The objectives that I’d like to accomplish over the next 45 minutes are to have you come away with a clear understanding of the multiple physical, psychological and social treatment targets for older adults with chronic pain, and specifically chronic nonmalignant pain and impaired function to be able to list so-called vital signs and treatment outcomes for our patients, and finally to have a understanding of a rational approach to treatment for older adults with the four main types of chronic nonmalignant pain; so pain is not pain is not pain, there is more difference than similarities. The main categories are no susceptive pain, which is pain in the face of a normal nervous system like arthritis for example; neuropathic pain, which is pain in the face of an abnormal nervous system; myofascial pain and fibromyalgia.  So this is why we are all at this conference, we know that the rate of increase in older patients worldwide is increasing exponentially and in less than decade there will be more people age – over age 65 than under age 5 owing to decreasing birth rates and increasing longevity, and arguably the conditions that most impact these patients’ quality of life and ability to function are the painful arthritidis and musculoskeletal disorders.

Our patients come to us with pain and they often say that pain is what’s interfering with their ability to function, with disabling them. In fact that may or may not be true.  Even in patients with chronic pain that attend pain clinics there’s only a modest overlap between pain and disability, so we should really think of these two things as related but distinct constructs. 

Take for example low back pain. This was a study using the over 3,000 patients that are part of Dr. Newman’s Health ABC Cohort and they were asked at baseline whether over the past 12 months they had had any back pain, and if they did the severity of it and how often they got it. So we - based on those responses we broke patients into no pain, mild pain of any frequency, moderate pain but not very often, and then people that we think of as our typical chronic pain patients which are people that have at least moderate pain very often. So it’s no surprises that there was a dose response relationship between the pain burden and patients’ self-reported difficulty in doing these different tasks, lifting, stooping, pulling and pushing, doing heavy housework, 2 flights of stairs and walking a mile.

What’s more interesting I think is if you look, so these are the percent of patients that report difficulty. And all activities with the exception of stooping, the vast majority of these patients report no difficulty with these tasks. So most older adults with chronic pain actually do well if there is not – if they are not doing well there is something else going on. But what’s more interesting is we looked at the relationship between pain burden and gait speed, why gait speed, Dr. Studensky gave a presentation earlier in the conference, so you all know that gait speed is a powerful predictor of morbidity and mortality. There was no relationship at all between pain burden and gait speed. Again, pain in and of itself is inadequate to explain disability in many of these patients. 

So again, just – sound like a broken record, but pain is not equivalent to disability. When we as geriatricians see disabled older adults we look at many different constructs, and if our patients are blessed with high levels of function in each of these constructs, their risk of disability is low; whereas if – and this may be representative of more of the patients that we see in our practices, if people are burdened in these constructs their risk of disability is high, so disability is a multi-factorial construct as is pain a multi-factorial construct.  This is a cartoon of the neurophysiology of pain so it’s not enough to look at the tissues that – in which the painful stimuli, the so-called no susceptive stimuli originate. We have to look broadly at the other processes that regulate patients’ ability to control and process pain, so the cognitive processes, the emotional processes. So again, pain and disability are both very complex phenomenon.

And there is overlap in terms of so what are the non-physical contributors to pain and disability?  What should you be asking your patients about?  There are psychological and mood factors.  So patients with comorbid depression and anxiety are much more likely to be disabled by chronic pain than patients that don’t have these comorbidities. What about self-efficacy, that is the patient’s belief in their ability to get well, to be able to function despite chronic pain. If they don’t believe they are going to be able to get better it’s highly likely they won’t get better. So this sort of treatment expectancy phenomenon is related, it’s part of the placebo effect. If patients believe that they are going to get better, that they are going to respond or the drug or the intervention much more likely that they will. On the other hand, the nocebo effect, which is if patients don’t believe that they are going to get better, their pain may actually get worse. There is very interesting experimental data to show this.

