Tuesday, 10 January 2012


Don’t you find it funny how doctors, especially specialists, ask you to “Relax” just before or while doing something that you and they both know is going to cause you extreme pain?  They push on your leg.  You yelp and jump. They twist your arm 270 degrees and wrap it around your head three times. You scream!

“Now Mrs. Thomas.  I need you to relax,” says the oh-so-kind-and-compassionate doctor.

“And I need you to shove this ball point pen from my purse five inches up your nose,” you think sweetly.

The truth is… most of us doctors are severely socially impaired, or just plain stupid. We’ve forgotten what it’s like to interact with normal human beings under normal circumstances. We stick a giant-sized popsicle stick down your throat and tell you to say “Ahhhhhh.”  Like… what the heck ELSE could you say?  We have immobilized your tongue with a stick that’s covered in splinters.

“Say Philadelphia.”

“Ah ah ah ah ah.”

We ask you to breath in -  “Then out.  Then in.  Then out.  Then in.  Now Hold it.” - while we listen intently through our stethoscopes for 14 minutes and you’re turning blue. We ask you to touch your nose.  Then our finger.  Then your nose. Then our finger. And back and forth again and again and again and again. Like… what the HECK is that all about?

We ask you if you'd mind having a couple of medical students come in and examine you... and then, before you even have a chance to answer, the room fills up with 26 juveniles in white coats and sneakers, all drooling.

And then we ask you to relax when we’re about to perform a rectal or pelvic exam. 

Yeah… sure.

Diagnosing fibromyalgia is not as hard as you have been led to believe (i.e., there’s no reason you should have to wait 6 years and see 15 specialists before someone figures it out). There are relatively few things that make someone ache all over.  A flu will do this… but it goes away usually in a few days to a few weeks. Listening to a political debate may do this, but this usually ceases when you finally give up and switch channels to watch The Cake Boss.

No… if you sincerely ache all over, and have done so for months or years, then fibromyalgia is quite likely. Your doctor certainly should suspect it. Not to say that you couldn’t have something else too.  Fibro CAN co-exist with other conditions, and these conditions MUST be recognized to maximize your likelihood of doing well.

But fibromyalgia is not a diagnosis of exclusion.  It is not what you have because the doctor has examined you and gotten several tests and X-rays and nothing else shows… “So it must be fibromyalgia.” Fibromyalgia is diagnosed when the doctor asks you what bothers you, finds out you have generalized musculoskeletal pain, debilitating fatigue and sleeplessness, and then examines you.

The specific examination finding he or she should be looking for is diffuse body tenderness.  Relatively light touch, when he or she pushes down on your skin with a thumb, will cause you pain… often quite severe pain. There are 18 specific body points the doctor or other health care professional will be examining.  These are called the fibromyalgia tender points. Some experts have recently called for these points to be abandoned, but I think this is a BAD idea (as I’ll comment further in a later blog).

Some doctors like to talk about ‘control points’.  Their contention is that, if you are tender at these so-called control points, in addition to the fibromyalgia tender points, this means you are just tender everywhere and, in their minds, faking it.  But this is, to use the scientific term, baloney. Most patients with fibromyalgia are diffusely tender, not just at the specific 18 points.  Tenderness at control points just means that you are tender at these points too. This should be obvious to anyone who understands the underlying cause of fibromyalgia (which is now known to be dysfunction of the central pain processing centre in the midbrain), which excludes MOST doctors your insurance company will send you to.

So… fibro is diagnosed by the history of chronic widespread pain and tenderness, especially tenderness at a majority of these 18 specific points.  NOT by exclusion. And almost all people with FM have debilitating fatigue and non-refreshing sleep… in addition to a constellation of other symptoms which many but not all people with fibro have - like headaches and migraine headaches, crampy abdominal pain, pain when you pee, numbness and tingling and other funny sensations, sensitivity to hot and cold and light and sound and chemicals and smells and silly long lists; and problems with concentration and... and... and... and... oh yeah - MEMORY!

To diagnose fibro, then, your doctor must…

1.                 Listen to your story… what symptoms you have.
2.                 Examine you, especially examining for diffuse body tenderness, especially at these 18 fibromyalgia tender points.
3.                 Make sure you don’t have something else as well, which might accompany fibro like arthritis, tendonitis or bursitis.

How does your doctor make sure you don’t have something else?  He or she must…

1.                 Listen to your story… what symptoms you have.
2.                 Examine you, especially examining your muscles, bones, joints, tendons, ligaments and bursae, as well as your neurological system, your skin and other organ systems.
3.                 Consider further testing, like blood or urine tests, X-rays or other imaging techniques, if he or she feels that some other conditions still are suspect, based upon your symptoms and physical findings.

There's a pattern here... I just KNOW it!

Listening to you and examining you are the two most crucial steps in diagnosing the cause(s) of your symptoms.  Lab tests and X-rays are secondary and, essentially, meaningless unless the first two essential steps have been taken.

So… “Relax while I hurt you.”

"Yeah... sure, Doc!"  Now WHERE did I put that fricken' pen?

Kevin White, MD, PhD

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