Date sent: Mon, 21 Aug 2000 Editorial Journal of Musculoskeletal Pain, Vol. 8(3) 2000 by I. Jon Russell, MD, PhD Consoler Toujours -To Comfort Always On Gotzon Borglum’s statue of Dr. Edward Livingston Trudeau at Saranac Lake, New York, was inscribed the following French phrase: 'Guerir quelquefois, soulager souvent, consoler toujours.' Idiomatically translated into English, the meaning is: 'to cure sometimes, to relieve often, to comfort always' (1). This folk saying, dating back at least to the fifteenth century, emphasizes the commission of all health care workers. Certainly, the goal is dramatic and permanent eradication of illness, but that is not always possible. Certainly, the objective is to relieve suffering, but that too can be elusive. The progress of modern medical science in some areas has been so rapid that expectations in other areas can become unrealistic. Many clinical disorders are still poorly understood, but our inadequacy should not cause us to blame the patients for being ill. Dr. T. F. Main raised the gauntlet when he said: 'The sufferer who frustrates a keen therapist by failing to improve is always in danger of meeting primitive human behavior disguised as treatment'(2). In his time, Dr. Trudeau was a well known physician and patient advocate. He offered humanistic hope for people with tuberculosis at a time when there seemed to be no hope. He developed a method of caring for patients in the early stages of the disease, then, he legitimated that system to the public, and finally, he defended it before his fellow physicians. The extent of his success is a testimony to the legitimacy of his approach. Fibromyalgia syndrome IFMSI, chronic fatigue syndrome, and the myofascial pain syndrome are just three of the many clinical disorders which are still poorly understood. In time, our understanding of these disorders will improve and with understanding, more effective therapeutic modalities will be developed. Until it is possible for health care professionals to cure or even to completely relieve, it is our reasonable responsibility to 'always' provide the comfort of genuine human empathy. If there were a theme for this issue of the Journal it would be 'seeking to understand the patient’s view.' The first three original manuscripts examine again the personality, the self-perception of body pain, and the patient’s perspective. It is clearly possible that patients could misinterpret their symptoms or over read the significance of predisposing factors, but their insight may also be instructive beyond current traditional thought. Despite the difficulties of interpretation, of valid comparison groups, of analytic methodology, how do patients with chronic pain view themselves? For years, it has been intimated that patients with FMS exhibit specific personality traits described by terms such as: compulsive, dependent, hypervigilant, depressive, anxious, somatizer, catastrophizer, list maker, etc. The lead article by Amir and colleagues from Israel (4) used validated questionnaire instruments and reasonable sample sizes to examine personality traits in women with three different painful conditions [rheumatoid arthritis, low back pain, FMS] compared with age-matched healthy normal women. Their analyses indicated that living with chronic pain was far more influential on personality patterns than was the specific diagnosis of FMS. From a rehabilitation unit in Finland, Viitanen and colleagues (5) compared subjective self-assessments of EMS patients with those of rheumatoid arthritis patients. Pain was a major problem for both groups but was perceived as being more severe in FMS. Both disorders exhibited comparable levels of perceived global ill health, poor quality of life, and inability to work effectively. They also had comparable expectations with regard to the ability of rehabilitation modalities to help them. The contribution by Prince and colleagues (6) from the University of Cincinnati and Southern Illinois University involved FMS outpatients from three states . The patients were recruited by their support group leaders, and were not specifically examined by a research physician for the purpose of confirming diagnostic criteria, so there is some uncertainty about the diagnosis of FMS and the extent of overlap with other medical conditions. For example, over 10% reported having had cancer and over 50% reported also having arthritis. On the other hand, their experiences and their opinions about