Between 2% and 4% of the general population suffers chronic widespread pain, accompanied by multiple complaints including paresthesias, fatigue, and sleep problems. These symptoms can seriously erode their quality of life.1 Despite the frequency and severity of these symptoms, some physicians disparage the concept of fibromyalgia (FM) and evade taking care of patients with this ailment. A recent survey among Norwegian doctors ranked FM as the least prestigious illness in medicine.2
There are several possible explanations for the disconnect between the severity of patient symptoms and the attitude of their physicians:
- Patients with FM have multiple symptoms, making office visits time consuming;
- Symptoms are not associated with objective alterations in the physical examination, laboratory tests, or imaging techniques;
- Psychological comorbidities complicate the clinical picture;
- In many instances, physicians may not believe what patients are telling them and, in their opinion, patients “somatize” their anxiety; and
- Often patients do not improve with prescribed medications.
These discrepancies may have an essential underlying reason: As physicians and other providers, we do not have a coherent theoretical framework to accommodate FM. Current linear-reductionist medical paradigm cannot explain this complex disease.3
This article discusses how new concepts derived from complexity theory may provide a logical explanation for FM. A holistic type of therapy is outlined on this basis.
Prevailing Medical Paradigm
The prevailing medical paradigm is based on a linear-reductionist algorithm: the clinical–patholog-ical correlation. In this construct, a group of symptoms and signs (the effect) is linearly explained by a discrete anatomical lesion, or an abnormal lab test (the cause). Reductionism proposes that the whole can be understood by analyzing each of its parts. Accordingly, at present, MRIs, biopsies, or blood or other tests are able to explain the cause of nearly all clinical syndromes. Nevertheless, this linear-reductionist model is clearly unable to explain complex illnesses such FM.3
Table 1: A Holistic Approach to Fibromyalgia
- Information: Explain complex characteristics of FM. A well-written and well-annotated book is useful in achieving this task. In my experience, most patients agree with the dysautonomia model. Points to highlight to patients are validation of symptoms; explanation of role of genetics and external stressors on the hyperadrenergic state; and explanation of the neuropathic nature of pain.
- Self-help groups: Such groups operate precisely as complex adaptive systems, in which the agents (patients) engage in an active change to a healthier lifestyle. Well-coordinated group therapies are effective, less expensive, and can free physician time.
- Diet: Most FM patients have irritable bowel. I think that their diet should be predominantly vegetarian. I also recommend a search for lactose or gluten intolerance.
- Avoidance of sympatho-mimetic substances: These include caffeine and nicotine.
- Exercises: Pool-based, dance, light aerobics, diaphragmatic, and tai chi.
- Different biofeedback techniques: Based on electromyography or heart rate variability.
- Sleep hygiene
- Cognitive-behavioral therapy and other self-efficacy techniques
- Psychological and psychiatry counseling
- Pharmacological therapy: Polypharmacy should be avoided. Drugs that may improve pain include paracetamol, tramadol, antineuropathic agents such as pregabalin and gabapentin, triciclic antidepressants, and tropisetron. Other types of drugs may be useful for anxiety, sleep problems, and irritable bowel.
Complexity Theory and Holism
There is a new scientific perspective that may have a profound impact in the practice of medicine: complexity theory.4-6 This paradigm derives from cybernetics and computer modeling of natural phenomena, such as weather. Basically, this new theory proposes that the universe is full of complex systems composed of many interacting agents. Such systems are open, elastic, and constantly adapting to the environment through positive and negative feedback loops (complex adaptive systems). The systems have nonlinear behavior; as such, the intensity of the stimulus is dissimilar to the magnitude of the response. These systems cannot be understood by analyzing each of its components individually, because for them, the whole is different than the sum of its parts. Examples of complex adaptive systems include the following: democratic societies, stock markets, ant colonies, and the major systems of the human body. Complex systems have wide varying behaviors. If a system becomes rigid, it ultimately dies.