Fibromyalgia
• Overview
• Diagnosis
• Treatment
OVERVIEW
Fibromyalgia syndrome (FS) is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, multiple tender points and poor sleep. "Tender points" refers to tenderness that occurs in precise, localized areas, particularly in the neck, spine, shoulders and hips. People with FS may also experience morning stiffness, fatigue, increased headaches or facial pain, irritable bowel syndrome, depression, anxiety and cognitive symptoms (troubles with concentration, short-term memory and handling multiple tasks). Other symptoms include irritable bowel syndrome (IBS), irritable bladder, headache, depression and anxiety.
Diagnosis of FS has been controversial because there are no specific laboratory tests to identify the disorder. Until the 1990s (and even during much of that decade), many health care professionals thought FS was largely psychosomatic (in a patient's mind), in part because the disease is often associated with depression. In recent years, however, health care professionals have come to understand that psychological factors contribute to an increased risk for disability, and may actually stimulate the central nervous system mechanisms that may lead to fibromyalgia. More important, people with fibromyalgia have been found to have different pain perception thresholds than healthy people or patients with depression only. It has also been found to be different from chronic fatigue, whose victims do not have abnormal pain perception.
According to the American College of Rheumatology (ACR), FS affects three million to six million Americans and is the second most common rheumatic ailment after osteoarthritis. As many as 80 percent of individuals diagnosed with FS are women. The syndrome primarily occurs in women of childbearing age, but children, the elderly, and men also can be affected. FS can be disabling: A survey of fibromyalgia patients found that 15 percent to 25 percent considered themselves disabled and 26 percent were receiving at least one form of disability payment.
Fibromyalgia is an abnormal processing of sensory information in which non-painful stimuli are perceived as painful, and the pain of painful stimuli is increased. The severity of fibromyalgia symptoms varies from person to person. For some women, pain or other symptoms can be so intense that they interfere with daily activities. For others, symptoms may cause discomfort, but are not incapacitating.
Light, unrefreshing sleep is one of the hallmarks of FS. Women with FS often have restless sleep, and may suffer restless-legs syndrome during the day. The problem isn't with quantity -- a woman with fibromyalgia may get eight to 10 hours of sleep but not enough of a form of deep sleep called delta sleep the name stems from the brain wave pattern produced in an electroencephalogram). Lack of deep sleep makes people with or without FS feel achy, tired and less able to concentrate. Sleep problems could thus be not only a symptom of FS, but also an underlying cause of many of the symptoms.
In addition to sleep problems, researchers have found many other links between various health problems and FS:
* FS may arise following an injury or trauma. For instance, a percentage of whiplash victims develop FS. Similarly, in an injury such as carpal tunnel syndrome, which may result in a chronic persistent regional pain, the pain may spread to adjacent areas in the upper extremities and neck, becoming a widespread pain. Sometimes the widespread pain may go on to become fibromyalgia, possibly because chronic, persistent pain can result in a widening of the pain-receptor field within the central nervous system.
* An infectious agent may trigger FS in susceptible people. Lyme disease is under study as one such trigger -- one study found 10 percent to 25 percent of patients with Lyme disease develop fibromyalgia. Another study found a link between small-intestinal bacterial overgrowth and fibromyalgia, with about 78 percent of patients with fibromyalgia and intestinal symptoms having such an infection. Patients whose infection was completely eradicated with antibiotics experienced an improvement in FS symptoms.
* FS is also associated with autoimmune disorders such as systemic lupus erythematosus and rheumatoid arthritis. People with these disorders are at higher risk of developing FS, however the reverse is not true. Women with fibromyalgia who develop Raynaud's phenomenon, characterized by extreme sensitivity to cold in the extremities, may be misdiagnosed as having lupus or scleroderma.
* Recent studies show that some women with fibromyalgia may have abnormally low levels of growth hormone. People whose bodies make inadequate amounts of growth hormone experience many of the same symptoms as people with fibromyalgia. These low levels of growth hormone may be related to disturbed sleep or circadian rhythms.
Central sensitization has been proposed as the unifying concept for FS and related conditions such as chronic fatigue syndrome, irritable bowel syndrome, Gulf War syndrome, and temporomandibular pain and dysfunction syndrome. There are especially strong links between irritable bowel syndrome and fibromyalgia and between chronic fatigue syndrome and fibromyalgia. More than half of women with IBS or CFS also have fibromyalgia symptoms.
