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An Overview of Fibromyalgia for Newly Diagnosed Patients

Robert Bennett MD
 


 

Fibromyalgia (fi-bro-my-AL-ja) syndrome (FM) is a very common condition of widespread muscular pain and fatigue. Seven to ten million Americans suffer from FM. It affects women much more than men in an approximate ratio of 9:1. It is seen in all age groups from young children through old age, although in most patients the problem begins during their 20s or 30s. Recent studies have shown that fibromyalgia syndrome occurs world wide and has no specific ethnic predisposition.

 The Symptoms of Fibromyalgia Syndrome

Fibromyalgia syndrome patients have widespread body pain which often seems to arise in the muscles. Some FM patients feel their pain originates in their joints. Pain that emanates from the joints is called arthritis; extensive studies have shown FM patients do not have arthritis. Although many fibromyalgia syndrome patients are aware of pain when they are resting, it is most noticeable when they use their muscles, particularly with repetitive activities. Their discomfort can be so severe it may significantly limit their ability to lead a full life. Patients can find themselves unable to work in their chosen professions and may have difficulty performing everyday tasks. As a consequence of muscle pain, many FM patients severely limit their activities including exercise routines. This results in their becoming physically unfit - which eventually makes their fibromyalgia syndrome symptoms worse.

In addition to widespread pain, other common symptoms include a decreased sense of energy, disturbances of sleep, problems with memory and concentration and varying degrees of anxiety and depression. Furthermore, certain other medical conditions are commonly associated with fibromyalgia, such as: tension headaches, migraine, irritable bowel syndrome, overactive bladder, pelvic pain, premenstrual tension syndrome, cold intolerance and restless leg syndrome. For more detailed descriptions see Clinical Features of Fibromyalgia. Patients with established rheumatoid arthritis, lupus (SLE) and Sjogren's syndrome often develop fibromyalgia during the course of their disease. The combination of pain and multiple other symptoms often leads medical providers to pursue an extensive course of investigations - which are nearly always normal.

 Diagnosing Fibromyalgia Syndrome

There are no blood tests or x-rays which show abnormalities diagnostic of FM. This initially led many doctors to consider the problems suffered by FM patients were all "in their heads" or that fibromyalgia syndrome patients had a form of masked depression or hypochondriasis. Extensive psychological tests have shown these impressions were unfounded. A physician's diagnosis of FM is based on taking a careful history and the finding of tender areas in specific areas of muscle. These locations are called "tender points" or "trigger points". They are tender to palpation and often feel somewhat hardened if the muscle is stroked. Frequently, pressure over one of these areas will cause pain in a more peripheral distribution, hence the term trigger point.

The Long Term Outcome for Fibromyalgia Syndrome

Musculoskeletal pain and fatigue experienced by fibromyalgia syndrome patients is a chronic problem which tends to have a waxing and waning intensity. There is currently no "total" cure for this disorder, however worthwhile improvement may be obtained with appropriate treatment, as will be discussed later in this article. There is often concern on the part of patients, and sometimes physicians, that FM is the early phase of some more severe disease, such as multiple sclerosis, systemic lupus erythematosus, etc. Long term follow up of fibromyalgia patients has shown that it is very unusual for them to develop another rheumatic disease or neurological condition. However, it is quite common for patients with "well established" rheumatic diseases, such as rheumatoid arthritis, systemic lupus and Sjogren's syndrome to also have fibromyalgia. It is important for their doctor to realize they have such a combination of problems, as specific therapy for rheumatoid arthritis and lupus, etc. does not have any effect on FM symptoms. Patients with fibromyalgia syndrome do not become crippled with the condition, nor is there any evidence it effects the duration of their expected life span. Nevertheless, due to varying levels of pain and fatigue, there is an inevitable reduction of social, vocational and avocational activities which may lead to a reduced quality of life. As with many chronic diseases, the extent to which patients succumb to the various effects of pain and fatigue are dependent upon numerous factors; in particular their psycho-social support, financial status, childhood experiences, sense of humor and determination to prevail.

 The Treatment of Fibromyalgia Syndrome

The treatment of FM is frustrating for both patients and their physicians. In general, drugs which are usually to treat pain, such as aspirin, non-steroidals (e.g. ibuprofen) and even cortisone are not of any proven benefit. As in any chronic pain condition, education is an essential component that helps patients understand what can or can't be done, as well as teaching them to help themselves.

Pacing

Most FM patients quickly learn there are certain things they do on a daily basis that seem to make their pain problem worse. These actions usually involve the repetitive use of muscles or prolonged tensing of a muscle, such as the muscles of the upper back while looking at a computer screen. Careful detective work is required by the patient to note these associations and where possible to modify or eliminate them. Pacing of activities is important; we have recommended patients use a stop watch that beeps every 20 minutes. Whatever they are doing at that time should be stopped and a minute should be taken to do something else. For instance, if they are sitting down, they should get up and walk around or vice versa. 

