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6 Articles in Volume 1, Issue #4
Breaking Down the Barriers of Pain: Part 4
Facing Reimbursement Challenges
Getting Back on Track
Taking the Hurt Out of Pain
The Mind-body Connection
The Neural Plasticity Model of Fibromyalgia Theory, Assessment, and Treatment: Part 2

Breaking Down the Barriers of Pain: Part 4

Part four of this series reviews fibromyalgia and somatoform pain disorder tests and treatment options.

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.

Unrecognized medical condition. In the back of a treating physician’s mind is the possibility that there is something else going on. Could the patient have multiple sclerosis, some rare metabolic disorder, or a thalamic tumor? This is perhaps one of the most difficult challenges for any clinician. The safe approach is to keep ordering more tests and consultations. But if the patient has somatoform pain disorder, this approach aggravates it. A consultation with a neurologist should be done early on since neurology is all about “localizing the lesion.” By knowing the nervous system pathways, a neurologist can determine if a given set of symptoms are anatomically possible or not.

Examination: Examination is normal except for tenderness to even light palpation. This can be quite striking. Some patients will wince and pull away almost before the examiner has touched them. This feature differentiates them from patients with fibromyalgia. In fibromyalgia, the tenderness to palpation tends to be in response to firmer pressure. Perhaps not surprisingly, these conditions can overlap.

Tests: By definition, there is no test for somatization, and yet these patients have typically had many tests, and many more than once.

Pathogenesis: The psychiatric theories of pathogenesis are of little practical value to the treating medical physician and psychiatric consensus seems to be that these patients are not good candidates for psychotherapy in any case. It is instructive to view this disorder as iatrogenic. The patient becomes aware of an abnormal sensation, which is interpreted as a symptom, seeks medical advice and then becomes more confused and frightened as each test comes back negative or ambiguous. It also doesn’t help when each physician offers a different answer and a different treatment. Even when the physician is aware of or suspects that there are significant emotional issues fuelling the symptoms, it is unusual for that physician to broach those concerns. It is characteristic of the disorder that the patient will reject it. The practical clinical challenge facing the treating physician is that the patient is confused, frightened, and fixated on his or her symptom and expects the medical profession to find the cause and cure it.

Treatment: Somatization patients angrily reject any suggestion that they seek psychological help. They are convinced they have a serious undiagnosed or untreated disorder. They present a difficult dilemma for physicians. Physicians’ self-esteem, not to mention their livelihood, is based on being able to do something for everything and to do anything, rather than nothing. This is a prescription for disaster with somatoform pain disorders. In the absence of an abnormal physiology or anatomy, any attempt to alter physiology or anatomy, with medication or procedure, will not only fail to correct an abnormality, but will certainly cause some new disturbance and some new symptom. It can cause some complication that adds real pathology to an already complicated syndrome. Somatoform pain patients notoriously report intolerable side effects to medications. Once they have had some procedure, such as a laporoscopy for unexplained abdominal pain or cervical rib removal in a patient with total body pain, they will be susceptible to scar tissue and whatever symptoms might be attributable.

Somatization patients angrily reject any suggestion that they seek psychological help. They are convinced they have a serious undiagnosed or untreated disorder.

What then is the proper approach to somatoform pain patients? Theoretically it is quite simple. The treating physician needs to patiently explain why a given test or given treatment is not appropriate. It must be explained, in the final analysis that the symptoms and abnormal sensations cannot be fixed by traditional medical science. When successful, the patient stops asking for more tests and treatments and begins to consider techniques that can be pursued on his or her own.

Here are some practical steps to help move the patient in the right direction:

1) Ask the patient to obtain whatever previous records he or she believes identified some disease or pathology. It is important that the patient themselves be engaged in this search. Go over these records with the patient.

2) Focus on the types of conditions or symptoms that medicine can fix. “I’m sorry Mr. Jones, but since we have not found an infection, I cannot in good conscience recommend an antibiotic.” “The good news is that there is no evidence of cancer, but of course the bad news is that we have not found anything that we can treat specifically.”

3) Do not order tests just to “appease” the patient. As B.F. Skinner pointed out, an intermittent reinforcement is the most difficult to extinguish. In addition, some of the tests will show minor abnormalities that will fuel the patient’s belief that there is something seriously wrong that needs to be pursued further. A good example of this is the antinuclear antibody (ANA) or sedimentation (sed) rate. In addition, these patients will often have co-existing conditions such as headache or irritable bowel syndrome that further confuses both the patient and the physician.

4) Do not prescribe treatments without a clear and specific rationale. For example, do not prescribe anti-depressants as a non-specific shotgun solution. If the patient is willing to acknowledge depression or anxiety, refer them to a psychiatrist rather than prescribing an anti-depressant or anxiolytic.

5) Encourage the patient to seek non-medical, self-help techniques like meditation or yoga.

6) Somatoform pain disorder patients will doctor-shop; it is a component of the condition. It is not a failure of the treating physician. Nevertheless once this occurs, the treating physician has a responsibility to assist the patient to avoid seeking care that is not in the patient’s best interest. Therefore, if the patient goes elsewhere, the managing physician should write a final report setting forth evaluations performed and the absence of findings so that subsequent physicians will not repeat unnecessary tests and procedures.

7) Keep in mind that these patients can be time-consuming and exasperating. It is natural to conclude that they are uncooperative and non-compliant. It is helpful to consider that in fact they are frightened, confused, and are desperately hoping the physician can fix it all for them. The treating physician is tempted to say, “There’s nothing else I can do for you!” It is more effective to try to be empathic and say something like, “I realize you are in pain and are suffering but unfortunately there is no specific treatment that is available to treat it. In my experience patients with these disorders are best staying away from us in the medical profession and may want to seek out more holistic approaches.”

Last updated on: January 10, 2012
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