![Page 1: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/1.jpg)
Chronic pain
![Page 2: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/2.jpg)
www.Thepracticalnursepractitioner.comT
![Page 3: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/3.jpg)
and other statements to address in primary care pain management.
“My whole body aches.”
“What do you mean my MRI is negative?
My back still hurts!
![Page 4: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/4.jpg)
Annemarie M. Kallenbach
RN CNPNo Disclosures
![Page 5: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/5.jpg)
![Page 6: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/6.jpg)
docakilah.wordpress.com
![Page 7: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/7.jpg)
![Page 8: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/8.jpg)
![Page 9: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/9.jpg)
Overview
Fibromyalgia and chronic back pain are two time consuming and frustrating diagnoses seen frequently in clinical practice
Choosing to treat or transferring care to a consultant or specialist has benefits and drawbacks.
Understanding the use of pain contracts /partner agreements and frequent intervals of visits will improve outcomes.
![Page 10: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/10.jpg)
Overview
Chronic low back pain and fibromyalgia share two clinical features. The visits are not quick The visits are not easy.
![Page 11: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/11.jpg)
Overview
Implementing a consistent algorithm that incorporates current recommendations in today’s busy clinic will yield improved results in patient care.
![Page 12: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/12.jpg)
Overview
Chronic pain must to be addressed in a multi directive model.
A clear, practical chart checklist will keep treatment plan on course.
![Page 13: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/13.jpg)
Pain response
![Page 14: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/14.jpg)
Personal experience Labor Stubbing toe on chair leg Burning shoulder pain from too much
time on computer
![Page 15: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/15.jpg)
![Page 16: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/16.jpg)
![Page 17: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/17.jpg)
![Page 18: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/18.jpg)
![Page 19: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/19.jpg)
![Page 20: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/20.jpg)
Provider Response
Jot down 5 honest reactions to seeing back pain-recurrent, fibromyalgia follow up on your schedule.
![Page 21: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/21.jpg)
Provider reactions
Time consumingFrustrated
AngryNervousAgitatedScared
Skeptical
![Page 22: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/22.jpg)
Provider reactions
Excited for the challenge.
Ready to try a multiple facet approach to treatment.
Armed with excellent resources.
![Page 23: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/23.jpg)
Provider reactions
Frustrated Angry Nervous Agitated Scared Skeptical
Excited for the challenge
Ready to try a multiple approach to treatment
Armed with excellent resources
![Page 24: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/24.jpg)
Bring it on!!
![Page 25: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/25.jpg)
Patient questions to ponder
Does you patient have chronic pain? Has a complete workup been done in
the past? Labs, diagnostics
![Page 26: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/26.jpg)
Patient questions to ponder
Has your patient been screened for mental health problems?
Does your patient have a diagnosis of mental health problems?
Is it the correct diagnosis? Is the patient adequately treated for
mental health (pharmacologic agents, talk therapy, support groups, behavior modification)
![Page 27: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/27.jpg)
Patient questions to ponder
Do you believe you can have an honest patient provider relationship?
![Page 28: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/28.jpg)
Kid, you’re asking the wrong guy.
![Page 29: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/29.jpg)
Patient questions to ponder
Does your patient have the ability to go to a chiropractor, PT, massage therapist, acupuncturist, etc?
![Page 30: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/30.jpg)
![Page 31: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/31.jpg)
Patient questions to ponder
Is your patient already on routine opiods?
Is your patient willing to partner to reduce/eliminate ineffective opiods?
![Page 32: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/32.jpg)
![Page 33: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/33.jpg)
Do you have time and interest in treating?
Do you have knowledge to treat?
Provider questions/beliefs
![Page 34: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/34.jpg)
Wasssup?
![Page 35: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/35.jpg)
Can you prescribe narcotics? What classes of narcotics? Long acting narcotics, including Methodone?
Do you have knowledge regarding medical marijuana?
Do you understand parameters for prescribing opioids?
Provider questions/beliefs
![Page 36: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/36.jpg)
Do you have relationships with local pharmacists?
Provider questions/beliefs
![Page 37: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/37.jpg)
Do you have the ability to drug screen your patient?
Provider questions/beliefs
![Page 38: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/38.jpg)
What? I was thiiiirrrsty
![Page 39: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/39.jpg)
State level questions
Does your state have medical marijuana?
Does your state have a narcotic prescription reporting mechanism?
