Case of the Month #17: Chronic Widespread Pain by Dr Kerry Bosworth

Published: 01/07/2022


For all types of chronic pain, NICE recommends a person-centred assessment with shared decision-making to develop an individualised care and support plan. Conventional disease-modifying anti-rheumatic drug (cDMARD) monotherapy (methotrexate, leflunomide, sulfasalazine or hydroxychloroquine) should be used first-line with the aim of achieving remission or low disease activity. Biological (including TNF-alpha inhibitors and IL-6 inhibitors) and targeted synthetic DMARDs (JAK inhibitors) may be required and short courses of glucocorticoids can be used for managing flares. This management will usually be undertaken by the patient’s rheumatologist and GP.

NSAIDs (traditional or cox II selective inhibitors) can be considered at the lowest effective dose for the shortest possible time with a PPI. There is little difference in the anti-inflammatory activity of different NSAIDs, but an individual’s response and tolerance can vary considerably so patients who do not respond to one may respond to another. TENS and wax baths can also be considered.
Patients should have access to a multidisciplinary team including specialist physiotherapists, occupational therapists and podiatrists. Psychological interventions such as relaxation, stress management and cognitive coping skills should be offered. Patients can be encouraged to adopt a Mediterranean diet.

Intra-articular steroid injections may be considered. Research has suggested intra-articular pulsed radiofrequency stimulation may have a role in delaying cartilage destruction. 

An early surgical opinion should be sought if there is persistent pain due to joint damage or other identifiable soft issue cause, worsening joint function, progressive deformity or persistent localised synovitis that does not respond to optimal non-surgical management.

An urgent MRI and surgical opinion should be requested if there are any signs/symptoms suggesting cervical myelopathy (paraesthesia, weakness, unsteadiness, reduced power, extensor plantar reflexes).