Hi. My name is Dr. Charles Argoff, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center in Albany, New York. One of the more common chronic painful conditions that we all encounter is fibromyalgia. As we continue to learn more about the mechanisms and the breadth of the involved areas of the nervous system, and we have changed the way we diagnose this condition, it is important to describe a typical scenario that I see very commonly in my practice at Albany Medical Center.
Consider a 42-year-old right-handed man who was involved in a motor vehicle accident. He was driving his truck and was hit by another truck, crashed, and immediately complained of pain in his middle thorax and spine, his neck, and lower extremities. He went to an orthopaedic surgeon; he went to his primary care doctor; he was advised to have physical therapy; x-rays did not show any type of fracture, and he did not do very well. He continued to have widespread pain. He had no family history of fibromyalgia or anything similar. Previously, he had worked for his company for 20 years and he was considered a good worker. He used a little bit of tobacco, but was not a significant alcohol or recreational drug user. He had no past surgeries.
He was then sent to a local rheumatologist who evaluated him and said, "You have fibromyalgia; sometimes trauma can cause fibromyalgia." The rheumatologist advised him to use typical treatments including exercise. He also talked to the patient about using a medication, such as duloxetine, that is now US Food and Drug Administration (FDA) approved for fibromyalgia. That did not help him, so he wound up using pregabalin, which is also FDA approved for fibromyalgia. That made him too tired, and so he was referred to the pain center at Albany with a diagnosis of fibromyalgia following trauma.
The first thing I did after taking his history -- and it is so important to review past records and take a careful history from someone with whom you don't have an extensive history -- I also learned that he was having difficulty sleeping. He was fatigued and felt stiff in the morning, so he had features that would have been considered consistent with the criteria we use for fibromyalgia.
Many of you may know that we have moved away from the older American College of Rheumatology 1990 criteria, which emphasized the presence of tender points in 11 out of 18 defined areas throughout our body, above and below the waist and on both sides. We have moved into an accepted means to diagnose fibromyalgia, not so much when there is no pain at all but when there aren't a full number of areas of tenderness, and there is also fatigue, cognitive dysfunction, and other measures that we see in fibromyalgia. This is something that has come out over the last year to aid in the diagnosis of fibromyalgia, so that people are not missed.
When I examined this patient, it was clear that there was something wrong with his central nervous system. He had diffusely enhanced brisk reflexes, plantar responses, sometimes called Babinski responses, that were extensor bilaterally; clonus -- sustained rhythmic movement of his joints when the maneuver was elicited -- in his ankles; bilateral Hoffmann signs; Lhermitte's sign -- neck flexion caused significant pain going down his spine; and then he told me it felt worse, not better, during a hot shower. I told him that we needed to do more studies. This patient had not been imaged at all other than with simple x-rays. Those of you who are neurologists probably know where I'm going with this. When we imaged his cervical, lumbar, and thoracic spine, and his brain, we found that he had widespread demyelinating disease. He had had a less than symptomatic case of multiple sclerosis for many years. After we figured this out there, we went back in his history and identified some signs that he had had this problem, but after his trauma he had much more widespread complaints.
The important point here is that it is essential to evaluate people you suspect of having fibromyalgia as extensively as possible so you can see the whole playing field. It is not uncommon, as in this case, to have a fibromyalgia-like presentation with a nondiagnosed multiple sclerosis. We have seen people for whom we have made a diagnosis of rheumatoid arthritis when that had not been considered previously. We see people who have localized symptoms of rheumatoid arthritis and more generalized complaints and other complaints that are consistent with fibromyalgia. You can have both. The most important thing, for treatment purposes, is to be able to work with a patient as successfully as possible. It is important to have a comprehensive evaluation so that people who are said to have fibromyalgia have been evaluated comprehensively so as to focus attention on all the conditions that might explain the problems they are experiencing. We often under-evaluate a patient and label their symptoms "fibromyalgia" without a full evaluation. Although some of you viewing this might think that is wasteful and expensive, it is not expensive if you do the right evaluation at least once. Then you have more evidence to support what you are treating. I hope this has been helpful, and thank you very much.