Journal of pain

Roy S c ot t

20 March 2012 • Nursing Management www.nursingmanagement.com

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[Chronic disease] series 1.9
CONTACT HOURS

Pain and
obesity Obesity-related pain conditions can limit quality of life.
Consider the use of a multimodal pain management
regimen to increase pain relief and positive outcomes
in obese patients.
By Yvonne D’Arcy, MS, CRNP, CNS

O b
besity is a national health issue that
affects every aspect of healthcare.
a
Comorbidities, such as diabetes,
C
hypertension, and dyslipidemia,
h
contribute to the complexity of care
required for effective treatment of
Healthcare practitioners need to
provide obese patients with a venue
to discuss pain management issues.
Information on obesity’s impact on
pain and weight reduction strategies,
coupled with pain management
obese patients and are commonly techniques, will help patients improve
addressed by healthcare practitioners. their health and pain relief.
However, pain-related comorbidi-
ties, such as diabetic neuropathy or Prevalence of obesity
low back pain related to an obese The prevalence of obesity is a global
body structure, appear to receive issue that’s increasing dramatically.
less attention. This may be related The World Health Organization
to the need to address the signifi- (WHO) reports that more than 1
cant issues of disease management, billion people worldwide are over-
such as glycemic control and BP weight; 300 million meet the criteria
management, in the short period for obesity.1 By 2030, if current pat-
of time that the primary care pro- terns persist, 58% of the world’s
vider has available for seeing each population is expected to be obese
patient. “Simple” pain issues may or overweight.2 The two main con-
be overlooked while discussing tributing factors to obesity identi-
more life-threatening health issues. fied at the WHO regional meetings

www.nursingmanagement.com Nursing Management • March 2012 21


[Chronic disease] series

were diet and lack of exercise. Obe- • Overweight is classified by a mediate insulin resistance and create
sity has serious consequences. In BMI of 25.0 to 29.9. a proinflammatory state that has
2002, the WHO identified the burden • Obese Class I is classified by a been associated with increased joint
of noncommunicable diseases, such BMI of 30.0 to 34.9. inflammation and osteoarthritis.4
as cardiovascular disease, diabetes, • Obese Class II is classified by a Increases in BMI can be directly
cancers, and obesity-related condi- BMI of 35 to 39.9. linked to a greater incidence of
tions, as accounting for 60% of global • Obese Class III—morbid obesity— pain-related conditions. Obesity
deaths and 47% of the global burden is classified by a BMI of over 40.3 has been cited as a contributor to
of these diseases.1 Using a BMI can help determine the development of low back pain
Given the serious health repercus- if the patient has an increased (possibly a result of increased load
sions of obesity, it appears inevita- potential for developing a comor- on spinal structures). Diabetes
ble that obesity-related pain has bid condition that will result in increases with the duration and
taken a back seat to the more serious pain. For example, the higher the degree of obesity, which can result
consequences of obesity. However, patient’s weight and the longer the in diabetic neuropathy in poorly
for the obese to become more active duration of obesity, the higher the controlled diabetes. There’s also
research indicating that obesity is
an exacerbating factor for migraine