Pain

Drugs such as aspirin and Advil are not particularly effective and seldom do more than take the edge off FM pain.  However, they are an important treatment modality for other common pain conditions such as osteoarthritis, which may accompany FM, thereby aggravating central sensitization. Opioid analgesics (e.g. propoxyphene, codeine, hydrocodone, morphine, oxycodone, methadone) may provide a worthwhile  relief of pain in a subgroup of severely afflicted patients, but fibromyalgia patients seem especially sensitive to opioid side effects (nausea, constipation, itching and mental blurring) and often decide against the long term use of these drugs. The use of opioid analgesics (narcotics) in the management of non-malignant pain has been a controversial issue for many doctors - the usually cited reasons for concern being addiction, oversight by state medical boards and criminal diversion of drugs.  However recent research has shown that addiction seldom occurs when these medications are use in chronic pain states. It is important to understand the difference between addiction and dependence (which occurs with all these drugs in the majority of patients (see Addiction/Dependence). Two particularly useful weak opioids in the management of FM pain are tramadol (Ultram) and the combination of tramadol with acetaminophen (Ultracet). Neither of these 2 medications is a FDA scheduled drug (i.e. they have minimal addiction potential). There is now good evidence that drugs commonly labeled for other uses are beneficial in treating FM associated pain. Antidepressants are one such class of drugs that also help pain irrespective of their antidepressant action. The most commonly used drugs of this class are the tricyclic antidepressants - TCAs (e.g. amitriptyline/Elavil, nortriyptyline
/Pamelor); a common drawback is the side effect profile of dry mouth, excessive drowsiness and weight gain. More recently a relatively new class of antidepressant medications has become available and proven beneficial in the treatment of FM associated pain, namely the SSNRIs. This stands for "selective serotonin and nor-epinephrine reuptake inhibitors" ; they differ from SSRIs (e.g. fluoxetine/Prozac, paroxetine/Paxil) in that they also inhibit the reuptake of nor-epinephrine in addition to serotonin. This combined increase of nor-epinephrine and serotonin has the effect of activating inhibitory pain mechanisms as well as improving symptoms of depression. It is important to note that you do not need to be depressed to benefit from this class of antidepressants; the available medications are duloxetine/Cymbalta and venlafaxine/Effexor, milnacipran is a similar drug currently in the testing phase.
Particularly painful areas often may be helped for a short time (2-3 months) by trigger point injections. This involves injecting a myofascial trigger point with a local anesthetic (usually 1% Procaine or lidocaine) and then stretching the involved muscle with a technique called spray and stretch. It should be noted the injection of a tender point is somewhat painful (indeed, if it is not painful the injection is seldom successful). After the injection, there is typically a 2-4 day lag before any beneficial effects are noted. Other techniques which directly help the tender areas on a transient basis are heat, massage, gentle stretching and acupuncture.

Sleep

It is important for a patient's physician to discover whether there is a cause for sleep disturbances. Such sleep problems include sleep apnea, restless leg syndrome and teeth grinding. If the cause for a patient's sleep disturbance cannot be determined, low doses of an anti-depressive group of drugs, called tricyclic anti-depressants or short acting sleeping medications such as zolpidem (Ambien), may be beneficial. Patients need to understand these medications are not addictive when used in low dosages (eg., Amitriptyline 10 mg at night) and have very few side effects. In general, routine use of sleeping pills such as Halcion, Restoril, Valium, etc. should be avoided as they impair the quality of deep sleep. Ambien (zolpidem), is claimed to avoid this problem. One of the most effective sleep medications for FM patients, sodium oxybate (Xyrem), was not approved by the FDA for use in FM patients due to concerns regarding safeguards for its distribution (it has an addictive potential). Interestingly Xyrem is FDA approved for use in patients with narcolepsy.

Exercise

There is increasing evidence that a regular exercise routine is essential for all fibromyalgia syndrome patients. This is easier said than done because increased pain and fatigue caused by repetitive exertion makes regular exercise quite difficult. However, those patients who persist with a low grade aerobic and stretching exercise regimen experience worthwhile improvement and are reluctant to give up. In general, FM patients must avoid impact loading exertion such as jogging, basketball, aerobics, etc. Regular walking, the use of a stationary exercycle and pool therapy utilizing an Aqua Jogger (a floatation device which allows the user to walk or run in the swimming pool while remaining upright) seem to be the most suitable activities for FM patients to pursue. Supervision by a physical therapist or exercise physiologist is of benefit wherever possible. In general, 20 minutes of physical activity, 3 times a week at 70% of maximum heart rate (220 minus your age) is sufficient to maintain a reasonable level of aerobic fitness.

Mood Disorders

About 40% of FM patients have a co-existing depression or anxiety state which needs to be appropriately treated with therapeutic doses of anti-depressants (e.g. TCAs, SSRIs and SSNRIs)or anti-anxiety drugs often in conjunction with the help of a clinical psychologist or psychiatrist. Basically, patients who have a concomitant psychiatric problem have a double burden to bear. They will find it easier to cope with their FM, if the psychiatric condition is appropriately treated. It is important to understand fibromyalgia syndrome itself is not a psychogenic pain problem and that treatment of any underlying psychological problems does not cure the fibromyalgia.

Disabillty

Patients who are involved in fairly vigorous manual occupations often need to have their work environment modified and may need to be retrained in a completely different job. Certain people are so severely affected, that consideration must be given to some form of monetary disability assistance. This decision requires careful consideration, as disability usually causes adverse financial consequences as well as a loss of self esteem. In general, doctors are reluctant to declare fibromyalgia patients disabled and most FM applicants are initially turned down by the Social Security Administration at the first review. However, each patient needs to be evaluated on an individual basis before any recommendations for or against disability are made.
 

 

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