Page Twenty P H Y S I O T H E R A P Y July, 1954. FIBROSITIS AND NON-ARTICULAR RHEUMATISM (International Congress Lecture) B y W ALLACE G R A H A M , m . d . , m . r . c . p . , f . r . c . p . ( c ) Assistant Professor o f Medicine, University o f T o ro n to ; President, C anadian R heum atism Association. A ST U D Y o f the rheum atic diseases reveals th at the diseases o f joints o r the m any form s o f arthritis are well defined and therefore readily classified into ~ their various groups. The diagnostic boundaries of rheum atoid arthritis, osteoarthritis, M arie-Strumpell arthritis, gouty arthritis, &c., are now more or less clear and universally accepted throughout the world. A lthough much remains to be learned about these articular diseases at least we all speak the same language, • and the results o f treatm ent in one country may be com pared with those in another.. D iagnostic agreement, based on the composite experience o f scientific workers throughout the world, has, therefore, led to good treatm ent. However, when we venture into the field o f non- articular rheum atism, particularly fibrositis, we find that all is confusion. A lthough fibrositis is c o n sid e re d 'b y many the most com m on form o f acute and chronic rheum atism there is little agreement concerning its definition, ■ aetiology, pathology o r treatm ent. The diagnostic bound­ aries defined in th e various countries are so elastic that total experience cannot be assessed; as a result, advances in knowledge and treatm ent have been retarded. This paper will deal prim arily with the non-articular condition known as fibrositis, and, its purpose is to try to dispel some o f the existing confusion and suggest a m ore positive approach to treatm ent. The term ‘fibrositis’ was first introduced by Sir William Gowers in 1904 when he used it to denote the inflammatory changes in fibrous tissue which he felt were responsible for lumbago. Stockm an (1920) first observed what he believed to be the underlying pathology, and he defined fibrositis as “ a condition o f chronic inflam mation o f the white fibrous tissue o f the fascial aponeurosis, sheaths o f muscle and nerves, ligaments, tendons, periosteum and subcutaneous tissues,- occurring in all parts o f the body and giving rise to pain, aching an d stiffness and other symptoms, the result o f preceding general infections o r local inflamma­ tion o r injuries.” This plausible theory was at first eagerly grasped by frustrated physicians seeking a 'cause for the manifold aches and pains in soft tissue structures, but subsequent histological studies failed to confirm the presence o f chronic inflammation in the muscles involved. F o r years the term fibrositis. was received w ith reluc­ tance and scepticism in America because o f its defined pathology, and the name was not formally introduced until about 1936. _ However, with increasing recognition o f the distinctive clinical pattern fibrositis is now con­ sidered by most rheum atologists to be the most common form o f acute and chronic rheum atism as well as the most controversial condition in the rheum atic field. Surely a condition with such widespread frequency is deserving of more serious attention than it has received.' A review o f the literature on fibrositis unfortunately only leads to confusion. It reveals a num ber o f authors vehemently defending a variety o f theories regarding its cause but, in most cases, basic histological studies necessary for support o f their theses are conspicuous by their absence. Nevertheless, the term fibrositis which suggests an inflam­ m atory cause, has crept into general use. N o common cause has yet been determined and it is not established that inflam mation o f fibrous - tissues is concerned., in its pathogenesis. Lacking a firm pathological background fibrositis has become the ‘phantom disease,’ the term being a veritable depot for many varieties o f non-articular rheum atism , a situation which is confusing to students, physicians and physiotherapists, and which does not helpy- to clarify the nature and identity o f this very com m oif com plaint. Clinical Manifestations T he chief symptoms are pain, stiffness and soreness, and the usual signs are tenderness and perhaps som e lim i­ tation o f movement. The most frequent sites are in the neck, shoulder, lower back and chest areas. The onset may be ; sudden o r slow and insidious, and the course may be acute, subacute o r chronic with remissions and exacerbations, the patient being relatively free o f symptoms fo r varying periods. There is little or no effect upon the general health except th a t most patients