Date: Sun, 13 Oct 1996 09:34:30 -0700 From: "Mark Street, D.C." Subject: Fibromyalgia Info Abstract Increased pressure pain sensibility in fibromyalgia patients is located deep to the skin but not restricted to muscle tissue. Pain 1995; 63:335-9 Kosek E, Ekholm J, Hansson P. Abstract: This study was aimed at comparing pressure pain sensibility in different tissues in fibromyalgia patients. Pressure pain thresholds (PPT's) were assessed in 16 fibromyalgia (FM) patients bilaterally at the bony part of epicondylus lateralis humeri, at the belly of m. extensor carpi ulnaris and at m. brachioradialis where the radial nerve branches pass underneath. Following a double blind design, either a local anesthetic cream (EMLA) or a control cream was applied to the skin and PPTs were reassessed. The site with the underlying nerve had a lower PPT than the bony site (P<0.001) and the "pure" muscle site (P<0.001), respectively. These relations remained unaltered by skin hypoesthesia. The PPTs over the bony and the "pure" muscle sites did not differ. Application of EMLA, compared to control cream, did not change PPTs over any area examined. The results demonstrated that pressure-induced pain sensibility in FM patients is not most pronounced in muscle tissue and does not depend on increased skin sensibility. Mark Street, D.C. - jet@sonic.net -------------------------- Date: Sun, 16 Aug 1998 11:42:30 -0700 From: Moses Jacob Subject: Re: Fibromyalgia and MVA At 11:52 AM 8/16/98 -0400, Alan M. Tebby, D.C. wrote: >Can anyone direct me to any sites that have information regarding the >onset of Fibromyalgia and Automobile Accidents? >Alan In reply hope this will help. Moses POST-Traumatic FIBROMYALGIA A Long-Term Follow-Up1 George W. Waylonis, MD and Robert H. Perkins, BS AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION copyright by Williams & Wilkins This Project was supported by the Research and Medical Education Departments of Riverside Methodist hospitals and by the Roessier Student Research Fund of the Ohio State University College of Medicine. From the Department of PM&R, Riverside Methodist Hospitals, College of Medicine, The Ohio State University, Columbus, Ohio. ABSTRACT Waylonis GW, Perkins RH: Post-traumatic fibromyalgia: a long-term follow-up. Am J Phys Med Rehahil 199473:403-412. This report describes a follow-up study of 176 individuals seen between 1980 and 1990, in whom a diagnosis of post-traumatic fibromyalgia was made. Sixty-seven people completed a lengthy questionnaire and underwent a confirmatory physical examination using the American College Of Rheumatology Criteria to confirm or deny the presence of fibromyalgia at the time of follow-up. A total of 60.7% noted the onset of symptoms after a motor vehicle accident, 12.5% after a work injury, 7.1% after surgery, 5.4% after a sports-related injury and 14.3% after other various traumatic events. Fifty-six of 67 individuals had 11 or more tenderpoints (average, 13.5), 3 had 10 tenderpoints, and 7 had fewer than 10 or no tenderpoints. Study subjects were asked to compare the use of the following for the first 2 yr after onset as well as the year preceding the current evaluation: biofeedback, medications, physical therapy, manipulation, massage therapy and tenderpoint injections. In addition, we asked detailed questions regarding symptoms commonly seen in association with fibromyalgia (fatigue, sleep disturbance, etc.). Symptoms of traumatically induced fibromyalgia are quite similar to spontaneous fibromyalgia. There was a dramatic reduction in the use of all forms of physical treatments. Fifty-four percent continued to use over-the-counter pain medications, and 39% were on antidepressants. Eighty-five percent of the patients continued to have significant symptoms and clinical evidence of fibromyalgia. KEY WORDS: Fibromyalgia, Post-Traumatic, Long-Term Outcome Physicians dealing with post-traumatic soft tissue pain problems are often asked the question: What happens to patients with post-traumatic fibromyalgia long after litigation/compensation issues are settled? Some physicians regard patients with fibromyalgia precipitated by trauma as somehow different than patients who develop the condition spontaneously. In 1992 Greenfield et al.; termed the latter condition "Reactive Fibromyalgia Syndrome." In that series, 23% of patients with fibromyalgia reported trauma, surgery or medical