The Challenge of Fibromyalgia

“The Healthy Geezer” answers questions about health and aging in his weekly column

Question: My sister went through a nightmare of doctor visits before she finally found out she has fibromyalgia. Why did it take so long for her to get a correct diagnosis?

Answer: What your sister endured is common. It’s not easy to diagnose fibromyalgia with just a laboratory test. Healthcare practitioners have to rely on symptoms to make a diagnosis.

Unfortunately, symptoms of fibromyalgia can vary, depending upon the person. To further complicate matters, fibromyalgia imitates other conditions, including rheumatoid arthritis, multiple sclerosis and lupus.

The word fibromyalgia comes from the Latin term for fibrous tissue (fibro) and the Greek terms for muscle (myo) and pain (algia). Fibromyalgia is not a disease. It’s a syndrome, which is a group of symptoms that doesn’t have a single cause. It is characterized by widespread pain, tenderness and fatigue.

Other symptoms of fibromyalgia may include cognitive difficulties (the so-called fibro fog); sleep disturbances; morning stiffness; headaches; irritable bowel syndrome; painful menstrual periods; numbness or tingling of the extremities; restless legs syndrome; and sensitivity to heat, cold, noise; and light.

About 5 million people in the United States have fibromyalgia. More than 80 percent are women. Most people are diagnosed during middle age.

While fibromyalgia is a chronic condition, it is not progressive. It is never fatal, and it will not damage the joints, muscles or internal organs. In many people, the condition improves over time.

The causes of fibromyalgia haven’t been found. There is speculation that the syndrome may be caused by trauma or repetitive injuries. According to one theory, people with fibromyalgia may have genes that cause them to react strongly to stimuli that most people would not perceive as painful.

The American College of Rheumatology has established criteria for diagnosing fibromyalgia. A person must have diffuse tenderness and a history of widespread pain lasting more than three months. Pain is considered to be widespread when it affects all four quadrants of the body.

Fibromyalgia can be difficult to treat. Often, treatment often requires a team of healthcare professionals including a doctor, a physical therapist and others. There are clinics that specialize in fibromyalgia.

Antidepressants may be prescribed to people with the syndrome. They work by elevating the levels of brain chemicals that are associated not only with depression, but also with pain and fatigue. Increasing the levels of these chemicals can reduce pain in fibromyalgia sufferers.

People with fibromyalgia also may benefit from a combination of physical and occupational therapy; pain management and coping techniques; and a proper balance of rest and activity. Some people also report benefit from massage, movement therapy, chiropractic treatment and acupuncture.

Lifestyle changes can also minimize the effects of fibromyalgia. Getting enough sleep, exercising and making changes at work can make a difference. For example, some people cut back on the number of hours they work or switch to a less demanding job. Working with an occupational therapist to design a more comfortable work station may also help.

3 Behaviors Make Kids More Likely to be Hit By a Car

Three behaviors put children at higher risk for being hit by a car, a new study finds.

Among kids under age 6, darting into the middle of the street — even while under supervision — was a common cause of injuries from cars. Older children were less likely to be supervised, and more likely to be hit by a car while they were crossing in the middle of the block (rather than at a corner), or while they were using an electronic device.

Increasing parental supervision and educating kids on how to cross safely, as well as reducing common distractions could play an important role in preventing accidents, the researchers said.

Dr. Nina Glass, of New York University’s Langone School of Medicine, and colleagues analyzed information from about 1,075 people who were struck by cars and treated at the researchers’ hospital between 2008 and 2011. Of these, 145 were under 18 years old.

When compared with adults, children struck by cars were more likely to be male (65 percent versus 53 percent), have head injuries (82 percent versus 73 percent).

Of the 39 children in the study under age 6, 17 were injured when they darted into the middle of the street, and 14 were hurt during a mid-block crossing. In all cases, the children were supervised at the time of the accident.

Among children ages 7 to 12, 53 percent were unsupervised at the time of the accident. Forty-seven percent were injured during a mid-block crossing, and 25 percent were injured after darting into the street.

Among teens ages 13 to 17, 88 percent were hit by a car while unsupervised. Thirty-two percent of accidents involved crossing mid-block, 18 percent involved use of an electronic device and 14 percent happened when a teen darted into the street. Just 4 percent of the teen accidents involved alcohol use.

In comparison, 18 percent of the adult accidents occurred while pedestrians were crossing in the middle of the street, 15 percent during alcohol use and 9 percent during electronic device use.

The study will be presented today (Oct. 19) at the annual American Academy of Pediatrics meeting in New Orleans.