complain o f unusual degree o f tiredness and easy fatigue which is not relieved by the night’s rest. The distress is m ost often a dull ache, some­ times a buring sensation. Unlike arthritis the patient is worse after rest, worse in the morning and worse after sitting. T he muscles seem to gel with rest, but the discomfort is relieved by activity. The patient can, to som e extent, ‘work it o ff’ by exercise, but with the onset o f fatigue the discomfort tends to return. The symptoms may be pre- • cipitated o r augmented by cold, dampness, draughts and emotional upsets. Relief is often obtained, at least tem por­ arily, by heat, such as a hot bath, salicylates, alcohol, and mental and physical relaxation. N o constitutional disturb­ ance is found and, ap art from local tenderness, physical exam ination is notoriously negative. Palpations may dis­ close a localized tender area o r myalgic spot, the so-called^ ‘trigger p o in t’ o f fibrositis, and it would seem that th e s e / tender areas may be largely responsible for th e symptoms -. ^Pressure on these areas may reproduce the patient’s pain not only locally but in the areas o f 't h e ir referred pain. Injections o f the area with a local anaesthetic may give complete relief, a full range o f painless movement being restored. Pain may also be produced by increasing tension in the suspected structures by stretching movements. Any discussion o f the so-called fibrositis nodule is still entirely speculative. M any claim to have-felt them, but I know o f nio one who has actually seen one. F o r this reason it is probable that nodules have been over-stressed as a diagnostic aid and, as one a u th o r stated, they are ‘only accessible to the finger o f faith.’ In 500 soldiers examined by C opem an and Pugh non-tender nodules were found w ith equal frequency in those with and those w ithout the symptoms o f fibrositis. C opem an’s work has revealed that m any such nodules represent herniations o f fat which as a rule produce no symptoms. It is probable th at the fibrositis syndrome represents a yet unknow n soft tissue reaction to a variety o f different stim uli: traum atic, infectious, toxic, endocrine, psychogenic, R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 1954-_________________ P H Y S I O T H E R A P Y ___________________ Page Twenty-One &c. It is not surprising th at B abylonian confusion has arisen when a-m u ltitu d e o f conditions differing in their clinical picture and probably in cause, such as D upuytren’s contracture, bursitis, fat hernias and psychosomatic states, are included in the present classifications.. U sed in its broad sense, the term fibrositis has little m ore value than its predecessor rheum atism ; it would seem im portant that an effort be m ade to establish a terminology based on cause which will m ake sense to the student, an d which will lead to m ore fundam ental treatm ent rath er than ‘teeth, tonsils, aspirin and physiotherapy.’ Classification Classified according to location fibrositis has been separated on an anatom ic basis into several groups: (1) intram uscular (myositis, muscular rheum atism ),' (2). p eri­ articular, (3) tendinous, o r fascial, (4) bursal, (5) perineural, and (6) panniculitis. On clinical grounds fibrositis has -been classified a s : (1) prim ary—without dem onstrable cause o r sign o f systemic disease; (2) secondary—a manifestation o f diseases such as infections, associated with various forms o f arthritis, such as rheum atoid, rheum atic fever, gout, &c.; the result o f ^strain o r traum a, exposure, occupation, postural and ^structural abnorm alities, &c. However, recent studies w ould suggest th at if the patient is adequately studied' n o t only physically but psychologically, a cause for the symptoms will not be lacking, and the use o f the term prim ary o r .idiopathic, fibrositis will seldom be necessary. Incidence ~ - The difficulty in establishing th e incidence o f fibrositis in relation to other rheum atic diseases is well shown in the figures published by various authors during W orld W ar II. The incidence o f fibrositis in the British Forces was many times th a t seen in American troops subject to the same conditions. It is fair to assume that the symptoms suffered' by both groups and studied by recognized observers were reasonably identical but, as H ench has pointed out, the discrepancy is due to the fact th a t no cases o f psychogenic rheumatism were listed separately in the B ritish series (and hence were included in the fibrositis group), whereas in the American group psychoneurosis was responsible for joint an d muscle symptoms in one out