Fibromyalgia Explained



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The word fibromyalgia comes from the Latin term for fibrous tissue (“fibro”) and the Greek terms for muscle (“myo”) and pain (“algia”). Fibromyalgia is a chronic condition that causes pain, stiffness, and tenderness of muscles, tendons, and joints. It is also characterized by restless sleep, awakening feeling tired, chronic fatigue, anxiety, depression, and disturbances in bowel function.

The condition is non-life-threatening and does not cause body damage, deformity, or injury to internal body organs. Fibromyalgia is sometimes referred to as fibromyalgia syndrome and abbreviated FMS. Fibromyalgia was formerly called fibrositis.

Fibromyalgia is considered an arthritis-related condition. However, it is not a form of arthritis (a disease of the joints) since it does not cause inflammation in the joints, muscles, or other tissues or damage them; [it is] rather a muscle disorder. But fibromyalgia can (like arthritis) cause significant pain and fatigue, and it can similarly interfere with a person’s ability to carry on daily activities.

The manner in which the brain and spinal cord process pain sensations is abnormal in fibromyalgia. The threshold at which stimuli cause pain or discomfort has been proven to be lower in fibromyalgia. The pain felt is more intense because the pain is amplified by the abnormalities in the central nervous system and in pain processing. Because of this, things that are not normally painful may be painful for someone with fibromyalgia. In addition, fibromyalgia causes the pain from any given cause to be worse. For example, a patient with fibromyalgia may find a massage painful instead of pleasant. In addition, back pain that someone without fibromyalgia experiences as moderate may be experienced as severe by someone with fibromyalgia, because the pain is amplified by abnormalities in pain processing by the central nervous system.

Fibromyalgia affects predominantly women (over 80% of those affected are women) between the ages of 35 and 55. Less commonly, fibromyalgia can also affect men, children, and the elderly. It can occur independently or can be associated with another disease, such as systemic lupus or rheumatoid arthritis..

The prevalence of fibromyalgia varies in different countries. In Sweden and Britain, 1% of the population is affected by fibromyalgia. In the United States, approximately 4% of the population has fibromyalgia..

What Causes Fibromyalgia?.

The cause of fibromyalgia is not known. 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 (brain) may be somehow supersensitive. Also, patients with fibromyalgia 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 and unrefreshed in these patients).

Fibromyalgia frequently becomes evident after stressful events. The stressful events may be emotional (such as a traumatic life event), physical (such as a motor-vehicle accident), or medical (such as certain infections). The chronic pain of rheumatoid arthritis, systemic lupus erythematosus, and other autoimmune diseases can trigger the development of fibromyalgia.

Increasing evidence supports a strong genetic component to fibromyalgia. Siblings, parents, and children of a person with fibromyalgia are eight times more likely to have fibromyalgia than those who have no relatives with the condition. There are several genes that have been suspected to play a role in fibromyalgia.

Symptoms and Signs

Fibromyalgia is not always easy to diagnose because symptoms vary from person to person, many of the symptoms mimic those of other disorders, there are no visible signs of the disorder that a physician can see, and there is no definitive laboratory test for fibromyalgia.

The defining feature of fibromyalgia is chronic widespread pain. This means pain in multiple areas of the body, most commonly in muscles, tendons, and joints. The pain is generally above and below the waist, on the left side of the body and on the right side of the body, but can be localized, often in the neck and shoulders or low back, initially. The pain is chronic, which means it is present for more than three months. Patients commonly feel as if they “hurt all over” or as if they have the flu, or are about to develop a cold or the flu. It is common for some days to be worse than others, and many patients report “flare-ups” where their pain and other symptoms are worse for several days in a row or longer.

Fatigue is the other universal symptom of fibromyalgia. It is most noticeable upon awakening, but it may also be marked in the mid-afternoon. It is very common to wake up in the morning not feeling refreshed, even after sleeping through the night. Patients commonly feel they sleep “lightly” and may have multiple nighttime awakenings with difficulty returning to sleep.

Tender Points

Fibromyalgia “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 and are typical signs of fibromyalgia. There are 18 such locations. In the past, studies required patients to have 11 out of a possible 18 fibromyalgia tender points in order to be included in a scientific study on fibromyalgia, but this definition of fibromyalgia has changed in the past few years.

Not all patients are tender at the tender points. For this reason, the American College of Rheumatology developed new guidelines to help diagnose patients with fibromyalgia. The new guidelines no longer require a certain number of tender points to be present to be confident that a patient has fibromyalgia. The new guidelines use pain and other symptoms of fibromyalgia to aid diagnosis. Patient questionnaires to assist in the diagnosis of fibromyalgia can be found online.