What about fear avoidance beliefs?  Are patients afraid to move around because they think they are going to harm themselves, they are going to make their pain worse?  They are going to contribute to their own disability.  If patients have high levels of fear avoidance beliefs, that actually acts as a barrier to successful rehabilitation.  And finally, what are their coping skills?  If they think they are never going to get any better, they are going to be crippled, you know they are going to end up in a nursing home, these kinds of beliefs actually inhibit people’s ability to be rehabbed with chronic pain and should make you think about enlisting the help of either a psychologist or actually we’ve found some very nice beneficial effects of physical therapists on reducing fear avoidance belief. So the best therapists are often the best psychologists too.

Social factors, unfortunately often these are the difficult to treat, but may be the main thing that’s driving these people’s disablement.  If people are socially isolated or don’t have good social interactions they may sort of perseverate or obsess or think about their pain more, and then that makes them become more disabled, but if somebody is socially isolated and they still have pain that doesn’t mean we need to push their drugs, we need to sort of try to think creatively out of the box because we may end up inducing toxicity.  Finally, cognitive function, people with dementia are clearly very, very challenging and for reasons that I’ll get into in just a moment, but comorbid cognitive dysfunction is a significant impairment to successful pain management, at least based on the evidence that we have right now.

So the patient presents to your office, what do we do?  So even before you see the patient you can have your staff get vital signs, right?  So these are the traditional vital signs, but there’s 3 or 4 others that I’d also like to add into the mix. So there’s all these pain scales, people do a lot of research trying to figure out pain scales. I actually think a lot of that is kind of hooey, we want to – a lot of older adults have a lot of trouble using numerical scales, they say I don’t know, it hurts, it interferes with my ability to do stuff. So in my mind do they have it?  In general how bad is it and do they perceive that it’s interfering with their ability to function?

Cognitive status, again this is before you see the patient.  A quick screen is something probably many of you are familiar with, the mini cog which takes 2 minutes to do, consists of a combination of 3 word recall and a clock draw.  Why is knowing that the patient is demented important?  It may affect their pain reporting.  You - probably many if not all of you have cared for patients with dementia. We know that as the illness advances one of the characteristics is that people tend to perseverate, they say the same things over and over and over again.  Pain is very concrete, it’s easy to talk about. Simply the fact that the patient is reporting pain does not mean the patient is suffering from pain. So I think it’s very, very important to try to distinguish that.  It may affect people’s ability to adhere to treatment.  People with dementia are more likely to become delirious with medications, they are more likely to fall. So they may be much more vulnerable to the adverse effects of our treatment. And then of course that will dictate how often we want to monitor these people, and what is our approach?  If these are people that are hard to get out of the  house, you may want an office person to regularly call them to see how they are doing. So knowing that there is dementia is very, very important.

Another characteristic of patients with dementia that’s been shown experimentally is remember we talked about treatment expectancy, sort of belief in the ability to get better, that tends to wane as people become increasingly demented. So there’s sort of less synergy therefore between the actual pharmacodynamic effects of a drug and treatment expectancy, so you may – you may not see these people respond to sort of the low doses of drugs we tend to give these people, we may actually have to push them higher. 

Mobility status, about a third of people fall each year as I’m sure Dr. Studensky told you, a half of them repeatedly. And often times so we say well we asked them and they said they didn’t fall. People can be afraid to admit to that because they think, oh my God if I, you know, if I make known that I’m having functional difficulty that may increase the risk of me being placed in God forbid a nursing home, and so self-report really isn’t enough.  And asking about overt falls isn’t enough, you have to ask about near falls.  Further, many of the medications that we use to treat a variety of pain disorders increase the risk of falls and so baseline mobility assessment is important for informed consent, telling people about the risk of them falling and breaking a hip, right? And if you ascertain that they do have an increased risk of falls it’s – would behoove you and the patient to refer them to physical therapy prior to prescribing these medications that may increase falls risk to make sure that their mobility is as good as possible.

So Dr. Studensky probably talked about these things, the postural, modified postural stress test where you just stand behind the patient say, she talked about that?  Okay, so we don’t need to go over that. 

