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.*
“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).
Trauma to the body causes tissue damage. Whereas healing is the expected outcome for trauma, it doesn’t always happen and PTF can develop. PTF does not occur immediately after an injury; it takes time to evolve and fully develop the characteristic tender points in distinct locations.
Just as trauma other than motor vehicle accidents can cause whiplash-type injuries, trauma other than whiplash-related ones can lead to PTF. Lifting injuries, falls, work injuries, sports injuries, and repetitive-type injuries are examples of other kinds of non-whiplash trauma.
The medical literature has numerous examples of persistent pain following trauma. Since fibromyalgia criteria were established by the American College of Rheumatology study published in 1990, various articles have appeared in the medical literature about PTF.
• Dr. T.J. Romano wrote in 1990 about patients with PTF who continued to require treatment for their condition years after settlement of litigation. (“Clinical experiences with post-traumatic Fibromyalgia syndrome.” )
• In 1992 Dr. S. Greenfield published a paper describing reactive Fibromyalgia syndrome in patients who report trauma as a precipitating event. (“Reactive Fibromyalgia Syndrome.”)
• Dr. G.W. Waylonis published a paper entitled “Post-traumatic Fibromyalgia, A Long Term Follow-Up” in 1994 that described a follow-up of 176 patients with PTF.
• Dr. F. Wolfe wrote a paper, “Post-traumatic Fibromyalgia: A Case Report Narrated by the Patient” in 1994.
• Dr. D. Buskila’s 1997 study showed a higher rate (about 22%) of fibromyalgia following trauma to the cervical spine (neck). (“Increased rates of fibromyalgia following cervical spine injury: A controlled study of 161 cases of traumatic injury.”)
A study by Dr. H.R. Walen (Journal of Musculoskeletal Pain, 2001) showed a remarkably high prevalence of over 90% of patients reporting at least one traumatic event prior to the onset of fibromyalgia symptoms. More and more researchers seem to be reporting on the importance of physical trauma as a factor in the development of fibromyalgia.
Among doctors in private practice, many (including me) have reported over half of fibromyalgia patients attribute the onset of their symptoms to a traumatic event. In my own private practice, about 65% of patients report a traumatic injury as the cause of their fibromyalgia….
Trauma-related fibromyalgia, or PTF, is a specific medical condition that exists regardless of individual physician’s beliefs or opinions. This diagnosis is never assumed before a patient is seen, or from the patient’s history alone. In order for a physician to diagnose PTF, information from the overall clinical evaluation needs to be analyzed. This evaluation includes the patient’s history and physical exam, supplemented by any diagnostic testing and review of any previous medical records. The final diagnosis of PTF is made if the total clinical picture “fits.”
PTF can be diagnosed if these features are present:
1. No previous pain complaints before the trauma similar to those experienced since the trauma. That is, the person didn’t already have a pre-existing fibromyalgia diagnosis or fibromyalgia-like symptoms before the trauma.
2. History of a trauma that led to the pain.
3. Pain resulting from the trauma that has persisted ever since the trauma. I call this the “unbroken chain of pain.”
4. Widespread pain persisting for at least 6 months after the injury, well beyond the usual soft tissue healing time.
5. The presence of characteristic painful tender points as defined by the American College of Rheumatology criteria; i.e., at least 11 of 18 positive tender points. If consistent reproducible tender points are present only in an injured region and not widespread, a subset of fibromyalgia – post-traumatic regional fibromyalgia – may be considered.
A person can be diagnosed with PTF after one evaluation with an experienced physician. The physician does not have to order specific tests first, or reevaluate the patient over time, to conclude PTF is present. The tender points are the key findings on exam, but muscle spasms and trigger points may be helpful to the physician to clarify the diagnosis. The physician’s exam will provide clues if something other than fibromyalgia (e.g., inflammation, or neurological disorder) or in addition to fibromyalgia is present.
Conditions in addition to PTF are often present.
They can include, but are not limited to, post-concussive syndrome, disc disease, facet dysfunction, and reflex sympathetic dystrophy.
After the initial diagnosis of PTF, the patient may visit the physician for subsequent evaluations to review the condition and effects of any treatment. Re-demonstrating the initial tender points upon follow-up examination is a reliable and supportive physical finding of PTF. The exam abnormalities are expected to persist over time in PTF, and the physician can confirm this expectation upon re-evaluation at a later date.
