If Physical Injury Does Not Trigger Fibromyalgia What Does?

[Cort]

Accidents and injuries are often associated with fibromyalgia. It makes sense, after all, that a chronic pain condition might be set off by painful events. A recent Canadian study, however, suggests that whiplash does not often lead to fibromyalgia.

RMD Open. 2015 Feb 18;1(1):e000007. doi: 10.1136/rmdopen-2014-000007. eCollection 2015. A prospective study of the 1-year incidence of fibromyalgia after acute whiplash injury. Ferrari R1.

The study retrospectively examined 264 whiplash patients a year later. Eighty percent reported they had recovered and 20% of them were still suffering from chronic pain - seemingly a major risk factor for FM.

[fright]

[/fright]In the end, though, only about 1% of the whiplash patients met the criteria for fibromyalgia. Since that number is actually lower than the prevalence of FM in the population (@2%) it's entirely possible that the 2 people in the study who did meet the criteria for FM would have developed it without the whiplash incident.

The study results were bolstered by the fact that patients with previously identified widespread chronic pain or fibromyalgia were eliminated from the study. The patients in the study may have had painful events in the past but they had no history of widespread pain.

Trauma Debunked as Trigger of Fibromyalgia

There is no scientific support for the idea that trauma overall causes FM, and evidence in regard to an effect of motor vehicle accidents on FM is weak or null. Wolfe et. al.

In fact, the connection between "trauma" (physical injury) and fibromyalgia is and has been hotly debated for over 15 years. A recent review article asserts that there is no connection between physical injury or trauma and FM, and indeed, several whiplash studies seem to bear this out. It suggests that the events many people associate with their FM may not have triggered it at all; they simply happened to occur at the about the same time.

A Chinese study that did not assess prior histories found that 27% of FM patients did report that some sort of physical trauma or infection triggered their illness but most (73%) reported no identifiable triggering factors - they simply got ill.

If physically traumatic events are not triggering FM in wide percentage of patients what is? Albin asserted that mostly general factors (hypermobility syndrome, stressful events (including early life trauma), obesity and disturbed sleep) risk factors for FM.

General Risk Factors for Chronic Widespread Pain

The same general factors show up in people with chronic widespread pain (CWP). One study found that being female, having a long duration of pain and a high rate of psychosomatic symptoms was a risk factor for CWP. Another found that people with CWP as opposed to localized pain were more likely to be female, to have been in pain for a longer time, to have more comorbid illnesses and "psychosomatic symptoms", and to suffer from "permanent pain" instead of transient attacks of pain.

[fleft]

[/fleft]A large eleven year cohort study suggested that similar factors - poor sleep, obesity and chronic disease - increase the risk for coming down with persistent CWP. Anxiety, depression, former smoking, and overweight, moderate exercise and alcohol had little or no impact on who developed CWP.

Being female, having poor sleep, being overweight and having other diseases, then, appears to increase one's risk of coming down with chronic pain. They are not determinative: many females who are overweight, have poor sleep and have other diseases do not come down with FM. These general factors also tell us little about the biological processes sparking the transition to chronic widespread pain or FM.

Because figuring out the biological processes triggering FM require collecting data before one gets ill they are much more difficult. Some studies have been done in ME/CFS but I'm not aware of any for fibromyalgia.

Studies tracing the development of widespread pain after hip and knee pain surgery found that increased pain sensitivity usually precedes the transition to widespread pain. That is, people with increased pain sensitivity (but not chronic pain) prior to surgery tended to be those who developed chronic widespread pain after surgery. (Note that these studies indicate that a traumatic event - surgery - is a trigger for CWP). Brain studies also suggest that changes in the brain prior to developing chronic pain set up some people to develop chronic pain later. Genetic studies suggest a genetic predisposition to coming down with FM exists.

Transition - Unclear

There is clearly a long way to go to understand why some people transition from pain to chronic pain to chronic widespread pain to fibromyalgia. Perhaps the best conclusion that can be drawn at this point is that for most people the onset of FM is a mystery. Even if some sort of event (injury, infection, stressful event) is associated with FM, researchers are having a hard time statistically associating it with the onset of FM. Instead, studies suggest that people with FM and/or chronic widespread pain are being set up biologically to experience these conditions. They may or may not experience a painful event prior to their coming down with FM, but they are being primed to get it.