This thing is the timber response where somebody just falls into your arms. I’ve only probably in the past 15 years seen that maybe twice and either the patient was very psychiatrically impaired or completely demented and had no sense of their interaction with the environment. And the other thing, did she talk about functional reach?  So that’s a test that we develop that Duke, basically what you do with this test is you are asking the patient to move their center of mass to the edge of their base of support. So you ask the patient to stretch out their dominant arm and you hold an object such as a pen about a foot away, and what you do is you say I’d like you to lean forward and grab this without taking a step. So the patient with intact postural control mechanisms can smoothly move their center of mass to the _______ base of support and easily grab the pen. If on the other hand they sort of lunge for it or you know can only go about 6 inches that tells you that this is a person with impaired postural control mechanisms.

Probably the most important, quote unquote, vital sign is the impact of the pain.  Does pain affect your energy, mood, appetite, sleep, these other things?  Literature indicates that pain can deleteriously affect all of these constructs. And then it’s really important to get input from the spouse or significant other. I can’t tell you the number of time, you know, I’ll say to the patient so how is your mood and the patient will shake their head and simultaneously the spouse sitting behind the patient will be going like this. And so it’s very, very important because that can be an indicator of depression, if a patient is agitated or very irritable for example.  And then if you want you can rate each item as it doesn’t interfere at all, a little, somewhat a lot or they can’t do anything at all because of pain.

So now you haven’t seen the patient yet, all of these data can be collected either by your office staff or you can mail them a little you know questionnaire, or have them do it in the waiting room. And so you have all of this information and you haven’t even taken any time from your schedule to see the patient. Now you are getting ready to enter the room and see the person. And so the first thing that’s critical to assess is to assess what they want to accomplish as a result of treatment.  If the answer is I want you to give me a shot to take my pain away, then you know that they need some education about realistic expectations.  The literature demonstrates that for chronic nonmalignant pain we can expect about 30% reduction in pain intensity, but significantly more potential to improve function. So we can make your pain better, but you are going to be able to function a lot better even though you still have some pain.  That’s the message.

What kind of triage questions might help you ascertain whether engaging other interdisciplinary staff is important?  So what do you hope happens as a result of treatment?  Again, are they realistic or not?  Do you have any fears or worries about your pain?  Yeah, I’m really worried I’m going to – you know it’s going to cripple me, I’m not going to be able to take care of my grandkids, I’m going to end up in a nursing home, right?  Do you think you’ll get better?  No, I’m never going to get better. If your pain isn’t entirely relieved by the treatment what will you do?  So a positive response will be that’s, that’s okay, I can do most things because of my pain. I’ll just, you know, I rest, I cope with it. So I think these things can give you a sense of whether you know sort of physical interventions are enough, or whether you need other sort of psychological interventions, or as I say physical therapy directed toward reducing fear avoidance beliefs.

People with dementia often have an excessive amount of fear, and that can be very, very difficult.  What’s the impact of the pain?  So you have based on the little questionnaire that either your staff or the patient fills out what pain is interfering with. But remember, that’s the patient’s perception of what pain is interfering with, right?  People for example with cognitive impairment or bad heart of lung disease may identify the pain as the thing that’s impairing them but that may not be at all true. So you can’t accept their responses at face value, that just gives you a starting point that allows you to probe further into what activities are being impaired and why. 

Okay, red flags, things that indicate an underlying inflammatory disorder, an infection or malignancy.  So do they have very prolonged morning stiffness, more than 30 minutes? That might indicate rheumatoid arthritis or polymyalgia rheumatica.  Has there been a sudden change in the quality, intensity or location of the pain, indicating for example possibly a pathologic fracture.  Are there systemic symptoms like fever and weight loss commensurate with the course of pain? 

Okay, so next we’ve eliminated - a very tiny minority of our patients have these red flags, okay.  But as practitioners we want to make sure that we identify people that are really sick and need a different and unique course of treatment. If they don’t, which is going to be the majority of them, or it gets down to do they have no – as I said, no susceptive neuropathic, myofascial or widespread pain.

Where is your pain, right?  It’s not enough, you have to get people to be very, very specific. They can’t – if they say it’s my low back, well that could mean any one of a whole bunch of things, right?  Have them put their hand on it, right. If they take one finger and they put it over their buttocks they probably have a myofascial trigger point of their piriformis, right?  If they say their leg hurts, well that could mean that they have neurogenic claudication related to spinal stenosis, it can mean they have hip osteoarthritis with referred pain to their thigh, it could mean that they have a radiculopathy, it can mean that they have you know irritation of their iliotibial band, it can mean they have a leak in irritated quadriceps because of knee osteoarthritis, so it’s really, really important to try to get them to be very specific about where their pain is and what precipitates it. 

The next thing you want to ask is what is the quality of your pain, so neuropathic, nociceptive and myofascial?  Often times people describe neuropathic pain and myofascial pain using exactly the same descriptors, burning, sharp, shooting, okay?  So don’t assume that if people use sort of neuropathic qualities that automatically assumes that this is neuropathic pain.  What makes the pain better or worse?  So heat helps nociceptive and myofascial pain, cold and stress make everything worse, people with neuropathic pain that they generally feel better when they walk and the interesting thing about both nociceptive and myofascial pain, so for example people with you know osteoarthritis or myofascial pain, when the blood starts flowing they start moving around, they start feeling better at first, but the longer they go the worse they feel, okay?   Neuropathic pain is worse at night. And interesting with myofascial pain a common question I ask people, like let’s say somebody comes in with abdominal pain and they’ve had you know this huge workup and you can’t find any internal organ derangement and they have this sort of quadrant pain, and you say how does it make you feel if you take your hands and you put pressure, you support that area of your abdomen?  And they say it makes me feel better. That is, is an indicator that it’s probably myofascial pain, it’s sort of like giving yourself a massage.  You know light, gentle pressure on sore muscles makes those muscles feel better. 

Often a important differential is whether the patient’s back pain is coming from the lumbosacral area, the sacroiliac area or the hip. And I’m not going to go through each of these because the point of the slide is that there is a lot of overlap in terms of quality, whether there is leg pain, groin pain, etc.  The key thing I find that’s helpful in differentiating these is what happens with movement?  So people that have lumbosacral disease feel worse when they extend their spine, okay.  On the other hand, people with lumbosacral disease or spinal stenosis, when they curl up in a fetal position they feel better. But if there is sacroiliac disease and they are in the fetal position they often feel worse because you are auto-compressing the sacroiliac joint when patients lay on their side. 

Bad hip disease typically with significant restrictions in the hip joint people feel worse when they extend that joint. So don’t automatically assume that if you watch the patient walk into the exam room and they are bent forward that that means that there is lumbosacral disease, you have to see where they are bent forward. If they are flexed at the hip, that indicates hip disease.  If they say they – when they lay supine in bed and it causes terrible pain in their leg, that’s almost a sure sign of hip disease. They say they lay on their back and they curl their leg up, that sort of relaxes the periarticular structures and makes them feel better.

Okay, very important question, do you often feel that you have pain all over?  And if the answer is yes, then think about fibromyalgia which is a real illness, it’s not a diagnosis of exclusion and it’s most common in older adults.  A big epidemiologic study showed that about 1 in 14 women between the age of 60 to 79 have fibromyalgia. A research colleague of mine that I was talking to the other day that’s doing a study on comorbid depression and back pain has found that 1 in 4 of these patients has fibromyalgia which requires very unique approach to treatment. 