illness as precipitating events. They noted that patients with "reactive" fibromyalgia are more likely to have loss of employment (70%), receive disability compensation (34%) and describe reduced physical activity (45%). In a 1990 report describing short-term follow-up of 14 patients with post-traumatic fibromyalgia, Romano2 noted that 9 of 14 patients continued to require treatment 2 yr after settlement of litigation. He indicated that the major obstacles to treatment of this group of patients result from (1) delayed diagnosis, (2) misperception of malingering, and (3) stress of legal proceedings. In a recent presentation to the American College of Rheumatology, Goldenberg3 indicated that patients with post-traumatic fibromyalgia were identical to patients with idiopathic fibromyalgia and that 5~60% of his fibromyalgia patients described the onset of symptoms of fibromyalgia to a traumatic or infectious event. The literature investigating post-traumatic fibro myalgia is quite limited. Various terms have been used to describe post-traumatic soft tissue pain syndromes, and only since 1990, as noted above, has fibroImyalgia clearly been separated from the broader description of soft tissue pain syndromes. The issue of outcome after settlement of litigation in the broader diagnosis of "soft tissue syndromes" has been of considerable concern for the last 25 yr. In 1966 Miller reported that (head) injured patients are likely to improve within 12 mo of cessation of litigation. An opposite position was taken by Menedelson in l982, who attempted to refute Miller's position and indicated that 75% of injured people fail to return to gainful employment 2 yr after legal settlement. Mendelson5 listed factors influencing outcome (1) psychological effect of injury, (2) ethics factors, (3) occupational factors, (4) premorbid personality and (5) psychodynamics. A 1988 report by Maimaris et al.6 described 2-yr outcomes in a diverse group of soft tissue patients; however, the report did not separate those with underlying Osteoarthritis. The Maimaris series6 described 102 patients of which 67% were asymptomatic 2 mo. post-trauma and 88% asymptomatic at 2 yr. Poor prognostic indicators included older age, occipital headaches, referred symptoms, interscapular pain and osteoarthritis. In a 1990 report, Gargan and Bannister7 described a 10-yr follow-up of 43 patients with soft tissue neck injuries. Only 12% of the patients had complete recovery, and 56% had been involved in litigation. Unfortunately the report did not include any description of physical findings at follow-up, but the reported symptoms included neck pain, paresthesias, low back pain, headache, dizziness, nonspecified auditory and visual symptoms and dysphagia.7 In 1993, Parmar and Raymakers8 described an 8-yr follow-up of 100 patients with a diagnosis of "neck strain." They found that 50% had pain 8 mo after neck trauma, 22% after 2 yr and 18% at 3 yr. The poorest prognosis was for patients with underlying cervical degenerative disc disease.8 The purpose of the present study was to examine two issues: (1) What is the eventual outcome of individuals with post-traumatic fibromyalgia? (2) is post-traumatic fibromyalgia a different condition than spontaneous fibromyalgia? METHODS We were interested in determining the long-term outcome for patients with post-traumatic fibromyalgia and to determine if the condition is the same as primary (spontaneous) fibromyalgia. To examine these two issues, we hoped to compare a group of patients with post-traumatic fibromyalgia with a group of subjects with primary fibromyalgia. We elected to contact patients with post-traumatic fibromyalgia, have them complete a questionnaire about symptoms and treatment and examine them to determine if they meet current American College of Rheumatology (ACR) criteria for the diagnosis of fibromyalgia. Initially, we contacted several insurance companies and attorneys' offices to obtain names of individuals with post-traumatic fibromyalgia. These two potential sources were not cooperative so we next elected to solicit patients with post-traumatic fibromyalgia through national fibromyalgia support group newsletters; we had a very limited response from 25 individuals. Finally we reviewed all medical records in the files of one of the authors (GWW) between 1980 and 1990. A total of 773 patients had a diagnosis of post-traumatic