What is fibromyalgia?
Fibromyalgia is a chronic condition that causes pain, stiffness, and tenderness of the muscles, tendons, and joints. Fibromyalgia is also characterized by restless sleep, awakening feeling tired, chronic fatigue, anxiety, depression, and disturbances in bowel function. Fibromyalgia is sometimes referred to as fibromyalgia syndrome and abbreviated FMS. Fibromyalgia was formerly known as fibrositis.
While fibromyalgia is one of the most common diseases affecting the muscles leading to chronic pain and disability, its cause is currently unknown. The painful tissues involved are not accompanied by tissue inflammation. Therefore, despite potentially disabling body pain, patients with fibromyalgia do not develop body damage or deformity. Fibromyalgia also does not cause damage to internal body organs. In this sense, fibromyalgia is different from many other rheumatic conditions (such as rheumatoid arthritis, systemic lupus, and polymyositis). In those diseases, tissue inflammation is the major cause of pain, stiffness, and tenderness of the joints, tendons and muscles, and it can lead to joint deformity and damage to the internal organs or muscles.
What causes fibromyalgia?
The cause of fibromyalgia is not known. Those affected experience pain in response to stimuli that are normally not perceived as painful. 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. Scientists note that there seems to be a diffuse disturbance of pain perception in patients with fibromyalgia.
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). The onset of fibromyalgia has been associated with psychological distress, trauma, and infection.
Whom does fibromyalgia affect?
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 are symptoms and signs of fibromyalgia?
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. Minor sensory stimuli that ordinarily would not cause pain in individuals can cause disabling, sometimes severe pain in patients with fibromyalgia. The body pain of fibromyalgia can be aggravated by noise, weather change, and emotional stress.
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. “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.
Fibromyalgia Tender Points Diagram
|Fibromyalgia “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.|
Fatigue occurs in 90% of patients. Fatigue may be related to abnormal sleep patterns commonly observed in these patients. 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 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 is difficult and no confirmatory laboratory tests are available, patients with fibromyalgia are often misdiagnosed as having depression as their primary underlying problem.
Other symptoms of fibromyalgia 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. Like fibromyalgia, irritable bowel syndrome can cause chronic abdominal pain and other bowel disturbances without detectable inflammation of the stomach or the intestines.
Each patient with fibromyalgia is unique. Any of the above symptoms can occur intermittently and in different combinations.
How is fibromyalgia diagnosed?
There are no blood tests or X-ray tests that specifically point the doctor to the diagnosis of fibromyalgia. These tests are done to exclude other possible diagnoses. Therefore, 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. Many medical conditions can cause pain in different areas of the body, mimicking fibromyalgia. These conditions include
- low thyroid hormone levels (hypothyroidism),
- vitamin D insufficiency,
- parathyroid disease (causing elevated blood calcium level),
- muscle diseases causing muscle pain (such as polymyositis),
- bone diseases causing bone pain (such as Paget’s disease),
- elevated blood calcium (hypercalcemia),
- infectious diseases (such as hepatitis, Epstein Barr virus, AIDS),
- and cancer.
Again, even though there is no blood test for fibromyalgia, blood tests are important to exclude other medical conditions. Therefore, thyroid hormone and calcium blood levels are obtained to exclude hypercalcemia, hyperparathyroidism, and hypothyroidism. The blood alkaline phosphatase (a bone enzyme) level is often raised in patients with Paget’s disease of the bone. The CPK (a muscle enzyme) level is often elevated in patients with polymyositis, a disease with diffuse muscle inflammation. Therefore, obtaining alkaline phosphatase and CPK blood levels can help the doctor decide whether Paget’s disease and polymyositis are the causes of bone and muscle pains. A complete blood count (CBC) and liver tests help in the diagnosis of hepatitis and other infections. A blood vitamin D level can detect vitamin D insufficiency.
Fibromyalgia can occur alone or in association with other systemic rheumatic conditions. Systemic rheumatic conditions refer to diseases that can cause inflammation and damage to numerous different tissues and organs in the body. Systemic rheumatic conditions associated with fibromyalgia include systemic lupus erythematosus, rheumatoid arthritis, polymyositis, and polymyalgia rheumatica. Blood tests which are helpful in evaluating these diseases when they are suspected include erythrocyte sedimentation rate (ESR), serum protein electrophoresis (SPEP), antinuclear antibody (ANA), and rheumatoid factor (RF). In patients with fibromyalgia without associated systemic illnesses, the ESR, SPEP, ANA, and RF blood tests are usually normal.
What are medications and other forms of treatment for fibromyalgia?
Since the symptoms of fibromyalgia are diverse and vary among patients, treatment programs must be individualized for each patient. Fibromyalgia treatment programs are most effective when they combine patient education, stress reduction, regular exercise, and medications. 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.
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. Therefore, community hospital support groups and the local chapters of the Arthritis Foundation have become important educational resources for patients and their doctors. The Arthritis Foundation is a national voluntary health organization that provides community education through their many local chapters. Community hospital support groups also provide an arena for patients to share their experiences and treatment successes and failures.
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. Stress reduction 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.
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.
Similarly, avoiding alcohol and caffeine before bedtime can also 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. There is no specific fibromyalgia diet or food supplements that are recommended for all patients. 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.
Traditionally, the most effective medications in the treatment of fibromyalgia have been the tricyclic antidepressants, medications traditionally used in treating depression. In treating fibromyalgia, tricyclic antidepressants are taken at bedtime in doses that are a fraction of those used for treating depression and actually can be beneficial as sleep aids. Tricyclic antidepressants appear to reduce fatigue, relieve muscle pain and spasm, and promote deep, restorative sleep in patients with fibromyalgia. Scientists believe that tricyclics work by interfering with a nerve transmitter chemical in the brain called serotonin. 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. These two medications also tend to cancel out certain side effects each can have. Tricyclic medications can cause tiredness and fatigue, while Prozac can make patients more cheerful and awake. A study of patients with resistant fibromyalgia found that lorazepam (Ativan) was helpful in relieving symptoms. Prozac has also been shown to be effective when used alone for some patients with fibromyalgia. Trazodone can be taken at bedtime to improve sleep when tricyclic antidepressants are not tolerated.
In 2007, pregabalin (Lyrica) became the first medication approved specifically for treating fibromyalgia. Lyrica may work by blocking nerve pain in patients with fibromyalgia. Lyrica has advantages of flexible dosing that can be adjusted according to persisting symptoms. A related medication, gabapentin (Neurontin), is also used to treat fibromyalgia.
More recently, drugs that simultaneously increase the amount of two brain nerve transmitters, serotonin and norepinephrine, have been approved to treat fibromyalgia in adults. These drugs include duloxetine (Cymbalta) and milnacipran (Savella). Research studies have shown significant effectiveness in decreasing pain and improving function in patients with fibromyalgia with these drugs. Cymbalta has been effective in treating depression and relieving pain in people with depression and is also used to treat anxiety.
Other fibromyalgia treatments
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. Some studies indicate that the pain reliever tramadol (Ultram) and tramadol/acetaminophen (Ultracet) may be helpful for the treatment of fibromyalgia pains. The muscle relaxant cyclobenzaprine (Flexeril) has been helpful for reducing pain symptoms and improving sleep.
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 and cortisone medications have not been shown to be beneficial in this condition. Narcotics and cortisone medications are avoided because they have not been shown to be beneficial, and they have potential adverse side effects, including dependency, when used long term.
Both biofeedback and electroacupuncture have been used for relief of symptoms with some success. Standard acupuncture has also been reported to be effective in treating some patients with fibromyalgia. Massage therapy is beneficial for some.
Of note, there are many other modalities and medications that are touted to be helpful for patients with this chronic condition. Unfortunately, most have no scientific basis for their usage. This includes guaifenesin (Humibid, Humibid LA, Robitussin, Organidin NR, Fenesin), copper bracelets, and magnets. Consumers should be especially cautious when products come with marketing claims such as “will cure,” “ancient remedy,” “has no side effects,” and “revolutionary new scientific breakthrough.”
What is the outlook (prognosis) for patients with fibromyalgia?
The outlook for patients with fibromyalgia is generally quite good. It is important to note that fibromyalgia is not an organ-threatening illness. 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.
Can fibromyalgia be prevented?
There is no method of preventing fibromyalgia. Exacerbations of fibromyalgia can be minimized with exercise, promotion of optimal sleep, stress reduction, and proper medical treatment.
What is in the future for fibromyalgia therapy?
The key to unlocking the mystery of fibromyalgia has yet to be found. Research scientists have been studying numerous viruses as potential causes for fibromyalgia. Identification of an infectious agent or toxin which causes the disease may one day lead to a laboratory test that can help doctors diagnose fibromyalgia. Specific fibromyalgia treatment aimed at a cure awaits future research that uncovers the exact cause of the disease.
Recent scientific studies suggest that a specific area of the brain called the insula may be involved in the pathophysiology of fibromyalgia. New drugs may be developed that block substance P or nerve growth factor to relieve pain of fibromyalgia. Many fibromyalgia patients can be helped by improved patient education, proper exercise, and medications. With ongoing research, the future prognosis will certainly improve for those affected by fibromyalgia.
Where can people find more information about fibromyalgia and support groups?
PO Box 19000
Atlanta, GA 30326
Klippel, John H., et al., eds. Primer on the Rheumatic Diseases. 13th ed. New York: Springer and Arthritis Foundation, 2008.
Rao, Srinivas G., Judith F. Gendreau, and Jay D. Kranzler. “Understanding the Fibromyalgia Syndrome.” Psychopharmacol Bull. 40.4 (2008): 24-56.