What is the best course of action for a patient with full body pain, considering their past medical history, demographics, and current symptoms?

Management of Full Body Pain

Begin with a comprehensive biopsychosocial assessment using a 0-10 numerical rating scale for pain intensity, followed by immediate investigation for underlying pathology before escalating analgesics, as full body pain requires systematic evaluation to distinguish between new disease processes, neuropathic mechanisms, or widespread musculoskeletal conditions. 1

Initial Assessment Framework

Pain Quantification and Characterization

• Assess current pain, worst pain in past 24 hours, and usual pain using the 0-10 numerical rating scale 1
• Evaluate pain characteristics including severity, type, spread, quality, location, and radiation pattern to determine if this represents neuropathic versus nociceptive pain 1
• Assess temporal factors: onset (acute versus gradual), duration, course, and specific factors that exacerbate or relieve symptoms 1
• Critical: Full body pain warrants immediate investigation for systemic causes including malignancy, inflammatory conditions, fibromyalgia, or metabolic disorders before attributing symptoms to benign musculoskeletal causes 2

Functional and Psychosocial Evaluation

• Document specific activities the patient cannot perform rather than focusing solely on pain scores, as functionality is a better endpoint than numerical ratings 3, 1
• Evaluate sleep disturbance patterns, as pain-related insomnia significantly impacts quality of life and requires concurrent management 1, 4
• Assess for catastrophizing cognitions, anxiety about pain, and patient's understanding of their condition 1
• Screen for depression, as widespread pain frequently coexists with mood disorders 1

Diagnostic Workup for Full Body Pain

Rule Out Serious Pathology First

• Severe uncontrolled pain is a medical emergency and should be responded to promptly 3
• Obtain basic laboratory studies: complete blood count, erythrocyte sedimentation rate, C-reactive protein, thyroid function, vitamin D, and metabolic panel to screen for inflammatory, endocrine, or metabolic causes 1
• Consider malignancy screening appropriate for age and risk factors, as cancer can present with diffuse pain 3
• Evaluate for fibromyalgia if pain is widespread, chronic (>3 months), and associated with fatigue, sleep disturbance, and cognitive symptoms 3

Multimodal Treatment Algorithm

First-Line Non-Pharmacological Interventions

Initiate these interventions immediately while diagnostic workup proceeds:

• Physical activity and exercise programs are strongly recommended with uniformly positive evidence for pain reduction across multiple conditions 3, 1

  • Prescribe aerobic exercise (brisk walking, swimming, cycling) for 30 minutes, 5 days per week 3
  • Include progressive resistance training to improve muscle strength and function 3
  • Low-cost options include brisk walking in public spaces or use of public recreation facilities 3

• Cognitive behavioral therapy (CBT) addresses psychosocial contributors to pain and improves function with strong evidence 3, 2

  • Primary care clinicians can integrate CBT elements by encouraging active patient participation in care plans 3
  • Provide education in relaxation techniques and coping strategies 3
  • Refer for formal CBT with mental health specialists for entrenched anxiety or significant psychological distress 3

• Patient education and supported self-management from an early stage 3, 1

  • Provide educational materials explaining pain mechanisms and realistic treatment expectations 1
  • Deliver psychoeducation addressing beliefs about pain and promoting adaptive behaviors 2

Second-Line Pharmacological Management

For neuropathic pain characteristics (burning, shooting, electric-like sensations):

• Gabapentin is first-line oral pharmacological treatment, titrating to 2400 mg per day in divided doses 2
• Alternative: Pregabalin (antiepileptic drug) 3
• Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine 3
• Tricyclic antidepressants (TCAs) at low doses for neuropathic pain 3

For nociceptive/musculoskeletal pain:

• Acetaminophen up to 3 grams daily is the safest first-line option, particularly in patients with liver disease, heart problems, or kidney disease 2, 5
• NSAIDs (ibuprofen 400 mg every 4-6 hours, maximum 3200 mg daily) used cautiously and for shortest duration 3, 5
  • Avoid NSAIDs in patients with cirrhosis, kidney disease, cardiovascular disease, or gastrointestinal bleeding risk 2, 5
  • If gastrointestinal complaints occur, administer with meals or milk 5

Interventional and Specialist Referrals

For refractory pain despite initial management:

• Refer to pain management services for comprehensive evaluation 3
• Consider interventional procedures including transcutaneous electrical nerve stimulation (TENS), though evidence for efficacy is inconclusive 3
• Physical therapy referral for targeted exercises and manual therapy 3, 1
• Acupuncture as an option for myofascial pain components, though evidence is limited 3

Opioid Considerations for Full Body Pain

Opioids should be avoided for widespread chronic pain without clear cancer etiology:

• Evidence is limited or insufficient for improved pain or function with long-term opioid use for chronic widespread pain, low back pain, headache, and fibromyalgia 3
• Use the lowest opioid dose possible if opioids are necessary, and functionality should be the endpoint rather than numerical pain ratings 3
• Reevaluate effectiveness and necessity of opioids regularly 3
• For cancer-related pain, morphine 5-15 mg oral short-acting formulation every 4 hours is the standard starting dose for opioid-naïve patients 3

Monitoring and Follow-Up

Assessment Framework ("Four A's")

• Analgesia: Degree of pain relief achieved 3
• Activities of daily living: Functional improvement in specific tasks 3, 1
• Adverse effects: Monitor for medication side effects including sedation, falls risk, gastrointestinal symptoms 3
• Aberrant drug taking: Screen for concerning medication behaviors if opioids prescribed 3

Follow-Up Schedule

• Schedule follow-up within 2-4 weeks to assess response to initial interventions 4
• For patients not responding to single-modality therapy, implement multimodal combinations tailored to patient needs 3
• Regular monitoring of stable patients, high-risk patients, and those with no improvement 1

Critical Pitfalls to Avoid

• Never rely solely on pain intensity scores without assessing functional impact and patient-centered goals 1
• Do not assume existing treatment is sufficient for new widespread pain—this delays diagnosis of serious pathology including malignancy or systemic disease 2
• Avoid providing only analgesics without addressing underlying treatable causes 1
• Do not undertreate high-risk patients; early identification allows more intensive management and reduces long-term disability 1
• Expect analgesic failure in some patients; individualize response and be willing to stop ineffective treatments 1
• Avoid prolonged immobility, as this worsens both pain and functional decline 4