What is Fibromyalgia?
Fibromyalgia (fye-bro-my-AL-jah) is a syndrome characterized by long-lasting widespread pain and tenderness at specific points on the body. The term “fibromyalgia” means pain in the muscles, ligaments and tendons. Although not defining characteristics, sleep disturbances and fatigue are also integral symptoms of fibromyalgia.
This condition is referred to as a syndrome because it’s a set of signs and symptoms that occur together with no known cause or identifiable reason. Fibromyalgia is an especially confusing and often misunderstood condition. Because its symptoms are quite common and laboratory tests results generally are normal, people with fibromyalgia were once told that their condition was “all in their head.” However, medical studies have proven that fibromyalgia does indeed exist, and it is estimated to affect about two to four percent of the U.S. population today.
Although fibromyalgia has no cure, it isn’t a progressive disease, meaning that although your symptoms may worsen, it will not spread to, or damage your organs and it’s never fatal. With a treatment plan that integrates several modalities that include exercise, rest, stress relief, coping skills and medications, people with fibromyalgia can live happy, productive lives.
What causes it?
No one knows what causes fibromyalgia. One hypothesis is that when a person who is genetically predisposed to the syndrome comes in contact with some environmental trigger, symptoms develop. Most patients attribute the onset of fibromyalgia to a stressor, such as an acute injury, an illness with fever, surgery or long-term psychosocial stress (sometimes childhood trauma).
Researchers have made some progress in determining what is happening in the body that might cause some of the symptoms people experience. Most agree that the central nervous system in people with fibromyalgia is not functioning properly and that components of the body’s stress response are responsible for symptoms.
• Sensory processing: Disturbances are probably general and not pain-specific. People with fibromyalgia often experience great sensitivity not just to pain but to loud noises, bright lights, odors, drugs, temperature changes and chemicals.
•Substance P: People with fibromyalgia have approximately threefold higher concentrations in their spinal fluid of this chemical that amplifies pain signals than healthy controls.
• Serotonin: This brain chemical is believed to modulate pain signals and has been found to be low or processed poorly in people with fibromyalgia
• HPA axis: Several abnormalities in the hypothalamic-pituitary-adrenal axis (the brain and hormone interactions that regulate virtually all physiologic activities, including the stress response) have been noted.
• Psychological and behavioral factors: Psychological disorders are no longer believed to cause fibromyalgia. However, the anxiety and depression brought about by chronic pain and fatigue can make fibromyalgia symptoms worse, creating a cycle of pain, fatigue, anxiety, maladaptive behaviors leading to more pain, etc.
What are the symptoms?
The main symptoms of fibromyalgia include:
Pain and tenderness
Musculoskeletal pain in all sections of the body is the most common symptom of fibromyalgia. The pain may begin in one region of the body, but eventually every section becomes affected. For some people, the pain waxes and wanes, and seems to travel throughout the body. The muscle and tissue pain has been described as tender, aching, throbbing, sore, burning and gnawing; it sometimes is accompanied by strange sensations such as tingling, numbness, burning or prickling.
In addition to this generalized feeling of aching all over, people with fibromyalgia experience tenderness to the touch. When pressure is applied to different points on the body, a person with fibromyalgia will feel pain whereas a person without fibromyalgia would feel only a bit of pressure. These spots on the body are called tender points. Studies now show, however, that people with fibromyalgia display increased sensitivity to pain throughout the body, not just at specific tender points. Quite often, the pain and stiffness are worse in the morning and you may hurt more in muscle groups that are used repetitively.
Fatigue and sleep disturbance
Most (75 to 80 percent) people with fibromyalgia experience chronic fatigue and tire quickly after only mild exertion. In fact, about half of individuals who meet diagnostic criteria for fibromyalgia also meet the diagnostic criteria for chronic fatigue syndrome. For many people, the fatigue can be more debilitating than the pain.
People with fibromyalgia often have trouble getting a good night’s sleep. Whether the fatigue is a symptom of the condition or a symptom of the lack of sleep is not known at this time. It is known that people with fibromyalgia usually can fall asleep without problem but their sleep is light and easily disturbed. They wake up in the morning feeling exhausted and unrefreshed.
Sleep laboratory tests have shown that patients’ deep sleep (stages 3 and 4) gets interrupted frequently and that, unlike most adults, their best sleep comes in the hour or two before arising in the morning. This disordered pattern of sleep does not allow the person’s body to rejuvenate itself. Sleep lab tests may not be necessary to determine if you have disturbed sleep. If you wake up feeling as though you’ve just been run over by a Mack truck—what doctors refer to as unrefreshing sleep—it is reasonable for your physician to assume that you have a sleep disorder. Many fibromyalgia patients have been found to have other sleep disorders in addition to the alpha-EEG, such as sleep apnea (as well as the newly discovered form of interrupted breathing called upper airway resistance syndrome, or UARS), bruxism (teeth grinding), periodic limb movement during sleep (jerking of arms and legs), and restless legs syndrome (difficulty sitting still in the evenings).
