Family Practice Guidelines 2017
Pain Management Guidelines

Acute Pain

Moya Cook

 

Definition

1. Acute pain is defined as pain of a short, limited duration, usually the result of an injury, surgery, or medical illness that generally results from tissue injury; however, it may be experienced even with no identifiable cause. Acute pain usually resolves when the tissue injury improves with the healing process. Most acute pain resolves in less than 6 weeks.

Incidence

1. Acute pain is the most common reason for self-medication and presentation for treatment in the health care system. Acute pain is very individual, and if not treated properly it can have devastating physiological and psychological effects. Because pain is very subjective, the patient care plan needs to be individualized to meet the patient’s needs. Proper treatment of acute pain could prevent the development of some types of chronic pain syndromes.

Pathogenesis

1. Acute pain is usually the result of stimulation of the sympathetic nervous system.

Common Complaints

1. Pain at the specific site
2. Increased heart rate

1. Increased respiratory rate
2. Elevated blood pressure (B/P)
3. Sweating
4. Nausea

Other Signs and Symptoms

1. Urinary retention
2. Dilated pupils
3. Pallor

Subjective Data

1. Elicit location of
2. Note effects of pain on activities of daily living (ADLs).
3. Note intensity of pain at rest and during
4. List precipitating
5. Identify alleviating
6. Note the quality of
7. Is there radiation of pain?
8. Rate pain on a pain scale (usually on the 1–10 scale, with 1 being the least and 10 being the worst).

Physical Examination

1. Check temperature, pulse, respiration, and blood
2. Inspect
   1. Observe overall
   2. Note affect and ability to express self and
   3. Note facial grimaces with
   4. Note gait, stance, and
   5. Inspect area at pain
3. Auscultate

1. Auscultate heart and
2. Auscultate neck and

1. Palpate: Palpate affected area of
2. Percuss
   1. Percuss
   2. Percuss
3. Perform musculoskeletal

1. Perform complete musculoskeletal examination, concentrating on the area of
2. Assess deep tendon reflexes (DTRs).

1. Neurologic examination
   1. Perform complete neurologic
   2. Identify change in sensory function, skin tenderness, weakness, muscle atrophy, and/or loss of

Diagnostic Tests

1. No diagnostic testing is required unless clearly indicated to rule out organic cause of pain. If organic disease is suspected, diagnostic testing may include:

1. CT imaging
2. MRI
3. Blood chemistries
4. Radiographic x-ray
5. Lumbar puncture
6. Ultrasound
7. Electrocardiogram (EKG)/echocardiogram

Differential Diagnoses

The differential diagnoses depend on the location of the acute pain.

1. Head
   1. Migraine
   2. Cluster headache/migraine headache
   3. Temporal arteritis
   4. Intracranial bleeding or stroke
   5. Sinusitis
   6. Dental abscess
2. Neck
   1. Meningitis
   2. Muscle strain/sprain
   3. Whiplash injury
   4. Thyroiditis
3. Chest
   1. Pulmonary emboli
   2. Myocardial infarction
   3. Pneumonia
   4. Costochondritis
   5. Angina
   6. Gastroesophageal reflux disease/esophagitis
4. Abdomen
   1. Peritonitis
   2. Appendicitis
   3. Ectopic pregnancy/uterine pregnancy
   4. Endometriosis
   5. Pelvic inflammatory disease
   6. Peptic ulcer
   7. Cholelithiasis
   8. Colitis/diverticulitis
   9. Constipation
   10. Gastroenteritis
   11. Irritable bowel syndrome
   12. Urinary tract infection, kidney stone, pyelonephritis
   13. Prostatitis

14. Malignancies

1. Musculoskeletal
   1. Muscle sprain/strain/tear
   2. Skeletal fracture
   3. Viral infection
   4. Gout
   5. Vitamin D deficiency

