Dr. Pellegrino explains his approach to fibromyalgia diagnosis and management as a board certified Physiatrist who has seen thousands of FM patients in his practice at Ohio Pain & Rehab Specialists. Dr. Pellegrino has been a fibromyalgia patient himself since childhood.
Numerous medical professionals and specialists treat Fibromyalgia. One specialty in particular, Physical Medicine and Rehabilitation, is especially skilled at diagnosing and treating this chronic condition.
A physician specializing in Physical Medicine and Rehabilitation is called a Physiatrist (pronounced fiz-eye-uh-trist).
The Physical Medicine and Rehabilitation specialty began in the 1930s to address musculoskeletal and neurological problems. Two historical events occurred to help shape and broaden this particular specialty.
• The first was the polio epidemic, which caused millions to suffer from acute pain and weakness and led to the physical medicine component of my specialty. Physical medicine modalities such as heat, electric stimulation, and water therapy, along with exercises to stretch, strengthen, and condition became important treatment approaches for acute polio, and ultimately for any problem that caused pain.
• The second event that helped shape the rehabilitation component of my specialty occurred after World War II. Improved medical technology and techniques on the battlefield, plus the availability of penicillin, led to increased survival among injured soldiers.
- Many soldiers with head injuries, spinal cord injuries, infections, and amputations survived. Consequently, the number of disabled soldiers increased. Rehabilitation strategies were developed to help these disabled veterans improve functional and vocational skills, and ultimately help them return to civilian society as productive workers.
- Thus, the rehabilitation component was more focused on optimizing functional abilities, and included retraining and an interdisciplinary team approach.
Focused On Restoring Function
Physiatrists treat a wide range of problems, from musculoskeletal pain to brain injuries. My specialty serves all age groups and treats problems that may affect all of the major systems in the body. The focus is on restoring function. A physiatrist diagnoses conditions that cause pain, weakness, and numbness, and may prescribe drugs, assistive devices, or a variety of therapies to improve functioning.
Specific philosophies unique to physiatry include:
• A team approach involving various medical professionals,
• Identifying rehabilitation goals to improve function, and
• Focusing on improving one’s quality of life.
The word “habile,” from which rehabilitation is derived, is Latin for “to make able again.” This word is an embodiment of our unique treatment philosophies.
This approach applies naturally to the diagnosis and treatment of Fibromyalgia because Fibromyalgia affects all aspects of our lives and makes it difficult to function. The Physical Medicine and Rehabilitation strategy empowers the Fibromyalgia person with abilities to improve the quality of life, even if the condition is still present.
My private practice group adopted a motto some years back: Reclaim Your Life! I think this is an apt statement of our main treatment goal, especially in the Fibromyalgia population.
Fibromyalgia Treatment Goals
It is a mistake to think of people with Fibromyalgia as if we all have the same thing.
Although we all have Fibromyalgia, we certainly do not behave in the same manner, nor do we all respond the same to treatment. What works for one person may not work at all for another, because each of us is unique. We each need to be handled with special unique care, and each of us needs to identify our own specific treatment goals.
Specific Fibromyalgia treatment goals that I identify for each individual include:
1. Decreasing pain, even if pain is still present. It would be great if everyone could go into remission and be pain-free, but this rarely happens. What usually happens is that the pain decreases, sometimes considerably, to a lower and more stable level. Some people achieve remissions where they feel hardly any pain.
2. Improving function. Even if the person is unable to resume activities enjoyed prior to developing Fibromyalgia, one can improve by learning to focus on current abilities. That is why I like the word “habile,” because it focuses on abilities, the positive. Too often, we tend to focus on the negative – our disabilities – by concentrating on things that we used to do. Remember habile!
3. Learning a successful program to self-manage the condition. Each of us with Fibromyalgia has to live with this condition every day, so we should try to find out what works and learn to do it ourselves. We can’t sling our doctors and therapists over our backs, carry them with us throughout the day, and pull them out when needed because of increased pain (this WOULD cause increased pain!). We must manage our pain as best we can by ourselves on a daily basis.
Again, one does not have to be a physiatrist to diagnose and treat people with Fibromyalgia. Many doctors and specialists want to help, will be open-minded, and use the best of all available treatment options to enable each individual to achieve the highest quality of life with the least amount of pain possible.
YOUR qualifications are the most important: YOU are the one with Fibromyalgia, and YOU must want to do better!
Evaluating the Patient
When I see a patient for the first time, I perform a comprehensive Physical Medicine and Rehabilitation evaluation. This includes a complete history and physical examination. I gather information on pain and various symptoms and particularly on how functional abilities have been impaired. Careful palpation is included as part of my physical examination. I examine the 18 designated tender point regions in addition to the rest of the musculoskeletal system to identify all areas that are particularly painful. I search for abnormalities that could help determine a diagnosis (spasms, weakness, swelling, etc.) Abnormalities are documented.
If the evaluation is consistent with Fibromyalgia, I document this diagnosis. I note any diagnosis that may apply to the individual’s pain, even if it is different from Fibromyalgia. For example, there may be shoulder bursitis, rotator cuff tendonitis, spinal facet arthritis, lateral epicondylitis ['tennis elbow'], hip sprain, or many other painful conditions.
I don’t simply put “Fibromyalgia” as a diagnosis, but try to be as descriptive as possible.
• If a cause such as trauma or infection can be determined, I will note post-traumatic Fibromyalgia or post-infection Fibromyalgia. [See also Dr. Pellegrino's articles on "Infection as One Possible Cause of Fibromyalgia" and "Fibromyalgia as a Complication of Injuries."]
• If the Fibromyalgia is widespread, I will note generalized Fibromyalgia.
• If it is more localized or regionalized, I will note regional Fibromyalgia.
• If certain areas are particularly flared-up, or if particular associated conditions such as myofascial pain syndrome, sleep disorder, and irritable bowel syndrome are present, I will note those as well.
[See also Dr. Pellegrino’s model describing FM as a broader condition including eight diagnostic subsets - “The Fibromyalgia Spectrum – Part of the Big Picture in Understanding Fibromyalgia”. These subsets range from most "normal" to most "diseased": from signs of being "predisposed" through to "regional" and "generalized" to "FM with associated conditions," "coexisting with mild disease," and "reactive to disease."]
“Mrs. Jones” – A Case Example
The following patient is an example of how I might approach my evaluation and conclusion. Mrs. Jones is a 36-year-old woman who reports pain throughout her body, particularly involving the muscles. She has a history of scoliosis. In her late teens she was involved in a couple of motor vehicle accidents where she had whiplash injuries. She received some therapies for these whiplash injuries, and said her pains completely resolved within a few months of treatment.
In her early 30’s she began to develop aches and pains that became more generalized and ultimately led to a diagnosis of Fibromyalgia. A month ago she took a job as a librarian and has noticed increased pain and fatigue since starting this job. Her mother has been diagnosed with Fibromyalgia. Mrs. Jones has two children, a 17-year-old son who has frequent headaches and a 20-year-old daughter who has scoliosis. Mrs. Jones’ examination revealed numerous painful tender points including 14 of the 18 positive designated tender points, but not the costochondral [second rib] or medial knee areas bilaterally.
I would diagnose Mrs. Jones with “generalized” Fibromyalgia [Subset 5 on the Fibromyalgia Spectrum]. I note that there are various contributing factors to her Fibromyalgia which include:
1. Heredity. Her mother has Fibromyalgia and her two children may have prodromal symptoms. [Subset 2, symptoms that precede or lead to FM.]
2. Scoliosis. This condition increases the risk of Fibromyalgia, presumably due to increasing strain on the back muscles and alteration of the biomechanics. This may be a form of cumulative trauma.
3. Trauma. This includes both the cumulative trauma from scoliosis and the trauma from the motor vehicle accidents. The accidents did not appear to cause the Fibromyalgia immediately because the pains disappeared after treatment, but they may have created pain memory and increased vulnerability that made it easier for Fibromyalgia to involve these injured areas at a later date.
Mrs. Jones’ Fibromyalgia represents a good example of how the exact cause may be unknown, but more than one factor is known to be involved. I may not know exactly which factor(s) caused the Fibromyalgia, but I know the cause is probably 1 or more of the three factors that I described. I would put Mrs. Jones’ Fibromyalgia in Subset 5, Generalized Fibromyalgia. The new physical activities required of her librarian job have caused a flare-up of her Fibromyalgia.
Different treatment recommendations for Fibromyalgia include reassurance and explanation of the disorder, removing any mechanical stresses, analgesic drug treatment, physical exercises, and psychotherapeutic support in a multidisciplinary setting (Dr. Spratt, 2003). Each Fibromyalgia patient requires an individualized program.
I review my findings and diagnosis with each patient. I discuss Fibromyalgia in detail and make treatment recommendations. Sometimes I recommend that other specialists be involved. For example, if I note my patient is clinically depressed, I may recommend a psychiatrist (specialist in depression) to specifically address the depression. I’ll certainly treat the Fibromyalgia, but I’m not a depression specialist.
My Fibromyalgia treatment recommendations will try to:
• Improve range of motion,
• Decrease spasms,
• Improve function,
• Increase knowledge,
• Develop a successful home program,
• Improve interpersonal skills and relationships,
• And optimize quality of life.
The first treatment (and the most important, I believe) is education.
[See the American Academy of Physical Medicine & Rehabilitation Website to locate hundreds of MDs who are Physiatrists - via a linked listing by state, city and Zip code, at www.aapmr.org/patients/findphysician/Pages/default.aspx]
* This article is reproduced with kind permission from Dr. Mark Pellegrino's classic book, Fibromyalgia: Up Close & Personal. © Anadem Publishing, Inc. and Mark J Pellegrino, MD, 2005. All Rights Reserved. This book may be purchased online at www.OhioPainRehab.com; or call toll-free, 1-800 529-7500.
Note: This information has not been evaluated by the FDA. It is not meant to prevent, diagnose, treat, or cure any illness, condition or disease. It is very important that you make no change in your personal healthcare plan or health support regimen without researching and discussing it in collaboration with your professional healthcare team.