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A 55 year old male presents to the clinic referred from his PCP for low back pain. He had an acute exacerbation of pain six months ago to which he was bed ridden for several days, but the pain levels improved within the week and was able to resume regular activity, but still experienced mild back pain. He has been taking Ibuprofen every day since the onset (6 months ago). He recently has seen his doctor who recommended he decrease his dose, however the patient says to you that he is fearful that pain will return back to the original severity if he stops.
Use the following questions and article to discuss your individual approach:
Using what you know about NSAIDs and other pain medication, how do you approach communication with patients regarding their use?
What information during the evaluation would guide or support any education you provide?
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As far as use and reliance on NSAIDs, I would address the length of time that he has had symptoms. If he’s been taking the NSAIDs for 6 months and only noticed a reduction in pain within the past week, then the likelihood that the NSAIDs are helping is small. You might have to encourage them to come to this realization although. We could educate on the relation of chronic symptoms (lack of inflammatory response) with the current NSAID use and likely lack of benefit. Also, we could educate on the relation of side-effects and potential risks of chronic usage of NSAIDs, like delayed healing, GI irritation, renal function, and hemorrhagic events to name a few. Additionally, we could drop in some analogies regarding acute and chronic pain with something the pt could relate to (i.e. sprained ankle). Hopeful the education on the risk/reward would be sufficient (in addition to his MD’s recommendation) to decrease his usage/reliance.
Based on the examination, we will likely find a couple movements, stretches, or exercises that reduce the patient’s symptoms to some degree. I like to encourage self-reliance for those who rely on pain medication by finding an activity that decreases their symptoms and utilizing it to replace pain medication or at least decrease the volume they’re taking. This could hopefully help this patient realize that his pain is multifactorial and not related to an inflammatory response specifically, harvesting self-efficacy and hopefully a realization that he can become the driver of his management (not the medications he takes).
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Jon, I’m in total agreement with your initial effort to educate on what is occurring during an acute onset and what is likely not occurring currently (inflammation, etc). What I’m not hearing is his concern for deleterious effects to his GI system, etc. It makes sense to me that he’s more afraid of avoiding a potentially immediate, definite pain experience than a vague warning of GI dysfunction that he doesn’t understand.
What if we poke holes in his logic just by asking him questions? Tell me what you guys think of this logical progression..
– We ask him why he chose Ibuprofen initially. We admit that Ibuprofen is intended to be a pain reliever, antipyretic, etc, so it might make sense to use it in an acute phase when inflammation, etc are occurring. But the good news is that it’s unlikely that these additional processes are occurring 6mos later, as tissue healing has already occurred.
– So, if anything, Tylenol should be our drug of choice since it’s primary job is to relieve pain.
– We ask him if he’s currently experiencing pain or when the last time period was when he was experiencing pain?
– We suggest that he 1) switch to Tylenol, then after the switch 2) begin to taper the dose with either less frequent or half doses to begin to measure his unmasked pain levels.We could justify our motivation so that we can accurately get a view of his physical progress as we complete our plan or care… ?
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I like those suggestions. I think switching to Tylenol is warranted and appropriate for the patient’s presentation. The justification of getting a better view of progress is also a good point and I think most people would buy in to that. I think the tapering off of the dosage would resonate more so with someone who is fearful of cutting the dosage dramatically so I agree that this is also a good suggestion.
How do you guys go about the discussion with a patient that is very pressing about medication usage despite this education and recommendations? I work with a lot of people with chronic pain and reliance on pain medicine is incredibly common. This is a challenging talk with certain individuals who have such a high psychological attachment to their current pain management strategies and I’d be curious of other discussions that everyone might create to mediate.
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I think I would start to first express what you can offer as a physical therapist in regard to the patient’s low back pain. Explain what your plan is to improve his pain and function based on your exam. I would then bring up the point that his doctor made, regarding decreasing his dose, then ask him what his thoughts were about that. I feel like most people will say, I don’t want to take pain medications for the rest of my life, but I am scared to stop because of the pain. I think then you can follow that up with stating that I (as the PT) can offer some techniques to help reduce your pain, but most importantly give you the tools and education so that you can manage your pain on your own without the need for taking medications for the rest of your life. I might then explain that ibuprofen is great for pain and inflammation in the early stages of acute back pain to calm the inflammatory process for a week or two, but it doesn’t have that great of long-term effects and can even cause stomach problems or other health related problems down the road. I might encourage the patient that he is already getting better due to the fact that he has returned to his normal activity. But now we need give him some safer techniques to help decrease his pain and learn self-management strategies for long term. I would not ask him to stop taking ibuprofen on day one. Yet, I would try to present the information to the patient in a way that encourages him to decrease his dose on his own. I think if you can acknowledge his fear of pain, acknowledge that his current self-management strategy is not the best, and give him an alternative solution – that should help with patient buy-in to decrease his NSAID use. I would also make sure that the patient knows his prognosis and that PT is not an overnight fix. Bring up the point that this has been going on for 6 months, so it might take a couple of weeks to months based on the chronicity.