o f every five patients who complained o f musculo-skeletal disorders, and these cases were not included in the fibrositis category. The conflicting figures published by leading rheum atologists support the view th at the composite term fibrositis is too broad a label and should be discarded o r at least broken down into many com ponents if diagnostic unanim ity is j p be obtained. ' Aetiology The cause o f fibrositis continues to be a controversial subject. M ost investigators agree that the syndrom e may be initiated by many factors, an d the relation o f injury, infection, exposure, fatigue, vascular, metabolic, postural, occupational and psychogenic conditions have all been put forward. The direct infective theory, originally proposed by Stockman in 1920, now has little support. N o organism has been demonstrated, arid antibiotic drugs have not been o f value in treatm ent. Nevertheless, the fibrositis syndrome does occur in association with influenza, m alaria and other general infections. T he relation o f septic foci in teeth, tonsils, &c., once strongly supported, is now, fortunately, losing ground rapidly. The theory th a t many rheumatic ailments owe their origin to infection in the ?ral cavity was originally proposed by William H unter in 1910. Over the years this plausible theory was' widely accepted by physicians and dentists, and thousands o f rheumatic patients were doom ed to a toothless existence, the result o f a theory utterly lacking in scientific support. After reviewing the unfortunate results o f the application o f this theory over a period o f forty years it is astonishing th at the wholesale rem oval o f teeth an d tonsils still exists as a ‘cure’ for many form s o f rheum atism , including fibro­ sitis. Injury is considered a com m on cause o f fibrositis: the result o f a single incident o r o f repeated strain over a long period: As a rule the discom fort is short in duration unless the strain is maintained by occupational factors. There would seem tp be no doubt th at exposure to cold,, wet, draughts, chilling an d sudden changes in tem perature can initiate an attack. C opem an feels that the symptoms may arise from the abnorm al retention o f fluid by fatty tissues, and that the origin o f this selective swelling is probably endocrine in nature. Sir Thom as Lewis believed th at the pain o f fibrositis is o f the same quality as th at experienced by a patient with diminished circulation in the legs due to arterial disease, so-cailed interm ittent claudication. Elliot ■ -is o f the opinion th a t the myalgia arises from an irritated nerve ro o t and th at the tender spots are due to local muscle spasm : electrom yographic studies were said to support this thesis. Steinberg, in the U nited States,-favours a nutritional theory: th at fibrositis is due to ab n o rm al m etabolism of vitamin E. This theory has no t been supported by o th ers.' Halliday feels th at most cases are psychogenic in origin. M any agree th at em otional factors play an im portant role, and -there w ould seem to be no doubt th a t the syn­ drom e m ay be initiated o r profoundly affected by the emo­ tional state o f the individual which reflects in th e fibrous tissues with aching, pain and stiffness. A lthough this view has been challenged by those who d efen d . th e organic theories its validity has been .strongly supported by many authors. It is probable th a t in m ost cases the fibrositis syndrome is precipitated by a psychosomatic disorder; this view is supported by the fact that the symptoms tend to come and go with a change in life situations an d often disappear when the em otional stress is over. Such a mechanism* has long been accepted as a basis fo r cardiac an d gastric complaints, but for som e'reason it has not been generally accepted in the field o f rheum atism. This failure to include fibrositis am ong the psychosomatic states has been the chief obstruction to more effective treatm ent. In the study o f non-articular rheum atism it is necessary to accept the basic concept th at the fibrositis syndrome is a symptom- complex o f bodily distress an d stiff action, and th at people can become physically sore an d stiff from m ental as well as physical trouble. There is nothing radical about this attitude: it simply implies treating the person as well as the disease. In o u r study o f patients with so-called fibrositis it soon became evident that, as a group, they presented a fairly well defined em otional p attern. They were not psychoneurotics in the tru e sense o f the term , but they were em otionally unstable and reacted with excessive responses both m ental