FM may be the endpoint of a pain/fatiguing process that at it's mildest manifests itself as chronic pain. According to the first study cited in this blog people with fibromyalgia tend experience a different suite of symptoms than people with chronic pain or CWP. They tend to experience pain in several parts of their body (they have widespread chronic pain) plus fatigue, depression and abdominal pain. In people with other types of chronic pain their pain is usually localized (i.e. to their back), they don't generally experience high levels of fatigue or depression and they don't tend to have abdominal pain. This spreading of symptoms suggests more central nervous system involvement is present in FM.

How these broad problems with pain, sleep and fatigue begin in FM, however, is still mostly a mystery.

 

[fdotx]

Mine started after 4 knee operations and probably from prolonged use of crutches since it started in my shoulders before becoming widespread.

 

[Cort]

Mine started after 4 knee operations and probably from prolonged use of crutches since it started in my shoulders before becoming widespread.

So you fit the condition of long duration pain....It didn't show up after the first or second operation - it took four operations for your system to change and for widespread pain to occur.

For me - I fit the criteria for ME/CFS and FM - it just happened! No triggering event that I could tell...It just happened over a month or two when I was in college. We may have different forms of FM.

 

[Folk]

I've always said that. Poor Morgan Freeman.

I don't associate anything with my Fibro onset, although looking back while telling my story to my Dr. I realize I had GI issues pior to the FMS... I don't think I can call it IBS but it is the closest thing I could find as a relation.

 

[MoJo]

In the summer of 1954 when I was 10 year old, I started feeling very tired with aching limbs. My Doctor said it was "Growing Pains" I continued to feel unwell and was having problems getting to sleep at night. My mother took me back to see another Doctor in the practise and he said I had "Muscular Rheumatism" and I had to stay in bed for a month. never really recovered from it and when I was about 13 I fell really sick again. Another Doc said I had Rheumatic Fever and again I was in bed for a month. Going back to school I had to stop all physical activity. I lost a lot of schooling as I felt so unwell. When I was 17 I had another attack of "Rheumatic Fever" I have suffered with pain and exhaustion all my life. I had 3 babies - the last one I was so exhausted I didn't know what sex it was and woke up in the Maternity Ward! I had several auto immune conditions and am hypothyroid. I was finally diagnosed with M.E/CFS at the end of 1988 after going through CBT and GET I have been in a wheelchair ever since and am unable to do any housework or cooking. My Husband does everything. I get so angry when people- especially Doctors- say its "All in the mind"

 

[Justarose123]

I was in a accident in 2005 severe whiplash, Couldn't sleep since. Fast forward to 2006 almost 1 year to date I contacted MRSA at work, again very hard to treat, ended up being operated on after many Iv antibiotics...December 2006 started to feel over stressed no amount of anti anxiety or anti depression couldn't suppress it. This is why my chronic fatigue and fibromyalgia took over. Though I later found I had Cavus equines in both feet, multi level spondylitis, multi level stenosis in my neck. So there were clear reasons for pain, Emg positive for carpal tunnel and left side nerve. And possible early signs Als. Today my pain is a 4 and not constant my biggest complaints are lack of sleep. App noted interrupted Rem sleep 205 times one night alone? Fatigue and weakness but also have pituary deficiencies and depression. Who wouldn't be when you go from a productive self reliant happy person to depending on Ssdi..the quality of life and the moods of your doctors. The loss of control is by the self worse system of these deaseases, Rita

 

[Folk]

In the summer of 1954 when I was 10 year old, I started feeling very tired with aching limbs. My Doctor said it was "Growing Pains" I continued to feel unwell and was having problems getting to sleep at night. My mother took me back to see another Doctor in the practise and he said I had "Muscular Rheumatism" and I had to stay in bed for a month. never really recovered from it and when I was about 13 I fell really sick again. Another Doc said I had Rheumatic Fever and again I was in bed for a month. Going back to school I had to stop all physical activity. I lost a lot of schooling as I felt so unwell. When I was 17 I had another attack of "Rheumatic Fever" I have suffered with pain and exhaustion all my life. I had 3 babies - the last one I was so exhausted I didn't know what sex it was and woke up in the Maternity Ward! I had several auto immune conditions and am hypothyroid. I was finally diagnosed with M.E/CFS at the end of 1988 after going through CBT and GET I have been in a wheelchair ever since and am unable to do any housework or cooking. My Husband does everything. I get so angry when people- especially Doctors- say its "All in the mind"

That's a though ride @MoJo :\
Do you think you're in the wheelchair because of GET?