fibromyalgia. We attempted to contact these patients by phone and were successful in reaching 176. The main problem encountered was a change of phone number and/or address. The bulk of the questions used in this study were identical to those used in the Waylonis and Heck9 study in 1992. We planned at the outset to compare the historical data obtained from the current group of post-traumatic fibromyalgia patients with the data obtained during the Waylonis and Reck9 study, which had baseline data on medical history, syptoms and aggravating factors obtained from 554 subjects with self-reported primary fibromyalgia and a control group of 161 subjects in good health. The Waylonis and Heck questionnaire was used in tact so that the post-traumatic population could be compared on an item-by-item basis. Because we also wanted to study other aspects of post-traumatic fibromyalgia, additional questions regarding past and current treatment were included (see Appendix A). The questionnaire was mailed to all 176 individuals who agreed to participate by phone, and the completed questionnaires were returned by 92 individuals. Many studies on fibromyalgia before 1990 were based on self-reporting of the diagnosis and did not use confirmatory physical examinations. Wolfe et al.10 advocated that research projects on fibromyalgia use the same criteria for establishment of the diagnosis, which requires the presence of at least 11 tenderpoints in 18 standard locations. We requested that the 92 patients who returned their questionnaires also undergo a confirmatory physical examination. Our examination consisted of a tenderpoint assessment, palpation of muscles, test for dermographism and jump sign along with a review of the patient's questionnaire responses. Fifty-five respondents were examined by the authors, and another 12 out-of-town respondents were examined by qualified physicians who sent written confirmation of the examination results. RESULTS Sixty-six individuals completed both the questionnaire and the physical examination. One individual was still involved in litigation for a work-related claim and was excluded from the study. Fifty-six (84.8%) demonstrated tenderpoints in I or more of the ACR tenderpoint locations. Another three demonstrated 10 tenderpoints, and, although considered borderline, they were not included in the findings as positive. Recently there have been questions from Europe by Raspe and Baumgartner'2 concerning the ACR standard of requiring II of 18 tenderpoints as being too strict. During the establishment of the ACR standards, as few as 8 and as many as 12 tenderpoints were considered, along with an appropriate history for fibromyalgia. In this series 3 of the 10 individuals who did not meet ACR standards had 10 tenderpoints. We elected not to include them as positive; however, if we had, the percent of positives at follow-up would have been 89.3%. The fifty-six individuals meeting ACR standards included 49 females and 7 males, with an average age of 46.0 yr. TABLE 1 Type of trauma precipitating onset of symptoms TABLE 3 Medication use: then and nQw (n 56) (1) Motor vehicle accident, 60.7% (2) Injury at work, 12.5% (3) After surgical procedure, 7.1% (4) After sports injury, 5.4% (5) Physical abuse and trauma, 1.8% (6) others, 12.5% The average duration of symptoms since traumatic onset of symptoms was 10.8 yr at the time of the follow-up evaluation. The types of trauma attributed to precipitating the symptoms are described in Table 1. Legal action had been instituted by 32 of 56 (57%) people. Thirty-nine percent had been involved in personal injury litigation and 11% involved in industrial compensation claims. In addition to determining the permanency of post-traumatic fibromyalgic symptoms, we also wanted to determine how individuals with the condition treated the symptoms and learned to cope. The questionnaire was designed to compare the types of treatment administered during the first 2 yr post-trauma with the treatment in the year preceding the study. We recognized that treatment practices would be different a decade later, but our goal was to determine general treatment approaches. Questions were included that inquired about physical treatments, which included physical therapy, chiropractic and osteopathic manual medicine, massage, acupuncture, biofeedback, trigger point injections and an open- ended question for