Fibromyalgia

Fibromyalgia is a complex and multifaceted syndrome causing chronic pain. It involves both widespread myalgia (muscle pain) and localized pain in specific areas, particularly in the muscles around the joints. The musculoskeletal symptoms include pain, stiffness and tenderness. Pain commonly occurs in the neck, back, shoulders, pelvis and hands. The vast majority of the individuals affected are women.

Contrary to popular belief, it is a disorder of muscles, not of joints. Though pain is the main component of this condition, fibromyalgia may also involve fatigue, sleep disturbances and mood disturbances, such as depression and anxiety. The condition is episodic, with flare-ups that vary in intensity and come and go over time.

Although no identifying agent has been thoroughly identified at the root of the problems associated with fibromyalgia, it is generally agreed that certain body chemicals, including substance P (responsible for initiating pain signals after injuries) and serotonin (responsible for toning down the intensity of pain signals) exist in abnormal levels. This causes ordinarily nonpainful stimuli to be translated into pain (allodynia) and amplifies the pain, resulting in a lowering of the pain threshold and increase in pain sensitivity.

Physicians often use fibromyalgia as a classic example of a central pain state, in which the cause of the pain cannot be identified in the local pain site and most of the processes resulting in pain occur at the level of the spinal cord and brain. However, the pain is not “imagined” or psychological. Some form of input from the pain site is required – even if it is as common as a touch, light or sound. In patients with fibromyalgia, these stimuli are misinterpreted as painful events.

Fibromyalgia is considered a benign condition. It is not degenerative or deforming, nor is it life-threatening. Though the pain may be severe and may significantly reduce quality of life, fibromyalgia causes no lasting tissue damage.

The symptoms associated with fibromyalgia may seriously affect competitive employment. Though most patients remain in the workforce, some claim disability. Doing so can be difficult, even when physicians agree that symptoms are severe enough to warrant aid.

Although fibromyalgia has been recognized by the Social Security Administration as a medically determinable impairment, a general misunderstanding and lack of education regarding it may cause many organizations and individuals to disregard the condition. The Arthritis Foundation reports that disability rates among fibromyalgia patients may be as high as 44 percent.

Fibromyalgia is the second most common disorder seen by rheumatologists and among the most common causes of widespread, chronic pain. According to the Arthritis Foundation, fibromyalgia affects an estimated 2 percent of the United States population – about 3.5 million Americans.

Men and women of all races and ages, including children and the elderly, may be affected, but fibromyalgia occurs most often in women over the age of 30. According to the American College of Rheumatology, about 80 percent to 90 percent of those affected by fibromyalgia are women.

Though uncertainty remains regarding the underlying cause, diagnosis and optimal treatment exist for fibromyalgia. Many professionals and researchers are making efforts to improve the quality of life for patients with fibromyalgia. Better ways to diagnose and treat this condition are being researched. In addition, remaining active as much as possible is a must for fibromyalgia patients.

Certain conditions are commonly associated with fibromyalgia, though their exact links to the condition are not well understood. The following conditions often appear along with fibromyalgia:

• Irritable bowel syndrome (IBS). Characterized by frequent abdominal pain, bloating and episodes of alternating constipation and diarrhea. More than half of all fibromyalgia patients suffer from this condition.
• Migraines. Many people with fibromyalgia also suffer migraines and other headaches. Researchers have found that a common link may be problems with a brain chemical called serotonin and adrenal hormones such as cortisol or adrenergic nerve fibers.
• Restless legs syndrome and periodic limb movement disorder. Characterized by uncontrollable contractions of the calf muscles and leg muscles that twitch, ache or feel like pins and needles. Many fibromyalgia patients experience this source of leg pain.
• Raynaud syndrome. Characterized by episodes of whitish and bluish discoloration of the fingers and toes, associated with tingling sensations, numbness or pain and the subsequent redness of the affected areas. It is usually triggered by cold temperatures and strong emotions. Researchers have reported that nearly half of all fibromyalgia patients suffer from this disorder.
• Urethral syndrome. Characterized by the often severe urge to urinate without an identifiable cause, such as infection. Often associated with urinary frequency and pelvic pain.
• TMJ disorder. Commonly associated with fibromyalgia. It is characterized by:
  • Jaw and facial pain or tenderness
  • Limited jaw movement
  • Clicking, snapping, or popping sounds while opening and closing the mouth
  • Pain within the facial or jaw muscles, as well as in or around the ear
  • Headaches
• Rheumatoid arthritis. A chronic disease primarily characterized by persistent inflammation of the joints, resulting in discomfort, pain, swelling and potential deformity of the affected joints. Fibromyalgia does not involve inflammation or deformity but may exist with rheumatoid arthritis. In fact, rheumatoid arthritis patients are more likely to develop fibromyalgia.
• Immune dysfunction. Fibromyalgia may cause a dysfunction with the immune system, making patients more susceptible to infections.

