What is the recommended treatment for a 73-year-old female with functional abdominal pain and musculoskeletal neck pain?

Management of Functional Abdominal Pain and Musculoskeletal Neck Pain in a 73-Year-Old Female

Acetaminophen should be considered as first-line pharmacotherapy for both the functional abdominal pain and musculoskeletal neck pain in this 73-year-old female, with a starting dose of 500-650 mg every 6 hours, not exceeding 3g/day. 1, 2

Pharmacological Management

First-Line Therapy

• Acetaminophen:
  • Dosage: 500-650 mg every 6 hours
  • Maximum daily dose: 3g/day (especially important in elderly patients)
  • Rationale: Preferred safety profile with no effects on platelet function, GI tract, or kidneys 1, 2
  • Monitoring: Liver function tests periodically

Second-Line Options for Musculoskeletal Neck Pain

If acetaminophen provides inadequate relief for neck pain:

1. Topical analgesics:

   • Lidocaine 5% patch applied to painful neck area
   • Can be used for up to 12 hours per day
   • Minimal systemic absorption with excellent safety profile 1

2. Low-dose tramadol (if pain remains uncontrolled):

   • Starting dose: 12.5-25 mg every 4-6 hours
   • Lower risk of GI and cardiovascular complications than NSAIDs 2
   • Monitor for confusion, constipation, and serotonin syndrome

Second-Line Options for Functional Abdominal Pain

If acetaminophen provides inadequate relief for abdominal pain:

1. Low-dose tricyclic antidepressants:

   • Amitriptyline starting at 10 mg at bedtime
   • Can be gradually increased to 25-50 mg if tolerated
   • Effective for visceral hypersensitivity in functional abdominal pain 3
   • Monitor for anticholinergic side effects (dry mouth, constipation, urinary retention)

2. Gabapentinoids (if TCAs contraindicated or ineffective):

   • Gabapentin starting at 100 mg at bedtime
   • Can be gradually increased to 300 mg daily in divided doses
   • Particularly effective for neuropathic pain components 2, 3
   • Requires dose adjustment in renal impairment

Non-Pharmacological Management

For Musculoskeletal Neck Pain

1. Structured exercise program:

   • Perform neck strengthening exercises 5-7 repetitions, 3-5 times daily 1, 2
   • Include:
     • Quad sets (squeezing muscles on top of thigh)
     • Short-arc quad sets (with pillow under knee)
     • Gluteal squeezes

2. Heat therapy:

   • Apply warm compress to neck for 15-20 minutes, 2-3 times daily
   • Particularly effective for muscle spasms and stiffness 2

3. Pool exercises in warm water (86°F) if available:

   • Reduces joint loading
   • Enhances pain-free motion
   • Provides resistance for strengthening 1, 2

For Functional Abdominal Pain

1. Cognitive behavioral therapy:

   • Focuses on pain coping strategies
   • Addresses catastrophizing thoughts
   • Helps manage stress that may exacerbate functional pain 3, 4

2. Relaxation techniques:

   • Diaphragmatic breathing
   • Progressive muscle relaxation
   • Guided imagery

Important Considerations and Cautions

1. Avoid NSAIDs in this elderly patient:

   • High risk of GI bleeding, cardiovascular events, and renal dysfunction
   • If absolutely necessary, use lowest effective dose for shortest duration with PPI protection 1, 2

2. Avoid benzodiazepines:

   • Risk of sedation, cognitive impairment, and falls
   • Can worsen functional pain over time 1

3. Limit opioid use:

   • High risk of adverse effects in elderly
   • May worsen functional abdominal pain over time
   • Consider only for severe, refractory pain and for shortest duration possible 1

4. Regular reassessment:

   • Evaluate pain intensity and functional impact
   • Monitor for medication side effects
   • Adjust treatment plan as needed 2

By following this approach, focusing on acetaminophen as first-line therapy and incorporating appropriate non-pharmacological strategies, both the functional abdominal pain and musculoskeletal neck pain can be effectively managed while minimizing risks in this elderly patient.