Pain management: Lessons from patients
Because pain has so many causes and treatments, one of the best ways to sharpen your pain-management skills is to study how your colleagues successfully handle particularly challenging patients. Here are two case histories of such patients — involving the knees, back and wrist — from two practitioners who are also pain experts.
Case 1: Alternatives to NSAIDs for knee pain
By Yvonne D'Arcy, MS, CRNP, CNS
Mrs. C, 65 years old, presented with complaints of increasing pain in both knees. She described the pain as moderate-to-severe and mentioned that it has made sleeping difficult and limited her walking ability to the point where she can no longer climb stairs. Methyl salicylate/menthol (Bengay) and other topical creams provided no relief. Mrs. C had been taking a nonsteroidal anti-inflammatory drug (NSAID) for pain, but she wanted to find an alternative.
Mrs. C was diagnosed with osteoarthritis five years before. She has diabetes that is controlled with oral medication. Obese, she had twice been referred to weight-loss programs by her diabetes educator, with little success, although she was compliant with her drug regimen. An allergy to eggs caused severe urticarial wheals. In addition to ibuprofen 400 mg four times daily, she was taking a proton pump inhibitor (PPI) for GI prophylaxis.
Using a cane for assistance, Mrs. C moved slowly into the exam room, then she used her arms to help lift her body up onto the table. Vital signs were normal. At 5 ft 6 in, she weighed 210 lb. Glucose was 135 mg/dL. Inspection of her knees revealed moderate swelling and warmth. Bilateral crepitus was heard in both knees. Deep tendon reflexes were normal. Flexion and extension were reduced in both knees, and Mrs. C complained of moderate pain when her knees were manually manipulated.
Because there was no significant fluid collection, aspiration was unnecessary. MRI revealed significant bilateral joint-space narrowing. Osteophytes were seen on patellar surfaces, and the cartilage on several areas had eroded. A complete blood count and metabolic panel were ordered to test for NSAID-induced anemia or liver dysfunction. All results were within normal limits.
While it would have been easy to simply refer Mrs. C back to her orthopedist, she had significant medical- and pain-management needs that required immediate intervention. In addition, Mrs. C did not like her NSAID, and extended use increases the risk for stroke, heart attack and GI bleeding. Even with the use of a PPI, stopping the NSAID would be a good decision.
Mrs. C mentioned that she had been unable to follow any previous weight-reduction programs and that physical activity was difficult with her current knee pain. However, patients with osteoarthritis can benefit significantly from losing 20 lbs. The reduced load on the joints can decrease pain and increase function.
Mrs. C was referred to a weight-reduction program that also focused on strengthening her quadriceps muscles through physical therapy. Stronger quadriceps allow for easier ambulation and pain reduction. After each therapy session, Mrs. C was advised to apply cold packs and iontophoresis.
Iontophoresis uses a mild electrical current to deliver topically applied anti-inflammatory agents directly to the site of the pain, while cold packs help reduce swelling. Referral was also made to a psychologist, with whom Mrs. C could discuss her weight-loss attempts and learn how to avoid the pitfalls that made her previous attempts fail.
Because Mrs. C complained of pain, she was provided with a transcutaneous electrical nerve stimulator (TENS) unit. This would allow her to control her pain between physical therapy sessions. Although the research on TENS with osteoarthritis is not conclusive, there is enough evidence to suggest that pain reduction is one benefit.
During her initial evaluation, Mrs. C stated that she did not like the idea of having needles inserted into her knees, but an NIH study, has shown that acupuncture increases function and decreases pain in patients with arthritis. Mrs. C agreed to an initial informational meeting with the acupuncturist at the physical therapy center.
Last, Mrs. C was prescribed lidocaine (Lidoderm) 5% gel patches, up to three patches daily. The patches can be applied to the knees for periods of 12 hours on, 12 hours off, with no systemic uptake. Because the pain was worse at night, she was told to use the patches whenever she had trouble sleeping.
Mrs. C is allergic to eggs, so she should not be given hyaluronate (Hyalgan) injections. Although such injections may significantly decrease pain, Hyalgan is made from the combs of roosters and should be avoided by those with egg allergies. Use of glucosamine chondroitin should also be avoided. Mrs. C is diabetic, and studies suggest that glucosamine can increase insulin resistance.
At six weeks follow-up, Mrs. C was no longer using a cane and her pain had diminished. She had been meeting three times a week with a physical therapist to work on her leg strength, and she has noted a difference in how she walks.
