What are the recommended treatments for managing pain in different parts of the body?

Pain Management Strategies for Different Body Sites

Physical activity and exercise interventions, combined with psychological approaches, are the most effective strategies for managing pain across different body sites, with specific treatment modalities tailored to the location and type of pain. 1

General Principles of Pain Assessment

Pain assessment should be conducted using validated tools such as:

• Visual Analogue Scales (VAS)
• Numerical Rating Scales (NRS)
• Verbal Rating Scales (VRS)

A comprehensive pain assessment should include:

• Pain intensity, location, and quality
• Functional impact and interference with daily activities
• Previous and ongoing pain treatments
• Psychological factors affecting pain perception

Pain Management by Body Region

Musculoskeletal Pain (Inflammatory Arthritis and Osteoarthritis)

1. First-line treatments:

   • Physical activity and exercise (strongest evidence for pain reduction) 1
   • Education about condition and pain management
   • Weight management for weight-bearing joints

2. Second-line treatments:

   • Psychological interventions (CBT, relaxation techniques, biofeedback)
   • Orthotics (splints for hand OA, knee orthoses, orthopaedic shoes)
   • Acetaminophen/paracetamol for mild pain

3. Third-line treatments:

   • NSAIDs (with caution regarding GI effects)
   • Sleep interventions if sleep disturbance is present

Cancer Pain

1. Mild pain (WHO Level I):

   • Non-opioid analgesics (acetaminophen/paracetamol, NSAIDs) 1
   • Consider gastroprotection with prolonged NSAID use

2. Moderate pain (WHO Level II):

   • Weak opioids (codeine, dihydrocodeine, tramadol)
   • Low doses of strong opioids as an alternative
   • May be combined with ongoing Level I agents

3. Severe pain (WHO Level III):

   • Morphine (oral route preferred)
   • Alternatives: hydromorphone, oxycodone, transdermal fentanyl
   • Schedule around-the-clock dosing with breakthrough doses
   • May be combined with ongoing Level I agents

Abdominal Pain

1. Inflammatory causes:

   • Treat underlying inflammation first 2
   • For Crohn's disease:
     • Mild disease: budesonide 9 mg daily
     • Moderate-severe: corticosteroids, biologic agents, immunomodulators

2. Non-inflammatory causes:

   • Antispasmodics for meal-related pain
   • Avoid NSAIDs in inflammatory bowel disease
   • Tramadol for severe or refractory pain (less effect on motility)

3. Adjunctive approaches:

   • Patient education and reassurance
   • Cognitive strategies to reduce catastrophizing
   • Sleep hygiene practices

Neuropathic Pain

1. First-line treatments:

   • Pregabalin: Start at 75 mg twice daily, can increase to 300 mg twice daily 3
   • Gabapentin for neuropathic pain

2. For spinal cord injury pain:

   • Pregabalin 150-600 mg/day, starting at 75 mg twice daily 3
   • Increase to 150 mg twice daily within 1 week based on efficacy and tolerability

3. Dose adjustment:

   • Adjust dose based on renal function
   • For patients with CLcr <60 mL/min, reduce dose accordingly

Multimodal Approach to Pain Management

For all pain types, consider combining:

1. Non-pharmacological interventions:

   • Physical activity and exercise (150-300 minutes/week moderate intensity)
   • Psychological interventions (CBT, relaxation techniques)
   • Sleep hygiene education
   • Ergonomic adaptations at home/workplace

2. Pharmacological treatments:

   • Select based on pain mechanism (nociceptive, neuropathic, nociplastic)
   • Consider step-wise escalation following WHO pain ladder
   • Adjust for comorbidities and potential drug interactions

Common Pitfalls in Pain Management

• Overreliance on pharmacological treatments without maximizing non-pharmacological approaches
• Failing to reassess pain after implementing interventions
• Not considering psychosocial factors that influence pain perception
• Using opioids for chronic non-cancer pain without proper risk assessment
• Dismissing pain reports when physical findings don't correlate with reported intensity
• Using NSAIDs in inflammatory bowel disease patients

Special Considerations

• Elderly patients: Start with lower doses and titrate slowly
• Renal impairment: Adjust medication doses, particularly for pregabalin and opioids
• Inflammatory bowel disease: Avoid NSAIDs, use tramadol for severe pain
• Chronic pain: Consider the biopsychosocial model and address psychological factors

By tailoring pain management strategies to the specific body site affected and considering both pharmacological and non-pharmacological approaches, most patients can achieve satisfactory pain relief and improved quality of life.