The ability to diagnose PTF is not dependent upon the person being seen immediately after the trauma. PTF takes time to develop, and once it does, it leaves telltale puzzle clues. If the pieces of the puzzle fit and form the “big picture,” a diagnosis of PTF can be made…
MECHANISMS OF PTF
There is a difference between cause and mechanism. The cause is WHY something developed. Trauma is the cause of PTF. The mechanism is HOW something developed, or the pathological events that led to the problem. If you fall on the ground and break your hip, trauma is the cause of the broken hip (WHY you have a hip fracture). The pathological mechanism of injury (the HOW) is that high amounts of compressive forces (momentum) impacted the hip and resulted in a fracture.
Many times it is difficult to determine if an abnormal research finding is part of the cause or the mechanism of fibromyalgia. Changes occur after fibromyalgia has developed, so an abnormality can be one of the consequences of fibromyalgia.
It’s like asking the famous question, “What came first, the chicken or the egg?”
INJURY PAIN MECHANISMS
Damage to body tissues from an injury can occur from muscle strains, ligament sprains, disc tear or herniation, joint impaction, direct nerve trauma, swelling and inflammation. A combination of injuries activates the normal pain cascades from multiple locations, bombarding the spinal cord and brain with pain signals.
Dr. Rajesh Munglani recently published a good review article on the neurobiologic mechanisms that can occur with whiplash injuries (Journal of Musculoskeletal Pain, 2000 – “Neurobiological Mechanisms Underlying Chronic Whiplash Associated Pain”). His descriptions help explain how some people develop chronic pain and others do not.
The road to PTF travels first through acute pain, and then chronic pain. As noted, PTF does not happen immediately after the accident. It takes time to fully evolve.
Presently, we have no way to determine which injured people will get PTF and which ones will heal and not develop chronic pain.
Complete healing without residual pain is attempted in all with injuries, and expected in most. If chronic pain persists several months after an injury, complete healing is not likely to occur, and the risk for getting PTF increases.
Let’s review the neurobiological mechanisms that lead to fibromyalgia after an injury.
• Nerve injuries, tissue inflammation, soft tissue damage and scarring activate the nociceptors (specialized nerve endings where pain originates) and signal pain. Localized injuries to the muscle components (spindles, intrafusal fibers, calcium pumps) can create biochemical, hormonal, and red blood cell changes that interfere with cells’ ability to receive oxygen, glucose, and other nutrients.
• Blood flow, energy formation, and bioelectrical harmony are all disrupted. In those who ultimately develop PTF, the nociceptors probably remain “faulty” and continue to signal pain. Like faulty electrical short-circuits, the nociceptors continue to release pain-producing neurotransmitters.
• Hypersensitization of the nociceptors also occurs, so they respond more dramatically to any stimulation (called allodynia). The nerves cannot “turn off” these continuous painful signals and undergo profound functional changes. Pain arises spontaneously from the nerves, causing the person to hurt “for no obvious reason.” Instead of waiting to be signaled from outside sources such as trauma, pressure, touch, or temperature changes, the nerves signal spontaneous pain without any outside help.
• Furthermore, permanent nerve changes cause outside sensory signals to be misinterpreted as pain. Instead of feeling ordinary touch, movement, or pressure, one feels painful touch, throbbing movement, and stabbing pressure. This exaggerated painful interpretation of ordinarily non-painful sensations is known as allodynia.
[For a detailed plain-language explanation of the mechanisms by which trauma and tissue injury may trigger persistent activation step-by-step throughout the pain pathway from nociceptors to brain, see Dr. Pellegrino’s article “Fibromyalgia – Ultimately a Disease of Amplified Pain”.]
Ongoing peripheral input that feeds into the centrally sensitized “fibromyalgia pain cascade” comes from different injured tissues. These areas are known as “triggers” or “pain generators” and can occur wherever there is residual damager or instability from injury. A number of pain generators exist and include:
1. Muscle triggers. Ongoing muscle spasms and restrictive muscle scars are examples of persistent triggers that can exist in muscles. Muscle bundles may go into protective spasms whenever there is inflammation or potential irritation in the region. For example, someone with a low back disc herniation may have spasms in the low back muscles as an involuntary attempt to protect, or guard from movements of the back. Any back movement could cause further damage or inflammation from the already damaged disc.
