What is Fibromyalgia?

Fibromyalgia is a chronic disorder that causes widespread pain and tenderness in the muscles and soft tissue (including tender points as well as sleep problems, fatigue, and a variety of other symptoms. These problems can be severe enough to disrupt a person's work and daily activities. Fortunately, the condition does not permanently damage the muscles, joints, or internal organs.

Fibromyalgia is a syndrome of chronic pain, not a disease or a psychological disorder.

Chronic pain is pain that continues after your body has healed from an illness or injury. There may not be an identifiable physical cause for the persistent pain. Chronic pain can be shooting, burning, or aching pain that causes discomfort, soreness, tightness, or stiffness. It can occur anywhere in your body, and can range from mild, annoying pain to severe pain that interferes with your mood and ability to function. Chronic pain is usually defined as pain that lasts longer than three months which is normally long enough for pain associated with an injury or illness to ease completely.

Chronic pain may also occur without clear-cut injury or illness. In these cases, the reason for chronic pain is not clear. Pain signals are somehow triggered by the nervous system, and continue to fire for months or even years. It is also possible that certain brain chemicals that suppress pain do not work properly.

Treatment of chronic pain depends upon the type of pain and whether it is mild, moderate, or severe and debilitating. Treatment usually includes behavioral therapy and a combination of medications (such as pain relievers or antidepressants), physical therapy, and exercise. Complementary therapies such as acupuncture or yoga may also be tried

Cause

No one has a clear understanding of what causes fibromyalgia. There are theories as to what may cause it, but there is not enough evidence to support any single theory. Since fibromyalgia is a syndrome of many symptoms, it has been difficult to find a specific cause for the combined symptoms. It has been recognized as a medical disorder only since the 1980s.

Some theories suggest that fibromyalgia may be:

• Associated with oversensitive nerve cells in the spinal cord and brain. Oversensitivity may occur as a result of changes in chemicals in the brain or spinal cord that regulate pain. As a result, the person senses pain more easily, and widespread muscle pain occurs.
• Linked to an imbalance in brain chemicals that control mood, which results in a lowered tolerance for pain and may also cause an unrestful sleep cycle and fatigue. Once this occurs, a person becomes less physically active, and the muscles and tissues become more sensitive and painful and more easily irritated.
• Caused by an imbalance of hormones such as cortisol and growth hormone. Their release is controlled by the pituitary gland and the hypothalamus. Imbalances of these hormones can result in fatigue, mood changes, concentration and memory difficulties, a lowered tolerance for pain, and other symptoms.

Fibromyalgia is a condition that causes widespread muscle and soft tissue pain and tenderness, especially in the trunk, neck, and shoulders. The pain of fibromyalgia can often be severe enough to disrupt a person's daily work and activities.

Other symptoms that may occur with fibromyalgia include:

• Pain at certain points on the body (called tender points).
• Disturbed, unrestful sleep (especially frequent waking during the night).
• Fatigue.
• Morning stiffness.

The exact cause and nature of fibromyalgia have not been defined. As with many conditions that cause chronic pain, depression, stress, and sleep problems are common in people with fibromyalgia and may make symptoms worse.

Treating fibromyalgia focuses on breaking the cycle of pain and decreased physical activity. Home treatment, especially exercise and improving sleep, is usually the most important part of treatment. In some cases, medication may be needed to help relieve pain and improve sleep problems.

Pituitary Gland

The pituitary gland is a small gland located beneath the brain. The pituitary gland produces substances (hormones) that enter the bloodstream and help control many processes of the body, such as:

• Growth.
• Blood pressure.
• Some aspects of pregnancy.
• Breast milk production.
• Sex organ functions in both women and men.
• Thyroid gland function.
• The conversion of food into energy (metabolism).
• Water balance in the body.

Hypothalamus

The hypothalamus is a part of the brain. It controls part of the autonomic nervous system, which is the part of the nervous system that controls the body organs. The hypothalamus releases substances (hormones) that help control the endocrine and nervous systems, regulate body temperature and sleep, and affect other body functions.

The hypothalamus produces a hormone called thyrotropin-releasing hormone (TRH), which stimulates the pituitary gland to produce thyroid-stimulating hormone (TSH). TSH, in turn, regulates the amount of thyroid hormone produced and released into the bloodstream by the thyroid gland. A problem in the hypothalamus can result in decreased release of thyroid hormone by the thyroid gland.

