LOCAL FRONTIERS: Multidisciplinary Treatments for Fibromyalgia

My interest in fibromyalgia syndrome (FMS) began when I was a fellow at the Mayo Clinic training in internal medicine and rheumatology from 1957 to 1960. At that time FMS was generally known as fibrositis, but the syndrome was later named fibromyalgia because of the lack of any findings of inflammation. Most physicians at the time (and many to this date) considered it a “wastebasket diagnosis.”

My perspective is that FMS is not really a disease (manifested by both signs and symptoms), but rather a somatoform disorder (manifested only by symptoms). As of this writing, there are no physical or laboratory findings that allow us to make a firm diagnosis of FMS. The syndrome is diagnosed almost entirely by symptoms and a tender-point examination, which is often inconsistent. Whatever you wish to call FMS--a disease, a somatoform disorder or a psychosomatic disorder--it can vary from a mild to a very debilitating condition. Empathetic physicians can be quite helpful in treating this enigmatic disorder.

Let me address some basic questions regarding FMS.

What are the symptoms of FMS?

A typical case may be illuminating. The patient, BJ, was a 26-year-old newly married secretary working in a law firm. She complained of generalized muscle pains and stiffness, neck and low back pain, chronic fatigue, poor sleep, paresthesias, headaches, frequent urination, and irritable bowel symptoms--all increasing for the past six months. She was depressed and anxious “because of my pain.” She had formerly been a trainer at a gym but was now working hard in the law office for up to 50 hours a week. She had no time to get any significant exercise.

BJ had an extensive workup with her internist, including a history, a physical exam, an arthritis panel, muscle enzymes, thyroid studies, Lyme and parvovirus titers, and MRIs of the cervical and lumbar spines. The results were all negative, except for a minimally positive RA factor and normal ESR and anti-CCP tests. She seemed unusually tender in many body points, but her muscle strength was good.

She was referred to specialists in neurology, neurosurgery, gastroenterology, endocrinology, urology and rheumatology. None found any pathology to account for her symptoms. Despite the lack of any joint swelling, the rheumatologist’s diagnosis was “probable early rheumatoid arthritis.” She was treated with Plaquenil, NSAIDs, analgesics, muscle relaxants, antidepressants, narcotics and even a brief course of prednisone. She did not improve. In fact, she felt worse.

BJ’s first physical therapy visit increased her pain, and she had to go to bed for three days. Her medical bills were mounting; she took more time off work; she was getting depressed; she asked to be put on disability. Meanwhile, her internist was becoming very, very frustrated. Her pains were considered to be an “industrial injury” and were reported as such. Her internist then became embroiled in an endless round of paperwork with the workers’ comp carrier and her attorney. The internist’s thoughts began drifting to taking a long vacation in Hawaii. Spurred by these thoughts, he got another rheumatology opinion.

The second rheumatologist got more history from BJ and learned that she hated her boss and her job. She had no time to exercise. Her major concerns, beside her symptoms, were the specter of permanent disability and the effects on her marriage. Her joint examination was normal. Her new diagnosis was classical and early FMS. She was given information on FMS and a two-month medical leave from work. She was also told to stop all medications, gradually get back to her previous exercises, and return in a month.

BJ called back three weeks later, laughing, and cancelled the appointment. Asked why, she said she was back to normal, had quit her job, was getting more exercise and might go back to being a physical trainer.

BJ’s case is illustrative in many aspects. First, the excessive number of referrals to other physicians and the delay in diagnosis is not unusual. Second, not getting a history of her lack of exercise and the stress of her work situation played major roles in the delay in diagnosis. Third, her unusually rapid recovery was most surely due to her understanding of the basis of her illness plus the resolution of her legitimate concerns regarding chronic disability and the subsequent strains on her marriage.

Who is best qualified to diagnose FMS?

Any physician who has a basic knowledge of the symptoms of FMS and is a good listener should do fine, whether it’s a family physician, an internist or a rheumatologist. A referral to a rheumatologist can be helpful if the primary care physician is concerned about another disorder, such as rheumatoid arthritis, lupus, polymyalgia rheumatica or Lyme disease. If the rheumatologist does not “believe” in FMS, avoid him or her. Too often, the non-believer will not recognize FMS developing in a patient with an associated rheumatic disease and will treat every symptom with potent medications that can make things worse.