[ ]
headaches.5

A multimodal pain management regimen
that combines medications and complementary
Women diagnosed with osteo-
arthritis have a BMI that’s 24%
higher than average.6 In a study of
677 patients who had a total knee
replacement and 547 patients who
techniques can help increase pain relief in had a total hip replacement with at
obese patients. least one MetS risk factor, findings
indicated the outcome of the sur-
geries was negatively affected by
metabolic abnormalities.4 The
two major factors that affected
and attain a higher quality of life, amounts of body fat causing negative outcomes were obesity
pain management is a key factor. increased insulin resistance, which and hypertension.4
Lifestyle changes alone may not can be a part of metabolic syn- Because of obesity, women may
reduce the pain of osteoarthritis or drome (MetS).3 MetS is a syndrome also suffer from low self-esteem
low back pain complicated by obe- that includes the conditions of that can lead to depression. Because
sity. Unfortunately, some healthcare hypertension, central adiposity, ele- depression may present comorbidly
providers see the obese patient as vated fasting blood glucose, and with chronic pain, these patients
someone who has created their dyslipidemia with high triglycer- have an increased risk factor for
own problem, one that weight loss ides and low high-density lipopro- both pain and depression.
would solve. The answer isn’t that tein cholesterol.3
simple. There are metabolic issues When insulin resistance is present Fibromyalgia
that need consideration when alongside MetS, negative effects on Obesity is a common comorbidity
assessing the full picture of obesity- the patient’s health are increased. of fibromyalgia.7,8 Studies indicate
related pain. MetS can cause higher rates of dia- that 32% to 50% of patients with
betes and cardiovascular disease, fibromyalgia are obese; an addi-
Factors for pain assessment especially in women. There’s also a tional 21% to 28% are overweight.9,10
One way to categorize obese positive correlation between MetS In the general population, fibromy-
patients is by using body mass and increased systemic inflammation, algia affects about 3% to 5% of the
index (BMI). Classifications are which is fed by adipose tissue.4 U.S. population.7,8 It affects more
as follows: Tumor necrosis factor, interleukin-6, women than men and is character-
• Normal weight is classified by a and C-reactive protein are all factors ized by chronic widespread pain
BMI of 18.5 to 24.9. secreted by adipose tissue that on both sides of the body with



hyperalgesia in at least 11 of 18 bral disks and indirect effects of ath- Even patients who were over-
specific points. In addition to the erosclerosis on decreasing blood weight but not morbidly obese had
widespread pain, patients may flow to the lumbar spine.3 a 2.2-increased risk factor for devel-
also experience sleep disturbances, Many practitioners feel that oping knee osteoarthritis when
chronic fatigue, functional disabil- weight loss is the solution to treat- compared with their normal weight
ity, mood disorder, “fibro fog” ing low back pain in these patients. counterparts.12 In the United King-
memory loss, headache, paresthesia, There are two important issues to dom, it’s estimated that 69% of
and irritable bowel disorder.7,8 consider. After low back pain is knee replacement surgeries in
In a study of 215 patients with already occurring, weight loss may middle-age women are attributed
fibromyalgia, 30% were overweight, not reverse the effect of mechanical to obesity.13
with an additional 47% recognized load bearing, and not all weight For the morbidly obese, knee
as obese. The obese patients reported loss strategies have the same result osteoarthritis presents a bigger
greater sensitivity to tender point on low back pain. In two studies of problem. If lifestyle changes and
palpation (especially in the lower morbidly obese patients who had increased exercise can’t produce
body), decreased physical strength bariatric surgery, there was a sig- weight loss or favorable outcomes,
and lower body flexibility, and shorter nificant decrease in low back pain total joint replacement is consid-
sleep duration with greater restless- after surgery.11 In a nonsurgical ered. If surgery is necessary, recon-
ness while sleeping.8 weight loss program, there was ditioning after surgery can be
Research hasn’t clearly defined little evidence that demonstrated complicated further by difficulty
the cause and effect relationship improvement in low back pain.11 with mobility.
between obesity and fibromyalgia. Multidisciplinary programs that
Animal studies suggest there’s a include exercise and weight loss, Pain management
link between greater levels of proin- as well as dietary and behavioral Treatment options for the obese
flammatory cytokines resulting in modification, have a better outcome patient with pain include medica-
central sensitization.8 The list of than treatment plans that aren’t as tions and nonpharmacologic modal-
mechanisms that might contribute comprehensive. ities, such as acupuncture or yoga.
to a link between fibromyalgia and It’s important to note that no When discussing options for con-
obesity include impaired physical matter which type of treatment is trolling pain, it’s important to
activity, cognitive and sleep distur- selected to reduce low back pain, inform patients that a combination
bances, psychiatric comorbidity and the ability of patients to adhere to of treatments is more likely to pro-
depression, dysfunction of the thy- the treatment requirements should duce optimum pain reduction.
roid gland, and impairment of the be considered to achieve the best Medications can be affected by
endogenous opioid system.7 The possible outcome for the patient. the ratio of adipose tissue to lean
only demonstrated outcome was In low back pain, weight loss may body tissue. In the obese patient,
that obesity contributes to the con- have a positive effect and help to there’s a higher ratio of adipose
tinued presence of fibromyalgia and relieve the pain. tissue when compared with lean
increases its severity. body tissue, which is thought to
Osteoarthritis interfere with the protein binding
Low back pain Symptomatic osteoarthritis is the of drugs, allowing an increased
Findings indicate that if a patient is presence of radiographic findings of concentration into the free plasma
obese at age 23, there’s a risk of low osteoarthritis in combination with concentration. Although obesity
back pain within 10 years. As obese symptoms attributable to osteoar- increases the total volume of both
patients get older, the probability of thritis.12 Magnetic resonance imag- lean and adipose tissue when com-
developing low back pain increases.3 ing findings include cartilage lesion, pared with nonobese patients of
There have also been associations osteophytes, bone marrow lesions, the same age, height, and sex, this
that show a BMI of over 30 puts synovitis, effusion, and subchondral difference requires individualized
patients at greater risk for low back bone attrition.12 The two major risk prescriptions for obese patients to
pain.11 Suspected mechanisms for factors for developing osteoarthritis ensure that medications are dosed
the increased occurrence of low are obesity and being female; knee appropriately.14
back pain in the obese patient are injury is also a predisposition to For most obese patients in pain,
mechanical stress on the interverte- developing knee osteoarthritis. opioids will be considered for pain



