Dr. Prakashkumar P Bhatt
Neurology
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Patient's Query
Hello doctor,
I am a 37-year-old male. I am an IT employee with chronic back muscle tightness but no pain at all in the thoracic region along the spine between shoulder blades and lats and traps and neck area for six months. It started with mild discomfort and progressed slowly. When side bending or twisting torso I feel tightness in the thoracic spine and neck region. At first, it was on the left side and now progressed to the right side. Tightness is more in the morning after getting up. No loss in muscle strength. Sometimes I get migraine type headaches. During very deep breathing, my back feels tight. Sitting is difficult for long hours and my back feels fatigued with increased irritability.
I am currently taking Flexabenz Plus, Mysospaz, Tolifast 150, and Volitra Spray.
Hi,
Welcome to icliniq.com.
Stiffness in the upper and middle back and shoulder blade muscles without any weakness and joint pain which is more in the morning hours. MRI (magnetic resonance imaging) spine shows some degenerative disc diseases and you also tried muscle relaxant without any improvement.
Suggestions: I am advising some investigation, it seems some connective tissue disorder or muscle disorders, so to differentiate both and to get some clinical evidence kindly do the following investigations:
1. ESR (erythrocyte sedimentation rate).
2. CRP (C-reactive protein).
3. CBC (complete blood count).
4. RA (rheumatoid arthritis) factor.
5. Anti GAD 65 antibodies.
6. Serum CPK (creatinine phosphokinase) level.
7. Uric acid level.
Treatment:
Try tablet Baclofen 5 mg 1-0-1 for five days and see the response. Rest of the advice I can give after investigations.
Patient's Query
Thank you doctor,
I have done a few of the tests already.
RA factor 9.52 (it is mentioned normal).
HLB27 was negative.
Uric acid 5.7 mg/dl.
Calcium 8.7 mg/dl.
Vitamin D 43.86 ng/dl.
ESR 30.
CBC attached.
I have been weightlifting for many years, now I have stopped for the last few months. I am also facing increased irritability however, strength and stamina is still good. Rest of the tests I will be arranging.
Hi,
Welcome back to icliniq.com.
I got some idea, Please do the rest of the investigation and start medicine which I have advised. And re-consult me after five days with the report of needed we will do electromyography of paraspinal muscles after all basic investigation.
Patient's Query
Thank you doctor,
I have done rest of the tests (report attached). I have ordered the medicine online, not received yet. Also, I wanted to mention, there are some tender points along the thoracic spine, back of the neck, back ribs- no pain but on pressure it feels tender. Overall it feels like I had a very heavy workout and muscles will not recover from it. Please let me know if you need any other information.
Hi,
Welcome back to icliniq.com.
I have seen the report (attachment removed to protect patient identity).
CK, ANA, GAD65 are normal. And you have given very important information that you have some tender points over back and neck. After looking at all the history and investigations nothing serious. Diagnosis is favoring fibromyalgia. Please start tablet I have advised you and also start two more tablets.
Tablet Nexito Plus 5 mg 0-0-1 for 15 days, and tablet Rejunex CD3 1-0-0 for 15 days.
Do regular physical exercise, meditation/yoga. Consult physiotherapist once for exercise recommendations.
Follow up after 15 days.
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Neurology
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