Fibromyalgia Opinions

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I am working on a semi-large scale project to determine how current FP/PC providers view FM. Hopefully you will see this published in primary care journal next year.

I am hoping to get a preliminary look at attitudes FPs have towards FM. Do you see it as a purely medical Dx, or more of a mental health condition? Do you think it really exists? Are Dx criteria up to snuff? Whatever you want to say....

thanks
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it gets better with therapy and ssri's.....it's a psych d/o as far as I am concerned. when folks in the er say" I have fibromyalgia" I list it in their pmh as a psych d/o.
 
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Fibromyalgia is a physicial condition.
The AAR's diagnostic criteria does leave a little bit to be desired. Still, it is a starting point.

Did you want to know about treatment modalties?

ntubebate
 
Miami_med said:
Then you are diagnosing it incorrectly.
Click to expand...

I don't ever diagnose it. as far as I am concerned it is not a real diagnosis but just another way of saying "depressed with somatic disorder". I'm guessing many emergency physicians here agree with me.....
 
In my experience, it's the rare fibromyalgia patient who doesn't have a comorbid psychiatric diagnosis (typically, depression). You have to treat the "whole patient," as they say. SSRIs (or, preferably, SNRIs) are very helpful in most cases, although treatment is highly individualized. Recently, I've had good results with Cymbalta. It's also important to get these patients involved in a low-impact exercise program.
 
from what i remember, only TCAs and aerobic exercise are helpful for fibro, but that was when i was studying for step 2 and 3, years ago... i am sure things have chnaged.

but my BP goes up maybe 20 mmHg when a pateint tells me they have a fibromyalgia exacerbation.

just being honest.

Q
 
See.... this is why I am doing this study. keep it coming......
 
DrQuinn said:
from what i remember, only TCAs and aerobic exercise are helpful for fibro, but that was when i was studying for step 2 and 3, years ago... i am sure things have chnaged.
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The usefulness of TCAs are frequently limited by their side effects (sedation, dry mouth, etc.) A low dose (10-50mg) of Elavil (amitriptyline) at bedtime is often helpful.
 
I hate to skew my own data collection, but this pre-preliminary. For sleep go with trazadone, low dose remeron(7.5 mg qhs) or low dose seroquel (12.5-25 mg qhs), and you will get much better results. You can use all 3 in addition to a normal qam dose of an antidepressant of your choice, but be careful with these, aside for seroquel if you are using tramadol.

;)
 
psisci said:
I hate to skew my own data collection, but this pre-preliminary. For sleep go with trazadone, low dose remeron(7.5 mg qhs) or low dose seroquel (12.5-25 mg qhs), and you will get much better results. You can use all 3 in addition to a normal qam dose of an antidepressant of your choice, but be careful with these, aside for seroquel if you are using tramadol.
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I haven't found Ultram (tramadol) to be all that helpful in fibromyalgia, although it's sometimes useful if there are comorbid pain syndromes (chronic back pain, etc.) I'm always cautious whenever I combine antidepressants, and I try to avoid Ultram with most of these. I've never prescribed Seroquel. I've used trazodone with mixed success, as with amitriptyline, at night. Again, treatment is highly individualized. In most cases, you just keep trying things until you find a combination that works.
 
The major Tx protocols for FM call for tramadol as opposed to other (so to speak) opiates. I agree, it is useless for the most part. Kent, do you refer FM patients to Rhuem?
 
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On my manipulative medicine rotation, we had very good success in treating FM patients with OMM.

I agree that you also have to treat the psych/pain component (I've seen good results with Cymbalta, too), but I do believe some of the physical modalities like OMM really make a difference in functionality.
 
seroquel o.d.'s are truly nasty....had someone take an entire bottle in a suicide attempt....he lived(barely) after several hrs in the er going in/out of multiple arrhythmias, etc...ended up intubated in icu for several days ....not that tca o.d.'s are much fun either.....for what it's worth I never start psych meds in the er without a psych consult and then only ssri's....if the psych doc wants them on abilify, seroquel, risperdal, etc he can write the rx himself....
 
emedpa said:
it gets better with therapy and ssri's.....it's a psych d/o as far as I am concerned. when folks in the er say" I have fibromyalgia" I list it in their pmh as a psych d/o.
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He was asking for a real doctor opinion.
 
Don't be mean. Actually the survey will be covering docs (MD/DO), as well as midlevels, so I want all opinions. I am wondering amongst many things if there will be a significant difference in attitudes between docs and mids, PA/NP etc.
 
erichaj said:
He was asking for a real doctor opinion.
Click to expand...

I've worked with a few ER docs, and the vast majority of them had exactly the same opinion as emedpa! Nearly all of them said that FM was psychogenic and rolled their eyes whenever a patient mentioned it. Maybe this is a difference between the attitudes of FPs and the attitudes of those in emergency medicine and not so much a difference between MD opinions and PA/NP opinions. Just a thought! :)
 
Melanie said:
I've worked with a few ER docs, and the vast majority of them had exactly the same opinion as emedpa! Nearly all of them said that FM was psychogenic and rolled their eyes whenever a patient mentioned it. Maybe this is a difference between the attitudes of FPs and the attitudes of those in emergency medicine and not so much a difference between MD opinions and PA/NP opinions. Just a thought! :)
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IMO, the difference is that EPs don't treat fibromyalgia...FPs do. I wouldn't expect them to be as familiar with it, just as I hope they wouldn't expect me to be able to crich someone. ;)
 
And a good one, that is why I am conducting a formal study on the matter.

:D
 
KentW said:
IMO, the difference is that EPs don't treat fibromyalgia...FPs do. I wouldn't expect them to be as familiar with it, just as I hope they wouldn't expect me to be able to crich someone. ;)
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Um, yeah, I agree. I was just saying that I thought that thinking of FM as purely a psych issue seems to be a somewhat common (although not absolute, before I get pounced on by the ER people) ER mentality as opposed to a PA vs. MD mentality.
 
Melanie said:
I was just saying that I thought that thinking of FM as purely a psych issue seems to be a somewhat common (although not absolute, before I get pounced on by the ER people) ER mentality as opposed to a PA vs. MD mentality.
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You're probably right. Unfortunately, it's also common among FPs, to the point that most of the fibromyalgia patients I have came to me after seeing several other docs who either couldn't help them, or dismissed their symptoms. I don't overdiagnose it, that's for sure, and I'm always initially skeptical of patients who come to me with a fibromyalgia self-diagnosis; however, if they've got it and you treat it, most people do get better.
 
Melanie said:
Um, yeah, I agree. I was just saying that I thought that thinking of FM as purely a psych issue seems to be a somewhat common (although not absolute, before I get pounced on by the ER people) ER mentality as opposed to a PA vs. MD mentality.
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It's definitely a physical diagnosis,in addition to the psych elements. It's not all in their heads--I've felt it. I can almost hear the eyeballs rolling from some of my allopathic colleages ;) , but when you've spent 4 years developing your palpatory skills, you learn to feel some pretty subtle tissue changes.

Fibromyalgia feels rubbery, almost smooth, and is best palpated in the tender points (there are 17 or 18, I believe, and are typically symmetrical). It's definitely distinguishable from normal tissue.
 
If you do not mind my asking, what do you attribute this difference to? Is it inflamation secondary to muscle damage, histological in nature? How do you see this interacting with the psychological aspects of the illness?
 
As I understand it, the etiology is unknown. At my school, we were taught the various theories, but no explanation was given for the tissue texture changes, probably because none have yet been found.

This is from UpToDate, and it pretty accurately reflects what we were taught about the histological changes:

"Magnetic resonance spectroscopy and histochemical techniques have revealed subtle differences between patients and controls. Examples include spectroscopic findings of reduced levels of phosphocreatine and increased levels of inorganic phosphate in muscle tissue [5,6] and increased fragmentation of DNA in nuclei of patients compared to healthy controls [7] Such differences between patients and controls may be the result of muscle deconditioning in FMS patients."

