Clinical Experiences With Post-Traumatic Fibromyalgia Syndrome
By Author: Thomas J. Romano, M.D., Ph.D •
January 2, 1996
Fibromyalgia Syndrome (FS) is a common yet relatively newly-recognized musculoskeletal problem that recently has been the subject of many studies and reviews (1-4). FS is characterized by polymyalgias, muscle tautness and muscle stiffness, accompanied by well-defined and amply described tender/trigger points, fatigue and non-restorative sleep. Neuropathic symptoms (e.g. numbness, tingling, lancinating pain) and anxiety are also frequent problems in FS patients (5). Three major types of FS exist. The first type, idiopathic or primary fibromyalgia (PFS), occurs for unknown reasons, but is aggravated by such factors as overuse, stress, poor sleep, weather changes, etc. No other medical problem is recognized in patients with primary FS.
In contrast, the second type, secondary or concomitant FS, occurs in patients with well-recognized medical problems, usually chronic in nature, but it is otherwise clinically identical to primary FS.
The third type of FS, and the variety about which this paper is concerned, is called post-traumatic FS (PTFS). It occurs in the setting of an acute injury, after which signs and symptoms of FS appear. Frequently, such patients are engaged in litigation to obtain funds necessary to compensate them for their medical bills and loss of income while unable to work. Because monetary matters are involved, there is a tendency on the part of some individuals (not surprisingly, insurance company adjusters, opposing attorneys, etc.) to accuse the patient of malingering or to suggest that PTFS patients are exaggerating their pain for the purpose of monetary gain. lf that were true, PTFS patients probably would not continue to see their treating physicians after a monetary award was granted either by a court or as a settlement before trial (i.e. they would "take the money and run"). This article demonstrates that the vast majority of PTFS patients continue treatment after a monetary award is obtained, suggesting that PTFS indeed is the cause of much suffering, and should be treated as a bona fide medical disorder.
PTFS was diagnosed in 14 patients (11 women, three men) in a general rheumatology practice between 1985 and 1989. The mean age was 37 for women and 37 for men. The vast majority of PTFS patients (12 of 14) seen in this four-year period were injured in auto accidents, but one case was precipitated by a fall, and another was a work-related injury. All the patients complained of fatigue, nonrestorative sleep, polymyalgias, and polyarthralgias. In addition, they reported an inability to work or perform activities of daily living such as shopping, running the sweeper, doing laundry, washing dishes, and lifting without precipitating a flare-up of their generalized painful condition, necessitating a long rest period to help control the pain. None of the patients had any signs of inflammatory arthritis, although signs of degenerative joint disease were present in four patients (Heberden's nodes in two women (ages 49 and 66) and in one 43-year-old man). Left knee crepitus was present in a 36-year-old man who had a high school sports injury. These findings were felt to be consistent with the patients' ages and past history, and were not causing symptoms prior to, or subsequent to, the accident.
All patients fulfilled the criteria for FS outlined in Table 1, and also fulfilled the new FS criteria proposed by the National Multicenter Fibromyalgia Criteria Committee (of which this author is a member) (5).
A careful "tender point count" was made on each patient. This entailed manual palpation of typical defined anatomic areas, many of which are illustrated in Figure 1. In addition, other areas such as the low cervical area, located at the anterior aspects of the inter-transverse spaces at C5-C7 and the paraspinous area three cm. Iateral to the midline at the level of the mid-scapulae, were palpated. Other "control" or typically non-tender areas were also examined. These included, but were not limited to, the forearm, thumbnail and mid-foot areas. A patient who was tender at the "control" sites or who complained of pain wherever he/she was touched would not meet classic FS criteria.
ln addition to a tender point count, dolorimetry testing was done. A dolorimetry is a pressure algometer. It is a spring-loaded gauge attached to a rod with a soft rubber stopper at one end. The other end of the rod is attached to the spring (Figure 2). The patient undergoes testing by having certain anatomic areas placed in contact with the rubber stopper. The shaft of the instrument is then advanced slowly (about one kg. per second) by the examiner, and progressively greater pressure is applied until the patient complains of pain. At that point a numerical value is assigned to the area tested. Higher numbers (e.g. five kg. or greater) indicate that the particular anatomic area is relatively insensitive to the pressure. Lower numbers (typically two kg. or less) suggest tenderness or sensitivity to pressure.
