SitaRana, a 38 year old Nepali woman presented to the doctor’s office with diffuse pain throughout the body associated with fatigue, insomnia, and difficulty concentrating for three months. The pain was difficult to localize but was not relieved by taking “brufen” ( ibuprofen). She also had a long history of being anxious. On examination she had generalized pain on pressing the muscle of her neck, back, arms and legs. Her laboratory tests were completely normal.
The problem that Sita presents is common throughout the world, and is also regularly seen in Nepal. When we were in medical school wewere unaware about this disease entity, now called fibromyalgia. In a general practitioner’s office, fibromyalgia patient population may be as high as 5 to 10 %. Fibromyalgia is not confined to any particular geographical region, ethnicity or climate. In our country patients like SitaRana will do the usual rounds of different doctors. As a matter of fact in the past, when we saw patients like Sita we would strongly consider sending them to the “bone” doctor ( an orthopedic surgeon).
The mechanism of this disease is unclear, but it occurs in a 9:1 female- to- male ratio; and the disease is associated with disturbed sleep and abnormal pain perception as seen in Sita.It is classically said that the focus of treatment should not be eliminating pain but rather improving function and quality of life which includes multifaceted exercise programme with aerobic exercise, strength training, and incorporating relaxation techniques like yoga and Tai Chi.
Drug therapy is available for fibromyalgia, but drugs like ibuprofen 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 realize that in the same manner as effective drugs are vital for treatment, it is equally important to avoid unnecessary drugs. Many doctors will not know about fibromyalgia, and due to the diffuse aches and pain will prescribe pain killer drugs like ibuprofen which is unhelpful.
Fibromyalgia is apparently so common that, although it was required to demonstrate pain on palpation at 11 of 18 tender pre- determined point sites ( back of neck, arm, hip and so forth), this was abandoned in the updated criteria because strict application of threshold of pain lead to under diagnosis of this common condition. Although general internists should be able to help patients with fibromyalgia, rheumatologists like DrBuddhiPaudyal from Patan Hospital are the specialists in this field.