Part 1 - Physically Traumatic Events

     The role of physical trauma in the development of Fibromyalgia Syndrome (FMS) continues to be deliberated in the literature. A major difficulty has been the reliance on someone’s ability to recall events that may have occurred thirty years prior. Post-traumatic fibromyalgia is also known as reactive fibromyalgia syndrome and the first paper on the subject was published in 1992. Those researchers reported that 23% of 127 FMS patients reported a specific event – trauma, surgery, or medical illness preceded their FMS. Patients in this group were significantly more affected with 70% losing their job, 34% receiving disability, and 45% having reduced physical activity. Shortly thereafter, in 1994, another study reported a follow-up of 176 FMS patients; 61% reported symptoms after a motor vehicle accident, 12.5% after a work injury, 7% after surgery, 5% after a sports related injury, and 14% after some other type of traumatic injury.

     A 2002 case-control study was published, which is a type of study where people with FMS are matched to healthy, normal individuals in as many characteristics as possible except for their disease, FMS. Then researchers try to find out what was different about people who had developed FMS. When the 136 FMS patients in this study were examined it was found that 39% had evidence of significant trauma within the 6 months prior to the onset of their FMS. The three most frequent types of trauma were surgery (38%), work injuries (14.7%), and childbirth (11.8%). A rather famous and experienced pain researcher, Dr. Dennis Turk, has found that compared to FMS without a known cause, post-traumatic FMS was associated with significantly higher degrees of pain, disability, life interference, affective distress, and lower levels of activity. Post-traumatic patients in his study were also more likely to be receiving opioid pain medications and to have more extensive treatment histories with nerve blocks, physical therapies, and modalities.

     The single event that has received the most attention is whiplash injury which has generated a number of studies and anecdotal reports. One of the more famous accounts is a family of 6 (2 parents and 4 children) who shared a complex of multiple constitutional and psychological symptoms who were evaluated 6 and 8 years after a minor car accident and all found to have FMS.  The major prospective studies, meaning studies that were conducted on people after their accident and followed forward in time, have been conducted by different Israeli researchers and they have reached opposite conclusions.
The first report of 161 cases, published in 1997 by Dr. Buskila and his colleagues suggested that FMS was 13 times more frequent following neck injuries than lower extremity injuries. FMS developed in 21.6% of individuals within 1 year after a motor vehicle accident compared to 1 individual with a lower extremity injury. This generated a number of critical letters to the editor with doctors suggesting possible confounding factors ranging from increased anxiety and sleep disturbances to biases introduced simply because there are more tender points in the upper body around the sites of neck injuries (10 of 18 tender points are in the neck and shoulder region).

     Of the 161 cases identified in 1997, 78 were able to be followed-up 3 years later. Even though 60% still had FMS all of the original cases were able to return to work. Of note, an additional 2009 study by Dr. Buskila found 15% of the survivors of a major train crash in Israel met the American College of Rheumatology’s criteria for FMS 3 years after the event.

     The findings of Dr. Buskila regarding whiplash and FMS remained the only prospective studies in the literature until another group of Israeli researchers, Dr. Tishler and colleagues, published two reports based on 153 patients presenting to the emergency department after whiplash injuries. The first in 2006 provided a mean follow-up of 14.5 months and found no association between injury and FMS with only one patient developing FMS.  A second report in 2010, was able to provide a 3 year follow-up of 126 of these 153 patients and confirmed the results of the authors’ earlier study showing that whiplash injury and FMS were not associated; only three patients in the study group had developed FMS in the intervening time.

     Why such discrepancies exist is still a matter of debate. Some researchers have proposed the potential role of interactions between genetics, prior experience, stress response systems, and central neurobiological pain processing systems as well as cultural differences. There will be a set of future short reports on the central neurobiological pain processing changes in FMS patients. Two studies on the development of chronic widespread pain and motor vehicle accidents suggest that the greatest predictors of persistent pain are related to pre-collision psychological and physiological health.

     Factors that influence if neck or back pain becomes chronic include the severity of pain, being female, having a history of abuse, a family history of chronic widespread pain, and the presence of additional diseases such as irritable bowel syndrome, restless leg syndrome, or migraines. It will be interesting to see how this debate unfolds using the new 2010 American College of Rheumatology criteria. However, until the debate is settled, it is probably best to avoid any whiplash injuries.