Journal of pain


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Journal of pain

  1. 1. Roy S c ot t20 March 2012 • Nursing Management Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  2. 2. [Chronic disease] series 1.9 CONTACT HOURS Pain andobesity Obesity-related pain conditions can limit quality of life. Consider the use of a multimodal pain management regimen to increase pain relief and positive outcomes in obese patients. By Yvonne D’Arcy, MS, CRNP, CNS O b besity is a national health issue that affects every aspect of healthcare. a Comorbidities, such as diabetes, C hypertension, and dyslipidemia, h contribute to the complexity of care required for effective treatment of Healthcare practitioners need to provide obese patients with a venue to discuss pain management issues. Information on obesity’s impact on pain and weight reduction strategies, coupled with pain management obese patients and are commonly techniques, will help patients improve addressed by healthcare practitioners. their health and pain relief. However, pain-related comorbidi- ties, such as diabetic neuropathy or Prevalence of obesity low back pain related to an obese The prevalence of obesity is a global body structure, appear to receive issue that’s increasing dramatically. less attention. This may be related The World Health Organization to the need to address the signifi- (WHO) reports that more than 1 cant issues of disease management, billion people worldwide are over- such as glycemic control and BP weight; 300 million meet the criteria management, in the short period for obesity.1 By 2030, if current pat- of time that the primary care pro- terns persist, 58% of the world’s vider has available for seeing each population is expected to be obese patient. “Simple” pain issues may or overweight.2 The two main con- be overlooked while discussing tributing factors to obesity identi- more life-threatening health issues. fied at the WHO regional Nursing Management • March 2012 21 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  3. 3. [Chronic disease] series were diet and lack of exercise. Obe- • Overweight is classified by a mediate insulin resistance and create sity has serious consequences. In BMI of 25.0 to 29.9. a proinflammatory state that has 2002, the WHO identified the burden • Obese Class I is classified by a been associated with increased joint of noncommunicable diseases, such BMI of 30.0 to 34.9. inflammation and osteoarthritis.4 as cardiovascular disease, diabetes, • Obese Class II is classified by a Increases in BMI can be directly cancers, and obesity-related condi- BMI of 35 to 39.9. linked to a greater incidence of tions, as accounting for 60% of global • Obese Class III—morbid obesity— pain-related conditions. Obesity deaths and 47% of the global burden is classified by a BMI of over 40.3 has been cited as a contributor to of these diseases.1 Using a BMI can help determine the development of low back pain Given the serious health repercus- if the patient has an increased (possibly a result of increased load sions of obesity, it appears inevita- potential for developing a comor- on spinal structures). Diabetes ble that obesity-related pain has bid condition that will result in increases with the duration and taken a back seat to the more serious pain. For example, the higher the degree of obesity, which can result consequences of obesity. However, patient’s weight and the longer the in diabetic neuropathy in poorly for the obese to become more active duration of obesity, the higher the controlled diabetes. There’s also research indicating that obesity is an exacerbating factor for migraine[ ] headaches.5 A multimodal pain management regimen that combines medications and complementary Women diagnosed with osteo- arthritis have a BMI that’s 24% higher than average.6 In a study of 677 patients who had a total knee replacement and 547 patients who techniques can help increase pain relief in had a total hip replacement with at obese patients. least one MetS risk factor, findings indicated the outcome of the sur- geries was negatively affected by metabolic abnormalities.4 The two major factors that affected and attain a higher quality of life, amounts of body fat causing negative outcomes were obesity pain management is a key factor. increased insulin resistance, which and hypertension.4 Lifestyle changes alone may not can be a part of metabolic syn- Because of obesity, women may reduce the pain of osteoarthritis or drome (MetS).3 MetS is a syndrome also suffer from low self-esteem low back pain complicated by obe- that includes the conditions of that can lead to depression. Because sity. Unfortunately, some healthcare hypertension, central adiposity, ele- depression may present comorbidly providers see the obese patient as vated fasting blood glucose, and with chronic pain, these patients someone who has created their dyslipidemia with high triglycer- have an increased risk factor for own problem, one that weight loss ides and low high-density lipopro- both pain and depression. would solve. The answer isn’t that tein cholesterol.3 simple. There are metabolic issues When insulin resistance is present Fibromyalgia that need consideration when alongside MetS, negative effects on Obesity is a common comorbidity assessing the full picture of obesity- the patient’s health are increased. of fibromyalgia.7,8 Studies indicate related pain. MetS can cause higher rates of dia- that 32% to 50% of patients with betes and cardiovascular disease, fibromyalgia are obese; an addi- Factors for pain assessment especially in women. There’s also a tional 21% to 28% are overweight.9,10 One way to categorize obese positive correlation between MetS In the general population, fibromy- patients is by using body mass and increased systemic inflammation, algia affects about 3% to 5% of the index (BMI). Classifications are which is fed by adipose tissue.4 U.S. population.7,8 It affects more as follows: Tumor necrosis factor, interleukin-6, women than men and is character- • Normal weight is classified by a and C-reactive protein are all factors ized by chronic widespread pain BMI of 18.5 to 24.9. secreted by adipose tissue that on both sides of the body with 22 March 2012 • Nursing Management Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  4. 4. hyperalgesia in at least 11 of 18 bral disks and indirect effects of ath- Even patients who were over-specific points. In addition to the erosclerosis on decreasing blood weight but not morbidly obese hadwidespread pain, patients may flow to the lumbar spine.3 a 2.2-increased risk factor for devel-also experience sleep disturbances, Many practitioners feel that oping knee osteoarthritis whenchronic fatigue, functional disabil- weight loss is the solution to treat- compared with their normal weightity, mood disorder, “fibro fog” ing low back pain in these patients. counterparts.12 In the United King-memory loss, headache, paresthesia, There are two important issues to dom, it’s estimated that 69% ofand irritable bowel disorder.7,8 consider. After low back pain is knee replacement surgeries in In a study of 215 patients with already occurring, weight loss may middle-age women are attributedfibromyalgia, 30% were overweight, not reverse the effect of mechanical to obesity.13with an additional 47% recognized load bearing, and not all weight For the morbidly obese, kneeas obese. The obese patients reported loss strategies have the same result osteoarthritis presents a biggergreater sensitivity to tender point on low back pain. In two studies of problem. If lifestyle changes andpalpation (especially in the lower morbidly obese patients who had increased exercise can’t producebody), decreased physical strength bariatric surgery, there was a sig- weight loss or favorable outcomes,and lower body flexibility, and shorter nificant decrease in low back pain total joint replacement is consid-sleep duration with greater restless- after surgery.11 In a nonsurgical ered. If surgery is necessary, recon-ness while sleeping.8 weight loss program, there was ditioning after surgery can be Research hasn’t clearly defined little evidence that demonstrated complicated further by difficultythe cause and effect relationship improvement in low back pain.11 with mobility.between obesity and fibromyalgia. Multidisciplinary programs thatAnimal studies suggest there’s a include exercise and weight loss, Pain managementlink between greater levels of proin- as well as dietary and behavioral Treatment options for the obeseflammatory cytokines resulting in modification, have a better outcome patient with pain include medica-central sensitization.8 The list of than treatment plans that aren’t as tions and nonpharmacologic modal-mechanisms that might contribute comprehensive. ities, such as acupuncture or a link between fibromyalgia and It’s important to note that no When discussing options for con-obesity include impaired physical matter which type of treatment is trolling pain, it’s important toactivity, cognitive and sleep distur- selected to reduce low back pain, inform patients that a combinationbances, psychiatric comorbidity and the ability of patients to adhere to of treatments is more likely to pro-depression, dysfunction of the thy- the treatment requirements should duce optimum pain reduction.roid gland, and impairment of the be considered to achieve the best Medications can be affected byendogenous opioid system.7 The possible outcome for the patient. the ratio of adipose tissue to leanonly demonstrated outcome was In low back pain, weight loss may body tissue. In the obese patient,that obesity