What do you use for chronic pain in patient's with CKD??

[physio]

]Is it the same as Chronic Renal Failure?[/b] On the ambulance we have many' date=' many patients who have CRF as a medical condition.

 

I recall the GFR and creatine from my A&P classes. Doesn't one use inulin to check the GFR?[/quote']

yupp, CKD=CRF

[bradtPA]

Honestly, my primary response to most of these people is THERAPY, THERAPY, THERAPY. Just saw an international patient last week referred to me for low back pain, unfortunately, the pain wasn't due to the mild facet arthritis, but to pelvic floor dysfunction. Wrote a script for therapy.

 

I'd say in a given week, I write 7-8 prescriptions for therapy for every 1 prescription for pain meds, and of the medications I write for, I maybe write for a narcotic 1-2 times per month. That's my approach.

 

Great option unless you have a lot of Medicaid patients like I do. They are limited to three PT visits per year, barely enough to teach them how to do exercises, and certainly not enough to provide treatment.

[ventana]

hummm if we can't offer him a pill we can't help???

 

Seriously lets think about this

 

PT

Chiro

Massage

bracing esp if patellar tracking but not much help for OA but is complication free

Acupuncture

Topical (voltaren gel, lidoderm, IBU20, Peper creams

Injections, steroid& synvisc

Exercise - trial work hardening program (might be tough in an 80 yr old)

Weight loss

TiChi, Yoga - it really works

Strength training in the local gym with a certified trainer

 

Then the toughest pill to swallow for typical Americans(only in my opinion) - life sometimes has pain involved in it and we can not fix it - enjoy the good days, get through the bad days

 

Gotta also look at his other meds......

 

IF he is on an ACE/ARB and a diuretic and taking OTC NSAID he is setting himself up for ARF and dialysis.... you have to warn him about this..... if he gets sick with diarrhea or vomiting he should hold the diuretic and ACE...... seriously, this is becoming a big issue as there is more data collected for hospitalizations and med issues....

 

 

As for introducing opiates in this patient, I would seriously argue against this especially for chronic use. Maybe an occasional T3 (1-2 week) but NOT in any way appropriate for chronic opiates.

 

The old BEERS list, not replaced with START/STOP lists as well as the growing body of knowledge about chronic opiate therapy in the elderly clearly show harm to the patient...... Just don't start down that road....

http://www.usafp.org/Word_PDF_Files/Annual-Meeting-2012-Syllabus/Spieker%20-%20New%20Drugs%20in%20Medicine%20Cabinet%20STOPP.PDF

[physasst]

hummm if we can't offer him a pill we can't help???

 

Seriously lets think about this

 

PT

Chiro

Massage

bracing esp if patellar tracking but not much help for OA but is complication free

Acupuncture

Topical (voltaren gel, lidoderm, IBU20, Peper creams

Injections, steroid& synvisc

Exercise - trial work hardening program (might be tough in an 80 yr old)

Weight loss

TiChi, Yoga - it really works

Strength training in the local gym with a certified trainer

 

Then the toughest pill to swallow for typical Americans(only in my opinion) - life sometimes has pain involved in it and we can not fix it - enjoy the good days, get through the bad days

 

Gotta also look at his other meds......

 

IF he is on an ACE/ARB and a diuretic and taking OTC NSAID he is setting himself up for ARF and dialysis.... you have to warn him about this..... if he gets sick with diarrhea or vomiting he should hold the diuretic and ACE...... seriously, this is becoming a big issue as there is more data collected for hospitalizations and med issues....

 

 

As for introducing opiates in this patient, I would seriously argue against this especially for chronic use. Maybe an occasional T3 (1-2 week) but NOT in any way appropriate for chronic opiates.

 

The old BEERS list, not replaced with START/STOP lists as well as the growing body of knowledge about chronic opiate therapy in the elderly clearly show harm to the patient...... Just don't start down that road....

http://www.usafp.org/Word_PDF_Files/Annual-Meeting-2012-Syllabus/Spieker%20-%20New%20Drugs%20in%20Medicine%20Cabinet%20STOPP.PDF

 

Yep.....Part of my five things talk is therapy. I tell patients it is the single BEST thing that I can prescribe them for their pain, and "therapy can consist of physical therapy, occupational therapy, massage, chiropractics, acupuncture, magnets, crystals, mangostene juice, yada, yada, yada. IT'S ALL therapy." that and changing their worldview from fix to manage, and from pain free to better.

