Doctor, I Hurt All Over!
Part 1
By Dr. L. William Lauro
One of the most difficult cases in a medical practice is the patient who “hurts all over.” This is a common complaint, yet it is very difficult to diagnose and treat. There are many syndromes that can cause a patient to have widespread pain in the connective tissues of the body. In this setting the physician must become a disciplined detective, trying his very best to nail down the cause of diffuse musculoskeletal pain. Lab tests, physical exam, and x-ray imaging might be necessary to get to the bottom of the complex patient who has pain just about everywhere. The physician must first rule out the more serious connective tissue disorders such as rheumatoid arthritis, lupus, polymyositis, and the like. Next, medical conditions such as low thyroid must be ruled out. Finally, medications that can cause diffuse muscle pain (e.g. statin drugs, steroids, anti-malarial drugs) must be investigated.
But what does one do next when the work-up is complete and no specific disease process has been identified-and the patient is still complaining that he “hurts all over?”
Well, the two most common syndromes to next consider are fibromyalgia (also called fibromyositis) and osteoarthritis. Part 1 of this article discusses fibromyalgia; part 2 will discuss osteoarthritis.
What is Fibromyalgia?
Fibromyalgia is a real syndrome, but because it has no clinical markers that can be identified in the laboratory we physicians often-times use this diagnosis as a last resort in the patient with widespread musculoskeletal pain. Unfortunately, this often leaves the patient with the impression that their pain is “all in their head.” We come into the exam room, announce that the tests for “more serious disorders” are all negative, and throw the term “fibromyalgia” at the patient, as if that is supposed to make them feel better knowing that they have something, but still not really knowing exactly what they have.
Fibromyalgia literally means pain in the muscles and fibrous connective tissues of the body. It is a term that we use to tell the patient that while they don’t have any overt evidnce of true musculoskeletal inflammation (such as that seen in rheumatoid arthritis or lupus for example), they do have something going on that is irritating their muscles and tendons and causing them to hurt all over. We just can’t identify what that something is.
Fibromyalgia causes widespread pain in the muscles and tendons, especially in the neck and back. Additional symptoms include fatigue, morning stiffness, headache, and waking non-refreshed after a night’s sleep. Symptoms must be present continually for at least three months to consider the diagnosis.
But to be honest, this list of symptoms is really so vague and so common that many medical conditions can manifest this way, so we can’t just label all people with muscle pain and fatigue as having fibromyalgia. This is why it is necessary to have the tests done for other conditions, which can mimic fibromyalgia.
The Impact of Fibromyalgia
It is estimated that 2% of the adult population in the U.S. has fibromyalgia-that is a lot of people. Fibromyalgia and its effects can be devastating and chronic. We learned a lot about its impact when we did medical “well-being” surveys on these patients and discovered that they consistently score lower than those patients with rheumatoid arthritis and even some cancers. Fibromyalgia is so frustrating to patient and physician alike that many patients end up having surgery in an attempt to relieve the pain. Back surgery, neck surgery, hysterectomy, carpel tunnel surgery, appendectomy have all been performed in hopes of alleviating the pain. It rarely works.
The average fibromyalgia patient uses three medications per day to relieve the symptoms. These patients go to the doctor, on average, ten times per year, and get hospitalized once every three years. This is significant morbidity.
Fibromyalgia can co-exist with many other functional disorders (i.e. conditions which have normal lab tests but whose pathology seems to exist in the way the system is functioning). Examples of functional disorders would be migraine headache syndrome, chronic fatigue syndrome, irritable bowel syndrome, irritable bladder syndrome, TMJ syndrome, and the mood disorders such as depression and anxiety. Because of the association of fibromyalgia with so many of these functional disorders, some experts are not sure if fibromyalgia itself is a true disease. But other physicians feel fibromyalgia might be a multi-system disease involving not only the muscles and tendons, but also other systems (like the central nervous system for example). Regardless, fibromyalgia is real, and has widespread and far-reaching implications. Therefore, I personally never cared whether fibromyalgia could be detected in the lab or not. My goal was to make patients feel better. This leads me to my next point.
