Breaking Down the Barriers of Pain: Part 4
Clinical Presentation: The predominant symptom in fibromyalgia is widespread aching pain, involving much of the body, especially the neck, back, and proximal extremities. The symptoms occasionally begin after a flu-like syndrome or a strain injury and progresses gradually. Associated symptoms are fatigue, sleep disturbance, lack of energy, and depressed mood. The term Chronic Fatigue Syndrome is used if fatigue symptoms predominate over the pain.
Exam: Diffuse tenderness to even moderate manual palpation pressure is so striking as to make the diagnosis, in combination with the pain drawing, unmistakable. The tenderness is most prominent in the soft tissues of the neck, shoulders, and back but is also present in the proximal extremities. There is tenderness over bone and joint as well as muscle. The tenderness is diffuse, not localized to discrete spots, as is the case with myofascial trigger points.
Tests: There are no diagnostic tests for fibromyalgia, although rheumatologists routinely rule out co-existing autoimmune disorders.
Pathogenesis: The cause of fibromyalgia is unknown. Many theories including viral and immunological have been investigated and abandoned. Current investigations focus on neurochemical hypothesis. At the present time the most solid finding is the disturbed sleep-rest cycle.
Treatment: The key to successful treatment of fibromyalgia is correcting the sleep-rest cycle disturbance. Fibromyalgia patients are, in essence, exhausted (“burnt out,” “run down”) but either don’t recognize this, or don’t believe there’s anything they can do about it. To reverse this, they must “rehabilitate” their sleep pattern. They should go to bed at approximately the same time each night, get up at approximately the same time each morning, and institute a regular period of exercise and rest during the day. The exercise should not be strenuous or involve muscle building. The best exercise programs for fibromyalgia patients is walking or gentle swimming, preferably for about 20 minutes per day.
The rest period is equally important. Fibromyalgia patients have a history of chronically pushing themselves too far, often in an effort to keep up with their social responsibilities and obligations. They need to build into their day a personal meditation period. Techniques such as Transcendental Meditation or diaphragmatic breathing are excellent if practiced daily for about 20 minutes. A daily period of undisturbed reading is also therapeutic, however television watching is not because it is more a distraction rather than being relaxing.
A good place to start is to ask the patient to keep a sleep-rest log. The patient should keep the log for at least 10 days without making any attempt to change his or her normal routine in order to get a baseline. Once the patient has identified a pattern, he or she needs to gradually move to a regular schedule within 20 minutes of a set time each night and morning. There is no right time to go to bed, right time to get up, or right number of hours of sleep the patient must get.
The patient then needs to institute a routine of exercise. This should not be a burden or another obligation in his or her day. A useful technique is to gradually incorporate a walk as part of the day. For example, he or she can take the “long way” to lunch or walk around the work area on his or her way to the parking lot at the end of the workday.
The patient should also incorporate a daily “meditation” routine that will not be disturbed by co-workers or family members. Sometimes this requires some creativity. For example, the patient can sit in his or her car down the block from home or use the chapel in the hospital or church.
Anti-depressants are typically helpful whether the patient is clinically depressed or not. Many fibromyalgia patients are clinically depressed and should therefore have a diagnostic psychiatric evaluation. If not diagnosed as having depression, then a low dose of amitriptyline may help the patient with his or her sleep disturbance. If the patient has depression, then he or she should see a psychiatrist. Depression in fibromyalgia patients is often more debilitating then the pain and fatigue itself.
Fibromyalgia patients have a history of chronically pushing themselves too far, often in an effort to keep up with their social responsibilities and obligations.
Non-steroidals are not effective and carry the risk of gastric irritation. Oftentimes it misleads the patient into thinking he or she has an inflammatory condition. Nutritional supplements beyond recommended daily requirements are also ineffective.
Somatoform Pain Disorders
Clinical Presentation: The most common pain pattern is total body pain. Less common, but unmistakable, is pain on one side of the whole body, classically splitting the mid-line. The other striking feature of somatoform pain patients is their fixation, even obsession, with their symptoms. They are convinced that they have a disease that has not been adequately evaluated and remains to be diagnosed. They are also convinced that the symptoms are in no way “mental” and are hostilely vigilant to any inference that they are. Somatoform pain patients have been known to tell the scheduling receptionist, “I will only make an appointment if you promise me that doctor will not say that my condition is in any way psychological.”
The symptoms tend to become more elaborate over time, typically over months to years. There are three other conditions that must be considered in the differential diagnosis:
Somatic Delusion. This is an Axis I condition. From the medical (as opposed to the psychiatric perspective) the primary difference is the quality of the symptom, which is overtly bizarre and typically associated with bizarre behavior as well. These patients can be substantially helped with neuroleptics and so every effort should be made to get them to a psychiatrist.
Malingering. In practice it is not difficult to distinguish somatization from malingering. The malingerer’s complaints are plausible, believable, and readily connected to a specific agenda, which usually has to do with receiving disability. Of course most physicians recognize this possibility in the workers’ compensation arena, but sometimes the source of disability is not apparent. For instance, some disability policies require that the patient be in treatment to receive their payments. Such a patient will not necessarily ask the treating physician to fill out disability forms or even tell the physician that he or she is on disability. But they will insist on staying in treatment at the same time they are stating that treatment isn’t helping. Perhaps an even less obvious situation occurs when there is a conflict between two family members and the pain condition becomes a bargaining chip.