Stepped Treatment Approach to Chronic Pain

Learn more about each step of the stepped treatment approach to treating chronic pain.

Step 1: Non-Pharmacologic Approaches

The stepped treatment approach to chronic pain starts with the nonpharmacologic options least likely to cause harmful side effects, such as exercise and manual therapies, weight loss, and assistive devices.

Potential accompanying treatments can include cognitive behavioral therapy, meditation, massage, acupuncture, and yoga. Self-management is also included in non-pharmacologic options. If the use of hot packs, thermal wraps, or ice packs helps relieve a patient’s chronic low back pain, encourage their continued use.

TENS units, transcutaneous electrical nerve stimulation, are safe to use but there’s no strong evidence that shows them to be effective for chronic low back pain.

Assistive devices may also be a choice for non-pharmacologic options.

For instance, an older adult with kyphosis who uses a walker to reduce the strain on the paralumbar musculature may be satisfied with the assistive device. Or a painful lower extremity that causes altered gait and dysfunction of the spine that contributes to lower back pain may be sufficiently relieved by the use of a cane.

Step 1: Non-Pharmacologic Approaches

Step 2: Topical Treatments

Step 2 in the stepped treatment approach to chronic pain includes topical treatments. They’re safe, but there’s no strong evidence for efficacy in treating low back pain. If you prescribe capsaicin, let the patient know they’ll feel a burning sensation that should pass in about a week or so.

Patients also need to know to apply the medication several times a day, and to remember to wash their hands thoroughly after application.

Step 2: Topical Treatments

Step 3: Local and Minimally Invasive Prescription

Step 3 pf the stepped treatment approach for chronic pain includes local and minimally invasive prescription, like local injections. A trigger point injection may help an area of especially excruciating myofascial pain. Corticosteroid knee or hip injections can be considered for patients with knee or hip arthritis contributing to low back pain.

Step 3: Local and Minimally Invasive Prescription

Step 4: Local and More Invasive Prescription

Step 4 of the stepped treatment approach for chronic pain includes spine injections, like sacroiliac, epidural, or facet joint injections.

Spine injections like sacroiliac, epidural, or facet joint injections are considered safe as long as they’re administered by a pain medicine specialist.

Spine injections may provide enough short-term pain relief, or analgesia, to encourage the patient’s interest in rehabilitation through exercise or physical therapy.

Because of mixed evidence on whether spine injections effectively relieve lower back pain, you should take the time to go through the 2008 Cochrane Review to come to your own conclusions.

Step 4: Local and More Invasive Prescription

Step 5: Systemic Oral Analgesics

Level 1: Acetaminophen/NSAIDS

Among systemic oral analgesics, acetaminophen is considered safe, but it can be toxic for patients with significant alcohol intake, and those with preexisting liver disease.

Also, many over the counter medications have acetaminophen in them, so when you take a patient’s medication history, be sure to include over the counter products to avoid over-prescribing.

The recommended daily maximum dose of acetaminophen is 3,000mg.

Systemic oral analgesics also include NSAIDS. Non-steroidal antiinflammatory drugs. They shouldn’t be used for an extended amount of time because of a number of harmful side effects.

Side effects from NSAIDS can include gastrointestinal bleeding, renal insufficiency, beginning or worsening of hypertensions and congestive heart failure. Find out more about why these medications need to be used with caution, especially in older adults, by examining the Beers Criteria.

Step 5: Systemic Oral Analgesics, Level 1: Acetaminophen/NSAIDS

Level 2: Non-acetylated Salicylates

Another form of systemic oral analgesics are non-acetylated salicylates. They can potentially be used for patients who do not respond to acetaminophen, like salsalate, and choline magnesium trisalicylate. These have the added benefit of being less potent prostaglandin inhibitors, which makes them safer to use.

Step 5: Systemic Oral Analgesics, Level 2: Non-acetylated Salicylates

Level 3:-4: Opioids

Opioids are another option within systemic oral analgesics, but they should be used with caution due to a number of harmful side effects. Patients should be aware about the potential harms when using opioids before they start taking them. Patients should also start with less potent doses of opioids, before potentially graduating to a higher dosage.

Step 5: Systemic Oral Analgesics, Level 3-4: Opioids

Duloxetine

Among systemic oral analgesics, Duloxetine has no specific slot. Duloxetine is a serotonin norepinephrine reuptake inhibitor that is approved for use in the treatment of musculoskeletal pain, including chronic low back pain. It most likely works because of the role central sensitization plays in chronic pain patients.

Step 5: Systemic Oral Analgesics, Duloxetine

Step 6: Surgery

Step 6 in the stepped treatment approach for chronic pain is surgery. Invasive spinal surgery is the most drastic treatment for chronic low back. Spinal surgery isn’t recommended for patients with multiple factors that contribute to their low back pain.

Step 6: Surgery

 

 

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