And typically although patients say that they feel pain all over, often it’s localized around the axial skeleton, so they may come to you and say my back is killing me. That may be the worst thing, right?  But in point of fact, the reason that their back is killing them is because the fibromyalgia has caused sort of decrease in pain tolerance and therefore the degenerative disease in their spine is that much more symptomatic.  So you have to treat both.  As I said, it’s not a diagnosis of exclusion and often times these people not only pain threshold but lots of stimuli they are more sensitive to, they have reduced threshold for auditory stimuli and visual stimuli. So it’s almost like the entire nervous system is up regulated.

Three-quarters of people will have nonrestorative sleep, so they spend lots of time in bed but they don’t feel rested.  They may wake up a lot, they may dream vividly, they may be aware of things in their environment when they are sleeping. They are stiff in the morning but generally they limber up within less than 30 minutes, and often times what’s more disabling than the pain is actually overwhelming fatigue.  I mean I’ve actually taken care of people that have had to go on disability because of the fatigue impact of their fibromyalgia, and they can have all sorts of other associated symptoms as listed here.

Okay, so now you are ready to look at the patient.  So far you’ve just talked to them and you may first look at them when they walk from the waiting room to the exam room if you happen to be there, if not you can watch them in the hallway. So it’s critical as I said to look at the posture, their gait, are they limping, is the reason that they have back pain because they have a leg length discrepancy related to their hip or knee replacement and that alters their gait and they sort of the movement of the lumbopelvic complex and that again requires a very different approach to treatment. Are there deformities distal from the area of pain that are impacting the biomechanics around the area that’s painful?

So scoliosis may be obvious. Here you can see this woman has rotational scoliosis so her scapula you can see her asymmetrical. If a patient is very kyphotic it’s not just that that causes mid-back pain, right, that can significantly contribute to lower back pain. These muscles are working extra hard to maintain upright posture, so often in patients with low back pain related to osteoporosis and kyphosis a 4-wheeled walker is all you need to control their pain. If they say oh, I don’t want to use that thing, give me some pain pills, my sort of response is well, you know, our goal is to you know help, not harm using the safest treatments possible. And so I’ve actually – I had a patient that, that he was so prideful he refused to use a 4-wheeled walker and wanted me to push his morphine and I told him that he was going to have to you know get, get care elsewhere because the risk associated with that decision was prohibitively high in my estimation.

So now you are ready to touch the patient.  Sometimes if you don’t see the scoliosis it’s easier to feel it.  So you take these two fingers and gently run it down on either side of the spine, or you can have the patient bend forward and look at the height of their paraspinal musculature.  Very important to look at leg length discrepancy, so your eyes are level with the iliac crest, you are kneeling down, you put your hands on top of the iliac crest and you see where your thumbs line up.  If there is leg length discrepancy does that mean that the patient needs a shoe insert?   Nope.  If somebody has had leg length discrepancy their whole life, for example, and they’ve learned to biomechanically compensate for it, if you give them even a very, very tiny shoe lift that can actually make them worse.  If on the other hand somebody has an acute leg length discrepancy, like after a fracture repair or after a joint replacement, that’s a situation where you know you want to refer to the physical therapist and have them assess whether a shoe lift actually helps their biomechanics. 

Even if the pain is axial, so cervical spine, thoracic spine, lumbar spine, it’s critical to examine the main movers, okay. So the main mover in the lower body is the hip, the main mover in the upper body is the shoulder.  So internal rotation of the hip, you have the patient lay supine, 90 degrees here and 90 degrees here and you move that foot toward you, it’s the direction, so the femoral head is moving internally, okay.  Critical when you examine the shoulder is that you sta – stabilize any potential for the scapula to move. So somebody can have severe glenohumeral disease and pretend like they are moving their humerus, right, and I was just moving my scapula along the thoracic cage. 

What about myofascial pain?  We are not taught anything about this in our training, so I know I’ve – for those of you that have attended the conference before I always sort of make a point to talk about this, and it’s really, really, really critical. So what is myofascial pain?  It’s pain in an irritated muscle that can be irritated from a whole bunch of reasons, but the way, the only way to diagnose this is by putting your hands on the patient. So a taught band, so instead of the muscles feeling nice and supple it feels like guitar strings, okay. And the so-called trigger point, which is a hyperirritable spot that sometimes can feel like a nodule, and when you press that trigger point that may reproduce the pain.

So myofascial pain can occur virtually anywhere in the body.  If you think about areas of the body that are not covered by muscles, right, it’s the cartilage of the nose and the cartilage of the ear, but otherwise everything is covered by muscle.  And even though trigger points – oops – can – are localized, so that for example this is the piriformis trigger point, the pain may be relatively widespread, okay. So the patient says I don’t know, generally I hurt kind of over here.  You may be looking for a very localized area of hyperirritability.

For example, this is a person that has cervicogenic headaches, okay. So the pain is coming from a very localized trigger point at the upper border of the trapezius, but actually they can – patients can feel pain in their jaw, over their eye, right. And to treat these patients you have to treat locally.  I had a colleague who recently had a nursing home patient that was actually bedbound because of horrific headaches and nausea and she wasn’t eating, she was losing weight. She said what do I do? And I said well, you know, is she tender over her trapezius?  Well, yes.  And so we put her on very low dose gabapentin to sort of calm down the hyperirritability of the nerve roots and physical therapy, and a month later she ran into the psychiatrist, said the patient was 100% better, up and around, back to their baseline personality, eating and interacting normally.  So it can be very, very gratifying to see a fantastic response with such a modest and safe intervention.  Sometimes when there is muscle irritability they can – there can be nerve entrapment with that. And so in the case of the piriformis, the sciatic nerve which runs through, it can entrapped and actually cause frank sciatica.  But what we do is we treat the muscle. 

How do we do the exam?  So just some pointers, everybody should be relaxed, okay. When the pain is unilateral make sure that you palpate the nonpainful side first, okay. There may be taught bands and trigger points on the nonpainful side too because that contralateral muscle is compensating for the pain that the patient is reporting.  You want to palpate from superficial to deep.  If a patient has a very irritated muscle, you want to make sure that you palpate gently first because if it’s red hot just very gentle palpation can, can actually cause pain.  And the other thing to point out is that when a patient has myofascial abdominal wall pain the abdominal wall musculature isn’t that thick, right. So if you palpate too deeply you are going to palpate right through that abnormal myofascial pathology in the abdominal wall. 

You want to palpate firmly.  You know trainees come and say oh, I don’t want to hurt the patient. Well, that’s how you make the diagnosis, right, you are trying to find out what it is that’s painful. And you want to palpate across the muscle fiber. So for example this is the tensor fasciae latae with its typical trigger point, and the typical radiating pain pattern. So this is sometimes referred to as pseudotrochanteric bursitis.   But so you want to palpate across that muscle fiber, you want to sort of as I say pluck the guitar strings. And this is a nice book, I think it costs about 20 bucks, it goes through all the major muscle groups, where the trigger points are, what the radiating pain patterns are, what typically activities precipitate what kind of stretching exercises people can do to alleviate it. But the main thing I like about the book is this subtitle. So the practice of informed touch, the only way for you to feel confident in your diagnostic tool, which is your hands, is to teach yourself what normal and abnormal muscles feel like, right.  Okay.

Other diagnostics like x-rays and blood work, why don’t we use them? Well, there’s a very high prevalence of incidental pathology, both and x-ray, an MRI, 50% of people with hip arthritis on x-ray have no pain.  You have to start with your history and physical, it’s critical.  Otherwise, patients, you are going to be sending people for unnecessary tests. And you are going to make patients worry.  How many times have I heard a patient come in and say, doctor, will you look at my MRI?  They said I have bulging disks?  I say well, I want to talk to you first, and I spend time educating them about these very data that a lot of people like in your age group without pain have these very same things. 

When do we do these other tests?  If there are red flags, right.  And if your history or physical specifically indicates that there may be a problem, not for screening.  So outside of your book you should have a handout that’s actually a book chapter for a book that hopefully will come out within the next 6 to 12 months.  I’m not going to go over all the medication doses that there’s nice tables and algorithms in that handout, so I refer you to that handout for specific dosing of medications for nociceptive neuropathic pain and for fibromyalgia.