1. Jon – I like the ankle sprain analogy and finding something on the eval that makes his pain better
2. Erik, I do like the recommendation to switch to Tylenol, especially based off this article. However, if we are trying to decrease medication use, do you think that just switching medications would help or harm the solution?
3. Jon – I feel like unless I can offer the patient an alternative solution to help with their pain, then they will not buy in to decrease their meds, but that’s just my opinion. Laura’s patient seems reasonable to decrease his pain medication use. However, folks who have been in chronic pain, fibromyalgia, or chronic pain med users then I feel like the focus can switch. I might then ask if they are being managed by pain management or their MD. Then educate the patient about pain meds within our scope and continue to work towards their goals. I haven’t had much success with these individuals. Jon, has anything worked for you? -
I agree with a lot of the things that have been brought up. I do have some further questions that I would want to find out about before I give specific recommendations:
– How has this patient been taking the Ibuprofen? Is he on a consistent regiment where there is a therapeutic dose, or is he taking the pain medication as needed?
– Does he have a history of GI issues, blood clotting issues, etc? Although it seems the physician is an advocate for him to decrease his pain medication, after reading this article, I would want to know more about his PMH before giving him any specific suggestions? If there is a significant PMH, this may warrant a conversation with the physician.I personally wouldn’t spend time trying to get the patient to switch Ibuprofen to Tylenol. To me that is just something else for him to become reliant on, and since his pain isn’t an acute inflammation response at this point, it doesn’t matter whether he is taking an anti-inflammatory medication or not. Although Tylenol has a slightly decreased chance of GI issues, the article seems to state that this is not vastly different than an NSAID.
Most patients don’t want to be on pain medication, so I would try to get the patient to admit that he doesn’t want to be on pain medication his entire life. It might not have to be a lengthy discussion or point of education if the patient begins to feel better after a couple weeks of PT. Similarly to what was mentioned above, if we can give the patient movement strategies to decrease his pain, and emphasize that he can do these if he is experiencing pain, he may naturally try to wean himself off the pain medication. If he does not and truly does have a psychological attachment to the pain medication, then I would go down the education/weaning off road.
Jon and Cam, I agree that the chronic pain patients with a psychological attachment to their pain medications are very difficult to successfully treat and to have them wean off pain medication. Unfortunately I don’t have an all-star strategy for this. In general with these patients, the goal for me is more based on improving their function rather than their specific pain levels. I try to emphasize their victories and give them a lot of praise for going out of their comfort zones and trying an activity or doing something for longer before pain onset. I think once you have developed rapport with them and they feel like that are improving, having them experiment and take one less pain pill a day, or waiting until later in the day to take it, is a less daunting task to them.
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Yeah, good question Cam.
My thought is that we use the switch to Tylenol as an intentional step in using medication for their actual purpose. If he’s not experiencing inflammation, why are we using an anti-inflammatory drug? It’s my segway to being logical about the situation, but I see your point.
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Jeff, are you ever frank with your patients about a psychological dependency?
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It depends on if I feel like I have developed a good rapport with them. But yes I have. I think this is where the “art” of PT comes in, because you have to read your patient, know what motivates them, know how they are motivated, and give them the education that they need in a way that will work best for them.
I recently had this conversation with a 16 yo female patient and her mother. She is a super interesting patient, as she has PFPS and is an Irish Riverdancer (I don’t come across these types of patients often in Woodstock). She has to dance for numerous hours in a row multiple days in a row. She is doing a lot better than before, however will still have a 3/10 pain by the end of several days of dancing in a row. She and her mom are a bit hyper-vigilant, as they are really afraid this pain is going to return if they don’t do everything right – including taking her pain medication before and after every practice religiously. She definitely has a psychological dependency on her Ibuprofen. As she is improving, I suggested her weaning off the pain meds. I can tell she is using them as a mental crutch, because she is so fearful that if she doesn’t, she will go back to her pre-PT self. She is a very motivated and works hard, and I know she is adherent with her HEP. I praised her on how hard she has worked to gain strength and mobility to improve her symptoms. I told her that it is normal to have some pain with that much dancing, and as long as she is listening to her body, continuing her exercises, and icing, that she will continue to improve, even with taking less and eventually no pain medication.
With her I knew I could be direct, but I wanted to highlight how hard she has been working. With other patients, I may have had to be more playful, others I would have to be more in-direct. I am no expert on this, but I think this is such an important skill that we have to work on.
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Great example Jeff. I am sure that you also demonstrated correct Irish Riverdancing form to correct her knee pain.
I feel like younger patients and acute patients are more likely to listen to you regarding this subject. Do any of you use the ‘Why do I hurt’ book regarding medications?