In central sensitization disorders, the nervous system develops heightened sensitivity in response to trauma, stress or overstimulation. This sensitivity can make ordinarily nonpainful stimuli -- such as mild pressure on the skin or muscle exertion -- painful. Abnormal levels of biochemicals such as hormones and neurotransmitters (chemicals that relay pain signals and other sensations) appear to be the direct physical agents.
A neurotransmitter is a chemical substance released by nerve cell endings to transmit impulses across the space between nerve cells, tissues or organs. In the brain, these chemicals -- such as serotonin, dopamine and norepinephrine -- affect mood as well as other emotional and physical functions.
The sensation of pain and quality of sleep may be modified by levels of neurotransmitters. Low levels of norepinephrine and serotonin have been implicated in fibromyalgia, and drugs such as Elavil -- which boosts the levels of serotonin -- may help relieve pain and improve sleep in some women with fibromyalgia.
Fibromyalgia is difficult to diagnose because many of the symptoms mimic those of other diseases. A health care professional reviews a patient's medical history and makes a diagnosis of fibromyalgia based on a history of chronic widespread pain that persists for more than three months. The American College of Rheumatology (ACR) has developed criteria for diagnosing fibromyalgia. According to ACR criteria, a person is considered to have fibromyalgia if he or she has widespread pain in combination with tenderness in at least 11 of 18 specific tender point sites.
Treatment of fibromyalgia requires a comprehensive approach. The physician, physical therapist, cognitive therapist and the patient herself may all play an active role in the management of fibromyalgia. Studies have shown that aerobic exercise, such as swimming and walking, improves muscle fitness and reduces muscle pain and tenderness. Heat and massage may also give short-term relief. Antidepressant medications may help elevate mood, improve quality of sleep, and relax muscles. Also, if the problem in fibromyalgia is hypersensitivity to pain, temperature, etc.), then training patients to become "hardier" is one possible approach. If you have fibromyalgia, work with your health care team to find the best combination of exercise, medication, physical therapy, and relaxation.
DIAGNOSIS
Fibromyalgia syndrome (FS), a chronic disorder characterized by widespread musculoskeletal pain, fatigue, multiple tender points and poor sleep, is difficult to diagnose because many of the symptoms are shared by other diseases. A health care professional will review your medical history and make a diagnosis of fibromyalgia based on a history of chronic widespread pain that persists for more than three months. The American College of Rheumatology (ACR) has developed criteria for diagnosing fibromyalgia: A person is considered to have fibromyalgia if he or she has widespread pain above and below the waist, on both sides of the body, in combination with tenderness in at least 11 of 18 specific tender point sites.
Although the diagnosis of fibromyalgia has been controversial, the condition is now recognized as a legitimate clinical entity. But despite greater acceptance of the disorder by the medical community in recent years, fibromyalgia continues to be under-diagnosed or misdiagnosed.
Diagnosis of FS is difficult in part because symptoms are variable and tend to come and go and because standard laboratory tests and x-rays are not able to detect the syndrome. Lab tests may be ordered, however, to determine whether you have another condition with similar symptoms, such as rheumatoid arthritis or lupus.
For an accurate diagnosis of fibromyalgia, look for a physician with experience identifying the syndrome. Many other illnesses share some of the same symptoms, including lupus, low thyroid, myositis and chronic fatigue syndrome. Rheumatologists or physiatrists are often experienced in diagnosing fibromyalgia. A rheumatologist is a doctor who specializes in disorders that affect the joints, muscles, tendons, ligaments and bones. A physiatrist is a physical medicine specialist who specializes in diagnosing and treating injuries and diseases causing pain, loss of function and disability.
In addition to the pain, sleeping difficulty and fatigue experienced by most fibromyalgia victims, FS patients also have extreme hypersensitivity, including:
* hypersensitivity to cold, especially in the hands and feet, often accompanied by color changes;
this condition is known as Raynaud's phenomenon
* hypersensitivity to distension of the bladder with even a tiny amount of urine, leading to
irritable bladder
* hypersensitivity to the menstrual cycle, when hormonal changes in pain perception occur
* hypersensitivity to sound, touch, light and odor
* hypersensitivity to vulvular stimulation, called vulvar vestibulitis or vulvodynia, characterized
by a painful vulvar region and painful sexual intercourse
Other symptoms include:
* stiffness, particularly in the early morning, after prolonged sitting or standing, or with changes in temperature or relative humidity
* increased headaches or facial pain, including frequent migraine, tension or vascular headaches, or pain behind the eyes
* light-headedness and/or balance problems
* difficulty swallowing food
* abdominal discomfort, often referred to as irritable bowel syndrome, which can include abdominal pain, bloating, constipation and/or diarrhea (some of this discomfort may be due to bacterial overgrowth)
* parenthesia (numbness or tingling), often in the hands or feet. Also known as "paresthesia," the sensation can be described as prickling or burning
* skin problems, including blotchy or itchy skin; also, a sensation of swelling, particularly in the extremities -- such as a ring suddenly not fitting -- is a common symptom
Other symptoms include
Cognitive disorders, most often short-term memory lapses and difficulty concentrating, as well as anxiety and depression related to the chronic pain and fatigue of fibromyalgia.
Of course, many of these symptoms can apply to a variety of diseases. To resolve the ambiguities, the American College of Rheumatology (ACR) in 1990 developed two specific criteria for diagnosing FS:
* chronic, widespread, musculoskeletal pain of longer than three months duration in all four quadrants of the body
* multiple tender points throughout the body -- 18 have been identified by the ACR and a patient must have 11 of the 18 for a diagnosis of fibromyalgia to be considered . A tender point is found by palpation -- applying approximately nine pounds of pressure to the area with the fingers; an area that hurts when the health care professional palpates it is a tender point. An illustration that shows the various tender point sites on the human body can be viewed on the National Fibromyalgia Partnership, Inc. Web site, located at http://www.fmpartnership.org/FMPartnership.htm.)
TREATMENT
Treatment of fibromyalgia syndrome (FS), a chronic disorder characterized by widespread musculoskeletal pain, fatigue, multiple tender points and poor sleep, involves a comprehensive, multidisciplinary approach, along with self-management strategies. Among the most effective techniques are exercise, sleep management, positive attitude and sticking to a daily routine.
Aerobic exercise is essential because it strengthens the muscles; greater strength translates into improved ability to handle everyday activities without the strain that can worsen symptoms. You will probably want to avoid high-impact activities, however. Some patients also benefit from physical therapy and stretching exercises.
Exercise can improve mood and outlook, decrease pain, increase flexibility, improve the heart and blood flow, maintain weight, and promote general physical fitness. It is also inexpensive and, if done correctly, has few negative side effects. Note: Be sure to discuss any plan to start a new exercise program with a health care professional.
Exercise may seem an impossibly tall order -- after all, if you're in pain, how are you supposed to work out? Resting seems a more natural course of action. But if you don't regularly get aerobic exercise, your muscles will become weaker, making them even more susceptible to pain when doing everyday tasks. It is also harder to sleep well if you don't exercise. You have to build and maintain strength and muscle tone to minimize pain over the long run. Studies have shown that aerobic exercise, such as swimming and walking, improves muscle fitness and reduces muscle pain and tenderness in FS. Be sure, however, to choose a low-impact program.
Changing your attitude also can help improve your physical health. Several studies have shown the benefits of cognitive therapy for women with fibromyalgia. The three major research findings are:
* Negative thinking adds to stress.
* Thoughts affect the emotional perception of pain.
* Learning to control negative thoughts can have a major effect on symptoms.
The key is not so much to "think positively," but to "think non-negatively." When you have negative thoughts, put them to the test of reason and usefulness. Ask yourself: "Does this thought benefit me in any way -- does it improve the way I feel, advance my goals, or improve a relationship?"
Strategies for dealing with negative thoughts include the following:
* Alternative interpretation. You might start with a fairly neutral thought such as "I am tired today." From there, it's easy to go negative -- "I feel lousy. I won't get anything done today." An alternative, non-negative interpretation: "What strategies can I try for sleeping better, so I won't be so tired?"
* Anti-catastrophic reappraisal. This technique consists of challenging negative thoughts. You might have a catastrophic thought such as, "This fatigue is never going to get better. I'll never wake up with any energy." Try asking yourself: How likely is it that the fatigue will never get better? Have you ever been more fatigued than you are today?
* Coping statements. Try telling yourself you can handle the symptoms and reminding yourself of strategies you've used in the past to cope with or alleviate symptoms.
* Label shifting. The way we describe things influences our overall mood and physical sense of well being. You might describe someone who double-checks her work as either obsessive (negative) or careful (positive/neutral). Discarding a habit of negative labeling can boost your mood.
Changing the way you think, of course, is not easy. A cognitive therapist can guide the transition to a less-negative outlook.
As for medications, the drugs usually prescribed for muscular pain -- nonsteroidal anti-inflammatory drugs (NSAIDs), such aspirin, ibuprofen and naproxen -- are not as effective at treating fibromyalgia, but can be somewhat helpful in taking the edge off of pain. New types of NSAIDs known as COX-2 inhibitors are currently available by prescription only, and manufactured in two forms under the brand names of Celebrex and Vioxx. Unlike other NSAIDs, these drugs carry a much lower risk of GI side effects. Newer medications include tramdol (Ultram), a centrally acting analgesic, and neurontin (Gabapentin), a seizure medication that acts centrally on the brain. Ask your health care professional if these medications are appropriate for you. Occasionally, injections of anesthetics or corticosteroids (synthetic hormones with anti-inflammatory properties) are used to relieve acute tender-point pain. Narcotic pain medications should be avoided because they may result in dependence and may not improve quality of life.
When FS flares, your doctor may recommend a low-dose tricyclic antidepressant such as amitriptyline (Elavil) and a muscle relaxant called cyclobenzaprine (Flexeril), which may temporarily improve sleep and reduce pain. But the effects can wear off after a month, and these drugs have side effects such as grogginess and dry mouth. Tricyclics are not usually long-term treatment for FS.
Common sleeping aids are not effective for FS because they do not induce deeper sleep, or eliminate pain and fatigue. Instead, it's important to develop a daily schedule and stick to it, avoiding caffeine and other stimulants that might interfere with sleeping. Exercise during the day can also pay off with better sleep at night. The drug zolpidem tartrate (Ambien) is sometimes prescribed for short intervals to persons having severe sleep problems.
While these medications remain the mainstay of general FS treatment, health care professionals occasionally prescribe several other drugs for the treatment of particular FS-associated conditions: pramipexole (Mirapex) for restless legs syndrome, gabapentin (Neurontin) for nerve pain and tizandube hydrochloride (Zanaflex) for muscle spasm.
Other approaches to managing FS pain include physical therapy, massage, relaxation and biofeedback.
Treatment of fibromyalgia centers on managing its symptoms; there is no cure. Since symptoms vary, so will treatment. Treatment without medications -- such as exercise and improved sleep habits --may be as effective as drug-based strategies. Response to medications vary and may diminish over time.
If you are diagnosed with fibromyalgia, be prepared for trial and error in your medical treatment, as no definitive guidelines have been set. Researchers have reported some success with antidepressants, massage, hydrotherapy, biofeedback, hypnosis and acupuncture. It appears likely that a combination of exercise and counseling/education is an optimal approach, with other therapeutic alternatives used as needed.
Working on a positive attitude and improving your coping skills can also help. Improved sleep can decrease fatigue and pain.
Depression often accompanies fibromyalgia, although it is unclear whether the depression helps cause the disease, is a symptom of the disease, or arises in response to pain and other symptoms. Estimates vary, but 18 percent to 36 percent of fibromyalgia patients are depressed at any given time, and they have a greater than 50 percent risk of experiencing depression in their lifetime. However, despite the association, not everyone with fibromyalgia is depressed or will experience depression. If you have fibromyalgia and are also depressed, treating depression can help free your energy to manage the disease. But even if you don't have depression, antidepressants may be prescribed, since they have proven effective at treating some patients' symptoms in clinical trials.
Antidepressants, particularly fluoxetine (Prozac), nortriptyline (Pamelor), trazodone (Desyrel), doxepin (Sinequan) and amitrptyline (Elavil or Endep), are effective for pain and sleeplessness in some cases. In clinical trials, a combination of fluoxetine and amitriptyline worked better than the either drug alone. The drugs may work by addressing neurochemical imbalances, such as low levels of serotonin (a chemical in the brain that affects mood). Prozac is a selective serotonin reuptake inhibitor (SSRI) and can help keep normal levels of serotonin in the bloodstream. Tricyclic antidepressants can help patients relax and sleep better, but have side effects such as grogginess and dry mouth.
* If you’d like to join the support group Bipolarsucks2 go to: