Soft-Tissue Rheumatism in Arthritis
by Dr. Nachiket Kulkarni

Soft tissue Rheumatism(STR) in many terms is still an unsolved riddled. It is not a single  entity but a conglomerate of different conditions involving parts of musculoskeletal system other than joints. Technically it can be divided as generalised or localised . Localised forms are generally associated with injury, overwork or rarely with local anatomic abnormalities arising out of different causes. Generalised form of soft tissue rheumatism also referred as Fibromyalgia
(FMS) is characterised by widespread pain. Really speaking its a disease with multifaceted symptoms involving different organ systems. The crux of the pathology is disrupted pain perception.

The term Arthritis is an overreaching term signifying more than 150 different types of joint diseases. These are further divided into inflammatory (associated with swelling, pain, stiffness) and non inflammatory. Inflammatory arthritis(e.g. Rheumatoid Arthritis, Lupus) need special attention as they can involve young people and can cause joint destruction and need specific treatment that needs close monitering. It is not a matter of difficulty to imagine the discomfort a patient can suffer when these disorders of inflammatory arthritis and FMS come together.

In patients of Inflammatory arthritis where the pathology lies in involvement of joints it is very common to observe localised or generalised soft tissue pains. Whether it is part of disease or an independent entity is still a matter of debate. But one thing is obvious that STR needs treatment individually. As much is the occurrence of this association baffling for scientists it creates even more confusion for Rheumatologists. The patient can have persistence in pain even after controlling the baseline arthritis aggressively. Here comes the dilemma in patients mind – 'Doctor, why am in pain when all my reports are normal', 'Doctor my joints are better but my calf or thigh or arm feels swollen and painful.' It is likely that STR is playing its role in such scenarios and hence needs consideration. This can stem frustration as a person feels helpless .  STR hence has a bearing not only on pain but on all aspects of life. It leads to increased medication requirements mostly painkillers. Exercise becomes difficult and the budget of medication overshoots the planning. 

We are also aware that FMS is not only restricted to musculoskeletal system but can also have features of digestive system(abdominal bloating & pain, nausea, constipation or diarrhoea), headaches, urinary problems, chest pains and breathlessness. It becomes difficult to assess whether these are related to different disease or medicine side effects. Patients become incompliant with medicines which further worsens the condition. Impact of this co-occurrence of FMS and Arthritis in personal, professional and social life is profound. STR can also become an important reason for marital discord due to sexual problems.

We have up till now tackled only the impact of Generalised STR on Inflammatory Arthritis. It needs to be understood that other combinations between Generalised STR with non inflammatory arthritis and Localised STR with both inflammatory and non inflammatory arthritis does exist. Pain around joints but not in joints, pain in muscles and some specific trigger points are the presenting features of localised STR. Classical examples are tennis elbow and rotator cuff syndrome. These can be very painful. They can render a person incapable of performing the activity routinely done by that muscle. In fact severe forms of localised STR are an important cause for permanent work disabilities in western countries. In some arthritis there arise joint deformities. These lead to strain on the tissues of the joint. Any this itself can cause pain and disability. Even a small injury in such scenarios sometimes seemingly trivial can cause major soft tissue involvement. Timely medical help can save us of pain and sometimes of any permanent damage.

The physical limitations are obvious but the effect on a person's psychology remains undetected. With persistent pain and disability the self confidence gets dented. This can lead to a multitude of psychological problems. Apart from this effect the Generalised STR itself is associated with cognitive affections like easy forgetfulness. Fatigue as a symptom gets magnified when co-occurrence of STR and Arthritis is noted. Sleep difficulties are also known.

The discussion on impact on health can be an endless list.  More important question though would be – What can be done? The answer to this question is multi fold.

The first step to tackle any problem is to understand the phenomenon completely. With the basic knowledge you can gain through this MAI magazine please feel free to discuss with your Rheumatologist on this issue.

The second step is to bring to his notice in a precise and explicit way the problems you face. A correct description of the site and disability is better than talking on associated prospects. Please do not be prejudiced by self assessment of the problem. An assessment by a Rheumatologist depends greatly on the history and examination.

The third step is to be sincere on the prescription. Painkillers are not bad, but their unscientific use is. Some other medications might also be used by your Rheumatologist, the role of which are complex. The medications work in synergy and not in isolation, hence self omission or prescription can be harmful.

The forth step is to be sincere on the exercise and life style management as advised by your Rheumatologist. A graded and goal directed exercise program has been proven to be of benefit in tackling STR. The importance cannot be overemphasized. It is of critical importance that the plan for physiotherapy needs nod of your Rheumatologist, A wrong exercise would more cause more harm than good.

The fifth and in my opinion the most important step in belief and faith in continuous efforts. The sincerity becomes shaky when it is unreasonably emphasized that the Arthritis or STR is  permanent. Please understand that this is not synonymous with lifelong pain. A person with Arthritis or STR can have a pain free and quality life. Lets take healthy steps towards this goal.

In summary the co-occurrence of STR and Arthritis of all different forms in known to occur. The co-existence seems to worsen each other and can have bearing on treatment. The impact is multifold and hence needs early detection. Be aware of the features of STR and seeks a Rheumatologist's help. Effective treatment options are available to ensure a quality and comfortable life.