David S. Klein, M.D.
Fibromyalgia Syndrome
Fibromyalgia, Fibromyalgia Syndrome (FMS), and sometimes referred to as 'fibromyositis, is an interesting disorder that results in pain, often disproportionate to the physical findings. FMS sometimes results in symptoms that are more severe than might be anticipated by an injury or illness. FMS is not entirely well understood, but the basic pathological process involves vascular-induced fibrotic changes within the involved muscles. That is, the injured area slowly turns to “gristle.” Unfortunately, once Fibromyalgia has become established, the process may not be entirely reversible. Arrest of the progression of the illness is often a shallow victory.
Fibromyalgia afflicts between three million to six million Americans, the incidence is greater in women than in men, and a great many of these women are of childbearing age. Fibromyalgia affects as many as 1 in 50 Americans. Most people with fibromyalgia are women, most are diagnosed during middle age.
Physical activity and activities of daily life can influence the return of pain after a patient feels well, and certain physical activities can re-exacerbate the problem. The patient does not do this intentionally or even knowingly, but as the disease becomes controlled, and with the absence of the pain, a factor is removed that otherwise would have limited normal movement and activity. There is no real damage done.
The disease process which may have been controlled then becomes active once again; he injured area often becomes re-aggravated. It may not become apparent until a day of two following the physical activity or event, and often, for this reason, cause and effect may not be recognized by the patient. This is a common problem, but does not materially effect ultimate recovery. It is a minor set-back and is to be expected.
Fibromyalgia is a Constellation of Symptoms, not a discreet disorder.
Fibromyalgia is a disorder that causes muscle pain and fatigue. FMS suffers have symmetric "tender points" on the trunk, neck and extremities. People with fibromyalgia may also have other symptoms, e.g.:
- Insomnia
- Morning stiffness
- Headache
- Dysmenorrhea or excessively painful menstrual periods
- Tingling an/or numbness in hands and feet
- Cognitive & memory dysfunction
Etiology of Fibromyalgia:
FMS has no known cause. In fact, it is highly likely that FMS is caused by many medical problems. The most common cause of FMS is sub-clinical hypothyroidism, followed by adrenal fatigue syndrome (sub-clinical Addison's Disease) and auto-immune syndromes. Other causes include viral/parasitic illness, sleep deprevation and neoplasm. Fibromyalgia has been linked to:
- Auto-immune diseases
- Endocrine (hormonal imbalance) disorders
- Cancer
- Stressful or traumatic events, such as car accidents
- Repetitive injuries
- Illness
- Fibromyalgia can also occur on its own.
- There is some suggestion there may be a genetic predisposition to FMS.
How Is Fibromyalgia Treated?
Fibromyalgia is difficult to treat. Many different types of physicians are familiar with FMS, including: Pain Management, Anesthesiology, Physical Medicine/Rehabilitation, Family Physicians, Internists. Most patient with FMS are treated by Family Practitioniers, and the smallest minority of patients with FMS are referred to rheumatologists.
Fibromyalgia treatment often requires a team approach. The team may include your doctor, a physical therapist, and possibly other health care providers. A pain or rheumatology clinic can be a good place to get treatment.
The U.S. Food and Drug Administration (FDA) has not yet approved any medicines to treat fibromyalgia. Doctors treat fibromyalgia with medicines approved for other purposes. Pain medicines and antidepressants are often used in treatment.
What Can I Do to Try to Feel Better?
There are many things you can do to feel better, including:
- Taking medicines as prescribed
- Getting enough sleep
- Exercising
- Eating well
- Making work changes if necessary
Fibromyalgia (FM) is an increasingly recognized chronic pain illness which is characterized by widespread musculoskeletal aches, pain and stiffness, soft tissue tenderness, general fatigue and sleep disturbances. The most common sites of pain include the neck, back, shoulders, pelvic girdle and hands, but any body part can be involved. Fibromyalgia patients experience a range of symptoms of varying intensities that wax and wane over time.
It is estimated that approximately 3-6% of the U.S. population has FM. Although a higher percentage of women are affected, it does strike men, women and children of all ages and races. Because of its debilitating nature, Fibromyalgia has a serious impact on patients' family, friends, and employers, as well as society at large.
FM is characterized by the presence of multiple tender points and a constellation of symptoms.
Pain: The pain of FM is profound, widespread and chronic. It knows no boundaries, migrating to all parts of the body and varying in intensity. FM pain has been described as deep muscular aching, throbbing, twitching, stabbing and shooting pain that defines the very existence of the Fibromyalgia patient. Neurological complaints such as numbness, tingling and burning are often present and add to the discomfort of the patient. The severity of the pain and stiffness is often worse in the morning. Aggravating factors which affect pain include cold/humid weather, non-restorative sleep, physical and mental fatigue, excessive physical activity, physical inactivity, anxiety and stress.
Fatigue: In today's world many people complain of fatigue; however, the fatigue of FM is much more than being tired. It is an all-encompassing exhaustion that interferes with even the simplest daily activities. It feels like every drop of energy has been drained from the body, which at times can leave the patient with a limited ability to function both mentally and physically.
Sleep Problems: Many Fibromyalgia patients have an associated sleep disorder which prevents them from getting deep, restful, restorative sleep. Medical researchers have documented specific and distinctive abnormalities in the stage 4 deep sleep of FM patients. During sleep, individuals with FM are constantly interrupted by bursts of awake-like brain activity, limiting the amount of time they spend in deep sleep.
Other symptoms: Additional symptoms may include: irritable bowel and bladder, headaches and migraines, restless legs syndrome (periodic limb movement disorder), impaired memory and concentration, skin sensitivities and rashes, dry eyes and mouth, anxiety, depression, ringing in the ears, dizziness, vision problems, raynaud's syndrome, neurological symptoms and impaired coordination.
Currently there are no laboratory tests available for diagnosing Fibromyalgia. Doctors must rely on patient histories, self-reported symptoms, a physical examination and an accurate manual tender point examination. This exam is based on the standardized ACR criteria. Proper implementation of the exam determines the presence of multiple tender points at characteristic locations.
It is estimated that it takes an average of five years for a FM patient to get an accurate diagnosis. Many doctors are still not adequately informed or educated about FM. Laboratory tests often prove negative and many FM symptoms overlap with the symptoms of other conditions, thus leading to extensive investigative costs and frustration for both the doctor and patient. Another essential point that must be considered is that the presence of other diseases, such as rheumatoid arthritis or lupus, does not rule out a FM diagnosis. Fibromyalgia is not a diagnosis of exclusion and must be diagnosed by its own characteristic features.
To receive a diagnosis of FM, the patient must meet the following diagnostic criteria:
- Widespread pain in all four quadrants of the body for a minimum duration of three months
- Tenderness or pain in at least 11 of the 18 specified tender points when pressure is applied (see figure above) - NO FIGURE - EITHER SITE
While the underlying cause or causes of FM still remain a mystery, new research findings continue to bring us closer to understanding the basic mechanisms of Fibromyalgia. Most researchers agree that FM is a disorder of central processing with neuroendocrine/neurotransmitter dysregulation. The FM patient experiences pain amplification due to abnormal sensory processing in the central nervous system. An increasing number of scientific studies now show multiple physiological abnormalities in the FM patient, including: increased levels of substance P in the spinal cord, low levels of blood flow to the thalamus region of the brain, HPA axis hypofunction, low levels of serotonin and tryptophan and abnormalities in cytokine function.
Recent studies show that genetic factors may predispose individuals to a genetic susceptibility to FM. For some, the onset of FM is slow; however, in a large percentage of patients the onset is triggered by an illness or injury that causes trauma to the body. These events may act to incite an undetected physiological problem already present.
Exciting new research has also begun in the areas of brain imaging and neurosurgery. Continued work will look at the hypothesis that FM is caused by an interpretative defect in the central nervous system that brings about abnormal pain perception. Medical researchers have just begun to untangle the truths about this life-altering disease.
One of the most important factors in improving the symptoms of FM is for the patient to recognize the need for lifestyle adaptation. Most people are resistant to change because it implies adjustment, discomfort and effort. However, in the case of FM, change can bring about recognizable improvement in function and quality of life. Becoming educated about FM gives the patient more potential for improvement.
An empathetic physician who is knowledgeable about the diagnosis and treatment of FM and who will listen to and work with the patient is an important component of treatment. It may be a family practitioner, an internist or a specialist (rheumatologist or neurologist, for example). Conventional medical intervention may be only part of a potential treatment program. Alternative treatments, nutrition, relaxation techniques and exercise play an important role in FM treatment as well. Each patient should, along with the healthcare practitioner, establish a multifaceted and individualized approach that works for them.
Pain Management Over-the-counter pain medications, such as acetaminophen or ibuprofen, may be helpful in relieving pain. The physician may decide to prescribe one of the newer non-narcotic pain relievers (e.g. tramadol) or low doses of antidepressants (e.g. tricyclic antidepressants, serotonin reuptake inhibitors) or benzodiazepines. Patients must remember that antidepressants are "serotonin builders" and can be prescribed at low levels to help improve sleep and relieve pain. If the patient is experiencing depression, higher levels of these or other medications may need to be prescribed. Another beneficial pain therapy, which works well on localized areas of pain, is lidocaine injections into the patient's tender points.
An important aspect of pain management is a regular program of gentle exercise and stretching, which helps maintain muscle tone and reduces pain and stiffness.
Sleep Management Improved sleep can be obtained by implementing a healthy sleep regimen, which includes going to bed and getting up at the same time every day, making sure that the sleeping environment is conducive to sleep (i.e. quiet, free from distractions, a comfortable room temperature, a supportive bed), avoiding caffeine, sugar and alcohol before bed, doing some type of light exercise during the day, avoiding eating immediately before bedtime and practicing relaxation exercises as you fall to sleep. When necessary, there are new sleep medications that can be prescribed, some of which can be especially helpful if the patient's sleep is disturbed by restless legs or periodic limb movement disorder.
Psychological Support Learning to live with a chronic illness often challenges an individual emotionally. The FM patient needs to develop a program that provides emotional support and increases communication with family and friends. Many communities throughout the United States and abroad have organized Fibromyalgia support groups. These groups often provide important information and have guest speakers who discuss subjects of particular interest to the FM patient. Counseling sessions with a trained professional may help improve communication and understanding about the illness and help to build healthier relationships within the patient's family.
Other Treatments Complementary therapies can be very beneficial. These include: physical therapy, therapeutic massage, myofascial release therapy, water therapy, light aerobics, acupressure, application of heat or cold, acupuncture, yoga, relaxation exercises, breathing techniques, aromatherapy, cognitive therapy, biofeedback, herbs, nutritional supplements, and osteopathic or chiropractic manipulation.
Better than ever before! The efforts of individuals, support groups, organizations and medical professionals to help improve the quality of life for people with FM are starting to pay off. Better ways to diagnose and treat FM are on the horizon. The symptoms of FM can vary in severity and often wax and wane, but most patients do tend to improve over time.
Heightened sensitivity. It's common for people with fibromyalgia to report being sensitive to odors, noises, bright lights and touch.
Other common signs and symptoms include:
- Depression
- Numbness or tingling sensations in the hands and feet (paresthesia)
- Difficulty concentrating
- Mood changes
- Chest pain
- Irritable bladder
- Dry eyes, skin and mouth
- Painful menstrual periods
- Dizziness
- Anxiety
- Headaches and facial pain. Many people who have fibromyalgia also have headaches and facial pain that may be related to tenderness or stiffness in their neck and shoulders. Temporomandibular joint (TMJ) dysfunction, which affects the jaw joints and surrounding muscles, is also common in people with fibromyalgia.
- Irritable bowel syndrome (IBS). The constipation, diarrhea, abdominal pain and bloating associated with IBS are common in people with fibromyalgia.
Signs and symptoms of fibromyalgia can vary, depending on the weather, stress, physical activity or even just the time of day. Different people experience different signs and symptoms, but common signs and symptoms include:
- Widespread pain. Fibromyalgia is characterized by pain in specific areas of your body when pressure is applied. These areas include the back of your head, upper back and neck, upper chest, elbows, hips and knees. The pain generally persists for months at a time and is often accompanied by stiffness.
- Fatigue and sleep disturbances. People with fibromyalgia often wake up tired and unrefreshed even though they seem to get plenty of sleep. Some studies suggest that this sleep problem is the result of a sleep disorder called alpha wave interrupted sleep pattern, a condition in which deep sleep is frequently interrupted by bursts of brain activity similar to wakefulness. So people with fibromyalgia miss the deep restorative stage of sleep (stage 4). Nighttime muscle spasms in your legs (periodic limb movement disorder or nocturnal myoclonus) and restless legs syndrome also may be associated with fibromyalgia.
Over 6 million Americans, 90% of them women in the prime of their life, suffer from FMS and sometimes struggle for years before being correctly diagnosed.
Symptoms usually appear between 20-55 years of age, but children are also diagnosed with fibromyalgia syndrome.
Pain and severe fatigue may keep FMS sufferers from their chosen profession and unable to perform common daily tasks.
- Rheumatoid arthritis
- Systemic lupus erythematosus (commonly called lupus)
- Ankylosing spondylitis (spinal arthritis)
NOTE: Fibromyalgia is most likely a symptom complex caused by another, undelying problem. The first responsibility of the patient is to search for the underlying cause, because only then will treatment be effective.
In our population, the most common causes of Fibromyalgia are undiagnosed or sub-clinical hypothyroidism, adrenal fatigue and hypogonadism. That is, FMS is usually caused by an underlying endocrine problem.
David S. Klein, MD, FACA, FACPM, FACMIMS
Director, Pain Center of Orlando
www.suffernomore.com