Chronic pain: How to approach these 3 common conditions
Fibromyalgia, osteoarthritis, and low back pain require multimodal, evidence-based treatment plans. Tailoring those plans to the underlying mechanisms of pain is key.
PRACTICE RECOMMENDATIONS
› Recommend cognitive behavioral therapy for most patients suffering from chronic pain. A
› Recommend movement and exercise therapies for all patients with chronic pain. A
› Prescribe anti-inflammatory medications for patients with peripheral nociceptive pain and centrally-acting agents, such as tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, and alpha 2 delta ligands, for patients with centralized pain. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Guidelines tend to differ most widely with regard to recommendations for spinal manipulation and specific drug therapies.69 The classes of drugs that may be most useful when centralized pain is present include the SNRIs and the alpha 2 delta calcium channel ligands.4 See TABLE 470-89 for a summary of evidence-based treatment options.
CASE 1 › Ms. A is started on amitriptyline 25 mg at bedtime, which improves her fatigue and cognitive symptoms. During monthly office visits, her FP educates her about the pathophysiology of fibromyalgia and uses motivational interviewing to get her slowly moving and increasing her activity level. She is weaned off the gabapentin previously prescribed, as her symptoms stabilize and improve.
CASE 2 › Mr. P is sent for a steroid injection, which decreases his pain temporarily. During this time, he begins physical therapy; slowly, with increased movement, his function improves. A trial of duloxetine provides pain relief; that combined with intermittent nonsteroidal anti-inflammatory drugs (NSAIDs) has allowed Mr. P to maintain his function and his job.
CASE 3 › Because Mr. B was only taking the narcotics intermittently and wasn’t certain they were helping, CBT was sufficient to wean Mr. B off the medication without any worsening of his pain in the process. By participating in physical therapy, he has learned how to perform certain tasks at his job without pain or injury. He uses NSAIDs as needed for pain.
CORRESPONDENCE
Jill Schneiderhan, MD, 24 Frank Lloyd Wright Dr., Lobby H, Suite 2300, Ann Arbor, MI 48105; jillsch@med.umich.edu.
ACKNOWLEDGEMENTS
We thank Drs. Daniel Clauw (University of Michigan, Ann Arbor) and Martha Rumschlag (Providence Family Medicine Residency Program, Southfield, Mich), for their valuable contributions to this article.
