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Post-Trauma Fibromyalgia Controversial? Says Who?

  [ 31 votes ]   [ 4 Comments ]
By Mark J Pellegrino, MD* • www.ProHealth.com • August 3, 2011


Dr. Pellegrino is a specialist in Physical Medicine & Rehabilitation who sees many people with chronic pain and has managed more than 20,000 Fibromyalgia patients in his practice at Ohio Pain & Rehab Specialists.

Based on long clinical experience, he ranks trauma second after genetics in his list of probable fibromyalgia causes, and sees it as one factor contributing to many physicians' anti-fibromyalgia attitudes. (See "Genetics - Fibromyalgia Suspect #1") This article is excerpted with kind permission from Dr. Pellegrino's book Fibromyalgia, Up Close & Personal.* Though it was published in 2005, and studies constantly add to the evidence that FM involves amplified pain, continuing patient difficulties finding understanding medical attention point to lingering scepticism regarding their symptoms.

Fibromyalgia as a Complication of Injuries

“The pain started after the car accident, and it has never gone away. Before the accident I was perfectly healthy, and now I hurt all over and nothing has helped.” This is a typical story I hear from patients who have chronic pain after a whiplash injury. Some of the treatments may have helped reduce the pain, but it didn’t disappear. Many times, the pain is localized at first to the neck, shoulders and upper back areas, but over time, other areas of the body begin to hurt just as bad. Eventually, the person may say the classic four-word sentence that practically epitomizes Fibromyalgia: “I hurt all over.”

Fibromyalgia caused by trauma is called post-traumatic fibromyalgia (PTF). (To read more about PTF, see "Fibromyalgia as a Complication of Injuries".)

Why are Many Physicians Reluctant to Believe in Fibromyalgia and PTF?

Some doctors declare their beliefs that fibromyalgia doesn’t exist and, most certainly, trauma could not possibly cause fibromyalgia, even if fibromyalgia did exist! Yet these same doctors are never heard to utter opinions that migraine headaches, depression, irritable bowel syndrome and other conditions do not exist.

We Know less about some of these conditions than we do about fibromyalgia, so why aren’t these doctors voicing opinions about other less understood conditions? Why are they reluctant to believe in fibromyalgia?

Anti-Fibromyalgia Bias

Perhaps some physicians have a strong bias against acknowledging fibromyalgia. Physicians, like everyone else, base their opinions on their education, experiences, and biases. If a physician never learned about fibromyalgia during medical school, or was told by an instructor that the condition did not exist, he or she may conclude, with conviction, there is no such thing as post-traumatic fibromyalgia/PTF.

These doctors will point to the absence of absolute proof, the "hard evidence," to bloster their expert opinion.

As long as there are doctors willing to voice their opinions, there will be those who say fibromyalgia doesn't exist or trauma cannot cause fibromyalgia. I have never understood how a doctor who adamantly denies the existence of a condition, and therefore has never "seen" it or diagnosed it, feels qualified to say it doesn't exist. I would not ask a medical colleague for a knowledgeable opinion on a condition if I knew that person never made the diagnosis.

I would assume that "no experience" with a particular condition means "no expertise" about the condition.

A Third Model for Chronic Pain

Some physicians have a misconception that chronic pain cannot exist unless a detectable tissue lesion is present and, if pain is reported, it must be solely psychological in nature. This belief is akin to saying the victim is responsible for the pain, rather than the whiplash trauma. Blaming patients for their symptoms is not what Hippocrates seemed to have in mind when he wrote about the care of patients nearly 2,500 years ago.

Dr. Muhammad B Yunus, an FM researcher at the University of Illinois College of Medicine, has proposed that the medical community embrace a third model to explain chronic pain that is different from the traditional dual model structural/anatomic pathology versus psychological explanation. He proposes a neuroendocrine dysfunction/central sensitivity model as a third way to correctly explain a condition like fibromyalgia.(1)

Fibromyalgia does not have structural changes in joints like degenerative arthritis. Nor does it have microscopic or usual lab changes of an anatomic pathological disease. Yet many abnormalities are found in fibromyalgia by specific biochemical and hormonal testing, EEG studies, or functional imaging of the brain.

These dynamic and dysfunctional abnormalities do not fit neatly into either the anatomic model or the psychological mdel, but define a unique "new" model. [See Dr. Pellegrino's article, "Fibromyalgia - Ultimately a Disease of Amplified Pain."] I hope doctors will be open minded in accepting this new manner of thinking about fibromyalgia.

Trauma Bias

There exists a bias among many physicians that trauma implies liability, which means potential lawsuits. The mere implication of "trauma" being involved in a medical diagnosis pushes sensitive medico-legal buttons in many. The actual appearance of the word "trauma" in a diagnosis such as whiplash trauma or PTF may be too difficult for some to accept, so the diagnosis is avoided.

Unfortunately, these medico-legal perceptions can carry over into the actual practice of medicine. Many physicians choose not to get involved in the treatment of patients with work-related injuries or motor vehicle accident injuries. They may feel threatened or uncomfortable with treating someone who may have an attorney because of trauma issues. I don't think we should let our perceptions of the legal system ever influence how we practice medicine.

Our country has laws governing liability issues related to trauma, so sometimes patients find themselves involved in litigation matters. Patients have legal rights, and their attorneys, not their doctors, can advise them of these rights. We doctors should practice medicine on patients who seek our help, regardless of whether they've had an injury.

The medical diagnosis of PTF is independent of any medico-legal activity the patient may be involved in.

Interestingly, an article published in the New England Journal of Medicine(2) tried to imply that litigation interfered with recovery. In reality, only a small percentage of patients with PTF are involved in litigation. Studies have shown the pain in PTF persists whether or not any financial settlement is awarded - Dr. Romano,(3) Dr. Waylonis(4). [And "According to the literature, it is probable that the number of cases that involve malingering or secondary gain is low." - Sukenik(5).]

Research studies performed in environments that are "hostile" to the whiplash-injured patient, e.g., countries with "no-fault" systems, no insurance benefits, or disapproval of medical treatments, must be interpreted with caution as the negative biases can cause the results to be misleading.

People with whiplash injuries and ongoing problems living in a "hostile" environment may choose not to seek treatment, may not be medically acknowledged if they seek help, or may be denied treatments by the insurance company.

The "whiplash ship" is sailing the seas looking for a friendly harbor to dock, but none exists. Yet the harbor masters (insurance companies, governments) are proclaiming that the coast is clear, and no whiplash problem exists!

It is unfortunate that the insurance industry and other special interest groups seem eager to perpetuate a myth that most people are faking their injuries and that whiplash trauma is not serious enough to cause chronic pain. The medical condition of post-traumatic fibromyalgia needs to be managed by medical doctors, and not by governments or insurance companies. The doctor appreciates the actual human patient who has real medical problems. The true malingerer is rare, and only a small percentage of those with fibromyalgia are ever awarded disability benefits or financial settlements.

The vast majority of people with fibromyalgia are truthful and reliable. They are seeking help for their chronic pain and want to improve their quality of life. A few may ultimately be forced to seek financial relief options, such as applying for disbility benefits because of the severity of their condition, which prevents them from sustaining employment.

Many people with PTF have not had any treatments despite the chronic pain and functional impairment. They are not seeking "secondary gains" or some type of reward for their pain such as therapies, money, or an excuse not to work. If you ask these people, they will tell you there is no "reward" to having a condition that causes severe pain for the rest of their lives.

Consensus View

Sometimes the well-ingrained perceptions among scientists and physicians hinder the ability to be open-minded and see ideas from a different perspective. This "consensus" view can be wrong because science is not determined by consensus. Galileo was judged to be wrong by his peers for his view that the earth rotated around the sun. The consensus opinion against Galileo resulted in his imprisonment. Today, we know he was right.

In 1983, two doctors, Dr. Barry Marshall and Dr. Robin Warren, said bacteria caused stomach ulcers and the ulcers should be treated with antibiotics. They were ridiculed by their gastroenterologist peers because the consensus at the time was that ulcers were caused by stress and poor diet and the treatment was acid-neutralizing drugs. Today, a bacteria called Helicobacter pylori is recognized as the major cause of stomach ulcers, and is treated with antibiotics.

Consensus is not science, and neither is the belief that something cannot exist unless absolute proof is available.

Physicians who treat PTF could use the same rigorous absolute proof standard to support their conclusions as those wh don't belief in PTF. Just as one doctor may say there is no absolute proof that says whiplash trauma causes fibromyalgia, another doctor can say there is no absolute proof that whiplash trauma does NOT cause fibromyalgia.

We are allowed to accept the notion that trauma from whiplash injury caues severe injuries, and some injured patients get fibromyalgia because no other explanation accounts for the observations, experiences, and scientific studies we've accumulated to date. We are not abandoning  scientific standards, rather we are accepting the evidence we have as the most reasonable explanation.

Ultimately we are trying to help the patients do as well as they can. Because at the end of each day, when the courtrooms are quiet, and when all the scientists, medical experts, and authorities have gone to bed, the patients still have pain and need our help.

I have learned from patients that they are most concerned about what's going to happen to them and what can they do to help their condition. Patients do not care about the attempts by disbelieving doctors to create "controversies" regarding whiplash related fibromyalgia.

The patients already know their trauma was the cause of their fibromyalgia. They want their doctors to help them make the best recovery possible and restore as much ability as possible, not to tell them that some think their condition is "controversial."

* * * *

FIBROMYALGIA CONTROVERSIES: POINT-COUNTERPOINT
by Mark J Pellegrino, MD

Point: No obvious pathology in fibromyalgia
Counterpoint: We know a lot about the pathophysiology and have objective tender point abnormalities

Point: Therapy does not cure fibromyalgia
Counterpoint: Treatments can heal/help fibromyalgia even if there is no cure

Point: Treatments are costly
Counterpoint: What is the price of improving quality of life?

Point: No proof that trauma causes fibromyalgia
Counterpoint: Much evidence that trauma causes fibromyalgia. No proof that trauma DOESN'T cause fibromyalgia

Point: Legal system too involved in fibromyalgia
Counterpoint: This country has laws regarding trauma and liability

Point: Labeling people with fibromyalgia has gotten out of control
Counterpoint: Fibromyalgia is a legitimate, valid medical diagnosis

Point: It is a syndrome, not a disease
Counterpoint: It is a disease of pain perception

Point: We should limit treatments of fibromyalgia
Counterpoint: We should teach home programs and personal responsibility

Point: A few people use most of the care
Counterpoint: Some require more treatments to achieve a better outcome

Point: Fibromyalgia is over diagnosed
Counterpoint: Fibromyalgia is undertreated

Point: There should be no disability awards for fibromyalgia
Counterpoint: Each person's situation is unique and decisions regarding disability should be individualized

Point: Illness magnified by medical model of care
Counterpoint: Illness helped by chronic pain approaches

____

Resources:

1. Muhammad B Yunus was the first to publish a study describing FM's clinical characteristics, nearly 30 years ago. In 2000 he published the article, "Central Sensitivity Syndromes: A unified concept for fibromyalgia and other maladies," JIRA 2000;8:27-33. In June 2007 and Jan 2008, he published reports in the journal Seminars in Arthritis and Rheumatism suggesting that Fibromyalgia and overlapping disorders be categorized as "Central Sensitivity Syndromes" (CSS), based on "mutual associations" and evidence for central sensitization (hypersensitization of the central nervous system) among several of the disorders.

2. "Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury."

3. "Clinical Experiences with Post-Traumatic Fibromyalgia Syndrome."

4. "Post-Traumatic Fibromyalgia: A Long-term Follow-up."

5. "Physical Trauma and Fibromyalgia - Is There a True Association?"*

Note: This article is excerpted with kind permission from Dr. Pellegrino’s book, Fibromyalgia, Up Close & Personal © Anadem Publishing, Inc. and Mark Pellegrino, MD, 2005. You may purchase a copy of this highly recommended book by contacting Dr. Pellegrino's office at the Ohio Pain & Rehab Specialists Center (Phone: 330-498-9865, Toll-Free: 800-529-7500).




Discuss This Article Post a Comment 


Old Controversy?
Posted by: rtspivey
Aug 3, 2011
The fine print of this article shows the original publishing date of 2005! Is this content still relative six years later? I believe that some of the controversy about Fibromyalgia has resolved. There is still a long way to go to reach widespread understanding and acceptance of the diagnosis, but instead of inviting unnecessary reactions of frustration over the content of this article ProHealth should have made it clearer that the content may no longer be relative.and NOT in fine print at the end of the article) that the
Reply Reply

stating old facts that are not current
Posted by: msfortescue
Aug 3, 2011
I agree with comment above. This article is six years old and though much of the information may have been valid at one time, it is no longer valid simply due to the dated nature of the article. Information and medical perspectives have changed drastically, contrary to what Dr. Pellegrino states here. If his book was written in 2005, it would be counter-beneficial to encourage readers to order it now. It needs to be updated and completely revised in many sections. For more detailed, simple and complete information that is time sensitive, all readers would benefit from checking out videos currently on line by Dr. Johnathan Kuttner. His article encompass a wider view of useful information including very specific ways for readers/listeners to help themselves. He gives easy-to-understand accurate and detailed descriptions of fibromyalgia's many components starting with a simple explanation of pain, how it happens and why it happens. He is a prime example of having experienced severe physical trauma, particularly to the neck, so he, too, is a living testimony to how fibromalgia develops, acts, and can act or come about. His website is excellent, as his goal is to reach and help as many people as possible. Dr. Pellegrino should re-think ways of making his expert experience and information more widely available than just through this website, AND less expensive seeing that the folks who may need the information in his book (if it is updated) are the ones least likely to be able to pay that price for it. Yes, there is no price on good health, but we live in reality where not everyone can afford to abide by that premise.
Reply Reply

GREAT ARTICLE -- THANK YOU PRO-HEALTH!
Posted by: beartow
Aug 4, 2011
For someone who has never read this article, like me, this was very informative. So thank you very much ProHealth for sharing -- whether the article is considered outdated or not. Much appreciated. Genetic? Trauma-induced? Whiplash injury? Combination of? Who knows? Unless you go through the H-e-ll (excuse my language) of fibromyalgia yourself. And even then one doesn't know what caused it. One can only guess. Maybe put a before-and-after together, then surmise. That is where this article was VERY helpful to me. As I look back on my childhood with "Charlie-Horses" so agonizing that I remember my parents standing by my bedside looking scared and helpless. They themselves trying to figure out what was wrong, who in the family also suffered so, and what was causing me such agony? Then being involved in a car accident at the age of 16 through no fault of my own, before seatbelts, and suffering an unrealized major whiplash injury. I wasn't bleeding to death so no need to go to the doctor! Then the headaches and backpain started. The "talk" of whiplash just coming into vogue. But no help for me. Being made fun of because I started to walk and stand funny -- favoring one side of my hips over the other. I'd already suffered a lifetime of ridicule from family members because I had a difficult time settling down in school with a difficult time learning. What I've since learned this is "quiet attention deficit disorder". In other words, I wasn't disruptive to the classroom. And now the not-smart child was becoming even more problematic. So the "odd" child left home and got married at a very young age, because I knew I was different, and there really wasn't much hope for me. Then I went on the birth control pill! That's where the never-ending nightmare really began! The first doctor to even breathe the word fibromyalgia to me was my chiropractor. Imagine that! Chiropractors who endured years of ridicule also. But it meant nothing to me -- because what I accepted as normal -- really wasn't! The joke would soon be on me! Years later, my older cousin started suffering from "something" so bad she couldn't move. I pooh-poohed it! I, myself, was suffering from this "something" -- but I had not yet gone into the "darkest depths" of fibro. Then it hit! Head-to-toe, total, body-consuming pain. Bedridden for a year. Doctors telling me "It will get better". Doctors telling me "I shouldn't be experiencing SO much pain". Doctors calling me a "space cadet". So I Pro-Actively spent thousands-upon-thousands of dollars on shoes, orthotics, various types of therapies, on supplements and vitamins in order to crawl out of the cave into sunlight. And I literally mean crawl! So why expect doctors to believe in something that I, as one who unknowingly had this disease, didn't believe in either? Doctors getting mad at me because it has taken me so long to "recover". Doctors throwing papers down on their desks when I ask for their help in filling out an insurance form -- for something that I had paid for my entire working life -- before I couldn't work any longer. Oh yeah, things have changed all right..... I had to do MY own research on fibro to include PMS, polycystic-ovarian syndrome, hyper-mobility, irritable bowel syndrome, eye/muscle weakness problems. Researching on food, alcohol, drug and chemical sensitivities, etc. Living in daily fear that "some unknown" may trigger a relapse - yet trying to put up a brave front. Yet I'm thankful I'm still alive, and I try to live life to MY fullest, which is all I can do. Others don't accept IT, and I still don't accept IT, and I hate IT. But IT is real! Trust me. I know! Whether doctors believe me or not! May God Bless Each and Every One of You on this ProHealth Site. You've been such a great blessing to me, and I'm sure to millions of others. Thank you, so very, very much!
Reply Reply

Trauma and FMS
Posted by: IanH
Aug 10, 2011
One of the issues in this is that FMS is unclearly diagnosed and distinguished from ME. At least 40% of poeple with ME fit the criteria for FMS and vice versa. If you have ME (with FM) then your immune system is dysfunctional and if you have any musculo-skeletal pain it will be amplified. Normal stress points in tendons which in most people build discomfort on palpation will be amplified. Torsion of muscle tissue will induce an immunological response and in people with ME this will be painful. There is no trauma as such but if there is, such as in whiplash injury the pain experienced will be much more than objective data suggests. In this sense trauma is a cause of FMS. It can probably be an independent cause too - the point Mark Pellegrino is supporting.
Reply Reply


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