29 Aug - 5 Sept 2014 #722

Aches and pains

Dhanvantari by Buddha Basnyat, MD

Sita, a 38-year-old Nepali bank teller, came to her doctor’s office with diffuse pain throughout the body, saying she had difficulty concentrating since the last three months. She said she was also irritable, easily fatigued, and was becoming insomniac. The pain was difficult to localise but was not relieved by taking Ibuprofen. Sita admitted she had a long history of being anxious about the smallest things.

On examination she had generalised pain when the muscles of her neck, back, arms and legs were pressed. Laboratory tests, which included a complete blood count, thyroid, liver, and kidney function tests showed everything else was completely normal.

Patients with non-localised aches and pains are difficult for the doctor to diagnose, and often become a source of impatience. The patients then leave the doctor’s office with a handful of vitamins and paracetamol.

However the problem Sita presents is common throughout the world, and is also regularly seen in Nepal. In medical school we were unaware about what is now called fibromyalgia.

Up to 5-10 per cent of visitors to a general practitioner are fibromyalgia patients. It is not confined to any particular geographical region, ethnicity or climate. So it is possible to come across many patients like Sita whether in the Tarai, Kathmandu or the mountains.

Patients like Sita will do the usual rounds of different doctors without really being properly diagnosed. In the past, we would strongly consider sending them to the “bone” doctor (orthopedic surgeon) due to the extensive aches and pains. But the orthopedic surgeon who is very adept at fixing broken bones would find the vague aches and pains a real challenge to treat.

The mechanism of the disease is unclear, but it occurs in a skewed 9:1 female-to-male ratio, and it is associated with disturbed sleep and abnormal pain perception. Unfortunately, there is no specific blood test for this and diagnosis of fibromyalgia remains limited to patients’ history and physical examination. Basic blood tests are only done to rule out other diseases which may present in a similar fashion.

It is traditionally said the focus of treatment should not be on eliminating pain but rather improving quality of life through multifaceted exercise programs that include aerobics, strength training, and relaxation techniqes like yoga and Tai Chi. Drug therapy is available for fibromyalgia, but drugs like ibuprofen generally have no role.

Importantly, antidepressants like amitriptyline which can also double up as pain and sleep medicines have shown some efficacy. In medicine it is important to avoid unnecessary drugs as it is to identify effective ones. Many doctors will not know about fibromyalgia, and due to the diffuse aches and pain, may prescribe painkillers, which are most useful when fibromyalgia is triggered by a long-standing disease like rheumatoid arthritis.

Fibromyalgia is so common that although it was required to demonstrate pain on palpation at 11 to 18 tender pre-determined points (back of neck, arm, hip, etc), this was abandoned in the updated criteria by the American College of Rheumatology because strict application of threshold of pain led to under-diagnosis of this common condition. Although general internists should be able to help patients with fibromyalgia, rheumatologists like Buddhi Paudyal from Patan Hospital are the specialists in this field.

Read also:

Fighting fibrolyalgia, Buddha Basnyat

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