Who is best qualified to treat FMS?

I firmly believe that a family physician or internist who has the disposition to work with the patient could do as well or better than a rheumatologist. The primary care physicians probably have a better understanding than the specialist of the total physical and emotional state of the patient.

What are the treatments for FMS?

A multidisciplinary approach to treatment has been the most effective and is now generally accepted. In my book Chronic Muscle Pain Syndrome (1989), I advocated a program that I named RETRAIN, as summarized below.

R is for Rest and Relaxation. Most FMS patients are under stress from a number of causes, such as family, work and poor health. The method of R&R (they are two different things) will depend on understanding what stresses exist.

E is for Education. There are many good (and bad) basic books and articles that can offer the patient understanding and guidance. My guideline is that if a patient feels worse after reading certain information, they should ignore it. The same goes for support groups. Some are excellent. Others, as one patient told me, are just “pity parties” and should be avoided.

T is for Therapeutic Muscle Training. Many studies have shown that the muscles are normal in FMS. A good physical therapist can guide a patient through exercises that start slowly and gradually increase without creating additional discomfort.

R is for Responding to Stress. First, the origins of the stress must be uncovered, since the patient may be unaware of the origins or loath to discuss them with you. If the patient is not responding, a referral to a psychologist or psychiatrist is probably in order. Psychotherapy or cognitive behavioral therapy may be of benefit and can serve as a key to improvement.

A is for Analgesics and Other Medications. Medications such as acetaminophen and NSAIDs generally do not help FMS, and narcotics should be avoided. Trazodone or amitriptyline (may cause weight gain) in small doses at bedtime should be the first choice since they have relatively few side effects and are inexpensive. A host of other medications have also been used for FMS, the most popular being the SSRIs and the SSNRIs. They are more expensive and generally have more side effects, including weight gain. In my experience, the incidence of positive results is pretty similar with all of these medications--about 30%.

I is for Involvement and Alternative Therapies. If the patient is not personally involved in his or her therapy, you are probably fighting a losing battle. Many alternative therapies can be very helpful and do not require a doctor’s prescription. Choices include tai chi, Feldenkrais, yoga and meditation. See the sidebar for more information on tai chi, which has become one of my favorite alternative movement therapies.

N is for Never Give Up Hope. No matter how severe your patients’ symptoms are, there are many paths to relief. Many patients have informed me that their FMS is “cured,” despite some naysayers who are convinced that it never goes away. If these patients have no symptoms, they are presumably cured. You may find that your FMS patients are some of the most grateful in your practice!

Tai Chi for Fibromyalgia

Tai chi is a Chinese body-mind movement exercise based on the martial arts that goes back hundreds of years. Research has shown that it promotes balance control, flexibility and cardiovascular fitness. It also lessens the risk of falls in elderly patients and in those recovering from stroke and other conditions. According to estimates, Tai chi’s gentle, low-impact movements burn more calories than surfing and nearly as many as downhill skiing.

A recent study published in the New England Journal of Medicine found that “tai chi may be a useful treatment in the multidisciplinary management of fibromyalgia. Longer-term studies involving larger clinical samples are warranted.”

In my opinion--which is probably shared by many millions of people around the world--I doubt if further studies of tai chi are needed before trying the technique. Tai chi has been shown over the centuries to be helpful in many patients, so why not just try it? It is non-invasive and harmless, with no apparent side effects, and the cost to learn is relatively inexpensive compared to the cost of many medications.

The most popular form of tai chi is the Yang style. YouTube has many great videos of this particular style; they are a pleasure just to watch. A superb and widely available DVD is “Simplified Tai Chi Chuan” by Master Shou-Yu Liang.

---

Dr. Davidson, a retired rheumatologist, is the author of Chronic Muscle Pain Syndrome, a bestselling book on fibromyalgia.

Email: pauldavmd@aol.com