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A Publication of The McGraw-Hill Companies, Inc. JULY 2002







This Postgraduate Medicine Special Report, The ABCs of Musculoskeletal Pain, was made available through an unrestricted educational grant from Ortho-McNeil Pharmaceutical Inc. Published by Healthcare Information Programs, McGraw-Hill Healthcare Information Group, Minneapolis. Copyright 2002, by The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Healthcare Information Programs Editor-in-Chief William O. Roberts, MD General Manager Sarah DeMann Associate Editor Sarah Nafziger Bokenewicz

Intended Audiences: Physicians

This program was developed to address the undertreatment of musculoskeletal pain and will discuss program management of musculoskeletal pain.

Creative Director Paul F. Keiski Director of Production Suzanne Johnson Art Production Manager Beth Harvey Editorial Coordinator Emily Lenarz Contributing Editor Paul W. Mamula, PhD University of Wisconsin Medical School Educational Reviewer Thomas M. Best, MD, PhD

Faculty Disclosures
In accordance with the Essential Areas and Policies of the ACCME relating to commercial support, faculty and sponsors are required to disclose the existence of any significant financial interest or any other relationship they have with the manufacturer(s) of any commercial product(s) discussed in an educational program.

The articles in this publication have been independently peer reviewed. The sponsor has played no role in the selection of reviewers. The views and opinions expressed in this Special Report are those of the participants and authors and do not necessarily reflect the views of the publisher, editor, or editorial board of Postgraduate Medicine, or Ortho-McNeil Pharmaceutical Inc. All reasonable precautions have been taken by the authors and publishers to verify drug names and doses. Clinical judgment must guide each physician in weighing the benefits of treatment against the risk of toxicity. Dosages, indications, and methods of use referred to in the articles may reflect the clinical experience of the authors or may reflect the professional literature or other clinical sources. Please see the full prescribing information on any products mentioned in this publication.

Editorial Offices 4530 West 77th Street Minneapolis, MN 55435 (952) 832-7856 Group Vice President M. James Dougherty






Gary E. Ruoff, MD


David G. Borenstein, MD


Bill McCarberg, MD





Learning Objectives
At the conclusion of this activity, participants should be able to: Define the primary care physicians role in assessing, treating, and reassessing their patients suffering from musculoskeletal pain

Understand the importance of a thorough assessment prior to beginning treatment Evaluate the different nonpharmacologic and pharmacologic treatments available in selecting the most appropriate pain management regimen

Understand the importance of continuous reassessment and treatment adjustment to an effective pain management program, as well as the need to enlist patients as active members of their own care plan



The ABCs of Musculoskeletal Pain
Gary E. Ruoff, MD

patients. Consideration of the full range of treatment options, both nonpharmacologic and pharmacologic, can facilitate selection of the most appropriate combination for reducing pain and improving function in the individual patient with musculoskeletal pain. s
Gary E. Ruoff, MD Dr Ruoff is clinical professor of family practice, Michigan State University College of Human Medicine, East Lansing, Michigan. Dr Ruoff is a member of the speakers bureau and has conducted clinical research for Ortho-McNeil Pharmaceutical Inc, Merck & Co Inc, Pharmacia & Upjohn, Elan Pharmaceuticals, and Pfizer Inc.

s Pain has been defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.1 This definition is particularly relevant because it takes into account the emotional component of pain, which can modify the pain signal, and recognizes that tissue damage encompasses potential as well as actual damage. The 3 musculoskeletal disorders that most commonly produce pain requiring medical attention are osteoarthritis, fibromyalgia, and low-back pain.2-8 Osteoarthritis, the most common form of arthritis, affects more than 20 million Americans. Osteoarthritis is so prevalent in Americans older than 65 that 70% are estimated to have radiographic evidence of the disease. Fibromyalgia affects 6 million people and accounts for 10% of patients seen in general practice. Lowback pain, a major health problem, has a prevalence of 15% to 20% and a lifetime prevalence of 70%. The majority of the population will experience low-back pain at some point in their lives.

The high prevalence of painrelated musculoskeletal disorders emphasizes the need for understanding the ABCs of pain: Assessing pain, Beginning treatment, and Continuing care. This Special Report is based on the symposium, The ABCs of Musculoskeletal Pain, held on October 6, 2001, in Atlanta, Georgia. The symposium focused on how to assess and manage pain in patients with osteoarthritis, fibromyalgia, and low-back pain. The first section discusses the ongoing problem of underassessing pain and presents tips for taking medical histories and patient interviews, which facilitate diagnosis. In the second section, Dr Borenstein describes the many nonpharmacologic and pharmacologic modalities available for treatment of patients with musculoskeletal disorders. In the last section, Dr McCarberg examines the continuing challenge of caring for patients with unremitting, chronic pain. Understanding the proper way to assess patients with musculoskeletal disease can lead to better pain management for these

Address for correspondence: Gary E. Ruoff, MD Westside Family Medical Center 6565 W Main St Kalamazoo, MI 49009

References 1. Merskey H, Bogduk N. Classification of Chronic Pain. Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. 2nd ed. Seattle: IASP Press; 1994:209-14 2. Borenstein DG. A clinicians approach to acute low back pain. Am J Med 1997; 102(1A):16-22S 3. Borenstein DG. Chronic low back pain. Rheum Dis Clin North Am 1996;22(3): 439-56 4. Clark S, Odell L. Fibromyalgia syndrome: common, realand treatable. Clinician Rev 2000;10:57-83 5. Lawrence RC, Helmick CG, Arnett FC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 1998;41(5):778-99 6. Rosomoff HL, Rosomoff RS. Low back pain. Evaluation and management in the primary care setting. Med Clin North Am 1999;83(3):643-62 7. Solomon L. Clinical features of osteoarthritis. In: Kelley WN, Ruddy S, Harris EDJ, et al, eds. Textbook of Rheumatology. Volume 2. Philadelphia: WB Saunders; 1997:1383-1408 8. Centers for Disease Control and Prevention. Current trends: prevalence of disabilities and associated health conditionsUnited States, 1991-1992. MMWR Morb Mortal Wkly Rep 1994;43(40):730-9