Surprising Cause Found for Woman’s Wonky Pupils

When the pupil of one eye, but not the other, dilates abnormally or does not respond to light, doctors might suspect a nerve problem, or an aneurysm.

But in the case of one 35-year-old woman with an abnormally dilated pupil, the culprit turned out to be an over-the-counter medication she was using to treat her facial perspiration, according to a report on her case.

The woman’s spouse was a paramedic, and had noticed that one of her pupils was dilated when she woke up that morning. Doctors in the emergency room found that her left pupil measured 4 millimeters across, and responded to light. But her right pupil was twice that size, and didn’t respond to light.

She also had a mild headache, but no eye pain, trauma to her eye or change in vision. She initially reported that she was not taking any medications. About a year earlier, she’d suffered chronic headaches and had been diagnosed with a benign cyst on her brain, but a new MRI showed the cyst hadn’t grown, and so could not explain her pupil problem.

After further questioning, the patient said she regularly used medicated wipes to control hyperhidrosis, or excessive sweating, on her scalp and forehead. The wipes contained a drug called glycopyrrolate, and were purchased from a Canadian pharmacy.

The woman stopped using the wipes, and by the next day, her pupil had returned to normal.

The drug works by blocking a chemical, called acetylcholine, which is involved in nerve signaling, Dr. Clare Johnson and Dr. Janet Smereck, both of the emergency medicine department at Georgetown University Hospital in Washington, D.C., wrote in their findings.

The nerve signals to the sphincter muscle that controls the pupil were likely affected by the drug, causing the dilation, they said.

Emergency room doctors should be aware that all medications — including topical treatments, and those used for cosmetic reasons — may cause side effects, the researchers said.

The report was published online Nov. 19 in the Journal of Emergency Medicine.

Pass it on: An anti-perspiration drug may cause pupils to dilate.

Inattentional Blindness: How Memory Load Leaves Us ‘Blind’ To New Visual Information

Trying to keep an image we’ve just seen in memory can leave us blind to things we are ‘looking’ at, according to the results of a new study supported by the Wellcome Trust. It’s been known for some time that when our brains are focused on a task, we can fail to see other things that are in plain sight. This phenomenon, known as ‘inattentional blindness’, is exemplified by the famous ‘invisible gorilla’ experiment in which people watching a video of players passing around a basketball and counting the number of passes fail to observe a man in a gorilla suit walking across the centre of the screen. The new results reveal that our visual field does not need to be cluttered with other objects to cause this ‘blindness’ and that focusing on remembering something we have just seen is enough to make us unaware of things that happen around us. Professor Nilli Lavie from UCL Institute of Cognitive Neuroscience, who led the study, explains: “An example of where this is relevant in the real world is when people are following directions on a sat nav while driving. “Our research would suggest that focusing on remembering the directions we’ve just seen on the screen means that we’re more likely to fail to observe other hazards around us on the road, for example an approaching motorbike or a pedestrian on a crossing, even though we may be ‘looking’ at where we’re going.” Participants in the study were given a visual memory task to complete while the researchers looked at the activity in their brains using functional magnetic resonance imaging. The findings revealed that while the participants were occupied with remembering an image they had just been shown, they failed to notice a flash of light that they were asked to detect, even though there was nothing else in their visual field at the time. The participants could easily detect the flash of light when their mind was not loaded, suggesting that they had established a ‘load induced blindness’. At the same time, the team observed that there was reduced activity in the area of the brain that processes incoming visual information – the primary visual cortex. Professor Lavie adds: “The ‘blindness’ seems to be caused by a breakdown in visual messages getting to the brain at the earliest stage in the pathway of information flow, which means that while the eyes ‘see’ the object, the brain does not.” The idea that there is competition in the brain for limited information processing power is known as load theory and was first proposed by Professor Lavie more than a decade ago. The theory explains why the brain fails to detect even conspicuous events in the visual field, like the man in a gorilla suit, when attention is focused on a task that involves a high level of information load. The research reveals a pathway of competition in the brain between new visual information and our short-term visual memory that was not appreciated before. In other words, the act of remembering something we’ve seen that isn’t currently in our field of vision means that we don’t see what we’re looking at.