all other types of treatment. The questionnaire also assessed medication use patterns including use of prescription and over-the counter nonsteroidal anti-inflammatory drugs, muscle relaxants (other than tricyclics), narcotics and tricyclics and also included an open-ended question about other medications. Table 2 contains the results obtained regarding physical treatments; the data are presented as the percentage of positive responses for the various treatment modalities along with an indication of percentage of respondents indicating positive TABLE 2 Physical treatments use: then and now (n=56) Type treatments Yr 1-2 Help? Last yr Help? Physical therapy 59 82 18 60 Chiropractic 34 42 13 57 Osteopathic 21 75 9 100 Massage 45 80 18 80 Trigger point 37 60 9 60 injections Acupuncture 4 50 0 0 Biofeedback 13 86 4 50 other 18 90 27 93 No. of No. of Yr medi- Last medi- Type treatments 1-2 cations yr. cations Prescription Nsaids 38 21 20 12 Over-the-counter 50 28 54 37 Nsaids Muscle relaxants 23 15 20 11 Narcotic 13 7 11 6 Tricyclics 32 22 39 23 Other 11 10 29 2 benefit from the specific physical treatment approaches. For instance, 59% of respondents used physical therapy treatments during the first 2 yr after the onset of their symptoms, and 82% of positive respondents found physical therapy to be beneficial. However, in the year preceding this study, only 18 of respondents used physical therapy, and the positive response rate dropped to 60%. In general we noted a reduction in the use of physical treatment approaches during the follow-up period in comparison with the inltial treatment period. We also noted a change in the medication use patterns. Results of those observations are summarized in Table 3. We found that the greater reliance on prescription medications was during the initial 2 yr, whereas over-the counter medications were most frequently used at the time of follow-up. The one class of prescription medication use that was increased at the time of follow-up (1993) was the tricyclic group of antidepressants; they were used for the treatment of associated sleep disturbances commonly seen in fibromyalgia patients. In addition to studying outcomes, we were interested in determining whether post-traumatic fibromyalgia is the same condition as primary fibromyalgia. The bulk of the questions in our questionnaire were identical to those used in the Waylonis and Heck study. This was intentional because we planned at the outset to compare the data from the current study with the data from the earlier study, which had a large primary fibromyalgia group and a control group. The new data were examined statistically against the Waylonis and Heck data by (1) comparison with controls used in the Waylonis and Heck study, (2) comparisons with the fibromyalgic cases used in the Waylonis and Heck study, and (3) use of the ~2 test or Fisher's exact test (where expected value was 5). Tables 4, 5 and 6 are presented in a fashion similar to the ones reported in the Waylonis and Heck study. Each table has five columns. The first columns list the percentage of positive responses obtained from the group of post-traumatic fibromyalgia subjects (n = 56). The second columns list the percentage of positive / TABLE 4 Persoral history Waylonis Post-traumatic and Heck Post-traumatic V Waylonis Post-traumatic fibromyalgia Waylonis and v Waylonis and Heck fibromyalgia cases Heck controls and Heck fibromyalgia (n 56) (n 554) (n = 161) controls cases Allergy 66.1 64.3 40.8 <0.002 NS (0.902) Balance problems 35.7 34.7 10.6 <0.001 NS (0.781) Bruxism 41.0 33.6 14.2 <0.001 NS (0.328) Bursitis 51.8 54.7 21.3 <0.001 NS (0.783) Carpal Tunnel Syndrome 8.9 15.9 12.4 NS (0.644) NS (0.236) Chondromalacia 33.9 24.5 1.2 <0.001 NS (0.169) Cold sores, frequent 32.1 28.5 21.3 NS (0.138) NS (0.678) Constipation, chronic 32.1 40.2 16.6 <0.024 NS (0.299) Depression 51.8 64.4 14.2 <0.001 NS (0.084) Diarrhea, recurrent 37.5 34.5 8.3 <0.001 NS (0.760) Fluid retention 57.1 44.6 17.2 <0.001 NS (0.098) Heat intolerance 53.5 42.4 16.6 <0.001 NS (0.143) Mitral valve prolapse 17.9 18.9 5.3 <0.012 NS (0.984) neck surgery 7.1 15.3 12.4 NS (0.402) NS (0.145) PMS 39.3 47.5 23.1 0.029 NS (0.303) Raynaud's 48.2 38.0 13.0 <0.001 NS (0.172) Sciatica 16.1 53.2 13.6 NS (0.825) <0.001 Sinus problems 62.5 56.3 33.1 <0.