|Author||Daniel J. Wallace and Janice Brock Wallace|
|File size||1.5 MB|
Making Sense of Fibromyalgia
DANIEL J. WALLACE, MD
Associate Director, Rheumatology Fellowship Program
Clinical Professor of Medicine
Cedars-Sinai Medical Center
David Geffen School of Medicine at UCLA
Los Angeles, California
JANICE BROCK WALLACE, MPA
Oxford University Press is a department of the University of Oxford.
It furthers the University’s objective of excellence in research, scholarship,
and education by publishing worldwide.
Oxford New York
Auckland Cape Town Dar es Salaam Hong Kong Karachi
Kuala Lumpur Madrid Melbourne Mexico City Nairobi
New Delhi Shanghai Taipei Toronto
With offices in
Argentina Austria Brazil Chile Czech Republic France Greece
Guatemala Hungary Italy Japan Poland Portugal Singapore
South Korea Switzerland Thailand Turkey Ukraine Vietnam
Oxford is a registered trademark of Oxford University Press
in the UK and certain other countries.
Published in the United States of America by
Oxford University Press
198 Madison Avenue, New York, NY 10016
© Oxford University Press 1999, 2014
All rights reserved. No part of this publication may be reproduced, stored in a
retrieval system, or transmitted, in any form or by any means, without the prior
permission in writing of Oxford University Press, or as expressly permitted by law,
by license, or under terms agreed with the appropriate reproduction rights organization.
Inquiries concerning reproduction outside the scope of the above should be sent to the
Rights Department, Oxford University Press, at the address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Wallace, Daniel J. (Daniel Jeffrey), 1949–
Making sense of fibromyalgia / Daniel J. Wallace, MD, associate director, Rheumatology Fellowship
Program, clinical professor of medicine, Cedars-Sinai Medical Center, David Geffen School of
Medicine at UCLA, Los Angeles, California, Janice Brock Wallace, MPA.—Second edition.
Includes bibliographical references and index.
1. Fibromyalgia—Popular works. I. Wallace, Janice Brock. II. Title.
1 3 5 7 9 8 6 4 2
Printed in the United States of America
on acid-free paper
Preface to the Second Edition, ix
Fibromyalgia Made Simple, xiii
Part I The Whys and Wherefores of Fibromyalgia
1. How Our Understanding of Fibromyalgia Evolved, 3
2. What Is Fibromyalgia? 8
3. Who Gets Fibromyalgia and Why? 17
Part II Basic Science and Fibromyalgia
4. Why and How Do We Hurt? 27
5. What’s Wrong with My Muscles? 41
6. How Do Stress, Sleep, Hormones, and the Immune System Interact and
Relate to Fibromyalgia? 46
7. What Is the Autonomic Nervous System? 55
Part III How and Where the Body Can Be Affected by Fibromyalgia
8. Generalized Complaints, 63
9. “I’m Stiff and Achy”—Musculoskeletal Complaints, 70
10. Tingles, Shocks, Wires, and Neurologic Complaints, 74
11. Insights into Insides: Chest, Cardiovascular, and Other Concerns, 81
Part IV The Clinical Spectrum of Fibromyalgia
12. What Are the Regional and Localized Forms of Fibromyalgia? 89
13. What Conditions Are Associated with Fibromyalgia? 96
14. Controversial Syndromes and Their Relationship to Fibromyalgia, 113
Part V The Evaluation of Fibromyalgia Patients
15. What Happens at a Fibromyalgia Consultation? 123
16. Are You Sure It’s Really Fibromyalgia? 130
17. I’m Not Crazy! 137
Part VI Improving Your Quality of Life
18. Influences of Lifestyle and Environment on Fibromyalgia, 147
19. The Influence of Exercise and Rehabilitation on the Mind and Body, 155
20. How to Overcome Fibromyalgia, 167
21. Evaluating Medicines That Work for Fibromyalgia, 181
22. Drugs That May Be Useful in Fibromyalgia Patients: An Overview, 187
23. The Economic Burden of Fibromyalgia: Work and Disability, 209
Part VII Where Are We Headed?
24. What’s the Prognosis? 221
25. The Future Holds a Lot of Hope, 225
Appendix 1: Resource Information, 231
Appendix 2: Glossary, 233
Making Sense of Fibromyalgia is a well-written compendium directed to the
millions with severe fatigue, muscular pain, poor sleep patterns, and the other
symptoms characteristic of fibromyalgia. While there is continuing debate in
the medical and research community about the causes and treatments for this
misunderstood syndrome, Dr. Daniel J. Wallace’s clinical experience and studied
review of the current literature have enabled him to produce a book that discusses many of the current theories and understandings.