[Chronic disease] series

management. Some aren’t candidates General recommendations for tions and less research to support
for nonsteroidal anti-inflammatory pain management after surgery for use at this time.16
drugs due to impaired organ func- obese individuals include:15 The use of regional blocks with
tion, such as renal dysfunction, or • the use of multimodal analgesia local anesthetic for adjunct pain
comorbidities, such as diabetes or using regional and opioid sparing relief is recommended, as well as
the potential for gastric bleeding. techniques epidural pain management for sur-
Additional options for pain • avoidance of sedatives, especially gical pain. These techniques can
management in the obese patient when combined with opioids reduce the need for opioids and can
can include not only medication • noninvasive ventilation with have a positive effect on the risk of
management but also the use of supplemental oxygen respiratory depression. Obese
regional analgesia such as blocks • early mobilization and ambulation patients will need less local anes-
and physical therapy programs • elevating the head of the bed to thetic when administered as an epi-
geared to patients who need a less 30 degrees dural as compared with nonobese
strenuous approach. Referrals to • a low threshold for pulse oxime- patients. This can be correlated with
pain clinics, physical therapy pro- try, which should be continuous and the decreased cerebrospinal fluid
grams designed for the obese combined with end-tidal carbon volumes in obese individuals.14
patient, and physiatrists can help dioxide monitoring for added safety
Nonpharmacologic treatment
Less-invasive adjuvant pain relief

[ ]
modalities can also be considered.
In one study, aromatherapy with

R ecognizing the patient’s pain and working
with the patient to help minimize the effects of
lavender was shown to decrease
morphine dosage needed for pain
management in the postanesthesia
unit, although more research is
needed.15 Relaxation techniques
the pain can lead to a more positive outcome. such as music or relaxation tapes
can provide a way to avoid medica-
tions through distraction. Reiki or
therapeutic touch can also provide
relaxation. In the outpatient setting,
reduce pain and increase function- • arterial BP management patients can participate in pool
ality. If the obese patient needs a • placement in a nursing specialty exercise therapy to lessen the
surgical intervention, additional area, such as an ICU or step-down burden on joints.
concerns will need to be addressed. unit, with continuous, postoperative
Sedation and the maintenance of monitoring until oxygen saturation Rising to the challenge
a patent airway are always concerns is greater than 90% while asleep It can be a challenge to provide
when opioids are used for obese without supplemental oxygen. effective pain management for obese
patients, especially in the postoper- When obese patients use patient- patients; however, a multimodal
ative time period when anesthetic controlled analgesia, the use of con- pain management regimen that com-
agents have been used. However, tinuous infusion is contraindicated. bines medications and complemen-
reviews indicate that two factors, Opioid requirements aren’t related tary techniques can help increase
site of surgery (especially bariatric to body surface, age, gender, or pain relief. Recognizing that the
surgery) and coexisting sleep apnea, anesthetic regimen.15 Adding a patient may need to be in an area
have been cited as contributory to an nonopioid medication can decrease with continuous monitoring will
increased risk of pulmonary com- pain and provide an opioid-sparing help lessen the potential for adverse
plications in obese patients.15 Most effect.15,16 Other medications such events in postoperative patients.
obese patients can tolerate opioids in as clonidine, ketamine, and dexme- Always remember that most obese
the usual doses, although they require detomidine could be useful adju- patients are very familiar with the
close monitoring, especially for seda- vants for postoperative pain relief, healthcare system and may have
tion and respiratory depression. but have significant contraindica- had less than positive experiences.