As for the psychological issues, the research that suggests altered pain processing, sleep abnormalities, hypothalamic-pituitary hyperactivity, all of which can cause depression. I do not believe that the depression causes the pain. I tend to think it's the other way around.

I can't imagine how some doctors still feel FM is a made-up illness. I've never had an attending who didn't believe it was an actual illness.
 
Real or not, psych issue or not, has anyone EVER met a fibromyalgia patient without another psych diagnosis of some sort?
 
If anything... Below is a new study showing that there is a physical strength difference between women with FM and those without.... it also shows women with FM and healthy older women have no difference in strength.

I am guessing that in the future, FM will be discovered as early menopause. Bone, muscles and hormone wise possibly. If Fibromyalgia is early menopause or similar, then that would explain the psych component.

I like the above study mainly because it's the start of the fight.... you can set a threshold limit beyond which the patient is diagnosed with Fibromyalgia.

A comparison of physical functional performance and strength in women with fibromyalgia, age- and weight-matched controls, and older women who are healthy.Panton LB, Kingsley JD, Toole T, Cress ME, Abboud G, Sirithienthad P, Mathis R, McMillan V.
Department of Nutrition, Food and Exercise Sciences, College of Human Sciences, Florida State University, 436 Sandels Building, Tallahassee, FL 32306 (USA).

BACKGROUND AND PURPOSE: The purpose of this study was to compare functionality and strength among women with fibromyalgia (FM), women without FM, and older women. SUBJECTS: Twenty-nine women with FM (age [X+/-SD]=46+/-7 years), 12 age- and weight-matched women without FM (age=44+/-8 years), and 38 older women who were healthy (age=71+/-7 years) participated. METHODS: The Continuous Scale-Physical Functional Performance Test (CS-PFP) was used to assess functionality. Isokinetic leg strength was measured at 60 degrees /s, and handgrip strength was measured using a handgrip dynamometer. RESULTS: The women without FM had significantly higher functionality scores compared with women with FM and older women. There were no differences in functionality between women with FM and older women. Strength measures for the leg were higher in women without FM compared with women with FM and older women, and both women with and without FM had higher grip strengths compared with older women. DISCUSSION AND CONCLUSION: This study demonstrated that women with FM and older women who are healthy have similar lower-body strength and functionality, potentially enhancing the risk for premature age-associated disability.
Click to expand...
 
Melanie said:
I've worked with a few ER docs, and the vast majority of them had exactly the same opinion as emedpa! Nearly all of them said that FM was psychogenic and rolled their eyes whenever a patient mentioned it. Maybe this is a difference between the attitudes of FPs and the attitudes of those in emergency medicine and not so much a difference between MD opinions and PA/NP opinions. Just a thought! :)
Click to expand...

Just being realistic. The PA is just vomiting up what the ER docs tell them to say and do. I don't take them seriously. Even with other MDs you are taught in residency to alway double check everything, so When it comes to PAs I would be even more vigilant.

Any serious medical opinion should be given by MD or DO.

I would not want an opinion on astro physics from the undergrad physicas student, I would want it from the PHD. Same thing here.

The other MD is not going to want a medical opinion from his understudy.

Fibromyalgia is a complicated issue. It has roots all the way down to the immune system. Very little research has been done on it. It does deserve more. For a PA to just say Oh I give them ssri and its a psych issue is very irresponsible. These individuals have very unproductive lives because of what is taking place in their bodies. We don't know what it really is.

Even if Firbomyalgia is not a real diagnosis, something is going on that makes them the way they are and it deserves merit and research.

So, I'm not being mean, I'm just being correct.

I have worked in the ER as well and the ER docs opinions are not that. They simply don't have a soulution for the patients they see. So, they throw their hands up. I can understand their frustration. The same is true with some FPs. But, just becasue we don't understand a process does not mean that we have to dismiss them as crazy. We have failed the patient if we just dismiss them that way.

