FIBROMYALGIA, CHRONIC PAIN AND TRAUMA CONFERENCE

May 15-17, 2001, Bristol, UK

Here is a report provided by Dr. Andrei Calin for the RHUMA21 website on a 3-day conference on the possible links between Fibromyalgia, Chronic Pain, and Trauma. The conference was organised by Bernie Rowe of Lyons Davidson Solicitors in Bristol.

 
 

 

 

 

                                                                                                         
    From RHEUMA21      http://www.rheuma21st.com
     

FIBROMYALGIA, CHRONIC PAIN AND TRAUMA CONFERENCE       

Reported by Andrei Calin, MD, FRCP,
Royal National Hospital for Rheumatic Diseases, Bath, England

           Published 11. June 2001


 
About 200 delegates from around the world attended what turned out to be a fascinating and superbly organised 3-day workshop on Fibromyalgia, Chronic Pain, and Trauma, held May 15-17, 2001, in Bristol, UK. The workshop was organised by Bernie Rowe, an attorney with Lyons Davidson Solicitors in Bristol. One was immediately struck by the absence of any hidden agenda. If one puts a number of articulate individuals in the same room and focuses on the world literature in terms of trauma, and more particularly whiplash injuries, and the ensuing outcome in terms of return to normality or fibromyalgia/chronic pain, one is likely to be able to reach something of a consensus. Of course, we did not. But having said that, we did have an excellent opportunity to focus on the different schools of thought and opinions in this intricate field.

Although organised by a lawyer, the vast majority of speakers and perhaps half the audience were medical.  Most of the world's major players in fibromyalgia, whiplash, and the resulting litigation were present.

The firm of Lyons Davidson is somewhat unusual -- at least in the British setting -- as they work both for Plaintiff and Defence in personal injury claims and other areas.  Thus, in house they have a clear balance of views and the invited speakers reflected this, with opinions ranging from one end of the spectrum to the other.


TYPICAL DEFENDANT’S ATTACK AGAINST CLAIM THAT WHIPLASH INJURY RESULTED IN FIBROMYALGIA

Brian Barr, a claimant’s lawyer, summarised the typical defendant’s attack against the claim that a whiplash injury resulted in fibromyalgia, by stating that some lawyers and some physicians simply do not believe in fibromyalgia.

Of course, this was a theme throughout the 3 days. However, the vast majority of the audience believed in fibromyalgia, although many were less impressed by the apparent high prevalence of fibromyalgia following the traumatic episode/road traffic accident (RTA).

This lawyer made the point that a video can show the patient looking perfectly healthy. This may be misleading because the day before or the day after the video was taken the subject may have been in bed, exhausted, and in pain. I have to admit that I am not convinced that patients with fibromyalgia have perfect days interspersed with days when they feel ill. However, I am not sure if there is a consensus on that point.

In the old days, we used to think that litigation was a much bigger problem in Britain than in the United States, but this is no longer the case. For example, we heard about a woman who had recently won £1.25 million for an RTA-induced whiplash followed by fibromyalgia.

One theme related to the gap between the initial RTA and the onset of fibromyalgia.  How short must the gap be?  If the individual develops widespread body pain more than 6 months after the RTA, can this still be linked to the RTA?

Needless to say, there was a battle during the 3 days regarding the relevance of tender points in fibromyalgia and frequent mention was made of epidemiologic studies revealing, for example, that up to 10% of asymptomatic schoolchildren are found to have more than 11 out of 18 tender points when examined.  This issue, of course, led to discussions regarding exaggeration and even malingering.

Mark White, Executive Director of the Physical Medicine and Research Foundation in British Columbia, Canada, spoke as a patient about the disease, litigation following an RTA, and his own experience in this area.  For example, he summed up the long, drawn out litigation period by asking, "How can I get better when I have to prove that I am sick?" He described how his stress was bound to increase during the litigation process.  The inevitability of having to prove that one is more disabled than reality in order to receive benefits was discussed.

Another patient, Beryl Baxter from Bournemouth, England, spoke about how she found it helpful to keep a daily journal to define the relationship between varying symptoms and external influences.  As I heard this, I was aware that as a rheumatologist I find diary keeping to be total anathema, as it would seem to concentrate introverted feelings around one’s everyday symptoms, which can hardly benefit the individual. However, Richard Mayou, Professor of Psychiatry, Oxford University, explained how this can be used in a positive way, once one appreciates which factors are likely to be associated with deterioration.

Matthew Avery, who works in the Motor Insurance Repair Research Centre at Thatcham, England, pointed out that whiplash injuries are more likely to occur now than they did a decade ago. In essence, this relates to "improved" vehicle design, and in particular vehicle stiffness, which decreases damage to the car but may well increase damage to the occupant.

He stated that, "vehicle design, in particular vehicle stiffness, head restraint geometry, and seat yield strength all play a role in injury and its severity". He also spoke about the evolving research that began by noting the lack of biofidelity with the traditional "hybrid 3" dummy, which has now been replaced by the more physiological "bioRID". Apparently, this more accurately reproduces the complex kinematics of the human occupant involved in rear-end shunts.  It did seem encouraging to know that there is an international insurance whiplash prevention group organised by insurers and car manufacturers.

Avery summarised, "the crash performance of these two vehicles (a 1990 and a 2000 model) display a marked contrast. The latter manages the energy of the impact more effectively than the former, through the use of a very stiff vehicle structure together with softer sacrificial components thus preventing more severe damage and leading to a reduction in repair costs.  However, this very increase in efficient energy management leads to corresponding increase in acceleration levels for the vehicle’s occupants. Therefore, the whiplash protection performance of the latter vehicle must be considerably enhanced to offer the same level of protection as that of the older car."

Avery asked whether it is possible to engineer-out injury but still have good low-speed performance.  Happily, the answer appears to be yes. We all await this Utopic car!


REVIEW OF FIBROMYALGIA

Robert Bennett, from Oregon Health Sciences University, reviewed fibromyalgia from start to finish. He reminded us of the l990 criteria for the classification of fibromyalgia but admitted to the inevitable tautology.  Physicians interested in this area put forward their typical patients, and defined the situation of these difficult patients as having typical fibromyalgia -- all with 11 or more of the 18 tender sites. He reminded us that the tender sites must involve three or more of the four quadrants of the body. Furthermore, there must be axial areas of tenderness including the neck, anterior chest, and lower back. The 11 points, rather than 10 or 12, came from the receiver operating curve (ROC), which plotted the true positive ratio against a false-positive ratio in terms of establishing the best sensitivity and specificity of the number of points.

In terms of the prevalence of fibromyalgia, women outnumber men by a factor of almost 10:1, with up to 8% or 9% of women in the 7th decade suffering with this condition.

Of course, widespread pain is even more prevalent in the general population, with some 20% of women over the age of 50 having widespread pain, a figure significantly higher than that for fibromyalgia. The difference is that if tender points are also found in those with widespread pain, then the diagnosis changes! There is also a weak correlation between increasing number of tender points, level of fatigue, and psychologic distress.


IS FIBROMYALGIA MORE LIKELY TO FOLLOW WHIPLASH INJURIES THAN LOWER LIMB FRACTURES?

Dan Buskila, Professor of Medicine from Soroka Medical Centre, Beer Sheva, Israel, reviewed his now famous (or infamous) paper suggesting that fibromyalgia is more likely to follow whiplash injuries than lower limb fractures. He was gracious enough to admit that there were many problems inherent in his study, beginning with the problems relating to the l990 criteria in terms of diagnosis, i.e., no gold standard, the criteria are circular, pain is a continuum and doesn’t have a sudden start and stop, evaluating tender points is subjective both from the patient's and physician’s point of view, there is potential for abuse in terms of tender point criteria, etc, etc).  He pointed out that Smythe in l989 originally speculated that trauma could precipitate fibromyalgia. Buskila then quoted Greenfield et al in Arthritis & Rheumatism l992 who suggested that 23% of patients with fibromyalgia had identified a specific precipitating event.

In his own study (published in Arthritis & Rheumatism l997) he focused on 102 subjects with a neck injury and 59 who had had leg fractures, and assessed them 1 year later. Intriguingly, 22% of those with neck injury developed "fibromyalgia" compared to 2% of those with lower extremity fractures. However, the unusual aspects of this study related to the fact that all were in full-time employment at 12 months. When he reviewed the unpublished data 3 years later, of the 11 men and 9 women who had fibromyalgia at 12 months, only one of the 11 men was still symptomatic at follow up, compared to all 9 of the women. Nevertheless, all were in full-time work, even at this stage. He commented on the link between fibromyalgia and the social and political issue. It was noted that fibromyalgia had developed at a mean of 3.2 months after the trauma.