Recognizing the patient’s pain and osteoarthritis of the knee in women: a 12. Neogi T, Zhang Y. Osteoarthritis prevention.
working with the patient to help 4-year follow-up study. Osteoarthritis Curr Opin Rheumatol. 2011;23(2):185-191.
Cartilage. 2008;16(3):367-372. Epub 13. Liu B, Balkwill A, Banks E, Cooper C, Green
minimize the effects of the pain can 2007 Sep 20. J, Beral V. Relationship of height, weight,
lead to a more positive outcome. NM 7. Ursini F, Naty S, Grembiale RD. Fibromyalgia and body mass index to the risk of hip and
and obesity: the hidden link. Rheumatol knee replacements in middle-aged women.
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http://www.who.int/dietphysicalactivity. Relationship between fibromyalgia and considerations in the obese. Best Pract
2. Kelly T, Yang W, Chen CS, Reynolds K, He obesity in pain, function, mood, and sleep. Res Clin Anaesthesiol. 2011;25(1):27-36.
J. Global burden of obesity in 2005 and J Pain. 2010;11(12):1329-1337. Epub 15. Schug SA, Raymann A. Postoperative pain
projections to 2030. Int J Obes (Lond). 2010 Jun 9. management in an obese patient. Best Pract
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3. Kulie T, Slattengren A, Redmer J, Counts H, Shefer A, Buskila D. A cross-sectional study 16. D’Arcy Y. A Compact Clinical Guide to Acute
Eglash A, Schrager S. Obesity and women’s of the relationship between body mass Pain. New York, NY: Springer Publications;
health: an evidence based review. J Am index and clinical characteristics, tender- 2011.
Board Fam Med. 2011;24(1):75-85. ness measures, quality of life, and physical
4. Gandhi R, Razak F, Davey JR, Mahomed functioning in fibromyalgia patients. Clin Yvonne D’Arcy is a pain management and
NN. Metabolic syndrome and the functional Rheumatol. 2008;27(12):1543-1547. palliative care nurse practitioner at Suburban
outcomes of hip and knee arthroplasty. Epub 2008 Jul 12. Hospital-Johns Hopkins Medicine in Bethesda,
J Rheumatol. 2010;37(9):1917-1922. 10. Okifuji A, Bradshaw DH, Olsen C. Evaluating Md.
Epub 2010 Jul 15. obesity in fibromyalgia: neuroendocrine The author has disclosed that she’s a consultant
5. Bond DS, Vithiananthan S, Nash JM, biomarkers, symptoms, and functions. Clin for Ortho-McNeil, Pfizer, and Endo. She’s also on
Thomas JG, Wing RR. Improvement of Rheumatol. 2009;28(4):475-478. Epub the speaker’s bureau for Endo and Pfizer.
migraine headaches in severely obese 2009 Jan 27.
patients after bariatric surgery. Neurology. 11. Roffey D, Ashdown L, Dornan H, et al. Pilot This article is adapted from “Practical consider-
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6. Sowers MF, Yosef M, Jamadar D, Jacobson J, supervised, nonsurgical weight loss program The Nurse Practitioner Journal, December 2011.
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composition and radiographically defined adults. Spine J. 2011;11(3):197-204. DOI-10.1097/01.NUMA.0000411905.59061.5e

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