Fibromyalgia (or "FM" for short) is a complex, chronic condition which causes widespread pain and fatigue as well as a variety of other symptoms. The name fibromyalgia comes from "fibro" meaning fibrous tissues (such as tendons and ligaments), "my" meaning muscles, and "algia" meaning pain. Unlike arthritis, FM does not cause pain or swelling in the joints. Rather, it produces pain in the soft tissues located around joints and in skin and organs throughout the body.
The pain of FM usually consists of aching or burning described as "head-to-toe" and muscle spasm. Pain can vary in severity from day to day and change location, becoming more severe in parts of the body that are used the most (i.e., neck, shoulders, and feet). In some people, it can be so intense that it interferes with the performance of even simple tasks, while in others it may cause only moderate discomfort. Likewise, the fatigue of FM also varies from person to person ranging from a mild, tired feeling to the exhaustion of a severe, flu-like illness. Although fibromyalgia does not cause physical deformities or affect a person's expected life span, until the patient is able to manage it through appropriate treatment and medication, FM can make life very challenging on many different levels.
The exact prevalence of FM in the U.S. population has not been thoroughly studied, but conservative estimates place the total between 4 and 6 million. Other experts believe the true number is closer to 10 million. An estimated 80% of sufferers are women, most of them working age, so FM has obvious consequences in terms of employment and family stress. FM also occurs in all other age groups as well as in men, and it exists in all races worldwide.
Other FM-Related Symptoms & Syndromes: In addition to pain and fatigue, a number of symptoms are usually associated with FM. Like pain/fatigue, their severity may wax and wane over time, and individuals may differ in the extent to which they are troubled by them. Typically, patients suffer from one or more of the following:
Stiffness: Body stiffness is usually most apparent upon awakening and after prolonged periods of sitting or standing in one position. It may also coincide with changes in relative humidity.
Sleep Disturbance: Despite sufficient amounts of sleep, FM patients may awaken feeling unrefreshed, as if they have barely slept. Alternatively, they may have trouble falling asleep or staying asleep.
Cognitive Disorders: Individuals with FM report a number of cognitive symptoms which tend to vary from day to day. These include difficulty concentrating, "spaciness" or "fibro-fog," memory lapses, difficulty thinking of words/names, and feeling overwhelmed when engaged in multiple tasks.
Paresthesia: Numbness or tingling, particularly in the hands or feet, sometimes accompanies FM. Also known as "paresthesia," the sensation can be described as prickling or burning.
Chest Symptoms: Individuals with FM who engage in activities involving continuous, forward body posture (i.e., typing, sitting at a desk, working on an assembly line, etc.) often have special problems with chest and upper body (thoracic) pain and dysfunction. The pain may cause shallow breathing and postural problems. They may also develop a condition known as costochondralgia (also referred to as costochondritis) which causes muscle pain where the ribs meet the chest bone and is frequently mistaken for heart disease.
Dysequilibrium: FM patients may be troubled by light-headedness and/or balance problems for a variety of reasons. Since fibromyalgia is thought to affect the skeletal tracking muscles of the eyes, "visual confusion" and nausea may be experienced when driving a car, reading a book, or tracking objects. Alternatively, weak muscles and/or trigger points in the neck may cause dizziness or dysequilibrium. Finally, some FM patients develop a condition known as neurally mediated hypotension which causes a drop in blood pressure and heart rate upon standing, resulting in light-headedness, nausea, and difficulty thinking clearly.
Sensory Sensitivity & Allergic Symptoms: Hypersensitivity to light, sound, touch, and odors frequently occurs among those with FM and is thought to be a result of a hyperactive nervous system. In addition, persons with FM may feel chilled or cold when others around them are comfortable, or they may feel excessively warm. They may also have allergic-like reactions to a variety of substances accompanied by itching or a rash or a form of non-allergic rhinitis consisting of nasal congestion/discharge and sinus pain.
Skin Complaints: Nagging symptoms, such as itchy, dry, or blotchy skin, may accompany FM. Dryness of the eyes and mouth (sicca syndrome) is not uncommon.
Depression & Anxiety: Although FM patients are frequently misdiagnosed with depression or anxiety disorders ("it's all in your head"), research has repeatedly shown that fibromyalgia is not a form of depression or hypochondriasis. Where depression or anxiety do co-exist with fibromyalgia, treatment is important as both can exacerbate FM and interfere with successful symptom management.
In addition to the aforementioned symptoms, there are a number of syndromes which frequently co-exist with fibromyalgia and can complicate the symptom picture. These include:
Irritable Bowel Syndrome: Digestive disturbances, abdominal pain, and bloating are quite common with FM as are constipation and/or diarrhea. Together these symptoms are usually known as "irritable bowel syndrome" or IBS.
Genito-Urinary Disorders: FM patients may experience increased frequency of urination or increased urgency to urinate, typically in the absence of a bladder infection. These symptoms are usually referred to as irritable bladder syndrome. Some may develop a chronic, painful inflammatory condition of the bladder wall known as interstitial cystitis. Women with FM may have more painful menstrual periods or experience a worsening of their FM symptoms during this time. Conditions such as vulvar vestibulitis or vulvodynia, characterized by a painful vulvar region and painful sexual intercourse, may also develop.