![Page 40: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/40.jpg)
![Page 41: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/41.jpg)
https://sso.state.mi.us
![Page 42: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/42.jpg)
Elements of a Pain History
Taking a Pain History• Location• Radiation• Onset: sudden or insidious• Duration• Frequency: continuousor intermittent• Description• Intensity• Alleviating factors• Exacerbating factors
![Page 43: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/43.jpg)
![Page 44: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/44.jpg)
Chronic pain site
Lumbar
Knee
Neck
Shoulder
Total body
![Page 45: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/45.jpg)
Current (Previous) Medication Regimen
Anti inflamatory Elavil/Pamelor Neurontin Lyrica Antidepressent SSRI SNRI Mood stabilizer Anxiolytic Opiod Tramadol Sleep agent SUBOXONE, METHADONE
![Page 46: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/46.jpg)
Diagnostic work up
Was it complete?Exam findings
X-rayMRIConsult notes
![Page 47: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/47.jpg)
Referrals
Orthopedic Pain management Neurosurgeon Injection therapy Psychologist
![Page 48: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/48.jpg)
Physical therapy,Chiropractic care, massage therapy, Accupuncture
Dates Goals Patient’s adherence to sessions and
to home exercises Trial of TENS
![Page 49: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/49.jpg)
Additive disorder
Tobacco smoker Drug dependence Alcoholic
![Page 50: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/50.jpg)
Collaboration
Partner agreement Pain contract signed
![Page 51: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/51.jpg)
American Pain Foundation
Treatment Options:A Guide for People Living with Pain
![Page 52: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/52.jpg)
American Pain Foundation
Dedicated to eliminating the under treatment of pain in America.
![Page 53: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/53.jpg)
American Pain Foundation
www.painknowledge.org/opioidtoolkit/docs/Treatment%20Options.pdf
![Page 54: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/54.jpg)
American Pain FoundationThe following organizations are represented by those who helpedcreate this publication:
American Academy of Pain ManagementAmerican Academy of Pain MedicineAmerican Alliance of Cancer Pain InitiativesAmerican Board of Hospice and Palliative MedicineAmerican Holistic Nursing AssociationAmerican Pain SocietyAmerican Society for Pain Management NursingAmerican Society of Regional AnesthesiologistsAssociation of Oncology Social WorkHealing Touch InternationalIntercultural Cancer CouncilInternational Association for the Study of PainMidwest Nursing Research SocietyNational Association of Social WorkersOncology Nursing Society
![Page 55: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/55.jpg)
Keep the following tips in mind as you seek treatment for your pain:• Chronic pain can result in physical and psychological challenges. It is important to accept support from loved ones—you need and deserve all the help you can get.• Be sure to seek treatment as early as possible to avoid further problems.• Do not allow your physical illness or pain to take over your life. Pain is a part ofyou, but it should not define who you are.• Try not to let past frustrations of failed treatments stand in your way; there are a wide range of treatments available as detailed in this guide. While your pain might not go away completely, there are ways to reduce it so that it is bearable and you can reclaim parts of your life.
HELPFUL HINTS ON YOUR ROAD TO PAIN RELIEF
![Page 56: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/56.jpg)
Keep the following tips in mind as you seek treatment for your pain:• Chronic pain can result in physical and psychological challenges. It is important to accept support from loved ones—you need and deserve all the help you can get.• Be sure to seek treatment as early as possible to avoid further problems.• Do not allow your physical illness or pain to take over your life. Pain is a part ofyou, but it should not define who you are.• Try not to let past frustrations of failed treatments stand in your way; there are a wide range of treatments available as detailed in this guide. While your pain might not go away completely, there are ways to reduce it so that it is bearable and you can reclaim parts of your life.
HELPFUL HINTS ON YOUR ROAD TO PAIN RELIEF
![Page 57: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/57.jpg)
COMMON FEATURES OF AN OPIOID AGREEMENT
•Sign an opioid agreement to be kept in your medical file (ask for your own copy)•Obtain prescriptions from only one doctor•Have your prescriptions filled at one pharmacy•Come in for regular office visits (every 2-4 weeks or so)•Agree to have periodic urine drug screening•Bring your pills in to be counted during visits• Follow any additional rules not listed abovehttp://www.painknowledge.org/opioidtoolkit/docs/Treatment%20Options.pdf
![Page 58: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/58.jpg)
Additive disorder
Tobacco smoker Drug dependence Alcoholic
![Page 59: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/59.jpg)
Disability issues
In process
Resolved
![Page 60: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/60.jpg)
Mental health
Concern for metal illness Past history of mental illness Family history of mental illness Bipolar depression Yes/No
Treated satisfactorily Yes/No Depression Yes/No Treated satisfactorily Yes/No
![Page 61: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/61.jpg)
Disability issues
In process
Resolved
![Page 62: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/62.jpg)
![Page 63: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/63.jpg)
![Page 64: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/64.jpg)
Stable on current program
Mental health Addictive disorder Chronic pain
![Page 65: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/65.jpg)
NOT!
