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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. 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 generally accepted cure for this condition. 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 used to treat musculoskeletal 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. 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.
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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