In order to help distinguish between the malingerer and a patient who is truly in pain, and to avoid confusing FS with other pain states such as psychogenic rheumatism and somatization disorders, three "control" sites were tested in addition to the six sites that tend to be sensitive to pressure in FS sufferers. Low values in the "control" sites would tend to rule out FS even if other typical sites were tender. The "control" sites were the right thumbnail with the thumb placed on a flat surface like a desk or table, the dorsal distal third part of the right forearm, and the mid-point of the dorsal right third metatarsal. The six typical tender sites were also located on the right side of the body (by convention). These are the occipital area, trapezius muscle at the mid-point of the upper border, paraspinous muscle, second costochondral junction, lateral humeral epcondyle, and the medial knee fat pad (Figure 3).
All 14 patients had abnormal dolorimetry, with at least four of the six typical tender sites having scores of two kg. or less. None of the patients had "control" site values of four kg. or less.
Laboratory testing such as a complete blood count, Westergren erythrocyte sedimentation rate, electrolytes, liver function tests, kidney function tests, anti-nuclear antibody, and rheumatoid factor were all negative or within normal limits. None of the men was HLA-B27 positive. Bone scans, x-rays, CT scans, and electromyograms were performed where indicated. None was revealing.
None of the 14 patients was thought to be suffering from any other active disease at the time of evaluation, nor did any of the patients appear to be malingering or exaggerating his or her symptoms for the purpose of secondary gain. Therefore, I made the diagnosis of PTFS and initiated therapy.
The treatment of FS, regardless of the variety, can be difficult, and many approaches exist (7,10). Often, the diagnosis is delayed. In this series the mean length of time from the date of injury to date of diagnosis of PTFS was 17.3 months. Table 2 illustrates the time frames in question as well as other patient data. Despite this delay in treatment, many patients were helped, although the details of their response to treatment is outside the scope of this paper. The treatment included reassurance that the FS patients' pain was real and that it should cause concern but not worry.
I stressed that the patients must become active participants in their treatment and not merely passive recipients of medical care. Support from family and friends was encouraged as it is very helpful, if not essential. I also explained that no single "miracle drug" cures FS, but that certain medications can be very helpful.
Most frequently used medications were tricyclic agents, especially at bedtime. These included amitriptylene, nortriptylene and doxepin. Recently (10), cyclobenzaprine has been found to be very helpful at bedtime in doses ranging from 10-40 mg. It too is a tricyclic agent, but it also has direct muscle relaxant properties. Other muscle relaxants and mild-to-moderate narcotic analgesics such as acetaminophen with codeine or propoxyphene have also been used.
Many patients have required such physical therapy modalities as massage, acupressure, ultrasound, hot packs, "spray and stretch" treatments, and aerobic conditioning. Despite the use of all of the above modalities, some patients continued to have active FS with tenderness of specific muscles or muscle insertions, and muscle tautness and stiffness. These patients were good candidates for injection of a local anesthetic, with or without a glucocorticoid preparations, into trigger points. I usually injected the affected areas with two ml of one-per cent lidocaine or procaine with or without two to five mg. triamcinolone hexacetonide. This usually gave prompt, albeit temporary, relief, and was followed by local application of heat and avoidance of such aggravating factors as overuse of muscles and insufficient sleep. In some patients, the beneficial effects of these injections lasted for weeks or months, which far exceeded the half-life of the injected medications. Interruption of pain-spasm-pain cycle is thought to be a mechanism of action of these injections.
Patients under active care tended to be seen every four to six weeks and, when the FS got under better control, the interval between visits lengthened. Although the FS patients made progress, there were no cures. FS can be worsened by such aggravating factors as stress, overwork, etc. The stress of impending litigation may have contributed to the slow progress of some patients.
As outlined in Table 2, nine of 14 patients (64 per cent) continued to be seen in my office for the continued treatment of their PTFS after receiving a cash settlement or cash award from a civil court. The monies awarded ranged from $45,000 to $300,000. One patient (no. 11) moved out of the tri-state area and is currently being followed by another rheumatologist. Three patients (21 per cent) (Nos. four, five and 13) did not keep their follow-up appointments and have been lost to followup. Patient number seven was judged so much improved after one subsequent visit that she was referred back to her local doctor, and is being managed successfully by him.
Of the nine patients who have continued treatment with me, five have resumed employment (three full time, two part time), four have been discharged from physical therapy as having been improved and given home exercise programs, and six have ceased using narcotic-containing analgesics.However, there are times when FS symptoms become worse (periods of stress, sudden weather changes, periods of over-activity), and more intense treatment becomes necessary. Many of the problems can be handled over the phone, but patients were seen in the office before their regular appointments when necessary.
FS is a very common musculoskeletal disorder that literally affects millions of people in this country. It is a soft-tissue rheumatism condition that is becoming increasingly well recognized as a cause of chronic pain and discomfort, lost days from work, and decreased work efficiency. It has been estimated that FS may be the third most common rheumatic disorder (11), and is likely to confront physicians of all specialities. My experience parallels that of Mazanec (12) in that a great number of my patients suffer from FS. Nationally, the male:female ratio is 1:10. In the upper Ohio Valley it is about 1:3 (13). In PTFS, no such statistics are available to date, but the patient population in this study demonstrates a male:female ratio of 3:11 or 1:3.7, which is very similar to the PFS profile in this area.
The PTFS patients appeared to be helped by treatment, but several obstacles to treatment are found when dealing with these patients, as opposed to other accident victims who have sustained more obviously debilitating problems such as the loss of a limb, blindness, or multiple-organ system trauma. One obstacle is the delay in diagnosis. The longer a chronic pain state exists the more difficult the treatment. The hope of full recovery diminishes with time. With better recognition of PTFS, hopefully diagnosis can be made quickly, and appropriate treatment initiated.
Another roadblock confronting PTFS patients is the perception that they are malingering or are exaggerating their symptoms. There is no doubt that such exaggeration exists, but it is rare. After reviewing my records l can honestly say that in the nearly eight years of private practice I can count on the fingers of my hands the number of people who I felt had either psychogenic rheumatism, a somatization disorder, or who were out-and-out malingering.
Secondary gain is another issue. Patients with FS are in pain and want relief. Moreover, they want those closest to them to offer comfort. It is not inconceivable that some may adopt certain forms of behavior that help them obtain those goals, especially if they have been told that there was nothing wrong with them, or were made to feel in some way responsible for their disorder. The physical examination and dolorimeter testing in these patients, however, demonstrated that these patients have a definable soft-tissue rheumatism disorder, and that there was no evidence of malingering. On the contrary, the patients with PTFS were very helpful to the examiner. They would very accurateIy and reproducibly provide a tender point profile that fulfilled diagnostic criteria for fibromyalgia.
A third area which can cause confusion and render treatment less than optimally effective is the subject of litigation. Increased musculoskeletal pain prior to a trial or settlement meeting can be viewed in many ways. I tend to interpret these FS flare-ups as exacerbations of a painful state brought about the stress involved in legal proceedings. Those who feel such patients are dishonest might interpret an increase in symptoms as a ploy to obtain a larger award. The only way to settle this disagreement is to analyze what happens once PTFS patients are done with litigation and have obtained monies to be used to defray past, present and future medical expenses incurred as a result of their injuries. The vast majority of such patients (71 per cent) are still under the care of a rheumatologist. They have not been ordered by the court to be seen for treatment. They come willingly. While there is no cure for PTFS, there is good treatment which should and must begin within an atmosphere of mutual trust and respect.