A 35-year-old woman comes to the clinic complaining of aching pain and stiffness over her entire body for the past 3 months. She also has easy fatigability, poor sleep, and frequent headaches. The patient has had difficulty performing her daily tasks and feels that her work performance as an accountant has worsened. She has used over-the-counter pain medications with no relief. On examination, she has tenderness to gentle palpation over the muscles of her neck, shoulders, and back. Vital signs are within normal limits. Laboratory results show normal electrolytes, complete blood count, erythrocyte sedimentation rate, and thyroid function tests. Which of the following is the best initial therapy to improve this patient's symptoms?

Question

A 35-year-old woman comes to the clinic complaining of aching pain and stiffness over her entire body for the past 3 months.  She also has easy fatigability, poor sleep, and frequent headaches.  The patient has had difficulty performing her daily tasks and feels that her work performance as an accountant has worsened.  She has used over-the-counter pain medications with no relief.  On examination, she has tenderness to gentle palpation over the muscles of her neck, shoulders, and back.  Vital signs are within normal limits.  Laboratory results show normal electrolytes, complete blood count, erythrocyte sedimentation rate, and thyroid function tests.  Which of the following is the best initial therapy to improve this patient's symptoms?

Quizplus · Accepted Answer

This patient's presentation is consistent with likely fibromyalgia (FM). FM presents most commonly in young to middle-aged women with widespread pain, fatigue, and cognitive/mood disturbances. Patients tend to have a fairly normal physical examination except for point muscle tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter. FM has no specific diagnostic laboratory findings. Revised 2010 American College of Rheumatology criteria suggest using the widespread pain index and symptom severity scale, rather than trigger points, for diagnosis. The index and scale better emphasize cognitive problems, fatigue, and severity of somatic symptoms. widespread pain index and symptom severity scale Initial management of FM involves a multidisciplinary approach including patient education about FM, regular aerobic exercise, and good sleep hygiene. Education requires validating that FM is a benign condition with a favorable prognosis. Although patients may complain of increased short-term pain during or after activity, a regular exercise program (eg, aerobic conditioning, strength training, stretching) improves long-term pain. Water exercises also can greatly reduce the pain. Medications (eg, tricyclic antidepressants) are reserved for patients failing initial measures. There is limited evidence for other approaches, including trigger-point injections, analgesics, and alternative therapy (eg, tai chi, yoga). (Choices B, D, and E) High-dose prednisone is effective for giant cell arteritis; low-dose prednisone is used for polymyalgia rheumatica. Methotrexate is effective for inflammatory conditions such as rheumatoid arthritis. All of these conditions usually have an elevated erythrocyte sedimentation rate. However, FM is not an inflammatory condition (normal erythrocyte sedimentation rate) and does not respond significantly to methotrexate or corticosteroids. (Choice C) Hydroxychloroquine is effective for treating patients with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA). However, it is not effective for FM. This patient does not have other findings to suggest SLE or RA (eg, malar rash, joint abnormalities). (Choice F) Acetaminophen and tramadol (alone or combined) are effective in patients requiring additional treatment for acute pain or failing to respond to first line drug therapies. However, there is insufficient evidence on the effectiveness of opioids such as oxycodone. Educational objective: Fibromyalgia most commonly presents in young to middle-aged women with widespread pain, fatigue, and cognitive/mood disturbances. Patients have point muscle tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter. Exercise is the foundation of management, with medications (eg, duloxetine, tricyclic antidepressants) reserved for patients who fail initial measures. References: The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. (http://www.ncbi.nlm.nih.gov/pubmed/20461783) Exercise for fibromyalgia: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/18464301)

A 35-Year-Old Woman Comes to the Clinic Complaining of Aching