Case: Managing musculoskeletal pain in an elderly woman
26 May 2015 | Print
Dr Chris Edwards is consultant rheumatologist, University Hospital Southampton, UK.
Chronic pain can occur due to a number of musculoskeletal conditions. These conditions are common, with over nine million people in the UK affected by arthritis alone. An estimated 40% of adults experience an episode of spinal pain arising from the back or neck in any one year. The establishment of long-term pain in these individuals is often complicated by associated depression.
A 76-year-old woman presented to her rheumatologist. She complained of severe pain in multiple areas, including her lower back, shoulders, neck and knees. She described the pain as very severe and explained that it was aggravated by physical activity. There was some early morning stiffness but this did not last longer than 10-15 minutes. In the past, she had had pain in these areas and was diagnosed with osteoarthritis on the basis of X-ray findings. Both hips were replaced several years before. She had a past history of indigestion, as well as AF that had started following an inferior MI. Recent blood tests showed a mild iron-deficiency anemia, for which no cause could be found and reduced creatinine clearance. The ESR was normal.
The low back pain made it difficult to perform the examination because lying down was very uncomfortable. The examination revealed:
- Reduced movement of the shoulders and knees, associated with severe pain
- Severe crepitus and grinding on active movement of the knees, consistent with bone-on-bone contact between the femur and tibia.
Repeat X-rays of the knees, shoulders and lumbar spine confirmed osteoarthritic changes. In the knees there was clear bone-on-bone contact, as suspected from the examination.
The most severe pain originated from the knees. Ideally, this would have been resolved by bilateral knee arthroplasty. However, it was felt that the surgical risk from the other medical problems was too great and the patient was also against this. The rheumatologist felt that NSAIDs should be avoided due to the cardiac history, anemia and poor renal function. Initially, a combination of paracetamol 500 mg and codeine 30 mg was given three times per day. The rheumatologist also performed local injections of corticosteroid and lidocaine into both knee joints.
The patient returned one month later. The analgesics had produced some benefit but the pain was still intense. As a result, the patient’s GP had doubled the dose to paracetamol 1 g and codeine 60 mg three times per day. Unfortunately, this had resulted in constipation. The patient had also suffered with some indigestion and nausea. The steroid joint injections had been very effective for a few weeks but had now worn off. A further examination confirmed that the pain was coming from the same joints as before.
In view of the widespread pain, the GP had rechecked the ESR and sent a protein electrophoresis test to rule out polymyalgia rheumatica and myeloma. Both tests were normal. As the pain was severe and widespread, the GP also asked about symptoms of depression, but none appeared to be present.
The rheumatologist was concerned about the possible risks associated with the analgesic treatment options. The decision was to add a small dose of meloxicam (7.5 mg per day) to the paracetamol and codeine. Physiotherapy was also arranged to attempt to increase mobility and muscle strength around the painful joints. The physiotherapy resulted in a little benefit, as did a course of acupuncture performed by the physiotherapist.
One month later, the rheumatologist was called by the GP because the patient’s creatinine had increased significantly. The GP had therefore stopped the meloxicam and the renal function was now returning to the pre-treatment level. The patient was still complaining of pain from multiple joints. A further joint injection to the right knee produced only short-term benefit once again. The GP and rheumatologist agreed to discontinue codeine and to start tramadol 50 mg three times per day. This produced some benefit but the patient was troubled with breakthrough pain a few hours before the next dose of tramadol was due. Paracetamol 1 g four times per day was continued.
As a result of inadequate pain control, the rheumatologist suggested an opioid patch. The patch was continued with regular paracetamol. The GP was concerned that opioids might lead to confusion and falls at night and monitored for this, however, this did not occur. The patient continued to have some pain but found the new regimen provided an acceptable level of control. As a result, the patient was able to increase physical activity a little, which appeared to increase muscle tone around the affected joints.
- 1. Arthritis Care. OA Nation. London, Arthritis Care, 2004.
- 2. Department of Health. Musculoskeletal Services Framework. A joint responsibility: doing it differently. London, Department of Health, 2006.
- 3. Brevik H, Collett B, et al. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 2006;10:287-333.
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