Tender points are sometimes incorrectly referred to as “trigger points,” which is terminology that is used to describe a situation whereby pressing on certain trigger points can initiate a sequence of symptoms. This is not the case with fibromyalgia tender points, which are chronically a focus of pain and tenderness in the particular area involved.

Keep in mind each patient with fibromyalgia is unique. Any of the following symptoms can occur intermittently and in different combinations.

Pain

The universal symptom of fibromyalgia is pain. As mentioned earlier, the pain in fibromyalgia is not caused by tissue inflammation. Instead, these patients seem to have an increased sensitivity to many different sensory stimuli and an unusually low pain threshold. 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. The body pain of fibromyalgia can be aggravated by noise, weather change, and emotional stress.

Fatigue

Fatigue occurs in 90% of patients. Fatigue may be related to abnormal sleep patterns. 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

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

Additional Symptoms

While widespread pain, fatigue, and sleep disturbances are the defining symptoms of the syndrome, fibromyalgia is associated with many other symptoms. Disordered thinking (cognitive disturbances) is often referred to as “fibro fog.” Patients describe difficulty with attention and completing tasks, as well as a general sense of being in a fog.

Depression and anxiety are present in 30%-50% of patients at the time of diagnosis with fibromyalgia. Other symptoms 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. Patients also may have a variety of poorly understood pain symptoms, including dry eyes, dry mouth, chest wall pain, pelvic pain, heart palpitations, multiple allergies and chemical sensitivities, weight gain, and others.

How Is Fibromyalgia Diagnosed?

There are no blood tests or X-rays that specifically point the doctor to the diagnosis of fibromyalgia. Tests are often done to exclude other possible diagnoses. Ultimately, the diagnosis of fibromyalgia is made purely on clinical grounds based on the doctor’s history and physical examination. In patients with chronic widespread body pain, the diagnosis of fibromyalgia can be made by identifying point tenderness areas (typically, but not always, patients will have at least 11 of the 18 classic fibromyalgia tender points), by finding no accompanying tissue swelling or inflammation, and by excluding other medical conditions that can mimic fibromyalgia. According to the American College of Rheumatology, before the diagnosis of fibromyalgia can be made, the muscle pain must be present for longer than three months.

Treatment

Although there is no cure for fibromyalgia, treatment can relieve some of the symptoms. Since symptoms are diverse and vary among patients, treatment programs must be individualized for each patient. There are both medication and non-medication treatments for fibromyalgia. Treatment programs are most effective when they combine patient education, stress reduction, regular exercise, and medications. Ultimately, the physician, physical therapist, and patient may all play an active role in the management of fibromyalgia. 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.

Medication treatments frequently help manage the pain and sleeplessness from which fibromyalgia patients suffer. However, the non-medication treatments are really the basis of treatment for fibromyalgia. The non-medication treatments for fibromyalgia include education, exercise, and stress reduction. Sleep disorders may require both medication and non-medication treatments.

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. Community hospital support groups and the local chapters of the Arthritis Foundation have become important educational resources for patients and their doctors.

Often patients have suffered with symptoms for years, and simply knowing why they have pain can be a relief, as many patients become anxious not knowing what is causing their symptoms. Patients should also be educated about treatment approaches, good sleep hygiene, and the importance of treating conditions that may contribute to their symptoms. For example, when a patient with rheumatoid arthritis has fibromyalgia as well, poor control of their rheumatoid arthritis may lead to worsening of fibromyalgia pain and sleeplessness.

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. This 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.

Stress reduction is important in managing the symptoms of fibromyalgia. Many patients feel that their symptoms are triggered by stress. Stress reduction can be challenging. There are many stressors in life; some can be changed and others cannot. Stress reduction involves a combination of changing stressors that can be changed and learning to lessen the body’s stress reaction to the stressors that cannot be changed.

Exercise

The most important therapy for muscle pain is regular low-impact exercise. Exercise is a cornerstone of fibromyalgia treatment. Keeping muscles conditioned and healthy by exercising three times a week decreases the amount of discomfort. Low-impact aerobic exercises, 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.

