Fibromyalgia Disorder

Overview

Fibromyalgia is a chronic disorder characterized by widespread pain and reduced pressure pain threshold (tender points). People with fibromyalgia may also experience fatigue, sleep disturbances, stiffness, deep tenderness, soreness and achiness, increased headaches or facial pain, difficulty concentrating, forgetfulness and problems multitasking. Patients with fibromyalgia frequently report functional impairment and diminished quality of life.

The cause of fibromyalgia is unknown, but recent evidence suggests it is associated with abnormalities in the central nervous system processing of pain. Fibromyalgia patients develop an increased response to painful stimuli and experience pain from non-painful stimuli such as touch. This is thought to reflect enhanced pain processing that is characteristic of central pain sensitization.

Patients with fibromyalgia have been found to have elevated levels of substance P in their spinal fluid, a chemical that helps transmit pain signals from the brain. Fibromyalgia patients also have been found to have reduced spinal fluid levels of neurotransmitters such as norepinephrine and serotonin that are involved in the pain inhibitory pathways in the central nervous system. Scientists are investigating how the brain and spinal cord process pain and how substance P and other neurotransmitters fit into the process.

Diagnosis

Fibromyalgia is defined by the American College of Rheumatology as chronic (three months or more) widespread pain and pain on palpation of 11 of 18 tender points. Common associated symptoms include sleep problems, fatigue, cognitive impairment and mood disturbances. Even though it is recognized as a legitimate clinical entity, experts think it continues to be underdiagnosed or misdiagnosed.

If you suspect you may have this condition, discuss your symptoms with your primary care physician. Your primary physician may refer you to other medical professionals for further evaluation. For example, you may be referred to a rheumatologist, who specializes in disorders affecting the joints, muscles, tendons, ligaments and bones.

Even with the right doctor, fibromyalgia can be difficult to diagnose. Many of its symptoms are variable, so they’re not always there, and many are common across numerous medical conditions. There is no specific medical test for fibromyalgia.

The American College of Rheumatology criteria for fibromyalgia require that a person has had widespread pain above and below the waist, on both sides of the body and in the axial skeleton, for at least three months, as well as pain on palpation of at least 11 of 18 specific tender point sites. You can view an illustration of common tender points in fibromyalgia at http://www.nlm.nih.gov/medlineplus/ency/imagepages/9758.htm.

Treatment

Treating fibromyalgia requires a comprehensive, multidisciplinary approach. Among the most effective treatments are medications, exercise, sleep management and cognitive behavioral therapy.

Treatment centers on managing the symptoms of fibromyalgia; there is no cure. Since symptoms vary, so does treatment.

Exercise

Exercise may seem an impossibly tall order—after all, if you’re in pain, how can you work out? But if you don’t get regular aerobic exercise, your muscles become weaker, making them even more susceptible to pain during everyday tasks. In fact, studies find that aerobic exercise such as swimming and walking improves muscle fitness and reduces muscle pain and tenderness in people with fibromyalgia. Stick with a low-impact exercise program such as walking, swimming or water aerobics, and be sure to discuss any new exercise program with your health care professional if you’ve been inactive.

Exercise can also help you sleep better, improve your mood, reduce pain, increase flexibility, improve blood flow, help you manage your weight and promote general physical fitness. It is inexpensive and, if done correctly, has few negative side effects.

When you exercise, listen to your body and know when to stop or slow down to prevent pain caused by over-exercising. Talk to your health care professional about how to introduce exercise into your life in a way that is tolerable and safe. In some situations, your health care professional may recommend physical therapy with therapists knowledgeable in fibromyalgia management, who can help you with a physical rehabilitation program.

Attitude Can Improve Symptoms

Your psychological outlook is important, with studies finding benefits from cognitive therapy for women with fibromyalgia. Specifically, studies find, negative thinking increases stress and affects your perception of pain, so learning to minimize and control these thoughts can improve your symptoms.

The key is not so much to “think positively,” but to “think non-negatively.” So when negative thoughts occur, 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:

  • Alternative interpretation. You might start with a fairly neutral thought such as “I’m 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 could be: “What strategies can I try to sleep better so I won’t feel 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.” When you have such thoughts, ask yourself: How likely is it really that the fatigue will never get better? Have you ever been more fatigued than you are today?
  • Coping statements. In these statements, you tell yourself that you can handle these symptoms, and remind yourself of strategies you’ve used in the past to cope with or alleviate symptoms.
  • Label shifting. How we describe things influences our overall mood and physical sense of well-being. So instead of viewing your pain as excruciating, try describing it as uncomfortable, or view it as a warning that maybe you’ve been overdoing it.

Medications 

Pregabalin (Lyrica), previously approved by the U.S. Food and Drug Administration for adjunctive treatment of partial onset seizures and certain types of neuropathic pain, was the first medication to be approved for treating fibromyalgia. Common side effects may include dizziness, sleepiness, dry mouth, swelling, blurred vision, weight gain and difficulty with concentration and attention.

Duloxetine (Cymbalta), previously approved for the treatment of major depression, generalized anxiety disorder and diabetic peripheral neuropathic pain, is also approved for treating fibromyalgia and for treatment of chronic musculoskeletal pain due to chronic osteoarthritis pain and chronic low back pain. Common side effects of duloxetine may include nausea, dry mouth, constipation, sleepiness, increased sweating and decreased appetite. And the third medication approved for the treatment of fibromyalgia is milnacipran (Savella). Common side effects of milnacipran may include nausea, constipation, hot flush, increased sweating, vomiting, palpitations, increased heart rate, dry mouth and hypertension.