Plan

1. General interventions
   1. Acute pain is a symptom, not a
   2. Identify the cause or source of the acute pain depending on the location. If the pain is organic in nature, make the appropriate
   3. Overall goal is to treat the acute pain
2. Patient teaching
   1. The pain management plan must include patient and family education regarding preventing and controlling pain, potential medication side effects, and how to prevent the side
   2. Discussion must include addiction
   3. The newest recommendation from the Centers for Disease Control and Prevention (CDC) is the lowest possible dose of narcotics for pain for no longer than 3 to 5 days before reevaluation. Explain that risk of addiction is low when medication is used as directed for a short duration. Explain that complete pain relief may not be achievable initially, but the overall goal is to decrease the pain, thus allowing some daily activities at home to begin
3. Pharmaceutical therapy
   1. Visceral pain: Treatment of choice is corticosteroids, intraspinal local anesthetics, nonsteroidal anti-inflammatory drugs (NSAIDs), and
   2. Somatic pain: Acetaminophen, cold packs, corticosteroids, localized anesthetics, NSAIDs, opioids, and tactile
   3. Neuropathic pain: Tricyclic antidepressants (TCAs), using amitriptyline are the first-line treatment for neuropathic pain. Anticonvulsants like carbamazepine (Tegretol), phenytoin (Dilantin), and valproic acid (Depakene) can be useful in treating neuropathic pain. Other treatments include local anesthetics, tramadol (Ultram), and glucocorticoids.

Follow-Up

1. Once organic cause of pain has been ruled out, initial follow-up is 48 to 72 hours after
2. Ensure that the patient has access to care on a regular

Consultation/Referral

1. If the acute pain is organic, make the appropriate referral to a specialist.

Individual Considerations

1. Geriatrics
2. Physiologic changes that occur in the elderly, such as decreased body mass, hepatic dysfunction, and renal dysfunction may cause increased serum drug concentrations of pain medication. Use caution when prescribing pain medication to this
3. Antiinflammatories are not recommended for the elderly as a general rule due to the effects of the medication on the

Chronic Pain

Moya Cook 

Definition

1. Chronic pain is defined as an alteration in comfort that persists longer than 6 weeks (or longer than the anticipated healing time). The pain may be continuous or recurrent and of sufficient duration and intensity. Legitimate chronic pain interferes with a patient’s ability to function with normal daily activities and decreases quality of life.

Incidence

Pain syndromes are commonly seen in clinical practice and are the third most widespread health problem in the United States. Chronic pain costs the American people about $65 billion a year in health care expenses, disability costs, and lost productivity. The Centers for Disease Control and Prevention (CDC) found that 11.2% of adults state that they have pain daily. Chronic pain patients have a better than 50% chance of becoming addicted to prescription pain medications. As the U.S. population continues to age and the average life expectancy is increasing, the primary care provider will be providing care for more chronic diseases and handling more chronic pain patients.

1. Women are affected more than men by two to
2. Onset is usually in the fourth, fifth, or sixth decades and is often associated with marked functional

Pathogenesis

1. Skeletal muscle pain occurs in the soft tissue involving the neck, shoulders, trunk, arms, low back, hips, and lower extremities. Myofascial pain syndrome relates to the fascia surrounding the muscle
2. Inflammatory pain is caused by chemicals, such as prostaglandins, leading to the stimulation of the pain receptors. Examples include arthritis, infection, tissue injury, and postoperative
3. Mechanical/compressive pain is the direct result of the muscle, ligament, and tendon causing strain, leading to the stimulation of the pain receptors. Diagnosis may be based on diagnostic imaging results, which may include fracture, obstruction, dislocation, or compression of tissue by a tumor, cyst, or bony
4. Neuropathic pain involves dysfunction of the somatosensory system. The most common types are diabetic neuropathy, sciatica from nerve root compression, trigeminal neuralgia, and postherpetic

1. Nociceptive pain is caused by nociceptors, a type of sensory neuron that receives the pain signal. Mechanical/compressive pain and inflammatory pain are examples of this type of pain. They both respond well to opioids, with the exception of

Predisposing Factors

1. Age 30 to 50 years
2. Female gender
3. History of having seen many physicians
4. Frequent use of several nonspecific medications
5. Depression
6. Personality, including moods, fears, expectations, coping efforts, and resources

Common Complaints

1. Specific to site of pain
2. Emotional distress related to fear, maladaptive or inadequate support systems, and other coping resources
3. Treatment-induced complications
4. Overuse of drugs
5. Inability to work
6. Financial complications
7. Disruption of usual activities
8. Sleep disturbances
9. Pain becomes primary life focus

Other Signs and Symptoms

1. Pain lasts longer than 6
2. There may be anger and loss of faith or trust in the health care system. This type of patient frequently takes too many medications, spends a great deal of time in bed, sees many physicians, and experiences little joy in either work or

Subjective Data

1. Elicit a clear description of the onset, location, quality, intensity, and time course of pain and any factors that aggravate or relieve Use the acronym

OLD CARTS-U. O = onset, L = location, D = duration, C = characteristics, A

= aggravating triggers, R = relieving triggers, T = timing, S = severity, U = YOU. What do YOU think is going on? What have YOU done to relieve it?

1. Self-reporting pain assessment tools should be used early in the process of patient evaluation. Use the tool at each office visit to see progression or regression. Lack of pain assessment is a barrier to good pain control. Consider the age of the patient; his or her physical, emotional, and cognitive status; and preference when choosing the self-reporting pain assessment
   1. Verbal rating scales rate pain as mild, moderate, or
   2. Numeric rating scales rate pain intensity from 0 to 10. They are patient friendly and quick to
   3. The Faces scale is useful for pediatric and cognitively impaired patients. Multicultural translations may be downloaded at wongbakerfaces.org
2. Determine the extent to which the patient is suffering, disabled, and unable to enjoy usual activity. It is important to inquire about activities of daily living (ADLs) and functional
3. Obtain a complete review of systems, including nausea, numbness, weakness, insomnia, loss of appetite, dysphoria, malaise, fatigue, or depression signs and
4. Obtain a complete family and social history. Address spiritual and cultural issues. History of chemical dependency is of interest in this patient population.
5. Obtain the patient’s medical history relevant to the pain, including diagnosis, testing, treatments, and
6. Obtain a pain history to identify the patient’s attitudes, beliefs, level of knowledge, and previous experiences with pain. Are previously used methods for pain control helpful? What is the patient’s attitude toward the use of certain pain medications? Often, the patient discusses certain adverse side effects or allergies from undesired pain

Physical Examination

1. Check temperature, pulse, respirations, and blood
2. Inspect
   1. Observe overall
   2. Note affect and ability to express self and

3. Note facial grimaces with
4. Note gait, stance, and
5. Inspect area at pain

1. Auscultate
   1. Heart and lungs
   2. Neck and abdomen
2. Palpate the affected area of
3. Percuss
   1. Chest
   2. Abdomen
4. Perform musculoskeletal

1. Perform a complete musculoskeletal examination, concentrating on the area of
2. Note limitations in range of

1. Neurologic examination
   1. Perform complete neurologic
   2. Note the patient’s affect and mood. Is the patient cooperative during examination?
   3. Identify change in sensory function, skin tenderness, weakness, muscle atrophy, and/or loss of deep tendon reflexes (DTRs).
2. Functional assessment
   1. The baseline functional assessment provides objective measurable data on a patient’s physical abilities and limitations. It can be used to determine if the patient’s efforts are valid and complaints are
   2. The information may be used to identify areas of impairment, establish specific functional goals, and measure the effectiveness of treatment interventions.

3. These objective data may be used in worker compensation cases, returning-to-work status, federal disability, and motor vehicle accident lawsuits.
4. Know the resources in your area that are trained to perform functional assessments. Physical therapists and occupational therapists are the best qualified to perform the

Diagnostic Tests

1. None is required unless clearly indicated to rule out the organic cause of
   1. Remember that pain previously diagnosed as chronic pain syndrome can be organic and vice versa. Organic causes must always be evaluated and
   2. Plain radiography should be ordered first for muscle, inflammatory, or skeletal pain. Plain radiography will diagnose a fracture. Additional studies may be recommended by the radiologist if a lesion/abnormality is seen on plain
   3. MRI and CT are ordered if the plain radiograph is negative and the patient continues to complain of
   4. Electromyography and nerve conduction studies are used to evaluate neuropathic pain. Numerous serum and urine studies should also be considered if the neuropathic pain is
2. Depression screening tool: Consider using a depression assessment tool such as the Beck Depression Inventory or Patient Health Questionnaire 9 (PHQ9). These tools can be administered at a subsequent appointment to follow the patient’s

