Case: Fibromyalgia and early osteoarthritis pain
With Dr Amina Gsel, Dr Chris Edwards and Dr Hermann Ribera. | 20 Apr 2015 | Print
Dr Amina Gsel is consultant rheumatologist, Bon Secours Hospital, Galway, Ireland; Dr Chris Edwards is consultant rheumatologist, University Hospital Southampton, UK; Dr Hermann Ribera is the director of the pain unit, Hospital Universitari Son Espases, Palma de Mallorca, Spain.
Fibromyalgia syndrome (FMS) is a clinically well-characterized, chronic, widespread pain condition associated with symptoms such as fatigue, sleep disturbance or cognitive dysfunction.[1,2] This report describes the case of a 70-year-old woman with a long history of moderate to severe pain in multiple locations and radiographic findings of cervical spondylosis and degenerative disc disease.
A 70-year-old female presented to the rheumatology service with a longstanding history of moderate to severe pain in multiple areas, including:
- Back of the neck
- Upper arms
- Anterior chest wall
- Mid and lower back
She described the pain as being at times quite severe, worse at the end of the day, aggravated by physical activity and associated with some early morning stiffness lasting 5-10 minutes on most days
She was diagnosed with cervical spondylosis and early osteoarthritis on the basis of X-ray findings. She had an MRI of her cervical spine which revealed cervical spondylosis and degenerative disc disease at C5-C6 with nerve root entrapment where cervical discectomy with fusion had been performed several years previously. She had a past history of asthma, peptic ulcer disease and recurrent UTIs. Her recent blood test showed normal FBC, CRP, U&E, LFT and TFT. Her chest X-ray was normal with normal ECG, as was X-ray of her shoulders, hips and knees. Whole-spine MRI showed previous cervical spine surgery with minor degenerative disc disease (dorsal and lumbosacral) with no evidence of nerve root entrapment.
The mid and lower back pain made it difficult to perform the examination because lying down was very uncomfortable; on examination she looked quite distressed with pain. There was tenderness over the mid and lower cervical spine with good range of movement, there was tenderness over the costochondral junction from the second to the sixth as well as mid dorsal and lumbosacral spine with good range of movement of all joints. There was tenderness over 18/18 tender points. The most severe pain originated from the neck, mid dorsal spines and anterior chest wall.
The rheumatologist believed this to be a case of fibromyalgia and mild degenerative disc disease, but felt that NSAIDs should be avoided due to the history of peptic ulcer disease. Initially a combination of regular paracetamol 1,000 mg three times daily was given with topical diclofenac. The rheumatologist also performed local injections of corticosteroids and lidocaine into the costochondral junction and the facet joints.
The patient returned three weeks later with no improvement of her symptoms. She described how the pain was quite intense and interfered with her daily tasks as well as her sleep. As a result her GP had prescribed codeine 60mg four times daily, which unfortunately resulted in some indigestion and nausea. The steroid injection had been very effective for a few days but it eventually wore off. Further examination confirmed that the pain was coming from the same tender points as before and the patient again looked quite anxious and distressed.
In view of worsening of her symptoms the GP performed an ESR and CRP and requested protein electrophoresis to rule out polymyalgia rheumatica and myeloma; both tests where normal.
The rheumatologist was concerned about the possible risks associated with analgesics; so the patient was admitted for a trial of methylprednisolone infusion 250 mg daily for three days, diclofenac sodium 75 mg twice a day IM for two days and lidocaine patches 5% 12 hours a day. Her vitamin D level was normal. Physiotherapy was also arranged to attempt to increase muscle strength around the painful joints but resulted in very little benefit, as did a course of acupuncture.
Two weeks later the GP telephoned the rheumatologist because the patient described worsening of the symptoms, and a further series of tender point injections was performed with short-term benefit once again. The GP and rheumatologist agreed to discontinue her codeine and prescribed tramadol 50mg four times daily, this produced some benefit but the patient was troubled with breakthrough pain a few hours before the next dose was due. Paracetamol 1,000 mg three times daily was continued as well as the lidocaine patch.
As a result of the breakthrough pain the rheumatologist suggested an opioid patch. The patient continued to have some pain but found the new regimen provided an acceptable level of control of her symptoms, especially after the strength of the opioid patch was increased. As a result the patient was able to increase her level of physical activity and improve her muscle strength, and was able to perform her daily activity with less distress. She also reported a marked improvement in her
- 1. Wolfe F, Clauw DJ, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res 2010;62:600-610.
- 2. Wolfe F, Clauw DJ, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol 2011;38:1113-1122.
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