THERE’S “RHEUM” FOR IMPROVEMENT

How often have those words been said to patients when a doctor cannot identify the etiology of their complaints? In my world of rheumatology, it typically occurs when a patient complains of widespread pain, and most commonly when they suffer from fibromyalgia.

Fibromyalgia is a poorly understood condition characterized by widespread pain, fatigue, non-restorative sleep, and specific tender points on physical exam. Lab studies and X-rays are negative, and there really aren’t any obvious objective findings to identify the etiology of the pain. Patients with this condition are therefore commonly dismissed.

However, pain by definition is not an objective phenomenon. Pain is currently defined by the International Association for the Study of Pain as an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage. Pain is, in part, a learned experience and must be viewed through the filter of a patient’s prior biological, psychological, and social experiences.

As an example, when a patient had a tummy ache as a child, did their parent coddle them and put them to bed, or did the parent tell them to toughen up and go to school anyway?

Each of us has a multitude of lifetime experiences related to pain or discomfort. The way in which we experience pain is, in part, a function of those prior experiences.

In general, pain serves as an alarm system that protects us from further injury. Under normal circumstances, there is some type of tissue damage that results in a pain signal being sent to the brain. Examples would include a laceration or a sprained ankle. The pain warns us to protect the damaged area until it heals. When it does heal, the pain resolves.

However, that assumes that our pain system is functioning properly. Consider the analogy of a fire alarm. It makes a loud, unpleasant sound in the presence of a fire that warns us to leave the building. Suppose, however, that there is a short circuit in the alarm system, such that the alarm rings even though there is no fire. We escape the building and call the fire department, but they find no fire.

That is all well and good, but if there is a short circuit in the system, the alarm may ring over and over again, if not continuously. What happens if the fire department tells us that, since there was no fire, we must have imagined that the alarm actually rang, without considering the possibility that maybe the alarm is not working properly?

One of our basic human needs is the need to be validated. Being told by a physician that we are imagining symptoms can be harmful. In my entire 31-year career, I only met one patient who I felt was lying to me about being in pain, and that was because he made it clear to me that he wanted to avoid work.

Some physicians will discount the problem by saying that it is strictly an emotional issue. Maybe so, but that does not make the symptoms any less valid. There are numerous examples of emotional issues producing physical symptoms. Tension headache and stress ulcer immediately come to mind.

I often use the example of blushing, where an emotional stimulus produces embarrassment, which results in the physical response of dilation of the blood vessels in the face.

It should be noted that many patients with fibromyalgia do have underlying emotional issues, with a much higher percentage having been molested or abused as a child.

But pain and fibromyalgia are not strictly subjective entities. Research has shown objective evidence of physiologic changes in patients with fibromyalgia. For example, Substance P is a chemical mediator of pain. Studies have shown increased levels of Substance P in the spinal fluid of patients with fibromyalgia, as well as other neurochemical changes in the hypothalamic-pituitary-adrenocortical axis and the sympathetic nervous system that modulate our perceptions of pain.

Another example involves functional MRIs of the brain. Functional magnetic resonance imaging uses magnetic resonance imaging to measure changes in blood flow that take place in an active part of the brain.

As an example, if you give a subject a meal and then do a functional MRI, the parts of the brain that deal with digestion will light up. If you stimulate a patient sexually, the parts of the brain that deal with sexual responses will light up. If you inflict pain on a subject, the parts of the brain that deal with pain processing will light up. Functional MRI studies done in patients with fibromyalgia reveal evidence of augmented pain processing. The main issue in all of this is the arrogance of some physicians who assume that if they cannot find an objective etiology for a symptom, then the symptom does not exist. There is a big difference between saying “I cannot find the reason for your symptom” as opposed to “I cannot find the reason for your symptom, therefore the symptom does not exist.”

The latter statement is harmful to patients. I had one young fibromyalgia patient who told me that another doctor had patted her on the head and stated to her, “There, there, dear. There is nothing really wrong with you. You just need to get yourself pregnant.” This kind of attitude is harmful to patients and should be condemned. As physicians, we cannot always diagnose our patients. We cannot always cure them or relieve their symptoms. No shame in that. However, we can always validate them, and it is incumbent upon us to do so. For a number of patients with fibromyalgia, that may be all they need.

That is the very least we can do, and we fail in our role as physicians if we choose not to do so.

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