Her meetings with the psychologist revealed that her biggest downfall when it came to losing weight was the tendency to eat at night and between meals. Avoiding this has resulted in a weight loss of 10 lb. Her blood sugar levels have also improved. While she tried acupuncture, she felt it did not work well for her. She does, however, like the TENS unit and Lidoderm patches.
Overall, Mrs. C was happy with the pain relief she was getting. She rated her pain at 3/10, although she did note that sleep is still difficult at times. She was advised to listen to relaxation tapes during the evening. Although she has never used them, Mrs. C is open to trying them and planned to discuss their efficacy with her psychologist.Yvonne D'Arcy, MS, CRNP, CNS is the pain and palliative care nurse practitioner and outcomes manager for Suburban Hospital in Bethesda, Md.
Case 2: Pharmacologic intervention
By Gregory Holm, PhD, NP, FAANP
Ms. B, a 44-year-old, left-handed welder, was referred to our occupational medicine clinic by a local ER for follow-up treatment. Three days earlier, a loose thermocouple in her welding apparatus resulted in an alternating current, 400 V, high-amperage electrical shock to her left hand. Muscle tetany had prevented her from releasing her grip until a fuse blew, causing her to fall backwards, striking her back and left shoulder on a concrete floor. She did not hit her head, and there was no loss of consciousness or neck pain.
At the time of the accident, Ms. B was treated by paramedics and transported to the ER. An ECG and laboratory testing were within normal limits. She was released with a prescription for acetaminophen/hydrocodone (Vicodin), which she did not fill because she's “allergic to codeine.”
On presentation to our clinic, Ms. B complained of mild-to-moderate sharp pain, primarily in her left wrist and elbow. She also noted minor sharp discomfort in her left posterior shoulder and shoulder-blade area. There was no headache, chest pain or palpitations, nausea or vomiting, diarrhea, dyspnea, bowel or bladder symptoms, amnesia, focal weakness, muscle rigidity, tinnitus, seizures, paresthesias or changes in sensorium or gait.
Ms. B's medical history was significant for recurrent allergic sinusitis and bronchitis, gastroesophageal reflux disease, and arthritis in both wrists. Her only surgery was rhinoplasty eight years before. Current medications included ipratropium (Atrovent), fluticasone/salmeterol (Advair Diskus), lansoprazole (Prevacid), and acetaminophen (Tylenol) as needed.
Previous use of meperidine (Demerol) had precipitated an anaphylactic reaction, and codeine caused migraines. She also stated that aspirin, ibuprofen and naproxen caused gastric upset. Her last tetanus vaccination was three years ago.
Although Ms. B had a 15-pack-year history of cigarette smoking, she denied drinking alcohol or any substance abuse. Her family history was positive for stroke and diabetes.
Ms. B she did not appear to be in any acute distress. BP was 140/70 mm Hg, pulse 70 beats per minute, and respiratory rate 16 breaths per minute. There was no apparent respiratory distress. She was afebrile, with good color and warm, dry skin. Neurologic examination was normal. Auscultation of the heart revealed a regular rate and rhythm, without rubs, murmurs or gallops. There was no jugular venous distension.
Closer examination of the injury revealed a small area of “shininess” at the radial/dorsal aspect of the left hand, which Ms. B said was the “entrance wound.” A whitish, sensitive burn on the posterior elbow was the “exit wound.” Several clean, dry, scabbed linear abrasions were noted on the left wrist. There was no heat or erythema. The wrist and elbow had full range of motion (including elbow supination and pronation) without discomfort or tenderness. Cozen's test was negative.
The left shoulder exhibited full range of motion, with minor discomfort at the elbow during Apley's scratch test. Impingement, push-off and drop-arm assessments were negative. Apprehension sign was absent. The subacromial area of the left shoulder was somewhat tender as was the posterior aspect of the neck musculature. Lhermitte's and Spurling's signs were negative, and the neck was supple. Deep tendon reflexes were normal, and no pathological reflexes were elicited. All four extremities exhibited normal strength, and distal pulses were intact.
Cose inspection of the left hand revealed brisk nail beds. Allen's testing demonstrated normal circulation. Froment's sign and Finkelstein's test were both negative. Tinel's sign was negative at the wrist and elbow. Sharp-dull discrimination was intact.
ECG revealed normal sinus rhythm and was otherwise unremarkable. Urinalysis revealed a specific gravity of 1.020 and pH of 5; all other results were negative. There was no myoglobin in the urine.
Complete blood count with differential revealed a WBC count of 13,100/µL (normal 4,600-10,200), granulocytes 10,400/µL (normal 2,000-6,900) and monocytes 700/µL (normal 0-600).
Blood urea nitrogen was 25 mg/dL (normal 6-20), and creatine kinase was 108 units/L (normal <146). The remainder of the metabolic panel was normal.
An x-ray of the left elbow showed a normal fat pad sign. Bony structures were intact, and the joint surfaces were smooth. No fractures, dislocations or radiopaque foreign bodies were seen. X-rays of the left shoulder demonstrated some minimal degenerative calcifications in the area of the olecranon, but there was no evidence of fracture, dislocation or radiopaque foreign bodies.
At this point, Ms. B was diagnosed with electrical-shock and partial-thickness burns to her left arm and contusion to the left periscapular area.
The small burn areas were treated with daily silver sulfadiazine (Silvadene) cream and covered with vaseline gauze, 4 ´ 4 gauze, and an Ace bandage. Because Ms. B was intolerant of nonselective NSAIDs, she was started on celecoxib (Celebrex) 400 mg titrated 200 mg b.i.d. with food. She tolerated this regimen, with no side effects.
After being advised about wound care, smoking cessation and maintaining good hydration and nutrition, Ms. B was allowed to return to work with modifications.
Three days later, Ms. B's burns had improved, but she now complained of an increase in the left periscapular pain, with tenderness over the T7 region. The burns were debrided, and the original plan of care was continued.
Ms. B continued to experience left periscapular pain without pleuritic pain for another week. Left periscapular tenderness was still present, but there was no discomfort with the push-off test. The burn areas were healing well. A small amount of detritus and devitalized tissue in the elbow wound was mechanically debrided. Wound care was continued.
Over the ensuing several weeks, the arm discomfort diminished, but discomfort in the left periscapular area increased to a dull ache. Metaxalone (Skelaxin) 800 mg t.i.d. provided adequate relief, with no adverse effects.
Five weeks after Ms. B's injury, the pain and burns had resolved. All medications were discontinued. At work, she was placed on a trial of regular duty. Shortly thereafter, she returned to our clinic in tears, with markedly increased pain between the shoulder blades. She rated the left periscapular pain, which alternately burned and ached, as 8/10 in severity and worsening with activity.
The pain originated over the lateral aspect of the posterior rib cage and radiated toward the midline, with no anterior radiation. Ms. B was placed on tramadol/acetaminophen (Ultracet) as needed for pain.
An MRI of the dorsal spine demonstrated some mild degenerative changes. Left paracentral disk protrusion at the T11-12 interspace touched the ventral spinal cord and narrowed the canal and left neural foramen. Consultation with a neurosurgeon resulted in a tentative diagnosis of a spondylolytic lesion. Surgery was not indicated.
Ms. B was started on physical therapy. A physiatry consult revealed that Ms. B's persistent complaints were not related to spondylitic changes at T11-12 but rather to intercostal neuralgia at T7-8 or T8-9.
Because Ms. B had a long history of tobacco abuse, the possibility of intrathoracic pathology needed to be excluded. A chest CT without contrast was normal, except for some osteoarthritic changes of the dorsal spine, which was consistent with the results of her previous MRI.
The patient was also reporting headaches, which she believed were secondary to the Ultracet, so that medication was discontinued. At this point, she described her pain as burning and becoming less tolerable.
Ms. B was given gabapentin (Neurontin) 300 mg, one tablet on the first day, one tablet b.i.d. on the second day, and then one tablet t.i.d. thereafter. Gabapentin is indicated for postherpetic neuralgia and is frequently used successfully off-label for neuropathic pain. Ms. B experienced no adverse effects.
An algologist was consulted for evaluation and consideration of segmental thoracic and/or intercostal T7 through T9 nerve blocks. The gabapentin effectively managed Ms. B's pain until nerve blocks could be performed.
Six months after her initial injury, Ms. B was finally symptom-free. She had not taken the gabapentin for six weeks. Her final instructions were to follow up as needed.
Ms. B presented a classic case of progression of multiple pain responses to a clear initial insult. It is important to monitor the severity and characteristics of the pain on each follow-up visit in order to differentiate between the pain types, and manage them successfully.
A multidisciplinary approach is probably the best option for successfully managing more complicated and prolonged pain responses. Early and aggressive treatment options have a greater chance of eventual (and timely) symptom resolution.