What is the recommended treatment approach for soft tissue injuries, spinal sprain/strain injuries, and disc herniations in obese patients?

Treatment Approach for Soft Tissue Injuries, Spinal Sprain/Strain, and Disc Herniations in Obese Patients

For obese patients with soft tissue injuries, spinal sprain/strain injuries, and disc herniations, a comprehensive treatment approach should include weight management, appropriate physical activity, pain management with topical NSAIDs as first-line therapy, and avoidance of opioids whenever possible.

Initial Management of Acute Injuries

First-Line Pain Management

• Topical NSAIDs with or without menthol gel should be used as first-line therapy for acute soft tissue and musculoskeletal injuries to reduce pain, improve function, and increase treatment satisfaction 1
• Cold application (ice and water in a damp cloth) for 20-30 minutes, 3-4 times daily can help reduce pain and swelling in acute sprains and strains 1
• Compression wraps may be applied for acute ankle sprains to promote comfort, but care must be taken not to compromise circulation 1

Second-Line Pain Management

• Oral NSAIDs can be used to reduce pain and improve physical function 1
• Oral acetaminophen is an alternative to reduce pain 1
• Non-pharmacological approaches such as specific acupressure or transcutaneous electrical nerve stimulation (TENS) can be considered 1

Avoid Opioids

• Opioids, including tramadol, should be avoided for treating acute pain from musculoskeletal injuries 1
• There is significant concern about opioid use in obese patients due to potential respiratory complications 1

Weight Management as Essential Component

Importance of Weight Management

• Obesity contributes significantly to pain and disability in musculoskeletal conditions 1
• A BMI of 35 kg/m² appears to be a threshold at which functional impairment rates rise dramatically 2
• Weight loss can reduce or eliminate joint pain regardless of age 2

Weight Management Approach

• Set realistic weight loss goals of 5-15% over 6 months, followed by long-term weight maintenance 1
• Implement an individualized dietary intervention reducing calorie intake by at least 500 kcal/day 1
• For patients with class II (BMI 35.0-39.9) or III (BMI ≥40) obesity, aim for a more aggressive energy deficit of 500-1000 kcal/day 1
• Discuss accessible weight management options including referral to dietitian, psychologist, community lifestyle services, or bariatric surgery evaluation when appropriate 1

Physical Activity Recommendations

Exercise Prescription for Obese Patients

• Encourage 30-60 minutes per day of moderate-intensity aerobic exercise at least 5 days per week (≥150 min/week) 1
• For weight loss and maintenance, longer or more intensive exercise (200-300 min/week of moderate-intensity activity) alongside dietary modification may be needed 1
• Include resistance exercises 2-3 times per week to enhance muscular strength and physical function 1
• Gradually increase activity levels over time, tailored to the patient's current fitness level and complications 1

Special Considerations for Obese Patients

• Walking may represent moderate to vigorous-intensity activity for obese patients, who may use 56-98% of their aerobic capacity compared to 35% in normal-weight individuals 1
• Identify physical and behavioral barriers to activity and consider culturally appropriate alternatives 1
• Avoid activities that cause pain in injured areas 1

Specific Management for Disc Herniations

Conservative Management

• Lumbar spinal fusion is not recommended as routine treatment following primary disc excision in patients with isolated herniated lumbar discs causing radiculopathy 1
• Early mobilization guided by pain response promotes more rapid return to full functional recovery 3

Surgical Considerations

• Consider lumbar spinal fusion only in specific cases: patients with herniated discs who have significant chronic axial back pain, work as manual laborers, have severe degenerative changes, or have instability associated with radiculopathy 1
• Reoperative discectomy and fusion may be a treatment option for patients with recurrent disc herniations associated with instability or chronic axial low-back pain 1

Multidisciplinary Approach

Team-Based Care

• A multidisciplinary approach should be used where possible to support weight loss and manage musculoskeletal conditions 1
• If multiple treatment options are indicated (e.g., psychological distress with sedentary lifestyle) and monotherapy has failed, consider multidisciplinary intervention 1

Additional Supportive Measures

• Consider orthotics, assistive devices, or ergonomic adaptations if pain during activities of daily living impedes functioning 1
• Address sleep disturbances, which are common in patients with pain and obesity 1
• Evaluate psychological factors that may interfere with effective pain management and provide appropriate support or referral 1

Treatment Evaluation and Follow-up

• Evaluate the effectiveness of lifestyle changes within 3 months 1
• Assess treatments periodically in line with treatment goals and adjust as needed 1
• For soft tissue injuries, rehabilitation is complete when the injured and adjacent tissues are restored to full pain-free functional capacity 3