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Rheumatology

FIBROMYALGIA

What is Fibromyalgia?

Fibromyalgia (FMS) is a chronic pain syndrome associated with muscular pain, fatigue and mood changes. It affects about two percent of the U.S. population, is more common in women than in men, and is increasingly seen in children and teenagers. Its cause is unknown. Fibromyalgia cannot be diagnosed with laboratory tests. The results of X-rays and blood tests are normal. Thus, the diagnosis is based on a careful history and physical examination.

A person has fibromyalgia if he or she has a history of widespread, all over pain, of at least three months’ duration and abnormal pain sensitivity in at least 11 of 18 specific sites on the body that are called “tender points”; these are areas that are painful when pressed.

Symptoms And Signs Of Fibromyalgia

Pain: Widespread musculoskeletal pain is the most common symptom. It generally occurs at multiple sites, although it may start in one body region, and spread to other locations over time. Its pain has been described as burning, gnawing, aching, stiffness or soreness. The pain often varies according to time of day, activity level, weather, sleep patterns and stress. Most people with FMS say that some pain always is present. For some, the pain may be quite severe.

Although the results of a physical examination usually are normal, and the child may look healthy, specific examination for tenderness reveals pain in response to low levels (less than 4 kilograms) of pressure at a number of tender points. However, many people with this condition have tenderness throughout their body. The tender points associated with fibromyalgia are similar in location to the tender areas present in other common types of muscle and bone pain, such as tennis elbow. A tender point on one side of the body usually has a matching tender point on the opposite side., Many other muscles and areas of soft tissue can be painful as well. People often are not aware of the presence of many of these tender points until a doctor performs a tender point evaluation.

Fatigue and Sleep Disturbances: Most people with FMS have fatigue, decreased endurance or the kind of exhaustion felt with the flu, or lack of sleep. Sometimes the fatigue is severe, and a greater problem than the pain.

People with fibromyalgia may have fatigue that is similar to another condition called chronic fatigue syndrome (CFS). The Centers for Disease Control and Prevention developed criteria for diagnosing CFS. For a CFS diagnosis, a person must experience at least six months of severe fatigue that is not produced by other medical conditions, plus 4 of the 8 following symptoms:

• Difficulty thinking clearly
• Sore throat
• Tender lymph nodes
• Muscle aches
• Joint aches
• Headache
• Sleep disorders
• Malaise lasting more than 24 hours after exertion

It is clear how some people with fibromyalgia also may fit the definition of CFS, and vice versa. Because of the similar symptoms of these two conditions, some experts think they are either related or variations of the same disorder. Most people with fibromyalgia experience sleeping problems. They may have difficulty falling asleep, and/or sleep lightly and wake up frequently during the night. They often awake feeling tired, even after “sleeping” for many hours. The tiredness can range from listlessness and decreased endurance to exhaustion and can vary from one day to the next.

Research has shown that a disruption of the “deep” phase of sleep alters many crucial body functions, such as the production of chemicals needed by muscles, as well as how a person perceives pain. Some researchers think sleep problems may be a cause of fibromyalgia, but it is clear that sleep problems can aggravate fibromyalgia

Tips for Improving Sleep:

• Make the bedroom as comfortable and as quiet as possible. Set a comfortable temperature.
• If possible, use the bedroom only for sleeping.
• Avoid caffeine before bedtime.
• Take a warm bath before going to bed.
• If a nap is needed to get through the day, keep it short and nap well in advance of bedtime.
• Read before bedtime if desired, but avoid suspenseful, action-filled novels or school/work-related material that can preoccupy thoughts and cause a poor night’s sleep.
• Eat a light snack before bedtime. Don’t go to bed feeling hungry or too full.
• Set aside time before bed for relaxation.

Mood and Concentration Symptoms: Mood changes are common in fibromyalgia. Feelings of sadness or being down are frequent, and some people with FMS have depression. People with fibromyalgia also may feel anxious. Some researchers think there is a link between fibromyalgia and certain forms of depression and chronic anxiety.

However, any person with a chronic illness – not just fibromyalgia – may feel depressed at times while struggling with their pain and fatigue. People with FMS may have difficulty concentrating, or performing simple mental tasks. These problems tend to come and go and are often most prominent at times of extreme fatigue or anxiety. Similar problems have been noted in many people with mood changes, sleep disturbances or other chronic illnesses.

Other Problems: Tension or migraine headaches are common in people with fibromyalgia. FMS may also be associated with pain of the jaw muscles and face (temporomandibular disorder). Abdominal pain, bloating and alternating constipation and diarrhea (called irritable bowel syndrome or spastic colon) also are common. Additional associated problems may include dizziness, restless legs, numbness or tingling of the hands and feet, and bladder irritability or spasms.

How is Fibromyalgia Diagosed?

Fibromyalgia is diagnosed by the presence of widespread pain, in combination with tenderness (abnormal pain sensitivity) in response to low levels of pressure stimulation. There is no X-ray or laboratory test that can help a doctor diagnose FMS. But a physical examination, and tests can help to diagnose, or eliminate, other medical problems that may cause chronic pain and fatigue. Because the symptoms of FMS are so general and often bring to mind other medical disorders, many people undergo complicated and often repeated evaluations before they are diagnosed with FMS. It is important to see a physician or rheumatologist who knows how to diagnose and treat fibromyalgia.

What Causes Fibromyalgia?