A great deal of controversy remains as to the relationship between fibromyalgia and certain similar disorders. Two disorders seem particularly linked to fibromyalgia, although physicians and researchers disagree on whether these links are substantiated:

• Chronic fatigue syndrome (CFS). A condition characterized by excessive fatigue that seriously impairs the patient’s ability to function. Many physicians believe that fibromyalgia and CFS may be different manifestations of the same underlying disorder. Both conditions share a large number of symptoms (e.g., headache, fatigue, pain) and similar physical abnormalities (e.g., reduced blood flow to key areas of the brain). Also, brain scans of fibromyalgia and CFS patients display very little difference. The most prominent difference lies in whether pain or fatigue is the most dominant symptom. Although fibromyalgia is the more common of the two, more than half of those diagnosed with fibromyalgia also fulfill the criteria for CFS.
• Myofascial pain syndrome (MPS). A chronic disorder characterized by pain and tenderness confined to a specific body region, such as the neck and shoulders. Many researchers have suggested that this may be a localized or regional form of fibromyalgia.

The underlying cause or causes of fibromyalgia are still unknown, but there are many theories. Research in brain imaging and neurosurgery are exploring these theories as well as identifying new ones. Possible causes include:

Several factors lead to an increased risk of developing fibromyalgia. These include:

• Sex. Women are affected more often than men, although men may be underdiagnosed.
• Age. Onset of fibromyalgia occurs more often in early to middle adulthood than in childhood or late adulthood.
• Rheumatic disease. Fibromyalgia is found in increased numbers in individuals affected by rheumatic diseases.
• Family medical history. Individuals related to fibromyalgia patients have increased chances of developing fibromyalgia.
• Psychological and social factors. Fibromyalgia is found in increased numbers in individuals with histories of physical and sexual abuse, alcoholism or depression in their families.

In addition, the U.S. Institute of Medicine has found a higher prevalence of certain conditions in veterans deployed during the Gulf War of the early 1990s. These include fibromyalgia, chronic fatigue syndrome and a rare nerve disease called amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig’s disease).

Fibromyalgia is associated with a wide range of symptoms. Most studies report that these symptoms can be remarkably persistent and pervasive over the years, sometimes remaining as long as 15 years after onset. Most symptoms, however, do tend to improve over time.
Symptoms are typically worse during cold or damp weather, periods of emotional stress and at the beginning and end of the day. They may be aggravated by poor sleep, physical and mental fatigue, excessive physical activity or inactivity, anxiety or stress. Signs and symptoms include:

• Multiple tender points (trigger points). The presence of multiple tender points, usually at muscle-tendon junctions, is a major characteristic of fibromyalgia. These points are more susceptible to pain than the rest of the body.
• Chronic, widespread pain. Another major characteristic of fibromyalgia is tender skin and an overall reduction in pain threshold. The pain is most often within the muscles (myalgia). It may be confined to specific areas (e.g., neck, shoulders) early in the course of the disorder but usually spreads to other muscle groups over time (e.g., back, arms, legs, chest). This pain is often described as deep muscular aching, throbbing, twitching, stabbing and/or shooting pain. It may be accompanied by soreness, stiffness, numbness, tingling, burning and/or a crawling sensation. Though varying in intensity, some degree of muscle pain is always present. Pain behaviors such as limping, grimacing, or guarded movements and postures, may be easily noticeable and impair quality of life.
• Muscle stiffness. This is usually present upon awakening and tends to improve over time, but may remain throughout the day. Often, the joints feel swollen, although inflammation is not present.
• Fatigue. A general, all-encompassing exhaustion exists in the vast majority of fibromyalgia patients. Specific muscle fatigability and weakness is also increased. This fatigue tends to interfere with daily activities and may leave the individual with a limited ability to function, mentally and physically.
• Sleep problems. Includes disorders that prevent deep, restful, restorative sleep. An individual may have difficulties falling asleep or may be awakened repeatedly during the night. Other individuals may get a full night’s sleep, but awaken feeling unrefreshed and exhausted. Specific sleep problems, including sleep apnea (repeated episodes where an individual temporarily stops breathing) and bursts of awake-like brain activity that interrupts deep sleep may be observed.
• Headaches. More than half of all patients who have fibromyalgia report migraines and other headaches.
• Impaired cognitive function (“fibro fog”). Includes memory failure, poor working memory (ability to hold something in mind while using it for another mental process) and impairments in concentration, coordination and vocabulary retention. Research indicates that these individuals perform as poorly as healthy individuals 20 to 30 years their senior, although they retain a speed of mental processing roughly equal to healthy individuals their age.
• Hypersensitivity (increased sensitivity). Many fibromyalgia patients report heightened sensitivity to temperature, odors, sounds, lights and vibration. They also suffer from increased skin sensitivity.
• Mood disturbances. Irritability, depression and anxiety are common symptoms of fibromyalgia. Depressed individuals may not be aware of or deny their depression, which can complicate the treatment of fibromyalgia. The presence of these symptoms may be due to many factors, including:
  • Prolonged pre-diagnosis period
  • Disrespectful medical treatment
  • Grief and loss common to any chronic illness
  • Poor support
  • Sleep deprivation
  • Other coexisting chronic health conditions
  • Severe chronic pain
  • Neurotransmitter abnormalities
• Difficulty in sustaining repetitive motor tasks. Many fibromyalgia patients report trouble performing repetitive activities such as typing because of increased pain and fatigue.
• Reduced physical efficiency. Decreased physical efficiency, due to a longer time required to accomplish tasks, is common.
• Variations in alertness. Many fibromyalgia patients report a diurnal (daytime) variation in energy levels and alertness and describe a window of opportunity at which they are at their best that typically extends from about 10 a.m. to 2 p.m.
• Other symptoms, including:
  • Dry eyes and mouth
  • Rashes
  • Excessive menstrual pain
  • Ringing in the ears (tinnitus) and ear pain
  • Painful intercourse
  • Dizziness
  • Vision problems
  • Low-grade fever
  • Below-normal temperature

Most patients suffer with fibromyalgia for years before it is diagnosed. There are no diagnostic laboratory or imaging tests available for this disorder, and many physicians are not adequately informed or educated about it. Because there is no lasting tissue damage, fibromyalgia cannot be evaluated by the classical medical model, which uses degree of tissue damage for evaluation. Diagnosis and treatment are usually frustrating for the physician and the patient.

Medical history and physical examination are the keys for making the diagnosis. The American College of Rheumatology (ACR) has established criteria for fibromyalgia diagnosis in adults:

• Widespread pain in all four body quadrants. Pain must exist on the left and the right sides, and above and below the waist, and must persist for at least three months.
• Manual tender point survey (at least 11 of the 18 specified trigger points). A site is considered a tender point only if the individual feels pain upon the application of 4 kilograms (about 9 pounds) of pressure. Physicians may be trained to recognize “the feel” of this amount of force when applying pressure by finger.

There are different criteria for diagnosing fibromyalgia in children:

• Widespread pain in three sites without any other underlying cause lasting at least three months.
• Presence of five to 11 trigger points, which may be identified at less than 4 kilograms of pressure. Some researchers have suggested a standard of 3 kilograms (about 7 pounds) of pressure for children.
• Between three to 10 other major criteria. These criteria include:
  • Chronic anxiety or tension
  • Fatigue
  • Poor sleep
  • Chronic headaches
  • Irritable bowel syndrome
  • Soft-tissue swelling
  • Numbness
  • Pain varies with physical activity (more than with adult fibromyalgia)
  • Pain varies with weather conditions (less than with adult fibromyalgia)
  • Pain varies with anxiety and stress (less than with adult fibromyalgia)

These criteria do not have to be noted all in one examination but can be recorded over time.

In addition to the ACR criteria mentioned above, doctors rely upon thorough patient medical histories, patient-reported symptoms, clinical or physical examination, pain assessment forms and routine tests to help exclude certain other conditions with similar symptoms. Many conditions that mimic the symptoms of fibromyalgia must be ruled out. However, the presence of other diseases does not eliminate the possibility of a diagnosis of fibromyalgia. Conditions that may be tested for include:

Although there are no specific tests for fibromyalgia, certain abnormalities may be detected through blood tests, spinal tap or imaging tests. Levels of substance P (responsible for initiating pain signals) are high in the brain and spinal fluids, whereas levels of serotonin (responsible for reducing pain intensity) and growth hormone (responsible for building muscle) are low. These tests are not sensitive and specific for the disease and not commonly performed. Blood flow to the thalamus region of the brain is also low. Brain wave levels are high at night and low during the day. Normal findings in the levels of many blood chemicals may be used to eliminate other possible conditions.

