She sat straight up, gripping the arms of her chair as if by releasing them she might tumble forward on to the floor. “I’m tired of hurting,” were her first words to me as I entered the room. I barely recognized the person I’d seen occasionally over the last two years. She was only 32–years old but now she carried herself as if she were an octogenarian, missing only the rolling walker. “I hurt all over,” she continued. “I can’t sleep. I can barely get around at work; they even sent me home once. I’m exhausted but sleep doesn’t help. I have to do something or I could lose my job.” With that she began to cry softly, struggling to wipe away tears.
Her history came spilling out. Pain in her back, shoulders arms and upper leg muscles. Rest gave her little relief. Her sleep was fitful; if she was able to sleep more than five hours it seemed miraculous. She awoke with pain that started as she climbed out of bed and lasted all day. She tried taking Tylenol, ibuprofen, Aleve, and aspirin, first in separate small doses then in combination. All these drugs seemed to do was upset her stomach and diminish what little appetite she could muster. Consequently, she lost weight; down ten pounds since her last visit six months ago.
Her disturbed sleep pattern, accompanied by tender points of pain in different regions of the body both above and below the waist fit the diagnosis of fibromyalgia. Medicine is just now coming to terms with this disease that has become the most common cause of muscle pain in women ages 20 to 55. These patients can have numbness, tingling or burning sensations in the arms, legs or both. Not surprisingly they develop mood disorders—difficulty concentrating sometimes even frank, severe depression. Some patients with fibromyalgia also complain of chest pain or develop alternating diarrhea with constipation, what we innocently call ‘irritable‘ bowel syndrome. On close questioning she volunteered she had many of these problems.
This is one diagnosis where touch is critical—the physician’s touch. By touching over defined points of the body using enough pressure, we try to see if can elicit a pain response. On normal tissue and muscle most of us shouldn’t feel much of anything. To patients with fibromyalgia however, this pressure causes obvious pain and distress. Laboratory testing must also be done to make sure the patient doesn’t have other diseases that can mimic fibromyalgia, but usually the patient’s history reveals other reasons for their pain.
We’re not completely sure why certain patients develop this condition. There is some evidence promoting the lack of restful or stage 4 “dream” sleep as causing the pain cycle to begin. We know that exercise can help the painful muscles to relax but there’s the conundrum: if we’re too tired to exercise from lack of sleep how do we get ourselves out of this vicious cycle? This is one reason we need assurance that the patient doesn’t have a sleep disturbance, such as obstructive sleep apnea. Providing these patients with seven to eight hours of restful sleep is miraculous in breaking the grip of fibromyalgia. We sometimes use medications, such as antidepressants to help break the pain pathways in the brain and for their sleep–inducing properties. Using medications such as Tylenol or Advil can then be added to supplement and lessen the patient’s pain.
Once her examination was over she seemed to briefly relax. “The good news is you’re not crazy; your pain is real and we can get this under control,” I explained. I went on to give her the latest information about her disease and how we would approach treatment. She gave me a look that seemed to convey both skepticism but willingness to try anything to get relief and keep her job. “It takes time,” I suggested. “But we’ll get there.”
“We better,” she added. “Or we’ll be out of a job.” I respect her point; serious diseases can intervene, while striving to live our lives to the fullest. Sometimes the best we can do is provide knowledge that things will get better, the tools to make it happen and the willingness to be there when it doesn’t work out the way we thought. Knowing she could lose her job if we’re not successful is real pressure and only time is on our side.
Steve P. Sanders, DO, MBA, FACOI, FACPE was formerly the Chief Medical Officer for Carondelet Health System in Kansas City, MO with responsibilities for medical management, quality initiatives, residency training, long-term care initiatives and patient safety for St. Joseph Medical Center and St. Mary's Medical Center. Clinically, Dr. Sanders now serves as a traditional internist providing outpatient medical care and hospital services for patients ages 16 and beyond. He continues to write on issues in medicine and the promotion of patient-centered creation of value in health care at Knowmoremed's Blog.
I hope you thought of referring her to a physical therapist.
The new case definition for fibromyalgia no longer requires a tender point count but uses a symptom severity score, and a widespread pain index. See http://www.rheumatology.org/practice/clinical/classification/fibromyalgia/2010_preliminary_diagnostic_criteria.pdf