Differential Diagnosies

1. Pain disorder
2. Pain related to a disease with no cure/malignancy
3. Somatization disorder
4. Conversion disorder
5. Hypochondriasis
6. Depression
7. Chemical dependency
8. Fibromyalgia

Plan

1. General interventions
   1. Treatment is multidimensional and should not be focused on pharmacological treatment
   2. Offer hope and potential for improvement of pain control and improvement of function but not
   3. The pain is real to the patient, and acceptance of the problem must occur before a mutually agreed-on treatment plan can be
   4. Depression is a common emotional disturbance in chronic pain patients and is
   5. Identify specific and realistic goals for therapy such as having a good night’s sleep, going shopping, or returning to work. Patient discussion needs to include the idea that the goal may be decreasing pain intensity, not eliminating
   6. Carefully assess the level of pain using available tools such as a daily pain diary or other pain assessment
   7. Avoid pain reinforcement such as sympathy and attention to pain. Provide positive response to productive activities. Improving activity tolerance assists in desensitizing the patient to
   8. Shift the focus from the pain to accomplishing daily assigned self-help tasks. The accomplishment of these tasks functions as positive reinforcement.
2. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Chronic Pain.”
3. Pharmaceutical interventions
   1. Skeletal muscle pain: Treatment should focus on physical rehabilitation and behavioral management. Tricyclic antidepressants (TCAs) and muscle relaxants (cyclobenzaprine) may be used. Research is lacking regarding the need for
   2. Inflammatory pain: Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are first-line pharmaceutical interventions. Topical creams and solutions have been used in treating arthritis
   3. Mechanical/compressive pain: Opioids may be used to manage these symptoms while other measures are being
   4. Neuropathic pain

1. Gabapentin (Neurontin) and pregabalin (Lyrica) have become first- choice treatments in recent years for diabetic neuropathy and postherpetic
2. TCAs are extremely useful. Patients who are not depressed obtain excellent pain relief with TCAs such as amitriptyline and
3. Selective serotonin reuptake inhibitors (SSRIs) are also effective for chronic pain control. Duloxetine (Cymbalta) has been approved for chronic pain as monotherapy or in conjunction with
4. Anticonvulsants are useful in controlling some neuropathic pain: Carbamazepine (Tegretol), phenytoin (Dilantin), and valproic acid (Depakene). Patients need to be monitored monthly for hepatic dysfunction and hematopoietic
5. Topical agents: Capsaicin applied three to four times per day can reduce pain without significant systemic effects. Topical lidocaine 5% patches are approved for postherpetic
6. Carbamazepine is used as the first-line treatment for trigeminal neuralgia.
7. Opioids: Tramadol is considered to be a good choice if an opioid is indicated. In addition to pain control, tramadol also causes serotonin reuptake inhibition similar to that seen with the

5. All therapies need a 2- to 3-week trial period to adequately evaluate therapy. Some medications take longer than that to
6. NSAIDs should be used for flare-ups of mild to moderate inflammatory or nonneuropathic
7. Opioids require careful patient selection, titration, and monitoring. Avoid long-term, daily treatment with short-acting opioids (Vicodin, Norco, and Percocet). For as-needed use, prescribe small
8. Smiths Medical received Food and Drug Administration (FDA) approval in February 2013 to market ambulatory infusion pumps in the United States. These pumps can be programmed to administer pain management medication continuously, intermittently, tapered, or patient controlled.
9. Benzodiazepines and barbiturates are not advised for treatment of chronic pain due to the high risk of substance
10. Addiction risk interventions when considering opioids: A checklist for prescribing                   opioids          can           be          found          at

www.cdc.gov/drugoverdose/pdf/PDO_Checklist-a.pdf

1. Check your state’s prescription monitoring program (PMP) before prescribing controlled substances, as needed, and at least annually. PMPs are state-run electronic databases that track dispensing of controlled substances. PMPs provide clinicians with critical information about patient narcotic prescription history and identify drug-seeking behavior
2. Contact the patient’s pharmacy for a list of current medications. The PMP is not in real time, and all current patient prescriptions are available from the
3. Perform urine drug screen before prescribing controlled substances initially, as needed, and annually. National guidelines recommend the enzyme immunoassay (EIA) and gas chromatography/mass spectroscopy urine screen. Depending on the results of urine drug screening, the provider may seek additional consultation, change medication therapy, refer for substance abuse, or discharge the
4. A written controlled substance treatment agreement among patient, provider, and clinic is recommended. Include expectations of the patient: No other controlled substances will be prescribed by any other provider. One pharmacy only should be used. Medication must be taken as prescribed. These are no early refills on controlled substances. The patient must agree to random drug screens and may be called to report to the clinic for random drug screens and/or pill counts.
5. Utilize tools such as the Addiction Behavior Checklist, Diagnosis, Intractability, Risk, Efficacy (DIRE) score, or CAGE (have you ever tried to cut down on your alcohol/drug use? Do you get annoyed if someone mentions your use is a problem? Do you ever feel guilty about your use? Do you ever have an “eye-opener” first thing in the morning after you have been drinking or using the night before?) assessment.
6. Red flags for misuse, abuse, addiction, and diversion with opioids include:
   1. Psychiatric illness
   2. Personal history of alcohol or drug abuse

• Family history of alcohol or drug abuse

1. Alternative interventions
   1. Cognitive behavioral training: Examples of cognitive behavioral training include problem solving, guided imagery, hypnosis, controlled breathing exercises, attention diversion, meditation, and yoga exercises; progressive muscle relaxation (PMR) is recommended to help relax major muscle groups. Randomized controlled trials showed significant reduction in pain with alternative interventions such as music, relaxation, distraction, and massage
   2. Exercise: Examples of exercise include yoga exercises and PMR. PMR is recommended to help relax major muscle groups. Research indicates that yoga decreases bothersome pain after 12 weeks of regular exercise. The benefits of yoga exercise include improved strength, balance, coordination, range of motion, and reduced anxiety. Yoga instruction by a qualified teacher is a low-cost intervention. Yoga is an effective form of self-care and is an affordable way to alleviate pain. Always advise patients to start slowly and be prepared for an approach to pain management that may take several weeks of
   3. Alternative therapies: Randomized controlled trials showed significant reduction in pain with alternative interventions such as music, relaxation, distraction, acupuncture, myofascial release treatments, and massage
   4. Occupational therapy
   5. Vocational therapy
   6. Physical therapy such as noninvasive techniques, transcutaneous electrical nerve stimulation, hot or cold therapy, hydrotherapy, traction, massage, bracing, and exercise
   7. Individual and family therapy or counseling
   8. Aesthetic or neurosurgical procedures
   9. Patients will inquire about the use of herbal products to treat chronic pain. Advise patients that these products are not regulated by the FDA. Advise them that these herbal products may interact with current medications and cause complications. Advise them to research all herbal products on reputable medically based websites, not blogs or chat rooms. Caution patients regarding devil’s claw, feverfew, willow bark, glucosamine, and chondroitin. Discourage any use of

Follow-Up

1. See patients every 4 to 6 weeks for
2. Ensure that the patient has access to care on a regular
3. These brief visits should be regular so that care is not perceived to be dependent on escalation of

Consultation/Referral

1. Consider patient referral to a pain management clinic if pain control is not adequate. Interventions commonly performed at the specialty clinic include facet joint injections, percutaneous radiofrequency neurotomy, epidural corticosteroid injections, transforaminal epidural injections, and sacroiliac joint
2. Consult with a physician if referral is needed for psychological counseling or if substance abuse is
3. Refer to a certified pain specialist physician if the patient is taking high doses of opioids and detoxification is indicated. Buprenorphine (Suboxone) is the most common medication prescribed by a certified pain specialist physician.
4. Consider rheumatology consult if

 Lower Back Pain

Moya Cook 

Definition

Painful conditions of the lower back may be categorized as follows:

1. Potentially serious   disorders:   Acute   fractures,   tumor,   progressive neurologic deficit, nerve root compression, and cauda equina syndrome
2. Degenerative disorders: Aging or repetitive use, degenerative disease, and osteoarthritis
3. Nonspecific disorders: Benign and self-limiting with unclear etiology

Incidence

1. Lower back pain is commonly seen in patients from ages 20 to 40
2. Approximately 70% to 80% of people experience back pain at one point in their

Pathogenesis

1. Pain arises from fracture, tumor, nerve root compression, a degenerative disc, osteoarthritis, and strain of the ligaments and musculature of the lumbosacral area.

