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Although numeric pain ratings are helpful to determine if pain medication is effective, they are not meant to be the entire method for assessing pain in patients with chronic LBP. Functionality and increases in quality of life may be more important measurement for improvement. If the patient can walk further, shop independently, and attend church, these are all goals that have true meaning for maintaining the quality of life for patients with chronic pain. Continued tracking of numeric ratings may do more harm than good if pain intensities fail to improve.

Keeping an open mind about all treatment options is beneficial for patients. Encourage patients to look beyond medication management and seek opportunities to try additional types of pain relief. Medications for chronic pain should never be seen as the only option for pain relief. Using multimodal pain management will in the end produce the best outcomes for the patient and increase the potential for optimal pain relief.

To get more information on the LBP guidelines from APS, access the website at http://www.ampainsoc.org.

Case Study

Sara Stone, who is a 45-year-old patient, tells you she has had LBP for about 6 weeks. She says the back pain started when she was moving and she lifted a series of heavy boxes. She has tried a variety of treatments with little effect. She lists the things that she has tried as heat and cold, analgesic balms (Icy Hot), acetaminophen, over-the-counter ibuprofen, and a pain pill from an old surgery she had several years ago. Nothing seems to work, and the pain is very intense at night when she gets into bed. She can only tolerate the lying position for several hours, and then she gets up and sleeps the rest of the night in a recliner chair. She has an appointment with a chiropractor but thought she would see her primary care provider before she went and had an adjustment.

When you examine Sara, you note that she has pain in her lumbar spine that radiates down her left leg. When you ask her to rate the pain, she says the midback pain is a nagging pain that aches and she rates it as a 5/10. When you question her about the leg pain that radiates, she describes it as a shooting pain that increases in intensity the longer she ambulates. The radicular pain is described as an 8 out of 10 when it occurs. She describes the radiating pain as intermittent, sharp, shooting, and needlelike. It keeps her from having a good night's sleep because it wakes her periodically at night.

Sara tells you she has never had pain like this before. She has no other neurologic impairment, such as foot drop or bowel or bladder incontinence. She does have a significant neuropathic component to the pain. You send Sara for an MRI, and after reading the results, you diagnose her as having a herniated disc, HNP.

Questions to Consider

1. Consider that Sara is not a surgical candidate. What are some of the best strategies to manage her pain?

2. What types of medication will be the best option for controlling Sara's pain?

3. Should you combine your medication choices to address all the components of Sara's LBP?

4. What nonpharmacologic options are good suggestions for Sara?

5. Is Sara at risk for depression? If so, what types of treatment options will work best?

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