Other medications that have medical evidence to support their use in fibromyalgia but are not currently indicated for the treatment of fibromyalgia include the following:

  • Antidepressants, including the tricyclic antidepressant amitriptyline (Elavil) and the selective serotonin reuptake inhibitor fluoxetine (Prozac).
  • Tramadol (Ultram), a centrally acting analgesic for pain relief, which may be taken with or without acetaminophen.
  • Muscle relaxant, cyclobenzaprine (Flexeril), to improve sleep and reduce pain and muscle spasms.
  • Anticonvulsant, gabapentin (Neurontin), which is similar to pregabalin (Lyrica).

Complementary Approaches

In addition to medication, a variety of alternative and lifestyle approaches can help you deal with symptoms of pain. However, be aware that there is limited scientific evidence to support these approaches at this time.

  • Massage therapy can be very effective short-term. For the best results, look for a licensed massage therapist who has worked with fibromyalgia patients before.
  • Moist heat supplied by warm towels, hot packs, a hot bath or a shower can be used at home for 15 to 20 minutes three times a day to relieve symptoms.
  • Cold supplied by a bag of ice or frozen vegetables wrapped in a towel helps reduce pain when used for 10 to 15 minutes at a time. Don’t do this, however, if you have Raynaud’s phenomenon.
  • Hydrotherapy (water therapy) can reduce pain during exercise and help you improve endurance and conditioning. Exercising in a large pool may be easier because water has a buoying effect. Community centers, YMCAs and YWCAs have water exercise classes developed for people with arthritis and other conditions that may make exercise painful. To find a YMCA or YWCA in your area, check out http://www.ymca.net/find-your-y/. Some patients also find relief from the heat and movement provided by a whirlpool.
  • Relaxation techniques help reduce pain and anxiety. These include meditation and guided imagery. Check with local recreation centers and hospitals for courses.
  • Acupuncture is an ancient Chinese treatment that is often used for pain relief. A qualified acupuncturist places very thin needles in certain parts of your body. Some researchers believe that the needles may stimulate deep sensory nerves that tell the brain to release natural painkillers (endorphins). However, the well-controlled studies examining acupuncture as a treatment for fibromyalgia symptoms did not find acupuncture to be more effective than a placebo treatment for fibromyalgia, so it is difficult to know for sure if the practice produces any specific benefits. Acupressure is similar to acupuncture, but pressure is applied to the sites instead of needles.
  • Biofeedback is a form of therapy used to train your mind to understand and, to a degree, control your own physiological responses. An electronic device provides information about a body function (such as heart rate) so you learn to consciously control that function. For instance, it can help you learn to relax your muscles.

Prevention

There is no known way to prevent fibromyalgia. Instead, the most important thing is to find a way to manage it and to find a health care team to help you.

Once diagnosed, you should monitor your pain, noting activities that increase it and therapeutic approaches that reduce it. Repetitive activities may temporarily make things worse, such as sitting in one position for a long time. Pain can also flare when doing chores like cleaning, typing or driving for hours with your arms in the same tensed position. Even reading in a slumped position may trigger pain.

The key is to make adjustments—change positions, take a quick break or give your back, arms or neck more support—before the pain worsens. You can also make adjustments to your cleaning routine, using lighter appliances to minimize muscular distress.

Obviously, fibromyalgia can interfere with work, especially if your job involves a repetitive physical task, heavy lifting or working outdoors when it’s cold. Research finds that fibromyalgia patients tend to do better if they work, however, so if the disease is affecting your ability to work, talk to your health care professional about how you can reduce the strain.

Most important is to improve your physical conditioning and endurance, find ways to manage and reduce stress and maintain a regular schedule.

Facts to Know

  1. Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain and multiple tender points. “Tender points” refers to tenderness that occurs in localized areas, particularly in the neck, spine, shoulders and hips.
  2. People with fibromyalgia may also experience fatigue, sleep disturbances, morning stiffness, irritable bowel syndrome, anxiety, depression and other symptoms.
  3. At least 2 percent of the U.S. adult population suffers from fibromyalgia, and it predominantly affects women. The condition primarily occurs in women in early and middle adulthood, but children, the elderly and men can be affected.
  4. There is no cure for fibromyalgia, though the disorder can be successfully managed.
  5. Fibromyalgia is defined based on widespread pain in combination with tenderness in at least 11 of 18 specific tender point sites for at least three months. There are no lab tests to confirm a diagnosis, although some tests may be used to rule out other conditions with similar symptoms, such as rheumatoid arthritis or lupus.
  6. There appears to be a link between fibromyalgia and chronic fatigue syndrome (CFS). Up to 70 percent of people with fibromyalgia fit the criteria for CFS.
  7. Low-impact aerobic exercise such as walking and swimming can help manage the symptoms of fibromyalgia. Physical therapy and stretching exercises also help.
  8. A variety of medications are used to treat fibromyalgia, including the three FDA-approved medications for fibromyalgia: pregabalin (Lyrica), duloxetine (Cymbalta) and milnacipran (Savella). Additional medications include other antidepressants and anti-seizure drugs.
  9. If you are diagnosed with fibromyalgia, you should monitor your pain, noting activities that increase it and therapeutic approaches that improve it. Repetitive activities may temporarily exacerbate the condition, as may sitting in one position for a long time.
  10. Studies find that negative thinking increases stress and affects your perception of pain, so learning to minimize and control these thoughts can improve your symptoms. The key is not so much to “think positively,” but to “think non-negatively.”