Predisposing Factors

1. Trauma causing   ligament   tearing;   stretching  of   vertebra,   muscles, tendons, ligaments, or fascia
2. Repetitive mechanical stress
3. Tumor
4. Exaggerated lumbar lordosis
5. Abnormal, forward-tipped pelvis
6. Uneven leg length
7. Chronic poor posture due to inadequate conditioning of muscle strength and flexibility, improper lifting techniques causing excessive strain, and poor body mechanics
8. Inadequate rest
9. Emotional depression

Common Complaint

1. Pain in the lower back area may range from discomfort to severe back pain, with or without radiation.

Other Signs and Symptoms

1. Ambulating with a limp
2. Limited range of motion
3. Posture normal to guarded

Subjective Data

1. Ask the patient to discuss the origin of pain. How has the pain progressed or changed since the initial injury?
2. Ask the patient to point to an area where pain is
3. Have the patient describe the pain. Is it radiating, with sharp, shooting pain down to the lower leg and feet?
4. Ask: What makes the pain worse or better? Does activity make the pain

worse or better? Have the patient list current medications or therapies used for pain, noting results of treatment.

1. Investigate occurrence of systemic symptoms such as fever and weight loss.
2. Explore the patient’s past medical history. Note previous trauma or overuse, tuberculosis, arthritis, cancer, and
3. Inquire about symptoms such as dysuria, bowel or bladder incontinence, muscle weakness, paresthesia, and loss of sensation. Bowel or bladder dysfunction, bilateral sciatica, and saddle compression may be symptoms of severe compression of the cauda equina that necessitate an urgent workup and
4. Ask the patient about precipitating factors such as athletics, heavy lifting, driving, yard work, occupation, sleep habits, or systemic
5. Use a pain scale to describe the worst pain and the best pain

Physical Examination

1. Check temperature, pulse, blood pressure, and
2. Inspect
   1. Observe general   appearance;   note   discomfort  and   grimacing  on movement and/or
   2. Distraction may distinguish pain behavior from actual
   3. Note evidence of trauma with bruises, cuts, and
   4. Note posture and
3. Palpate
   1. Palpate spine and paravertebral structures, noting point tenderness and muscle spasm. Palpation elicits paravertebral tenderness and generalized tenderness over the lower back to upper
   2. Examine abdomen for
   3. Extremities: Palpate peripheral
4. Perform neurologic examination
   1. Identify sensation and pain
   2. Determine motor strength and evaluate whether muscle strength is symmetrical: Upper extremity resistance is equal
   3. Test deep tendon reflexes (DTRs) and dorsiflexion of the big
5. Check sensation of perineum to rule out cauda equina
6. Perform traction tests: Straight leg raises, crossed leg raises, Yeoman

Guying, Patrick’s test. Musculoskeletal findings include the following:

1. Straight leg raising and dorsiflexion of foot on the affected side may reduce lower back
2. Elevate each leg passively with flexion at the hip and extension of the knee. Positive straight leg raise gives radicular pain when the leg is raised 30° to 60°.
3. Crossed leg raises: Test is positive when pain occurs in the leg not being
4. Yeoman Guying: Unilateral hyperextension in prone position identifies lumbosacral mechanical
5. Patrick’s test: Place heel on opposite knee and apply lateral force; check for hip or sacroiliac
6. Range of motion: Increased pain with extension often indicates osteoarthritis. Increased pain with flexion often indicates strain or injured disk.