No one knows what causes FMS. Researchers suspect that many different factors, alone or in combination, may contribute to the development of fibromyalgia. For example, an infectious illness, physical or emotional trauma, or hormonal changes may trigger the development of generalized pain, fatigue and sleep disturbances that characterize FMS. Studies have suggested that people with fibromyalgia have abnormal levels of several different chemicals in their blood or cerebrospinal fluid that help transmit and amplify pain signals to and from the brain. There also is evidence that the central nervous system’s ability to inhibit pain is impaired in these people. Whether these abnormalities are a cause or a result of fibromyalgia is unknown.

How Is Fibromyalgia Treated?

Your doctor can create a treatment plan specifically for you. Some people with FMS have mild symptoms, and need very little treatment once they understand what fibromyalgia is and how to avoid what worsens their condition. Others, however, require a comprehensive care program, involving medication, exercise, and pain coping skills training. Treatment options include:

• Medications to diminish pain and improve sleep, anxiety or depression
• Exercise programs that stretch muscles and improve cardiovascular fitness
• Relaxation techniques to ease muscle tension and anxiety
• Educational programs to help you understand and better manage the symptoms of fibromyalgia

Medications: Modest doses of aspirin, ibuprofen, acetaminophen or naproxen, may provide some pain relief. Severe pain can sometimes be treated with medications such as Neurontin. Most doctors do not prescribe narcotic pain relievers except for the most severe cases of fibromyalgia. Medications that promote sleep and relax muscles help many people with FMS get more rest.

Doctors also may antidepressants to treat fibromyalgia. These drugs work by elevating the levels of serotonin and norepinephrine in the brain and spinal cord. Low levels of serotonin and norepinephrine are linked not only to depression but also to the pain sensitivity and sleeping problems associated with FMS. These medications, which are typically prescribed for late evening, at lower doses than those used to treat depression, have been shown to improve the chance of a good night’s sleep.

There are two major types of antidepressants: 1) tricyclics, such as amitriptyline (Elavil ), nortriptyline (Pamelor) and doxepin (Sinequan); and 2) selective serotonin reuptake inhibitors, such as fluoxetine (Prozac), paroxetine (Paxil ) and sertraline (Zoloft ). Flexeril, classified as a muscle relaxant, but similar to an antidepressant, is sometimes prescribed.

There are also new dual-acting inhibitors, such as venlafaxine and nefazodone, that act on two neurotransmitters involved in pain inhibition, serotonin and norepinephrine. These medications have not been studied as extensively in FMS; however, they have produced positive results in some people with CFS.

Although many people sleep better and have less discomfort when they take antidepressants, the degree of improvement varies greatly from person to person. These medications may have side effects such as daytime drowsiness, constipation, dry mouth and increased appetite. Some studies suggest that combining bedtime tricyclics with morning SSRIs may increase the benefits of each drug, while canceling the side effects of each other out.

Exercise and Physical Therapy: Exercise is an extremely important part of fibromyalgia treatment. Exercises help to stretch tight, sore muscles, and increase cardiovascular (aerobic) fitness. Studies show aerobic exercise programs give people with FMS an improved sense of well being, increased endurance and decreased pain. Pilates, stretching and isometric exercises (exercises in which you tighten your muscles without moving your joints) are good for FMS. Isotonic exercises, such as weight lifting and rowing, are not recommended.

Often people are be reluctant to exercise if they are already tired and in pain. Generally low or non-impact exercises, such as walking, biking, water aerobics or swimming are the best types of exercises to start with. It is important to begin exercising at a level that can be tolerated without experiencing a substantial increase in pain. Many people with fibromyalgia find it necessary to consult with an experienced physical therapist for best results.

It is best to begin slowly and start by exercising five minutes, three times a day, to achieve a total of 15 minutes for that day. Over a period of time, people can try to extend the endurance part of their exercise program to achieve a total of 30 minutes per day.

It is recommended to:

• Exercise every other day, if possible, and gradually increase activity to reach a better level of fitness.
• Gently stretch muscles and move joints through their range of motion daily, and before and after exercise.
• Consult with physical to design a specific exercise program to improve posture, flexibility and fitness.

Coping Skills

Many people benefit from learning how to better cope with pain. Strategies include muscle relaxation, meditation or biofeedback. In addition, some cognitive coping strategies can help you better control feelings of being overwhelmed by the pain, and the stress, associated with FMS. Stress management techniques, such as alternating periods of activity with periods of rest and breathing exercises, can help control the feelings of anger, sadness and panic that often overwhelm people living with frequent pain and fatigue. Learning pain control and stress management techniques often requires help from health professionals. These strategies usually work best if they are tailored to fit the needs of individual patients.

Managing Fibromyalgia

People with FMS often have undergone many tests, and seen many specialists, in their search for answers. Because they look well and their tests are normal, they often are told there is nothing wrong with them. Their family and friends, as well as physicians, may doubt the reality of their complaints, increasing their feelings of isolation, guilt and anger. People afflicted with FMS and their families should understand that fibromyalgia causes chronic pain and fatigue.

Fortunately, fibromyalgia is not life threatening and does not lead to muscle or joint damage. Although symptoms may vary in intensity, the overall condition rarely worsens over time. Although symptoms may persist, many people feel better with treatment and time. While nine out of 10 people with fibromyalgia work full-time, 30 percent have had to change jobs, and 30 percent have changed their job description.

Some people with FMS have such severe symptoms that they are unable to function well at work or socially. These individuals may require greater attention in a program, such as a multi-disciplinary pain center, that utilizes physical or occupational therapists, social workers, nurses, mental health professionals, rehabilitation counselors and sleep specialists. Your primary care doctor or rheumatologist can refer you to a pain center or similar program.

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