Exams and Tests

Fibromyalgia is a difficult condition to diagnose, and there are no specific tests that can confirm the diagnosis. It often is diagnosed when other disorders with similar symptoms of chronic pain have been ruled out with laboratory tests.. Your health professional will also take your medical history and do a physical exam.

The formal criteria used to diagnose fibromyalgia include:⁶

• Widespread pain that has been present for at least 3 months.
• Pain and tenderness at 11 or more of 18 specific tender points, which usually occurs only when the areas are pressed. (Some people may have fewer than 11 tender points but still have fibromyalgia.)
• The presence of other symptoms typical of fibromyalgia, such as stiffness, fatigue, or sleep difficulties. These may get worse with increased stress, anxiety, exertion, or changes in the weather.

However, these criteria are most useful in clinical research settings, where precise measurements of specific symptoms are needed to evaluate, for example, the effects of a treatment being studied. For patients and health professionals in the day-to-day setting of a medical practice, the diagnosis is rarely so clear-cut. Many people for whom a diagnosis of fibromyalgia is appropriate and for whom treatment may be helpful do not meet these criteria. By its very nature, fibromyalgia is a hard-to-define syndrome of varied signs and symptoms that vary from individual to individual.

Laboratory Tests and Fibromyalgia

Laboratory tests are not used to diagnose fibromyalgia. The results of lab tests done on people with fibromyalgia should be normal unless another condition is present.

Laboratory tests may be done to rule out other diseases or to determine whether you have another disease in addition to fibromyalgia. Fibromyalgia may occur along with other joint and muscle (rheumatic) diseases, such as rheumatoid arthritis. Discovering these other conditions is important because they may require different treatment.

If your doctor thinks that you may have another muscle or joint disease based on your symptoms, history, and physical exam, he or she may do any of the following tests:

• A complete blood count (CBC)
• An erythrocyte sedimentation rate (ESR) or a C-reactive protein (CRP) test to help identify diseases that cause inflammation, such as polymyalgia reumatica
• A rheumatoid factor (RF) test to check for rheumatoid arthritis.
• An antinuclear antibodies (ANA) test to check for certain conditions such as systemic lupus erythematosus (a condition that can affect the bones and skin and several other organs)
• Thyroid hormone tests to check for low or high thyroid gland activity. Thyroid problems can cause fatigue and muscle soreness.
• A blood calcium level test to check for a low calcium level, which can cause muscle cramps

The test results may show that you have a disease other than fibromyalgia. It is also possible that you have both fibromyalgia and another condition. Test results can be false-positive.

These tests are not used to diagnose fibromyalgia and only need to be done if your medical history and physical exam suggest that you might have a condition other than fibromyalgia.

Polymalgia Rheumatica

Polymyalgia rheumatica (PMR) is an inflammatory disease of the muscles. It usually begins after age 50. The most common symptoms are pain and morning stiffness in the shoulders, back, and neck. The symptoms are usually worse in the morning. Depression and weight loss may also occur.

The cause of PMR is poorly understood, but it is known that PMR is the result of the body's immune system reacting against itself, known as an autoimmune response. Although this kind of reaction resembles lifelong (chronic) autoimmune diseases, PMR often responds to treatment, with symptoms decreasing within weeks to 1 or 2 years.

Polymyalgia rheumatica sometimes occurs along with a condition called temporal arteritis (TA), which causes symptoms such as headache, jaw pain, and loss of vision.

PMR is usually treated with corticosteroids.

Rheumatoid Arthritis (RA)

Rheumatoid arthritis (RA) is a form of arthritis in which the membranes or tissues lining the joints become inflamed. The symptoms of RA include:

• Painful, swollen, tender, "hot" joints. The same joints on both sides of the body are usually affected, especially the hands, wrists, elbows, shoulders, and feet.
• Stiffness. Joint stiffness may develop after long periods of sleeping or sitting and may last at least 30 minutes and often up to several hours.
• Formation of bumps (nodules) in the pressure points on the body, such as the elbows, knuckles, spine, and lower leg bones.
• Tiredness, a general feeling of illness (malaise), mild fever, a loss of appetite, and weight loss.

Over time, rheumatoid arthritis may destroy the joint tissues, including cartilage, ligaments, tendons, and bone. In a small number of severe cases, RA may also damage other organs, such as the heart, lungs, skin, blood vessels, nerves, and eyes.

