COMMENTARY

Is Fibromyalgia Real?

Jonathan Kay, MD; Charles E. Argoff, MD

Disclosures

January 10, 2011

In This Article

Editor's Note: What exactly is fibromyalgia? And what causes it? Medscape invited Dr. Charles Argoff, a neurologist specializing in pain, and Dr. Jonathan Kay, a rheumatologist, to debate via email this controversial and complex issue.

What Is Fibromyalgia?

Jonathan Kay, MD: "Fibromyalgia" is a label that has been given to a large number of patients who experience chronic pain. A small subset of these patients have characteristic tender points, but the vast majority of patients who carry this label describe diffuse pain that is not more pronounced when specific areas are palpated. The vast majority of these patients also describe migraine headaches, shooting pains in their extremities, chronic fatigue, and sleep disturbances. Some report alternating constipation and diarrhea, which usually is labeled as being "irritable bowel," but others do not experience these gastrointestinal symptoms.

Also, patients with inflammatory arthritis or early fibrosing syndromes may experience pain in multiple areas without manifesting detectable signs of joint inflammation or tissue fibrosis. Some of these patients may be labeled as "fibromyalgia," but display signs of more typical disease as time passes. Other conditions, such as certain endocrinopathies, may also present with fatigue, generalized aching, and other symptoms that prompt giving these patients the label of "fibromyalgia."

Although a few patients may present with increased tenderness over characteristic tender points, fatigue, migraine headaches, shooting pains in the extremities, fatigue, and irritable bowel syndrome symptoms, without another obvious diagnosis, it is clear that "fibromyalgia" is not by itself a distinct condition with a single pathophysiologic mechanism. Rather, it is a common symptom complex that is characteristic of the heightened perception of pain associated with a number of different precipitating factors.

Charles Argoff, MD: Clinicians should be accustomed to being faced with managing conditions for which absolute knowledge regarding the conditions and their etiology and pathophysiology are not known. In fact, this is true for most medical conditions we encounter including many nonpain-related conditions such as hypertension, various cancers and diabetes. Even the wisest among us cannot state with absolute certainty the exact cause(s) of fibromyalgia syndrome and/or its mechanisms(s). Fibromyalgia syndrome is not a label to be applied to another human being. It is a common chronic medical condition associated with widespread pain, lowered pain thresholds, and augmented sensory perception. Recent efforts by the American College of Rheumatology have focused attention as well on the nonpainful aspects of fibromyalgia syndrome such as fatigue and sleep disturbances as important diagnostic features.

Dr. Kay: I agree with Dr. Argoff that clinicians often face and manage conditions for which the etiology is unknown. In rheumatology, we do not know the etiology of most rheumatic diseases. However, the pathophysiology of most diseases that we treat is understood, at least to the extent that there is some understanding of the mechanism by which therapies interfere with the disease process.

I disagree with Dr. Argoff that the pathophysiology of "fibromyalgia" syndrome is not known. No specific pathophysiology is ascribed to the label of "fibromyalgia"; however, patients develop the symptoms of this syndrome in association with various underlying disorders. Applying the label of "fibromyalgia" syndrome to the syndrome of widespread pain, lowered pain thresholds, and augmented sensory perception without attempting to identify an underlying pathophysiologic process makes treatment of patients with this symptom complex more difficult than necessary. Considering sleep disturbances, for example, to be "aspects" of the syndrome rather than predisposing factors is "chicken and egg" logic. It is important to acknowledge which comes first, so that the predisposing factor may be treated to prevent the resulting symptoms.

Dr. Argoff: Given that all patients currently diagnosed with fibromyalgia do not have completely identical symptoms including the fact that not all patients share the same sleep disturbances, Dr. Kay's comments actually underscore the complexity of managing the person with fibromyalgia as well as the urgent need to learn more about its pathophysiology, which is currently incompletely understood.

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