~ NS (0.454) Stomach ulcer 19.6 18.2 5.9 <0.004 NS (0.937) Temporomandibular 22.4 46.9 8.1 <0.001 NS (0.766) joint dysfunction Vertigo 44.6 40.2 15.4 <0.001 NS (0.621). responses from the Waylonis and Heck fibromyalgics group (n = 554). The third columns list the percentage of positive responses from the Waylonis and Heck controls (n = 161). The fourth columns present the statistical relationships between the post-traumatic fibromyalgia group and the Waylonis and Heck control group with p values. The fifth columns present the statistical relationship between the post-traumatic group of this study with the Waylonis and Heck fibromyalgia cases. Table 4 compares the results of the personal medical history obtained. Table 5 presents the results obtained from the questions about family history. Table 6 compares the symptom patterns among the three groups. We asked questions about factors aggravating the symptoms commonly associated with fibromyalgia. The data presented in Table 7 compare the reported TABLE 5 Family History Waylonis Post-traumatic and lleck Post-traumatic V Waylonis Post-traumatic fibromyalgia Waylonis and v Waylonis and Heck fibromyalgia cases Heck controls and Heck fibromyalgia (n 56) (n 554) (n = 161) controls cases Allergy 50.0 55.0 21.3 <0.001 NS (0.577) Children with fibromyalgia 19.6 12.4 6.5 <0.008 NS (0.190) Dermatomyositis 8.9 6.9 13.6 NS (0.482) NS (0.762) Fatigue, chronic ~ .0 46.7 16.6 <0.001 <0.001 Heart disease 32.1 42.3 23.1 NS (0.238) NS (0.187) Parent with fibromyalgia 17.9 25.4 8.2 NS (0.072) NS (0.275) Rheumatism 16.0 39.5 15.4 NS (0.907) Rheumatoid arthritis 6.8 30~3 22.5 NS (0.624) NS (0.691) TABLE 6 Symptom history WayTonis Post-traumatic and Heck Post-traumatic v Waylonis Post-traumatic fibromyalgia Waylonis and V Waylonis and Heck fibrornyalgia cases Ileck controls and Heck fibromyalgia (n = 56) (n = 554) (n 161) controls cases Cough, chronic 16.1 17.1 8.3 NS (0.147) NS (0.986) Fatigue, chronic 71.4 72.0 17.8 <0.001 NS (0.951) Feet, burning 64.3 64.1 18.3 <0.001 NS (0.908) Concentration problems 55.4 59.6 14.3 <0.001 NS (0.640) Coccyx pain 39.3 35.9 8.3 <0.001 NS (0.724) Dry eyes 28.6 35.9 21.3 NS (0.399) NS (0.342) Dry skin 57.1 53.8 25.4 <0.001 NS (0.735) Memory problems 44.6 53.2 17.2 <0.001 NS (0.276) Muscle fatigue 85.7 65.2 17.2 <0.001 0.003 Nervousness 53.6 52.0 24.3 <0.001 NS (0.931) Numbness/tingling 78.6 72.6 14.8 <0.~ NS (0.419) Palpitations 30.4 ~.7 7.8 <0.0~ NS (0.187) Pelvic pain 39.3 66.1 23.1 0.029 <0.001 Pins and needles 67.9 49.1 21.3 <0.001 0.01 Rib cage pain 51.8 26.3 5.9 <0.001 <0.001 Sexual dyslunction 23.2 66.6 21.9 NS (0.966) <0.001 Sleep disorder 89.3 79.8 20.7 <0.001 NS (0.124) Falling asleep 50 80.1 23.7 0.02 <0.001 Awaken during sleep 75.0 39.0 36.7 <0.001 <0.001 AM fatigue 91.1 48.7 32.5 <0.001 <0.001 Sore throat, recur 16.1 18.6 5.3 0.03 NS (0.777) Stiffness 94.6 45.0 16.4 <0.001 <0.001 Swallowing problems 21.4 28.9 5.9 <0.~ NS (0.305) Swollen glands 16.1 66.8 7.1 NS (0.073) <0.001 Tachycardia 19.6 50.4 17.2 NS (0.86) Trigger points 83.9 26.0 14.2 <0.001 <0.001 Temper, short 46.4 24.5 21.3 NS (0.491) NS (0.836) Tinnitus 37.5 505 10.6 <0.001 NS (0.085) aggravating factors obtained from the post-traumatic and idiopathic fibromyalgia groups along with P-values. We did not run comparisons with the Waylonis and Heck control group because they were null with respect to these questions. There are wide variations among individuals with fibromyalgia reported as to the effects of cold, noise, visual stimuli, stress and repetitive activities. The current fibromyalgia literattire13 suggests that the best treatment for fibromyalgia is a regular exercise program, but many individuals with fibromyalgia report a difficult time getting started on or maintaining a regular exercise/fitness program. A recent newspaper report indicated that only 10% of the general population over 40 yr exercise one time per week. We were pleased to note that our post-traumatic group was exercising. Twenty-seven of 56 (48%) exercised "regularly," with 37% exercising 2-3 hr/wk. Sixty-four percent indicated some problems with fatigue after exercise. The most popular form of exercise was walking (34%), followed by cyclLng (25%), stretching (14%), weight training (9%) and swimming (7%). DISCUSSION We indicated at the outset that there is no specific study of long-term outcome for post-traumatic fibroimyalgia. The results of this study are similar to the observations of Gargan and Bannister7 in