Assessing Pain as the Fifth Vital Sign

Gary E. Ruoff, MD

Pain is the most common reason why patients seek medical attention; however, pain is often underassessed because of clinician, system, and patient barriers. Proper pain assessment can improve outcomes, prevent adverse effects and psychosocial complications, and decrease healthcare costs. Pain assessment should include a complete medical history, a thorough patient interview and examination, evaluation of comorbidities, consideration of differential diagnoses, and performance of diagnostic tests. Osteoarthritis, fibromyalgia, and low-back pain have specific characteristics that can help clinicians make the appropriate diagnosis.

s Pain is one of the most frequent complaints that bring patients to the physicians office.1 Pain that triggers an office visit can be either acute or chronic. Acute pain has a short duration and an identifiable pathology. The prognosis is predictable and treatment is typically with analgesics; however, acute pain improves quickly, with or without these drugs. Chronic pain, on the other hand, is characterized by long duration6 months or more. The pain often starts a few months earlier, sometimes as an acute process. But by the time the pain becomes chronic, the underlying pathology

may no longer be evident and the patient may have forgotten the acute episode. The pain signal is still present but modified, pain characteristics have changed, and prognosis is unpredictable. Management of chronic pain, therefore, often requires multiple treatments and a multidisciplinary approach.2 When patients are seen during an office visit, their vital signs are takenpulse rate, respiratory rate, temperature, and blood pressure. Because pain is such a common, critical component of the many disorders that trigger office visits, it should be assessed as the fifth vital sign.

Underassessment of pain Two decades of efforts to publicize proper pain management have failed to resolve the problem of undertreatment. Both physicians and patients often consider pain to be an expected, relatively insignificant symptom. Accordingly, pain is not routinely assessed, documented, or reassessed.1 Underassessment of pain can be associated with various clinician, system, and/or patient barriers.1,3 These barriers indicate the need for addressing multiple issues to achieve proper recognition and management of pain throughout the healthcare system. Quality improvement in the entire system is clearly needed. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued standards for pain (table 1), and other agencies and associations have proposed their own. Physicians readily support the basic concepts expressed by such standards and guidelines, but they are constrained by time and resource limitations, as well as difficulty in following guidelines that may differ and have inconsistencies.1 Steps for pain assessment Despite these difficulties, practicing physicians can follow certain steps to achieve proper pain assessment. Appropriate assessment can improve clinical outcomes and prevent further complications and psychosocial adverse effects, as well as decrease healthcare costs. The medical history and patient interview are crucial to


the proper assessment of pain and are bolstered by findings from the physical examination. The primary concern when obtaining a medical history is to rule out a serious problem such as cancer or infection. Physicians should also evaluate psychosocial issues (eg, anxiety and depression) that can modify pain signals and impede recovery. Knowledge of patient response to prior treatment can guide future therapeutic choices.2,4,5 Use of pain assessment tools is an important part of the patient interview. Various devices are available and include the visual analog scale (VAS), numerical rating scale, verbal rating scale, functional status questionnaire, verbal descriptor scale, faces scale (figure 1), pain chart, and daily pain diary. The patient interview should provide a detailed description of the pain as well as an indication of functional status. Use of a diary can help obtain an accurate description of pain. The description that emerges from such devices should include onset, duration, location, radiation, quality, severity, and precipitating or

aggravating factors. The VAS is probably the best tool for determining the severity of the pain and how it changes in response to treatment. The scale consists of a line with the words no pain at one end and the most pain you ever had or imagined at the other end. The patient marks a slash on the line to indicate pain severity. The functional status questionnaire is important because the patient may be able to manage pain but not the associated disability. Once disability develops, the patient may regard even mild pain as severe. Accordingly, early satisfactory treatment for pain is crucial to prevent subsequent disability, which can exacerbate perception of pain and complicate treatment. Even if it is manageable with disability, pain can

require additional analgesia that would otherwise have been unnecessary with prompt management. The physical examination supplements the findings from the medical history and patient interview. One effective method is to watch the patient walk, sit, stand, and lie down. This observation takes only about 1 minute but can often enable the physician to make the differential diagnosis. The neurologic examination can provide further refinement. Laboratory tests (eg, erythrocyte sedimentation rate [ESR], complete blood count) may be useful for ruling out serious diseases. Finally, although x-rays may provide additional information, they are often not definitive. A positive radiographic finding

Table 1. JCAHO standards for pain and its management

Patients have the right to recognition and control of their pain Thorough pain assessment of patients identified with pain Perform effective pain management and rehabilitation Educate staff, patient, and family about pain Ongoing quality improvement of pain management
JCAHO, Joint Commission on Accreditation of Healthcare Organizations. Adapted from Berry et al.1

Figure 1. The faces scale pain assessment tool. This device is a pictorial pain assessment tool that is particularly useful for evaluating children. Young patients are asked to select the face that best describes how much pain they feel. Adapted with permission from Bieri et al.11


1. Insertion of nuchal muscles into occiput (bilateral) 2. Upper border of trapezius midportion (bilateral) 3. Muscle attachments to upper medial border of scapula (bilateral) 2 3 4 4. Anterior aspects of 5th and 7th cervical intertransverse spaces (bilateral) 5. 2nd rib space, about 3 cm lateral to the sternal border 9 (bilateral)

most important risk factor, especially for osteoarthritis of the knees.5 The physical examination helps make the diagnosis and usually reveals a disturbed gait plus swelling and deformity of the peripheral joints. Laboratory tests and synovial fluid analyses are not generally helpful. Radiographs may show characteristic changes and provide additional diagnostic information.5 Assessment of fibromyalgia Although its existence has been questioned, fibromyalgia represents a real clinical entity. Fibromyalgia may be a sensory dysfunction disorder involving altered processing with central sensitization (increased excitability). It is characterized by pain without inflammation (tender points); involvement of fibrous tissues, muscles, tendons, and ligaments; and physiologic abnormalities (neuroendocrine, neurotransmitter, muscle tissue, sleep disturbances).7,8 The American College of Rheumatology 1990 criteria for classification consider the presence of 11 or more of the 18 specific tender sites, in conjunction with a history of widespread pain, to be characteristic of fibromyalgia (figure 2).9 Bilateral involvement implicates fibromyalgia, while unilateral involvement, especially radiating pain and a trigger point, suggests myofascial pain syndrome. Patients with fibromyalgia need to be asked about problems with pain, sleep, fatigue, and psychological distress, as well as other symptoms that

