When we contacted Dr. Goodwin and Dr. Bennett for their comments on the fibromyalgia article in this issue, both of them had more to say.
Dr. Goodwin addressed an apparent widespread misunderstanding concerning psychogenic pain. He also stressed the importance of distinguishing FMS from other pain syndromes and a rheumatologic disorder of similar presentation.
Contrary to popular belief, Dr. Goodwin notes, fewer than 5% of patients seen in pain clinics for the assessment and management of chronic pain have a purely psychologic basis for their physical symptoms, although about 60% of such patients have significant psychosocial factors impacting their presentation and ability to cope with physical pain.
He cautioned that a diagnosis of FMS should be based on a three-month history of aches and pains, as well as the presence of 11 out of 18 standardized tender points all of which feel painful (not just tender) and which do not radiate to distant areas when pressed firmly enough to blanch the thumb nail. The number of tender points may vary each day, sometimes falling just below or above the 11/18 criteria. The so-called “control points” which should not be painful even in those suffering from FMS, are no longer considered a reliable sign of somatization.
Dr. Goodwin stresses that FMS is neither a “wastebasket” term nor a diagnosis of exclusion as is sometimes thought and misused by clinicians. For example, 20-30% of patients with rheumatoid arthritis may suffer concomitant fibromyalgia. Also, many patients suffer a concomitant and more regional disorder, Myofascial Pain Syndrome (MPS) a.k.a Chronic Myofascial Pain (CMP). This disorder is based within soft tissues and is characterized by trigger points or painful regions which, when palpated, refer or radiate pain distally. The term “post traumatic” (or “secondary”) FMS is now outdated since it cannot be differentiated clinically from FMS per se. The same term can be used for what was once called primary or secondary FMS.
Fibromyalgia is most common in the 50-70 year old range, affecting women more often than men. People this age tend not to seek care, accepting pain and fatigue as a consequence of aging. Failing to report or properly diagnose fibromyalgia symptoms may lead to serious consequences. Fibromyalgia symptoms, Dr. Goodwin explains, are not a normal consequence of aging and if FMS is suspected, rheumatologic consultation is strongly advised to differentiate it from the potentially dangerous polymyalgia rheumatica (PMR) in those over 50 years old. Polymyalgia rheumatica presents similarly to FMS, but is associated with giant cell arteritis, a potential cause of temporal arteritis headaches and subsequent blindness. PMR is also treated differently: steroids help PMR, but not FMS. Again, rheumatologic consultation is advised when FMS is suspected, if only to avoid missing the diagnosis of a concomitant illness requiring a separate approach to treatment or management.
Dr. Bennett suggested that our readers may also be interested in the results of two other studies on fibromyalgia. He sent an abstract of an article published in Arthritis & Rheumatism in March 1997, “Increased Rates of Fibromyalgia Following Cervical Spine Injury: A Controlled Study of 161 Cases of Traumatic Injury,” by Buskila, Dan (MD); Neumann, Lily (Ph.D.); Vaisberg, Genady (MD); Alkalay, Daphna (MD); Wolfe, Frederick (MD).
The study involved 102 patients with neck injuries and 59 patients with leg fractures (control group). Although no patient had a chronic pain syndrome prior to the trauma, FMS was diagnosed following the injury in 21.6% of those with neck injury versus 1.7% of the control (lower extremity fracture) patients. (FMS was diagnosed using the American College of Rheumatology 1990 criteria). Almost all symptoms were more common and more severe in the group with neck injury. Also, the neck injury patients with FMS had more tenderness, more severe and prevalent FMS-related symptoms, and reported lower quality of life and more impaired physical functioning than did those without FMS. The conclusions: FMS was 13 times more frequent following neck injury than following lower extremity injury; also, all patients continued to be employed; and insurance claims were not increased in patients with FMS.
Dr. Bennett also sent a recent (2002) article from Rheumatology, the journal of the British Society for Rheumatology, “A Case-control Study Examining the Role of Physical Trauma in the Onset of Fibromyalgia Syndrome,” by A. W. Al-Allaf, K. L. Dunbar, N. S. Hallum, B. Nosratzadeh, K. D. Templeton and T. Pullar. The study revealed a significant association between FMS and physical trauma within 6 months prior to its onset. Of 136 FMS patients completing questionnaires, fifty-three (39%) reported significant physical trauma in the 6 months prior to the onset of their disease. By contrast, only 24% of the 152 non-rheumatology (control) patients returning questionnaires reported physical trauma in the 6 months before the onset of their disease. There was no significant difference between the FMS patients who had a history of physical trauma and those who did not with regard to age, gender, disease duration, employment status and whether their job at onset was manual.
While the details of ongoing fibromyalgia research exceed the scope of this MEDICAL-LEGAL JOURNAL, studies continue to confirm Dr. Goodwin’s testimony that fibromyalgia results from physical trauma, especially neck injuries (“whiplash”) of the type commonly suffered in motor vehicle accidents.
This article was prepared by Peter E. Yeager