(Personal notes: Back mice were also named fibrositis of the back -specially along the first half of the 20th century-. Later the term fibrositis became in disuse, and during the years it has transformed to became fibromyalgia. In this article from 1990, they STILL use fibrositis as a synonym of fibromyalgia). Maybe the fibromyalgic syndrome is related to the fibro-fatty tissue?; in fact, some of my patients labeled as fibromyalgic present painful fibro-fatty nodules, not just painful points, especially if the examiner is skilled to find them.)
The article exposes 2 opinions/answers to certain questions by 2 different rheumatologists. (Personal note: I found it very superficial, sometimes they just mention others’ works without trying to analyze exactly what the possible etiopathogenic explanations are, sometimes the answers are difficult to understand).
This article is titled Fibrositis/Fibromyalgia: a Difference of Opinion. The term fibromyalgia came from the term fibrositis since it was first suggested by Gowers in 1904. In this article the term fibrositis is used as a synonym of fibromyalgia by the authors. (Personal note: I found it interesting to study this article to see what their views about the whole subject of fibrositis were).
NOT nodules…. just TENDER POINTS or INDURATIONS
They discuss different questions, but it seems that they do NOT mention any presence of NODULES; they just discuss the existence of tender points (despite the fact that in the old articles about FIBROSITIS the authors talked about points or nodules). They mention a kind of “indurations” in the miofascial syndrome; could that be the “fibrositic nodules”?
NO peripheral nerve entrapments… just mysterious trigger points
They DO NOT MENTION the possibility that the trigger points could be related to the peripheral nerve involvement. They hypothesize that the trigger points are related to the REFERRED PAIN, but they do not mention any peripheral nerve involvement.
They DO NOT MENTION anything about the controversy of the term fibrositis, since the term suggested “inflammatory changes in the fibrous tissue by the termination -itis”. Such inflammatory process suggested by the termination -itis hasn’t been proved. This has led to many discussions by the medical community, and even it has led to doubt of the existence of fibrositis itself. The original name was proposed by Sir Gowers in 1904 to explain the LUMBAGO symptoms, which he thought could be by a kind of “inflammatory process in the FIBROUS tissue of the capsule that surrounds the muscle spindles fibers”; that “inflammatory process” could also spread to other fibrous tissues as fascias, aponeurosis or tendons.
Smythe comments that one of the tender points is located in the medial side of the knee, over the subcutaneous fat pads. BUT he does NOT mention its significance despite he is locating it in the FATTY TISSUE, he does not make any hypothesis of the significance of that finding.
About the references: the article includes 46 references, but mainly they all are from the 80s. NOT a single reference to the old work of the authors of the early years that also studied the fibrositis syndrome, the tender points, the trigger points and the “indurations”.
(Personal note: I think that, in medicine, it is an error to omit the old articles, since the doctors by then were also trying to find out the truth underlying the diseases. And we can learn as much from them as from the new studies. Omitting them just leads to get maybe more lost. They do not refer to the original work from Gowers that proposed the name, or to other many articles about the entity fibrositis).
Personal notes on the article:
FIBROSITIS / FIBROMYALGIA: A DIFFERENCE OF OPINION
By Hugh A. Smythe and Robert P. Sheon
Dr. Smythe, professor and director of the Division of Rheumatology of the University of Toronto, Ontario, Canada.
Dr. Sheon, professor and senior Rheumatologist at the Toledo Clinic, Toledo, Ohio.
The terms fibrositis and fibromyalgia both refer to a syndrome of musculoskeletal pain within the broad spectrum of NONARTICULAR RHEUMATISM.
Although during the last decade there has been the tendency to use the terms fibrositis and fibromyalgia as a DIAGNOSTIC LABEL, it is a SYNDROME that is very controversial and promotes debate.
- What is fibrositis / fibromyalgia?
- What is the difference between tender and trigger points?
- What is the role of tender and trigger points?
- What is the role of referred pain?
- What is the role of sleep deprivation?
- What is the recommended treatment?