Dr. Wallace’s specific discussions on the diagnostic elements; procedures that
support, differentiate, and exclude fibromyalgia as a primary or secondary condition; and specific therapies and their expected efficacies continue the learning
process for the reader and provide hope through better understanding of this
often maligned condition.
This is an important book that provides a nice complement to the Arthritis
Foundation’s own publication Your Personal Guide to Living with Fibromyalgia.
The Arthritis Foundation, Southern California Chapter, is grateful to Dr. Daniel
J. Wallace and Oxford University Press for their support of our program for
people with fibromyalgia through donations from the sale of this book, Making
Sense of Fibromyalgia.
Medical & Scientific Committee
Arthritis Foundation, Southern California Chapter
Los Angeles, California
Preface to the Second Edition
To talk of diseases is a sort of Arabian Night’s entertainment
Sir William Osler (1849–1919)
Among the childhood pastimes we enjoyed was a peculiar board game known as
“Uncle Wiggily” (Fig. 1). Its premise seems quaint when viewed from an adult
perspective many years later, but the first player enabling Uncle Wiggily to reach
Doc Possum’s house so that his rheumatism could be treated was the winner.
Along the way, all sorts of nostrums, barriers, diversions, and misinformation
deterred Uncle Wiggily from his goal. What, we asked our child’s mind, was
rheumatism? This mysterious, all-encompassing term could apply to fibromyalgia. Fibromyalgia is a syndrome that defies our usual concepts of a disorder and
is classified by the Arthritis Foundation as a form of “soft tissue rheumatism.”
The purpose of this monograph is to enable you to help yourself; to make it easier to work with your doctor and other allied health professionals; to improve the
way you feel; and to promote a better quality of life. To begin, there are several
reasons why fibromyalgia is plagued by misunderstanding:
Although it is now recognized as a legitimate syndrome by the American
Medical Association, the American College of Rheumatology, the Arthritis
Foundation, and the American College of Physicians, as well as the World
Health Organization, some doctors still question its existence. This is largely
a consequence of incomplete medical training that was (and often still is)
primarily hospital-based. Outpatient (office-based) clinical medicine training, which included fibromyalgia, was largely overlooked. Patients are
rarely, if ever, hospitalized for fibromyalgia. Also, statistically validated criteria for defining fibromyalgia were not endorsed by organized medicine
Fibromyalgia patients often have normal blood tests and imaging studies and are thought by some health care professionals to make up many
of their symptoms. Certain doctors consider fibromyalgia patients to be
Preface to the Second Edition
Fig. 1. An achy Uncle Wiggily on his way to visit Doc Possum.
hypochondriacs or seekers of medical attention for purposes of litigation or
secondary gain. Fortunately, there are now reproducible tests documenting
that these complaints are real and studies showing that hypochondriasis is
extremely rare in fibromyalgia.
Six million people in the United States meet the criteria for fibromyalgia.
On average, they saw about four doctors before they were correctly diagnosed, and many were convinced they had a life-threatening illness such
as a body-wide cancer. Fibromyalgia is a combination of pain, fatigue, and
systemic symptoms. Ten million patient visits to doctors every year in the
United States are for pain; $600 billion is spent annually to diagnose or
manage chronic pain, including litigation fees. One group has estimated that
patients with fibromyalgia run up $20 billion in medical expenses annually.
Some 10% of US adults have moderate pain and 1% have severe pain; 12%
have functional disability due to chronic pain. Additionally, at any visit,
15% of all patients tell their doctor they are tired. There is a paucity of reliable, detailed information about the fibromyalgia syndrome that patients can
use to help themselves or others.
Many employers do not realize that fibromyalgia is a treatable workplace
problem. It can impair job performance even though its symptoms and signs
Preface to the Second Edition
are invisible. Over a billion workdays costing $300 billion are lost annually
due to pain and 50 million Americans are partially disabled due to chronic
pain. Up to 10% of fibromyalgia patients are totally disabled, 30% require
job modifications, and 30% have to change their job in order to remain
employed. Appropriate treatment, workstation modifications, and counseling could save the American public hundreds of millions of dollars, improve
our productivity, and maintain the self-esteem of the fibromyalgia sufferer.
Every year, over $13 billion is spent out of pocket for non-insurancereimbursed care by alternative medicine physicians and other caregivers in
the United States. Some of this is spent by fibromyalgia patients who are
frustrated by the lack of attention, knowledge, and concern of their primary
care and specialist physicians.
In our opinion, there is a relative shortage of rheumatologists, the subspecialists within internal medicine who deal with fibromyalgia, and too little
research is ongoing to understand its cause, diagnosis, and treatment. In
2011, the National Institutes of Health allocated only $12 million for fibromyalgia research.