![Page 66: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/66.jpg)
![Page 67: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/67.jpg)
Dad left when he found out about Mom and Panda.
![Page 68: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/68.jpg)
Screening for depression and bipolar disease
Depression screen Becks inventory PHQ-9
Bipolar screen – Mood disorder questionnaire (MDQ)
![Page 69: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/69.jpg)
Beck’s Inventory
http://www.fehb.org/CSE/CCSEConference2012/BeckDepressionInventory.pdf
http://www.nhlbi.nih.gov/meetings/workshops/depression/instruments.htm
![Page 70: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/70.jpg)
PHQ-9
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/
![Page 71: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/71.jpg)
Mood disorder questionnaire
www.ncbi.nlm.nih.gov/pubmed/12505821
![Page 72: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/72.jpg)
Referral to psychiatrist
![Page 73: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/73.jpg)
EVIDENCE – Know it!
![Page 74: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/74.jpg)
Early MRI
The rate of lumbar spine magnetic resonance imaging in the USis growing at an alarming rate.
Evidence that it is not accompanied by improved patient outcomes.
Overutilization correlates with, and likely contributes to, a 2- to 3-fold increase in surgical rates over the last 10 years.
Knowledge of imaging abnormalities can actually decrease self-perception of health and may lead to fear-avoidance and catastrophizing behaviors that may predispose people to chronicity.
LEVEL OF EVIDENCE: Diagnosis/prognosis/therapy, level 5.Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in
low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011 Nov;41(11):838-46. Epub 2011 Jun 3.
![Page 75: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/75.jpg)
Reason’s to do MRI
Suspect cauda equinaLonger pain than 6-12 weeks
Patient is amenable to injection therapy
Directed care to PT
![Page 76: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/76.jpg)
Ya gonna get a snot bath!!
![Page 77: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/77.jpg)
Referall to pain psychotherapist
![Page 78: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/78.jpg)
![Page 79: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/79.jpg)
Pain management 4 legs of treatment w/ psychologist
Borrie, RA. (2001). Thinking About Pain Psychologically based pain management can provide relief for pain patients. http://www.practicalpainmanagement.com/treatments/psychological/thinking-about-pain
![Page 80: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/80.jpg)
Got MILK? Nope.
![Page 81: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/81.jpg)
Clinical guidelines NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low
back pain), and tricyclic antidepressants (for chronic low back pain) are effective for pain relief.
Opioids, tramadol, benzodiazepines, and gabapentin (for radiculopathy) are effective for pain relief.
Systemic corticosteroids are ineffective . Adverse events, such as sedation, varied by medication, although
reliable data on serious and long-term harms are sparse. Most trials were short term (< or =4 weeks). Few data address efficacy of dual-medication therapy compared with
monotherapy, or beneficial effects on functional outcomes.
Chou R, Huffman LH; American Pain Society; American College of Physicians. (2007). Medications for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):505-14.
![Page 82: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/82.jpg)
Selected Nonpharmacologic Treatment Options from Practice Guidelines
Osteoarthritis(AC R 2000)• Self-management programs• Weight loss• Aerobic exercise• Range-of-motion exercises• Muscle-strengthening
exercises• Assistive devices• Occupational/physical
therapy• Joint protection/energy
conservation
Low Back Pain(Chou 2007) Acupressure/acupuncture• Functional restoration• Interdisciplinary rehabilitation• Interferential therapy• Massage• Transcutaneous/percutaneouselectrical nerve stimulation• Spinal manipulation
![Page 83: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/83.jpg)
Invasive interventions
![Page 84: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/84.jpg)
Sciatica or prolapsed lumbar disc with radiculopathy (level of evidence)
Chemonucleolysis is moderately superior to placebo injection but inferior to surgery. (good)
Epidural steroid injection is moderately effective for short-term (but not long-term) symptom relief. (fair)
Spinal cord stimulation is moderately effective for failed back surgery syndrome with persistent radiculopathy, though device-related complications are common. (fair)
Prolotherapy, facet joint injection, intradiscal steroid injection, and percutaneous intradiscal radiofrequency thermocoagulation are not effective. (good)
Insufficient evidence exists to reliably evaluate other interventional therapies.