1. Pelvic examination: Consider pelvic and rectal examination, if indicated. If the patient has fallen on the coccyx, a rectal examination is needed to check for

Diagnostic Tests

1. Laboratory: Complete blood count, erythrocyte sedimentation rate, serum calcium, alkaline phosphatase, urinalysis, and serum immunoelectrophoresis when inflammatory, neoplastic, diffuse bone disease, or renal disease is suspected
2. Radiography of spine
3. Consider the following tests
   1. MRI to rule out disk disease and tumors
   2. Bone scan to rule out cancer

Differential Diagnoses

1. Back pain secondary to musculoskeletal pain
2. Herniated intervertebral disease
3. Sciatica
4. Fracture
5. Ankylosing spondylitis
6. Malignancy/tumor

1. Abdominal aneurysm
2. Pyelonephritis
3. Metabolic bone disease
4. Gynecologic disease
5. Peripheral neuropathy
6. Depression
7. Prostatitis
8. Spinal stenosis
9. Osteoarthritis
10. Osteoporosis

Plan

1. General interventions
   1. The patient should continue physical activity as
   2. For acute muscle strain, have the patient apply local cold packs 20 to 30 minutes several times a day for the first 24 hours. Heat packs are recommended after the initial 24 hours of
   3. Chronic or recurrent pain may be treated with either ice or heat applications, whichever gives
2. Patient teaching
   1. Give accurate information on the prognosis for quick recovery such as continuing light physical activity, performing back-strengthening exercises, and avoiding overuse of
   2. Improvement occurs in most cases in a few weeks, although mild symptoms may
   3. Joint guidelines by the American College of Physicians and the American Pain Society recommend rehabilitative therapies for patients who do not improve after medications and self-care recommendations. Rehabilitative therapies include exercise therapy, acupuncture, massage therapy, spinal manipulation, cognitive behavioral therapy, and
   4. Provide educational handouts on back exercises; see Section III: Patient Teaching Guide for this chapter, “Back Stretches.”
   5. After intense pain abates, the patient may perform low-back exercises for range of motion and strengthening, and isometric tightening exercises of abdominal and gluteal
   6. Teach patient knee–chest exercises. Recommend to the patient to

place his or her back against the wall and contract abdominal and gluteal muscles with 5 to 10 repetitions four to six times per day.

7. Research indicates that yoga is beneficial for many types of back pain. Types of back pain benefited by yoga include musculoskeletal injury, herniated disc, spinal stenosis, spondylolisthesis, piriformis syndrome, arthritis, and sacroiliac joint
8. Encourage the patient to perform walking exercise
9. Teach relaxation
10. Encourage the patient to modify work hours and job
11. Refer the patient for therapeutic massage or physical therapy as needed.
12. Obesity is often related to decreased exercise and poor physical fitness with reduced trunk muscle strength and endurance. Obese patients may experience back pain with normal

1. Pharmaceutical therapy
   1. Analgesics: Acetaminophen 350 to 650 mg every 4 to 6 hours. Maximum dose is 4,000 mg a day. Inquire of any other current medications and/or over-the-counter preparations containing acetaminophen.
   2. Nonsteroidal anti-inflammatory drugs (NSAIDs): Unless contraindicated due to gastrointestinal symptoms or cardiovascular disease
      1. Aspirin:325 to 650 mg every 4 to 6 hours
      2. Ibuprofen:200 to 800 mg every 6 to 8 hours; maximum dose is 3.2 g a day under the care of the provider, otherwise 1.2 g a day
      3. Naproxen:500 mg initially, followed by 250 mg every 6 to 8 hours
      4. Piroxicam (Feldene):20 mg every day
      5. Meloxicam (Mobic):7.5 to 15 mg daily
      6. Celebrex:100 to 200 mg twice a day
   3. Muscle relaxants
      1. Cyclobenzaprine Hcl (Flexeril):10 mg three times daily
      2. Carisoprodol (Soma):350 mg four times daily—use with extreme caution due to risk of addiction
      3. Methocarbamol (Robaxin):1.5 g every day initially, and then 750 to 1,000 mg every day
      4. Orphenadrine citrate (Norflex):100 mg twice a day

1. Metaxalone (Skelaxin):800 mg three to four times a day

Follow-Up

1. If pain is severe or unimproved, follow up in 24
2. If pain is moderate, reevaluate the patient in 7 to 10
3. See the patient in 2 to 4 weeks to reevaluate his or her condition and behavioral
4. Recurrences are   not   uncommon   but   do   not   indicate  a   chronic  or worsening

Consultation/Referral

1. Consult with a physician when considering red-flag diagnoses such as cauda equina syndrome, herniated disk, widespread neurologic involvement, carcinoma, or significant
2. Referral to a physician is needed for patients who note significant morning stiffness with a gradual onset prior to age 40 years, with continuing spinal movements in all directions, and involving some peripheral joints, iritis, skin rashes indicating inflammatory disorders such as ankylosing spondylitis and related

