Hello. My physician husband recently attended a lecture on fibromyalgia. I have invited him to use my blog as a forum to express his impressions. The vast body of information provided could not fit into 1 blog, so consider this as Part 1 of a continuing series on fibromyalgia:
I have observed doctors arguing over the existence of fibromyalgia since I was a medical student 30 years ago. As mood problems were commonly associated with the condition, many felt it was simply depression causing the symptoms. The lack of any confirmatory lab test was used as evidence that FM did not exist. However, there are many conditions which do not have a blood test to confirm the diagnosis. An example would be schizophrenia. There are diagnostic criteria used to decide if a patient has schizophrenia just like there are for diagnosing FM. Like FM there is no blood test to confirm the presence of schizophrenia, however, few doubt its existence. Perhaps it's because observers can see and hear differences in the way schizophrenics talk and act from others whereas patients with FM look the same as everyone else. Why does FM get such a bad rap? Perhaps it’s bad marketing?
I am in the unique situation of being a physician whose wife has fibromyalgia. Since her diagnosis 4 years ago, I have been more alert to the arguments over fibromyalgia. I am seeing a steady increase in acceptance by physicians of the condition. However, as recently as last year I attended a conference on Pain and Addiction in which an arthritis specialist who worked at a pain clinic told the audience he did not think that FM was real. Part of the problem is that specialists only see the worst cases and they see the cases that are least likely to be improved by any therapy. One review showed that almost no patients were improved by treatment offered by specialists, whereas family doctors had a 25-30 % response to treatment. It is usually specialists that teach family doctors at lectures - if specialists have no success in treating the condition they may promote an ongoing negative view of the condition. Specialists may be the cause of the bad marketing alluded to in the previous paragraph. At lectures on fibromyalgia that I attend, it is often the older doctors who argue that FM is simply in the patient’s head and is due to depression. Younger physicians (like myself – age 55) seem much more willing to accept that FM is real.
At a recent review on fibromyalgia I attended, the lecturer argued that the existence of fibromyalgia should no longer be doubted. Research now shows marked differences between FM patients compared to 'normals.' Spinal fluid analysis shows much higher levels of substance P (a protein associated with pain) in those suffering FM. Endorphin levels are higher in FM patients but their narcotic receptors are blocked so they do not benefit from the endorphins. In the past, static brain scans showed no difference between FM sufferers and normals in response to a painful stimulus. However, on functional scans where brain activity was recorded over time, FM sufferers were shown to have 6-8 times more activity to a painful stimulus. The brain cortex appears to light up in FM sufferers in response to pain. There is still no simple blood test to diagnose FM. However, there is clear evidence that FM can now be differentiated from other conditions in the research lab.
Research shows that in FMS, pain signals going up the spinal cord are magnified at 2 levels in the spinal cord. As a result, the pain signals that reach the brain are much more intense. The brain also has pathways that send signals down to the spinal cord to dampen down pain signal activity. These descending pathways act as a brake to reduce pain information going to the brain. This was described years ago and was called the Gate Theory of Pain. If the gate was fully open, then all the pain impulses were transmitted up the spinal cord. If the gate was closed, then less pain information was sent up to the brain. In fibromyalgia, there is very little braking occurring so the gate stays wide open. A painful stimulus such as a needle poke to the finger can cause increased brain activity in both normals and FM sufferers for up to 36 hours. In normals, the braking mechanism causes the perception of pain to settle down in a few minutes by closing the gate on pain impulses up the spinal cord. In people with FMS, the gates do not get closed so the pain can continue to be felt for the entire 36 hours.
In fibromyalgia, the pain signal is amplified and additionally the signals do not get reduced due to a lack of a brake. It is no wonder that people with fibro suffer pain. Research shows that there are biological markers for FM so in time there should be fewer medical skeptics. Even more exciting is the hope that research will identify areas to focus treatments for FM. Already there are drugs that can reduce the amplification of the pain signal in the spinal cord. Other drugs can improve the brake to reduce the pain signal. Narcotic receptors are blocked in FM so research to focus on how to unblock the narcotic receptors may prove useful in treatment.
Thanks for reading.