From the Guidelines
The patient should continue taking Tramadol 50 mg as needed, up to 2 pills on workdays, to manage her back pain, as it has been shown to reduce her pain from 9/10 to 4/10, and consider alternative therapies such as physical therapy, which she is scheduled to restart on July 1st at Cascade Summit, to improve her quality of life and reduce morbidity. For her back pain, which radiates from her right scapula/shoulder down to her upper arm, she is currently taking Tramadol 50 mg as needed, which reduces her pain from 9/10 to 4/10, as well as methocarbamol 500 mg three times daily as needed and acetaminophen (2 Tylenol) as needed 1. She avoids ibuprofen due to being on Xarelto. The patient uses ice and heat therapy for additional pain relief. She attempted physical therapy but couldn't complete it due to her Crohn's disease, though she's scheduled to restart on July 1st at Cascade Summit.
She tried chiropractic care with initial success but later found it intolerable, and while massage therapy was helpful, it wasn't covered by insurance. For her Crohn's disease, she takes daily budesonide and avoids gluten, which is in line with the Canadian Association of Gastroenterology clinical practice guideline for the management of luminal Crohn's disease, which recommends continued anti-TNF therapy to achieve and maintain complete remission in patients who have achieved symptomatic response with anti-TNF induction therapy 1. She hasn't experienced a flare-up recently, with her last one occurring about three months ago. She manages her condition by being prepared with appropriate undergarments.
Some key points to consider in managing her back pain include:
- The use of opioids, such as Tramadol, as second-line treatments for chronic pain conditions, including neuropathic pain and fibromyalgia 1
- The effectiveness of physical activity and epidural blockade for treating low back pain and lower-extremity pain 1
- The importance of considering alternative therapies, such as physical therapy, to improve quality of life and reduce morbidity. It is also important to note that the patient's Crohn's disease is currently well-managed, and she should continue to follow the recommended treatment guidelines to maintain remission and prevent flare-ups.
From the Research
Patient's Current Condition
The patient is experiencing back pain radiating from her right scapula/shoulder to her upper arm. She has undergone 5 physical therapy sessions but was unable to complete the therapy due to her Crohn's disease. The patient is currently taking pain medications, including Tramadol 50 mg PO PRN, which provides relief from pain, reducing it from 9/10 to 4/10 2, 3.
Medications and Their Effects
The patient is taking the following medications:
- Tramadol 50 mg PO PRN: provides pain relief, reducing pain from 9/10 to 4/10 2, 3
- Methocarbamol 500 mg PO TID PRN: used to relieve pain and discomfort 4
- Acetaminophen PRN: used to relieve pain and reduce fever 4, 5
- Budesonide daily: used to manage Crohn's disease
Alternative Therapies
The patient has tried the following alternative therapies:
- Chiropractor: initially helpful, but the pain became intolerable
- Massage therapy: helpful, but not covered by insurance and expensive
Studies on Tramadol
Studies have shown that Tramadol is effective in managing chronic low back pain, with a significant reduction in visual analog scale (VAS) scores after four weeks of treatment 3. However, Tramadol is associated with side effects such as constipation, nausea, drowsiness, and dizziness 3, 5, 6. The combination of Tramadol and acetaminophen has been shown to be no more effective than ibuprofen in the acute setting 5.
Management of Acute Pain
According to studies, pharmacologic management of acute pain should be tailored to each patient, with a review of treatment expectations and a plan for the time course of prescriptions 4. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are first-line treatment options for most patients with acute mild to moderate pain 4.