ALL THAT ACHES AND PAINS IS NOT ALWAYS ARTHRITIS. SOMETHING ABOUT SOFT TISSUE RHEUMATISM! (STR)

Dr Vaijayanti-Lagu-Joshi

Mrs. Kalpana is 30 yrs old married lady, mother of 2 kids, from a good family. She works in a bank and handles her job and house very efficiently. But since last 6 months she is disturbed, irritated due to the health reasons. She gets aches and pains all over body, neck, back, thighs, that make her ill, her sleep gets disturbed. She goes to several doctors searching for a solution. Every time she under – goes examination and battery of investigations but nothing comes out of it as all reports are normal. Doctor label this as “psychological”. Poor Kalpana gets more depressed and wants to get a “diagnosis” and a “solution”.

This is a very classical example of soft tissue rheumatism. Many young females do suffer from widespread pains and tenderness of body which is “non inflammatory” rheumatism. It is not just psychological but a “psychosomatic” illness with a number of other associated abnormalities like sleep disturbances, headache, fatigue, irritable bowel syndrome, migraine and depression.

Soft tissue rheumatism is broad form covering pains and stiffness in and around the joints, in soft tissues like muscles, tendons, ligaments, nerves, fascia etc. It can be generalised or localised to a region like elbow, knee or shoulder.

Generalised soft tissue rheumatism is diffuse, shows pain and tenderness distribution in all quadrants of body as shown in figure. Those who satisfy 11/18 tender point sites are labelled as fibromyolgia patients. Those who do not satisfy are still considered as cases of generalised STR.

Regional STR are pains and tenderness restricted to limited sites like elbow pain, knee, wrist pain occurring in those involved in sports activities, occupations demanding repetitive work strains to those joint regions.

TENDER POINTS OF FIBROMYLAGIA

The precise cause of soft tissue rheumatism (fibromyalgia) is not known. There is no demonstrable inflammation in the tissues but an altered central pain processing regulatory mechanism so that even a non-nociceptive stimulus can elicit extreme pains. Number of environmental factors like physical trauma, infection, autoimmune disorder, endocrine conditions and emotional stress are capable of triggering fibromyalgia.

There are no diagnostic tests to diagnose fibromyalgia but routine blood tests with ESR, CRP, thyroid function tests, if any doubt, RF, anti CCP are important to rule our other cases of pain. Detailed history and clinical examination clinches the diagnosis.

Treating soft tissue rheumatism like fibromyalgia is simple as well as difficult. Simple because there are not many medications/drugs to treat it but difficult because it involves many non pharmaco therapies like exercises, congnitive behavioral therapy. The drugs like paracetamol, tramadol can be good analgesics apar t f rom ami t ryptyl ine, cyclobenzaparine, pregabalin which do interfere with pain perception and depression. A graded, low impact aerobic exercise program is must to break the vicious cycle of pain, stiffness and fatigue. Cognitive behavior therapy includes biofeedback and relaxations measures.

Although fibromyalgia/soft tissue rheumatism are chronic illnesses lasting for Physical Mental stress lack of exercises several years, most patients can lead a relatively normal life with appropriate management. Regional soft tissue pains can also be settled by avoiding mechanical activities precipitating the pain and simple analgesics, rest.

So all that aches and pains in joints or around joints need not always be inflammatory arthritis. Soft tissue rheumatisms need special attention, understanding and follow up.