 

I don't generally use chronic opiates...the single biggest thing for long term chronic pain? CBT. I swear we need to have psychologists in EVERY pain office in the country.

[Nakasoner]

That's a good list by Ventana. Do PT, chiro, acu, home exercise program/diet/weight loss, bracing, bracing with electrical stim, topicals, Lyrica, viscosupplementation injections, judicious use of corticosteroid injections, surgery.

[Hemegroup]

They include:

 

1.Arthritis

2.Fibromyalgia

3.Ligament or tendon injuries of a severe nature

 

Those are generally the four main reasons that you may be suffering from chronic pain in the joints.

 

You actually listed 3 ... and are also obviously not trained in medicine. Can someone delete the advertiser please?

[Hemegroup]

Honestly, my primary response to most of these people is THERAPY, THERAPY, THERAPY. Just saw an international patient last week referred to me for low back pain, unfortunately, the pain wasn't due to the mild facet arthritis, but to pelvic floor dysfunction. Wrote a script for therapy.

 

I'd say in a given week, I write 7-8 prescriptions for therapy for every 1 prescription for pain meds, and of the medications I write for, I maybe write for a narcotic 1-2 times per month. That's my approach.

 

Let's just hope they don't have to rush your pt to the OR like they did one of mine ... of course this is an isolated type of occurrence, one with an 11 mm lumbar disc bulge. The manager ran out onto the floor to stop the PT because they were administering the wrong program for the wrong patient but it was too late. Unfortunate mistakes can happen ... just an equally unfortunate reminder to be mindful of detail. I'm a big fan of MRI before PT, in clinical sense situations.

 

For the daily rigmarole, I am a total fan: http://www.foxnews.com/health/2013/07/05/relieving-pain-through-exercise-not-medication/?intcmp=obnetwork

[Nakasoner]

A good history and physical should be able to pick up progressively worsening neurological signs/symptoms that should alert the provider to severe disc herniations/extrusions/SOLs/cauda equina.

I don't think it's good medicine to order an MRI everytime you want to order PT. Standards of care suggest the reverse in most cases.

[Hemegroup]

A good history and physical should be able to pick up progressively worsening neurological signs/symptoms that should alert the provider to severe disc herniations/extrusions/SOLs/cauda equina.

I don't think it's good medicine to order an MRI everytime you want to order PT. Standards of care suggest the reverse in most cases.

 

As I stated but no problem, will again, in clinical sense situations.

[physasst]

Most of my patients have lumbar disc bulges.....in fact, I seem to spend an inordinate amount of time showing people their images and going through them detailing that central disc bulges, para central too, are present in a lot of people. Having a disc bulge means nothing unless it is causing symptomatic nerve root compression, severe stenosis with pseudoclaudication, compression of the cauda, or a lumbar myelopathy.

 

Even then, it depends on their symptoms. For example, I had a patient last week with one of the most severe cases of stenosis I've ever seen. At L4-5, he closed down to about 5mm of canal, and predictably, his PCP freaked out. He was having bilateral symptoms, but they were consistent with bilateral 5-1 radics and mechanical, facet mediated back pain, which is also what his exam was consistent with. He had NO symptoms of pseudoclaudication.....I had to explain to him that he had some bilateral lateral recess stenosis, and that that was likely causing his symptoms, but he had NO weakness on exam, his sensory was intact, and his reflexes were intact. I suggested an ILESI and PT.

 

One of the banes of my existence is the patient who was told that they have "spinal stenosis" and that is the cause of their axial back pain.......ugh. I end up having to have a long discussion about the fact that yes, they have spinal stenosis on MR, but who cares?, their axial back pain is NOT from the stenosis. Same with disc bulges. Discogenic pain is likely a real entity, but we don't have any real answers for it. Annular tears, fissures with associated bulges get treated the same as all axial back pain.

 

Short way of saying that I don't get an MRI for axial symptoms unless there are abnormalities on exam. Every once in a while, I get a patient with clearly facet mediated back pain on H&P, but they have some focal weakness on exam, hyperreflexia, or positive upper motor neuron findings. Then depending on the level of involvement in exam, I may get an MRI of their spine, but sometimes it may be a cervical MRI even though they have lumbar pain. That's always a joy to explain. I also have a group of myelopathic patients that I just follow. No imaging, just exams every 3-6 months to ensure their is no progression.

