From the outside of Plato's cave

F. Wolfe

National Data Bank for Rheumatic Diseases, Department of Internal Medicine and Family and Community Medicine, University of Kansas School of Medicine, Wichita, USA. E-mail: fwolfe{at}arthritis-research.org

SIR, Hazemeijer and Rasker's entertaining and erudite essay on fibromyalgia [1] contains many threads, but one thread, repeated several times and summarized as ‘...Wolfe's assertion that fibromyalgia will always exist regardless of the name given to the syndrome ... is unlikely to be true,’ stimulates me [Wolfe] to response. I have been in the forefront of those who recognize that the fibromyalgia appellation has not served patients or society well [24]. But to say that it doesn't exist should perhaps require proof by the authors rather than assertion.

So here is some proof that it does exist. In response to Hazemeijer and Rasker's article, I studied 1000 randomly selected RA patients from the US National Data Bank for Rheumatic Diseases. To my knowledge, none had been diagnosed as having ‘fibromyalgia’. I then applied proposed survey fibromyalgia diagnostic criteria (regional pain score >=8 and visual analogue fatigue >=6) [5]. Seventeen per cent of RA patients satisfied these criteria. As shown in Table 1, the RA patients identified by survey fibromyalgia criteria had all of the characteristics found in patients who meet formal American College of Rheumatology (ACR) criteria: widespread pain and high levels of pain, fatigue and sleep disturbance. All rheumatologists who care for RA patients are aware of this group of patients, even though they do not apply the fibromyalgia diagnostic label—QED.


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TABLE 1. Fibromyalgia among patients with RA

 
Those of us who played a part in the identification of fibromyalgia almost 3 decades ago did so because we, in caring for our patients, saw pain and distress that did not fit into the then, and now, prevalent model of organic disease. For a physician to identify fibromyalgia rationally is to mean that he or she is aware of the importance of biopsychosocial aspects of illness, for tender points are only a diagnostic shorthand. When we approach RA patients with ACR and disease activity score (DAS) criteria [6, 7] in randomized trials, we perforce ignore psychosocial issues. But in the clinic, we do this at our peril. Note in Table 1 that the difference in health assessment questionaire (HAQ) scores between those with and without survey fibromyalgia is greater than that seen in clinical trials involving the best of the biological agents. Clinicians know this. Is it that philosophers do not?

The author has declared no conflicts of interest.

References

  1. Hazemeijer I, Rasker JJ. Fibromyalgia and the therapeutic domain. A philosophic study on the origins of fibromyalgia in a specific social setting. Rheumatology 2003;42:507–15.[Abstract/Free Full Text]
  2. Wolfe F. For example is not evidence: fibromyalgia and the law [editorial; comment]. J Rheumatol 2000;27:1115–6.[ISI][Medline]
  3. Wolfe F. Sayin' ‘Stand and deliver, for you are a bold deceiver’: Faking fibromyalgia. J Rheumatol 2000;27:2534–5.[ISI][Medline]
  4. Wolfe F. The fibromyalgia problem. J Rheumatol 1997;24:1247–9.[ISI][Medline]
  5. Wolfe F. Pain extent and diagnosis: development and validation of the regional pain scale in 12 799 patients with rheumatic disease. J Rheumatol 2003;30:369–78.[ISI][Medline]
  6. Felson DT, Anderson JJ, Boers M et al. American College of Rheumatology preliminary definition of improvement in rheumatoid arthritis. Arthritis Rheum 1995;38:727–35.[ISI][Medline]
  7. van der Heijde DMFM, Vanthof M, van Riel PLCM, van de Putte LBA. Development of a disease activity score based on judgment in clinical practice by rheumatologists. J Rheumatol 1993;20:579–81.[ISI][Medline]
Accepted 14 May 2003