The correct response would be that we don't know why they have what they have. yes, tell them you DON'T KNOW. That is the truth. then send them to someone who can help them to some extent, and explain to them that the ER is not the place for it because what they have is not an emergency. (regardless of how much they feel it is). They need someone who can give them the time they need.

There are multiple factors that are causing their problems.

The ER docs who do have a poor attitude about these patients are being arrogant and should change their attitudes and should have trained the PA correctly. Or, maybe the PA should have gone to medical school.
 
I understand that. However my research has nothing to do with ER anyone, but only primary care providers. I have my own opinions on Fm, and as a clinicain they come into play when I am treating someone with FM, but as a researcher they cannot. Thanks for your input, I really appreciate it all. I have to say that this little sample experiment mirrors what I have seen in person as far as attitudes go, and that is why I am doing this study.
 
KentW said:
Statistically, one out of every four people are mentally ill. Check three friends...if they're OK, you're it. ;)
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My guess is when you factor in all the various personality disorders and their spectrum of severity....it's probably a lot higher than that.

I think sometimes we label chronic pain-ers as wacko before we ever give them a chance.
 
KentW said:
Statistically, one out of every four people are mentally ill. Check three friends...if they're OK, you're it. ;)
Click to expand...

No have no fear. my x and her family will cover that requirement for many people.
 
I want to thank everyone who has responded to this!! I hope for alot more, and an ongoing dialogue, for my own interests and I think it will interesting to compare the data on this totally unscientific survey to the real-deal I am going to do.

;)
 
I want to thank everyone who has responded to this!! I hope for alot more, and an ongoing dialogue, for my own interests and I think it will interesting to compare the data on this totally unscientific survey to the real-deal I am going to do.

;)
 
DrQuinn said:
from what i remember, only TCAs and aerobic exercise are helpful for fibro, but that was when i was studying for step 2 and 3, years ago... i am sure things have chnaged.

but my BP goes up maybe 20 mmHg when a pateint tells me they have a fibromyalgia exacerbation.

just being honest.

Q
Click to expand...

I'm not a FM/PCP, but I feel the EXACT same way. At that point, I usually also get a glossed over look in my eyes that I find difficult to cover up. It's usually because I think it's becoming a wastebasket diagnosis that physicians(and other health care professionals) just LOVE to give out when they can't find anything. And patient's latch onto that diagnosis like there is no tomorrow. I've almost never had a diagnosis that is so difficult to un-diagnosis in someone.
 
Whodathunkit said:
I'm not a FM/PCP, but I feel the EXACT same way. At that point, I usually also get a glossed over look in my eyes that I find difficult to cover up. It's usually because I think it's becoming a wastebasket diagnosis that physicians(and other health care professionals) just LOVE to give out when they can't find anything. And patient's latch onto that diagnosis like there is no tomorrow. I've almost never had a diagnosis that is so difficult to un-diagnosis in someone.
Click to expand...

Actually, it's a very specific diagnosis.

This is from UpToDate:

"CLASSIFICATION CRITERIA — A number of classification criteria for the diagnosis of fibromyalgia have been proposed. In 1990, the largest diagnostic criteria study, under the auspices of the American College of Rheumatology, enrolled 293 fibromyalgia patients and 265 patients with chronic rheumatic disorders such as low back pain, neck and arm pain, osteoarthritis, and rheumatoid arthritis [9]. These controls were selected, since they would be most difficult to distinguish from patients with fibromyalgia. Over 300 variables, including symptoms, physical findings, and laboratory and radiologic studies, were analyzed. The recommended diagnostic criteria were quite simple:

1. Widespread musculoskeletal pain
2. Excess tenderness in at least 11 of 18 predefined anatomic sites

Requiring both criteria to be present results in 80 percent sensitivity and specificity in differentiating patients with fibromyalgia from controls with other chronic painful disorders."

I think the "wastebasket" diagnosis comes more from physicians who don't understand how fibromyalgia is diagnosed.
 
