Fibromyalgia

Fibromyalgia is a chronic condition that causes pain, stiffness, and tenderness of the muscles, tendons, and joints. It is also characterized by restless sleep, awakening feeling tired, chronic fatigue, anxiety, depression, and disturbances in bowel function. Fibromyalgia is sometimes referred to as fibromyalgia syndrome (FMS) and was formerly known as fibrositis.

While fibromyalgia is one of the most common diseases affecting the muscles, its cause is currently unknown. The painful tissues involved are not accompanied by tissue inflammation. Therefore, despite potentially disabling body pain, patients with fibromyalgia do not develop body damage or deformity. Fibromyalgia also does not cause damage to internal body organs. In this sense, fibromyalgia is different from many other rheumatic conditions (such as rheumatoid arthritis, systemic lupus and polymyositis). In those diseases, tissue inflammation is the major cause of pain, stiffness, and tenderness of the joints, tendons and muscles, and it can lead to joint deformity and damage to the internal organs or muscles.

What Causes Fibromyalgia?

The cause of fibromyalgia is not known. Those affected experience pain in response to stimuli that are normally not perceived as painful. Researchers have found elevated levels of a nerve chemical signal, called substance P, and nerve growth factor in the spinal fluid of fibromyalgia patients. Levels of the brain chemical serotonin are also relatively low in patients with fibromyalgia. Studies of pain in fibromyalgia have suggested that the central nervous system may be somehow supersensitive. Scientists note that there seems to be a diffuse disturbance of pain perception in patients with fibromyalgia.

Patients with fibromyalgia also have an impaired non-rapid eye movement, or non-REM, sleep phase (which likely, at least in part, explains the common feature of waking up fatigued in these patients). The onset of fibromyalgia has been associated with psychological distress, trauma and infection.

What Are The Symptoms of Fibromyalgia?

The universal symptom of fibromyalgia is pain. This pain is not caused by tissue inflammation. Instead, fibromyalgia patients seem to have an increased sensitivity to many different sensory stimuli and an unusually low pain threshold. Minor sensory stimuli that ordinarily would not cause pain in individuals can cause disabling and sometimes severe pain in patients with fibromyalgia. The body pain of fibromyalgia can be aggravated by noise, changes in weather and emotional stress.

The pain of fibromyalgia is generally widespread, involving both sides of the body. Pain usually affects the neck, buttocks, shoulders, arms, the upper back and the chest. "Tender points" are localized areas of the body that are tender to light touch. Fibromyalgia tender points, or pressure points, are commonly found around the elbows, shoulders, knees, hips, back of the head and the sides of the breastbone.

Fatigue occurs in 90 percent of fibromyalgia patients, and may be related to abnormal sleep patterns commonly observed in these patients. Normally, there are several levels of depth of sleep. Getting enough of the deeper levels of sleep may be more important in refreshing a person than the total number of hours of sleep. Patients with fibromyalgia lack the deep, restorative level of sleep, called "non-rapid eye movement" (non-REM) sleep. Consequently, patients with fibromyalgia often awaken in the morning without feeling fully rested, even though they seem to have had an adequate number of hours of sleep time. Some patients awaken with muscle aches or a sensation of muscle fatigue as if they had been "working out" all night.

Mental and/or emotional disturbances occur in over half of people with fibromyalgia. These symptoms include poor concentration, forgetfulness, mood changes, irritability, depression, and anxiety. Since a firm diagnosis of fibromyalgia is difficult and no confirmatory laboratory tests are available, patients with fibromyalgia are often misdiagnosed as having depression as their primary underlying problem.

Other symptoms of fibromyalgia include migraine and tension headaches, numbness or tingling of different parts of the body, abdominal pain related to irritable bowel syndrome ("spastic colon"), and irritable bladder, causing painful and frequent urination. Like fibromyalgia, irritable bowel syndrome can cause chronic abdominal pain and other bowel disturbances without detectable inflammation of the stomach or the intestines.

Each patient with fibromyalgia is unique. Any of the above symptoms can occur intermittently and in different combinations.

Many medical conditions can cause pain in different areas of the body, mimicking fibromyalgia. These conditions include:

Low thyroid hormone levels (hypothyroidism)
Vitamin D insufficiency
Parathyroid disease (causing elevated blood calcium level)
Muscle diseases causing muscle pain (such as polymyositis)
Bone diseases causing bone pain (such as Paget's disease)
Elevated blood calcium (hypercalcemia)
Infectious diseases (such as hepatitis, Epstein Barr virus, AIDS)
Cancer

How Is Fibromyalgia Diagnosed?

Although there is no blood test for fibromyalgia, blood tests are important in order to eliminate the possibility of other medical conditions. Therefore, thyroid hormone and calcium blood levels are obtained to exclude hypercalcemia, hyperparathyroidism, and hypothyroidism. The blood alkaline phosphatase (a bone enzyme) level is often raised in patients with Paget's disease of the bone. The CPK (a muscle enzyme) level is often elevated in patients with polymyositis, a disease with diffuse muscle inflammation. Therefore, obtaining alkaline phosphatase and CPK blood levels can help the doctor decide whether Paget's disease and polymyositis are the causes of bone and muscle pains. A complete blood count (CBC) and liver tests help in the diagnosis of hepatitis and other infections. A blood vitamin D level can detect vitamin D insufficiency.