their outcome study of "post-traumatic soft tissue problem and support the hypothesis that the symptoms of post-traumatic fibromyalgia do not disappear after litigation issues are settled. We found that 89% (depending on whether we used 10 or 11 tenderpoints as the cut-off level to make the diagnosis) of patients continued to have symptoms 10 yr after the onset of symptoms and that they meet the current ACR criteria for establishing the diagnosis of fibromyalgia. In a recent review, Wolfe, who was one of the authors of the ACR 1990 standards, reviewed the problem of how to handle the issue of TABLE 7 Symptoms aggravated by P value Post- Factor trauma fibromyalgics cases Caffeine 30.4 35 NS (0.581) Cold 82 47 <0.001 Heat 34 26 NS (0.262) Noise 42.8 75 <0.001 Lights 33.9 78 <0.001 Mental stress 50 75 <0.001 Physical stress 89.3 75 0.026 Posture 82.4 81 NS (0.984) Repetitivemotion82.1 43 <0.001 Weather change 89.3 80 NS (0.131) the patient with an appropriate history, widespread pain and 10 tenderpoints and concluded that "while the patient does not quite meet current criteria, he almost certainly has the disorder." We agree with Wolfe that there is a need to have criteria or standards to make the diagnosis of fibromyalgia but must emphasize that the ACR criteria were based on the result of a committee that had to make compromises to reach collective agreement. There is no doubt that our three additional follow-up cases that missed meeting ACR criteria by one tender-point certainly have post-traumatic fibromyalgia. Our findings, whether we use the 85 or 89% result, confirm our hypothesis that patients with post-traumatic fibromyalgia exhibit a history and symptom profile very similar to those with primary fibromyalgia. The observations reported here were also compared with the group of 554 fibromyalgia patients studied by Waylonis and Heck; the two groups appear to be quite similar, and statistically the two groups appear to come from the same population. We concluded that the observations reported here support the hypothesis that primary fibromyalgia and post-traumatic fibromyalgia actually represent a single condition and that separation into Type I (spontaneous) and Type II (post-traumatic) are artificial. Our studies demonstrated some slight differences between the groups, which may be explained on the basis of sample selection. It should be pointed out that the 554 individuals reported in the earlier Waylonis and Heck study were self-reported, and the diagnosis was not confirmed by a confirmatory physical examination using ACR criteria, which was not in universal use at the time of the earlier study. The post- traumatic group and the Waylonis and Heck group were very similar; however, the post-traumatic group tended to report more somatic symptoms, whereas the Waylonis and Heck group reported more visceral symptoms. The post-traumatic group had a significantly higher family history of chronic fatigue, whereas the Waylonis and Heck group reported significantly more rheumatism (Table 5). The post-traumatic group was significantly more symptomatic with respect to muscle fatigue, tingling in hands or feet, rib cage pain, sleep disturbance, stiffness and trigger points than the Waylonis and Heck group. The post-traumatic group was significantly less symptomatic with respect to pelvic pain, problems with getting to sleep, swollen glands, tachycardia and sexual dysfunction than the Waylonis and Heck group. The post-traumatic group was significantly more likely to report cold, physical stress and repetitive motion as aggravating their symptoms. The post-traumatic group was significantly less likely to report noise, lights and mental stress as aggravating their symptoms. The post-traumatic fibromyalgia patients exercised with great regularity and reduced their dependency on expensive and time-consurrnng physical treatments and expensive prescription medications over the years but slightly increased their use of tricyclic antidepressants for the treatment of sleep disturbance. Perhaps the most important finding is that, in general, the post-traumatic fibromyalgia group simply "learned to cope" with their condition. SUMMARY Eighty-five percent of patients with a previous diagnosis of post-traumatic fibromyalgia still had symptoms and physical evidence of the condition 10 (~13) yr later. They were for the most part identical to the fibromyalgia patients who developed their symptoms spontaneously. These results closely parallel the findings of Garage and Bannister and support the concept that the symptoms of post-traumatic FIBROMYALGIA do not disappear when litigation has been completed. There was a significant reduction in the use of physical treatments: physical therapy, chiropractic, osteopathic manipulation, massage and biofeedback by the post-traumatic group of patients. It appears that individuals with post-traumatic fibromyalgia do not rely on expensive physical treatments on an indefinite basis. A significant percentage (48%) exercised on a regular basis. Most post-traumatic fibromyalgia patients relied on the use of over-the-counter NSAID medications and tricyclic antidepressants for control of their symptoms. Fifty-four percent were using over-the counter and 16% were using prescription NSAIDs at the time of the follow-up evaluation. Over 38% were on tricyclic antidepressant medications at the time of follow-up. Neither class of medication is expensive. Most patients indicated that they had learned to "live" with the symptoms of post-traumatic fibromyalgia. At the present time, the best treatment for post-traumatic fibromyalgia appears to be education, over-the counter pain medications and encouragement to use personal exercise programs. ACKNOWLEDGMENTS Special thanks to Mary Anne Zanetos, Director of the Riverside Research Department, who performed the statistical analysis of our data and to Chrisanne Gordon, M.D., and Kurt Kuhiman, M.D., for assistance in preparation of the manuscript. REFERENCES I. Greerfield S, Fitzcharles M, Esdaile J: Reactive fibromyalgia syndrome. Arthrihs Rheum 1992,35:678-680. 2. Romano Tw: Clinical experiences with post-traumatic fibromyalgia syndrome. Va Med J 1990,86:198-202. 3. Goldenterg D: Presentation to the American College of Rheumatology, San Antonio, Texas, November 7-11, 1993. 4. Miller H: Accident neooosis. Proc Med l,'g Soc 1966;l():~-82. 5. Mendekon G: Not cured by a verdict Med J Aust 1982;2: 132-134 6. Maimaris C, Barnes M, Allen M: Whiplash inluries of the neck: retrospective study. Br J Accident Surg 1988;19:39~3%. 7. Gargan M, Bannister G: Long-term prognosis of soft tissue injuries of the neck. J Bone Joint Surg Br 1990;72B:901-903. 8 Parmar H, Raymakers R: Long-term follow-up of post-traumatic neck injuries. Br J Accfdent Surg 1993;24:7~7g 9 Waylonis GW, Heck W: Fibromyalgia: new associations. Am ! Phys Med Rehabil 1992;71 :34~348. 10). Wolfe F, Smythe HA, Yunus MB: The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990,33:160-172. 11. Wolfe F: Fibromyalgia: on diagnosis and certainty. I Musculoskeletal Med 1993;1 (3):1 7-35. 12. Raspe H, Baumgartner C: Epidemiology of the fibr~ myalgia syndrome (FMS): different criteria different results. I MuscuIoskletal Med 1993;1 (3):149-152. 13. Mocain GA, Bell DA, Main FM, et al.: A controlled study of the effects of supervised cardiovascular fitness training pr~ gram on the manifestations of primary tibromyalgia. Arthritis Rheu.1988;31:l13~1l41. APPENDIX A Post-Traumatic Fibromyalgia Questionnaire We are conducting a study on the long-term outcome of individuals with post-traumatic fibromyalgia. We would like to determine if there are any differences in the long-term course of the post-traumatic variety compared with other varieties of fibromyalgia. We would appreciate it if you could take the time to look over this questionnaire and answer the questions to the best of your ability. Some of the questions require a short answer or circling yes (Y) or no (N). Please be concise with your short answers because we will be entering your responses into a computer program. All responses will be confidential, and no names of respondents will be used or revealed. Personal Information Sex? M F Age: Race? White Black Yellow American Indian Hispanic Other: Occupation: Who made the diagnosis of fibromyalgia: What specialty: Age of onset of fibromyalgia: Type of trauma leading to first symptoms of fibromyalgia Mter motor vehicle accident? Y N After work injury? Y N Postsurgical? Y N Mter sports injury? Y N After physical traumatic abuse? Y N Other: Did you file any legal action? a) Personal? Y N b) Industrial? Y N c) Other: Medications? Y N which meds: 1) 2) 3) 4) 5) Treatment during the First Two Years after the Trauma Did it (they) help? Y N How long and how effective: Other