See Attatched

MEDICAL MYSTERY FOR CHAPTER 4

HER STORY
Melissa arrived in my office looking exhausted but relatively healthy, so I was surprised when she told me she’d been
in constant pain for 6 months. At first, Melissa had thought the dull aches in her knees, elbows, and shoulders were
early signs of osteoarthritis.

At night, the pain kept her up, and as it got worse, she found it harder to play tennis, a sport she’d always enjoyed.
She also started to put on weight and over the course of 6 months had gained 20 pounds. In addition, Melissa had
been extremely tired. Even on nights when she managed to sleep 9 hours or more, she was having trouble getting out
of bed and staying awake at her job as a technical writer.

THE EVALUATION
By the time she came to see me, Melissa was no longer certain she had arthritis, but she was eager to find out what
was causing her baffling symptoms, especially her deep muscle aches. She mentioned that she’d recently been in a
minor car accident and was still experiencing neck pain.

In addition to a routine physical exam, I tested her deep tendon reflexes and did some range-of-motion testing. The
tests showed that the nerves in her muscles were fine, and she still had mobility in her joints and some muscle
strength. Melissa also described her debilitating fatigue. She was having difficulties concentrating, and no matter
how much sleep she got, she was tired.

THE DIAGNOSIS
Although the fatigue sounded like chronic fatigue syndrome, I began to suspect that Melissa actually had
fibromyalgia, a condition that causes chronic widespread pain, sleep disturbances, and fatigue. Fibromyalgia is a
mysterious condition that affects around 4% of all Americans, the vast majority of them women. The cause is
unknown, though some experts suspect there is a genetic link. Many patients develop it after a major stressor such
as a car accident, viral infection, or emotional or physical stress.

Because there is no definitive test for this syndrome, making a diagnosis first involves ruling out other conditions. The
pain wasn’t in her joints, so I crossed arthritis off the list of possibilities. Blood tests ruled out conditions such as anemia
or lupus, which could also have accounted for Melissa’s symptoms.

The only way to confirm that Melissa had fibromyalgia was to do a digital palpation exam, in which I applied pressure
to specific sites on her body. The exam revealed that she had many tender points—areas where she was sensitive to
the pressure of my touch—in her shoulders, neck, elbows, knees, and below the buttocks. To meet the diagnosis
criteria for fibromyalgia, a patient must have widespread pain for at least 3 months and must also be tender in at least
11 of 18 specific sites on the body. Melissa had pain in 13 of those sites and had significant sleep disruptions and severe
fatigue, all symptoms of fibromyalgia.

THE TREATMENT
To help her sleep, I prescribed a low dose of trazodone (Desyrel), an antidepressant that would not only improve the
quality of her sleep but also help her fall back to sleep when she awoke in the night. I also prescribed the
antidepressant duloxetine (Cymbalta), which would block the transmission of pain signals in the spinal cord so
Melissa’s muscles wouldn’t hurt so much.

Exercise was essential to her treatment, too. Since she’d gotten out of shape, I told her to start by taking a brisk 5-
minute walk and to then increase that by a minute a day until she was doing 30–45 minutes a day most days of the
week. I suggested that she see an exercise physiologist to develop an ongoing program once she was comfortable with
walking. Exercise would ease pain, improve sleep, and help Melissa begin the gradual process of losing weight. In
addition, I suggested that Melissa find a qualified massage therapist and obtain myofascial release treatment, which
I thought might help restore some of her strength, flexibility, and muscle function.

CASE CLOSED
Fibromyalgia fluctuates, and Melissa’s situation was no exception. After an initial period of improved energy, she had
a slight setback 6 months later when her pain got worse. I put her on pregabalin (Lyrica), an antiseizure drug that
relieves pain.

It’s been almost a year since Melissa’s diagnosis, and she has made great progress. After overcoming that slight setback
at 6 months, she is now doing yoga twice a week. Now that she’s active again, she’s sleeping better and feeling better.

Discussion Questions
1. What are the word parts that make up the term fibromyalgia?

2. The doctor refers Melissa to an exercise physiologist. What does an exercise physiologist do?

3. The doctor considers and then rules out chronic fatigue syndrome. What is this?

4. Melissa is advised to try myofascial release. What is this?