Articles from prior issues of The Advocate

November/December 1998

Focus On Fibromyalgia
Conference Presentation by Cynthia Weaver, M.D.
Rheumatologist, University of South Dakota
by Ellen Cook, Illinois DDS

Fibromyalgia is a syndrome which is characterized by chronic, diffuse pain, stiffness, fatigue and restless sleep. It is one of the most common non-arthritic causes of pain. It affects approximately 27 percent of the general population. These patients hurt from head to toe, not just certain joints. Physical exam shows no heat, redness, stiffness, swelling or loss of range of motion. The American College of Rheumatologists directs that the diagnosis is made based on a history of widespread pain in all four quadrants of the body and at least eleven of eighteen possible tender points being positive. These points are specifically defined by body location. To meet the diagnostic criteria, patients must have widespread pain in all four quadrants of their body for a minimum duration of three (3) months and at least 11 of the 18 specified tender points. These 18 sites cluster around the neck, shoulder, chest, hip, knee and elbow regions. Negative control (non-tender) sites (such as forehead, distal forearm, and lateral fibular head) can be used by the physician to determine validity of patient’s report of pain.

Who Gets Fibromyalgia?

Women of childbearing age.

Women are seven times as likely as men to get the disease.

20-60 years old.

Caucasian

Etiology

There are several theories, none of them proven.

Decreased blood flow to the tender points.

Decreased blood flow to nerves or to brain itself.

Autoimmune causes such as lupus, etc. Hypothalamus dysfunction so that correct hormones are not released.

Changes in neuro-transmitters in brain, decrease in serotonin in brain. A decrease in this can also cause depression.

Previous trauma, such as an accident.

Sleep disturbance.

Association with an affective disorder. As many as 18 percent of patients also have depression.

Previous virus.

Clinical Characteristics

These patients usually report:

Diffuse aches or pains.

Multiple tender points, otherwise normal physical examination.

Non-restorative sleep (sleep many hours but not rested).

General fatigue.

Symptoms worsened by physical activity.

Effects of weather changes.

Anxiety or stress.

Chronic headaches.

Irritable bowel syndrome: Constipation, diarrhea, frequent abdominal pain, abdominal gas and nausea represent symptoms frequently found in roughly 40 to 70 percent of patients.

Subjective swelling and numbness (not evident on physical examination) Treatment

Reassurance and patient education that disease is not life threatening.

Syndrome will not destroy joints.

Syndrome will not shorten life.

Medication

Many have been tried but anti-depressants are most effective. This is probably because they increase serotonin (a neurotransmitter that modulates sleep, pain, and immune system functioning in the brain) and increase restorative sleep. Examples of drugs in this category would include Elavil, Prozac, Flexeril, Sinequan, Paxil, Xanax and Klonopin. In addition, nonsteroidal, anti-inflammatory drugs (NSAIDS) like Ibuprofen may also be helpful. One should avoid narcotic pain relievers.

Aerobic exercise.

Physical therapy and massage.

Trigger point injections.

Prognosis

One study found that:

55 percent still had moderate to severe pain after 10 years.

79 percent still took medications.

71 percent stated pain interfered very little with their ability to function and work.

A survey done in 1995 found that 25.3 percent of fibromyalgia patients received some kind of disability payment. Only 14.8 percent of the patients received Social Security disability benefits. These were patients involved in treatment with a rheumatologist.

Deciding Severity of Disability

In 1984, Congress passed the Disability Reform Act to deal with the evaluation of pain. Basically, it provides that if one has a diagnosed disease that could reasonably cause pain, then we (DEs) need to look at a description of the pain, precipitating factors, types and doses of medications. Fibromyalgia is a disease that CAN potentially cause pain, so a description of the pain needs to be considered. SSA obtains this through a ‘pain ADL’. We also need a medical report which should contain:

Accurate diagnosis made according to the above criteria. Clinical measure of severity including current tender points and physical exam findings.

Lab reports to rule out other potential causes of pain.

Response to treatment and any side effects of medications.

Current activities.

Work capacity - How many days per week or month are they severely affected?

Ability to concentrate.

Emotional features: How does this patient respond to chronic pain?

This is a disease which CAN be disabling but a diagnosis alone does NOT make it disabling. This disease is like other arthritic diseases in that it has periods of exacerbation and partial remission, so that patients function better during some periods and worse during others. It runs the spectrum from mild in some patients to extremely severe in others. Dr. Weaver has worked as an in-house physician at the Utah DDS and as a consultative examination panel physician for the South Dakota DDS.