a number of clinical phenomena were remarkably similar from one region to the other across the country. For example, about one-third perceived that an accident had contributed to the onset of their symptoms and a similar proportion believed that other family members were similarly affected. Their perception that their symptoms change with the barometric pressure could easily be critiqued because it is unlikely that they actually know the barometric pressure on an ongoing basis. In this case, the barometric pressure is probably an alias for what the individual perceives as a change in the weather. On the other hand, two studies have shown that FMS symptoms do not consistently change with the weather (7,8), so what is the essence of this observation? When I was a child, I had a reactive airway condition that was called asthma. Melodramatically perhaps, I thought that it would cause my death at a young age. In fact, my cousin actually did die of asthma in a college dormitory room. My perception during an attack was that I could not get air in. My pulmonary medicine professors later taught me that the problem was getting air out, but the two mechanistic explanations are clearly related. The question is, what should we be learning from these perceptions of the FMS patients? Other contributions of interest include another attempt by Drewes and colleagues from Denmark (9) to document the induction of pain by deprivation of slow wave sleep. The previous literature on this question is well documented by the authors. Kuan and colleagues from Taiwan (10) further expand our understanding of the myofascial trigger point in an animal model. Chen and colleagues from the same institution in Taiwan (11) report a transient decrease in forearm muscle pressure pain threshold following 20 minutes of continuous piano practice. Don’t miss the outstanding feast of information in the Literature Review columns, an interesting Research Ideas contribution, the Letters to the Editor, and the Book Reviews sections. If the contents of this issue please you, or prompt concern, you are welcome to share your opinions in a Letter to the Editor. If you are a reader of the Journal, but not a member of the International MYOPAIN Society, consider joining this growing organization of health care professionals who intend to make a difference. The Journal subscription is just one of many benefits of membership. Applications for membership can be obtained from the Editorial Office or from any of the officers. I. Jon Russell, MD, PhD REFERENCES 1. Anonymous: Familiar Medical Quotations. MB Strauss, Editor, Little, Brown and Co., Boston, 1968, page 410. 2. Main TF: British Heart Journal, 1957. 3. Ellison DL: Healing Tuberculosis in the Woods, Medicine and Science at the End of the Nineteenth Century. Greenwood Press, Westport, Conn. 1994 [ISBN: 0-313-29005-91.] 4. Amir M, Neumann L, Bor 0, Shir Y, Rubinow A, Buskila D: Coping styles, anger, social support, and suicide risk of women with fibromyalgia syndrome. J Musculoske Pain 8(3):7-19, 2000. 5. Viitanen J, Ronni 5, Ala-Peijari 5, Uoti-Reilama K, Kautiainen H: A comparison of self-estimated symptoms and impact of disease in fibromyalgia and rheumatoid arthritis. J Musculoske Pain 8(3):21-34, 2000. 6. Prince A, Bernard AL, Edsall PA: A descriptive analysis of fibromyalgia from the patients’ perspective. J Musculoske Pain 8(3):35-47, 2000. 7. de Blecourt AC, Knipping AA, de Voogd N, van Rijswijk MH: Weather conditions and complaints in fibromyalgia. J Rheumatol 20(11):1932-4, 1993. 8. Viitanen J, Kautialnen H, Isomaki H: Changes in atmospheric pressure do not influence the pain of patients with primary fibromyalgia. J Musculoske Pain 3(1):77-82, 1995. 9. Drewes JAM, Nielsen KD, Rasmussen C, Arimar T, Svensson P, Rössel P, Arendt-Nielsen L: The effects of controlled delta sleep deprivation on experimental pain in healthy subjects. J Musculoske Pain 8(3):49-67, 2000. 10. Kuan T-S, Lin T-S, Chen J-T, Chen S-M, Hong C-Z: No increased neuromuscular jitter at rabbit skeletal muscle trigger spot spontaneous electrical activity sites. J Muscu loske Pain 8(3):69-82, 2000. 11. Chen S-M, Chen J-T, Kuan T-S, Hong J, Hong C-Z: Decrease in pressure pain thresholds of latent myofascial trigger points in the middle finger extensors immediately after continuous piano practice. J Musculoske Pain 8(3):83-92, 2000. Journal of Musculoskeletal Pain, Vol. 8(3) 2000 © 2000 by The Haworth Press, Inc. All rights reserved.