contributes to the con- have a positive effect and help to there’s a higher ratio of adiposetinued presence of fibromyalgia and relieve the pain. tissue when compared with leanincreases its severity. body tissue, which is thought to Osteoarthritis interfere with the protein bindingLow back pain Symptomatic osteoarthritis is the of drugs, allowing an increasedFindings indicate that if a patient is presence of radiographic findings of concentration into the free plasmaobese at age 23, there’s a risk of low osteoarthritis in combination with concentration. Although obesityback pain within 10 years. As obese symptoms attributable to osteoar- increases the total volume of bothpatients get older, the probability of thritis.12 Magnetic resonance imag- lean and adipose tissue when com-developing low back pain increases.3 ing findings include cartilage lesion, pared with nonobese patients ofThere have also been associations osteophytes, bone marrow lesions, the same age, height, and sex, thisthat show a BMI of over 30 puts synovitis, effusion, and subchondral difference requires individualizedpatients at greater risk for low back bone attrition.12 The two major risk prescriptions for obese patients topain.11 Suspected mechanisms for factors for developing osteoarthritis ensure that medications are dosedthe increased occurrence of low are obesity and being female; knee appropriately.14back pain in the obese patient are injury is also a predisposition to For most obese patients in pain,mechanical stress on the interverte- developing knee osteoarthritis. opioids will be considered for Nursing Management • March 2012 23 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  5. 5. [Chronic disease] series management. Some aren’t candidates General recommendations for tions and less research to support for nonsteroidal anti-inflammatory pain management after surgery for use at this time.16 drugs due to impaired organ func- obese individuals include:15 The use of regional blocks with tion, such as renal dysfunction, or • the use of multimodal analgesia local anesthetic for adjunct pain comorbidities, such as diabetes or using regional and opioid sparing relief is recommended, as well as the potential for gastric bleeding. techniques epidural pain management for sur- Additional options for pain • avoidance of sedatives, especially gical pain. These techniques can management in the obese patient when combined with opioids reduce the need for opioids and can can include not only medication • noninvasive ventilation with have a positive effect on the risk of management but also the use of supplemental oxygen respiratory depression. Obese regional analgesia such as blocks • early mobilization and ambulation patients will need less local anes- and physical therapy programs • elevating the head of the bed to thetic when administered as an epi- geared to patients who need a less 30 degrees dural as compared with nonobese strenuous approach. Referrals to • a low threshold for pulse oxime- patients. This can be correlated with pain clinics, physical therapy pro- try, which should be continuous and the decreased cerebrospinal fluid grams designed for the obese combined with end-tidal carbon volumes in obese individuals.14 patient, and physiatrists can help dioxide monitoring for added safety Nonpharmacologic treatment Less-invasive adjuvant pain relief[ ] modalities can also be considered. In one study, aromatherapy with R ecognizing the patient’s pain and working with the patient to help minimize the effects of lavender was shown to decrease morphine dosage needed for pain management in the postanesthesia unit, although more research is needed.15 Relaxation techniques the pain can lead to a more positive outcome. such as music or relaxation tapes can provide a way to avoid medica- tions through distraction. Reiki or therapeutic touch can also provide relaxation. In the outpatient setting, reduce pain and increase function- • arterial BP management patients can participate in pool ality. If the obese patient needs a • placement in a nursing specialty exercise therapy to lessen the surgical intervention, additional area, such as an ICU or step-down burden on joints. concerns will need to be addressed. unit, with continuous, postoperative Sedation and the maintenance of monitoring until oxygen saturation Rising to the challenge a patent airway are always concerns is greater than 90% while asleep It can be a challenge to provide when opioids are used for obese without supplemental oxygen. effective pain management for obese patients, especially in the postoper- When obese patients use patient- patients; however, a multimodal ative time period when anesthetic controlled analgesia, the use of con- pain management regimen that com- agents have been used. However, tinuous