Chou R, Atlas SJ, Stanos SP, Rosenquist RW.Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009 May 1;34(10):1078-93
![Page 85: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/85.jpg)
Case studies
![Page 86: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/86.jpg)
Arthritis on NSAIDS and HS opioids
![Page 87: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/87.jpg)
Methadone endometriosis
![Page 88: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/88.jpg)
High dose narcotics for chronic low back pain
![Page 89: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/89.jpg)
Overview of some of the more commonly
used nonopioid and ajuvant analgesics.
used to treat chronic pain, including salicylates, acetaminophen, nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, anticonvulsants, N-Methyl-D-Aspartate receptor antagonists, lidocaine, skeletal muscle relaxants, and topical analgesics.
http://www.ncbi.nlm.nih.gov/pubmed/14567202
Gordon, DB, (2003). Nonopioid and adjuvant analgesics in chronic pain management: strategies for effective use. HYPERLINK North Am. 2003 Sep;38(3):447-64,vi.
![Page 90: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/90.jpg)
http://www.ncbi.nlm.nih.gov/pubmed/21176430
Mease, PJ. (2009). Further strategies for treating fibromyalgia: the role of serotonin and norepinephrine reuptake inhibitors. Am J Med. Dec;122(12 Suppl):S44-55
![Page 91: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/91.jpg)
Franco M, Iannuccelli C, Atzeni F, Cazzola M, Salaffi F, Valesini G, Sarzi-Puttini P. Pharmacological treatment of fibromyalgia. Clin Exp Rheumatol. 2010 Nov-Dec;28(6 Suppl 63):S110-6. Epub 2010.
11/18 painful tender points Multimodal pharmacological treatment also combined with non-
pharmacological therapy. Only three drugs (duloxetine, milnacipram, pregabalin) are approved
by the American Food and Drug Administration (FDA) and none by the European Medicines Agency (EMEA
Most of the drugs improve only one or two symptoms; no drug capable of overall symptom control is yet available.
Tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), opioids, non-steroidal anti-inflammatory drugs (NSAIDs), growth hormone, corticosteroids and sedative hypnotics.
As no single drug fully manages FM symptoms, multicomponent therapy should be used from the beginning.
Gradually increasing low doses is suggested in order to maximize efficacy.
The best treatment should be individualized and combined with patient education and non-pharmacological therapy.
![Page 92: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/92.jpg)
CME: Help Your Patients Break Free Assessing and Managing Chronic Pain in Primary Care: Applying Evidence to Practice
http://www.omniaeducation.com/emails/2012images/echo_pain/ECHO_Pain_web.pdf?utm_source=Omnia+Education&utm_campaign=43b013690c-Pain_Echo1_4_2012&utm_medium=email
CME
![Page 93: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/93.jpg)
![Page 94: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/94.jpg)
Bibliography
Borrie, RA. (2001). Thinking About Pain Psychologically based pain management can provide relief for pain patients. http://www.practicalpainmanagement.com/treatments/psychological/thinking-about-pain
Chou R, Qaseem A, Snow V, et al; for the Clinical Efficacy Assessment Subcommittee of the American
College of Physicians and the American College of Physicians/American Pain Society Low Back Pain
Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478-491.
Chou R, Fanciullo GJ, Fine PG, et al; for the American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
Chou R, Atlas SJ, Stanos SP, Rosenquist RW.Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009 May 1;34(10):1078-93
![Page 95: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/95.jpg)
Bibliography
Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011 Nov;41(11):838-46. Epub 2011 Jun 3.
Franco M, Iannuccelli C, Atzeni F, Cazzola M, Salaffi F, Valesini G, Sarzi-Puttini P. Pharmacological treatment of fibromyalgia. Clin Exp Rheumatol. 2010 Nov-Dec;28(6 Suppl 63):S110-6. Epub 2010.
![Page 96: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/96.jpg)
Each king in a deck of playing cards represents a great king from history.
Hearts - CharlemagneDiamonds - Julius Caesar. Clubs - Alexander the GreatSpades= King David
![Page 97: T “My whole body aches.” “What do you mean my MRI is negative? My back still hurts!](https://reader036.vdocuments.us/reader036/viewer/2022070323/56649dbf5503460f94ab3a1d/html5/thumbnails/97.jpg)