FIB-romyalgia

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FIB-romyalgia

Excuse me while I stand inside my hefty suit of armor, because I have a feeling that a torrent of projectiles will soon be hurled unapologetically at me. You may soon be hollering invectives at me and quoting Monty Python when you state, "I fart in your general direction! Your mother was a hamster and your father smelt of elderberries!"

Fibromyalgia, as it is currently construed DOES NOT EXIST!

I will take this stance as the unofficial official ambassador for what I feel many of my colleagues understand. I will state this proudly and defiantly, while my fellow physicians cower behind me with.... well cowardice.

Fibromyalgia DOES NOT EXIST!

Now that's not to say that people who are diagnosed with FM do not feel real pain, nor that I do not have the utmost of sympathy for people who have been labeled as such. It just does not exist in a form as currently classified.

What is fibromyalgia? It has classically been defined as unremitting pain at various specific trigger points of the body of which one must demonstrate tenderness in at least 11 of 18 different areas (see above picture). Additionally, one must demonstrate several of the following symptoms:

fatigue irritable bowel

sleep disorder

chronic headaches

jaw pain

cognitive or memory impairment post-exertional malaise and muscle pain morning stiffness

menstrual cramping

numbness and tingling sensations dizziness or lightheadedness skin and chemical sensitivities

Esoteric enough for you? Depending on how hard I push, and whether I have eaten my Wheaties, I could probably elicit 11 of the 18 trigger points depicted in the picture above. Especially if I wanted to prove my pretest suspicion that the person I am testing does in fact have fibromyalgia. And what about the additional associated symptoms listed? I can name at least 6 of the above symptoms I am currently experiencing. And if I was 18 again I would list morning stiffness as an additional symptom, for a grand total of 7. Oh wait..... I think I just got what they mean by that one.

Let's examine how Doctors diagnose disease. This is a process by which we have spent many years learning about, studying, examining, refining and relearning.

We'll take a relatively straightforward case of hepatitis or inflammation of the liver.

First, a patient may come to us with a list of complaints. "Doc, I ain't feeling so right. I've been tired and vomiting. I have a very poor appetite, with some abdominal pain. I've felt chilled and feverish and my wife notices that my eyes have turned a bright yellow."

From this initial subjective history (perhaps except the yellow eyes) the Doc will ask additional questions that will help her refine and generate a differential diagnosis.

How long has this been going on? Anybody else in your household sick? Has your stool changed color? How about your urine color? Have you lost any weight? What medications are you on? Have you ever used drugs? And if so, IV? And so forth

From the history and additional questions the Doc should begin to (at least hopefully) suspect hepatitis as a very likely cause for the patient's symptoms. She will then perform a physical exam to either support or contradict her suspicions. For example, right upper quadrant abdominal tenderness, and hepatomegaly (big liver).

From here the doctor will probably order basic screening labs with an emphasis on the liver profile. If the liver tests are elevated, specifically AST and ALT, the confirmation of hepatitis is made. But what kind of hepatitis? Additional tests are now needed, but possibilities include, viral, parasitic, autoimmune, medications, familial, alcohol, non-alcoholic steatohepatitis, tumor, environmental toxins.

At this point one may order still additional tests such as, antibody screens, autoimmune markers, CT scans, ultrasound's, MRI's, HIDA scans and finally perhaps even a liver biopsy.

Whew! That's quite a list, but it can roughly be divided up into the following subjective and objective categories;

Subjective- patient tells her side of story Objective- Doc does physical exam Objective- Doc orders labs Objective- Doc orders imaging tests Objective- Doc orders more labs Objective- Doc orders biopsy

So how does this relate to fibromyalgia you may ask? With any physical disease one should always be able to find confirmatory physical exam findings, lab tests, imaging tests and pathology if done properly and diligently. Fibromyalgia fulfills none of the above criteria. NONE, NADA, ZILCH!

But what about the elicitation of pain upon palpation of various trigger points? I consider this a subjective finding, since the Doc is essentially taking the patient's word that pressing on that spot hurts.

Now for the 50,000 dollar question. What kind of illnesses are there in which one cannot find any confirmatory objective data?

Wait for it..

Wait for it.....

Psychiatric disease of course! Fibromyalgia is a psychiatric illness!

This is not to say it is not real. On the contrary.... It is as real as depression, schizophrenia, bipolar, PTSD, somatization disorder, etc. And these are very, very real diseases.

The nosology makes perfect sense when taken to its logical extreme as I delineated above.

Fibromyalgia belongs in the DSM-IV and not in on's book of Internal Medicine.

This explains why the most successful treatments for fibromyalgia are in fact those where the patient must seek extrinsic therapy, rather than medicinal. The most successful treatments are and continue to be behavioral modification, biofeedback, aerobic exercise, meditation and etc.

Most of us deal with aches and pains on a daily basis and deal with it because we are adapted to do so. People diagnosed as have fibromyalgia have aches and pains on a daily basis and can't deal with it because of a psychological or biochemical maladaption to do so.

I see FM patients quite often in the ED because of "flare-ups" of their pain. As far as the pain issues I see each and every shift, I quite enjoy these people. They are usually pleasant, appreciative and talkative and I don't get the sense that they are seeking drugs for the most part. However, when one meets an FM patient one gets an indescribable sense that they are a little "off". By this I mean a spectrum of distinctive personality traits that seems to carry over from one FM patient to another. This detail is neither good, bad nor indifferent. It just is, and one cannot help to note it and observe it. I think many of my fellow physicians have noted it as well.

So come on everybody, say it with me.

I fart in your general direction! Your mother was a hamster and your father smelt of elderberries!

http://www.thedocaroundtheclock.com/dribear/2006/12/fibromyalgia_an.html