Myofascial Pain Syndrome: A significant number of people with FM have myofascial pain due to trigger points, a neuromuscular condition in which hyper-irritable spots (trigger points) form in taut bands in muscles or other connective tissue, often as a result of repetitive motion, injury, prolonged poor posture, or illness. Not only are these spots very painful, but they also refer pain to other parts of the body in very predictable ways and cause limited range of motion, loss of strength and stamina, and a variety of non-pain conditions. (Note: Myofascial trigger points should NOT be confused with the diagnostic tender points of fibromyalgia.) Temporomandibular joint (TMJ) dysfunction, a condition which affects the jaw joints and surrounding muscles and occurs in an estimated one-third to one-half of those with FM, often includes significant myofascial pain.
Restless Legs Syndrome: Some FM patients may develop a neurologic disorder known as restless leg syndrome (RLS) which involves a "creepy crawly" sensation in the legs and an irresistible urge to move the legs particularly when at rest or when lying down. The syndrome may also involve periodic limb movements during sleep (PLMS) which can be very disruptive to both the patient and to her/his sleeping partner.
Mitral Valve Prolapse: Persons with FM are prone to a largely asymptomatic heart condition known as mitral valve prolapse (MVP) in which one of the valves of the heart bulges during a heartbeat causing a click or murmur. MVP usually does not cause much concern unless another cardiac condition is also present. (Note: Anyone experiencing chest pain should immediately consult a physician.)
Official Diagnostic Criteria
Fibromyalgia has had a long, if rather obscure, history as an illness. Masquerading behind numerous medical aliases, it has existed throughout history and throughout the world. It was only in 1990 that official diagnostic criteria for FM were established by the American College of Rheumatology (ACR). They include:
(1) A History of Widespread Pain: Chronic, widespread, musculoskeletal pain lasting longer than three months in all four quadrants of the body. ("Widespread pain" is defined as pain above and below the waist and on both sides of the body.) In addition, axial skeletal pain (in the cervical spine, anterior chest, thoracic spine, or low back) must be present.
(2) Pain in 11 of 18 Tender Point Sites on Digital Palpation: There are 18 tender points that doctors look for in making a fibromyalgia diagnosis. (See Table 1 at the end of this article.) According to the ACR requirements, a patient must have 11 of the 18 tender points to be diagnosed with fibromyalgia. Approximately four kilograms of pressure (or about 9 lbs.) must be applied to a tender point, and the patient must indicate that the tender point locations are painful. (Wolfe F, et al. Arthritis & Rheumatism 1990;33(2):160-172.
As the ACR criteria suggest, a fibromyalgia diagnosis requires the "hands-on" evaluation of a patient by a skilled medical professional, typically a rheumatologist, though other medical specialists are becoming very knowledgeable in this area. As patients are not usually aware of the specific anatomical origins of pain in their bodies, self-diagnosis is not advised.
Because routine laboratory and x-ray testing is usually normal in fibromyalgia patients, a complete medical history and physical exam are crucial for a correct diagnosis. Since FM symptoms mimic several other diseases (for example, systemic lupus, polymyalgia rheumatica, myositis/polymyositis, thyroid disease, rheumatoid arthritis, multiple sclerosis, and others), it is necessary to rule out those conditions before a FM diagnosis is made. While a diagnosis of fibromyalgia does not preclude the co-existence of another illness, it is important to ensure that no other condition is mistaken for fibromyalgia so that appropriate treatment may be initiated.
Fibromyalgia Management
Because there is currently no "magic pill" for fibromyalgia, treatment aims at managing FM symptoms to the greatest extent possible. Just as individual manifestations of fibromyalgia vary from patient to patient, so do successful forms of treatment (e.g., what works for one patient may not work for another). In addition, medical practitioners often have different preferences as to treatment. Because successful FM treatment can involve a variety of medical professionals, patients usually benefit from a coordinated, team approach to disease management. The most common treatment strategies, used alone or in combination, are:
Medications for Fibromyalgia
Analgesics are drugs that have been designed to relieve pain. Those commonly used to treat fibromyalgia include acetaminophen (i.e., Tylenol); non-steroidal anti-inflammatory medications (or NSAIDs) with analgesic properties (i.e., Advil, Naprosyn, Toradol); and narcotic drugs which are sometimes combined with acetaminophen for added strength for the treatment of acute pain (i.e., Percocet, Vicodin). As a group, analgesics are typically used to "take the edge off" of pain or to combat flare-ups.
Ultracet (tramadol hydrochloride combined with acetaminophen) is a unique new centrally acting, synthetic, opioid analgesic which helps to relieve pain in three ways. Laboratory studies performed by Ortho McNeil suggest that it acts directly on parts of the brain where pain is received and on the spinal cord, and it reduces the size of the pain signal passed from one nerve to another.