[Hemegroup]

For multiple and/or severe bulges, I'm a huge fan of minimally invasive discectomy. We have a great Spinal Surgeon here in town who seriously rocks them. I'll choose that, for severe cases, over PT anyday. The PT can come afterwards. Like I always tell patients who are treating their muscle tension with opiates (versus relaxants), better to get to the cause of the pain than attempt to mask over it.

 

I'm not saying PT doesn't have its place, it can do amazing things, but some cases warrant and others warrant other alternatives. My story of the pt who was given the wrong PT regimen wasn't meant to scare anyone away from PT without a MRI, just a story to remind caution. I'm glad I'M not the one who he's taking legal action against; I found the 11mm bulge (with MRI), I certainly didn't throw him on the ball and start rolling him around incorrectly.

 

And just so I'm clear, when I stated clinical sense I figured that was obviously inclusive of exam. Sense, warrant, etc. I can't count the number of normal xrays that come back with serious MRI-determined abnormalities. Just like the recent pt who had a normal xray of her knee but had a MRI showing full thickness cartilage tear as well as meniscal rupture. I ordered the MRI due to her limp ... it doesn't take a genius. She's consulting with Ortho Surg 4 days later, after advice to stay off her feet.

 

I don't generally use chronic opiates...the single biggest thing for long term chronic pain? CBT. I swear we need to have psychologists in EVERY pain office in the country.

 

physasst, I don't mean to be intrusive, but can I ask you if you have any chronic pain issues? Because I have two desiccated discs and a 3 mm lumbar bulge. I wouldn't survive without relaxants. When I have a subluxation that presses that bulge into the nerves, I have to call the ambulance to get me off the floor (thankfully hasn't happened since 2010 after some amazing PT). If you had been in my face telling me I needed CBT while I was spasming to the floor trying to get to the bathroom, I would have popped you one straight in the smacker. Proper management of pain, including pharmaceuticals or whatever other means provide relief for a legitimate patient is what's important in the end; quality of life is what's important. That being said, ending up on high doses of opiates can oftentimes be a nightmare. It's a fine line.

[physasst]

For multiple and/or severe bulges, I'm a huge fan of minimally invasive discectomy. We have a great Spinal Surgeon here in town who seriously rocks them. I'll choose that, for severe cases, over PT anyday. The PT can come afterwards. Like I always tell patients who are treating their muscle tension with opiates (versus relaxants), better to get to the cause of the pain than attempt to mask over it.

 

I'm not saying PT doesn't have its place, it can do amazing things, but some cases warrant and others warrant other alternatives. My story of the pt who was given the wrong PT regimen wasn't meant to scare anyone away from PT without a MRI, just a story to remind caution. I'm glad I'M not the one who he's taking legal action against; I found the 11mm bulge (with MRI), I certainly didn't throw him on the ball and start rolling him around incorrectly.

 

And just so I'm clear, when I stated clinical sense I figured that was obviously inclusive of exam. Sense, warrant, etc. I can't count the number of normal xrays that come back with serious MRI-determined abnormalities. Just like the recent pt who had a normal xray of her knee but had a MRI showing full thickness cartilage tear as well as meniscal rupture. I ordered the MRI due to her limp ... it doesn't take a genius. She's consulting with Ortho Surg 4 days later, after advice to stay off her feet.

 

 

 

physasst, I don't mean to be intrusive, but can I ask you if you have any chronic pain issues? Because I have two desiccated discs and a 3 mm lumbar bulge. I wouldn't survive without relaxants. When I have a subluxation that presses that bulge into the nerves, I have to call the ambulance to get me off the floor (thankfully hasn't happened since 2010 after some amazing PT). If you had been in my face telling me I needed CBT while I was spasming to the floor trying to get to the bathroom, I would have popped you one straight in the smacker. Proper management of pain, including pharmaceuticals or whatever other means provide relief for a legitimate patient is what's important in the end; quality of life is what's important. That being said, ending up on high doses of opiates can oftentimes be a nightmare. It's a fine line.

 

 

Actually, yes, I have A.S., it came along with Crohns. In fact, my back pain predated my Crohn's diagnosis. I have back pain every day. I choose not to take anything for it. I usually do not have an issue with a patient who has occasional flares getting occasional meds to get through these. But chronic maintenance medications for me are in the non relaxant, non opioid category, IE; Neurontin, Lyrica, Cymbalta, tricyclics.....etc. Sometimes creams.

 

As far as discectomies, our surgeons here won't do them unless there is CLEAR evidence of disc herniation and neuropathic pain. Not saying discogenic pain isn't real, just that most of the guys here don't think surgery will be of any benefit.