Rheumatoid arthritis can most often be managed with a combination of medications and home treatment. Surgery may be needed in some severe

Lupus

Lupus (systemic lupus erythematosus, or SLE) is a chronic inflammatory disease that can affect almost any organ. It is an autoimmune disease in which the immune system attacks normal body tissues as if they were foreign substances.

Inflammation caused by lupus can affect the skin, the joints, and most other organ systems in the body, including the kidneys, heart, lungs, and nervous system. It causes a variety of symptoms, depending on which organ systems are affected and how severely they are affected. The disease is more common in women than in men.

The most common symptoms of lupus include fatigue, fever, skin rashes (a butterfly-shaped rash across the cheeks is common), and muscle and joint pain. Other symptoms may also occur, depending on which organs are affected.

Symptoms of lupus may come and go in episodes called flares. Some people may have severe episodes; others may have a milder form of the disease. Home treatment and, if needed, medications to control inflammation are the primary treatments for lupus. There is no cure for lupus.

Medical History to Assess Chronic Pain

Your doctor will obtain your medical history by asking questions related to:

• Your general medical history, past illnesses, and overall health.
• Your pain: how long it has lasted, whether you have had it before, how it was treated, and what or relieves your pain.
• Describe your pain: where, how severe, how often?
• Do any movements or activities make it better or worse?
• Do you have burning sensations, pins-and-needles feeling, or shooting pain?
• What medications or other treatments have you tried? Were they effective? Any side effects?
• Your family history of chronic pain: whether other members of your family have had it and how it was treated.
• Prescription and nonprescription medications that you are taking.
• Any history of alcohol or drug dependence.
• Any complementary or alternative medicine therapies that you are using or have tried.

Physical exam for Fibromyalgia

A physical exam for any suspected joint or muscle condition involves checking the:

• Joints for range of motion, swelling, and warmth.
• Skin for redness or rash.
• Muscles for strength and tenderness.
• Nervous system for reflexes and ability to maintain balance.

These parts of the body are usually normal in a person who has fibromyalgia. An abnormal finding in one of these areas makes it more likely that you have a condition other than or in addition to fibromyalgia.

To evaluate tender points, the doctor may apply pressure on or near one of these points. In people with fibromyalgia, the points will often be tender and painful. The doctor will also press on areas that are not normally painful in fibromyalgia, such as the middle of the forehead or the nail beds.

Treatment Overview

Currently, there is no cure for fibromyalgia. Treatment is focused on managing pain, fatigue, depression, and other symptoms common in fibromyalgia in an attempt to break the cycle of increased sensitivity to pain and decreased physical activity.

Treatment may include:

• Medications to help you sleep better, such as tricyclic antidepressants, SSRIs, or cyclobenzaprine (Flexeril) cations to relieve muscle and joint pain, such as tricyclic antidepressants, , cyclobenzaprine (Flexeril) or, less often, nonprescription pain relievers..
• Exercise therapy to relieve sore muscles and increase energy.

Cycle of Pain and Decreased Activity in Fibromyalgia

Fibromyalgia seems to involve a cycle of muscle pain, increased sensitivity to pain, and inactivity that may be made worse by sleep problems and fatigue.

• Increasing pain makes a person less physically active.
• Muscles that are not exercised regularly are more likely to be injured during activity. It is also possible that people with fibromyalgia are more sensitive to pain or have muscles that are more easily irritated or injured.
• The irritated or injured muscles are painful. Some doctors think that the muscles of people with fibromyalgia remain sore because they do not repair themselves as well as the muscles of people who do not have this condition.
• Muscle pain, sometimes together with disrupted sleep and daytime fatigue, leads to less and less activity.

Tricyclic Antidepressants for Fibromyalgia

Examples

How It Works

It is not known exactly how tricyclic antidepressants improve symptoms of fibromyalgia. They may help some people with fibromyalgia to sleep better through the night.

These medications can also be used to treat depression.

Depression

Depression is an illness that causes a person to feel sad and hopeless much of the time. It is different from normal feelings of sadness, grief, or low energy. Besides feeling very sad and hopeless, people who are depressed often:

• Think and speak more slowly than normal.
• Have trouble concentrating, remembering, and making decisions.
• Have changes in their eating and sleeping habits.
• Lose interest in things that they once enjoyed.

Depression affects men and women of all ages. A person can have one or many episodes of depression in a lifetime. Each episode of depression makes a person more likely to have another episode of depression. Episodes of depression can be short or long and mild or severe.

Most people who are depressed get better with medication and counseling.

Why It Is Used

Tricyclic antidepressants may be used when sleep problems are a major symptom of fibromyalgia.