6 7

6. Muscle attachments to the lateral epicondyle (bilateral) 7. Upper outer quadrant of gluteal muscles (bilateral) 8. Muscle attachments just posterior to greater trochanter (bilateral) 9. Medial fat pad of knees proximal to the joint line (bilateral)
Figure 2. Tender point sites for classifying patients with fibromyalgia. The American College of Rheumatology 1990 criteria can be used to classify patients with fibromyalgia. The presence of 11 or more of the 18 paired tender points in conjunction with a history of widespread pain is considered characteristic of fibromyalgia. Adapted from Wolfe et al.9

may not correlate with the symptoms and cause of the patients pain.2 Assessment of osteoarthritis Osteoarthritis is typically characterized by joint pain rather than inflammation and by bony enlargement, crepitus on movement, and limitation of joint

movement.6 Inflammation, if present, is usually mild and localized to the affected joint.5 Risk factors for the development of osteoarthritis include age (older), gender (female), race, obesity, use and abuse of joints, and joint instability and malalignment. After age, weight is probably the next


might suggest other conditions. Because of the sensory system disorder, these patients often have associated comorbidities. These can include chronic fatigue syndrome, chronic pelvic pain/dysmenorrhea, urinary urgency/frequency, irritable bowel syndrome, migraine headaches, multiple chemical sensitivities, and anxiety and depression.7,8 Assessment of low-back pain Low-back pain can arise from many different conditions, including back strain or sprain, acute disc herniation, osteoarthritis, spinal stenosis, spondylolisthesis, ankylosing spondylitis, infection, or malignancy. The patients age can provide a clue to the diagnosis. In younger patients, back strain or sprain is likely. A herniated disc is more probable in middleaged patients, and osteoarthritis or spinal stenosis should be considered in older patients.2 Attention to psychosocial factors is also important in assessing these patients.10
References 1. Berry PH, Dahl JL. Making pain assessment and management a healthcare priority through the new JCAHO pain standards. J Pharm Care Pain Symptom Control 2000;8:5-20 2. Borenstein DG. Etiology of low back pain. Fam Pract Recert 1999;21:3-8 3. American Pain Society Quality of Care Committee. Quality improvement guidelines for treatment of acute pain and cancer pain. JAMA. 1995;274(23): 1874-80 4. Ruoff GE. Pharmacologic treatment of low back pain. Fam Pract Recert 1999;21:15-21 5. Solomon L. Clinical features of osteoarthritis. In: Kelley WN, Ruddy S,

The physical examination should evaluate range of motion; stance and gait; mobility (sitting, lying down, standing); and straight-leg raise. Physicians can obtain valuable diagnostic information by watching patients move. For example, patients who have pain on standing may have spinal stenosis or osteoarthritis, whereas patients who have pain on sitting may have a herniated disks.2 Computed tomography, magnetic resonance imaging, and radiography are sometimes useful in evaluating these patients.10 Other tests can help rule out unrelated disorders. An ESR can help to rule out infection and malignancy. Clues such as weight loss, fever, and/or a history of malignancy should also raise red flags.2,10 Conclusion Although pain is very commonly seen in office practice and may be considered the fifth vital sign, it is frequently

underassessed. Proper assessment of musculoskeletal pain includes a complete medical history and patient interview, use of pain assessment tools, a thorough physical examination, performance of appropriate laboratory tests and imaging techniques, evaluation of comorbidities, and consideration of differential diagnoses. Appropriate assessment of these patients can facilitate the development of suitable pain management plans. s

Gary E. Ruoff,MD Dr Ruoff is clinical professor of family practice, Michigan State University College of Human Medicine, East Lansing, Michigan. Dr Ruoff is a member of the speakers bureau and has conducted clinical research for Ortho-McNeil Pharmaceutical Inc, Merck & Co Inc, Pharmacia & Upjohn, Elan Pharmaceuticals, and Pfizer Inc.

Address for correspondence: Gary E. Ruoff, MD Westside Family Medical Center 6565 W Main St Kalamazoo, MI 49009


7. 8. 9.

Harris EDJ, et al, eds. Textbook of Rheumatology. Vol 2. Philadelphia: W.B. Saunders; 1997:1383-1408 American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum 2000;43(9):1905-15 Clark S, Odell L. Fibromyalgia syndrome. Common, realand treatable. Clinician Rev 2000;10:57-83 Leventhal LJ. Management of fibromyalgia. Ann Intern Med 1999;131(11):850-8 Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology

1990 criteria for the classification of fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990;33(2):160-72 10. Rosomoff HL, Rosomoff RS. Low back pain. Evaluation and management in the primary care setting. Med Clin North Am 1999;83(3):643-62 11. Bieri D, Reeve RA, Champion GD, et al. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain 1990;41(2):139-50. 1990 Elsevier Science



