Specifically, she replaced this automatic thought with “I am doing my job well” and “I don’t care as long as I do what I have to do.” In addition, she attempted to take regular breaks during work. As a result, she was able to reduce her overactivity and maintain a regular bedtime.
At the final visit, she stated, “I just want to live comfortably.” Despite her lower back feeling occasional pain because of the physical burdens of caregiving, she was not worried about such pain. Although she still faced an excessive workload at certain times, she adjusted by refusing the requests for more work from her colleagues. Again, this allowed leaving work earlier and maintaining a regular bedtime.
Outcome measure at six months and at the final visit
At six months and at the final visit, she completed the same questionnaires from the first visit. At six months, her NRS scores were 7 (worst), 0 (least), 5 (average), and 6 (current), while the scores for the remaining five scales were as follows: PDAS (10); PCS (15); PSEQ (42); AIS (8); HADS-Anxiety (6); and HADS-Depression (3) (see Table 1). At the final visit, her NRS scores were 3 (worst), 0 (least), 2 (average), and 2 (current), while the scores for the other five scales were as follows: PDAS (13); PCS (13); PSEQ (38); AIS (7); HADS-Anxiety (8); and HADS-Depression (6). Based on the findings, catastrophic thinking decreased, pain-related disability increased, and the other scores remained relatively the same.