What is the best approach to manage pain and optimize functional status in a 70-year-old male patient with a history of MVA, back and hip fractures, and current lower back and right hip pain, with a bolt in his right hip and ongoing physical therapy for knee pain?

Multimodal Pain Management for a 70-Year-Old Male with Post-MVA Back and Hip Pain

A comprehensive multimodal approach combining physical therapy, non-opioid analgesics, and targeted interventions is the most effective strategy for managing this patient's complex post-traumatic pain and optimizing functional status.

Assessment of Current Pain Condition

The patient presents with:

• Lower back and right hip pain following MVA 1.5 years ago
• History of fractures in back, right hip, and both knees
• Hardware (bolt) in right hip
• Currently receiving physical therapy for knee pain

Treatment Algorithm

Step 1: Non-pharmacological Interventions (First-line)

1. Enhanced Physical Therapy Program

   • Continue and expand current PT to address all affected areas 1
   • Include specific components:
     • Progressive quadriceps and hamstring strengthening 2
     • Hip-focused exercises to reduce load on painful joints 2
     • Balance training to prevent falls 1
     • Functional exercises to improve activities of daily living 1

2. Orthotics and Assistive Devices

   • Evaluate need for walking aids (cane, walker) to reduce load on affected joints 1
   • Consider shoe inserts/orthoses if biomechanical issues are identified 2

3. Patient Education

   • Explain relationship between pain and function 1
   • Teach proper body mechanics to avoid positions that exacerbate pain 2
   • Educate about pacing activities to manage pain flares 1

4. Thermal Therapy

   • Apply heat for muscle spasm and stiffness
   • Apply cold for acute pain flares 2

Step 2: Pharmacological Management

1. First-line Analgesics

   • Acetaminophen (up to 3g/day due to age >65) 2
   • Topical NSAIDs for localized pain (preferred over oral NSAIDs given patient's age) 2

2. If inadequate relief:

   • Consider short-term oral NSAIDs at lowest effective dose with gastroprotection
   • Avoid in presence of renal impairment, heart failure, or GI risk factors 1

3. For moderate-severe pain:

   • Consider short-term tramadol (lower doses for patients >75 years) 3
   • Monitor closely for side effects, especially given age and potential polypharmacy 3

Step 3: Advanced Interventions (if above measures inadequate)

1. Interventional Procedures

   • Consider intra-articular corticosteroid injection for hip pain if evidence of inflammation 2
   • Evaluate for potential epidural steroid injection for back pain 1

2. Orthogeriatric Assessment

   • Comprehensive geriatric assessment to address multiple comorbidities 1
   • Evaluation for osteoporosis and fracture risk 1

3. Multidisciplinary Pain Management

   • Consider referral to comprehensive pain program if pain remains disabling 1
   • Include psychological support for pain coping strategies 1

Special Considerations

• Age-related factors: Adjust medication dosing given patient's age (70 years)
• Hardware complications: Evaluate if hip bolt is contributing to pain (possible hardware failure or loosening)
• Fall prevention: Implement strategies to prevent further falls and injuries 1
• Sleep management: Address any sleep disturbances that may be exacerbating pain 1

Monitoring and Follow-up

• Reassess pain and function every 4-6 weeks
• Monitor for medication side effects, especially with NSAIDs or tramadol
• Adjust treatment plan based on progress and functional improvements
• Set realistic expectations about recovery timeline

Pitfalls to Avoid

• Overreliance on opioids: Long-term opioid use carries significant risks and should be avoided when possible 1
• Inadequate physical therapy: Discontinuing exercise once symptoms improve can lead to relapse 2
• Focusing only on pain scores: Functional improvement is equally important to pain reduction 1
• Neglecting psychological aspects: Pain catastrophizing and fear of movement can impede recovery 1
• Treating in isolation: This complex case requires coordination between orthopedics, physical therapy, and primary care 1

By implementing this comprehensive approach, the patient has the best chance of achieving improved pain control and enhanced functional status while minimizing medication-related risks.