Beginning the Treatment of Musculoskeletal Pain

David G. Borenstein, MD

plinary, and constant therapy is almost always needed. The goal of chronic pain therapy is to improve and restore function how well does the patient function despite having pain? Using more than 1 therapeutic modality improves the chances for success. As much time should be spent getting patients to use nonpharmacologic measures as is spent informing them about the benefits and risks associated with the use of medications. Osteoarthritis: nonpharmacologic treatment Many nonpharmacologic options are available to treat patients with osteoarthritis. These measures should be tried or, at least, considered before drugs.2 Patients need to be educated about their disease. Many patients may mistake osteoarthritis for rheumatoid arthritis. Learning that osteoarthritis is a slowly progressive disease of aging and not disabling rheumatoid disease is often a relief. Both rest and exercise are important. The affected, irritated joints must be rested, either by having the patients refrain from activity for part of the day and/or by bracing joints that are still being used.2 Patients should engage in aerobic and strengthening exercises (eg, on a stationary bike or in the pool). Physical and occupational therapy can also be helpful.2 Being overweight or obese can contribute to the development of osteoarthritis of the knee and hip in women. Weight loss should be encouraged; putting these patients in the pool allows them to burn calories by moving in a nonweightbearing environment.2 The therapeutic goal of

The selection of appropriate therapy for the management of musculoskeletal pain requires understanding the general principles of pain management and recognizing the importance of using both nonpharmacologic and pharmacologic modalities. Aspects to consider include the type of pain, its intensity and duration, presence of comorbidities and/or use of concomitant medications, patient age, likelihood of adverse effects, psychosocial factors, past pain treatments, patient preferences, and costs.1,2

s As the population ages and the prevalence of musculoskeletal disorders increases, treatment of the pain associated with these disorders will assume an even greater importance. Pain is both a societal and a patient problem. Patients want to have their pain eradicated, whereas the societal goal of pain management is, according to the American Pain Society, To advance the treatment of people in pain by ensuring access to treatment, removing regulatory barriers, and educating practitioners.3 Pain treatment is constantly changing, and physicians must keep abreast to be able to offer their patients optimal care.

General principles of pain management The approach to treatment differs for acute and chronic pain. Acute pain occurs rapidly and usually lasts less than 3 months. The therapeutic goal is 100% pain relief. Within 1 to 2 weeks or, at most, 2 to 3 months, the damage heals and the pain resolves. In contrast, chronic pain is not acute pain that lasts longer. Although the damage may have healed, system plasticity has altered the nociceptors. Once the pain switch is turned on, pain continues without requiring any further damage. If the pain switch can be turned off, the patient experiences a significant decrease in pain, but 100% pain relief is not likely. The approach to the patient with chronic pain is multidisci-


minimizing joint loading can be accomplished by using assistive devices. Substituting a fancy umbrella may help some patients overcome their reluctance to use a cane.2 Osteoarthritis: pharmacologic treatment A broad range of pharmacologic agents is available to treat osteoarthritis. The American College of Rheumatology has suggested acetaminophen (APAP) as initial therapy for mild osteoarthritis pain. APAP does not have the adverse effects of many other drugs, and most patients can use it on their own without physician instruction. But as the disease progresses, APAP usually becomes inadequate to treat the pain.2

Topical creams such as capsaicin (derived from chili peppers) can be useful, especially for the fingers. Capsaicin must be used 3 to 4 times a day, but patients must be careful to avoid getting any in their eyes because it can cause severe tearing. Capsaicin is not effective long-term, and patients tire of chronic use.2 Nonsteroidal antiinflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inihbitors are mainstays of therapy for osteoarthritis patients. These drugs effectively decrease pain and inflammation. NSAIDs are a good choice for patients with appreciable inflammatory changes, but gastrointestinal (GI), cardiovascular, and other side effects are a concern. Coadministration of a GI protectant and proper fluid intake are recommended.

COX-2 inhibitors are as effective as NSAIDs and may have fewer adverse GI effects.2 Tramadol, a non-narcotic, nonscheduled analgesic, is effective for treating moderateto-severe pain in osteoarthritis patients, including the elderly. Tramadol and tramadol/APAP (37.5mg /325 mg) have been shown to be effective in acute osteoarthritis flare, as well as in chronic pain states.4-6 Since perception of pain involves multiple pathways, combination therapy is well suited to pain management. Combination therapy with agents that have different mechanisms (eg, tramadol/APAP) can increase effectiveness by providing a more rapid onset and longer duration of effect, and may decrease adverse effects.7 In acute flares, tramadol/APAP provided statistically significant pain relief in patients with knee and hip osteoarthritis who were on chronic NSAID therapy.4 Tramadol with or without APAP can also be used in patients for whom NSAIDs or COX-2 inhibitors are contraindicated, as well as for additional pain relief in patients already taking these drugs. Tramadol does not have the serious adverse effects associated with traditional opioids, but it can cause nausea, GI upset, constipation, and drowsiness in some patients.2 OPIATESOpioid analgesics can help osteoarthritis patients who have more severe, prolonged, or nocturnal pain. However, opioids produce constipation, somnolence, dependence, and rarely, addiction. While patients may not become addicted in the true sense of the word, they emphat-

ically seek to continue the therapy when it effectively treats their pain.2

plementation with hyaluronic acid injections is another therapeutic option. These injections into the knee can decrease pain and delay joint replacement; the effects last 6 to 12 months. Effectiveness for other joints and the long-term benefits and risks to the joint are unknown.2,8 and chondroitin sulfate have some effectiveness, but definitive answers will depend on ongoing trials.2,9 Joint replacement surgery in patients with intractable pain can be quite effective in appropriately selected patients with knee or hip osteoarthritis. Patients who are potential surgical candidates should be encouraged to meet with an orthopedic surgeon to make informed decisions.2 Fibromyalgia: nonpharmacologic treatment Fibromyalgia remains a continuing challenge for primary care physicians and rheumatologists, but can also be treated by nonpharmacologic and pharmacologic measures.9 Unfortunately, many available drugs have limited effectiveness.10 Patient education is essential.9 Patients must be assured that they have a recognized problem, that their sensory nervous system is more sensitive than normal, and that treatments are available to help them. They must be encouraged to gradually work toward the goal of exercising 3 times per week, whether


