The challenges of chronic pain and fatigue, by Jessica A Eccles and Kevin A Davies in Clin Med January 2021 [doi.org/10.7861/clinmed.2020-1009]
In this review, we explore the challenges of chronic pain and fatigue in clinical practice. Both pain and fatigue are common, troubling and frequently overlapping symptoms, and we describe both the clinical burden and the ‘clinical problem’. We explore commonly associated symptoms and possible pathological associations, including variant connective tissue (joint hypermobility), small fibre neuropathy, mast cell activation, dysregulated inflammatory and interoceptive processes, which may inform treatment targets. We suggest a multidisciplinary management approach.
[The paper explores ME/CFS, Fibromyalgia, POTs, Long COVID, Mast Cell Activation, Small fibre neuropathy, Joint hypermobility, IBS]
Outpatient assessment of a patient with fatigue and chronic pain can be challenging. This is particularly the case when the patient is polysymptomatic and they have had many interactions with healthcare professionals before. It is all too easy to ‘admit defeat’ as in Dr A’s case, or initiate a test or another referral in ‘response’ to every symptom described by the patient during the course of their illness (Dr B). How can this be avoided?
One approach is to adopt the ‘snapshot’ approach and ask the patient to identify a maximum of three ‘live’ clinical problems (eg in the previous 2 weeks), highlighting which is the most significant one. If the primary problem is fatigue or pain (as in our exemplar Patient A), it can be highly informative to identify the single most important additional symptom: the ‘plus one’ approach. This should raise a specific subset of diagnostic possibilities, often limited in number, which will prompt further, more focused ‘direct’ questioning, and may inform an initial investigation strategy, if considered appropriate.
All physicians are trained to identify ‘red flag’ symptoms, such as unexplained weight loss, which, in older patients particularly, may point to a diagnosis of malignancy, malabsorption, endocrine disease or depression. However, there is a number of conditions that are frequently missed, and easily identified. Some of these are summarised in Table 1. We focus on the ‘plus one’. The average time it takes to diagnose Behçet’s, for example, may be up to 7 years and there is frequently a delay in the diagnosis of Sjogren’s syndrome; few doctors ask about sicca.64 Inflammatory bowel disease or endometriosis can also easily be missed, as can HIV, especially in older patients.65,66.
What is rarely helpful or informative in a busy clinic setting is to rehearse in detail with a patient the detailed chronology of what may be several years of ill-health. This can all too often result in a ‘memory test’ for the patient, with the physician seeking to corroborate dates and details in the notes or electronic patient record. This wastes time, and can be frustrating for all concerned. However, it may be useful before, or more often after, the consultation to look back at previous letters, imaging or pathology results to help substantiate or refute a presumptive diagnosis.
In patients with a ‘long history’ and multiple medical interactions, it is, however, important to avoid ‘medical transference’ and give undue credence to diagnoses made by other doctors, often years before. Firstly, the patient’s recollection of the outcome of a previous consultation may be far from accurate, and secondly, the professor may well have been wrong. It does happen.