Buskila fully accepts that there is potential tautology in terms of their study findings.  Specifically, most of the tender points are around the neck and shoulders, which is where whiplash symptoms reside. Thus, it is very easy for a patient with whiplash symptoms to have "fibromyalgia." In terms of a lower limb injury, it is difficult to have symptoms around the neck and shoulders!

Buskila also suggested that there may be a relationship between neck injury, cervical spine pain, nocturnal pain, and sleep disturbance, and, therefore, fibromyalgia.  In his conclusion, he suggested that trauma may cause fibromyalgia, but fibromyalgia does not necessarily cause work disability. Clearly, what works in Israel may not be extrapolated to other countries.


DURATION OF WHIPLASH SYMPTOMS

Gordon Bannister, Orthopaedic Surgeon, Bristol, England, reviewed his series of descriptive studies focusing on the duration of whiplash symptoms following rear end shunts. I am always concerned about these studies that fail to have a population control group. Because chronic neck pain has a prevalence of 10% to 20% in the general population, it is difficult to know whether his data have any real meaning without adequate controls.


PSYCHIATRIC ISSUES OF FIBROMYALGIA

Richard Mayou, from Oxford University, discussed the psychiatric issues focusing on whether compensation issues themselves may be determinants of the severity of symptoms either relating to the role of conscious simulation and exaggeration or malingering.  He focused on the evidence for the interaction of physical, psychologic, and social factors in the full range of pain syndromes, stressing how medico-legal bewilderment and acrimony are powerful factors for maintaining individual disability and distress.  He spoke of the individual vulnerability and beliefs in terms of personality, mental state, expectations and meaning, and the social circumstances relating to life’s stresses, quality of life, vulnerability of work, other interests, financial situation, and inter-personal reactions.  In terms of fibromyalgia and other functional syndromes, which include irritable bowel disease, chronic fatigue, tension headaches, non-cardiac chest pain, environmental allergy, Gulf War Syndrome, etc, he pointed out that the evidence does not support validity of specific syndromes, but rather these labels reflect history, specialist clinical experience, and lay pressure groups.  He showed how medical care itself can reinforce misinterpretation, confusion, and the subjective impression of discomfort.

Mayou concluded that several major issues related to pre-accident vulnerability and nature of the accident itself in terms of how frightening it was, the severity of the injury, the amount of post-accident distress, and finally the pessimistic beliefs of the patient as well as the medical, legal, and financial issues that ensue.


EPIDEMIOLOGY OF PERSISTENT PAIN

A theme throughout the meeting related to the epidemiology of persistent pain. There appears to be a consensus that 20% or more of primary care attenders have chronic pain, and a large percentage of these have relatively widespread pain.

In terms of the psychosocial aspects of whiplash, the "innocent" nature of the car occupant was stressed. The driver in the offending car virtually never gets whiplash injury, rugby players don’t get whiplash injuries, and drivers in "dodgem" cars don’t get whiplash injuries.

Anthony Dickenson, Professor of Neuropharmacology at University College, London, stressed that a l998 WHO study suggested that the prevalence of long-term pain is about 22% in a survey of more than a dozen countries.  He spoke about the mechanisms of inflammatory neuropathic pain being different from acute pain. Dickenson focused on the plasticity that occurs in both the transmission and modulating systems in prolonged pain states, adding that plasticity occurs at both peripheral and central sites. In terms of central excitatory systems, interaction between peptides and excitatory amino acids are critical for pain transmission from peripheral nerve to the spinal cord and to the brain.  He explained how release of peptides and their receptor actions allows the NMDA (N-methyl D-aspartate) channel receptor for glutamate to be activated.  Activation of this NMDA receptor underlies "wind-up," whereby the baseline response is amplified and prolonged even though the peripheral input remains the same. This increased responsivity of dorsal horn neurones is probably the basis for central hypersensitivity. We were introduced to future pharmacologic possibilities that would have an impact on NMDA receptor antagonism, calcium channel blockade that would affect transmitter release, and neuronal excitability.
Although Dickenson suggested that in fibromyalgia N-type and P-type calcium channels may be more active after nerve or tissue injury, we do not have any clear evidence that there really is nerve or tissue injury in these conditions.