This book is intended not only for fibromyalgia patients, but also for their
loved ones, primary care physicians, allied health professionals (nurses, social
workers, dentists, physical therapists, psychologists, occupational therapists,
vocational rehabilitation counselors, physician assistants, chiropractors, and
dietitians), and other people who care about them. A few portions of this book
were originally published in a monograph I wrote with Dan Clauw for the
Oxford American Rheumatology Library in 2009. Some of Dr Clauw’s insights
are included verbatim in this update.
Since the original iteration of this concept, originally published as Making
Sense of Fibromyalgia, was written 15 years ago, many advances have been
made in fibromyalogy. This includes three FDA approved medications and over
10,000 peer-reviewed publications. We hope that you find this update informative and useful.
Los Angeles, California
Fibromyalgia Made Simple
Pain has an element of blank;
It cannot recollect
When it began, or if there were
A day when it was not.
It has no future but itself
Its infinite realms contain
Its past, enlightened to perceive
New periods of pain.
Emily Dickinson (1830–1886)
Pain Has an Element of Blank
If you have the chronic pain of fibromyalgia, you may be frustrated by the lack
of understanding shown by people around you. This is particularly true of the
people you live and work with. If only they could feel for one day how you feel
all year! Pain has no memory and no mercy. Is it like a bad flu or a severe headache? How can you find the words to describe it? You might wish to recite this
short explanation; the next 200 pages provide the details.
Picture your body as being a series of electrical circuits. Suppose that you
have the unfortunate tendency to injure your shoulder repeatedly. What happens? As part of a chronic pain response, a wire goes from the shoulder to your
spine, and a second wire then travels up the spinal cord to your brain. The brain
receives a signal that says, “I hurt my shoulder; let me do something about it.”
The brain then makes a chemical or chemicals that suppress the pain. It wires a
signal back down the spinal column, and a second wire returns to the shoulder.
The chemical is released, and the pain gets better or goes away.
What happens in fibromyalgia? Your body becomes “cross-circuited” (Fig. 2).
The body gets flooded with “input” circuits giving it information. The spinal
cord can’t sort out and filter these signals. Larger circuits close off smaller
ones. With time, the electrical circuits become “wiry” and excitable. Normally
Fibromyalgia Made Simple
Fig. 2. Cross-circuiting giving the wrong message after shoulder trauma.
non-painful stimuli are regarded as painful ones. The “output” wires fail to alleviate discomfort. The circuits discharge signals that increase your perception
of pain, not only in the region that was hurt but also in the area around it. As a
result, the processes that regulate your body become confused and you start to
develop all sorts of troublesome symptoms. You can’t get a good night’s sleep,
your muscles go into spasm, and you become fatigued. This aggravates you further and creates a vicious cycle that makes the pain even worse. In a nutshell,
this series of events is observed in fibromyalgia.
Let’s explore how this happens and what can be done about it.
THE WHYS AND
Is it nothing to you, all that pass by? Behold and see. Is there any pain
like unto my pain, which is done unto me, wherewith the Lord has afflicted
me in the day of his fierce anger? From above, he has sent fire into my
bones. . . . and I am weary and faint all the day.
Jeremiah, in Lamentations 11:12–13
In this part the reader will discover how fibromyalgia evolved and was ultimately defined. Although descriptions of it date back to biblical times, the perception of fibromyalgia as a syndrome represents a convergence of two historical
threads: those relating to ongoing musculoskeletal pain (joint and muscle aches)
and those dealing with chronic fatigue and a sense of debility. Both official and
practical definitions of fibromyalgia will be discussed, and we will consider the
number of people who have the syndrome, as well as population groups that
most frequently develop it.
How Our Understanding of
. . . and wearisome nights are appointed to me. When I lie down, I say, When
shall I arise, and the night be gone? And I am full of tossings to and fro
unto the dawning of the day . . . and the days of affliction have taken hold
upon me. My bones are pierced in me in the night season; and my sinews
take no rest.
Job 7:3–4 and 30:16–17.
There are times when rheumatologists have been accused of making up new syndromes. For example, in the last 40 years, our specialty has described new rheumatic entities including Lyme disease, the musculoskeletal manifestations of
acquired immune deficiency syndrome (AIDS), eosinophilic-myalgia syndrome
(from L-tryptophan contamination), and siliconosis (which, if it exists, results
from silicone breast implants). Fibromyalgia is not in this group. Evidence for
the syndrome can be found as far back in history as the book of Job, where he
complained of “sinews (that) take no rest.”
Concepts of what is now regarded as fibromyalgia date to the Babylonian epic
of Gilgamesh, the Bible, and Shakespeare (Therefore the moon, the governess of
floods. Pale in her anger; washes the air. That rheumatic diseases do abound.
A Midsummer Night’s Dream, Act 2, Scene 34, I, 105). The term “rheumatism”
was first used by Guillaume de Baillou around 1592 and was included in a 1763
glossary of rheumatic diseases by FB de Sauvages de la Croix.
