Dr. David Ring,  Associate Dean for Comprehensive Care and Professor of Surgery at Dell Medical School, answers four questions on  fibromyalgia, among other things. [Related information can be found in the Orthopaedia chapter on fibromyalgia.]

Orthopaedia: Fibromyalgia is a controversial condition: some say it’s not a musculoskeletal disease but a psychological one. Given that you earned your PhD studying the psychology of arm pain, you probably have some feelings about that controversy. Yet without wading into any of the details of the argument, what do you think is the correct therapeutic approach to a 45-year-old, moderately overweight female patient with disturbed sleep, widespread musculoskeletal pain and no objective findings–somebody, that is, likely to earn the “fibromyalgia” label?

DAVID RING: I suggest we might want to start by avoiding labels and instead use descriptive terms. For fibromyalgia, the terms that come to mind are multifocal, idiopathic, daily, troubling pain.
When I’m trying to help the 45-year-old woman with multifocal, idiopathic, daily, troubling, musculoskeletal pain, I’m definitely considering her as a whole person–a person with hopes, fears, thoughts, cherished roles, and a complex identity. I may not be able to measure or treat a specific pathophysiology, but I can definitely help her improve her health.

Pain is the cognitive and emotional experience of nociception. The word “nociception” might have been hijacked into many different domains of late, but its definition – “the sensory nervous system’s process of encoding noxious (meaning potentially damaging to tissues) stimuli”–is very useful to the discussion of fibromyalgia. This definition underscores the idea that all pain is, ultimately, in the brain and mind.

One of my mentors, Dr. Albert Barsky, reminds us that almost every region and organ in the body has an associated syndrome characterized by the absence of objectively measurable pathophysiology. In fact, even for objectively discernable conditions like arthritis, the level of symptoms does not correspond with pathophysiology severity. Kim and colleagues studied people in a Korean town and found that less than half the patients with severe radiographic arthritis had significant knee symptoms. Even more interestingly, perhaps, they also found that a large number of people with little or no radiographic knee arthritis had significant knee symptoms– if they had depression as well! In other words, mindsets account for a large part of the gap between pathophysiology and the state of being unwell.
So when I am trying to help a person with multifocal, idiopathic, daily, troubling, musculoskeletal pain, I’m less concerned that I may not be able to measure or even identify the pathophysiology and more concerned in guiding the patient to the healthiest possible mindset.

Orthopaedia: Sports betting has become legal in most American states, but prediction markets are still not yet widespread. So I can’t ask you to put any money on this, but which of the following two statements you would be to be more likely to be true in the year 2075? “Fibromyalgia will be an historical artifact, like the diagnosis of “railroad spine” from the early 20th century” or “the pathophysiology of fibromyalgia will be understood on a biological level.”

DAVID RING: When you and I were young, peptic ulcer disease was caused by stress. Now, thanks to the Nobel winning work of some unconventional Aussies, we know that it’s related to colonization of the stomach by H. Pylori. And we now treated ulcers with antibiotics.

Given this experience, we should always be on the lookout for the next “H. Pylori.” But such breakthroughs are rare–that’s why Dr. Marshall and friends won their Nobel. In the meantime, for people that seek help now, we cannot simply wait in wishful anticipation of discovering that elusive pathophysiology-treatment combination. We must help people accommodate illness. That’s true whether there ends up being an H. Pylori or not.

The emphasis on accommodation is essential because—as the studies like that of Kim and colleagues demonstrate—even when you understand the pathophysiology, mindsets matter. Sticking with the knee as an example, we know that about 1 in 5 people with seemingly “perfect” total knee replacements have persistent discomfort and incapability. I think that mindsets may be a key reason for this. As such, attempts to address an illness (whole person) by addressing disease (pathology) alone is not a recipe for success. Engaging a medical problem without considering mindsets may represent inadequate diagnosis and undertreatment of the illness.

Given everything we know about the history of human illnesses, the probability that a specific pathophysiology will be identified for any given non-specific illness, fibromyalgia as well, is exceedingly low. Yet the chance that a person will benefit from supportive, comprehensive treatment approaches 100%, so I will always bet on that.

Orthopaedia: Fibromyalgia is associated with sleep disturbances. Do you think this is a cause or an effect? As we know, when one is sleep-deprived it is all too easy to feel lousy all over.

DAVID RING: Medicalizing multifocal, idiopathic, daily, troubling pain of unknown origin by assigning it a Greco-Roman biomedical name like “fibromyalgia” reflects our society’s mental and social stigmatization of illness. By that I mean that people with unhelpful thoughts, feelings of distress, and sources of stress are treated or may fear being treated as not fully human or as broken or flawed.

Sleep–which we all engage in, typically without shame– can be a comfortable topic of conversation in a world in which talking about distress can risk offense due to mental health stigma. More than that, my research and that of others have found that the vast majority of people do want to connect with us on the emotions of their experience. If you pay attention, people often lead with or emphasize the impact of the symptoms and how drained, worried, fearful, desperate, and overwhelmed they feel. They are inviting us to talk about mental health. And we can learn to do so with grace and compassion.

Keep in mind that most mental-physical health relationships are bidirectional, and that it usually doesn’t matter if there is a specific “starting point.” Suffice to say that distress disrupts sleep and limited sleep can be distressing. Competent and compassionate care does not require resolving this chicken-and-egg conundrum.

Orthopaedia: Do you think patients with Fibromyalgia tend to be over-treated or under-treated for related musculoskeletal conditions? One could see it going both ways. For instance, true carpal tunnel syndrome might be ignored or overlooked, with the symptoms attributed to the fibromyalgia. On the other hand, patients with fibromyalgia may be more engaged with the medical system, and thus more prone to get treatment for things that may be overlooked in other people.

DAVID RING: A useful approach is to focus on pathophysiology for which there is a disease-modifying treatment. Idiopathic median neuropathy (carpal tunnel syndrome) is a great example of a condition where do have a disease-modifying treatment. If we miss the diagnosis, a person may develop permanent loss of sensibility, which is preventable with carpal tunnel release.

Given that there are very few diseases like that in musculoskeletal medicine–most of orthopedic surgery is discretionary and addresses discomfort and incapability– it’s possible that prioritizing healthy mindsets and circumstances could reduce the appeal of many musculoskeletal tests and treatments. In my practice, this is already the case.
Consider people with new shoulder pain. If I discover that the symptoms are due to age-appropriate degeneration of the rotator cuff (as they usually, but not always, are), I try to help the patient understand that the new pain is not a new disease or an injury. I try to help them understand that the problem is likely generally accommodated (given that most of us get it as we age). And I try to help them understand that most of our treatments are palliative (symptom alleviating) rather than disease-modifying (curative). If have done my job helping them understand, most people choose to forego interventions like injections or surgery and instead choose accommodation and an independent exercise program.

If I successfully help patients understand that “fibromyalgia” is a concept, that, as of now, has no treatable pathophysiology associated with it, if I successfully help patients understand that all human illness has mental, social, and pathophysiological components, they might decline the diagnosis of “fibromyalgia” and any associated tests and treatment. Instead, they may choose to focus on health strategies that emphasize mental and social wellbeing along with non-specific palliative treatments.  All this to say, if I successfully help the patient understand their body and their mind, gently reorienting common misconceptions, they reclaim agency and accommodate the sensations that brought them to me.