March/April 2016

Chronic Musculoskeletal Pain: Initial Pharmacological and Nonpharmacological Therapies
By Rosemary Laird, MD, MHSA, AGSF, and Ashish R. Udeshi, MD
Today's Geriatric Medicine
Vol. 9 No. 2 P. 10

Concerns surrounding harmful side effects and medication interactions associated with prescription medications has led to increasing support of the use of OTC medications and nonpharmacological multimodal therapies to treat chronic musculoskeletal pain.

Musculoskeletal pain is a common occurrence affecting many older adults. It is estimated that one in four older adults will suffer chronic nonmalignant musculoskeletal pain. With the increase in the geriatric population (35 million people who are aged 65 and older), the number of individuals suffering from musculoskeletal pain has grown exponentially.1 In light of this trend, it is extremely important to have a pain management strategy that helps to decrease patients' suffering and disability.

The treatment options for elderly individuals can pose challenges, including concomitant medical conditions leading to drug-disease contraindications, polypharmacy with drug-drug interactions, and medical compliance with tolerance issues. Moreover, elderly individuals are high-risk candidates for surgical interventions.2 This article highlights common musculoskeletal pain conditions in the elderly and offers providers insight into the management of these conditions, utilizing nonpharmacological and over-the-counter (OTC) treatment options.

Chronic Musculoskeletal Pain Conditions
Older adults can suffer from various types of musculoskeletal conditions. These include degenerative changes related to osteoarthritis, chronic joint pain of the upper and lower extremities (eg, hips, knees, shoulders, and hands), low back pain, fibromyalgia, myofascial pain, and previous fracture sites. Additionally, elderly patients are prone to a higher incidence of tendonitis and bursitis.1-3

From 2010 through 2012, one-half (49.7%) of adults aged 65 and older reported physician-diagnosed arthritis, and it is estimated that by 2030, 67 million adult Americans could be diagnosed with the condition. According to recent statistics from the Centers for Disease Control and Prevention, nearly one in two people may develop symptomatic knee osteoarthritis by the age of 85, and one in four people may develop painful hip arthritis. In 2011, there were more than 750,000 knee and 500,000 hip replacement procedures related to arthritis alone.4-7 Chronic pain associated with arthritis can impose serious activity limitations on individuals. People can suffer significant declines in walking, climbing, bending, and social interactions; this leads to an overall decrease in quality of life.

Chronic low back pain is one of the most frequently reported musculoskeletal problems. It is the third most reported symptom of any kind in individuals over the age of 75.8 A study examining Medicare data from 1991 and 2002 showed a 132% increase in the number of patients with low back pain, and a 387% increase in costs related to low back pain.9 From 1992 to 2003, the number of surgical procedures for low back pain increased significantly. For example, there was a three-fold increase in lumbar fusion surgeries in Medicare patients during that time span.10

Some potential causes of back pain in the elderly include muscle strain/sprain, compression deformities related to falls and osteoporosis, degenerative facet joint conditions, lumbar spondylosis, lumbar spinal stenosis, and lumbar disc degenerative changes. Chronic low back pain can significantly interfere with an individual's gait, mobility, and posture, and increase the risk of falls.

Elderly individuals are also at high risk of fractures. Fracture sites of injury involving joints and bones not only cause acute pain conditions but can also lead to severe chronic pain conditions. It is estimated that 29% of Medicare patients living in nursing homes who have had a fracture suffer with daily chronic pain and activity limitations within six months.11

Impact of Chronic Musculoskeletal Pain
The chronic pain associated with musculoskeletal conditions can pose serious activity, physical, and emotional limitations. Chronic musculoskeletal pain can lead to a vicious cycle of disuse and inactivity.2 People can suffer significant decline in function, decreased ambulation, fear of movement, functional dependence, disability, impaired posture, and muscle atrophy. Elderly individuals may also suffer sleep disturbances, behavioral problems, social isolation, depression, and anxiety related to their chronic musculoskeletal pain. It is extremely important to employ treatment programs that can overcome the cycle of disuse and inactivity. Moreover, it is important to focus on improvement in quality of life through effective and comprehensive treatment strategies.

Treatment Strategies
The main purpose of treatment programs is to decrease pain and improve function. Multidisciplinary programs incorporate several modes of therapy such as pharmacologic and nonpharmacologic options. These options have demonstrated the greatest benefit and highest efficacy in managing chronic musculoskeletal pain. An individualized program that identifies current medical conditions, medications, home life, and goals is cardinal for geriatric patients.