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I’ve read it, Cam, but I haven’t purchased it for myself bc I have a hard time picturing how I’d use it as a tool with a patient.
Do you mind hitting me with an example?
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Interesting articles here especially being performed in two very different regions of the world. I am not sure what the PT curriculum was in these regions of the world when these articles were published, but I had a separate pharmacology course which I am not going to lie was like a different language for me. My understanding is that they take different pathways for their effects hence the different side effects listed, but beyond that I feel that my knowledge is not comprehensive as the ontario article had mentioned.
WIth that being said during my first year of practice I have found myself to be on the more conservative side when it comes to recommendations for NSAIDs and acetaminophen. I would typically ensure that patients are not abusing their use and staying within the recommended amounts and doses and attempt to wean them off of their use as treatment progresses. At the same time I make sure they are aware that these are not completely scope of practice as we cannot prescribe meds and if they had more questions to address it with their doctor or pharmacist.
I loved that the New Zealand article (2011) brought up the discussion of NSAID use within the first 24-48 hours of sprain/strain as there is conflicting views. Thus far I have yet to see patients day of or the day after injury so I have not had to make these recommendations. I believe that NSAIDs should be withheld during the first 24-48 hours due to impairing the inflammatory response necessary for tissue healing. While these medications do have their benefits when used appropriately I believe the more we can sway individuals away from a pill to solve their problems it may deter them from seeking more medications for their problems in the future. -
Yeah, good point Matt. The NZ article points out that Direct Access is expanding, and that’s in large part a reflection of the expanding education we’re required to receive to achieve a DPT degree (Which includes education of pharmaceuticals). That makes it extra interesting that of the ~300 participants, only 2 were DPTs.
I don’t see a problem with providing education on OTC meds, and I really think the biggest issue is the reality that the drug class is so readily available combined with not knowing when/ how much to take them. I appreciate Aspirin’s universal (Cox 1 and 2) and predictable effects for true inflammation beyond beneficial timelines, and I appreciate Tylenol’s acute pain-relieving benefits.
I’m not biased against other members of the drug classes… does anyone else have different preferences?
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Pretty interesting findings from these articles. I found this quote from the second article a little concerning, “Almost half of the respondents who recommend NSAIDs are doing so despite being uncertain of the sufficiency of their knowledge or reporting that their knowledge is insufficient.” Basically saying the PT’s who are recommending NSAIDs are doing so without an appropriate knowledge of why they are using it.
I will make OTC NSAID recommendations if I feel like there is a high presence of an inflammatory process or chemically driven pain producer. With that being said, I try to make it clear that as PT I cannot officially recommend medications. I try to also go over some main side effects briefly. And for those patients with an extensive medical/medication history, I recommended communicating with their MD before taking anything new. Does anyone do this differently or any concerns with this?
With that being said, there are other things that I recommend that might be outside my scope of practice such as counseling. I may make general stress/emotional/depression/sleep recommendations yet I am not a therapist/counselor. I think referring out to a therapist when appropriate could be just as important as referring to a PCP for medication management. I think the big thing is knowing what is in your scope of practice and refer out when appropriate.
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Matt I agree that my general pharmaceutical knowledge is limited even after taking an introduction course. However my takeaway is that there are numerous ways the drugs are consumed by the body, and that there are a variety of potentially harmful side effects and negative drug interactions. I could better my practice with being more familiar with the different classes of CV medications, knowing which ones specifically affect blood clotting, or which ones cancel the blood clotting effects out from each other.
When reading the article, it was comforting to see that the majority of PTs were able to list 3 conditions in which NSAIDs were appropriate, and 3 conditions in which NSAIDs were contraindicated. I also found it helpful that most are also recommending their patients speak to their physicians or pharmacists about drug interactions, and that the majority are documenting these conversations.
Like all of you, I always say something like, “it is not within my scope to specifically recommend medications, however taking an anti-inflammatory medication may help with the initial healing process in a recent injury.” If I know they are on multiple medications, especially ones that may affect blood clotting, I always urge them to contact their physicians to ensure that this is okay (CYA). Cam I think what you say is appropriate, and I think I could be better about going over the potential side effects like you do with your patients. To your point about over half of PTs making recommendations with insufficient knowledge, I think ensuring we are urging them to get the okay for their physicians makes this less-bad of a finding.
I don’t think its outside our scope of practice to make general recommendations regarding stress/depression/sleep, etc. If this was, we would unnecessarily refer out for every single patient. I think referring out is more appropriate when we recognize that a situation is beyond our expertise. I was shadowing our very experienced hand OT yesterday. The patient had been in a traumatic MVA and after talking to her about her accident, it was apparent the patient was suffering from depression and PTSD. The hand OT did an amazing job of recognizing this and urging her to seek counseling, and also referred her to PT because the patient was having back pain from the MVA as well.
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