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Does trauma cause fibromyalgia? (Pro And Con).


Of the almost 1,000 fibromyalgia patients in my practice, I would estimate that half have fibromyalgia associated with trauma. Of those, three-quarters have had head or neck trauma.

A growing body of evidence, while not exactly proving that musculoskeletal injury can cause fibromyalgia, gives us that picture as well as some ideas of what mechanisms might result in fibromyalgia.

One of the most convincing studies to link fibromyalgia and trauma suggests that head and neck trauma are more strongly associated with fibromyalgia than are other types of trauma. The investigators in Israel assessed 102 patients with traumatic neck injury and 59 control patients with leg fractures. The patients were evaluated for tender points, interviewed about the presence and severity of neck or fibromyalgia-related symptoms, and diagnosed using the 1990 American College of Rheumatology criteria.

The neck-trauma patients were 13 times more likely to have fibromyalgia than were the controls (Arthritis Rheum. 40[3]:446-52, 1997). This would appear to make sense. Injuries dose to the head and central nervous system would be more likely to cause generalized symptoms or a generalized syndrome.

Of course, assessing pain and determining how much pain or injury a particular trauma might inflict are problematic, particularly with head and neck trauma. Therein lies the rub of associating fibromyalgia and trauma.

Autopsy studies indicate that even when x-rays of the cervical spine are negative, there can be occult fractures and injury to the cord itself. Also, patients with neck injuries have more sleep difficulties than patients with other types of injuries. It is during sleep--specifically stage IV non-REM sleep--that human growth hormone is released. Human growth hormone abets healing, and good stage IV non-REM sleep appears necessary for patients with fibromyalgia to improve.

The theory of expanding receptive fields perhaps best explains how a local injury gets translated into a generalized syndrome like fibromyalgia. According to that theory, injured tissues release substance P. When healing is prolonged, chronic release of substance P can sensitize noninvolved dermatomes, leading to neuroplastic changes in the central nervous system through a feedback loop.

None of this evidence is a smoking gun, but it becomes compelling given that so many patients report that their fibromyalgia arose after trauma. Knowing the etiology of fibromyalgia doesn't cure these patients, but it does give them some credible explanation for their condition.

Dr. Thomas J. Romano, president of the board of directors of the American Academy of Pain Management, practices in Wheeling, W.Va.


The American College of Rheumatology's 1990 Criteria for the Classification of Fibromyalgia (Arthritis Rheum. 33[2]:160-172, 1990) were designed to identify a uniform set of patients for the purposes of research. But the general application of these criteria to the clinic has resulted in the inappropriate transmogrification of a syndrome into a disease, and in the medico-legal setting has resulted in a veritable epidemic of disability claims and awards.

To "have" fibromyalgia in the medicolegal setting takes little more than reporting pain and saying that you have pain when the examiner palpates the tender point sites. Easily learned by claimants and attorneys, the examination is totally devoid of validity in that setting!

That trauma can cause pain, including chronic pain, is obvious. But in the setting of fibromyalgia, as practiced in the clinic and the courts, there is little relation between the extent of trauma and the subsequent claim of fibromyalgia.

I have seen medico-legal cases where the alleged trauma came from operating a copy machine, sexual harassment, or falling into a filled swimming pool and cases in which fibromyalgia developed following the use of high doses of progesterone or corticosteroids.

There is no consistent relationship between the extent of the patient's trauma and the risk of the later "development" of fibromyalgia.

The most consistent relationship that precedes fibromyalgia in patients is that of psychosocial distress, a relationship that has been confirmed by epidemiology studies.

But it gets worse. Not only is fibromyalgia "faceable" and often associated with underlying psychosocial issues, there are no reliable methods to determine the extent and severity of the pain and/or disability. It is entirely based on self-report: "I am the evidence."

To accept the trauma-fibromyalgia-disability theory on the evidence that is available at this time, and then to apply that theory to specific patients, is to defy logic and to live in an Alice in Wonderland fantasy world to which we have added attorneys.

It is not my intention for a second to state that trauma does not cause pain in many individuals, or even chronic pain. Nor do I wish to suggest that that there are not patients who actually satisfy criteria for fibromyalgia.

But I would argue that the intellectual jump from variously described trauma to self-reported illness to self-reported disability simply beggars the imagination.

Dr. Frederick Wolfe, director of the National Databank for Rheumatic Diseases, is clinical professor at the University of Kansas, Wichita.
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Publication:Internal Medicine News
Date:Nov 15, 2002
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