Fibromyalgia represents a convergence of concepts, as shown in Table 1.1. In
other words, a similar clinical presentation ultimately evolved, and by the late
20th century it was apparent that these musculoskeletal manifestations of central
pain or sensory augmentation represented a similar process.
EVOLUTION OF TRIGGER AND TENDER POINTS
The British physician RP Player first described what are now regarded as tender
points in 1821 and were described in more detail by F Villeix in an 1841 treatise
(“points douloureaux”). Additional insights derived in the 19th century include
its predilection for females, the presence of nodules, associated muscular spasm,
The Whys and Wherefores of Fibromyalgia
Table 1.1. Fibromyalgia: A Convergence of Concepts
Trigger and tender points
Postinfectious fatigue syndromes
Chronic widespread pain in wartime
Post-traumatic myofascial pain
pain and stiffness, and somatic complaints. Sir William R Gowers (1845–1915)
coined the term “fibrositis” in a paper on lumbago (low back pain) in 1904.
Sir Thomas Lewis and Jonas Kellgren mapped out tender and trigger points
as well as referred pain patterns in the 1930s. Arthur Steindler demonstrated
amelioration of local symptoms with procaine injections in 1937. Janet Travell
(1901–1997) was the White House physician to John F Kennedy and Lyndon B
Johnson. She elaborated upon these findings and is felt to be largely responsible
for founding the discipline now known as physical medicine. In part because
of a differing philosophy regarding the underlying pathophysiology, there has
been a gradual divergence between what the terms tender point (an area of the
body that displays increased tenderness upon palpation—the number of which is
an (albeit poor) measure of an individual’s overall pain sensitivity) and trigger
point (a regional phenomenon accompanied by the presence of “taut bands” and
referred pain) have come to mean.
The term “nervous exhaustion” or chronic fatigue was first studied by Austin
Flint in the early 1800s and detailed by George Beard (1839–1883), who coined
the term “neurasthenia” and Silas Weir Mitchell (1829–1914), who “packaged”
the condition in the United States and treated it with a combination of Faradic
currents and misogynistic approaches (e.g., removal of the clitoris, encouraging
masturbation via horseback riding). Neurasthenia was the longest section in the
1899 edition of Sir William Osler’s textbook of medicine. The term largely disappeared after World War I.
POST-INFECTIOUS FATIGUE SYNDROMES
The association between established infections and psychological or fatigue
states was attributed to malaria or “wasting fevers” in the 1860s and typhoid
fever by Osler among others. In the 1930s and 1940s, reports of post infectious
fatigue syndromes were published relating to polio and brucellosis. In the 1970s,
chronic fatigue was attributed to yeast and the Epstein-Barr virus, but rigorous
Author Daniel J. Wallace and Janice Brock Wallace Isbn 9780199321766 File size 1.5 MB Year 2014 Pages 272 Language English File format PDF Category Personality Book Description: FacebookTwitterGoogle+TumblrDiggMySpaceShare Six million people in the United States meet the criteria for fibromyalgia, which is a disorder characterized by a combination of pain, fatigue, and related symptoms. On average, these patients see about four doctors before they are correctly diagnosed, and many are convinced they have a life-threatening illness such as an advanced stage of cancer. About $600 billion is spent annually in the United States to diagnose or manage chronic pain, including litigation fees, and it is estimated that fibromyalgia patients run up $20 billion in medical expenses annually. Despite these alarming numbers, there is a lack of understanding and a dearth of reliable information about fibromyalgia for patients. This fully updated edition of Making Sense of Fibromyalgia distills complex concepts and symptoms into an easily understandable narrative. Daniel J. Wallace, a leading rheumatologist at Cedars-Sinai Medical Center, and Janice Brock Wallace, an expert medical writer, have updated the original classic resource, which has sold over 100,000 copies since 1999. Making Sense of Fibromyalgia provides clear answers to common questions, explains findings from the latest research, and discusses treatment options for complex symptoms. Detailed information is provided about topics such as who gets fibromyalgia and why; how stress, hormones, and your immune system interact and relate to fibromyalgia; what conditions are associated with it; why and how you might be misdiagnosed; how to overcome fibromyalgia; and how to understand your prognosis. The authors share all there is to know about the syndrome as well as how our understanding of it has changed over time. This comprehensive companion covers the entire spectrum of issues for those suffering from fibromyalgia, as well as their families, friends, caretakers, primary care physicians, and other health professionals. Download (1.5 MB) The Tapping Solution For Pain Relief Compact Clinical Guide to Chronic Pain Management Meditation (the Only Book Youll Ever Need) Living With Bipolar Disorder(McFarland Health Topics) Brilliant Mindfulness: How The Mindful Approach Can Help You Towards A Better Life Load more posts