infusion is contraindicated. bines medications and complemen- reviews indicate that two factors, Opioid requirements aren’t related tary techniques can help increase site of surgery (especially bariatric to body surface, age, gender, or pain relief. Recognizing that the surgery) and coexisting sleep apnea, anesthetic regimen.15 Adding a patient may need to be in an area have been cited as contributory to an nonopioid medication can decrease with continuous monitoring will increased risk of pulmonary com- pain and provide an opioid-sparing help lessen the potential for adverse plications in obese patients.15 Most effect.15,16 Other medications such events in postoperative patients. obese patients can tolerate opioids in as clonidine, ketamine, and dexme- Always remember that most obese the usual doses, although they require detomidine could be useful adju- patients are very familiar with the close monitoring, especially for seda- vants for postoperative pain relief, healthcare system and may have tion and respiratory depression. but have significant contraindica- had less than positive experiences. 24 March 2012 • Nursing Management Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  6. 6. Recognizing the patient’s pain and osteoarthritis of the knee in women: a 12. Neogi T, Zhang Y. Osteoarthritis prevention.working with the patient to help 4-year follow-up study. Osteoarthritis Curr Opin Rheumatol. 2011;23(2):185-191. Cartilage. 2008;16(3):367-372. Epub 13. Liu B, Balkwill A, Banks E, Cooper C, Greenminimize the effects of the pain can 2007 Sep 20. J, Beral V. Relationship of height, weight,lead to a more positive outcome. NM 7. Ursini F, Naty S, Grembiale RD. Fibromyalgia and body mass index to the risk of hip and and obesity: the hidden link. Rheumatol knee replacements in middle-aged women.REFERENCES Int. 2011;31(11):1403-1408. Epub 2011 Rheumatology (Oxford). 2007;46(5):861- 1. World Health Organization. Global Strat- Apr 8. 867. Epub 2007 Feb 4. egy on diet, physical activity, and health. 8. Okifuji A, Donaldson GW, Barck L, Fine PG. 14. Leykin Y, Miotto L, Pellis T. Pharmokinetic Relationship between fibromyalgia and considerations in the obese. Best Pract 2. Kelly T, Yang W, Chen CS, Reynolds K, He obesity in pain, function, mood, and sleep. Res Clin Anaesthesiol. 2011;25(1):27-36. J. Global burden of obesity in 2005 and J Pain. 2010;11(12):1329-1337. Epub 15. Schug SA, Raymann A. Postoperative pain projections to 2030. Int J Obes (Lond). 2010 Jun 9. management in an obese patient. Best Pract 2008;32(9):1431-1437. Epub 2008 Jul 8. 9. Neumann L, Lerner E, Glazer Y, Bolotin A, Res Clin Anaesthesiol. 2011;25(1):73-81. 3. Kulie T, Slattengren A, Redmer J, Counts H, Shefer A, Buskila D. A cross-sectional study 16. D’Arcy Y. A Compact Clinical Guide to Acute Eglash A, Schrager S. Obesity and women’s of the relationship between body mass Pain. New York, NY: Springer Publications; health: an evidence based review. J Am index and clinical characteristics, tender- 2011. Board Fam Med. 2011;24(1):75-85. ness measures, quality of life, and physical 4. Gandhi R, Razak F, Davey JR, Mahomed functioning in fibromyalgia patients. Clin Yvonne D’Arcy is a pain management and NN. Metabolic syndrome and the functional Rheumatol. 2008;27(12):1543-1547. palliative care nurse practitioner at Suburban outcomes of hip and knee arthroplasty. Epub 2008 Jul 12. Hospital-Johns Hopkins Medicine in Bethesda, J Rheumatol. 2010;37(9):1917-1922. 10. Okifuji A, Bradshaw DH, Olsen C. Evaluating Md. Epub 2010 Jul 15. obesity in fibromyalgia: neuroendocrine The author has disclosed that she’s a consultant 5. Bond DS, Vithiananthan S, Nash JM, biomarkers, symptoms, and functions. Clin for Ortho-McNeil, Pfizer, and Endo. She’s also on Thomas JG, Wing RR. Improvement of Rheumatol. 2009;28(4):475-478. Epub the speaker’s bureau for Endo and Pfizer. migraine headaches in severely obese 2009 Jan 27. patients after bariatric surgery. Neurology. 11. Roffey D, Ashdown L, Dornan H, et al. Pilot This article is adapted from “Practical consider- 2011;76(13):1135-1138. evaluation of a multidisciplinary, medically ations for pain management in obese patients,” 6. Sowers MF, Yosef M, Jamadar D, Jacobson J, supervised, nonsurgical weight loss program The Nurse Practitioner Journal, December 2011. Karvonen-Gutierrez C, Jaffe M. BMI vs body on the severity of low back pain in obese composition and radiographically defined adults. Spine J. 2011;11(3):197-204. DOI-10.1097/01.NUMA.0000411905.59061.5e ▲▲ For more than 20 additional continuing education articles related to pain topics, go to Earn CE credit online: Go to and receive a certificate within minutes. 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Nursing Management • March 2012 25 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.