Fibromyalgia syndrome: what it is and what it isn’t – discuss

In this extract from a longer paper, Dr Anthony Hammond describes the littleunderstood condition that is debilitating for many sufferers.

[FIBROMYALGIA SYNDROME (FMS) is by definition a syndrome: an association of clinical features which are recognised as occurring together but do not have an established disease-based explanation. In this case it comprises chronic widespread pain (CWP), aspects of fatigue, depression and polysymptomatic distress.

At the outset it was intended to define a group with ‘medically unexplained’ pain, but that has been revised and it may now stand alongside other diagnoses and may not be the dominant clinical issue.

The commonest causes of CWP are mechanical, osteoarthritis and spinal degeneration. My own work in discogenic pain management can often be helpful in understanding spinal problems.

The condition was mooted in 1990 by an American College of Rheumatology committee and was redefined in 2010 and 2016, for example deleting physical examination findings (tender points) and creating a simplified scoring of criteria which are essentially wholly subjective; there is no external objective test to validate the diagnosis.

The result of those sequential changes is that the performance of the diagnosis in daily practice is often poor and many clinicians diagnose it loosely – many assuming, alongside patients, that the diagnosis is a disease. That often casts a pall over a case and its assumed poor prognosis.

Fibromyalgia, once established, tends to persist and treatment is commonly unhelpful. However, since it is not a disease with a driving pathology, it does not, in my view, impose a natural history of progression on the patient.

Fibromyalgia is common, at around 1-7%, and the antecedents are well established. Chronic widespread pain is more common and occurs earlier, mainly in women, so there are therefore a significant group of individuals who are at high risk of developing FMS, and in whom pre-existing psychological or degenerative problems create a trajectory towards the diagnosis which occurs most commonly around age 50 in females.

Accordingly, an accident or trauma may be the final straw and the diagnosis may ‘appear’ after an accident and be retrospectively attributed to it by working clinicians. Often, careful consideration of records shows that the issue is about acceleration of otherwise probable outcomes and an expert with a clear understanding of those factors can assist in clarifying and quantifying the diagnosis and its implications to the court. q • A much fuller discussion of the issues is available from the author for those who might be interested.