Fibromyalgia: Wastebasket Diagnosis or Just Garbage?

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There is a sham going o­n in American medicine and no o­ne wants to talk about it. Fibromyalgia is the most common cause of generalized, musculoskeletal pain in women between ages of 20 and 55 years. There is no tissue diagnosis. No radiologic findings. No typical histology.

There is a sham going on in American medicine and no one wants to talk about it.

A patient walks into an office and complains of diffuse muscle pains of nonspecific nature in several different skeletal regions. No trauma was sustained. No bruising is present. The patient is not febrile and cannot distinguish whether the pain feels like it arises from the joint or the muscles themselves. Not unlikely, the patient also comments on their persistent fatigue and other nonspecific symptoms like abdominal cramping, on and off visual disturbances, dizziness, etc.

In his or her head, the doctor is thinking: somatizer. But in this day and age of malpractice and better-be-safe-than-sorry medicine, a full work-up is initiated -- sadly. Films are shot, labs are drawn, history and physical is repeated. Lo and behold, all is negative. Even the sed rate, (miraculously).

So what do we do as physicians? We reassure the patient that this is not a physical malady and suggest that this might be something stemming from their psyche, right? Wrong. We make up a diagnosis so we have something to label it and thus, something to treat. Now, suddenly there are mavens of this fictional disease. There are conferences dedicated to it; text books authored about it; medications designed for it; TV and radio commercials exploiting it.

Not me.

I won’t be a part of it any more. It's out of hand, and a recent study is helping delineate this point. Fibromyalgia is the most common cause of generalized, musculoskeletal pain in women between ages of 20 and 55 years; in the United States, the prevalence is approximately 2 percent and increases with age. The cardinal manifestation of fibromyalgia is diffuse musculoskeletal pain. Plus, a variety of poorly understood pain symptoms, including abdominal and chest wall pain and symptoms suggestive of irritable bowel syndrome, pelvic pain and bladder symptoms of frequency and urgency suggestive of the female urethral syndrome or of interstitial cystitis.

Fatigue is present in more than 90 percent of cases and is occasionally the chief complaint. There is no tissue diagnosis. No radiologic findings. No typical histology. How, then, can this be classified as a physical illness? I was taught way back in medical school that if it smells like a duck, and walks like a duck, it's probably a duck. Well, I'll tell you what this smells like…

A recent study, reported by the Associated Press, is shedding some light on the true nature of fibromyalgia. The study looked at "real" acupuncture verses improperly applied acupuncture (accu-placebo) in patients with fibromyalgia.

Now, it wasn't surprising to us that real acupuncture failed to show benefit versus fake acupuncture. And this fact did not lend credence to our theory of fibromyalgia as a fictional disease. Rather, it was that all patients, in both arms of the study showed dramatic improvement in just o­ne or two sessions, a much shorter treatment course than expected.

Whether the treatment used was real or fake made no difference in the study participants. Their symptoms improved greatly just after one or two sessions suggesting that just enrolling in the study may have been the best treatment course. Or, perhaps, the attention that was given to their "disease" improved symptoms.

Adam Burke, an acupuncturist who treats patients with fibromyalgia and was not connected with the study, said the findings were not conclusive, nor was the treatment the study's subjects received consistent with real-life alternative therapies for the condition.

Typically, such treatment can consist of more than a year of acupuncture, along with complementary therapies like herbs and lifestyle changes, he said. Also, acupuncture involving electrical stimulation that has been effective for fibromyalgia wasn't looked at in the study, said Burke, an assistant professor of health education at San Francisco State University.

Of course, they should be treated for more than a year. I'm sure Mr.Burke lets them know that right from the start of treatment.

Are we too cynical? Possibly. But you show me a patient with no physical exam findings, no radiologic abnormalities, no tissue diagnoses, and no gold standard of diagnosis, and I'll show you a patient that has an excellent physical prognosis.

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J.G. Safirstein
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