A 24 Hispanic female came into my office as a new patient complaining of "pain all over my body", "bad headaches", and "I can't sleep through the night". "No body believes me not my family or my prior doctor who told me to see a psychiatrist". She described her pain to be in her neck, low back, arms, legs, and head. Today her pain was all over aching with tingling in her arms and legs. She states it is a 9/10 on the pain scale. I listened to this girl who was sitting rigidly in the chair, anguished, fatigued appearing, and crying. Her history revealed the pain started about two years ago after her last car accident which was a milder and aching type of pain. She described the pain as intermittent but at times bad enough to be incapicitated for days not being able to perform daily functions at home or work. Her headaches were unilateral, radiating and accompanied by photo and phonophobia but not preceded by an aura. Her past medications included Percocet for pain and Advil or Excedrin Migraine for the headaches.
Her medical history included motor vehicle accidents x3 with the last accident occurring 2 years ago. Her surgical history was negative. After each accident, she was treated by the local hosptial emergency room. Her neck and back xrays were negative for fractures, and disc disease. Her labs were normal.
Her exam revealed normal vital signs and normal musculoskeletal strength,motor, and sensory testing. She had 18/18 body trigger points positive with allodynia. Cardiovascular exam was normal.
I explained to her that her pain was very real and I can help her with this. I explained Fibromyalgia was a constellation of painful symptoms across the body associated with fatigue and migraines. She met criteria for Fibromyalgia with upper and lower body pain for a period of 6 months with other pathology ruled out. I explained that her multiple motor vehicle accidents was the possible precursor to the painful condition. Fibromyalgia occurs to individuals when there is a history of multiple physical or psychological events occurring at some point in their life before the painful condition manifests itself. Her question, "will I be like this for life?" The painful truth is yes, but it can be controlled so that you can function with the right medications and understanding of the condition to know your limits. I explained Fibromyalgia is a central neural pathway disorder coming from the brain in the nerve pathways creating this widespread body pain which often exacerbates with stress, fatigue,or menses.
Her medications was a titrating dose of Cymbalta, and Tizanidine. She was placed on natural Progesterone and Armour Thyroid. I explained to her that the Cymbalta regulates neural pathways for pain control, the Tizanidine helps with muscular stiffness, the natural Progesterone helps with menses along with body pain , and the Armour Thyroid balances energy to help with fatigue. Her treatment plan also included hydrotherapy, and adherence to the 40-30-30 protein, carbohydrate, and fat dietary regimen. The hydrotherapy allows the needed exercise in a warm pool with a physical therapist and the dietary regimen prevents sugar highs and lows to help with weight control and consistent energy.
She asked me for more Percocet. I explained the literature shows limited benefit for pain relief with narcotic medication for this condition. She was given additional handouts on Fibromyalgia to read and a body frame picture to mark her painful areas before the next visit. She was in agreement with the plan of care and verbalized her understanding after questions were answered. She was instructed to follow up in two weeks for evaluation of her symptoms and progress. She understood to call for any change in condition that worsens before her appointment in two weeks.
In newly diagnosed Fibromyalgia patients, I like to follow them closely until they have full understanding of the disease process that impacts their limits in daily functioning, and tolerable pain control. Fibromyalgia is chronic condition that can be debilitating at times impacting one's life with work and home. The major goal is sleep restoration and pain control with continued activity to one's tolerance.