Individual Considerations

1. Pregnancy: Pregnancy is often associated with low-back discomfort. This is due to the redistribution of body weight. As weight increases in the abdominal area with the growing fetus, patients tend to compensate by changing posture and tilting the spine
2. Adults
   1. For patients older than 50 years presenting with no prior history of backache, consider a differential diagnosis of neoplasm. The most common metastasis seen is secondary to the primary site of breast cancer, prostate cancer, or multiple myeloma. Pain most prominent in a recumbent position rarely radiates into the buttock or
   2. Men and women in their early adulthood (ages 20–45 years) who present with chronic back pain that improves with activity should be further evaluated for ankylosing

 Bibliography

Centers for Disease Control and Prevention. (2016, March 15). CDC guidelines for prescribing opioids for chronic pain—United States, 2016. Morbidity and Mortality Weekly Reports. Retrieved from https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

Centers for Disease Control and Prevention. (2016, March 22). Checklist for prescribing opioids for chronic pain. Retrieved from https://www.cdc.gov/drugoverdose/pdf/PDO_Checklist-a.pdf

Chronic Pain Perspectives. (2013). Ambulatory infusion system gets FDA clearance. Retrieved from https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF- 8#q=Ambulatory+infusion+system+gets+FDA+clearance

Costead, L., & Banasik, J. (2012). Pathophysiology (5th ed.). St. Louis, MO: Elsevier Saunders.

Dunphy, L., Brown, J., Porter, B., & Thomas, D. (2015). Primary care: The art and  science  of  advanced practice nursing (4th ed.). Philadelphia, PA: F.A.Davis.

Fishman, L. (2012). Efficacy and application of yoga for back pain. Chronic Pain Perspectives.  Retrieved from http://chronicpainperspectives.com/articles/feature-article/article/efficacy-and- application-of-yoga-for-back-pain/8c51fc8df7a517da1a5e8baa1f28d7e8.html

Goertz, M., Thorson, D., Bonsell, J., Bonte, B., Campbell, R., Haake, B., . . . Timming, R. (2012).   Health care guideline: Adult acute and subacute low back pain (15th ed.). Bloomington, MN: Institute for Clinical Systems Improvement. Retrieved from https://www.icsi.org/_asset/bjvqrj/LBP.pdf

Hooten, W. M., Timming, R., Belgrade, M., Gaul, J., Goertz, M., Haake, B., . . . Walker, N. (2013). Health care guideline: Assessment and management of chronic pain (6th ed.). Bloomington, MN: Institute    for Clinical Systems Improvement. Retrieved from https://pdfs.semanticscholar.org/e1f7/c26a36d83686607ad89ee835daa3c9db3f4c.pdf

Michigan Quality Improvement Consortium. (n.d.). Management of acute low back pain. Retrieved   from https://www.guidelines.gov

National Guideline Clearinghouse. (2011a). Guideline summary: Guideline for the evidence-informed primary care management of low back pain. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from https://www.guideline.gov/content.aspx? id=37954&search=chronic+low+back+pain+and+acute+low+back+pain+and+assessment+and+man

National Guideline Clearinghouse. (2011b). Guideline summary: Managing chronic non-terminal pain   in adults including prescribing controlled substances. Rockville, MD: Agency for Healthcare Research    and Quality. Retrieved from https://www.guideline.gov/summaries/summary/25657/managing-chronic-nonterminal-pain-in- adults-including-prescribing-controlled-substances? q=Managing+chronic+nonterminal+pain+including+prescribing+controlled+substances

National Guideline Clearinghouse. (2013, November). Guideline summary: Assessment  and  management of chronic pain. Rockville, MD: Agency for Healthcare Research and Quality.  Retrieved from https://www.guideline.gov/summaries/summary/47646

Rosenquist, E. (2016). Evaluation of chronic pain in adults. In T.W. Post & M.Aronson (Eds.), UpToDate. Retrieved from https://www.uptodate.com/contents/evaluation-of-chronic-pain-in- adults?source=search_result&search=chronic+pain&selectedTitle=3%7E150