[Nakasoner]

Heme: Please explain what you mean by "clinical sense situations."

 

Would you get an MRI on a Lumbar Spine for a 45 year old patient with LBP x 2-3 weeks after doing yardwork, localized to the left lumbosacral region, rated 6/10, taking NSAIDS and even Norco, without numbness or tingling down the extremities and with symmetrical DTR's and good motor strength 5/5 in the LE's. No bowel or bladder dysfunction. XR shows Mild DDD at L4-5 and L5-S1 without Fx.

 

What would you do? Would you get an MRI and then order PT? Or would you just order PT?

 

Personally, I try to avoid surgery unless there are clear indications and imaging matches the clinical picture. I will more often than not order a diagnostic and therapeutic epidural before recommending microdiscectomy, particularly if there are multiple bulges involved. The same goes for the cervical spine.

[Hemegroup]

Actually, yes, I have A.S., it came along with Crohns. In fact, my back pain predated my Crohn's diagnosis. I have back pain every day. I choose not to take anything for it. I usually do not have an issue with a patient who has occasional flares getting occasional meds to get through these. But chronic maintenance medications for me are in the non relaxant, non opioid category, IE; Neurontin, Lyrica, Cymbalta, tricyclics.....etc. Sometimes creams.

 

As far as discectomies, our surgeons here won't do them unless there is CLEAR evidence of disc herniation and neuropathic pain. Not saying discogenic pain isn't real, just that most of the guys here don't think surgery will be of any benefit.

 

I am fortunate to have found one who will do them, considering the underserved status of most of the patients who he'll consider. Of course, I only send people with clear evidence (as in MRI) of severe herniation or bulge as well as extreme neuropathic pain or focal deficit. As for chronic meds ... whatever works. My lumbar issues give me severe tension of the cervical paraspinal mm. and relaxants are the only primary form of relief for me. If I had time to do yoga I would although I do try other relaxation techniques (I have a board I lay down and hang my neck over which presses hard into the knot and that will bring much needed relief albeit usually temporarily ... if I could find someone who would inject the muscle with Botox I would, the primary cause of my pain is severe tension of semispinalis capitis).

[Hemegroup]

Heme: Please explain what you mean by "clinical sense situations."

 

Would you get an MRI on a Lumbar Spine for a 45 year old patient with LBP x 2-3 weeks after doing yardwork, localized to the left lumbosacral region, rated 6/10, taking NSAIDS and even Norco, without numbness or tingling down the extremities and with symmetrical DTR's and good motor strength 5/5 in the LE's. No bowel or bladder dysfunction. XR shows Mild DDD at L4-5 and L5-S1 without Fx.

 

What would you do? Would you get an MRI and then order PT? Or would you just order PT?

 

Personally, I try to avoid surgery unless there are clear indications and imaging matches the clinical picture. I will more often than not order a diagnostic and therapeutic epidural before recommending microdiscectomy, particularly if there are multiple bulges involved. The same goes for the cervical spine.

 

I'm not going to get into a long discourse or argument regarding clinical sense, warrant, picture that's up to each of us individually as providers. Let's just leave it at 'good sense' based on evidence, as much as we have or can acquire as necessary. In answer to your proposed situation, no I would not get an MRI and yes I would order PT. If there was difficulty of gait then that would up the ante for me. The pt you presented would not be a candidate for MRI at this point in time for me, no.

 

I am full on-board with you about surgery, however I have had better success with minimally invasive procedures such as discectomy ... which is no more invasive than an epidural under fluoroscopy. Slightly different mode of action, but the invasion is about the same. I've ordered (and assisted) in many epidurals after which it's 40/60 for pt's to receive long-term relief (dare I say even 30/70). That's just been my experience and again, we're lucky to have a surgeon here who will take the 'minor procedure' cases instead of the full-on fusion nightmare surgeries (at least they more often than not turn out to be).

[Hemegroup]

Actually, yes, I have A.S., it came along with Crohns. In fact, my back pain predated my Crohn's diagnosis. I have back pain every day. I choose not to take anything for it.

 

Sorry to hear about the A.S., my dad was diagnosed with it in his 70s. I don't take anything for my back either, except the relaxants when the tension headaches become too severe. As for the Crohn's, might I suggest turmeric without black pepper extract ... many of the turmeric supplements now do have the b.p. extract due to its increasing absorption by up to 2000%. However, for issues of intestinal inflammation you don't want the absorption into the bloodstream, you want it to go pass through the intestinal tract.