In PTF, muscles have a double whammy effect on the pain-generating cascade. The injury itself caused muscle damage and persistent localized spasms, causing ongoing pain signals. But the muscles may be forced to work harder because tother tissues (e.g., discs, facets, ligaments) were permanently damaged and cannot do their jobs of stabilizing the spine. Hence, the muscles tighten and spasm up to assist in the stabilization, and more persistent pain signals are sent…the double whammy effect.
2. Facet joint dysfunctions. Australian researcher Nikolai Bogduk and his colleagues have demonstrated how the cervical facet joints (joints in the vertebra of the neck) especially are a major trigger of chronic pain. The facet joints may be unstable because the capsular ligaments were damaged or overstretched from the whiplash. Loose ligaments cannot hold the joints together as tightly as needed to stabilize them, and any “extra” movement in the facet joints triggers pain. The facet joints may be too restricted or tight, leading to instability. Muscle spasms can tighten or restrict the facet joints, causing pain from immobility.
3. Intervertebral discs. These areas can become chronic pain generators if the whiplash trauma caused tears or defects in the disc’s annular ligament. Dr. Bogduk’s work noted up to 50% of chronic whiplash patients have problems with these discs.
4. Nerve injuries. Direct injuries to nerves can result in chronic pain generation, as opposed to indirectly signaling chronic pain through normal uninjured nerves. Nerve roots, brachial plexus, and sympathetic nerves can all be bruised, stretched or damaged from the whiplash trauma and never heal properly, causing chronic pain signals.
All of the above sources can feed into the sensitized central nervous system (spinal cord and brain) and maintain, aggravate, and permanently worsen the PTF’s chronic pain state.
TREATMENT OF POST-TRAUMATIC FIBROMYALGIA (PTF)
Just as in nontraumatic fibromyalgia, no one single treatment eliminates the symptoms of PTF. Currently there is no cure for this disorder. However, various treatments can help those with PTF even if the condition is not cured. Each person’s treatment program needs to be individualized, and what works for some may not work for others. Hopefully each patient will find some treatment that helps to deal with the chronic pain.
[Other chapters on medications, therapeutic injections, and physical medicine treatments] review in detail the various treatments for fibromyalgia. The treatments for PTF are really the same, since fibromyalgia is fibromyalgia regardless of the cause!
Overall, six main treatment goals can be identified for each person with PTF:
1. Decrease pain. The ideal goal is to eliminate pain altogether, but this rarely happens because PTF has no known cure at this time. Many treatments can reduce the pain, however, even if it is still present. Sometimes a remission occurs where the pain is hardly noticed although painful tender points are still palpable on exam.
2. Improve function. The ability to perform everyday activities such as dressing oneself, driving, moving about, and eating is the basis for “quality of life” issues. If pain interferes with basic daily activities, the patient with PTF usually reports a poorer quality of life. Pain can interfere with work abilities, especially if the job requires a lot of reaching, bending, or lifting. Optimizing job functions is an important treatment goal.
3. Promote healing of any residual injuries. If residual damage to tissues is still present and contributing to pain, instability, ongoing irritation or inflammation, then treatments to promote healing of this damage should help.
4. Prevent worsening or complications. If residual damage to tissues is present and cannot be healed, then the goal becomes avoiding further damage or complications.
5. Decrease the risk of re-injury or flare-up. If PTF is chronic and permanent, than a goal is to keep it at a stable baseline, or a level where the pain can be successfully managed. A stable baseline free from annoying flare-ups may sound boring, but is exactly what is hoped for.
6. Find a successful home program to control symptoms. This goal is the ultimate prize. One hopes the therapy program works, and learns to do the program on his/her own to maintain a stable baseline.
In PTF, various types of treatments are prescribed in order to achieve as many individual treatment goals as possible. Some treatments may work better than others, and usually the combination of all the different treatments can lead to overall improvement.
* This article is excerpted with permission from Dr. Pellegrino’s very popular book Fibromyalgia: Up Close & Personal, © Anadem Publishing, Inc. and Mark Pellegrino, MD, 2005, all rights reserved. The book also includes chapters on trauma, the whiplash injury and specific types of whiplash, the evaluation and treatment of injuries, and the legal aspects of post-traumatic fibromyalgia. To purchase a copy, call Dr. Pellegrino’s staff at Ohio Pain & Rehab Specialists – 330/498-9865; toll free 800/529-7500.
Note: This information has not been reviewed by the FDA. It is generic and is not intended to prevent, diagnose, treat or cure any illness, condition, or disease. It is very important that you make no change in your healthcare plan or health support regimen without researching and discussing it in collaboration with your professional healthcare team.