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Vol. 16. Issue 2. P1.
Pages 69-70 (March - April 2020)
Vol. 16. Issue 2. P1.
Pages 69-70 (March - April 2020)
Editorial
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Passive Voice of Fibromyalgia
La voz pasiva de la fibromialgia
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Alejandro Olivé Marqués
Servicio Reumatología, Hospital Universitari Germans Trias i Pujol, Badalona (Barcelona), España
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I joined the world of Rheumatology in the Orwellian year of 1984, when I started my residency. At that time, the word fibromyalgia hardly existed; it was mentioned timidly in the English-speaking literature under the misleading term of fibrositis. Phillip Sholwater Hench, discoverer of glucocorticoids and Nobel Prize winner in Medicine, was one of the first to coin this term.1 Here, in our country, the terms psychogenic rheumatism and cellulitis were used, among others. In this sense, a search in Pubmed with the term fibromyalgia will reveal that in 1984 there were 23 citations, nothing like the more than 549 citations of 2018, and a historical accumulation of 11,000 citations to date.

You will already be wondering where on earth people with fibromyalgia were in the last century. Rotés Querol, the key figure in Catalan and Spanish rheumatology - used the expression psychogenic rheumatism. He referred to it as a syndrome of the locomotor system that was poorly structured and debatable. However, he stressed that the painful disorders of this entity were as frequent as other psychogenic functional disorders, such as those affecting the digestive system: irritable bowel. Note that there is no anatomopathological substrate or specific laboratory test for either entity. Likewise, he highlighted that psychogenic rheumatism was one of the most frequent disorders in general practitioner and rheumatologist consultations. He defined it as any painful manifestation of the locomotor system in whose onset mental illness is a determining condition.2

Boland established certain criteria in 1960: a) absence of organic disease or insufficient presence of organic disease; b) functional character of the disorders and c) positive diagnosis of mental illness.3

I would add to Boland's criteria the absence of a characteristic anatomopathological result or any determining laboratory test.

A recent study by the Catalan Society of Rheumatology described the number of consultations in specific areas of interest in hospitals in Catalonia. There were all kinds, namely: early arthritis, gestation and arthropathies, lupus, ultrasound, paediatric rheumatology, among others. In the survey of rheumatologists in Catalonia, fibromyalgia was an area of specific interest for only 10% of rheumatologists.4 In my opinion, fibromyalgia lacks scientific appeal today. It is a “must” of the specialty and of the practitioners dedicated to this specific area.

Patients with psychogenic rheumatism were subdivided into primary and secondary. Until recently, this terminology was also applied to fibromyalgia. The overlap of psychogenic rheumatism with other functional disorders of other organs or systems was also highlighted. Rotés Querol pointed out some clinical data that characterised these patients, which apply to patients currently “baptised” as having fibromyalgia. They presented to their doctor with a series of signs which, taken together, would constitute a setting which should alert the doctor to the possibility of this entity: a) inexorable and unjustified urgency in requesting a visit; b) maladies du petit papier, i.e. a written list of questions, often exhaustive; c) a large bag with imaging tests and other explorations; d) concern for future disability; e) 2 types of accompanying persons: accomplice type (sharing the suffering) or released type (absent from the interview); f) lack of correlation in the physical examination, presence of the sign of the airplane and abundant facial expressions; and g) often holding the hand of the doctor during the physical examination as a way of preventing or avoiding pain. As you can see, these characteristics, formerly described as typical of psychogenic rheumatism, are seen in patients with fibromyalgia.5,6

As you know, physical examination attaches considerable importance to painful or trigger points. Rotés Querol referred to these points as: a) nothing more imprecise than where to press, b) nothing more subjective than the intensity with which one presses, and c) nothing more decisive than the patient's mood. He ended by commenting that, if we try, we can induce these in almost all patients.6 On trigger points, Hench commented that finger pressure was like “the finger of faith”.7

To paraphrase Skinner, the creator of the behavioural school: “Give me a fibromyalgia patient and I will make the trigger points positive”. Time has proved Dr Rotés right: today the trigger points explored by doctors have disappeared from the new established criteria and instead it is the patient who indicates painful points in a self-questionnaire.8

A clinical sign that I value highly in the physical examination of fibromyalgia or cellulitis (perhaps more than the reviled points) is the pseudo pinching sign, an exploratory manoeuvre to which doctors who deal with this entity have not paid due attention. It is practiced by compressing and at the same time sliding the skin and the subcutaneous tissue between the thumb and the index finger forming a V: not exerting pressure on the fingertips as in a real pinch. The difference between positive and negative pseudo-pinching is clear. The areas where it is applied are the inner side of the thighs, the arms and the calves. Finally, I take the liberty of mentioning a clinical sign added by experts in fibromyalgia: when blood pressure is taken the cuff evokes pain in the patient's arm.2,3,6,8

The entities included in the psychogenic syndrome of the locomotor system should be mentioned: a) benign dorsalgia; b) cervicocranial or cervicocephalic syndrome, which includes frontal or fronto-occipital headache, cervicalgia, sensation of dizziness, tinnitus, pain in the eyeballs, oropharyngeal dryness and dysphonia; c) nocturnal acroparesthesias; d) restless legs, e) coxygodynia and f) diffuse cellulitis. Many of these conditions are present in the patient with fibromyalgia, with different combinations throughout their life. However, the last is the most common entity, termed diffuse or painful cellulitis, which affects perimenopausal women in the main and is characterised by whole body pain (“my whole body aches”), morning asthenia (“as if I had been beaten up”). On physical examination, the pseudo-pinching sign is invariably present.2,3,8

Like many rheumatologists of my generation, those of us who have passed the equator of professional life were perplexed to see how psychogenic rheumatism of the locomotor system had disappeared, which until then had flooded our practices. We observed how one entity transformed into another, mutated. Whether due to the lack of structure of psychogenic rheumatism, due to the connotations of the word “psychogenic”, due to the quantification of trigger points, or due to the medicalisation of life, the term fibromyalgia banished the term psychogenic rheumatism completely and began to occupy a considerable space in all the rheumatology textbooks.

A condition that once did not occupy 2 paragraphs in texts went on to occupy entire chapters, all due to the new name and the appearance of quantifiable pain points. This is how fibromyalgia was born, a clinical entity that explores the existence of people with generalised, persistent and idiopathic pain that is defined as a chronic and non-inflammatory rheumatic process that affects the soft tissues of the locomotor system. It is characterised by a low pain threshold (hyperalgesia) and pain on harmless stimuli (allodynia) accompanied by fatigue, impaired functional capacity, sleep and bowel rhythm disturbance, rigidity and depression. The same entity with a different name.8

This introduction leads me straight into the section “it's the economy, stupid”, a phrase coined by one of Bill Clinton's advisors that helped defeat George Bush in the 1992 presidential elections in the United States. James Carville based the campaign on 3 ideas: a) change versus more of the same; b) it's the economy, stupid! and c) don’t forget health care. These 3 sentences can be applied to the issue we are discussing today. I will only focus on section b. The macroeconomic figures of fibromyalgia are of great magnitude. On the one hand, there are the direct costs: in 2004 in Europe a patient with fibromyalgia cost 5,240 euros per year (note that the cost of spondyloarthritis per patient was 2,373 euros per year). In the United States, in 2006, the cost per patient was $9,573 per year, derived from 7,440 hospitalisations, 2.2 outpatient visits and 1.8 specialist visits. It is estimated that patients with fibromyalgia make 10 visits to the doctor per year. Indirect costs in the United States are $2,573 per patient per year, with a total cost of $1 billion per year.9

The magnitude of the tragedy of the cost of fibromyalgia patients is enormous, and therefore it is a problem that the Congress of Deputies and the Parliament of Catalonia have entered the debate. In Catalonia, fibromyalgia also took on political overtones due to the fact that a distinguished person had developed this disease, became an activist (always with elegance) and managed to get Parliament to discuss the subject and issue recommendations. It was a real tidal wave (now called a tsunami), which put enormous pressure on rheumatology services and ordinary rheumatologists. These facts, the economy and the political nature that fibromyalgia has acquired, are unique in the specialty and have overtaken other perhaps more common and very costly diseases, such as osteoporosis or inflammatory arthropathies.

As the English-speakers say, there is an elephant in the room, that is, there is no denying the obvious. We have to face the problem without awkwardness, avoidance, contempt, denial, ignorance, deviation or silence. The current undertones do the disease no favours. A media dynamic and the interference of politicians, I think, do not serve us well.

I conclude: a) Psychogenic rheumatism (especially diffuse cellulitis) and fibromyalgia are one and the same entity; b) the absence of a diagnostic test and the lack of appeal is a burden for fibromyalgia; c) nothing is more subjective than trigger points and e) economic data and politics per se have interfered in this entity

Acknowledgements

The author would like to thank Dr Xavier Tena for his critical reading of this editorial.

References
[1]
P.S. Hench.
Psycogenic rheumatism: Its differentiation from true rheumatic diseases.
Bristol Med Chir J, 66 (1949), pp. 48-50
[2]
J. Rotés Querol, J. Muñoz Gómez.
Síndrome psicógeno del aparato locomotor.
En: Tratamiento de las enfermedades reumáticas, Toray, (1971), pp. 364-376
[3]
J. Rotés Querol.
Síndrome psicógenos del aparato locomotor.
En: Reumatología clínica, Espaxs, (1983), pp. 527-532
[4]
Grados D, Retamero A, Olivé A, Martínez-Morillo M, Guañabens N, Nolla JM. Estado de la asistencia reumatológica en el sector sanitario público de Cataluña. Reum Clin. (en prensa).
[5]
J.F. Burnum.
La maladie de petits papiers.
New Engl J Med, 313 (1985), pp. 690-691
[6]
J. Rotés Querol.
Veinticinco años de reumatismo psicógeno.
Med Clin, 90 (1988), pp. 456-458
[7]
H.A. Smythe.
Nonarticular rheumatism and psychogenic musculoskeletal syndrome.
En: Mc Arty and Allied conditions, Lea Febiger, (1979), pp. 881-891
[8]
D.J. Clauw.
Fibromialgia: Clinical review.
JAMA, 311 (2014), pp. 1547-1555
[9]
E. Ghoy, N. Hassam, P. Sarzi-Puttinii.
Generalized pain sindromes including fibromyalgia and chronic fatigue syndromes.
Eular Textbook of Rheumatic diseases, pp. 1123-1142

Please cite this article as: Olivé Marqués A. La voz pasiva de la fibromialgia. Reumatol. Clín. 2020;16:69–70.

Copyright © 2020. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
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