POST TRAUMATIC FIBROMYALGIA: A SPECIAL TYPE OF FIBROMYALGIA CAUSED BY TRAUMA

By Mark J. Pellegrino, M.D.

Fibromyalgia is a common condition causing painful muscles. The pain is severe and involves many muscles as well as tendons, ligaments and other soft tissue areas. Distinct areas of tenderness in specific locations called "tender points" are characteristic findings. Fibromyalgia can be generalized, affecting the whole body, or regional, affecting specific areas of the body. In recent years, increased awareness of what previously was a mysterious and controversial condition has made fibromyalgia a well-recognized and legitimate syndrome.

Health care professionals of all specialties are involved in treating fibromyalgia patients. We have recognized a variety of factors that are important in causing fibromyalgia including genetics, infections, connective tissue diseases, and trauma. Post-traumatic fibromyalgia is a special type of fibromyalgia that is caused by an injury.

Doctors who treat large numbers of fibromyalgia patients report that the majority of patients say that their fibromyalgia was caused by an injury. In my own private practice, I analyzed patients with the diagnosis of fibromyalgia to determine the cause. From 1990 to 1995, 2,000 records of fibromyalgia patients were reviewed. Of those, 65% reported the onset of their symptoms of fibromyalgia after a traumatic event. Of this group, 52% of them were involved in a motor vehicle accident, 31% had work injuries, and the remaining 17% had another type of trauma; included in this category were sports injuries, recreational injuries, fractures, surgical procedures, head injuries and pregnancy. Of the post-traumatic patients involved in motor vehicle accidents, whiplash injury was the most common type of trauma.

There have been various studies published on soft tissue injuries and pain. A recent study done by Dr. Buskila published in "Arthritis and Rheumatism", March 1997, specifically studied persons with trauma to determine if fibromyalgia developed after the trauma. Dr. Buskila followed 161 people with traumatic injury, 102 of them had neck injuries, i.e. the typical whiplash injury, and 59 people had leg fractures. The follow-up evaluations determined that people who had the neck injuries developed fibromyalgia 22% of the time, whereas people with the leg injuries developed fibromyalgia only 2% of the time. This means that post-traumatic fibromyalgia is 13 times more likely to occur following neck injury than following a leg injury. This study supports trauma as a cause of fibromyalgia.

Patients with fibromyalgia that developed after a trauma will have a "typical history". The person reports severe pain as the chief complaint with the pain commonly in the neck, shoulders and back areas. Usually, the person had no previous problems with ongoing pain and was in perfect health until the trauma occurred.

Within a short while after the accident, the person developed pain that persisted ever since. There may have been a visit to the emergency room, X-rays and evaluations, medications, and other medical treatments. Some of these treatments may have helped, but the pain never disappeared and continued to be described as severe.

When this person is examined by a physician, certain abnormalities can be detected in those who have post-traumatic fibromyalgia. The main abnormal findings upon physical examination are the tender points. Tender points are areas in the soft tissues, especially the muscles, which are very sensitive and painful when pressed. These tender points are in distinct locations of the body. The presence of tender points are the main criteria used to diagnose fibromyalgia; if they are widespread in numerous distinct locations, then fibromyalgia is considered to be generalized. If they are more localized, i.e. involving upper body only or low back only, they could indicate a more regional or localized fibromyalgia. Typically, the muscles in individuals with post-traumatic fibromyalgia will have an abnormal consistency where the muscle is tight or nodular and has localized spasms that can be palpated.

There is no single testing procedure that is diagnostic of post-traumatic fibromyalgia. In fact, routine labs and other tests are normal in fibromyalgia. There are specialized tests for fibromyalgia which are abnormal but these tests are not considered routine and are often done only in specialized labs or research centers. However, specialized lab tests or X-rays are NOT needed to diagnose fibromyalgia; the key diagnostic finding is the characteristic tender points on the physical examination.

There is no single treatment that eliminates or cures post-traumatic fibromyalgia. However, various treatments can help individuals with post-traumatic fibromyalgia and the goals of the treatment are to help one get to the best possible level, even if the condition does not completely disappear or become cured. Each person's treatment program needs to be individualized, and what works for some may not work for others. Hopefully the person will find some treatment that is helpful in dealing with the pain.

Once a person is diagnosed with post-traumatic fibromyalgia, various types of treatments can be recommended in order to achieve the best "cure" or remission possible. A combined treatment approach is usually most effective and can include prescription medicines, nutritional supplements, physical therapy, soft tissue therapy, massage, relaxation techniques and stress management. I emphasize trying to find out what works, and teaching the person to follow through with an independent home program to control the chronic problems associated with post-traumatic fibromyalgia. Even if fibromyalgia cannot be cured yet, it can still be healed enough so the person can achieve a high level of function in spite of the persistent pain. Although we know that trauma can cause fibromyalgia, we are still studying the exact pathologic mechanism that occurs at the time of trauma that ultimately leads to fibromyalgia. Localized trauma to a region of the body produces changes in the muscles and probably causes changes in the pain pathways. As a result, the pain signals are amplified and travel up the central nervous system to the brain, causing further changes that affect the entire nervous system and muscles. Dr. Robert Bennett has described the "amplified pain" in fibromyalgia (as a disorder of sensory processing).

Fibromyalgia is a permanent condition. Trauma can lead to regional fibromyalgia, or it may cause generalized fibromyalgia. Regional post-traumatic fibromyalgia can cause permanent changes in the pain processing centers in the brain that cause evolution into a more diffuse pain disorder, i.e. generalized post-traumatic fibromyalgia. Dr. Buskila's study supports how a localized injury to the neck region can, over time, lead to a generalized post-traumatic fibromyalgia. Ongoing research will shed additional light into the exact pathologic mechanisms of post-traumatic fibromyalgia.

The key features of post-traumatic fibromyalgia are as follows:

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1. No previous pain complaints before the trauma similar to those experienced since the trauma.

2. A history of a trauma which caused pain to develop.

3. Pain resulting from the trauma that has persisted ever since the trauma, i.e. an "unbroken chain" of pain.

4. The pain persists for at least six months, well beyond the period of time where healing will take place. By six months, healing of soft tissue injuries should have occurred; if not, fibromyalgia could develop.

5. The presence of characteristic painful tender points in a regional or generalized location that are consistently present upon repeated follow-up medical exams.

6. Post-traumatic fibromyalgia can improve with a comprehensive treatment program although there is no complete cure yet.

In my book, Understanding Post-Traumatic Fibromyalgia, I discuss in detail fibromyalgia syndrome that develops following a trauma. This 130 page book is the first book written that focuses exclusively on post-traumatic fibromyalgia. It is available through Anadem Publishing, phone 1-800-633-0055, fax 614-262-6630.