An exercise program is crucial in the treatment of fibromyalgia and should include stretching, strengthening, and aerobic exercise. Many patients with fibromyalgia find it difficult to institute a regular exercise program because they feel they are too tired to exercise and they may perceive that their pain and fatigue worsen when they begin to exercise. However, numerous scientific studies have shown that exercise for fibromyalgia, especially aerobic exercise, can improve pain, physical function, and a sense of well-being. Starting slow and sticking with the exercise program is very important. Many patients find it helpful to exercise in the morning. Some patients find yoga helpful for strengthening and stretching. This should also be accompanied by an aerobic exercise program.

Diet

Research hasn’t shown that there are specific foods that all fibromyalgia patients should avoid or add to their diets. But it may still be worthwhile to take a closer look at how foods impact the way you feel. A good way to start identifying the foods that may aggravate your symptoms, experts say, is by keeping a daily food journal. To find out what works for you, try eliminating foods one at a time. As you make changes to your diet, keep in mind that people with fibromyalgia tend to benefit most from taking a variety of approaches to managing their symptoms.

Avoiding alcohol and caffeine before bedtime can help promote a more restful sleep. Foods that lead to comfortable sleep should be favored. While these dietary changes may not apply to everyone, they can be very helpful for some. When patients have accompanying irritable bowel syndrome, the diet should be adjusted to not aggravate the bowels. Likewise, when patients have accompanying interstitial cystitis, foods that irritate the bladder should be avoided.

A healthy diet of vegetables, fruits, lean protein, and whole grains that is low in sugar and low in processed food and saturated fat can be generally beneficial.

Medications

Medications are most effective for pain relief when combined with ongoing non-medication treatments. Traditionally, the most effective medications in the treatment of fibromyalgia have been the tricyclic antidepressants, medications often used in treating depression. Tricyclic antidepressants appear to reduce fatigue, relieve muscle pain and spasm, and promote deep, restorative sleep in patients with fibromyalgia. Examples of tricyclic antidepressants commonly used in treating fibromyalgia include amitriptyline (Elavil) and doxepin (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. In 2007, pregabalin (Lyrica) became the first medication approved specifically for treating fibromyalgia. Lyrica may work by blocking nerve pain in patients with fibromyalgia. More recently, duloxetine (Cymbalta) and milnacipran (Savella), drugs that simultaneously increase the amount of two brain nerve transmitters, serotonin and norepinephrine, have been approved to treat fibromyalgia in adults.

Other Medications

Local injections of analgesics and/or cortisone medication into the tender point areas can also be helpful in relieving painful soft tissues, while breaking cycles of pain and muscle spasm. The nonsteroidal anti-inflammatory drugs (NSAIDs), while very helpful in treating other rheumatic conditions, have only a limited value in treating fibromyalgia pain. Narcotic pain relievers are typically avoided in fibromyalgia patients because they have not been shown to be beneficial and have potential adverse side effects, including dependency, when used long term.

Alternative Treatments for Fibromyalgia

For people with fibromyalgia, some alternative treatments work well. That’s because holistic therapies influence your total being. In that way, they may allow you to reduce your medications and increase your normal activities.

Check to see what limitations might apply to you. Working with your doctor, you can find an acceptable way to blend conventional medicine with alternative treatments or natural remedies. When you do, you may be able to increase restful sleep and reduce your fibromyalgia pain.

Acupuncture

With acupuncture, a practitioner inserts one or more dry needles into the skin and underlying tissues at specific points. Gently twisting or otherwise manipulating the needles causes a measurable release of endorphins into the bloodstream. Endorphins are the body’s natural opioids. In addition, according to acupuncture practitioners, energy blocks are removed. Removing them is said to restore the flow of energy along the meridians, which are specific energy channels. Studies show that acupuncture may alter brain chemistry. It appears to do this by changing the release of neurotransmitters. These neurotransmitters stimulate or inhibit nerve impulses in the brain that relay information about external stimuli and sensations such as pain. In this way, the patient’s pain tolerance is increased. One acupuncture treatment in some patients may last weeks to help alleviate chronic pain.

Electroacupuncture and Laser Acupuncture

Electroacupuncture is another way of stimulating the acupuncture points. It uses a needle hooked up to small wires connected to very slight electrical currents. Heat (moxibustion) and massage (acupressure) can also be used during this electroacupuncture process.

Laser acupuncture is yet another offshoot of this alternative therapy. It may occasionally be effective for the treatment of carpal tunnel syndrome. While it uses the same points, there are no needles involved.

Chiropractic Care

Chiropractic care is a very common alternative treatment for fibromyalgia pain. People use it to treat pain of pressure points, back pain, neck pain, shoulder pain, headaches, and pain from musculoskeletal injuries. Chiropractic may be effective for fibromyalgia because it helps improve pain levels and increases cervical and lumbar ranges of motion. Chiropractic is based on the principle that the body is a self-healing organism. To reduce pain and increase healing, the doctor of chiropractic uses spinal adjustments. The goal is to increase the mobility between spinal vertebrae, which have become restricted, locked, or slightly out of proper position. With gentle pressure or stretching, multiple gentle movements of one area, or specific high-velocity thrusts, the adjustments are said to help return the bones to a more normal position or motion. This return is said to relieve pain and reduce ill health.

Massage Therapy

Massage can reduce muscle tension and ease pain in the muscles and soft tissue. It can also improve circulation and range of motion and boost production of natural painkillers. Some studies suggest it can improve your mood. And it may help people with fibromyalgia sleep better, too. Formal studies of the effects of massage on fibromyalgia symptoms are few and results are mixed. However, researchers at the University of Miami’s Touch Research Institute report that just 20 minutes of moderate-pressure massage can lessen the flow of chemicals associated with pain and stress while increasing production of serotonin. The result is a better night’s sleep. That can help combat fatigue and the inability to concentrate known as “fibro fog.”

Biofeedback

To individualize the reduction of stress in the treatment of fibromyalgia, biofeedback is often recommended. This mind/body relaxation technique uses electronics to measure stress-related responses in the body. The idea behind biofeedback is that people can use information about their body’s internal processes to learn to control those processes. With fibromyalgia pain, you know the “real stressor” is the pain itself. Nevertheless, other daily stressors can cause your fibromyalgia to flare. What you want to do is respond in a healthy way to the chronic stressors. If learned properly, electronic biofeedback can help you control your heart rate, blood pressure, breathing patterns, and muscle tension, potentially reducing pain.

Meditation

With meditation, you allow your thoughts to take a break from daily analytical routines and give support to the spiritual dimension of life. When you meditate, your body switches from the pumping “fight or flight” response to a calmer, more peaceful mood. Studies show that meditation produces brain waves consistent with serenity and happiness. Meditation provides nourishment for your soul, satiates inner spiritual hunger, and helps you to develop your ability to pay attention to all areas of life without distraction. Preliminary findings suggest that a meditation-based stress-reduction program is effective for patients with fibromyalgia.

A few notes on other treatments for fibromyalgia: Acupuncture can be helpful for some patients with fibromyalgia but is not usually recommended as one of the first-line treatments for fibromyalgia because the scientific studies on acupuncture for fibromyalgia patients have not shown definite benefit. Alternative medicines have not been proven to be helpful in fibromyalgia; in particular, scientific studies on guaifenesin (Mucinex) show that it does not work. Of note, patients with vitamin D deficiency can have widespread arthralgia and myalgia, like fibromyalgia, which improves with vitamin D supplementation. While having a sufficient level of vitamin D is important to maintain bone health, a healthy immune system, and perhaps prevent certain types of cancer, vitamin D supplementation does not improve fibromyalgia symptoms in patients who have sufficient levels of vitamin D. Narcotic pain medications should be avoided in fibromyalgia because they may worsen the underlying problem.

What Is the Outlook for Patients With Fibromyalgia?

The overall mortality is not increased in patients with fibromyalgia, and it is not an organ-threatening disease. However, many patients with fibromyalgia continue to suffer from chronic widespread pain for years. Once the diagnosis is confirmed, many fibromyalgia patients find their overall sense of well-being and their pain improves to more moderate levels with the treatments discussed above. There are some patients who experience a dramatic reduction in pain with changes in their life to reduce stress. However, these patients are always at risk for worsening of their symptoms in the future and should maintain efforts for a healthy lifestyle, including sleep hygiene, ongoing exercise, and stress management. Fibromyalgia patients have a higher rate of disability than the general population, but seeking permanent disability status is generally discouraged because it frequently leads to worsening of symptoms.

The outlook for patients with fibromyalgia is generally quite good. Those patients with an approach to treatment that involves optimal understanding of the condition, as well as sleep improvement, stress reduction, and exercise, tend to do best.

Are there support groups for fibromyalgia?

Yes, there are support groups for fibromyalgia.
Local support groups can be found through:

Arthritis Foundation (http://www.arthritis.org)
National Fibromyalgia Association (http://www.fmaware.org)
Fibromyalgia Network (http://www.fmnetnews.com)
National Fibromyalgia Partnership, Inc. (http://www.fmpartnership.org).

          

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