Fibromyalgia

Fibromyalgia is a condition characterized by widespread pain

Fibromyalgia syndrome is a chronic pain condition (not a type of arthritis) that affects 4% of people in the United States. The pain syndrome commonly affects the muscles and ligaments and usually has been present for years when a health care professional diagnoses the condition. Fibromyalgia was formerly known as fibrositis.

Fibromyalgia syndrome has been shown to be genetic. The disorder 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 health conditions and autoimmune diseases can trigger the development of fibromyalgia.

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 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.

Is fibromyalgia hereditary?

Increasing evidence supports a strong genetic component to fibromyalgia. Siblings, parents, and children of people with fibromyalgia are eight times more likely to have the disorder than those who have no relatives with the health condition. Several genes that have been suspected to play a role in fibromyalgia syndrome. Studies in twins suggest that half the risk of fibromyalgia and related disorders is genetic and half is environmental.

Because it is in part hereditary, a family history of fibromyalgia syndrome is a risk factor for the development of fibromyalgia. Other risk factors include autoimmune diseases such as rheumatoid arthritis, lupus, and ankylosing spondylitis, as people with these diseases are more likely to have fibromyalgia than the general population. These patients are referred to as having "secondary fibromyalgia" because the autoimmune disease may trigger fibromyalgia.

Other emotional and physical stressors such as physical trauma (especially involving the spine and trunk), emotional stress, and certain infections (hepatitis C, Epstein-Barr virus, parvovirus, and Lyme disease but not the common cold) are associated with the development of fibromyalgia in some.

The defining feature of fibromyalgia syndrome is chronic widespread pain and tenderness. This means pain in multiple areas of the body, most commonly in muscles, tendons, and joints. Joint stiffness and irritable bowel syndrome (IBS) are common, as well. 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. People commonly feel as if they "hurt all over" with flu-like symptoms, or are about to develop a cold or the flu. It is common for some days to be worse than others are, 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.

While widespread pain, fatigue, and sleep problems 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 co-occur in 30%-50% of patients at the time of diagnosis with fibromyalgia. Headaches are present in more than half of patients. Patients also may have a variety of poorly understood additional symptoms, including abdominal pain, diarrhea, constipation, nausea, dry eyes, dry mouth, chest wall pain, pelvic pain, and bladder symptoms, heart palpitations, numbness, and tingling (pins and needles), multiple allergies and chemical sensitivities, weight gain, and others.

Fibromyalgia tender points

The physical examination is remarkable for tenderness, particularly in specific anatomic locations, such as the back of the neck where the neck muscles connect to the skull. There are 18 such locations, which are referred to as fibromyalgia tender points. 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.

Rheumatologists, internists, family medicine doctors, pain-management doctors, physical medicine and rehabilitation doctors, and primary care providers all treat fibromyalgia. Health care practitioners other than physicians are also frequently involved in the treatment of fibromyalgia, including clinical psychologists, physical therapists, nurse practitioners, and physician assistants.

Health care professionals diagnose fibromyalgia based on the patient's symptoms, primarily widespread pain. Chronic widespread pain in the muscles and joints, in combination with fatigue and poor sleep, leads to the consideration of fibromyalgia. A health care professional will perform a thorough history and physical exam to exclude other illnesses presenting with similar symptoms.

There is no widely accepted blood test or X-ray test for fibromyalgia at this time. Any testing is done to exclude other conditions. Tests for inflammation are generally normal in isolated fibromyalgia.

Usually, multiple soft-tissue areas ("fibromyalgia tender points") are tender to palpation. However, not all patients are tender at the tender points. In general, females are more likely to be tender at the classic fibromyalgia tender points than males.

The American College of Rheumatology developed new guidelines and diagnostic criteria 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.

There are both medication and non-medication treatments for fibromyalgia. 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.

Education about fibromyalgia is very important. Often patients have suffered from 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.

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. Low-impact aerobic activities such as swimming, water aerobics, walking, and biking are activities that patients with fibromyalgia find helpful. Many patients find it helpful to exercise in the morning. Some patients find yoga helpful for strengthening and stretching. An anaerobic exercise program should also accompany this.

Stress reduction is important for the self-management of fibromyalgia symptoms. 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.

Cognitive-behavioral therapy is a form of psychological therapy whereby a therapist and patient work together, to establish healthy patterns of behavior by replacing negative thoughts with more productive thoughts and actions. This has been proven to work in fibromyalgia. This form of therapy can be done one on one in an office setting, or even over the Internet.

Non-medication therapies are the cornerstone of treatment for fibromyalgia. With them, many people improve and may not require medications. Moreover, without focusing on sleep hygiene, stress reduction, and exercise, it is difficult to improve, even with medication.

When used with non-medication therapies, medication treatments can help improve sleep, pain, and function in fibromyalgia. Administration of medications is most effective for pain relief when combined with ongoing non-medication treatments as discussed above. Medications often used in the treatment of fibromyalgia include medications in the antidepressant class (medications originally developed to treat anxiety and depression) and anticonvulsants (medications originally developed to treat seizures).

• Medications called "tricyclic antidepressants" have been used to treat fibromyalgia for many years. These medications include amitriptyline (Elavil), doxepin (Sinequan, Silenor), and desipramine (Norpramin). These medications are generally started in low doses and increased until an adequate response is achieved. The advantage of these medications is that they are effective for sleep and pain, widely available, and less costly for most patients than some of the newer agents. Cyclobenzaprine (Flexeril) is a medication that is both a muscle relaxant and tricyclic antidepressant that can be used to help with sleep and pain in patients with fibromyalgia.
• Medications in the antidepressant class that affect the serotonin and the norepinephrine neurotransmitters (SNRI antidepressants) are frequently used in the treatment of fibromyalgia. These medications include duloxetine (Cymbalta), milnacipran (Savella), and venlafaxine (Effexor). Norepinephrine is a neurotransmitter in the brain, and increasing the levels of norepinephrine with these medications decreases pain levels. Fluoxetine (Prozac) is an antidepressant that affects mainly serotonin at low doses but increases norepinephrine as well at higher doses. Higher doses of fluoxetine can be used to treat fibromyalgia pain.
• Pregabalin (Lyrica) and gabapentin (Neurontin) are anticonvulsants (medications initially developed to treat seizures). There are many scientific studies showing that pregabalin and gabapentin can be effective for fibromyalgia pain.
• Tramadol (Ultram) is an opioid pain reliever, which is helpful in some patients with fibromyalgia but should be used with caution as sometimes the use of opioids can worsen the pain cycle in fibromyalgia.
• Memantine (Namenda) is a medication commonly used for dementia. Preliminary studies show that memantine may be helpful with pain and other symptoms of fibromyalgia, but further studies are needed to confirm this.
• There have been small scientific studies of low-dose naltrexone (Revia, Vivitrol) in fibromyalgia. Naltrexone's main scientifically proven use is in treating narcotic addiction. In one small study, a very low dose of naltrexone was shown to benefit some patients with fibromyalgia. Further studies of low-dose naltrexone in fibromyalgia are needed to know if it really works.

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. Likewise, trigger point injections help some patients. 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.

The non-medication treatments for fibromyalgia are the cornerstone of the treatment of the syndrome. These include

• lifestyle changes like education,
• stress reduction,
• improving sleep, and
• exercise.

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 long-term widespread pain. Once the diagnosis is confirmed, many fibromyalgia patients find their overall sense of well-being and their pain improves to pain levels that are more moderate 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 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.

Fibromyalgia is a syndrome with a genetic predisposition. It can be triggered by certain events, but the exact events leading to the onset of fibromyalgia are unknown. Because of this, there is no known way to prevent fibromyalgia.

However, leading a healthy lifestyle, including getting enough sleep, eating healthy foods, and exercising, is the best way to stay healthy.