T
“What do you mean my MRI
is negative?
My back still hurts!
“My whole body aches.”
Annemarie M.
Kallenbach
RN CNP
No Disclosures
docakilah.wordpress.com



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.

Chronic low back pain and fibromyalgia
share two clinical features.
 The visits are not quick
 The visits are not easy.
Implementing a consistent algorithm that
incorporates current recommendations
in today’s busy clinic will yield improved
results in patient care.


Chronic pain must to be addressed in a multi
directive model.
A clear, practical chart checklist will keep
treatment plan on course.
Pain response



Labor
Stubbing toe on chair leg
Burning shoulder pain from too much time on
computer
Jot down 5 honest reactions
to seeing back painrecurrent, fibromyalgia
follow up on your
schedule.
 Time consuming
 Frustrated
 Angry
 Nervous
 Agitated
 Scared
 Skeptical
 Excited for the challenge.
 Ready to try a multiple facet
approach to treatment.
 Armed with excellent
resources.






Frustrated
Angry
Nervous
Agitated
Scared
Skeptical
Excited for the
challenge
 Ready to try a multiple
approach to treatment
 Armed with excellent
resources



Does you patient have chronic pain?
Has a complete workup been done in the
past? Labs, diagnostics




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)

Do you believe you can have an honest
patient provider relationship?

Does your patient have the ability to go to a
chiropractor, PT, massage therapist,
acupuncturist, etc?


Is your patient already on routine opiods?
Is your patient willing to partner to
reduce/eliminate ineffective opiods?


Do you have time and interest in treating?
Do you have knowledge to treat?



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?

Do you have relationships with local
pharmacists?

Do you have the ability to drug screen your
patient?


Does your state have medical marijuana?
Does your state have a narcotic prescription
reporting mechanism?
Taking a Pain History
• Location
• Radiation
• Onset: sudden or insidious
• Duration
• Frequency: continuous
or intermittent
• Description
• Intensity
• Alleviating factors
• Exacerbating factors



Neck

Shoulder

Total body
Lumbar
Knee













Anti inflamatory
Elavil/Pamelor
Neurontin
Lyrica
Antidepressent
SSRI
SNRI
Mood stabilizer
Anxiolytic
Opiod
Tramadol
Sleep agent
SUBOXONE, METHADONE
 Was it complete?
 Exam
findings
 X-ray
 MRI
 Consult notes





Orthopedic
Pain management
Neurosurgeon
Injection therapy
Psychologist




Dates
Goals
Patient’s adherence to sessions and to home
exercises
Trial of TENS



Tobacco smoker
Drug dependence
Alcoholic


Partner agreement
Pain contract signed
Treatment Options:
A Guide for People Living with Pain
Dedicated to eliminating the under treatment
of pain in America.
www.painknowledge.org/opioidtoolkit/docs/Tr
eatment%20Options.pdf
The following organizations are represented by those who helped
create this publication:
American Academy of Pain Management
American Academy of Pain Medicine
American Alliance of Cancer Pain Initiatives
American Board of Hospice and Palliative Medicine
American Holistic Nursing Association
American Pain Society
American Society for Pain Management Nursing
American Society of Regional Anesthesiologists
Association of Oncology Social Work
Healing Touch International
Intercultural Cancer Council
International Association for the Study of Pain
Midwest Nursing Research Society
National Association of Social Workers
Oncology Nursing Society
HELPFUL HINTS ON YOUR ROAD TO PAIN RELIEF
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 of
you, 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
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 of
you, 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.
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 above
http://www.painknowledge.org/opioidtoolkit/docs/Treatment%20Options.pdf



Tobacco smoker
Drug dependence
Alcoholic

In process

Resolved







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

In process

Resolved



Mental health
Addictive disorder
Chronic pain
NOT!

Depression screen
 Becks inventory
 PHQ-9

Bipolar screen – Mood disorder questionnaire
(MDQ)
http://www.fehb.org/CSE/CCSEConference201
2/BeckDepressionInventory.pdf
http://www.nhlbi.nih.gov/meetings/workshops/
depression/instruments.htm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC
1495268/
www.ncbi.nlm.nih.gov/pubmed/12505821





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 fearavoidance 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.
 Suspect cauda equina
 Longer pain than 6-12 weeks
 Patient is amenable to
injection therapy
 Directed care to PT
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/treatmen
ts/psychological/thinking-about-pain






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.
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/percutaneous
electrical nerve stimulation
• Spinal manipulation
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 devicerelated 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

Case studies
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.
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
11/18 painful tender points
Multimodal pharmacological treatment also combined with nonpharmacological 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.


http://www.omniaeducation.com/emails/2012i
mages/echo_pain/ECHO_Pain_web.pdf?utm
_source=Omnia+Education&utm_campaign=
43b013690cPain_Echo1_4_2012&utm_medium=email

CME
Borrie, RA. (2001). Thinking About Pain Psychologically based pain management can
provide relief for pain patients.
http://www.practicalpainmanagement.com/treatments/psychological/thinkingabout-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
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.
Each king in a deck of playing
cards represents a great king from
history.
Hearts - Charlemagne
Diamonds - Julius Caesar.
Clubs - Alexander the Great
Spades= King David