types of treatment (first two years): Physical therapy? Y N Chiropractic? Y N Osteopathic? Y N Other Spinal? Y N Massage Therapy? Y N Trigger point injections? Y N Acupuncture? Y N Biofeedback? Y N Other: Medications? Y N Did it help? Y N Did it help? Y N Treatment during the Last 12 Months Does it (they) help? Y N Other types of treatment (the last 12 months) Physical Therapy? Y N Does it help? Y N Chiropractic? Y N Does it help? Y N Osteopathic? Y N Does it help? Y N Other Spinal? Y N Does it help? Y N Massage Therapy? Y N Does it help? Y N Trigger point injections? Y N Does it help? Y N Acupuncture? Y N Does it help? Y N Biofeedback? Y N Does it help? Y N Other? Does it help? Y N How long you had symptoms before the diagnosis was made: How your symptoms have changed since the very acute onset: Exercise Do you exercise regularly? Y N Do you exercise  hour/week? Y N Do you exercise more than  hour/week? Y N How many hours: What exercises you do: Fatigue after exercise? Y N Family History To what: Allergy? Y N Ankylosing spondylitis? Y N Do any of your children have fibromyalgia? Y N How many: Dermatomyositis? Y N Heart disease? Y N Lupus erythematosus? Y N Did one of your parents have fibromyalgia? Y N Rheumatoid arthritis? Y N Rheumatism? Y N Sjogrens syndrome? Y N General Medical History To what: Allergy? Y N Balance problems? Y N Bladder problems? Y N Breast bone tenderness (sternum)? Y N Bruxism (grinding teeth at night)? Y N Burning or aching feet? Y N Bursitis? Y N Where? Shoulder Elbow Wrist Fingers Hip Knee Ankle Cancer? Y N Where: Carpal Tunnel Syndrome? Y N Chondromalacia (grinding of kneecap)? Y N Chronic cough? Y N How long did it help: How long and how effective: (please list below) How long does it help: Chronic Fatigue Syndrome? Y N Cramps (nocturnal or night leg cramps)? Y N Coccyx pain (tail bone problems)? Y N Cold sores (frequent or recurrent canker sores)? Y N Concentration problems? Y N Chronic constipation? Y N Depression? Y N Diarrhea (recurrent)? Y N Dizziness (vertigo)? Y N Dry eyes? Y N Dry skin? Y N Esophagus problems? Y N Facial pain? Y N Fatigue (chronic fatigue)? Y N Fever (low grade, chronic, recurrent)? Y N fluid retention problems? Y N Gallbladder problems? Y N Heat intolerance? Y N Headache Front of head Y N Top of head Y N Back of head Y N Migraine Y N Hearing problems? Y N Hemorrhoids (rectal problems)? Y N Hiatus hernia (esophageal reflex)? Y N Hives? Y N Hypertension (high blood pressure)? Y N Hyperventilation syndrome? Y N Iritis (chronic eye inflammation)? Y N Itching? Y N Joint swelling? Y N Kidney problems? Y N Lactose intolerance? Y N Liver problems? Y N Low back surgery? Y N Memory problems? Y N Mitral valve prolapse? Y N Muscle fatigue? Y N Neck surgery? Y N Nervousness? Y N Short-term? Y N Where? Arms lingers Legs Feet Where: Nocturnal leg cramps? Y N Numbness and tingling? Y N Pain? Y N Palpitations (heart)? Y N Pelvic pain? Y N Perceptual problems? Y N Perfectionist (are you one)? Y N Personality type (are you an AA, A, -A, B, -B)? Pins and needles sensations in hands/feet? Y N PMS (premenstrual tension syndrome)? Y N Raynaud's (cold sensitivity of hands/feet)? Y N Rib cage discomfort? Y N Sciatica? Y N Sexual dysfunction? Y N Sinus problems? Y N Sleep disorder? Y N Trouble falling asleep? Y N Awaken in middle of night? Y N Worn out/fatigued in morning? Y N Past events? Y N Sore throat, chronic? Y N Sports Were you good at sports as a child? Y N Are you good at sports now? Y N Which sports do you engage in: Standing: poor tolerance for prolonged? Y N Stiffness? Y N Morning Day Evening Night Location: Neck Back Shoulders Arms Hands Hips Legs feet Stomach ulcer? Y N Stroke (CVA)? Y N Swallowing problems? Y N Swollen glands? Y N Symptoms aggravated by Caffeine? Y N Cold? Y N Heat? Y N Noise? Y N Lights? Y N Mental stress? Y N Physical stress? Y N Posture? Y N Repetitive motion? Y N Weather? Y N Tachycardia (fast beating heart)? Y N Tender trigger points? Y N Temper (short)? Y N Thoradc Outlet Syndrome? Y N Tinnitus (ringing in ears)? Y N TMJ (temporomandibular joint dysfunction, jaw pain? Y N Weakness (where): Any additional symptoms not mentioned above: We would appreciate it if you could come in some time so that we could do a brief physical examination that will last about 15 minutes to verify your diagnosis of fibromyalgia. Please indicate which date would be most convenient for you.