Other common symptoms
• Frequent headaches: tension and migraine – Recurrent migraine or tension-type headaches are seen in about 70% of fibromyalgia patients and can pose a major problem in coping for this patient group.
• Cognitive difficulties: poor attention span, trouble with short-term memory, inability to think clearly; often called “fibro fog,” possibly related to lack of sleep
• Irritable bowel syndrome: – Constipation, diarrhea, frequent abdominal pain, abdominal gas, and nausea represent symptoms frequently found in roughly 40 to 70% of fibromyalgia patients. Acid reflux or gastroesophageal reflux disease (GERD) also occurs with the same high frequency.
• Dry eyes and mouth
• Temporomandibular joint syndrome (TMJ): – This syndrome, sometimes referred to as TMJ or TMD, causes tremendous jaw-related face and head pain in one-quarter of fibromyalgia patients. However, a 1997 published report indicated that close to 75% of fibromyalgia patients has a varying degree of jaw discomfort. Typically, the problems are related to the muscles and ligaments surrounding the jaw joint and not necessarily the joint itself.
•“Allergic” symptoms: multiple chemical sensitivity, nasal congestion, rhinitis (inflammation of the nasal passages). The reactions are not actually allergic because the defining immunologic responses are not present, but the symptoms felt are similar.
• Restless leg syndrome: numbness, tingling and crawling sensations that necessitate constantly moving the legs; contributes to poor sleep
• Premenstrual syndrome and painful periods, chest pain, morning stiffness, cognitive or memory impairment, numbness and tingling sensations, muscle twitching, irritable bladder, the feeling of swollen extremities, skin sensitivities, dry eyes and mouth, dizziness, and impaired coordination can occur. Fibromyalgia patients are often sensitive to odors, loud noises, and bright lights, and have heat and/or cold intolerances.
How is it diagnosed?
The difficulty diagnosing fibromyalgia is that there is no clear-cut test to determine fibromyalgia. No evidence of it appears on X-rays or in laboratory test results. There is no diagnostic marker in the blood. People with fibromyalgia often look healthy and have no outward signs of pain or fatigue.
Instead, fibromyalgia is diagnosed by the identification of symptoms and the exclusion of other conditions. In 1990, the American College of Rheumatology, the official body of doctors who treat arthritis and related conditions, developed criteria for the diagnosis of fibromyalgia. It is diagnosed when the patient displays the following symptoms:
• A history of widespread pain (pain on both sides of the body and above and below the waist) that is present for at least three months.
• Pain in at least 11 of 18 tender-point sites. These points are considered positive when pain is felt upon the application of 4 kilograms of pressure – the approximate amount of pressure required to blanch the examiners’ fingernail.
It is important to note, however, that these criteria were written to help researchers identify patients for clinical trials, not for diagnosing the disease in individual people. Not all doctors agree with these guidelines. Some believe that the criteria are too rigid and that you can have fibromyalgia even if you don’t meet the required number of tender points. Others question how reliable and valid tender points are as a diagnostic tool.
At least half of the individuals who have the clinical diagnosis of fibromyalgia will not fulfill this definition. Your doctor will listen to you explain all of your symptoms, will order laboratory tests to rule out other conditions with similar symptoms, and will use his or her experience to decide if you have fibromyalgia.
The following simulate fibromyalgia or occur concurrently with the condition:
• Sleep apnea
• Cervical stenosis/Chiari malformation
• Chronic fatigue syndrome
• Medications such as lipid-lowering drugs or antiviral agents
• Autoimmune disorders, such as rheumatoid arthritis and lupus, especially early in the course of the disease
• Endocrine disorders, such as Addison’s disease, Cushing’s syndrome and hyperparathyroidism
• Lyme disease
The diagnostic process can take years, partly due to the fact that fibromyalgia remains unfamiliar to many people, including doctors. Fortunately, a greater understanding of fibromyalgia now exists within the medical community. Finding the right doctor can help expedite diagnosis. A rheumatologist or a doctor at a pain clinic could help make the diagnosis.
Because the central cause of fibromyalgia is unknown, there is no one treatment that will make your symptoms go away. Therefore it is important to work closely with your doctor and other health professionals to develop a complete body and mind treatment plan that will help you feel better.
Currently, Lyrica and Cymbalta are the only FDA-approved drugs for the treatment of fibromyalgia, but this is just the beginning. Several medications are being developed specifically for this condition.
Pregabalin (Lyrica) may reduce pain and improve function in people with fibromyalgia. Pregabalin is an anti-seizure medication that’s also used to treat some types of pain. Studies show pregabalin reduced signs and symptoms of fibromyalgia in some people. Side effects of pregabalin include dizziness, sleepiness, difficulty concentrating, blurred vision, weight gain, dry mouth, and swelling in the hands and feet.
Studies have found that duloxetine (Cymbalta) may help control pain better than placebo in people with fibromyalgia. Small trials of venlafaxine (Effexor) suggest the same, though more study is needed to confirm these findings.
Other options for your treatment plan include:
• Education: Understanding the nature of the condition and learning ways to manage your symptoms are the basis of any treatment program.
• Medications: Some can diminish pain and others can improve sleep.
• Analgesics: Acetaminophen (Tylenol, others) may ease the pain and stiffness caused by fibromyalgia. However, its effectiveness varies. Tramadol (Ultram) is a prescription pain reliever that may be taken with or without acetaminophen. Your doctor may recommend nonsteroidal anti-inflammatory drugs (NSAIDs) — such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen sodium (Anaprox, Aleve) — in conjunction with other medications. NSAIDs haven’t proved to be effective in managing the pain in fibromyalgia when taken by themselves.
• Tricyclic antidepressants: This class of antidepressants, including amitriptyline (Elavil) and nortriptyline (Pamelor) work by raising the levels of norepinephrine (formerly called adrenaline) in the brain. Given in doses lower than what is required for antidepressant effects, these drugs can improve the quality of your sleep. They also can relax painful muscles and heighten the effects of endorphin – the body’s natural painkiller.
• SSRIs: The selective serotonin reuptake inhibitors are antidepressants, such as fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), that increase the amount of serotonin in your brain, reducing fatigue and possibly pain in people with fibromyalgia. SSRIs will often be prescribed in combination with a tricyclic antidepressant because SSRIs alone may interfere with sleep.
• Mixed reuptake inhibitors: Some newer antidepressants raise levels of both serotonin and norepinephrine and are being studied for their use in treating fibromyalgia. These drugs include venlafaxine (Effexor) and nefazadone (Serzone).
• Muscle relaxants: The muscle relaxant cyclobenzaprine (Cycloflex, Flexeril) has proved useful for the treatment of fibromyalgia and is often prescribed to help ease muscle tension and improve sleep.
• Other medications: Benzodiazepines (clonazepam [Klonopin] and diazepam [Valium]) may help relax painful muscles, improve sleep and relieve symptoms of restless legs syndrome (unpleasant sensations in the legs that force you to move them constantly), but they are addictive. Gabapentin (Neurontin) is an anticonvulsant medication that is being studied for use in people with fibromyalgia. Opioids such as morphine, codeine, propoxyphene-containing medications such as Darvocet, hydrocodone-containing medications such as Vicodin, and oxycodone-containing medications such as Oxycontin, are frequently prescribed. However studies have shown them ineffective in some patients due to reduced binding ability of a type of receptor in the brain that is the target of opioid painkiller drugs
• Exercise: Studies have shown that exercising is essential for easing the symptoms of fibromyalgia. Because of the pain, fatigue and weakness felt by people with fibromyalgia, most have become physically unfit. Aerobic exercise, however, has analgesic and antidepressant effects, and it enhances your sense of well-being and control. Warm water exercise can be an effective treatment. If you start in an exercise program slowly and build gradually, you will reap the benefits of exercise without becoming more fatigued and having more pain.
• Coping skills: There are many techniques you can learn to help ease tension, anxiety and pain, including relaxation, visualization, meditation and biofeedback, as well as minimizing negative self talk, hopelessness and victimization.
• Complementary therapies: Some people with fibromyalgia have gotten relief from such therapies as massage, movement therapies (such as Pilates, Yoga or Tai Chi) among others.
• trigger point injections with lidocaine
• physical therapy
• occupational therapy
• relaxation/biofeedback techniques
• osteopathic manipulation
• chiropractic care
• therapeutic massage
Your doctor can tailor your treatment plan to meet your individual needs. Some people with fibromyalgia have mild symptoms and need very little treatment once they understand what fibromyalgia is and how to avoid what worsens their condition. Other people, however, require a comprehensive care program, involving medication, exercise and training to help them cope with pain.
Who is at risk?
The typical fibromyalgia patient is a woman between the ages of 30 and 50 years. Prevalence studies in the United States indicate that fibromyalgia affects about three to five percent of adult women and about 0.5 percent of adult men. Prevalence increases with age but the syndrome is also seen in children.
People with established autoimmune disorders may experience symptoms of fibromyalgia. Studies have suggested that up to 25 percent people with systemic inflammatory disorders, such as systemic lupus erythematosus, rheumatoid arthritis and ankylosing spondylitis, also meet criteria for fibromyalgia.
Fibromyalgia is a common and chronic problem. The symptoms sometimes improve. At other times, the symptoms may worsen and continue for months or years. The key is seeking professional help which includes a multi-faceted approach to the management and treatment of the disease. There is no proof that fibromyalgia syndrome results in an increased death rate.
Conditions reported as associated with fibromyalgia or that mimic its symptoms include: rheumatoid arthritis, hypothyroidism, cervical and low-back degenerative disease, Lyme disease, chronic fatigue syndrome, sleep disorders, depression, cancer, and HIV infection. Call your health-care provider if symptoms of fibromyalgia develop.
There is no proven prevention for this disorder. However, over the years, the treatment and management of the disease has improved.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies.