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?
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.
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.
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
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.
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).