on a stationary bike, taking a brisk walk, etc.11 Cognitive-behavioral therapy is another valuable nonpharmacologic tool for fibromyalgia patients. Patients are taught to deal with the activities of daily living and maximize function. Electromyographic biofeedback training also helps patients control their discomfort. Electrical stimulation devices are available for treating patients, although using such devices, and cold, heat, and massage therapies have short-acting effects. For longlasting benefits, other modalities such as motion and strengthening exercises may be used.11,12 Fibromyalgia: pharmacologic treatment Many pharmacologic agents are useful for treatment. Because many patients with fibromyalgia have sleep disturbances, anxiety, and/or depression, treatment with tricyclic antidepressants (TCAs) and selective serotoninreuptake inhibitors (SSRIs) can be helpful.11,12 Reduction of sleep disturbances can be achieved fairly rapidly. TCAs increase serotonin in the pain inhibitory pathways. The drugs are useful in improving characteristic problems, but manifest tachyphylaxis and can cause anticholinergic effects (eg, dry mouth and eyes). SSRIs may be effective for pain in patients with associated depression. Other antidepressants, such as venlafaxine, are useful in selected patients. Muscle relaxants such as tizanidine can also help with sleep disturbances.11,12 Trial and error may be needed to find the appropriate muscle relaxant for a given patient. Occasionally, sedatives may improve sleep disturbances.

Although APAP is easy to use, it is not very effective for fibromyalgia. Similarly, despite their widespread use, NSAIDs are only marginally effective and have potentially serious adverse effects.9,11 Opioid analgesics are rarely used and should be reserved for those with severe pain and only in specific patients who have signed opioid contracts. Few controlled studies have been performed using opioids to treat these patients.9,12,13 Tramadol can be useful as adjunctive therapy in patients with fibromyalgia to decrease pain and tender points and improve function.10 Tramadol alone 10 or in combination with APAP has been shown to provide analgesic efficacy with limited adverse effects.14 NSAID therapy alone is not usually sufficient for fibromyalgia patients, and adding analgesic agents can permit patients to successfully engage in nonpharmacologic modalities (eg, exercise).9,12,13 Corticosteroid injections are generally not helpful for fibromyalgia, especially on a recurrent basis. Moreover, the extent of the involved areas would require too many injections. Occasionally, a local anesthetic (eg, lidocaine) may be useful.9 The real benefit of injection therapy may be to mobilize the affected part and facilitate physical therapy for strengthening. For specific problem areas (eg, concomitant myofascial pain), injection can provide long-term relief and improve function.11,13 Acute low-back pain: nonpharmacologic treatment Treatment options differ for acute and chronic disease.

Patients with acute pain usually improve quickly, almost regardless of the specific therapy used. Range-of-motion exercises are important for these patients, so long periods of bed rest should be minimized. Patient education is therefore necessary. Other modalities, such as heat and cold treatments and chiropractic procedures, can be helpful for mobilizing the patient. Local injections can be effective when a very specific localized area of pain is present.1,15,16 Acute low-back pain: pharmacologic treatment Pharmacologic agents include some of those used for other disorders, but the risks for adverse effects must be considered (table 1). For patients with acute lowback pain related to sciatica, opioid analgesics and epidural corticosteroid therapy can help.1,15 Chronic low-back pain: nonpharmacologic treatment Patients with chronic low-back pain require a more sustained effort, and long-term function becomes an important concern. These patients can have associated neurologic and psychosocial factors that affect the therapy chosen. Nonpharmacologic modalities also play an important role in chronic low-back pain treatment. Educating patients about their problem is essential. Patients must be told that short-term bed rest should be used only for specific, brief periods. Exercises, temperature modalities, and massage keep the patient mobile. Surgery is used infrequently, but in some disorders (eg, spinal stenosis) decompressing affected nerves can be helpful.1,17



Table 1. Pharamacologic therapies for low-back pain

Medication Acetaminophen NSAIDs COX-2 inhibitors Muscle relaxants Tramadol Advantages Useful for mild pain only and for patients with aspirin sensitivity Effective for moderate pain; anti-inflammatory effect at high doses As effective as NSAIDs As effective as NSAIDs; good for muscle strain Effective for moderate-to-severe pain; non-narcotic analgesic; not associated with GI or renal adverse effects Same as for tramadol; multiple mechanisms of action Good for severe pain Localized effect; can be used if oral therapy fails Disadvantages Not effective for severe pain; liver toxicity may occur in high doses GI, renal, and CV adverse effect Renal and CV adverse effects possible Drowsiness Associated with nausea and dizziness; may increase seizure risk in some patients Same as for tramadol Constipation, somnolence, tolerance, dependence, and addiction seen Requires several days to have improvement

Tramadol/acetaminophen (37.5 mg/325 mg) Opioids Epidural corticosteroids

COX-2, cyclooxygenase-2; CV, cardiovascular; GI, gastrointestinal; NSAIDs, nonsteroidal anti-inflammatory drugs.

Chronic low-back pain: pharmacologic treatment Combined therapies are used to mobilize the patient. APAP, NSAIDs, and COX-2 inhibitors have all been used successfully for patients with chronic pain of mild-tomoderate severity.1 Acetaminophen can be used for mild pain and in patients with aspirin sensitivity. NSAIDs are useful for moderate pain and have anti-inflammatory effects at high doses, but they can produce serious adverse effects. COX-2 inhibitors are as effective as traditional NSAIDs in pain relief, but they have fewer adverse effects. Muscle relaxants, which can be taken with NSAIDs, can decrease spasm and improve function, but because the drugs cause drowsiness, they should be used only in appropriately selected patients. Patients who have had

Table 2. Overview of pharamacologic therapy for musculoskeletal disorders

Medication Acetaminophen NSAIDs/COX-2 Tramadol/APAP (37.5 mg/325 mg) Opioids Tricyclic antidepressants Selective serotonin-reuptake inhibitors Muscle relaxants Epidural corticosteroids Osteoarthritis + + + + Fibromyalgia Low-Back Pain + + + + + + + + + +

+ +

COX-2, cyclooxygenase-2 inhibitors; NSAIDs, nonsteroidal anti-inflammatory drugs.