The overdiagnosis of fibromyalgia syndrome.
Am J Med. 1997 Jul;103(1):44-50.

CONCLUSION: Spondyloarthropathy in women may present subtly and have considerable overlap in symptomalogy with FM. A diagnosis of spondyloarthropathy should be considered in women with an ill-defined pain syndrome with prominent spinal pain and associated enthesopathy, or history or family history of seronegative-associated disease. It is possible that a primary diagnosis of FM is being made too freely, without consideration of other diagnoses, in the setting of ill-defined musculoskeletal pain.
Click to expand...

Inaccuracy in the diagnosis of fibromyalgia syndrome: analysis of referrals.
Rheumatology (Oxford). 2003 Feb;42(2):263-7.

CONCLUSION: There is a disturbing inaccuracy, mostly observed to be overdiagnosis, in the diagnosis of FM by referring physicians. This finding may help explain the current high reported rates of FM and caution physicians to consider other diagnostic possibilities when addressing diffuse musculoskeletal pain.
Click to expand...

The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: an observational study based on clinical practice.
Arthritis Rheum. 2006 Jan;54(1):177-83

CONCLUSION: Primary care patients who had been diagnosed as having FM reported higher rates of illness and health care resource use for at least 10 years prior to their diagnosis, which suggests that illness behavior may play a role. Being diagnosed as having FM may help patients cope with some symptoms, but the diagnosis has a limited impact on health care resource use in the longer term, possibly because there is little effective treatment.
Click to expand...

This was in the UK, however, unlike in the US where someone can try and get Permanent Disability for said diagnosis.


Is there benefit in referring patients with fibromyalgia to a specialist clinic?
J Rheumatol. 2004 Dec;31(12):2468-71.

CONCLUSION: An important value of specialist rheumatology contact for patients with a symptom suggestive of diffuse musculoskeletal pain is to ensure that some other potentially treatable condition is not overlooked, rather than the provision of ongoing care for those with FM. Continued followup in a specialist clinic for patients with a primary diagnosis of FM is of questionable benefit.
Click to expand...

The reliability of examination for tenderness in patients with myofascial pain, chronic fibromyalgia and controls.
J Rheumatol. 1995 May;22(5):944-52.

CONCLUSION. Both dolorimetry and palpation are sufficiently reliable to discriminate control patients from patients with myofascial pain and FM, but may not discriminate patients with myofascial pain from those with FM. Neither method appears to correlate well with the location of the clinical pain complaint, regardless of diagnosis.
Click to expand...

I tend to diagnosis myofascial pain with a mood disorder(anxiety/depression) well before I'd diagnose someone with Fibromyalgia.
 
Any future diagnostic techniques to diagnose FM should include muscle mass and function... unless they come up with the etiology of the disease.


Again I repeat one study and here is the other as well.

A comparison of physical functional performance and strength in women with fibromyalgia, age- and weight-matched controls, and older women who are healthy.Panton LB, Kingsley JD, Toole T, Cress ME, Abboud G, Sirithienthad P, Mathis R, McMillan V.
Department of Nutrition, Food and Exercise Sciences, College of Human Sciences, Florida State University, 436 Sandels Building, Tallahassee, FL 32306 (USA).

BACKGROUND AND PURPOSE: The purpose of this study was to compare functionality and strength among women with fibromyalgia (FM), women without FM, and older women. SUBJECTS: Twenty-nine women with FM (age [X+/-SD]=46+/-7 years), 12 age- and weight-matched women without FM (age=44+/-8 years), and 38 older women who were healthy (age=71+/-7 years) participated. METHODS: The Continuous Scale-Physical Functional Performance Test (CS-PFP) was used to assess functionality. Isokinetic leg strength was measured at 60 degrees /s, and handgrip strength was measured using a handgrip dynamometer. RESULTS: The women without FM had significantly higher functionality scores compared with women with FM and older women. There were no differences in functionality between women with FM and older women. Strength measures for the leg were higher in women without FM compared with women with FM and older women, and both women with and without FM had higher grip strengths compared with older women. DISCUSSION AND CONCLUSION: This study demonstrated that women with FM and older women who are healthy have similar lower-body strength and functionality, potentially enhancing the risk for premature age-associated disability.
Click to expand...