BIOPSYCHOSOCIAL MODEL OF FIBROMYALGIA

Dr Chris Main from Hope Hospital, Salford, Manchester, England, focused on the biopsychosocial model to explain the link between pain and trauma. As a psychologist, he focused on the inter-relationship between sensory awareness, cognitive, affective, and other psychologic components, illness behaviour, and the social environment.  He concluded that we have paid a heavy price for our over-reliance on disease models of illness. We need to focus more on the biopsychosocial influences, because all pain has both a peripheral and a central component, pain influences function and our dysfunction is influenced by our thoughts, feelings, and behaviour.


PRECIPITANTS OF FIBROMYALGIA

Goldenberg, from Tufts University School of Medicine, spoke about the various factors that have a putative role in precipitating fibromyalgia, including flu-like viral illnesses, physical trauma, emotional trauma, and medication. He focused on the interface between so-called chronic fatigue syndrome and fibromyalgia and the various rheumatologic disorders said to be associated with fibromyalgia, such as rheumatoid disease, systemic lupus, Sjogren’s syndrome, and other conditions.  The inter-relationships between physical trauma, emotion, infection, endocrine abnormalities, neurochemical changes, nociceptive changes, sleep disturbance, tissue hypoxia, pain, fatigue, and depression were explored.

In terms of basic research, Goldenberg spoke of the neuro-endocrine, peripheral, and central pain regulation, autonomic changes, circadian rhythm, and genetic susceptibility.

Ongoing NIH funded research is focusing on neurogenic dysfunction, the role of neurotropins in an animal model of fibromyalgia, and the neurobiology of chronic muscle pain, together with neuro-endocrine alterations in fibromyalgia and irritable bowel syndrome, exercise-induced changes in the hypothalamic-pituitary axis, and the recognised abnormalities of regional cerebral blood flow in the thalamus and caudate nucleus in those with low pain thresholds.

Goldenberg suggested that certain data argue for impaired ability to activate the hypothalamic pituitary portion of the hypothalamic-pituitary-adrenal axis in fibromyalgia, together with abnormalties in the sympatho-adrenal system leading to reduced ACTH and epinephrine responses to hypoglycaemia.


REPETITIVE STRAIN SYNDROME

Several presenters spoke about the past epidemic of so-called repetitive strain syndrome that had plagued Australia until the late l980s. Many of us questioned the possibility that fibromyalgia would follow the same pathway.

Daniel Clauw, the Scientific Director of the Chronic Pain and Fatigue Research Center in Washington, DC, at Georgetown Medical Center, reviewed animal studies of stress, neurobiology of stress response, stress and fibromyalgia, and other issues.  Again we were reminded about the epidemiology of chronic symptoms in the general population. For instance, tension headaches occur in about 70% of women and 50% of men, while migraine affects 18% of women and 3% of men followed by irritable bowel syndrome occurring in 20% of women and 15% of men, chronic fatigue in 20% of women and 12% of men, regional pain syndromes in more than 20% of women and more than 15% of men, and chronic widespread pain in 12% of women and 8% of men.  The overlap between fibromyalgia and the so-called exposure syndromes following Gulf War illness, silicone breast implants, and sick-building syndrome and the various somatoform disorders affecting more than 4% of the general population, chronic fatigue syndrome, and the multiple chemical sensitivity syndromes was discussed.

He showed us how the Gulf War syndrome is no different than the clinical situation after many other stressful situations, particularly when politics and economics colour the issues.  In summary, Clauw reported that $150 million have been spent on research relating to the Gulf War experience. Moreover, the veterans' symptoms were exactly the same as those seen in the general population and have been noted in every war in which the United States has been involved. There was no evidence of any specific exposures leading to specific symptoms.


NEUROCHEMISTRY OF PAIN IN FIBROMYALGIA

Jon Russell, from the University of Texas, spoke on the neurochemistry of pain in fibromyalgia, reviewing what we know about substance P nerve growth factor, C-terminal fragment of substance P, excitatory amino-acids, serotonin, norepinephrine, opioids, N-terminal fragment of substance P, and other chemicals.  Substance P in fibromyalgia is said to be normal in serum, plasma, and saliva but elevated in spinal fluid, as it is in diabetes.
Cytokine studies in fibromyalgia suggest that IL-8 and IL1Ra and IL-6 are increased. Abnormalities in serotonin and other neuropeptides were reviewed.


TRAUMA AND FIBROMYALGIA

Chris Moran, from Bournemouth, England, reviewed his experience with trauma and fibromyalgia, suggesting that it is between 6 and 12 weeks after the RTA that the systemic features develop in the typical situation.

Robert Bennett, from the Oregon Health Sciences University, Portland ,Oregon, provided objective findings in fibromyalgia. He discussed the sensory thermal testing studies, the elevated CSF levels of neurotransmitters, enhanced somatosensory potentials, abnormal brain scans, abnormal sleep EEGs, abnormal sympathetic function, and disregulated hormonal secretion. Apparently, brain scan findings in fibromyalgia are said to be similar to those found in other chronic pain states. Specifically, fibromyalgia subjects have reduced thalamic blood flow, increased anterior cingulate activity, and reduced activity in the inferior pontine tegmentum and the right lentiform nucleus.

Tom Bohr, Associate Professor of Neurology at the Loma Linda University, California, summarised the atheist's point of view by saying that the field is an enormous tautology, possibly doomed from the start.  He reviewed much of the world literature, pointing out that the methodology was at fault, there was often failure to report power calculations, failure to state an a priori sample size, inappropriate controls, and other factors.  Even those studies with apparent statistical significance often had a good deal of overlap and no obvious biologic significance.  Those studies purporting to show neuro-imaging differences often had a very small number of patients and inadequate controls.  The fact that ankylosing spondylitis patients report function that dovetails with the independent observer’s impression was pointed out in contrast to fibromyalgia where perceived lack of function was strikingly different from observed function.  In terms of the inter-relationship between psycho-pathology and pain, the debate continues as to whether the former is secondary to the latter, or vice versa. His reading of the literature suggested that psycho-pathology comes first.

Those studies purporting to reveal a link between trauma and fibromyalgia were often flawed by inadequate attention to the background epidemiology, the number of traumatised patients, absence of long-term follow up, and other problems. He also spoke about primary gain from the point of view of the patient, secondary gain, and even, of course, tertiary gain whereby at least in litigation lawyers and physicians benefit more than the patients.

I spoke of the link, or lack thereof, between trauma and fibromyalgia. I focused on the background epidemiology, pointing out how easy it is for the unwary to fall into the trap of believing that because "a" preceded "b", "a" caused "b", and commented on the vicious cycle of pain with increasing pain, decreasing function, and increasing anxiety. The impact of litigation was discussed at length.


EVOLVING COURT RULES IN BRITAIN

Ian Goldrein, an attorney from London (Queens Counsel), gave a brilliant and colourful presentation regarding the evolving Court rules in Britain, and what is expected of the expert witness and how easily such an individual can be destroyed by an intelligent lawyer! Norman Cottington from the Bodily Injury Claims Management Association, England, spoke about the Association representing a body of Claimant and Defendant Solicitors Insurers and re-insurers. Certainly, this sounded something like a social Utopia, whereby the focus was on rehabilitation and "best practice" codes ensuring that the patient/plaintiff remains the focus of attention to the benefit of the patient and society.  The philosophy behind this group is that the more money spent on rehabilitating the patient and the less on medico-legal expenses, the better for the individual and society.

Charles Pither, Pain Specialist from INPUT, St Thomas’ Hospital, London, gave an historical review and reminded us that Victorians suffered from "fibrositis" or a similar condition while others were labelled as having neurasthenia.  He concluded that the inexorable increase in incidence and severity of fibromyalgia is largely due to cultural and psychosocial features fuelled by medicalisation of the problem. From his perspective, treatment should focus on self-management and maintenance of function.


COMPENSATION AND THE SOCIO-POLITICAL ISSUES

Nortin Hadler, from the University of North Carolina, spoke of compensation and the socio-political issues surrounding fibromyalgia. Inevitably, his presentation was erudite and believed by half the audience and disbelieved by the other half. He concluded by saying that "Participating as a physician in the disability determination process is an act of iatrogenecity. It is time to dismantle the sophistry. Only then do alternatives reveal themselves."



COMMENT:

The 3 days were well worthwhile in terms of having fine presentations from most of the major protagonists and antagonists around the world.  At the end of the day, we still do not know why the vast majority of patients are Caucasian and most of the subjects are women. We have no good feel of whether the condition is becoming more prevalent or whether we are simply diagnosing it more frequently.  Although we know a great deal more about chronic pain, we remain uncertain where fibromyalgia fits in.  Much of the neuro-hormonal aberrant function could be either causative or a result of the pain. More studies should be done.

Overall, it was particularly appealing to have discussion not simply between rheumatologists, but between rheumatologists, orthopaedic surgeons, pain management specialists, patients, neurobiologists, psychologists, psychiatrists, and lawyers together with ergonomic specialists, car manufacturers, and insurers!