surgery but continue to experience pain can be treated with long-acting opioid analgesics. Opioids are used for severe pain, but they have troublesome adverse effects. Epidural corticosteroids are useful in

treating selected patients with sciatica (eg, spinal stenosis or herniated disc).1,16 Both tramadol alone and in combination with APAP have been shown to decrease pain and improve function in



patients with chronic low-back pain.18 Tramadol also offers an alternative for patients who are either unable to tolerate NSAIDs or not sufficiently responsive to nonpharmacologic modalities.6,19,20 Tramadols absence of serious respiratory and cardiovascular adverse effects, lack of GI irritation, and low incidence of constipation represent further advantages over some analgesics. The combination of tramadol/ APAP also provides additional analgesic effect with fewer adverse effects.5 This combination employs 25% less tramadol than monotherapy and can decrease dose-related side effects. Conclusion Several different drugs can be used alone or in combination to treat patients with painful musculoskeletal disorders (table 2). It is important, however, to emphasize that pharmacologic therapy is not the only treatment option. Nonpharmacologic therapy should play a key role in the treatment. Physicians should tell patients what is wrong, that they understand their problem, that there is a therapeutic goal for the various treatment modalities, and that patients should use a range of appropriate modalities. Optimal pain management should include consideration of monotherapy vs combination therapy, individual patient factors, adverse effects, and possible referral to a specialist. No single therapy works for everyone, and physi-

cians must proceed largely through trial and error. Periodic reassessment is essential.13 s


7. David G. Borenstein, MD Dr Borenstein is clinical professor of medicine, division of rheumatology, George Washington University Medical Center, Washington, DC. Dr Borenstein is a member of the speakers bureau for Ortho-McNeil Pharmaceutical Inc, Merck & Co Inc, Pharmacia & Upjohn, and Pfizer Inc and has conducted clinical research for these companies as well as for Procter & Gamble. He is a consultant for Ortho-McNeil Pharmaceutical Inc, Merck & Co Inc, and Pharmacia & Upjohn.


9. 10.

11. 12. 13. 14.

Address for correspondence: David G. Borenstein, MD Arthritis and Rheumatism Associates 2021 K Street NW, Suite 300 Washington, DC 20006

References 1. Ruoff GE. Pharmacologic treatment of low back pain. Fam Pract Recert 1999; 21:15-21 2. American College of Rheumatology Subcommittee on Osteoarthritis. Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis Rheum 2000;43(9): 1905-15 3. American Academy of Pain Medicine, American Pain Society, American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain: a consensus document from the American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine. Available at: opioids2.htm 4. Silverfield JC, Kamin M, Rosenthal N, et al. Efficacy and safety of combination tramadol and acetaminophen tablets (ULTRACET) for the treatment of pain associated with osteoarthritis flare: a multicenter, outpatient, randomized, double-blind, placebo-controlled study [abstract]. Arthritis Rheum. 2001;44:S135 5. Mullican WS, Lacy JR. Tramadol/ acetaminophen combination tablets and codeine/acetaminophen combination capsules for the treatment of pain:

15. 16. 17.




a comparative trial. Clin Ther 2001; 23(9):1429-45 Katz WA. Pharmacology and clinical experience with tramadol in osteoarthritis. Drugs 1996;52(suppl 3): 39-47 Raffa RB. Pharmacology of oral combination analgesics: rational therapy for pain. J Clin Pharm Ther 2001; 26(4):257-64 Buckwalter JA, Stanish WD, Rosier RN, et al. The increasing need for nonoperative treatment of patients with osteoarthritis. Clin Orthop 2001;36-45 Bennett RM. Treatment strategies for fibromyalgia syndrome. J Musculoskeletal Med 1999;16(6):S20-6 Russell IJ, Kamin M, Bennett RM, et al. Efficacy of tramadol in treatment of pain in fibromyalgia. J Clin Rheumatol 2000;6:250-7 Clark S, Odell L. Fibromyalgia syndrome. Common, realand treatable. Clinician Rev 2000;10(5):57-83 Leventhal LJ. Management of fibromyalgia. Ann Intern Med 1999; 131(11):850-8 Barkhuizen A. Pharmacologic treatment of fibromyalgia. Curr Pain Headache Rep 2001;5(4):351-8 Bennett R, Kamin M, Rosenthal N, et al. Efficacy and safety of a tramadol/ acetaminophen combination (ULTRACET) in the management of fibromyalgia-related pain: a multicenter, outpatient, randomized, double-blind, placebo-controlled study [abstract]. Arthritis Rheum 2001;44(9 suppl):S67 Borenstein DG. A clinicians approach to acute low back pain. Am J Med. 1997;102(1A):16-22S Paster RZ. Nonpharmacologic management of low back pain. Fam Pract Recert 1999;21:9-14 Rosomoff HL, Rosomoff RS. Low back pain. Evaluation and management in the primary care setting. Med Clin North Am 1999;83(3):643-62 Borenstein DG, Kamin M, Rosenthal N, et al. Combination tramadol and acetaminophen (ULTRACET) for the treatment of chronic lower back pain: a multicenter, outpatient, randomized, double-blind, placebo-controlled study [abstract]. Arthritis Rheum 2001;44:S67 Schnitzer TJ, Gray WL, Paster RZ, et al. Efficacy of tramadol in treatment of chronic low back pain. J Rheumatol. 2000;27(3):772-8 Raber M, Hofman S, Junge K, et al. Analgesic efficacy and tolerability of tramadol 100 mg sustained-release capsules in patients with moderate to severe chronic low back pain. Clin Drug Invest 1999;17:415-23




Continuing the Care of Musculoskeletal Pain

Bill McCarberg, MD

Providing continuing care for patients with chronic musculoskeletal pain who do not improve poses a substantial challenge. Patients referred to a pain specialist often have had all appropriate treatment, yet still have pain and seek help. What can be done for these patients? Rehabilitation becomes the new treatment goal. Medication is used to facilitate rehabilitation, and patients are encouraged to play an active role. Modalities employing the cognitive-behavioral approach can be effective in reducing pain and improving function in such patients.