I'm no expert (I don't even know if I should be saying this but just so you keep that in mind and/or take a look at it) but I would guess you're a good candidate for Rituximab.

 

[Angie]

I was 12 years old, super fit, active, ideal body weight for my age and height, when a simple slip and fall resulted in a fracture to L5 (lowest bone in your spinal column for those unfamiliar with it). I walked away from the accident, never went to the hospital as the nearest one was 2 hours away and an hour of that was on a river with portages. By the end of that summer, perhaps 3 or 4 weeks later I was having horrible pains in my lower back, pain that stopped me in my tracks. I couldn't run, had to sit a lot, couldn't ride my bike, couldn't jump, nothing at all that might cause vibration or bending from the waist. It took a while for a doctor to order an xray and by then it had been too long and nothing else could be done but was cautioned that there was a good chance arthritis would one day develop. I spent the next 25 years trying to find help with the lower body pain. Most docs brushed it off as the injury. Desperate, I went to see a surgeon, looking for anything to relieve it. He took the time to carefully examine me, did all the right tests, but there was nothing anatomically wrong other than some irregular bone growth from the remodeling of the break and it shouldn't have been causing the pain that I was experiencing. I suffered for years, had regular cortizone injections around it that didn't do much and it didn't last long. It wasn't until my regular GP diagnosed fibro (after 4 years with sudden onset CFS) and put Nabilone into my hands did I experience any relief, it was nearly instantaneous and it was magical. If my break didn't trigger my fibro then it's one heck of a coincidence. My fibro flares still focus in my lower back, hips and legs, and not in a pattern typical to spinal injury or nerve compression. Why no one picked up on that is beyond me.

 

[Aidan Walsh]

Ehlers Danlos Syndrome is Chronic Fatigue Syndrome Fibromyalgia Gulf War Illness so called Lymies all Labels just Labels...Get a proper diagnosis...EDS/MCAD EDS with Mast Cell Activation Disorder...Genetic Tests are available except for Hypermobility type some can have 'partial incomplete' Marfan Syndrome do the measurements at home for Marfan Score plus Breighton Score/Beighton Score in EDS some have other Connective Tissue Disorders...

 

[fdotx]

So you fit the condition of long duration pain....It didn't show up after the first or second operation - it took four operations for your system to change and for widespread pain to occur.

For me - I fit the criteria for ME/CFS and FM - it just happened! No triggering event that I could tell...It just happened over a month or two when I was in college. We may have different forms of FM.

Hi Cort, had it been just one operation but the same amount of time on crutches I think the outcome would have been the same. That is so weird how yours just happened - I wonder how often that occurs?

 

[Steve]

Cort, you had no category for psychological trauma in the questionnaire. In the clinic where I worked, virtually all of the psychiatric patients I saw who had FM had trauma histories. A confounding variable, maybe, but I date my own FM onset to when my brother was dying of AIDS in 1988.

 

[Folk]

Cort, you had no category for psychological trauma in the questionnaire. In the clinic where I worked, virtually all of the psychiatric patients I saw who had FM had trauma histories. A confounding variable, maybe, but I date my own FM onset to when my brother was dying of AIDS in 1988.

I bet all patients without FM had trauma histories too.

 

[Fibro Far Out]

My onset was slow and steady and still going. Since menarche have had extremely painful periods, as a teenager I had a lot of sore throat super bad colds that would make me so sick for a week ever 2 months. Then I noticed that I would get tired more easily than my friends. I was active, thin and happy. Fatigue got much worse in my first year of university and I got diagnosed with CFS and took an extra year to finish school. Over time I had good periods of energy in the summers and was managing with healthy diet and consistent light exercise. I was never an extreme case. In my mid-thirties I developed more specific pains in hips and other main trigger points. Got diagnosed with FM after strange pain in knee sent me to rheumatologist. Got some meds that helped but still have some pain all over 60% of time and great pain making it hard to move 20% of time. Also developed migraines. My summer energy gets shorter and shorter. I live in Canada and find the cold is bad for me so will winter on Florida coast asap.

 

[shira]

Yrs before I had a rough case of mono while pregnant. Never 100 % after, but ok. Then started developing flu like symptoms day after exercise continually. Worked a very high stress job. Finally a minor car accident & that was the beginning about 27 yrs ago. fibro, cfids/me

 

[SherriNC]

Like Mojo, I had pain in legs in childhood - was also exposed to Meningitis when a classmate died from it. Also had thyroid disease, which was not treated until late teens, and ongoing stomach problems. Auto immune disorders are very strong on my father's side and my thyroid disease was auto immune type. I do remember having a severe case of the flu when I was in grade school and also was told that I had mononucleosis in my early teens. Also should mention that I grew up in a stressful family and endured bullying when growing up, so I feel that I have adrenal problems as well.
Sounds kind of like the perfect storm, doesn't it?

 

[Kimmi]

It seems to be different for everyone. In hindsight I now know my FMS/CF and myofascial pain syndrome was set off by a number of things.
1. Chronic parasite infection for 20 years that I wasn't aware of that led to brain fog and IBS. This was the start of worse to come.
2. A bad bout of food poisoning that probably exacerbated my IBS and may have caused SIBO.
Both of these may have caused intestinal permeability, many food intolerances, worsening IBS, resulting in chronic inflammation and associated systemic body aches and pain, and disabling fatigue and brain fog.
3. Coming off the contraceptive pil after 20 years causing a hugs hormonal imbalances that my already weakened body couldn't handle.
4. A whiplash injury (reversal of normal cervical lordosis) that I wasn't aware of for many years (I think from a skiing fall) that caused chronic neck pain. This pain became substantially worse after wearing a mandibular adjustment device (MAD) for my sleep apnea. This device shifts the jaw forward that connects/pulls C2 further out of alignment. My neck, whole spine, calves and feet all became extremely achy, tight and painful. I have since learned through trial and error (many chiropractors and cranialsacral therapists later) that my sphenoid bone is misaligned (possibly my atlas/C1 too) causing the dura mater (membrane that wraps around the skull and spine) to tighten and cause compression/pain all through my head and spine. I had a 2 week period of relief recently using a technique called neurocranial reconstruction, and the pain disappeared briefly, but an incorrect adjustment brought all the pain back. During this 2 weeks the flexibilty in my spine was completely different suggesting this misalignment in the skull/neck is contributing to compression and pain. It also suggests this spinal compression may be effecting in my nervous system (especially the vagus nerve), and that this and the reverse cervical curve is compressing my brain stem. Together these must be contributing to my many other FM symptoms. The brainstem has integrative functions being involved in cardiovascular system control, respiratory control, pain sensitivity control, alertness, awareness, and consciousness all of which do not function well for me since having FMS. In addition, 90% of our brain’s output goes into something called the pontomedullary area, it’s the lower two-thirds of the brain stem, and that goes into the vagus, or the pneumogastric nerve, which innervates the digestive tract. With an already compromised digestive system due to dysbiosis/leaky gut my body was overwhelmed and did not have the capacity to deal with all these issues, and of course they are all connected.

I do think whiplash/spinal injury can cause FMS, for me it was combined with other factors but I now know it is extremely important and may be enough on it's own as this important area can affect the whole body. There is also much research connecting TMJ disorders with FMS, although I'm not that familiar with it. The increase in pain, fatigue and sleep disturbance after wearing the MAD was huge, and knowing the sphenoid adjustment can profoundly reverse some of these symptoms is suggesting that the neck, skull and jaw alignment are essential to human health and vitality.

 

[Nickylou]

I developed symptoms of FM after a long period of major depression, I also have a benign recurrent surgery resistant tumour on my pituitary gland. I have found a number of FM sufferers have benign tumours under their brain, I wonder if there is any significance and if my FM symptoms will go when I am able to undergo gamma knife treatment.

