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About Geoff Littlejohn


Why my interest in fibromyalgia?
Recently, I was talking to Anne a schoolteacher and mother with fibromyalgia. She was very well informed, understood the nature of fibromyalgia and had developed a large number of useful strategies for dealing with the problem. She had traveled a long way to see me and explained “I don’t expect a cure, I just wanted to talk to you about fibromyalgia”. She said she appreciated talking to someone who took the problem seriously yet not “over the top about it”. She wondered why many other health professionals had not taken time to understand fibromyalgia and to help people with the problem. She was particularly interested in why I developed an interest in fibromyalgia. Was it by accident or design – some personal experience, or some other reason?


Art, science, body and mind
My initial answer was that it was by accident – it just came with the territory. I was after all a rheumatologist and bodily pain is a common result of many rheumatic and arthritic disorders. However, on further reflection I realized that fibromyalgia is as personal to me the treater as it is to the person being treated. Fibromyalgia is a condition that allows exploration of the breadth of medicine like no other disorder. It requires skills in both the science and the art of medicine. But perhaps more importantly it links change in function of both body and mind, both contributing to the full picture, without prejudice, both important, both part of the one human condition.


Dimensions of fibromyalgia
There are many interesting aspects to fibromyalgia. The first is that of diagnosis. This involves careful definition of the complaints and examination findings, looking at results of appropriate investigations and considering all possibilities. Then, these elements are pieced together like an elaborate jigsaw puzzle to make a diagnosis, which is unique to each person.


What are the mechanisms of the complaints? This requires analysis of research information ranging from molecular biology of chemicals involved in pain transmission, knowledge of anatomical pathways of pain and how pain mechanisms are modulated, amplified or damped down, by the brain. As well, why does the body react as it does? What causes the altered biomechanics of the body, the stiff and painful spine, muscles and joints? Why the fatigue, dizziness and change in many body functions?


Finally, what determines the severity of the responses of the individual to the problem? How does societies’ response to the problem affect the individual and what differences are there in this response between different parts of any one society and between those in different countries.

Fibromyalgia allows for understanding of all of the above dimensions which in themselves each contribute to the essential nature of an individual – their beliefs, their fears, their tragedies and their triumphs – and the symptoms their bodies produce. As a process, fibromyalgia allows for exploration of the very broad expanse of medicine, which I had long ago sought when I chose this as my life’s work. Perhaps I would never be that bare-foot doctor that I had once perhaps imagined but at least I could be a similar medical pilgrim in the society in which I lived.


Training
I trained to be physician, a specialist in medical disorders. In the late 1970’s I wanted to choose one particular specialty on which to focus. I had trained in most of the relevant areas – cardiology, endocrinology, gastroenterology, respiratory medicine - but I had not experienced rheumatology. There seemed to be a deficiency in this area in my hometown at the time and I was encouraged to train further in this area. At the same, at my hospital in Melbourne, Prince Henry’s Hospital, there was strong influence from the Department of Psychological Medicine in the training of medical specialists. In particular, Dr Bill Orchard, one of the hospital’s leading psychiatrists, developed a program where the psychological aspects of illness were discussed in the context of patients’ medical complaints. It was my role to help organize these interactive sessions for the non-psychiatric medical trainees and through these sessions a lot of his influence rubbed off on my approach to illness. He emphasized the link between psychological and somatic aspects of illness. Even in patients with conditions that seemed entirely due to a very specific organic course, such as a heart attack, the effect of the individual’s moods, their distress, and their life circumstances all contributed to their medical presentation.


I decided to specialize in rheumatology and traveled to Toronto to train for a further two and half years. The head of that innovative and extensive training program was Professor Hugh Smythe. Smythe was one of the great Canadian rheumatology thinkers. He had an established interest in Fibrositis, as it was then called, having written a key textbook chapter on the condition and he regularly discussed aspects of management on his routine Wednesday ward round. He focused on the biomechanical aspects of the disorder, realizing that much of the pain mechanism related to strain or poor support of the low neck and back. He established methods for neck support at night and the emphasized the value of abdominal stabilizing exercises for low back complaints. He defined the clinical characteristics of fibromyalgia linking the complaints of musculoskeletal pain to the individual’s tenderness, particularly at specific sites known as tender points.