want? Ive done everything possible. Other people dont report this much pain, and theyre not this disabled. Physicians may wonder if these patients just want time off from work and household chores. Many careproviders raise questions about the possible secondary gain these patients get from the experience of pain, particularly when motor vehicle accidents, workers compensation, and litigation are involved. But in most cases, even after the matter is resolved financially in the patients favor, the pain does not necessarily improve. Patients with pain would do anything to reduce their pain. Given appropriate therapy, these patients can improve like other patients who are not involved in litigation. The pain game Whether or not secondary gain is a factor, by the time the patient reaches the stage when he or she is continually returning to the physician, a disconnect occurs between physician and patient. This is what R. Sternbach calls the pain game.1 The patient says, Please help me. The doctor responds, I will help you. The patient doesnt get better. The physician now thinks, I can find nothing wrong. My treatments are ineffective. The patient is exaggerating the pain. The doctor trained to deal with this kind of pain is a psychiatrist. The patient in turn thinks, The doctor is telling me its all in my head. Hes just a quack like all the other doctors. Now the physician has a patient who sought to have pain reduced and function improved, but neither goal has

Saga of the chronic, disabled pain patient The usual pattern for patients with chronic, disabling pain starts with diagnosis and treatment. All the correct treatments are employed by the primary care physician and the specialists who see these patients, but the treatments fail. The patient then returns to the primary care physician. At this point, rehabilitation becomes the desirable goal. The primary care physician, however, would prefer for someone else to see such patients because they present difficulties. The pain behavior, limping, disability, and long list of complaints now far exceed the original injury. In short, the pain behavior becomes disproportionate to

the injury. The expected healing time is long past and the patient has not improved. Numerous interventions have been tried without success, the biopsychosocial model has failed, and yet the problem cannot be found. All the possible treatment strategies have been attempted and pain has been reduced, but the patient remains in pain. Whats next? From the patients perspective, chronic pain impairs multiple aspects of his or her life. Sleep is disturbed. Sexual function is altered. The patients functioning, both at work and in daily life, is disturbed. Role identity is disrupted, and patients beg to have their life back. Physicians treating these patients ask, What do they



Table 1. Continuing care goals for patients with musculoskeletal pain

Rehabilitation Medication (if it improves rehabilitation) Prevention of unnecessary healthcare visits

Table 2. Components of the cognitive-behavioral approach

Education Meditation Cognitive restructuring Distraction Pacing Laughter

by enabling patients to participate in exercise programs and maximize their function. Patients with chronic conditions should learn to master their own problems. Physicians can teach patients what they can do to get betterbut not by having them continually make office visits. The more patients see the doctor, the more convinced they become that something is wrong that needs to be found, that more testing will be done, and that different treatments will be tried. Instead, physicians need to minimize contact, and seek to increase these patients functioning by encouraging them to become more self-sufficient. The cognitive-behavioral approach The cognitive-behavioral approach that combines education, meditation, cognitive restructuring, distraction, pacing, and laughter can help control pain, improve function, and achieve rehabilitation (table 2).2 Cognitive-behavioral therapy programs are designed to decrease the patients feelings of helplessness, restructure negative thought patterns that produce pain amplification, and help the patient cope with situations that can increase pain perception.3 Cognitivebehavioral methods have been shown to have positive results in patients with fibromyalgia, probably because they target more than a single symptom and actively involve the patient in the therapeutic alliance.4,5 Cognitive restructuring helps these patients modify their thinking patterns. Many patients with a chronic, painful

been met. The physician and patient are playing the pain game. Continuing management of chronic pain patients Patients like this say, I just want the doctor to believe me. I want the doctor to listen. I dont want my doctor to abandon me. I want the doctor to help me through this pain. I want my doctor to be honest with me. What can the doctor do, now? He can set new continuing care goals for rehabilitation (table 1). By reducing the pain even a small degree, pain medication can be valuable by allowing participation in a rehabilitation program. Even if the pain cannot be lessened, rehabilitation can help the patient return to as normal life as possible. Acute passive therapies may play a beneficial role

condition have intrusive, disabling thoughts. If the physician can help them reframe these thoughts, the patient will improve. Distracting techniques and laughter therapy may also be useful. In addition, patients must be taught how to pace themselves. If they have a good day, they may try to do everything that they have put off because they dont know what the next day will bring. In my pain management practice, we have taught cognitivebehavioral techniques to more than 9,000 patients in over 15 years. Patients receive education about their pain and learn meditation techniques, allowing them to become masters of their own pain. Teaching these techniques to patients takes about 16 hours, and occurs in structured group settings. It is difficult for a busy practitioner to incorporate the group dynamics that take place in classes. However, helping patients indentify intrusive thoughts (ie, catastrophizing, all or none thinking, etc.) will help them deal with chronic pain. The effects of cognitivebehavioral therapy were evaluated in a group of 2,037 patients.6 Most patients experienced low-back pain, and almost 50% had pain in more than 1 site. Pain levels averaged 7.5 (severe pain by American Pain Society standards: mild pain, 1-3; moderate, 4-6; severe, 7-10). The mean duration of pain was almost 8.1 years. Most patients were referred to the program by primary care doctors (42% of referrals) and physical medicine specialists (22%).