 

[Steve]

I bet all patients without FM had trauma histories too.

A good number, as I noted, but I didn't. Did have mono twenty years earlier, though, maybe set me up.

 

[VLynx]

While doing my pain fellowship I noticed that medical field has largely confused two different pain syndromes: fibromyalgia and myofascial pain syndrome. Myofascial pain syndrome is associated with trauma and injury and I think this is where the notion that trauma causes fibromyalgia comes from. Myofascial pain syndrome occurs when a person develops painful "trigger points" in muscles that are injured or that are near an area of injury. Trigger point pain is often referred to areas distant from the trigger points (hence "trigger"), so can appear to be widespread pain. Nevertheless, with a good examination, the practitioner can find discrete sources of the pain that can be treated (with trigger point injections, massage, stretching, better ergonomics, etc).

Fibromyalgia, on the other hand, is true widespread pain: not limited to one limb, or to just the legs, or the neck, for example. The "tender points" of the old fibromyalgia definition are not trigger points. Pressure on trigger points hurts, but doesn't radiate or refer to distant sites. Tender points also are not treatable with injections or massage.

Of course, these different syndromes can and often do, coexist. My fibromyalgia is frequently overlaid with areas of myofascial pain. I would even say that fibromyalgia predisposes one to myofascial pain. Fortunately, treatment of the myofascial pain areas decreases my overall pain levels. For me, this treatment consists mostly of frequent Thai massage. I also use Voltaren gel, heat, pressure and ultrasound on painful muscles. For fibromyalgia pain, I use pain medication. I've noted that the pain medication (opioids) doesn't help much with myofascial pain. NSAIDs do, but I can no longer use them (except topically) as chronic NSAID use has scarred up my small intestine.

 

[Sally]

It's all so confusing, I'll try not to bore you unmercifully.
- perfectly healthy just (typical childhood stuff, like chicken pox, measles. etc.) until diagnosed with scoliosis at about 12 (no mention of treatment)
- both parents were mentally unstable & abusive, anxiety followed by migraines before puberty
- infectious mononucleosis at 14 (that means EBV, right?)
- sexual abuse at my first job as a secretary at 18 (it was the 1970's, baby), beginning of chronic insomnia
- relocated every 3-4 years for spouse's promotions (repetitious traumas)
- 2 C-sections; I discovered postpartum depression (Surgery #1 and Surgery #2)
- December 8, 1994 I had to put my 16-year-old dog down. Cried hysterically for a week--suddenly lost my peripheral vision for a month. Blind, except for a small circle in the middle; kinda the opposite of macular degeneration. Neurologist dx: 'conversion disorder,' not uncommon in people with abusive childhoods. I'd say so far that was the epitome of trauma in my life, losing my constant companion
- bi-lateral carpal tunnel surgery, late 1990's (Surgeries #3 and #4)
- major insomnia: I was sleeping 2-3 hours/night for years (unaware its source was anxiety), not realizing the future consequences
- 2005: lumbar spinal fusion due to worsening scoliosis (Surgery #5)
- after flu vaccine in 2009, I felt my health really take a downturn; the flu that never went away
- February 2011 broke my neck due to a fall from an extension ladder; scans revealed nodules on my thyroid, bloodwork revealed Hashimoto's thyroiditis
- after 5 doctors, an unusually informed rheumatologist diagnosed fibromyalgia, cfs, and joint-disfiguring OA), later recommends right thumb basal joint replacement in near future (steroid injections are staving that off for now)
- hip replacement, May of 2015 (Surgery #6). Left hip pain relieved; the rest of my body not so much
- Now mostly homebound due to pain and fatigue, so rheumatologist sent me for more X-rays a few weeks ago, thinking it was the other hip. Hip was fine--I was shocked when comparing my 2005 X-ray with last week's--above the hardware at L-4 and L5, my spine is turning into an 'S' shape. Explained how I went from 4'11" to 4'9" over 10 years. I'm 60, so more fusion is not probable (thank the gods). Confusion over the source of the pain--referred degenerative pain or fibromyalgia pain?
- Husband has been transferred once again--we'll see if I survive this one