Fibromyalgia: The Answer Is Blowin' in the Wind
© KEVIN P. WHITE, MD, PhD
Source: J Rheumatol. 2004 Apr;31(4):636-9
How many times can a man turn his head and pretend that he just doesn't see? --Bob Dylan, "Blowin' in the Wind"
These immortalized words have rung true repeatedly throughout the sordid history of humankind. Yet it should seem startling that Dylan's words might apply to physicians, who recite the Hippocratic Oath, and promise to ease pain and suffering and "do no harm." Nonetheless, these words too often do apply to physicians, perhaps no more frequently than when many such physicians are asked to deal with fibromyalgia (FM).
For those unfortunate patients who suffer from FM, "Hippocratic" often rings more like "hypocritical." In desperation, patients turn to those learned in Medicine and professing to help them, only to hear their malady called - nothing at all: "an illusionary entity"(1), "a common non-entity"(2), "mass hysteria"(3),"the syndrome of feeling out of sorts"(4). Many in the medical profession have chastised FM, calling for "a return to common sense"(5) by discarding the label, and the concept, altogether.
But why? And why are these comments so often laced with venom? Why are those who oppose the FM concept so verbal and destructive, many going out of their way to write position papers about an area in which they have done no research, and seem so oblivious and impervious to the research of others?
The answer lies far beyond a lack of acceptance of a poorly understood and poorly treated entity. We have little understanding of disease mechanisms for many well accepted disorders, such as polymyalgia rheumatica, migraine headache, and trigeminal neuralgia. And we have very few effective treatments for disorders such as scleroderma and ankylosing spondylitis. Yet none of these disorders comes under the same intensely zealous scrutiny as FM. What is it about FM that provokes such ire?
It should not be that FM symptoms all are subjective - all symptoms are, by definition, subjective(6,7), irrespective of their setting. Whether caused by FM or cancer, tendonitis or ischemic heart disease, symptoms such as pain, fatigue, nausea, and dizziness cannot be measured objectively. We must rely on patient reports, then choose to believe them, or not.
Some have used objective evidence of tissue pathology, such as gross swelling or radiographic changes, as an objective proxy for pain; the corollary to this is that they believe that the absence of objectively measurable tissue pathology is an argument against the presence of "true pain." However, both halves of this reasoning are flawed. Medical practice abounds with disorders in which the degree of pain and degree of objective tissue