Physical performance characteristics of women with fibromyalgia.
Mannerkorpi K, Burckhardt CS, Bjelle A.

OBJECTIVE. The aim of this study was to examine physical performance in women with fibromyalgia (FM) using methods that are easy to use in clinical settings and to compare our findings with published norms or a healthy comparison group. METHODS. Measures of shoulder pain and range-of-motion, isometric shoulder endurance, neck rotation, leg strength, hand grip strength, back flexibility, 6-minute walk distance, and symptom duration were completed on 97 subjects with FM. The comparison group was 30 age-matched healthy women. RESULTS. The FM group had significantly lower physical functioning scores on all variables when compared to the healthy group or published norms. When pain at rest was controlled, pain on motion was the most significant predictor of variance in shoulder range of motion, whereas range of motion was the most significant predictor of right shoulder endurance and grip strength of both hands. CONCLUSIONS. Women with FM are markedly below average in physical performance abilities when measured by clinical tests.
Click to expand...
 
KentW said:
IMO, the difference is that EPs don't treat fibromyalgia...FPs do. I wouldn't expect them to be as familiar with it, just as I hope they wouldn't expect me to be able to crich someone. ;)
Click to expand...

Right. I don't know if I believe in Fibromyalgia or not but when somebody comes into the ED with that as their chief complaint I kind of think, "Uh, OK....what do you expect me to do about it?"

Usually they just want pain meds and we give 'em four vicodin or something.
 
Panda Bear said:
Right. I don't know if I believe in Fibromyalgia or not but when somebody comes into the ED with that as their chief complaint I kind of think, "Uh, OK....what do you expect me to do about it?"

Usually they just want pain meds and we give 'em four vicodin or something.
Click to expand...
exactly.....ever seen "end stage fibromyalgia"....I had a pt with that complaint..I was thinking she needed an eval for trigger point transplant from a cadaveric donor.....:)
 
emedpa said:
exactly.....ever seen "end stage fibromyalgia"....I had a pt with that complaint..I was thinking she needed an eval for trigger point transplant from a cadaveric donor.....:)
Click to expand...

:laugh: :laugh: :laugh: :laugh:

Clearly someone soliciting pain medication.... Tell them you need a bone marrow sample to see how bad it is.
 
Panda Bear said:
Right. I don't know if I believe in Fibromyalgia or not but when somebody comes into the ED with that as their chief complaint I kind of think, "Uh, OK....what do you expect me to do about it?"

Usually they just want pain meds and we give 'em four vicodin or something.
Click to expand...

Lodine. Rhymes with codeine. ;)
 
Just like Ultracet(tramadol with acetaminophen) sounds like Percoset(oxycodone with acetaminophen). :laugh:
The ones that have been around the block a few times know the difference though.
 
Whodathunkit said:
Just like Ultracet(tramadol with acetaminophen) sounds like Percoset(oxycodone with acetaminophen). :laugh:
The ones that have been around the block a few times know the difference though.
Click to expand...

Then it's time for Dolobid (say it fast so it sounds like "Dilaudid"). ;)
 
psisci said:
I hate to skew my own data collection, but this pre-preliminary. For sleep go with trazadone, low dose remeron(7.5 mg qhs) or low dose seroquel (12.5-25 mg qhs), and you will get much better results. You can use all 3 in addition to a normal qam dose of an antidepressant of your choice, but be careful with these, aside for seroquel if you are using tramadol.

;)
Click to expand...

This is a huge pet peeve of mine, when I see people write for low dose seroquel prn for sleep. Professional speakers who lecture on behalf of the company acknowledge that the primary mechanism of sedation at low doses is via histamine blockade. This is like using a $3.00/dose Benadryl. Just my two cents.
 
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