Editor's Message  |   November 2004
New Advances in the Treatment of Patients With Pain
Author Notes
  • Dr Rubin is a member of the speakers bureau of Merck & Co and Pfizer Inc. He has received research support from Merck & Co, Pfizer Inc, and Novartis. 
  • Correspondence to Bernard R. Rubin, DO, Chief of the Division of Rheumatology, Department of Medicine, University of North Texas Health Science Center at Fort Worth—Texas College of Osteopathic Medicine, 855 Montgomery St, Floor 4, Fort Worth, TX 76107-2553. E-mail: 
Article Information
Pain Management/Palliative Care
Editor's Message   |   November 2004
New Advances in the Treatment of Patients With Pain
The Journal of the American Osteopathic Association, November 2004, Vol. 104, 1S. doi:
The Journal of the American Osteopathic Association, November 2004, Vol. 104, 1S. doi:
Successful pain management challenges physicians on a daily basis. Certainly, dealing with patients with osteoarthritis, rheumatoid arthritis, low back pain, and other even more common mechanical, nonarthritic pain syndromes challenges primary care physicians to tailor treatment plans that incorporate optimal pharmacologic and nonpharmacologic modes of therapy. Most important, physicians must avoid undertreating or inadequately treating patients with pain syndromes. 
The series of articles included in this supplement carefully review several key topics relevant to the management of pain syndromes in 2004. 
Nicholas A. DeAngelo, DO, and Vitaly Gordin, MD, provide an excellent overview of the treatment of patients with arthritis-related pain, noting that pain may certainly be the primary reason for a patient to seek medical attention. They divide the treatment into pharmacologic and nonpharmacologic modalities. The ability to plan and then achieve a treatment plan that will restore the ability of a patient to perform activities of daily living is a priority. The strategies used in individuals with arthritic diseases may incorporate both nonpharmacologic and pharmacologic modes of treatment. Many of these pain management strategies are used in addition to the usual medical therapy for the arthritic condition. DeAngelo and Gordin describe modalities such as patient education, self-management programs, weight loss, and physical and occupational therapy among others. They also review various medications used in the treatment of patients with arthritic pain, citing examples of when each modality may be useful. 
The articles by Scott A. Nadler, DO, Raymond M. Pertusi, DO, and John C. Licciardone, DO, describe specific areas in more detail. For example, Dr Nadler's excellent review of nonpharmacologic management of pain details the use of bed rest and bracing, noting that prolonged bed rest is of little value, and also without much evidence to document its effectiveness. He therefore recommends minimal bed rest and a resumption of activities (perhaps with some modification) as soon as possible. He also finds fault with bracing of either the cervical or lumbar spine as a treatment modality for patients with persistent pain syndromes involving these regions. In his review of nonpharmacologic treatment of pain, Nadler discusses traction, electrical stimulation, ultrasound, superficial heat, and cryotherapy. Finally, he offers a detailed rationale for the use of exercise, starting with correction of posture.1 He then discusses passive and active exercises and points to the success that comprehensive pain management programs have had in patients with low back syndromes by focusing on exercises that can translate into an ongoing home program. 
Nadler's brief discussion of manipulative treatment is enhanced by Licciardone's excellent research-based discussion of osteopathic manipulative treatment (OMT) in the management of low back pain. In contrasting OMT to treatment modalities offered by allopathic physicians, Licciardone correctly notes that OMT can be integrated into the usual healthcare services provided by osteopathic physicians. He notes that physicians who administer OMT may provide more cost-effective care, particularly with regard to low back pain.2 He cites three randomized controlled trials of OMT used in addition to standard medical therapy in the treatment of patients with low back pain. Licciardone makes the case that future trials must look at the unique role of OMT in combination with standard modalities for the management of low back pain (and by extension, other painful conditions, as well) rather than as a stand-alone treatment method—an interesting and somewhat controversial notion. 
Last, Pertusi offers a detailed review of nonsteroidal anti-inflammatory drugs (NSAIDs) and selective cyclooxygenase inhibitors (coxibs) in the management of painful conditions. He reviews acute and chronic pain and highlights the mechanism by which prostaglandins enhance pain perception. Pertusi reviews published data in preoperative and perioperative settings using coxibs, and he briefly reviews studies of newer coxibs (lumiracoxib, etoricoxib, paracoxib) that have not yet become available in the United States. He concludes that coxibs may clearly have a role in the management of surgical pain and other acute pain syndromes where traditional NSAIDs are either contraindicated or ineffective. 
In summary, this series of articles provides an excellent discussion of pain management that is practical, relevant, and applicable to primary care practice. We hope that readers will find these articles stimulating to read and useful in everyday practice. 
 This continuing medical education publication supported by an unrestricted educational grant from Merck & Co
 Editor's Note
 Production of this supplement to the JAOA was under way 6 months before Merck & Co voluntarily withdrew rofecoxib (Vioxx) from the market because of increased cardiovascular events associated with the medication's long-term use.
Black KM, McClure P, Polansky M. The influence of different sitting positions on cervical and lumbar posture. Spine. 1996;21(9):65-70.
Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans. A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. N Engl J Med. 1999;341:1426-1431.