Table 3. Comparison of cognitive-behavioral and standard therapies for pain treatment

Group Cognitive-behavioral therapy Control Number 251 95 Pre-study $2,155 $1,568 Post-study $785* $1,225 Difference $1,370 $343

* P<0.01; Data from Medicare charges for pain-related outpatient care

Cognitive-behavioral techniques resulted in a statistically significant (P<0.01) reduction of pain levels. Pain scores fell from an average value of 7.51 at baseline to 5.91 at the 6-month follow-up, an excellent result. Statistically significant (P<0.01) improvement also occurred in such measures of function as interference of pain with life, self-control, and negative mood. Did learning these techniques save money? The answer was a resounding yes. In a study of pain patients, 251 patients attended classes and 95 control patients had no special treatment. Among patients attending classes, pain-related outpatient utilization costs fell substantially (table 3); the
References 1. Sternbach RA. Psychological aspects of pain and the selection of patients. Clin Neurosurg 1974;21:323-33 2. Bennett RM. Treatment strategies for fibromyalgia syndrome. J Musculoskeletal Med. 1999;16(6A)(suppl):S20-6 3. Clark S, Odell L. Fibromyalgia

difference was statistically significant. Conclusion Regaining function is always the objective in treating chronic pain patients. The Joint Commission on Accreditation of Healthcare Organizations states that every patient must be asked about pain. Pain can be assessed as the fifth vital sign, but treating pain alone is not sufficient. Patients also need to be told that function must also be improved. An inability to function because of adverse effects or other problems, despite a reduction in pain, is not a good result. Active involvement of the patient in partnership with the healthcare team, using such techniques as

cognitive-behavioral therapy, can considerably benefit chronic pain patients. s

Bill McCarberg, MD Dr McCarberg is director of pain services, chronic pain management program, Kaiser Permanente, Escondido, California and assistant clinical professor, department of family medicine, University of California, San Diego. Dr McCarberg is a member of the speakers bureau for Ortho-McNeil Pharmaceutical Inc, Janssen Pharmaceutica, Purdue Pharma LP, and Endo Pharmaceuticals Inc.

Address for correspondence: Bill McCarberg, MD Director of Pain Services Physician-in-Charge Chronic Pain Management Program Kaiser Permanente 732 N Broadway Escondido, CA 92025

syndrome. Common, realand treatable. Clinician Rev 2000;10(5): 57-83 4. Barkhuizen A. Pharmacologic treatment of fibromyalgia. Curr Pain Headache Rep 2001;5(4):351-8

5. Leventhal LJ. Management of fibromyalgia. Ann Intern Med 1999; 131(11):850-8 6. McCarberg B, Wolf J. Chronic pain management in a health maintenance organization. Clin J Pain 1999;15(1):50-7




CME Self-Study Examination

After filling in the answer form, complete the registration form and return both. The envelope must be postmarked no later than July 1, 2004.

Accreditation This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the University of Wisconsin Medical School and DesignWrite. The University of

Wisconsin Medical School is accredited by the ACCME to provide continuing medical education for physicians. The University of Wisconsin Medical School designates this educational activity for a maximum of 3 hours in category 1 credit toward the AMA Physicians Recognition Award. Each physician should claim

only those hours of credit that he/she actually spent in the educational activity. In accordance with the Essential Areas and Policies of the ACCME relating to commercial support, the reader is advised that this Special Report contains references to unlabeled or unapproved uses of drugs or devices.

ABCs of Musculoskeletal Pain Registration Form

Please print Medical License: Name: Degree: Specialty: Address: How much time did you spend on this activity? ____ hours Signature: Mail this form to: Continuing Medical Education University of Wisconsin Medical School, Room AB 2715 Marshall Court Madison, WI 53705

Fill in the circles on the answer sheet, making sure that each answer corresponds to the appropriate question.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. A q q q q q q q q q q B q q q q q q q q q q C q q q q q q q q q q D q q q q q q q q q q E q q q q q q q q q q



CME Self-Study Examination The ABCs of Musculoskeletal Pain

Fill in the circles on the answer sheet, making sure that each answer corresponds to the appropriate question. 1. What is the leading cause of all disabilities among people 15 years of age or older in the United States? A. Arthritis/rheumatism B. Back/spine trouble C. Heart trouble D. Lung/respiratory problems 2. What is a factor contributing to the underassessment of pain? A. Lack of consistent reevaluation of patients pain by clinician B. Payers concerns about increased healthcare costs from undertreating pain C. Overreporting of pain due to feeling that good patients dont complain D. Highly standardized pain scores for inter/ intra-institutional treatment comparisons 3. Which test has been shown to be the best tool for determining the severity of the pain and how it changes in response to treatment? A. Verbal rating scale B. Functional status questionnaire C. Visual analog scale D. Numerical rating scale 4. After age, what is the next most important risk factor for osteoarthritis, especially of the knees? A. Gender B. Race C. Stability of joints D. Weight 5. Which statement is false regarding pharmacologic treatment options in osteoarthritis? A. Acetaminophen has been suggested as initial therapy for mild pain B. Capsaicin creams can be useful, especially on the fingers C. Tramadol/acetaminophen can relieve pain from acute osteoarthritis flare D. Glucosamine has no effectiveness for treating osteoarthritis 6. Which statement is false regarding treatment options in fibromyalgia? A. TCAs and SSRIs can be helpful in patients with sleep disturbances, anxiety, and/or depression B. NSAIDs are only marginally effective for the treatment of fibromyalgia C. Corticosteroid injections are generally helpful for the treatment of fibromyalgia, especially on a recurrent basis D. Tramadol can be useful as first-line therapy in patients with fibromyalgia 7. Which statement is false regarding treatment options in chronic low-back pain? A. Acetaminophen can be used for mild pain and in patients with aspirin sensitivity B. Tramadol alone or in combination with acetaminophen can be useful to decrease pain and improve function in patients with chronic low-back pain C. NSAIDs are useful for moderate pain D. Surgery is a frequent option in patients with chronic lowback pain. 8. What is an appropriate option for a patient whose pain is not controlled, even though both the primary care physician and specialists have administered treatment? A. Pain game B. Rehabilitation C. Psychiatric counseling D. PCA (patient-controlled analgesia) 9. Cognitive-behavioral methods have been shown to have positive results in patients with A. Fibromyalgia B. Acute low-back pain C. Osteoarthritis D. Chronic low-back pain 10. The study of 2,037 patients on the effects of cognitivebehavioral therapy in pain control found a statistically significant improvement in such measures of function as interference of pain with quality of life, self-control, and negative mood. True or False? A. True B. False