CCE-CBD-200

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How do you differentiate between nociceptive, neuropathic, and central sensitisation pain?
• Prompt: What factors contribute to chronic pain persistence?

Q2. What are your initial management steps?

• Prompt: What multimodal approaches are effective for chronic pain?
• Prompt: When would you refer to a pain specialist or psychologist?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you discuss opioid reduction and alternative pain management strategies?
• Prompt: How can you support the patient’s emotional and functional well-being?

Q4. What lifestyle and psychological interventions can help manage chronic pain?

• Prompt: What role does exercise and pacing play in chronic pain?
• Prompt: How does cognitive behavioural therapy (CBT) help with chronic pain?

Q5. What are the red flags that would necessitate further assessment or specialist referral?

• Prompt: What clinical features suggest an underlying serious pathology (e.g., malignancy, infection)?
• Prompt: How would you manage suspected opioid dependence or misuse?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

Chronic pain is complex and influenced by biological, psychological, and social factors.

Differential Diagnoses:

1. Chronic Lower Back Pain with Central Sensitisation (Most Likely Diagnosis)
   • Key features: Persistent pain beyond tissue healing time, no nerve root compression.
   • Psychosocial factors (low mood, social isolation) contribute to chronicity.
2. Neuropathic Pain (Failed Back Syndrome, Radiculopathy)
   • Key features: Burning, shooting pain with sensory changes.
   • Absent in this case—no neurological deficits.
3. Osteoarthritis (OA) of the Spine
   • Key features: Progressive pain and stiffness, relieved by rest.
4. Inflammatory Arthritis (Ankylosing Spondylitis, Psoriatic Arthritis)
   • Key features: Morning stiffness >30 minutes, improves with activity.
   • Less likely here—no inflammatory markers or systemic symptoms.
5. Opioid-Induced Hyperalgesia
   • Key features: Worsening pain despite opioid use.

Most Likely Diagnosis:

• Chronic lower back pain with central sensitisation, worsened by psychosocial factors.

---

Q2: What are your initial management steps?

Answer:

1. Multimodal Approach (Biopsychosocial Model)

• Physical therapy:
  • Gradual graded exercise program, hydrotherapy.
  • Pacing strategies to avoid pain flares.
• Psychological Interventions:
  • Cognitive Behavioural Therapy (CBT) to address pain-related distress.
  • Mindfulness-based stress reduction (MBSR).
• Pharmacological Adjustments:
  • Reduce opioids (gradual tapering).
  • Consider pregabalin or duloxetine for neuropathic pain features.

2. Referral & Monitoring

• Pain specialist referral for complex cases.
• Follow-up in 4 weeks to monitor function and medication use.

---

Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Chronic pain is a condition where the nervous system remains sensitive, even after the initial injury has healed.”
• “This does not mean the pain isn’t real—it’s very real, but we need to retrain your nervous system.“

Treatment Plan:

• “We will focus on exercise, pacing, and psychological strategies to manage pain long-term.”
• “Opioids are not ideal for chronic pain, so we will explore safer alternatives.”

Safety-Netting:

• “If you experience worsening pain, new weakness, or bowel/bladder issues, return immediately.“
• “We will follow up in 4 weeks to track progress.”

---

Q4: What lifestyle and psychological interventions can help manage chronic pain?

Answer:

• Exercise & Pacing:
  • Low-impact aerobic exercise, hydrotherapy, yoga.
  • Avoid boom-bust cycles by pacing activities.
• Psychological Approaches:
  • CBT to address pain perception.
  • Acceptance and Commitment Therapy (ACT).
• Sleep & Stress Management:
  • Good sleep hygiene and relaxation techniques.
• Nutrition & Weight Management:
  • Anti-inflammatory diet, maintaining a healthy weight.

---

Q5: What are the red flags that would necessitate further assessment or specialist referral?

Answer:

• Cauda Equina Syndrome (Emergency):
  • Saddle anaesthesia, bowel/bladder dysfunction, bilateral leg weakness.
• Spinal Infection or Malignancy:
  • Unexplained weight loss, night pain, history of cancer.
• Severe Opioid Dependence:
  • Escalating doses, withdrawal symptoms, aberrant behaviour.

Management of Red Flags:

• Urgent MRI and neurosurgical review if cauda equina suspected.
• Pain clinic referral for opioid tapering or interventional procedures.

---

SUMMARY OF A COMPETENT ANSWER

• Identifies chronic lower back pain with central sensitisation as the likely diagnosis.
• Implements a multimodal approach (physical, psychological, and pharmacological).
• Encourages opioid reduction with safer alternatives.
• Recognises red flags requiring urgent investigation.
• Provides clear patient education and follow-up plan.

---

PITFALLS

• Focusing solely on medications without non-pharmacological management.
• Not recognising opioid-induced hyperalgesia.
• Failing to assess psychosocial contributors to pain.
• Overlooking red flags requiring urgent referral.

---

REFERENCES

• RACGP Guidelines – Chronic Pain Management
• GP Exams – Chronic pain management

---

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Engages the patient to gather information about their symptoms, concerns, and expectations.
1.2 Uses effective communication to provide clear information on chronic pain management.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to chronic pain, including functional impact and psychosocial factors.
2.2 Identifies red flags requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between nociceptive, neuropathic, and central sensitisation pain.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate multimodal management, including non-pharmacological and pharmacological strategies.
4.2 Recognises when specialist pain clinic referral is required.

5. Preventive and Population Health

5.1 Provides education on lifestyle modifications, pacing, and mental health strategies.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD