FIBROMYALGIA

Guiomar Goransson, RN

Fibromyalgia is a chronic idiopathic illness characterized by pain in muscles, joints, ligaments and tendons; chronic fatigue, and multiple tender points. "Tender points" refers to tenderness that occurs in precise, localized areas, particularly around the neck, spine, shoulders, hips, knees, and elbows. People with this syndrome may also experience sleep disturbances, morning stiffness, irritable bowel syndrome, and anxiety. (National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse, December 1999)

Increased sensitivity to pain is the hallmark of fibromyalgia. Many other symptoms also occur in people with this disorder. Symptoms may come and go and can get worse and vary in response to activity, stress, weather changes and other factors. Some may have muscle tightening or spasms with a deep ache or a burning pain. Some have migratory pain. Sensitivity to odors, bright lights, loud noises and even medicines, along with headaches, jaw pain, vertigo, chest pain, tachycardia, or dyspnea, numbness in limbs, difficulty swallowing, heartburn, flatulence, cramping, abdominal pain, dry eyes or difficulty focusing on nearby objects, polyuria, alternating diarrhea and constipation are also common. (American Adcademy of Family Physicians, Treating Fibromyalgia Nov. 2001)

Most people with fibromyalgia are chronically fatigued. This may be mild or very severe. They may also have trouble sleeping, which adds to the fatigue.

Depression or anxiety may occur as a result of chronic pain, fatigue, and frustration experienced. (American Adcademy of Family Physicians)

Fibromyalgia affects an estimated 6 million to 8 million people. Approximately 80 percent of affected people are women. It tends to develop in people between the ages of 20 and 60. But it can occur in children. (Fibromyalgia, May 23, 2001 Mayo Foundation for Medical Education and Research - MFMER)

The etiology of fibromyalgia is so far unknown, however, much research is currently being done. One study suggested that the same chemical imbalances in the brain that causes fibromyalgia also causes depression and anxiety. (American Adcademy of Family Physicians) Another suggests that some people with fibromyalgia have alterations in the regulation of certain neurotransmitters. Particularly serotonin, which is linked to depression, migraines and gastrointestinal distress. Also substance P, a brain chemical associated with pain, stress and anxiety, as well as depression. (MFMER)

Recent National Institute of Arthritis and Musculoskeletal and Skin Diseases studies show that abnormally low levels of the hormone cortisol may be associated with fibromyalgia. At Brigham and Women's Hospital in Boston, Massachusetts, and at the University of Michigan Medical Center in Ann Arbor, researchers are studying regulation of the function of the adrenal gland (which makes cortisol) in fibromyalgia. People whose bodies make inadequate amounts of cortisol experience many of the same symptoms as people with fibromyalgia. It is hoped that these studies will increase understanding about fibromyalgia and may suggest new ways to treat the disorder. (National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse)

Some researchers theorize that disturbed sleep patterns may be a cause rather than just a symptom of fibromyalgia. Studies have shown abnormally low levels of a hormone called somatomedin C in the blood of people with fibromyalgia. Somatomedin C is thought to be essential for the body to rebuild itself and is secreted only during stage 4 sleep. (MFMER)

Injuries to the upper spinal region; and viral or bacterial infection may trigger the development of fibromyalgia in some individuals. (MFMER)

Several studies have looked at the responses of the sympathetic nervous system in subjects with fibromyalgia. Abnormalities of the sympathetic nervous system has also been been identified as a possible trigger. The sympathetic nervous system releases norepinephrine and influences the release of epinephrine from the adrenal gland. The sympathetic nervous system controls bodily functions that are not consciously controlled, such as heart rate, blood vessel contraction, sweating, salivary flow and intestinal movements. There are reports of reduced epinephrine responses to low blood sugar levels and exercise. Other reported abnormalities include decreased responses to cold and altered heart rate and blood pressure responses during tilt-table testing — a noninvasive procedure normally used to help diagnose a common form of fainting (syncope). (MFMER)

Risk factors for fibromyalgia include: disturbed sleep patterns. It's unclear whether sleeping difficulties are a cause or a result of fibromyalgia, but people with sleep disorders such as sleep apnea or restless legs syndrome can also develop fibromyalgia. Heredity and gender can also play a role. It's estimated that fibromyalgia occurs between 70 percent and 90 percent more often in women than in men. (MFMER) Women experience significantly more fatigue, morning fatigue, hurt all over, total number of symptoms, and irritable bowel syndrome than men. Women usually have significantly more tender points. Pain severity, global severity and physical functioning are not significantly different between the sexes, nor are psychologic factors, eg, anxiety, stress, and depression. (Yunus MB, Curr Rheumatol Rep 2001 Apr;3(2):128-34 The role of gender in fibromyalgia syndrome.)

The American College of Rheumatology has established some general classification guidelines for fibromyalgia to help in the assessment and study of the condition. The guidelines require that the patient have widespread aching for at least 3 months and a minimum of at least 11 of 18 (National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse) specific tender point sites. Not all doctors agree with the guidelines. Some believe that the criteria are too rigid and that fibromyalgia can exist even if the patient does not present the required number of tender points. Others question how reliable and valid tender points are as a diagnostic tool. (MFMER)

Fibromyalgia and chronic fatigue syndrome (CFS) share a number of symptoms, and the names are often used interchangeably in medical literature. Many experts, however, think fibromyalgia and CFS are the same, or are at least variations of the same, pain and fatigue syndrome.

Research shows that between 50-70% of those with fibromyalgia also fit the criteria for CFS, and vice versa. Because the symptoms are so similar, the difference between one diagnosis and another may be simply a matter of degree. "Most patients with CFS have some kind of pain, and, as noted earlier, that is a hallmark of fibromyalgia. And most patients with fibromyalgia report fatigue, a hallmark of CFS. Likewise, both involve a high frequency of sleep and cognitive disturbances," says Cary Engleberg, MD, chief of the infectious diseases division at the University of Michigan Medical School in Ann Arbor. (Arthritis Foundation, 2003, What's in a Name: Fibro vs. CFS)

There are a few documented differences between the conditions. Fibromyalgia often is traced to an injury or physical or emotional trauma, whereas CFS tends to have a flu-like onset. People with CFS only do not have tender points. (Arthritis Foundation)

Treatment of fibromyalgia requires a comprehensive approach. The physician, physical therapist, and patient may all play an active role in the management of fibromyalgia. Studies have shown that low-impact aerobic exercise such as swimming, walking or water exercise, stationary bicycling and exercising on ski-type machines (American Adcademy of Family Physicians) improves muscle fitness and reduces muscle pain and tenderness. Heat and massage may also give short-term relief. Antidepressant medications, such as Wellbutrin, may help elevate mood, improve quality of sleep, and relax muscles. Muscle relaxants can provide relief of muscular stiffness and pain. Patients with fibromyalgia may benefit from a combination of exercise, medication, physical therapy, and relaxation. (National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse)

Because the symptoms of fibromyalgia are made worse by stress and poor sleep, it is important that the patient learn how to lower his stress levels and get an adequate amount of sleep. Since alcohol and caffeine cause poor sleep, these substances should be avoided around bedtime. Psychological counseling may be beneficial to the individual who can not manage his stress responses.

Other simple lifestyle changes may be helpful: Pacing of one’s activities from day to day. Many people with fibromyalgia try to do as much as possible on "good" days, which leads them to have several "bad" days.( American Adcademy of Family Physicians)

Some physicians, in an attempt to combat a debilatating illness about which little is known, are prescribing off-label uses of other drugs, such as Guaifenesin to combat symptoms. Guaifenesin is a component of many cold and cough preparations added to liquefy mucus. It is throught to help reverse some symptoms of fibromyalgia. (Starlanyl, MD, Devin, Guaifenesin - Fibromyalgia/Myofascial Pain Syndrome Medications, 1998)

Gabapentin (Neurontin), a novel antiepileptic has a growing multitude of medical studies showing it effective for off-label illnesses, such as muscle pain associated with fibromyalgia, multiple sclerosis, and diabetic neuropathy among many others. (Rosenberg JM, Harrell C, Ristic H, Werner RA, de Rosayro AM, The effect of gabapentin on neuropathic pain. Abstract. Clin J Pain 1997 Sep;13(3):251-255) While its off-label use has been very controversial, there is a large body of literature detailing individual case reports of gabapentin used to treat neuropathic pain associated with infection, noninfective illness, injury/trauma, or pain of uncertain origin; these reports generally show gabapentin to be effective and relatively free from adverse events. The same conclusions have been drawn from case series and open-label clinical trials, and has most recently found support in double-blind, placebo-controlled trials. Further study is certainly needed to evaluate the clinical efficacy of gabapentin in treating neuropathic pain, however, the findings so far available indicate that it is an effective treatment for pain originating in a wide variety of neuropathic states. (Johnson FN, Johnson RD, Armer ML Prestations à l'intention de médecins et pharmaciens suisse. Gabapentin in the treatment of neuropathic pain. Rev Contemp Pharmacother, 2001;12(3/4):125-211)

Although fibromyalgia causes symptoms that can be very uncomfortable and debilatating, muscles and organs are not being damaged. This condition is not life-threatening, but it is chronic. At this time there is no cure (American Adcademy of Family Physicians) and it is important that both the physician and the patient take a comprehensive approach to treating symptoms. "Rational treatment” consists of maintaining good general health -- in other words, a balanced diet and exercise as tolerated, and symptomatic relief of pain, sleep or mood disorders with carefully selected medications or cognitive behavioral therapy, (Arthritis Foundation)

RESOURCES

American Adcademy of Family Physicians

Treating Fibromyalgia,

November 2001

http://familydoctor.org/handouts/070.html#symptoms

http://www.arthritis.org/resources/news/news_fibro_cfs.asp

Johnson FN, Johnson RD, Armer ML Prestations à l'intention de médecins et pharmaciens suisse. Gabapentin in the treatment of neuropathic pain. Rev Contemp Pharmacother, 2001;12(3/4):125-211

http://www.neurontin.ch/fr/therapy/literature/lit_002_2.html

Mayo Foundation for Medical Education and Research (MFMER), Fibromyalgia, May 23, 2001. http://www.mayoclinic.com/invoke.cfm?id=DS00079

National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse December 1999

http://www.niams.nih.gov/hi8iitopics/fibromyalgia/fibrofs.htm#fib_a

Rosenberg JM, Harrell C, Ristic H, Werner RA, de Rosayro AM, The effect of gabapentin on neuropathic pain. Abstract. Clin J Pain 1997 Sep;13(3):251-255

Department of Anesthesiology, University of Michigan Health System, Ann Arbor,

http://home.tampabay.rr.com/lymecfs/list3.htm

Starlanyl, MD, Devin, Guaifenesin - Fibromyalgia/Myofascial Pain Syndrome Medications, 1998

This is EXPERIMENTAL THERAPY.

http://www.tidalweb.com/fms/guai.shtml

Yunus MB, Curr Rheumatol Rep 2001 Apr;3(2):128-34 The role of gender in fibromyalgia syndrome. ABSTRACT

College of Medicine at Peoria, University of Illinois, One Illini Drive, PO Box 1649, Peoria, IL 61656, USA. Yunus@uic.edu

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11286669&dopt=Abstract