What is fibrositis / fibromyalgia? ANSWER from Dr Smythe
-Dr Smythe explains that, in 1990, 24 investigators yielded the CRITERIA FOR THE CLASSIFICATION OF FIBROMYALGIA that was formally recognized by the American College of Rheumatology.
The proposed criteria for the diagnosis of fibromyalgia were:
-tenderness at 11 of 18 specified sites
- They also decided to abandon the difference between the primary and the secondary fibromyalgia.
Dr Smythe wonders:
- -What diagnostic level should be applied to patients with fewer than 11 tender points?
- -What is the relation of the restricted affection with the more generalized one?
In 1977, he published an article titled: “Two Contributions to Understanding “Fibrositis” Syndrome”, where he indicated that the TENDER POINTS occurred in this syndrome at precisely predictable sites.
-The sites can be unknown to the patient.
-There was a clinical association with the symptoms of NONRESTORATIVE SLEEP (with sleep EEG with a disturbance pattern).
What is fibrositis / fibromyalgia? ANSWER from Dr Sheon
-Dr Sheon prefers to differentiate fibromyalgia from other very common regional pain syndromes as tennis elbow.
-Dr Sheon stated that fibromyalgia is a PERSISTENT GENERALIZED PAIN DISORDER that does not respond completely to treatment, “fibromyalgia is forever”.
-The diagnosis of fibromyalgia is for “exclusion”.
-Other frequent fibrositic complaints include: aggravation by cold and damp, Raynaud’s phenomenon, sicca complex, anxiety or stress, irritable bowel syndrome, tension headache and migraine, arthralgias, numbness and tingling, a loss of libido and premenstrual pain.
-He thinks that the difference between the primary and secondary fibromyalgia should be done through a competent examination, not by the number of points.
What is the difference between TENDER and TRIGGER POINTS? ANSWER from Dr Smythe
Dr Smythe considers that the difference is semantic.
Dr Smythe’s consideration of trigger points:
-He says that the trigger point is a tender point that determinates remote symptoms. (Personal note: I am surprised that they do not mention the peripheral nerves involvement related to the etiopathogenic explanation of the trigger points).
-He states that the trigger points are usually related to the MYOFASCIAL PAIN SYNDROMES.
-He mentions that the tender points are related to the idea that ‘repetitive strain’ caused local injury.
-There is the idea that histological study of the trigger points show little findings.
-They cannot be studied in scientific terms since there are little studies (Dr Smythe says that “you either accept the concepts on faith, or you do NOT”).
Dr Smythe’s consideration of tender points:
-He says that the TENDER POINTS have been extensively studied.
-To him, most TRIGGER POINTS are anatomically identical with the TENDER POINTS in FIBROMYALGIA.
-He related the trigger point to REFERRED PAIN MECHANISMS.
Dr. Smythe comments on Livingston’s work (Livingston, 1943):
-Dr. Smythe says that Livingston was the first to use the term “trigger point”.
-Livingston explains his theories about the pain mechanisms by explaining the effects after local novocaine injections.
Dr. Smythe also comments the recent observations of the substance P.
What is the difference between TENDER and TRIGGER POINTS? ANSWER from Dr Sheon
-Dr. Sheon states that trigger points occur only in muscles, they are often the result of a repetitive trauma and return to normal with the treatment. (Personal note: I don’t agree that the trigger points occur in the muscle).
-Dr Sheon does not think it is a referred pain phenomenon.
-He states that trigger points are transient, while tender points are persistent.
-He thinks that if they can measure the substance P in the tissue, they will find the answer.
What is the role of tender and trigger points in fibrositis / fibromyalgia? ANSWER from Dr Smythe.
-The skilled examination for TENDER POINTS is central to the diagnosis.
-Sometimes it is difficult due to the possibility of bias due to stoicism or histrionic exaggeration.
-The tenderness in PRESPECIFIED sites serves as an objective measure.
-The patient does not often know the location of the tender points. This naivety is so valuable that the doctor is almost RELUCTANT to divulge all his secrets.
-For example, the region of the knee has a very characteristic tender area: tenderness in the medial fat pad 5cm proximal to the jointline and 5 cm distal. But there is much less tenderness at the level of the jointline itself.