Pelvic Exams While Under Anesthesia Sparks Debate

As a medical student, Dr. Shawn Barnes had an experience that he says left him feeling ashamed and conflicted. During his rotation through the obstetrics and gynecology ward of a teaching hospital in Hawaii, Barnes performed pelvic exams on women under anesthesia without the women’s explicit consent to the procedure. The women were all having gynecological surgery, and had signed a long form indicating they agreed to allow medical students to be involved in their care. However, to Barnes, the “implicit consent” patients gave when signing the forms didn’t ensure they understood exactly what happened while they were unconscious — a relatively inexperienced medical student palpated their ovaries and uteruses to check for, and better understand, potential abnormalities in these organs. “For three weeks, four to five times a day, I was asked to, and did, perform pelvic examinations on anesthetized women,” Barnes wrote in an editorial published in the October issue of the journal Obstetrics and Gynecology. Teaching hospitals should stop this practice, Barnes told MyHealthNewsDaily. Instead, patients should be asked to “explicitly consent” to the procedure, meaning they specifically say they will allow a medical student to conduct a pelvic exam. Two doctors at a Boston hospital, writing in a counterpoint to Barnes’ editorial, say they agree that obtaining only implicit consent is “morally unsound,” but also say that this practice has largely faded away. Guidelines from doctors’ groups say that women should be fully informed about the procedure, they noted. “We have many providers who trained in other institutions, and in conversation with them,” it’s clear that women are usually asked specifically for their consent to a student-performed exam, said Dr. Carey York-Best, an obstetrician and gynecologist at Massachusetts General Hospital and one of the doctors who wrote the counterpoint to Barnes’ editorial. But Barnes says the exams are done without explicit consent more often than these doctors indicate. A 2003 survey of Philadelphia medical students found that 90 percent reported being asked to perform pelvic exams on women who had not explicitly consented to the procedure. Both Barnes and York-Best said there are no recent data available on exactly how many hospitals nationwide are not abiding by the guidelines recommending that explicit consent be obtained. In any case, Barnes said that guidelines do not govern real-world practice — for this, laws are needed. During his residency, Barnes said he raised his concerns regarding pelvic exams with his superiors, but was told these exams were a long-standing, standard practice. “In fact, I was told I was the first medical student or resident in institutional memory to express concern over the practice,” he wrote in his editorial. York-Best said such laws would potentially overregulate doctors’ activities, and that the field is already far more regulated than many others. Why not just ask for permission? Performing pelvic exams on anesthetized women just prior to surgery provides medical students with a unique and valuable learning experience, Barnes and York-Best both said. For one, muscles relax under anesthesia, allowing the exam to proceed more easily and giving the surgeon and medical student a clearer picture from which to plan the details of the surgery. Additionally, women undergoing surgery have conditions that make their anatomy abnormal. Most patients who come in for routine exams performed by medical students don’t have gynecological diseases, but medical students need to be able to recognize and diagnose abnormalities. [5 Things Women Should Know About Ovarian Cancer] In his editorial, Barnes presented the arguments he heard — from attending physicians, residents, and other medical students, along with published medical literature — that a woman’s signature on a long form was sufficient proof of her consent. One argument is that such consent forms are simply the standard practice, so the exams are not an issue. But the fact that professional guidelines — from groups such as the American College of Obstetricians and Gynecologists and the American Medical Association — say that explicit consent is needed shows that this should not be the standard practice, Barnes said. Another argument he heard is that medical students don’t ask for specific permission to retract tissue or cut sutures during surgery, and that the pelvic exam portion of the procedure is no different. But Barnes argues that it is different. In fact, male medical students must be chaperoned when performing pelvic exams on conscious patients, but not when they remove surgical staples — this requirement reflects an understanding on the part of medical practitioners a pelvic exam is a more personal practice. Do guidelines do enough, or are laws needed? York-Best and her co-author, Dr. Jeffrey Ecker, suggest that the physician responsible for the patient’s care should ask the patient for permission to allow a student to perform the exam, ideally well before the surgery. Patients should also be given the opportunity to meet the medical student prior to the surgery, they write. Most patients are willing to let the student do an examination when asked by their own physicians, York-Best said, pointing to a 2009 study in which 74 percent of patients consented to a student performing a pelvic exam when they were asked by their doctor. In contrast, another study found that 53 percent consented when they were asked by students. “When it is a stranger, especially a nervous or awkward student, who asks, they do not yet know if they can trust that person, and are likely to err on the side of saying no,” York-Best said. It’s important for doctors at teaching hospitals to advocate for the teaching process in order to ensure that their students receive adequate training, she said. Barnes called this “a good idea,” but maintained that laws are needed to make sure that women understand what they are consenting to. Hawaii is now one of four states (California, Illinois and Virginia are the others) where doctors are legally required to obtain specific consent for pelvic exams under anesthesia. The Hawaii law grew out of Barnes’ outreach to lawyers about the issue, and he testified before the state legislature regarding the practice while the bill was under consideration.