Once fibromyalgia is diagnosed, physicians may require formal or informal assessments to detect potential mood disturbances such as depression and anxiety, and a sleep history including investigation into possible disturbances such as restless leg syndrome or sleep apnea.

There is no known cure or preventive method for fibromyalgia, but symptoms can be treated. Treatment usually concentrates on reducing symptoms and improving function. No one treatment method can control all symptoms. In fact, most options control only one or two. This makes finding the right combination important.

Other conditions, including many that are symptoms of or occur simultaneously with fibromyalgia (e.g., migraines, depression, anxiety, irritable bowel syndrome) should be treated, as they may aggravate fibromyalgia symptoms when uncontrolled.

Finding the right physician is crucial in treating fibromyalgia. An empathetic physician who understands the diagnosis and treatment of fibromyalgia and is willing to listen to and work with the patient is important. A family physician may send a fibromyalgia patient to a rheumatologist. Patients’ self-education is a key to better results. Individuals are encouraged to keep communication with their physicians open. It may help to make a list of everything that needs to be discussed and bring it along to appointments. All treatment options, including those individuals can do on their own, should be discussed with a physician.

In 2007 the U.S. Food and Drug Administration gave its first approval of a medication specifically to treat fibromyalgia: an anticonvulsant called pregabalin (Lyrica). This drug is also used to relieve diabetic nerve pain, post-shingles pain and some types of seizures.

Other medications may also reduce symptoms of fibromyalgia. These include:

Muscle relaxants may be prescribed, but they are usually not very effective even though sometimes they work by acting as depressants on the central nervous system.

Most medications useful in the treatment of adults with fibromyalgia have demonstrated little or no effect in children, though TCAs have had good results in pediatric patients.

Nutrition may also play an important role in the treatment of fibromyalgia. Proper nutrition ensures that the body has what it needs to function and heal. Fibromyalgia patients have been encouraged to reduce certain foods (e.g., corn, wheat, dairy products, citrus fruits, sugar). Doing so is believed to help improve symptoms of pain, depression, fatigue, headache and digestive tract difficulties.

Remaining active as much as possible is a must for fibromyalgia patients. Regular exercise has been shown to decrease pain and increase endurance and may be essential to managing fibromyalgia, but it must be done correctly. Most fibromyalgia patients will need to modify their old exercise habits. Eccentric contraction (contracting and lengthening at the same time, such as with reaching motions) should be avoided. It is recommended for fibromyalgia patients to start at a low level of exercise and increase gradually, working with low-impact forms of exercise such as walking. The type of exercise activity should be alternated at least every 20 minutes.

Fibromyalgia patients are more likely to experience more intense and longer-lasting pain than healthy individuals. Muscle soreness may be minimized with relaxation, heat, steady breathing and drinking plenty of water. Stretching is important to lengthen muscles and maintain their length, help muscles relax, improve ability to move muscles and decrease pain. Proper exercise has been shown to decrease symptoms of fibromyalgia and reduce severity of symptoms.

Striving for restful sleep is important in the treatment of fibromyalgia. A healthy sleep regimen is crucial to improving sleep and includes:

• Going to bed and getting up at the same time every day
• Avoiding caffeine, sugar and alcohol before bed
• Avoiding eating immediately before bed
• Practicing relaxation exercises while falling to sleep
• Avoiding exercising within three hours of bedtime
• Maintaining a sleep environment that is quiet, free from distractions such as TV and of comfortable room temperature

In some cases, sleep medications may be helpful, particularly when sleep is disturbed by aggravating conditions such as restless leg syndrome.

Many other therapies may be used in the treatment of fibromyalgia. It is important to find therapists specially trained and educated for working with fibromyalgia. A physician may be able to recommend a qualified therapist. Not all therapies are equally efficient and what works for one patient may not work for another.

Patients are advised to consult their physician before considering any complementary or alternative therapy.

Many fibromyalgia patients have trouble coping with their disorder. There are many means to help an individual cope with fibromyalgia or any other chronic illness. Psychological counseling may also help. Fibromyalgia support groups can provide important information, encouragement and positive feelings.