If you have to prove you are ill, you can't get well. The object lesson of fibromyalgia

Chronic widespread pain as a medico-legal issue

A systematic approach to the determination of disability in persons with chronic widespread pain is based on a careful history, examination for tender points, and special investigations to establish a firm diagnosis. Further assessment requires determination of subjective and objective measures of impairment. The causes of fibromyalgia are multifactorial and understanding them requires an appreciation of the role of physical or psychological trauma, and associated medical and psychosocial factors. Despite the presence of disability risk factors, most patients with fibromyalgia maintain a good range of normal daily activities and continue working.

Roadblocks to effective pain treatment

Managed care "backlash" rhetoric to the contrary, roadblocks to effective pain treatment occur both intrinsic and extrinsic to the healthcare system. Pain medicine, an emerging, formally recognized specialty, and the special population of patients which it serves, experience additional discreet barriers. Chief among these is a lack of clear identity and recognition of the specialty and the disenfranchisement of many of the patients it serves in the American healthcare system. Special problems within various healthcare financing environments is discussed.

A comparative study of iatrogenesis, medication abuse, and psychiatric morbidity in chronic pain patients with and without medically explained symptoms

We report a case control study comparing patients attending a pain clinic whose symptoms were not considered medically explained (cases) with those whose symptoms were considered medically explained (controls). Principal comparisons were psychiatric morbidity, medication use, and iatrogenic factors assessed by interview, and questionnaire measures of anxiety, depression, functional impairment, coping strategies and pain beliefs. Medically unexplained symptoms were associated with the presence of psychiatric morbidity (odds ratio = 3.4, 95% C.I.: 1.4,8.2), and of possible iatrogenic factors. There were no significant differences with regards to medication abuse/dependence.

Fibromyalgia, chronic fatigue, and other iatrogenic diagnostic algorithms. Do some labels escalate illness in vulnerable patients?

Contemporary medicine has the sophistication to identify the clinical settings in which the hunt for a diagnosis can be harmful to a patient's health. Which patients are best served by a prolonged search for a cause? Why has the disease-illness paradigm backfired for so many patients? Dr Hadler challenges readers to look at the difficult questions linked with diagnostic labels that might teach patients to stay sick.

The integration of pain sciences into clinical practice

In the past three decades, a scientific revolution has occurred in the understanding of the experience of pain. However, a clinical revolution based on the new science is yet to occur. Pain is a multidimensional experience with many contributing and interacting biological/pathobiological mechanisms. These mechanisms may be nociceptive, peripheral neurogenic, central, affective/cognitive or relate to output systems such as the motor and autonomic nervous system. With a better understanding of pain-related neurobiology and some clinical decision making skills, reasoned attempts at a diagnosis of pain can be made. The essential question and first step related to clinical integration is to ask, "what is (are) the predominant mechanism(s) in a given patient's pain state?" This paper provides the underlying clinical biology of pain mechanisms and proposes pain patterns related to the mechanisms.