Medications for Treating Centrally Mediated Pain and other symptoms have become a more popular concept in recent years as more research points to the brain and central nervous system, and not the periphery of the body, as the source of dysfunction in fibromyalgia.
Tricyclic Antidepressants have been adopted for use in the treatment of fibromyalgia because of their ability to boost levels of the brain neurochemical serotonin (usually deficient in FM patients) and to control pain and promote sleep. They are usually prescribed in much lower dosages for FM than for depression, however. Examples of common tricyclics include Elavil, Pamelor, and Desyrel.
Selective Serotonin Reuptake Inhibitors(SSRIs) are a newer form of anti-depressants which not only boost serotonin levels but also help to keep serotonin available longer in the system after it has been secreted by the brain. These medications can help manage the fatigue, cognitive impairment, and depression associated with fibromyalgia and are often taken in the morning. Common SSRIs include Prozac, Zoloft, and Celexa.
Selective Serotonin & Norepinephrine Reuptake Inhibitors (SSNRI's) are a new group of drugs that are thought to work by increasing the activity of both serotonin and epinephrine in the brain. They include Effexor XR, Cymbalta, and Savella.
Muscle Relaxants can decrease pain in FM patients by minimizing muscle spasms and muscle pain. Because of their sedating qualities, they also help to increase sleep and are usually taken at bedtime. Typically used muscle relaxants are Flexeril, Soma, and Skelaxin.
Sleep Medicines are useful for persons with fibromyalgia who have trouble falling asleep, staying asleep, or getting quality, restorative sleep. By improving sleep, it is also possible to decrease pain and achieve better daytime functioning. Examples of commonly prescribed drugs include Ambien, Lunesta, and Sonata.
Anti-Spastic Medications were developed to treat the muscle spasm associated with multiple sclerosis and certain injuries to the spine but have been adopted for use in FM. Two anti-spastic medications of interest in FM are Zanaflex (tizanidine) and Baclofen (lioresal).
Anti-Convulsant Medications, originally developed for the treatment of epilepsy, are sometimes prescribed for the relief of neuropathic pain in fibromyalgia patients (i.e., burning and electric shock-like feelings in the extremities). If tolerated, these medications can help relieve nerve irritation. Examples of anti-convulsants are Neurontin, Dilantin, and Tegretol. A new product, Lyrica, is structurally related to the amino acid and neurotransmitter GABA.
Benzodiazepines, also very sedating and usually taken at bedtime, are sometimes used to help patients feel calmer and cope with pain more effectively. They include Klonopin, Valium, and Xanax. (Note: Klonopin and Valium also have muscle relaxant properties that are useful in FM treatment.)
Physical Rehabilitation
A wide variety of hands-on "body work" therapies are available to individuals with FM. Some can only be provided by trained physical rehabilitation professionals familiar with fibromyalgia while others may be practiced at home under the guidance of a professional.
The most widely used body work therapies include Swedish massage, craniosacral therapy, chiropractic, myofascial release, muscle/joint re-education, osteopathic manipulation, and the application of hot/cold packs. Also widely recommended are gentle stretching exercises and low-impact exercises (i.e., walking/treadmill, aquatic exercise, gentle yoga, tai chi, and bicycling/stationary bicycle). Stretching/exercise videotapes designed specifically for FM patients are also commercially available.
Complementary Treatments
Other approaches have proven useful in FM management: postural training, relaxation therapy, acupuncture, hypnotherapy, cognitive behavioral therapy, and occupational therapy, among others. Increasingly, research studies are being done to evaluate the effectiveness of these modalities.
Fibromyalgia: The Basicsis a publication of the National Fibromyalgia Partnership, Inc (NFP). For a free copy of the NFP's brochure and catalog, write: NFP, Inc., P.O. Box 160, Linden, VA 22642. More detailed information on fibromyalgia is available for download at the NFP's central website: www.fmpartnership.org.
Table 1: Fibromyalgia Tender Points Identified By The American College Of Rheumatology In 1990*
(at digital palpation with an approximate force of 4 kg)
1 & 2, Occiput: bilateral, at the sub-occipital muscle insertions.
3 & 4, Low cervical: bilateral, at the anterior aspects of the inter-transverse spaces at C5-C7.
5 & 6, Trapezius: bilateral, at the midpoint of the upper border.
7 & 8, Supraspinatus: bilateral, at origins, above the scapula spine near the medial border.
9 & 10, Second Rib: bilateral, at the second costo-chondral junctions, just lateral to the junctions on upper surfaces.
11 & 12, Lateral epicondyle: bilateral, 2 cm distal to the epicondyles.
13 & 14, Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle.
15 & 16, Greater trochanter: bilateral, posterior to the trochanteric prominence.
17 & 18, Knee: bilateral, at the medial fat pad proximal to the joint line.
*Wolfe F, et al. The American College Of Rheumatology 1990 Criteria For The Classification Of Fibromyalgia: Report Of A Multicenter Criteria Committee. Arthritis & Rheumatism 1990;33(2):160-172.