Treating Fibromyalgia
As with many other medical syndromes where testing is normal and diagnosis rather subjective, fibromayalgia treatment is varied and legion. However, there are some specific treatments, which hold up when studied in large patient populations. The first treatment is exercise. This seems counter-intuitive, as one would think that a person who is hurting all over and is chronically tired should rest, not exercise. But exercise really helps. We must understand however, that when a chronic pain patient first starts exercising they may get worse in the short term. But after a while the benefits do emerge. Consider this: about 20% of fibromayalgia patients see a decrease in their major symptoms when they exercise, and 37% specifically feel less pain.
Exercise, in these studies, was defined as any activity which increased the heart rate by 40-85 %; a frequency of at least three times a week; a duration of at least 20 minutes; and a term of at least six weeks.
What about more structured treatments like physical therapy, massage, or chiropractic? All three do seem to help, but studies do not seem to indicate they’re much better than simple regular exercise for fibromyalgia. I am not saying that if a patient is undergoing one of these specific treatments and getting some benefit he should stop-I am just pointing out that in large patient studies they do not seem to be significantly better than exercise alone.
What about acupuncture? Only one small study has addressed this, but it did seem to indicate some improvement in pain.
What about counseling, behavioral therapy, relaxation therapy, or group therapy? All seem to help somewhat, but the improvement really varies from patient to patient. The results from studies are so mixed that one cannot advocate any of these treatments for patients in general. If you want to try this approach, I am not against it as it might be beneficial, so go ahead and try it, with the understanding that it might help or it might not help-it is difficult to predict.
Medications
What about medications? Several classes of medicines have been studied in fibromyalgia. The standard anti-inflammatory meds really don’t do much for this syndrome. Some patients say they feel a little better if they take an ibuprophen; others get no benefit at all. You will have to try and see for yourself, but studies do not seem to indicate a great response.
Muscle relaxers have been tried but they do not show any significant improvement, and they have many side effects (fatigue, sleepiness, etc).
Dietary supplements, herbs, and vitamins have not been significantly effective at all. In well- controlled studies they are no better than a placebo.
The most studied class of medications for fibromyalgia is the anti-depressant class. I know, I know, many of you are going to accuse me of “pushing” anti-depressants. I am only trying to present what the studies reveal about their use in fibromyalgia in hope that someone out there might get some improvement in their syndrome.
The most commonly used anti-depressants (and the best studied in fibromyalgia) are the tricyclics (Amitriptyline, Imipramine) and the serotonin agents (Prozac, Paxil, and the like). Numerous studies have been performed and the results of these studies show this: a majority of patients noted moderate improvement in sleep, mood, and general well- being, with slight improvement in fatigue and pain. Overall, anti-depressant medications worked in fibromyalgia about as well as anti-rheumatoid medications work for rheumatoid arthritis. Good, but not great. Side effects were generally mild and tolerable for most patients studied-dry mouth, nausea, sleepiness, dizziness, decreased sex drive, and, with the tricyclics, weight gain.
Summary
Fibromyalgia is a real syndrome, although it doesn’t get the attention or respect it should because all known lab tests are normal in this condition. Fibromyalgia may be a multi-system illness, involving not only the muscles and the tendons but the central nervous system as well (thus its association with fatigue, insomnia, migraine, depression, etc). Because the disease is allusive and difficult to diagnose with certainty, many varied treatments have emerged, most of which are not effective when studied in large patient populations. We do know that exercise and anti-depressant medications are generally effective, helping most patients, at least moderately. Physical therapy, acupuncture, chiropractic, massage, and behavioral counseling can be effective but are costly, and results vary from patient to patient. Muscle relaxers, vitamins, and herbs are not effective in most patients, may have side effects, and are also costly.