How Well It Works

Tricyclic antidepressants improve sleep problems by helping you sleep through the night. Some research indicates that tricyclics may be more effective than other antidepressants for treating fibromyalgia symptoms.¹ However, tricyclics may not be as effective at reducing pain and stiffness associated with fibromyalgia as they are at helping with anxiety and sleep problems.

Side Effects

Side effects vary among the different medications in this class. They may include:

• Drowsiness.
• Dry mouth.
• Constipation.
• Confusion.
• Agitation or nightmares.
• Lightheadedness when a person stands up too quickly (caused by lowered blood pressure).

Tricyclic antidepressants may make symptoms worse in people who have seizures (epilepsy), difficulty urinating (urinary retention), glaucoma (an eye disease), or heart conditions.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What to Think About

Studies suggest that using the combination of a tricyclic antidepressant and a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine hydrochloride (Prozac), may be more successful at breaking the cycle of pain and sleep problems caused by fibromyalgia than using just a single medication.

These medications may take 2 to 3 weeks to start working fully. They usually work quickly to improve sleep but may take several weeks to improve pain—up to 6 to 12 weeks in older adults. Treatment with antidepressants does not always relieve symptoms caused by fibromyalgia. Even when the treatment does work, some people may find the side effects of these medications unacceptable.

Using an antidepressant medication to treat fibromyalgia does not mean that the condition is “all in your head.” The dose of a tricyclic antidepressant used to treat fibromyalgia is usually much less than that needed to treat depression.

Selective Serotonin Reuptake Inhibitors

(SSRIs) for Fibromyalgia

Examples

How It Works

It is not known exactly how SSRIs work to improve fibromyalgia, but people with fibromyalgia who take SSRIs seem to have improved mood and less fatigue.

These medications are a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs), and they are also used to treat depression.

Why It Is Used

SSRIs may be used when fatigue and mood problems are major symptoms of fibromyalgia.

How Well It Works

SSRIs seem to help relieve fatigue and sleep problems and to improve mood, although they are not effective for everyone with these symptoms of fibromyalgia.

Side Effects

Side effects of selective serotonin reuptake inhibitors (SSRIs) include:

• Nausea, loss of appetite, and diarrhea.
• Anxiety.
• Sleeping problems.
• Loss of sexual desire or ability.
• Headaches.
• Weight gain.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

FDA Advisory. The US Food and Drug Administration (FDA) has issued an advisory to patients, families, and health care providers to closely monitor adults and children taking antidepressants for signs of suicide. This is especially important at the beginning of treatment or when doses are changed.

The FDA also advises that patients be observed for increases in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania. It is most important to watch for these behaviors in children who may be less able to control their impulsivity as much as adults and therefore may be at greater risk for suicidal impulses. The FDA has not recommended that people stop using antidepressants, but simply to monitor those taking the medications and, if concerns arise, to contact a health professional.

What to Think About

Recent studies suggest that using an selective serotonin reuptake inhibitor (SSRI) and a tricyclic antidepressant (such as amitriptyline hydrochloride) together may be more successful at breaking the cycle of pain and sleep problems caused by fibromyalgia than using just a single medication.

Treatment with antidepressants does not always relieve symptoms caused by fibromyalgia. Even when the treatment does work, some people may find the side effects of these medications unacceptable. The dose of an SSRI used to treat fibromyalgia is usually the same as that needed to treat depression.

Using an antidepressant medication to treat fibromyalgia does not mean that the condition is “all in your head.”

Cyclobenzaprine Hydrochloride for Fibromyalgia

Examples

How It Works

Cyclobenzaprine is a drug used to relax muscles. It is not known exactly how this drug works to improve fibromyalgia. Cyclobenzaprine is chemically similar to amitriptyline hydrochloride, a tricyclic antidepressant, so it is believed that the two drugs may work in similar ways.

Why It Is Used

Cyclobenzaprine may be used to reduce the pain, stiffness, and sleep problems that occur with fibromyalgia. This is currently an unlabeled use of the drug.

How Well It Works

People with fibromyalgia who take cyclobenzaprine seem to have less pain and fatigue, fewer painful trigger points, and improved sleep.

Side Effects

Side effects include:

• Drowsiness.
• Dry mouth.
• Dizziness.

Less common side effects include fatigue, weakness, nausea, constipation, stomach upset, blurred vision, nervousness, and confusion.

Nonsteroidal Anti-Inflammatory Drugs for Fibromyalgia

Aspirin (such as Anacin, Bayer, or Ecotrin), ibuprofen (such as Advil or Motrin), naproxen sodium (such as Aleve), and ketoprofen (such as Orudis KT) are called nonsteroidal anti-inflammatory drugs (NSAIDs). They relieve pain and reduce inflammation.

NSAIDs may help reduce the pain that develops when you have a severe attack of fibromyalgia. However, there is no evidence that fibromyalgia causes inflammation. Because of this, NSAIDs generally do not help with the long-term pain caused by this disorder.

NSAIDs are also available in prescription strength. If NSAIDs seem to help relieve your pain, your doctor may prescribe one of the stronger forms.

Long-term use of large amounts of NSAIDs can cause stomach ulcers or kidney damage. Older people who take NSAIDs may be at greater risk of having these side effects.

Exercise and Fibromyalgia

Exercise is one of the most important treatments for fibromyalgia. Regular exercise will strengthen your muscles and reduce the risk of tiny injuries to the muscles, which may cause more pain. It may also help you sleep better and improve your overall sense of well-being.

Mild to Moderate exercise is appropriate for most people with this condition. A balanced exercise program should include:

• Low-impact aerobic exercise, such as walking, swimming, biking, or water aerobics. This is the most beneficial type of exercise for people who have fibromyalgia.
• Stretching exercises.
• Strengthening exercises to build stronger muscles.

The key is to establish exercise habits that you can maintain over the long term. Here are some tips for starting and maintaining a good exercise program:

• Start slowly. Many people with fibromyalgia have been inactive for a long time because of fatigue and pain and should not start a vigorous exercise program. Overexerting yourself may make your symptoms worse.
• If 3 to 5 minutes of activity are all you can manage at first, just do that.
• Increase by 1 minute per session every 3 to 4 days until you can exercise for 20 to 30 minutes.
• Try to exercise 3 to 4 times a week.
• When you can comfortably exercise for 30 minutes, increase the intensity slowly by pedaling or swimming harder or by walking faster for the same period of time. Try to increase your exercise program gradually, eventually working out 5 to 7 days per week.
• Stretch before and after exercising to improve flexibility, maintain good posture, and prevent injury. Stretch slowly and gently. Do not bounce, but maintain a gentle pull on the muscle.
• Stick with it. When you have a flare-up of your symptoms, do not stop exercising. Instead, cut back slightly. Try to get back to your regular routine as soon as possible so that you don't lose any of the benefits you've gained.

May 3, 2002 -- A new study points to a possible growth-hormone defect in women with fibromyalgia. Researchers are suggesting that a drug currently used to treat a nerve and muscle disorder might be helpful for fibromyalgia.

The finding comes from a report by Robert M. Bennett, MD, and colleagues at the Oregon Health Sciences University, Portland, in the May issue of the journal Arthritis & Rheumatism.

FM appears to be a complex illness in which the body's normal means of regulating stress and pain gets out of whack. One of the hormones involved is called growth hormone.

Bennett's team put 20 women with fibromyalgia and 10 normal women through physical stress by having them run on a treadmill until they were exhausted. They found that growth-hormone levels went up in the healthy women, but not in the women with fibromyalgia.

What caused this growth-hormone defect? The researchers guessed that it might be too much of another hormone -- somatostatin -- which blocks growth hormone. They did the test again, only this time the women with fibromyalgia exercised after taking a drug that blocks somatostatin. This time, their growth hormone levels went up just like those of the healthy women.

The drug, Mestinon, currently is used to treat myasthenia gravis, an autoimmune disease in which people suffer attacks of muscle weakness. Bennett and co-workers suggest that it should be studied as a possible treatment for fibromyalgia.

Other researchers have tested fibromyalgia patients for growth hormone defects. But a common test for growth-hormone defect -- measurement of blood levels of a substance called IGF-1 -- seems not to work for many fibromyalgia patients. Indeed, many of the fibromyalgia patients with growth-hormone defects in the Bennett study had normal IGF-1 levels. The researchers therefore recommend different tests should be used in fibromyalgia patients.

The Author dedicates this article to victims that are suffering from this syndrome and who are frustrated with the experimental treatment.  This author opinion is that depression is the precipitating factor that in turn interferes with the neurotransmitters of the brain, possible neurotransmitters we have yet to discover the function or name.

By Jan Parrish, RN, BSN, LNC

Legal Nurse Consultant

Independent Medical Evaluations, Inc.