What is Fibromyalgia?

Fibromyalgia is a chronic condition that causes pain all over the body. It can be associated with pain in multiple joints and muscles, and fatigue. It affects between 4-8% of people, and is more common in women than in men. People with a rheumatic disease such as lupus or rheumatoid arthritis are at an increased risk for developing fibromyalgia.

Symptoms associated with fibromyalgia can include:

Pain

This is a diffuse, chronic and persistent pain all over, including the muscles, joints, and tendons. The pain is often described as burning, aching, stiffness, or soreness. It can vary with times of the day, weather, sleep patterns, and amount of stress. People with fibromyalgia often feel like they constantly have the flu.

Fatigue

Fatigue is one of the hallmarks of fibromyalgia syndrome and can be severe in some people. There may be a close relationship between fibromyalgia and chronic fatigue syndrome (CFS).

Poor sleep

Most people with fibromyalgia complain of poor sleep- either difficulty falling asleep staying asleep, or both. Poor sleep is known to aggravate fibromyalgia, so improvement of sleep quality is one of the treatments of fibromyalgia. 

Mood changes

Anxiety and depression are common in people with fibromyalgia.

Abdominal pain, diarrhea, constipation

Many people with fibromyalgia also have a diagnosis of irritable bowel syndrome or spastic colon.

Bladder pain, frequent need to urinate

Interstitial cystitis is a common diagnosis in people with fibromyalgia

Headaches (tension or migraine headaches)

Memory problems

Jaw pain, temporomandibular joint (TMJ) syndrome

Tendonitis

Numbness and tingling in hands and feet

What causes fibromyalgia?

The exact cause of fibromyalgia is unknown. Although the pain experienced by people with fibromyalgia is very real, no abnormalities may be found on exam or lab tests. It is thought that the cause of fibromyalgia is “multi-factorial”, meaning that various physical and emotional factors (like infections, physical or emotional trauma, genetic factors, etc.) may play a role in development of fibromyalgia. Studies have pointed to a central process in fibromyalgia, which means something in the brain and the nervous system may be responsible. It is thought that people with fibromyalgia may have an impaired pain perception, and a decreased ability to lower pain. This means that the nervous system interprets a stimulus to be much more painful than it really is. For example, while a person without fibromyalgia will perceive a hug as mild pressure on their muscles, the nerves of the person with fibromyalgia may perceive a hug as a painful stimulus and will send signals to the body that will experience pain. 

How is fibromyalgia diagnosed?

There are no blood tests or imaging studies specifically to diagnose fibromyalgia. Fibromyalgia is diagnosed after a thorough history, a complete physical exam, and labs to rule out other diseases.

There are 2 classification criteria developed by the American College of Rheumatology (ACR), that rheumatologists often use to help the diagnosis.

The 1990 ACR criteria established fibromyalgia as “widespread musculoskeletal pain” plus tenderness at 11 or more of the 18 fibromyalgia tender points (see figure).

The 2010 ACR criteria are significantly more complicated (see table below). According to these criteria, tenderness in specific areas PLUS some of the symptoms are required to be classified as fibromyalgia.

A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met:1) Widespread pain index (WPI) _7 and symptom severity (SS) scale score _5 or WPI 3–6 and SS scale score _9.2) Symptoms have been present at a similar level for at least 3 months.3) The patient does not have a disorder that would otherwise explain the pain.
Ascertainment1) WPI: note the number areas in which the patient has had pain over the last week. In how many areas has the patient had pain? Score will be between 0 and 19.Shoulder girdle, left Hip (buttock, trochanter), left Jaw, left Upper backShoulder girdle, right Hip (buttock, trochanter), right Jaw, right Lower backUpper arm, left Upper leg, left Chest NeckUpper arm, right Upper leg, right AbdomenLower arm, left Lower leg, leftLower arm, right Lower leg, right2) SS scale score:FatigueWaking unrefreshedCognitive symptoms
For the each of the 3 symptoms above, indicate the level of severity over the past week using the following scale:0 _ no problem1 _ slight or mild problems, generally mild or intermittent2 _ moderate, considerable problems, often present and/or at a moderate level3 _ severe: pervasive, continuous, life-disturbing problemsConsidering somatic symptoms in general, indicate whether the patient has:*0 _ no symptoms1 _ few symptoms2 _ a moderate number of symptoms3 _ a great deal of symptoms
The SS scale score is the sum of the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus theextent (severity) of somatic symptoms in general. The final score is between 0 and 12.* Somatic symptoms that might be considered: muscle pain, irritable bowel syndrome, fatigue/tiredness, thinking or remembering problem, muscleweakness, headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen,nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, itching, wheezing, Raynaud’s phenomenon, hives/welts, ringing in ears,vomiting, heartburn, oral ulcers, loss of/change in taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, sun sensitivity, hearingdifficulties, easy bruising, hair loss, frequent urination, painful urination, and bladder spasms.

2010 ACR Fibromyalgia diagnostic criteria

Criteria

How is fibromyalgia treated?

There is no cure for fibromyalgia. However, symptoms can be treated with lifestyle changes and medications. 

Non-pharmacological treatment

I think this is the most important aspect of fibromyalgia treatment. Since we know that stress, poor sleep, and physical inactivity exacerbate fibromyalgia, no fibromyalgia treatment is complete without addressing all of these issues. Think of fibromyalgia as a lake, where each of these factors is a stream feeding into the lake. To dry up the lake, we must first take care of these streams.

Improve your sleep!

Refreshing sleep is helpful in reducing the pain of fibromyalgia. If you snore, you may have sleep apnea interrupting your sleep even if you don’t realize it. Restless leg syndrome is not uncommon in people with fibromyalgia. Having a sleep study may help diagnose these problems. If pain wakes you up at night, you can try Tylenol-PM before going to bed (if there are no contraindications).  Everyone, including people with fibromyalgia, needs good sleep hygiene. 

These are some important steps for good sleep hygiene:

  1. Have a regular bed-time
  2. Stop drinking caffeine at least 6 hours before going to bed
  3. Lighten up dinner, and avoid eating 3 hours before bed time
  4. Avoid vigorous physical activity or exercise close to your bed time
  5. Make your bedroom a sanctuary for sleep. This means taking out EVERYTHING that is not related to sleep- including your TV. Your bed is your place for sleeping, not for talking on the phone, eating, watching TV, or talking on the phone.
  6. Turn your clock away from you. If you cannot sleep, DO NOT check out the time!
  7. Avoid taking naps during the day. This just makes you not be tired at night.

Exercise!

Many people with fibromyalgia have a hard time exercising because of the pain. Other reasons for lack of exercise may include long work hours, busy family life, fatigue after a long day, etc.  However, exercise is one of the best treatments for fibromyalgia. Exercise helps tone and condition your muscles. In addition, it increases the levels of natural chemicals in the body that reduce pain and fatigue. People with fibromyalgia will need to start exercising lightly and build slowly over time. Expect some discomfort initially, but not pain. Most people with fibromyalgia find exercises in the water most tolerable, because water cushions the impact. Water-aerobics and Aquatherapy are excellent ways to start. Stretching and yoga are also very helpful. Other low-impact exercises include walking, biking, and Pilates. The goal is to exercise at least 30 minutes, 3 times per week.

Reduce your stress!

Relaxation techniques, Yoga and Tai-Chi may be very helpful in stress reduction and can significantly improve symptoms of fibromyalgia. Biofeedback and cognitive behavioral therapy are also two evidence-based modalities that have been successful in improvement of fibromyalgia symptoms. In biofeedback, persons with fibromyalgia gain awareness of their typically unconscious bodily responses to stress, such as breathing and heart rate, and learn to modify these responses to physical and emotional stress. The goal of cognitive behavioral therapy is to change the way a person thinks about (cognitive) and responds to (behavioral) their disease.

Other therapies…

Acupuncture

Some studies have shown benefits of acupuncture in treatment of fibromyalgia pain. 

Pharmacological treatment

Anticonvulsants: Gabapentin (Neurontin) and Pregabalin (Lyrica)

It is thought that these medications reduce pain by blocking certain chemicals that increase pain transmission.

Serotonin/Norepinephrine reuptake inhibitors: Duloxetine (Cymbalta) and Milnacipran (Savella)

These medications block the re-uptake of both serotonin and norepinephrine by nerve cell endings and can help with pain and fatigue.

Tricyclic antidepressants: Amitriptyline (Elavil), Nortriptyline (Pamelor)

The most common side effects are dry mouth and grogginess.

Selective serotonin reuptake inhibitors (SSRIs): Fluoxetine (Prozac), Paroxetine (Paxil), others

These are antidepressants that work by increasing serotonin levels in the brain and have been helpful in fibromyalgia.

Muscle relaxant: Cyclobenzaprine (Flexeril), Carisoprodol (Soma)

Usually used in combination, these drugs can help relieve muscle tension.

Other medications:

Nonsteroidal anti-inflammatory drugs (NSAIDs): Ibufprofen, Meloxicam, etc.

Topical analgesic creams and patches: Capsacin, Aspercreme, Voltaren gel, Flector patch, etc.

Analgesics: Tramadol (Ultram)

Opioids/narcotics: I usually do not recommend these medications for a chronic pain condition like fibromyalgia.

References

  1. The American Fibromyalgia Syndrome http://www.afsafund.org/
  2. American College of Rheumatology http://www.rheumatology.org/practice/clinical/patients/diseases_and_conditions/fibromyalgia.asp
  3. Arthritis foundation http://www.arthritis.org/
  4. Uptodate http://www.uptodate.com/contents/fibromyalgia-beyond-the-basics?source=search_result&search=fibromyalgia+patient&selectedTitle=1%7E150
  5. F Wolfe, DJ Clauw, MA Fitzcharles, DL Goldenberg, RS Katz, P Mease, AS Russell, J Russell, JB Winfield, MB Yunus. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care & Research,Vol. 62, No. 5, May 2010, pp 600–610
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