Elderly individuals are at an increased risk of side effects and interactions from certain classes of prescribed medications for managing chronic pain (eg, opioids, neuromodulators, and antidepressants). Increasing evidence of this issue has led to growing support for the use of OTC medications and nonpharmacological multimodal treatment programs in older adults.12

OTC Options

Acetaminophen
According to the 2009 American Geriatric Society expert panel recommendations, acetaminophen is the recommended first-line therapy option for mild to moderate musculoskeletal pain.13 Acetaminophen (Tylenol), a para-aminophenol derivative with analgesic and antipyretic properties similar to aspirin, focuses on inhibiting central prostaglandin synthesis to reduce pain and fever but lacks peripheral anti-inflammatory activity. Since acetaminophen is not associated with significant gastrointestinal bleeding, adverse renal effects, or cardiovascular toxicity, it is generally recommended as a safe first-line treatment option in elderly patients. Prior to initiating acetaminophen, it is important to evaluate hepatic function because of increased risk of hepatoxicity.14,15

The adult daily dose and frequency for generic acetaminophen is 325 mg to 650 mg every four hours or 650 mg to 1 g every six hours as needed for pain. The half-life of generic acetaminophen is roughly two hours; the maximum daily recommended patient-directed use, according to the FDA, is <3 g per day and, under physician-instructed use, <4 g per day. Additionally, new recommendations limit the amount of per day combination pills to 325 mg of acetaminophen.15-17 The brand name Tylenol is also available over the counter and comes with specific products for headache/muscle pain, arthritis pain, and sleep/pain (see Chart 1).

NSAIDs
NSAIDs are a diverse group of compounds and medications with analgesic, antipyretic, and anti-inflammatory activity. NSAIDs are among the most widely prescribed types of medications. When acetaminophen alone does not provide sufficient relief, NSAIDs can be extremely effective for musculoskeletal pain related to inflammation and are suggested as a treatment option. OTC NSAID options include aspirin, ibuprofen, and naproxen sodium.13-15

However, NSAIDs must be used with severe caution in older individuals due to the high risk of potentially serious and life-threatening side effects. Some of those side effects include gastrointestinal bleeding, stroke, renal failure, and ischemic heart disease. Individuals with low creatinine clearance, gastropathy, or cardiovascular disease must take NSAIDs with extreme caution due to their higher risk profile. The risk of serious complications associated with NSAIDs increases 4% for each one-year increase in age after the age of 65.18 There is also an increased likelihood of adverse gastrointestinal effects when an NSAID is coadministered with low-dose aspirin, which many elderly patients may take for antithrombotic effects. Proton pump inhibitors can help reduce the gastrointestinal effects, and the lowest effective dose should be initiated if NSAIDs are prescribed on a chronic basis.15

The following medications are NSAIDs available over the counter. Aspirin (eg, Bayer, Bufferin, and Ecotrin) is part of the salicylate family with a dosing regimen that can be prescribed at 600 mg to 1,500 mg every six hours as needed for pain. The maximum daily dosing is 2.4 g to 6 g per day with a half-life of two to three hours. Ibuprofen (eg, Motrin and Advil) is part of the propionic acid derivative family with OTC doses ranging from 200 mg to 400 mg every six hours as needed for pain. The maximum daily doses range from 1.2 g to 2.4 g for pain with a half-life of six hours. Naproxen sodium (eg, Aleve) is also part of the propionic acid derivative family. OTC doses range from 275 mg to 550 mg every 12 hours as needed for pain. The maximum daily dosing is 550 mg to 1100 mg with a half-life of 12 hours.15 (See Chart 2 for common OTC NSAIDs.)

Topical Ointments
OTC pain-relieving ointments can be effective therapies for localized pain conditions. These medications can be applied directly at the site of musculoskeletal conditions to help reduce swelling, intensity, and sensations of pain. Additionally, there is improved tolerability with topical administration over oral routes of medications, which is especially important in the older population. Thus, topical NSAIDs may provide an alternative to oral NSAIDs for localized pain conditions. There are various combinations of topical treatments and formulations. It is extremely important to use the agents as directed and ensure the creams, sprays, rubs, or patches do not interfere with current medications or comorbidities.2,4,19 (See Chart 3 for a brief list of some ingredients and indications.)

Nonpharmacologic Options
The best form of treatment is to combine a safe pharmacological program with nonpharmacological medications for patients' maximum benefit to relieve pain. Nonpharmacological treatment programs are aimed at targeting the site and source of pain conditions. They involve exercise programs (eg, physical therapy, tai chi, and aqua therapy), transcutaneous electrical nerve stimulation (TENS) application, heat/ice therapy, assistive devices, psychological methods (eg, relaxation, biofeedback, hypnosis, cognitive behavioral therapy, social interventions), and targeted interventional options for pain conditions.2,4,20 In older individuals, nonpharmacologic options have benefits that include fewer risks of side effects and less expensive treatment. This offers two key advantages that benefit the patients and their insurance providers such as Medicare.

Exercise Programs
Regular and structured exercises play a key role in managing musculoskeletal pain conditions. Passive or active exercises allow for more joint mobility, increased blood flow, decreased edema, inhibition of muscle spasms, enhanced range of motion, improved strength, flexibility, and weight loss. The most studied literature on exercise programs has been with patients who suffer from osteoarthritis of the knees. Patients have benefited from aerobic exercise, water-based treatments, land-based exercises, quadriceps strengthening exercises, and resistance exercise.2,21

The most effective exercise regimen is a program that combines a patient's condition and a physical therapist. A physical therapist is responsible for planning an exercise program that generally focuses on the basic components of flexibility, strength, and aerobic education.

Tai chi, a traditional Chinese mind-body exercise, has shown great promise in adults with musculoskeletal conditions and is gaining popularity. Tai chi emphasizes diaphragmatic breathing and relaxation with coordinated, smooth, gentle body movements. A 2011 study established that combined exercises (aqua/land, walking, strengthening, resistance, and tai chi) could reduce pain and disability from knee osteoarthritis. Patients suffering from other musculoskeletal conditions, such as fibromyalgia, rheumatoid arthritis, and chronic low back pain, also have reduced pain complaints with tai chi.2,21

Aquatic exercise is extremely beneficial in older adults who suffer from chronic musculoskeletal pain. The water allows for less impact on the joints with more pain-free motion. The ideal water temperature for arthritic older adults is between 85° and 90° F.2,22 Studies have shown that attendance of hydrotherapy and aquatic exercise programs is higher than that of tai chi.2,23

TENS Therapy
The American Geriatrics Society recommends the use of TENS therapy for chronic pain. This can be performed alone or in combination with other strategies to enhance effectiveness of treatment. There are a few studies that explore further treatments of TENS therapy, but it is a considered a minimal risk option in the elderly that can help decrease pain.2,20,22

Ice/Heat
Hot and cold therapy agents are helpful in pain management. Heat agents such as a hot pack and warm hydrotherapy can help to improve blood supply and blood flow to an area. The increase in blood flow permits more tissue extensibility and joint range of motion to decrease chronic pain symptoms. Cold therapy helps to reduce inflammation and decrease swelling; it can also be effective after acute incident-related pain.2,12,20

Assistive Devices
Protective and supportive devices have been shown to help reduce pain intensity relative to older people not provided with devices. Such devices include custom orthotics, bedside supportive devices, and ambulation devices (eg, wheelchairs, walkers, canes, and crutches). They provide more independent function, reduce care costs, decrease pain, and improve function. The type of and need for a supportive device are determined on an individual basis and are unique to each patient's condition and ailments.2,20

Psychological Programs
Chronic musculoskeletal conditions can take their toll both physically and emotionally. There are strong links between depression and chronic pain in the elderly. A multidisciplinary pain management program that includes a psychological program can have significant impact on a patient's quality of life. Coping strategies and techniques include cognitive behavioral therapy, mindfulness, meditation, guided imagery, biofeedback, and educational support groups. Cognitive behavioral therapies use techniques to alter dysfunctional ways of thinking and assist with a patient's control over pain. Guided imagery and biofeedback use sights, sounds, music, and words to create feelings of empowerment and relaxation. Thus, incorporating a pain psychologist into a patient's medical team can be of great assistance and insight when managing chronic pain conditions.2,20

Interventional Targeted Treatments
For many localized chronic musculoskeletal conditions, further treatments can be performed directly at the site of discomfort. Evidence indicates that targeted treatments with pharmacological and nonpharmacological therapies can improve patients' quality of life and function and decrease the need for chronic pain medications.2,24 Interventional pain management techniques focus on areas of the low back, knees, hips, shoulders, trigger points, neck, and nerves. A trained interventional pain specialist uses anti-inflammatory medications, thermal radio frequency ablation, joint fluid supplementation, or nerve blocks to perform various types of procedures. Procedures are conducted with the use of fluoroscopy or ultrasound guidance and include epidural steroid injections, facet joint injections, intra-articular injections, nerve blocks, vertebroplasty, spinal cord stimulation, and thermal radiofrequency ablation. Targeted treatments allow significant improvement for extended periods of time, avoid the risk of surgical procedures, limit additional medication side effects, assist to further therapy, and improve overall quality of life.25

Conclusion
As the population ages, a majority will suffer from a plethora of musculoskeletal pain. Unfortunately, for the geriatric population, chronic musculoskeletal pain can lead to a vicious cycle of discomfort and disuse. However, with multimodal treatment regimens that incorporate OTC medications, topical agents, exercise programs, psychological support, and interventional therapies we can hopefully end the cycle of chronic pain and improve overall quality of life.

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, executive medical director of senior services for Florida Hospital at Winter Park, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss.

— Ashish R. Udeshi, MD, is an interventional pain specialist with Florida Pain Institute in Merritt Island, Florida, and a board-certified anesthesiologist. He is also a voluntary assistant professor at the University of Miami in the department of clinical anesthesiology.

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