Fibromyalgia can occur alone or in association with other systemic rheumatic conditions. Systemic rheumatic conditions refer to diseases that can cause inflammation and damage to numerous different tissues and organs in the body. Systemic rheumatic conditions associated with fibromyalgia include systemic lupus erythematosus, rheumatoid arthritis, polymyositis, and polymyalgia rheumatica. Blood tests that are helpful in evaluating these diseases when they are suspected include: erythrocyte sedimentation rate (ESR), serum protein electrophoresis (SPEP), antinuclear antibody (ANA), and rheumatoid factor (RF). In patients with fibromyalgia without associated systemic illnesses, these blood tests are usually normal.

What Are the Common Treatments For Fibromyalgia?

Since the symptoms of fibromyalgia are diverse and vary among patients, treatment programs must be individualized for each patient. Fibromyalgia treatment programs are most effective when they combine patient education, stress reduction, regular exercise, and medications. Recent studies have verified that the best outcome for each patient results from a combination of approaches that involves the patient in customization of the treatment plan.

Patient Education

Patient education is an important first step in helping patients understand and cope with the diverse symptoms. Unfortunately, not all physicians are intimately acquainted with the vagaries of this illness. Therefore, community hospital support groups and the local chapters of the Arthritis Foundation have become important educational resources for patients and their doctors. The Arthritis Foundation is a national voluntary health organization that provides community education through their many local chapters. Community hospital support groups also provide an arena for patients to share their experiences and treatment successes and failures.

Stress Reduction

It is extremely difficult to measure stress levels in different patients. For some people, spilling milk on the table can represent a significant tragedy. For others, a tank rolling into the living room might represent "just another day." Therefore, stress reduction in the treatment of fibromyalgia must be individualized. Stress reduction might include simple stress modification at home or work, biofeedback, relaxation tapes, psychological counseling, and/or support among family members, friends, and doctors. Sometimes, changes in environmental factors (such as noise, temperature, and weather exposure) can exacerbate the symptoms of fibromyalgia, and these factors need to be modified. Optimal sleep is encouraged.

Exercise

Low-impact aerobic exercise, such as swimming, cycling, walking and stationary cross-country ski machines can be effective fibromyalgia treatments. Exercise regimens are most beneficial when performed on an every-other-day basis, in the morning. How exercise benefits fibromyalgia is unknown. Exercise may exert its beneficial effect by promoting a deep level of sleep (non-REM sleep). Sometimes physical therapy can be helpful to optimally guide the exercise plan.

Fibromyalgia Diet

Avoiding alcohol and caffeine before bedtime can also help promote a more restful sleep. While these dietary changes may not apply to everyone, they can be very helpful for some. There are no specific fibromyalgia diet or food supplements that are recommended for all patients. When patients have accompanying irritable bowel syndrome, the diet should be adjusted to not aggravate the bowels.

Fibromyalgia Medications

Traditionally, the most effective medications in the treatment of fibromyalgia have been tricyclic antidepressants - medications traditionally used in treating depression. In treating fibromyalgia, tricyclic antidepressants are taken at bedtime in doses that are a fraction of those used for treating depression. Tricyclic antidepressants appear to reduce fatigue, relieve muscle pain and spasm, and promote deep, restorative sleep in patients with fibromyalgia. Scientists believe that tricyclics work by interfering with a nerve transmitter chemical in the brain called serotonin. Examples of tricyclic antidepressants commonly used in treating fibromyalgia include amitriptyline (Elavil) and doxepine (Sinequan).

Studies have shown that adding fluoxetine (Prozac), or related medications, to low-dose amitriptyline further reduces muscle pain, anxiety, and depression in patients with fibromyalgia. The combination is also more effective in promoting restful sleep and improving an overall sense of well-being. These two medications also tend to cancel out certain side effects each can have. Tricyclic medications can cause tiredness and fatigue, while Prozac can make patients more cheerful and awake. A study of patients with resistant fibromyalgia found that lorazepam (Ativan) was helpful in relieving symptoms. Prozac has also been shown to be effective when used alone for some patients with fibromyalgia. Trazodone can be taken at bedtime to improve sleep when tricyclic antidepressants are not tolerated.

In 2007, pregabalin (Lyrica) became the first medication approved specifically for treating fibromyalgia. Lyrica may work by blocking nerve pain in patients with fibromyalgia. Lyrica has advantages of flexible dosing that can be adjusted according to persisting symptoms. A related medication, gabapentin (Neurontin), is also used to treat fibromyalgia.

More recently, drugs that simultaneously increase the amount of two brain nerve transmitters, serotonin and norepinephrine, have been approved to treat fibromyalgia in adults. These drugs include duloxetine (Cymbalta) and milnacipran (Savella). Research studies have shown significant effectiveness in decreasing pain and improving function in patients with fibromyalgia with these drugs. Cymbalta has been effective in treating depression and relieving pain in people with depression and is also used to treat anxiety.

Complementary Medicine

Complementary treatments can be effective in relieving fibromyalgia pain without adding medication. Traditional Chinese medicine (TCM) offers different treatments to relieve pain. In addition to acupuncture, which is widely known as an effective way to treat pain, cupping and herbal medicine may also be recommended. Osteopathic manipulation therapy can relieve pressure with various techniques, including high velocity low amplitude (HVLA) technique, muscle energy technique, strain-counterstrain technique, myofascial release technique, and osteopathy in the cranial field, on the musculoskeletal systems.