-By examination, the examiner can learn that the tenderness lies in the SUBCUTANEOUS FAT (an not in the muscles, tendons or bursae).
-Another doctor’s example is the case of “tennis elbow”, where the point of maximum tenderness extends 10 cm distally the epicondyle, as the graphic shows. The tender structure rotates with and it is attached to the radius, rather than the lateral epicondyle, and it lies deep, close to the attachment of septum to bone.
-Dr Smythe also mentions that the dolorimetres have certain limitations.
What is the role of tender and trigger points in fibrositis / fibromyalgia? ANSWER from Dr Sheon
-The doctor states that the measurement of tender points has been critically reviewed, and that not all studies correlate the number of tender points to the number or severity of symptoms.
-Dr Sheon suggests that if the “control points” are equally tender, then the “touch me not” syndrome should be considered.
-Patients with rheumatic disease also manifest tender points.
-Tender points remain a subjective phenomenon.
-No one had studied tender points in a general population.
-He insists that the trigger points are temporary and the tender points are persistent.
-He considered “tennis elbow” as a treatable self-limited disorder.
What is the role of referred pain in fibrositis / fibromyalgia? By Dr Smythe
-Dr Smythe states that doctors remain uncomfortable with concepts of “referred pain and referred tenderness”.
-He insisted that sometimes the pain is misdiagnosed since the patient is not aware of the real place of tenderness.
What is the role of referred pain in fibrositis / fibromyalgia? By Dr Sheon
-He mentions Kellgren’s work.
-He states that patients with fibrositis have significant features of autonomic dysfunction and identify stress or anxiety as key factors in their complaints.
-The induration of trigger points disappears after sympathetic blockade, but not with general anesthesia (Bengtsson, 1988).
What is the role of sleep deprivation in fibrositis / fibromyalgia ? By Dr Smythe
-Dr Smythe himself wonders how come it can be that sleep deprivation is related to tenderness in the inner knee or the outer elbow.
-He also mentions that the LOWER NECK and the LOWER back seem to be the site of origin of pain in a great majority of these patients.
What is the role of sleep deprivation in fibrositis / fibromyalgia? By Dr Sheon
-He mentions previous work by Smythe and Moldofsky that relates the presence of tender areas with specific sleep abnormality (alpha-delta-non-REM sleep or nonrestorative sleep).
-Also the work of Moldofsky that produced tenderness by depriving sleep in healthy volunteers.
What is the recommended treatment for fibrositis / fibromyalgia? By Dr Smythe
-First, they identified and corrected the neck and low back problems.
-Second, they assisted the patients to develop a high degree of general fitness.
-Tricyclic agents may be helpful in improving the restorative sleep.
-Tender points can be injected, rubbed, heated or cooled, with some local and temporary relief.
-Dr Smythe has the theory that the human anatomy that shoulders have determines that, while sleeping, C5-C7 support abnormalities that give rise to pain with decades.
-He recommends patients with lower back pain to develop stronger abdominal muscles.
What is the recommended treatment fibrositis / fibromyalgia? By Sheon
-Dr Sheon says that, first of all, it is necessary to identify a possible outcome factor and differentiate the different chronic pain syndromes from TABLE 1.
-Sympathetic blockade from reflex dystrophy and causalgia or intralesional point injections for multifocal or regional myofascial pain are often rewarding.
-The patients with generalized pain differ from those with LOCAL REGIONAL PAIN.
-Tender points may relate to persistent symptoms, but not always.
-If anxiety or emotionally charged events stimulate autonomic nervous system activity, a minor injury as repetitive strain might initiate a vicious cycle of pain, tender points, poor sleep, and fibrositis.
Published in October 2018 By Marta Cañis Parera
-Smythe HA, Sheon RP. Fibrositis/fibromyalgia: a difference of opinion. Bull Rheum Dis. 1990;39(3):1-8. Review. PubMed PMID: 2194615.
-Bengtsson A, Bengtsson M. Regional sympathetic blockade in primary fibromyalgia. Pain. 1988 May;33(2):161-7. PubMed PMID: 3380557.