Smythe joined forces with Harvey Moldofsky, later Professor of Psychiatry in Toronto. Moldofsky brought input from a psychological dimension and together they identified and studied the poor quality sleep that characterizes fibromyalgia. They thus linked factors affecting the individuals’ emotional well being to their bodily symptoms. This was pretty impressive for a trainee in Rheumatology. The personalities of these two individuals, their expert clinical skills and their enquiring minds led to the laying down of a substrate of information on this disorder which I have drawn on, and expanded, since that time.


In those days, the early 1980’s, fibromyalgia was not considered a mainstream problem to deal with in rheumatology. In fact, prior to my going to Toronto, I was warned by the leading rheumatologist in Melbourne that Smythe “believes in fibrositis”. I didn’t know quite how to take that at the time. It was as if I was being warned that Smythe believed in fairies at the bottom of the garden and that fibrositis was an imaginary disorder. It was not important, had no impact, and was best forgotten about, too difficult, not to be encouraged, “the soft under belly of rheumatology”. These observations have been reflected by others and remain far from the truth.

Clinical work
I returned to take up the position of head of Rheumatology at Prince Henry’s Hospital. I was armed with the latest knowledge of a wide variety of rheumatic disorders. Patients I saw came from many backgrounds, had many conditions and required many different treatments. Pervading through the whole group however was the complaint of widespread pain, the finding of abnormal tenderness and the other associated features of fibromyalgia. This group of patients was common. Patients with these symptoms were often dismissed as being depressed, dismissed as being unimportant, dismissed as having another non-specific diagnosis, or as was often the case treated for a condition that they didn’t have. There was no plan of attack; no understanding of the mechanisms of the problem and the outlook for some people in those times was poor.
It took sometime to establish the legitimacy of fibromyalgia in those days. This initially came through regular discussion with colleagues, including many publications. Also, I became involved in early fibromyalgia research that later was to boom.


Another important factor in my interest in chronic pain and fibromyalgia came through an epidemic of work related arm pain in Australia. I recall reading a front-page article in the local paper, The Age, in August 1980. The president of the local arthritis foundation, a prominent rheumatologist, was discussing the problem of work-related tendonitis and how it was increasing. This received much publicity. Others started to observe the same effect and soon patients started to report more frequent episodes of work-related pain. Over time an incredible epidemic of arm pain occurred not only in my home state but also throughout Australia. This peaked in the mid-1980’s and gradually subsided to the background levels by the early 1990’s. At one stage up to a third of work places had persons off work due to arm pain.


This condition became known as “RSI” (repetitive strain injury). Yet despite intensive investigation ongoing injury was not found to be the cause for the problem. Application of knowledge about fibromyalgia allowed for understanding of this condition as a regional or localized type of fibromyalgia that was called among other things regional pain syndrome. With better understanding of this condition the epidemic waned. Application of the knowledge that colleagues and myself had of the essential process behind fibromyalgia and its application to this “new” disorder helped the epidemic subside. This epidemic vividly demonstrated the highly potent effects of emotionally charged societal events in causing human distress with its subsequent translation into activation of pain pathways.


Progress
Over time fibromyalgia has become accepted as a common and characteristic chronic pain condition. The mechanism of fibromyalgia and the implications of the word are now much better appreciated in the medical and health community. This has led to better management of the problem with particular strategies exploring just who is responsible for the condition. As time passes the mechanism of fibromyalgia will be further elucidated. It is possible that another name will be applied to the disorder, just as over 40 previous names have been applied over the last 100 years. As with all human biological processes we must expect change and we must adapt and move with it to allow better understanding and management.

Pain and hope
I have never experienced the symptoms of fibromyalgia -the persistent muscular stiffness, the widespread pain, aching and burning discomfort, the numbness and tingling in the hands, the headaches, the profound fatigue, the sleep disturbance. To have such symptoms must induce considerable distress in an individual. This is distress that I haven’t experienced. Like many health care professionals I can only offer empathy and encouragement towards seeking a solution to the problem.


My hope is that the biological process that we name as fibromyalgia is more clearly understood by both health professionals and by those with the disorder. I believe this is the first and most essential part of an appropriate management strategy to reverse fibromyalgia. With time better, quicker and more resilient treatments will be identified but will not replace what we already know – that the start of fibromyalgia reversibility is already in our own hands.

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