and physically. W hen they meet w hat most people would consider ordinary trials o f life they-becom e tense, keyed up, tied in knots, and unable to relax. Their attitude was one o f physical and m ental restraint in which they felt em otions o f anger, fear o r resentment, but for various reasons they were unable to give vent to these _ feelings. A correlation' o f the physical and m ental pheno­ mena suggested th at in periods o f prolonged em otional restraint these people have their fibrositic sym ptom s. If they can relax, as on a holiday, o r with reassurance and relief o f stress they become com fortable. As Halliday states, the symptoms are an outw ard m anifestation o f inner em otional tensions th at have been provoked by disturbing external events o r internal conflicts. Symptoms o f being sore an d stiff represent the p a tie n t’s deep-seated feeling o f being h urt by circumstances. In this way his inward feelings are, so to speak, pushed out o f his mind and his attention is distracted from his inner problem s and becomes focused on his bodily discomforts. T reatm ent, - therefpre, must be directed along the line of psychotherapy, R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Twenty-Two P H Y S I O T H E R A P Y July, 1954, as physiotherapy and other form s o f treatm ent will only tend to fix the disability in the p atient’s mind. In such patients the resulting clinical picture may exactly duplicate the fibrositis syndrome with aching muscles, soreness and stiffness, local tenderness and trigger points. I t is very im portant, however, th a t the pain and dis­ com fort m ust not be thought o f as something imaginary in the patient’s mind. A lthough some psychological fault is uniform ly present in such patients the local stiffness, pain and tenderness is real and is due to a related physical fault, the exact nature o f which is still iunknown. The emotional stress appears to cause a tautness in the muscles with a local neurom uscular or vascular disturbance which seems to come and go with the rise and fall o f em otional tension. In some way this tautness must stim ulate the muscle pain mechanism with resulting aching and tenderness, trigger points and referred sensations. . T he. electrom yographic studies of Holmes and W olff are o f interest in this regard. U sing needle electrodes in various areas they measured increased muscle tension and activity while the subject’s feelings o f hostility and resentment .were brought to peak . intensity and then they noted th a t the muscle activity subsided rapidly with em otional support and reassurance. In 65 subjects with backache a sustained increase in m otor and electrical activity was a com m on reaction when the subject was confronted by situations which threatened their security and engendered apprehension, conflict, anxiety, resentm ent, hostility, h u m iliatio n / frustration and guilt. - The reaction often provoked pain in the neck, back and extremities. One cannot deprecate too severely the frequent use of th e label ‘arthritis’ fo r these people who complain o f m uscu­ lar stiffness and aching. A ccurate diagnosis is largely a m atter o f tim e'and interest, and a few m inutes spent inquiring a b o u t the person.and not the com plaint will open new and •im portant avenues fo r treatm ent. As Sir William Osier said, “ inquire not only as to what kind o f sickness has this m an, but also what kind o f m an has this sickness.” As has been m entioned before, failure to explore the person and his environment can only lead to m isfortunes in treat­ ment. In dealing with these problems, Weiss castigates the organically minded physician who becomes a p ath o ­ genic agent in perpetuating the illness by his well meaning but mistaken and never-ending efforts to find a physical cause. “We m ust interest ourselves in not so much a lack o f vitamins as the lack o f em otional satisfaction in their lives . . . instead o f looking for focal infection we m ust look for focal c o n flic t. . . what they need is:not a lum bar support byt psychological support. The exact role o f psychogenic factors in the aetiology o f fibrositis rem ains a controversial subject, b u t to most observers this syndrom e is seen in nervous and anxious people who seem to have a tension state and who find it difficult and impossible to relax. In view o f the many causative factors which have been outlined—infection, traum a, exposure, &c.