And so for myofascial pain I’ll just summarize what – how we approach myofascial pain, the main thing is to decrease people’s injury pool so that we bring them into a pain free zone rather than a painful zone.  So if a patient has you know depression and anxiety and a leg length discrepancy and hip arthritis and degenerative disease of the spine they may be living here, and it may take very little else to push them over into the pain zone.  Pathology does not indicate pain, except when you cross a critical threshold.  Don’t use Occam’s razor to evaluate people as I’m sure Dr. Reznick has told you.  Multiple factors contribute to any one symptom in older adults, and the good side is there’s lots that we can do to help people.  So we use the rules of multiplicity, multiple physical contributors to one constellation of symptoms, multiple contributors beyond pain to disability and therefore multiple interventions to improve quality of life.   So we don’t want to use Occam’s razor for treatment either except when we think about systemic medications, then we want to use Occam’s razor, right. So the law of parsimony, if somebody is depressed and he has fibromyalgia and he has peripheral neuropathy, maybe you know duloxetine is a good choice so to try to kill many birds with one stone.

And general you want to use a stepped care approach to treatment, and this is also in that extra handout.  At the base always is education, education, education, education, right.  People are scared about why they have pain, they need to be taught what’s going on in their body, how to manage flairs, how to pace their activities.  If somebody hasn’t responded to physical therapy it doesn’t mean that they can’t respond, it may mean that the therapist did the wrong thing.  Find out what the treatment approach was and what the response was, and then again just to reinforce with assistive devices, they are not just for mobility and stability as in this woman, they are for pain management.  Although we are worried about opioids because of all these side effects, know that pain in and of itself can cause the same deleterious effects in patients.

For myofascial pain treatment we can’t just send a patient to a pain specialist and get a trigger point injection, okay. We have to find out what it is that’s making that muscle dysfunctional and try to attach the so-called perpetuating factors, okay, not just treating the myofascial dysfunction.

This so-called local twitch response, I mean I was thinking maybe we should, you know at one of these annual conferences we should have kind of a practicum on diagnosis and actual treatment of myofascial pain, learn what the local twitch response is and how easy it is to treat some of these conditions, especially in the upper body. People can get immediate relief of symptoms and it makes you feel really good. And then also the physical therapy for gentle stretching and strengthening, clonazepam has been shown to help but we are worried of course about clonazepam in our frail, older, dysmobile patients.

With neuropathic myofascial pain so when there is axial spondylosis that irritates nerve roots, which not necessarily causes radiculopathy, just irritation that decreases neurotrophic factors, causes muscle shortening that may or may not be painful when there is pain, this isn’t – this condition is described in the literature but the treatment other than sort of injections is not. But what I’ve tried as I mentioned in my nursing home patient that had debilitating headaches and pain, low dose gabapentin, and this one was just put on 100 milligrams twice a day, that’s it. Often times I start with 100, increase.  You often don’t have to go beyond 300 milligrams twice a day, occasionally 600 milligrams once a day, but people can be extremely responsive to this.

So when you – then so you’ve implemented treatment, and now you see the patient back; well you go right back to your vital signs, right, to figure out the beneficial as well as the deleterious effects of your treatment.  Same things that you asked before.  Again, make sure you get input from that spouse when possible.  So the main thing – this is all a balancing act, right.  There is no quick fixes for these patients, that’s probably the most important message.  You – it’s constantly evaluating and reevaluating and balancing the effects of drugs versus the effects of the pain itself. 

So in summary, older adults with chronic pain are not simply a chronologically older version of younger pain patients.  First, they are an older adult, second they are a pain patient.  Occam’s razor?  No.  Rules of multiplicity?  Yes.  There’s lots that we can – there’s lots of pathology, there’s lots of contributors so there’s lots that we can do to help these people. Thank you for your attention.