Case Study 2
Instructions: Spend 5 minutes reviewing the case below and considering the questions that follow.
Mike, 21, presents to a primary care clinic as a new patient. On his intake form, the clinic nurse has written that the patient made an urgent appointment yesterday with a chief complaint of “back pain.” When you enter the room, Mike appears not to be in acute distress as he is texting on his phone. The patient briefly winces when he stands up from his chair to shake your hand. He sits back down and tells he is generally healthy but that two years ago, he fell while working on a roof. You express concern, but he shrugs it off, saying that he fell into the bushes, which broke his fall, but that he did hurt his back. At the Emergency Room the ER attending diagnosed him with a muscle injury, prescribed oxycodone, and sent him home to rest. However, the patient says he continues to have chronic back pain and would like another prescription for oxycodone so that he can go back to work.
1. Given the subjective nature of pain, how can a clinician more objectively assess the kind of pain reported by patients such as Mike?
2. What kinds of non-opioid treatments might you suggest Mike try before writing a new prescription for oxycodone?
3. What types of functional goals might be appropriate as part of a treatment plan for Mike?
Tai chi A meta-analysis of 15 randomized trials in patients with musculoskeletal pain (80% OA) found tai chi to be moderately effective in improving both pain and disability at up to 3 months compared to no intervention. 50 No statistically significant differences were observed at 3 months to 1 year, or >1 year. A randomized trial with 204 adults with symptomatic knee OA compared 12 weeks of twice- weekly tai chi vs. standard physical therapy and followed patients for 52 weeks. Both study arms showed significant improvements from baseline pain scores at 52 weeks, but there was no statistically significant difference between groups in terms of pain or function. 51 Yoga A review of 12 studies (including four RCTs) involving 589 patients with OA symptoms comparing a variety of yoga regimens to usual care found suggestions that pain, stiffness, and swelling were reduced. No effect on physical function was observed. 52 A randomized trial of 131 older adults with lower extremity OA compared twice-weekly sessions of chair yoga vs. a health education program. 53 At 3-month follow-up, participants in the yoga group showed greater reductions in pain interferences (P=0.01) compared to control. During the intervention, patients in the yoga group had reduced pain on the WOMAC scale and improved gait speed compared to the control group, but the differences were not sustained at 3-month follow-up. 53
Acupuncture A Cochrane review of six randomized trials evaluating acupuncture in 413 patients with hip OA found conflicting evidence on its effects on pain and function. 54 In analysis of two trials with 105 patients comparing acupuncture to sham acupuncture there were no significant differences after 5-9 weeks in pain or function. One trial, however, that compared 13 weeks of acupuncture plus routine primary care vs. routine primary care alone in 137 patients found reduced pain and improved function. Two trials reported minor side effects with acupuncture, mostly bruising, bleeding, or pain at needle insertion site. An unblinded trial randomized 221 adults with hip or knee OA to acupuncture, sham acupuncture, or mock electrical stimulation. 55 After five weeks of treatment no significant differences in mean improvements on a 0-100 pain scale were found for any comparisons. Acupuncture trials can be particularly susceptible to placebo effects, as illustrated in a study comparing needle or laser acupuncture to no acupuncture or sham laser treatment in 282 patients with chronic knee pain (mean age 63). After 12 weeks of treatments, needle and laser acupuncture reduced self-reported knee pain more than no acupuncture (control) but not more than sham acupuncture, suggesting strong placebo effects. The benefits were not sustained at one year follow up. 31
Massage A review of seven randomized trials with 352 participants suggests that massage may be better than no treatment for reducing OA pain. 56 The trials were diverse with respect to outcomes, massage techniques, and patient populations. Clinical effect sizes for pain were moderate with about a 20-point reduction in WOMAC scores from a baseline of 50-60 points. The functional benefits were less clear; some trials showed no benefit while others showed improvements in the 50-foot walk test. 56,57 Self-management education programs Small effects were noted in three meta-analyses of studies evaluating self-management education programs, though the benefits were not considered clinically important. Arthritis-specific programs included techniques to deal with problems associated with arthritis, appropriate exercises and medications, nutrition, and effective communication with healthcare providers and family. Other non-drug interventions TENS has been used for pain relief for decades, but studies evaluating effectiveness have shown mixed results. Data from four trials, including two RCTs, showed no statistical improvement in pain over placebo. 58 CBT interventions typically address comorbid conditions, such as insomnia and depression. A systematic review, without meta-analysis, of four trials involving CBT or CBT-like pain coping skills trainings found inconsistent evidence for reduced pain at 12-month follow-up. 59
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