— it is obvious that fibrositis is not a disease entity but a syndrome brought about by a variety o f widely separate conditions and, if considered in this light, much confusion will be avoided, as D r. Him sworth said in a recent lecture. I t must be" realized th at a group o f symptoms may be brought a b o u t by a chain o f events and interference with the chain a t any point may produce the same im pairment o f bodily ' function. The sam e group o f symptoms, therefore, may arise from different causes. This thesis would appear to provide a satisfying explanation for the controversial origin o f fibrositis. Pathology Pathological studies have no t yet revealed the funda­ m ental nature o f the syndrome. F ibrositic nodules and thickenings,varying in size, shape a n d location, have been described by m any authors but, in spite o f biopsy studies, there is as yet no typical microscopic appearance whereby they can be indentified histologically. A uthors have pic­ tured the out-pourings o f serofibrinous exudate, the p ro ­ liferation o f fibroblasts and laying dow n -of fresh fibrous tissue as th e pathological basis for the sym ptom atology, but such theories still lack microscopic support. A patho- • logical basis for pain and local tenderness in a few cases has been adequately established in the herniated fat nodule, and many nodules, tender o r non-tender, formerly referred to as fibrositic nodules undoubtedly represent such fat herniation. Similarly, laboratory studies have failed to clarify the situation. Treatment ' The beneficial but tem porary effect o f rest, heat, massage, analgesics, the injection o f local anaesthetics and an exercise program m e are accepted, but fundam ental treatm ent o f the syndrome must naturally be directed against the agent which is felt to be the cause. The tendency to group many form s o f non-articular rheum atism under one label has led to an unfortunate ‘fibrositis treatm ent’ which has been useless in the majority o f cases. The hypothesis th at fibrositis is a chronic inflammatory lesion o f fibro-/’ muscular tissues has led to the extensive misuse o f massagd- in an attem pt to relieve the inflammation and cure the p atient’s symptoms. The fact that no such inflammatory lesion exists explains why thousands o f physiotherapists all over the world have wasted millions o f. hours rubbing patients, with little success in ‘curing’ them o r even signifi­ cantly relieving their symptoms. Relief for short periods may follow massage, but surely the attack should be on the cause and not on th e effect.. •T M ost patients who have fibrositis th in k ’th a t they have arthritis and are filled with the fear and anxiety which accom panies this diagnosis. Reassurance th a t the trouble does not represent progressive destructive jo in t disease lifts a great weight from the patient’s m ind and is the most potent factor in treatm ent. When a psychological fault has definitely been estab­ lished as the cause, psychotherapy and not physiotherapy in its ordinary sense is indicated. As Weiss suggests: “ When' we say to these people th at their aches and pains and fatigue are due to the fact th at they are always in a state o f tension; th a t they do not know how to relax, even a t night, and th at because they are tau t their muscles are crying out in protest with aches and pains, it carries con­ viction and provides a stepping-stone fo r them to begin to talk ab o u t their em otional problem s.” Such patients can often be shown from their own history th at their symptoms-* increase when they are emotionally upset and subside af < they gain m ental physical relaxation. In the tension group-- an effort should be m ade to teach the patient how to relax, which requires only a limited am ount o f time and patience on the p art o f the physiotherapist but, what is m ore im por­ tan t, it stimulates the patient to m ake his own contribution tow ards the control o f his disability. T he physician o r the physiotherapist cannot change the personality of the patient and seldom can they alter the environm ent, but a t least an effort can be m ade to determine and treat’ the cause rath er than thrust all patients with non- articular symptoms into the grab-bag labelled fibrositis. In the tension group an explanation of the mechanism of their pain will often lead to a complete change in attitude and consequent relief. W hile waiting for further study to clarify the many com ponents o f non articular rheum atism it would seem beneficial to consider fibrositis not as a clinical entity but as a syndrome with a wide variety o f causes. The patient will then m ore likely receive the physical and psychological investigation which his problem dem ands, and this should lead to a m ore positive approach to treatm ent. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )