IntroductionFibromyalgia syndrome is a chronic disorder characterized by widespread muscle pain, diffuse tenderness and fatigue. The word “fibromyalgia” comes from the Latin term for fibrous tissue (fibro) and the Greek ones for muscle (myo) and pain (algia).1, 3 Fibromyalgia is considered a rheumatic condition, a medical condition that impairs the joints and/or soft tissues and causes chronic pain. Like arthritis, fibromyalgia can cause significant pain and fatigue, and it can interfere with a person’s ability to carry on daily activities.4 Fibromyalgia is a disorder of unknown etiology characterized by widespread pain, abnormal pain processing, sleep disturbance, fatigue and often psychological distress.5 Fibromyalgia can have a negative effect on careers, mental health, and personal relationships, and leads to increased work absences, decreased productivity, and higher direct and indirect medical costs.4 Fibromyalgia is an elusive diagnosis because vague fibromyalgia symptoms that include widespread body pain, fatigue, poor sleep and mood problems are common to many other diseases.2 Because a person may have two or more coexisting chronic pain conditions and because fibromyalgia symptoms can come and go, it can take time to determine which symptom is caused by which condition. Such conditions could include chronic fatigue syndrome, endometriosis, inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction, and vulvodynia. It is not known whether these disorders share a common cause.9
StatisticsFibromyalgia affects about 6 million people in the United States3. Between 80 and 90 percent of those diagnosed with fibromyalgia are women; however, men and children also can be affected 4. Most people are diagnosed during middle age and prevalence increases with age. Typically, a diagnosis of fibromyalgia is made between the ages of 20 and 50 years. Incidence increases with age; therefore, by 80 years, approximately 8% of adults meet the criteria for fibromyalgia, according to the National Fibromyalgia Association9. In terms of lost productivity due to fibromyalgia, working age women with fibromyalgia that were hospitalized for occupational musculoskeletal disorders or fibromyalgia were 10 times less likely to return to work and 4 times less like to retain work at 1-year post hospitalization. Statistics gathered by the Center for Disease Control indicates that working adults with fibromyalgia average 17 days of missed work per year compared to 6 days for persons without a diagnosis of fibromyalgia. Fibromyalgia has been associated with lower levels of health-related quality-of-life and more work productively loss. 5 Symptoms Fibromyalgia is a syndrome that causes pain on both sides of your body, as well as the upper and lower half of your body. Areas called “tender points” may be especially painful when pressure is put on them. Tender points are specific places on the neck, shoulders, back, hips, arms, and legs. These points hurt when pressure is put on them.1 Symptoms of fibromyalgia can include the following:
- Increased sensitivity to pain, temperature and sensitivity to loud noises or bright lights
- A deep ache or a burning pain that gets worse because of activity, stress, weather or other factors
- Muscle stiffness or spasms Pain that moves around your body
- Feeling very tired or fatigued, even when you get enough sleep 2, 3
- Morning stiffness
- Tingling or numbness in hands and feet
- Headaches, including migraines ◦Irritable bowel syndrome
- Sleep disturbances
- Cognitive problems with thinking and memory
- Painful menstrual periods and other pain syndromes5
Other ConditionsIt bears repeating that Fibromyalgia is an elusive diagnosis because the vague symptoms are common to many other diseases.2 Excluding other possible causes is paramount to making the diagnosis of fibromyalgia. It is important to determine whether the symptoms are caused by some other underlying problem. Fibromyalgia often coexists with other health problems, so inform your healthcare provider if you experience: Irritable bowel syndrome, Headaches, Sleep apnea, Jaw pain, Anxiety, Depression or frequent and painful urination.2 Common conditions that present similarly to fibromyalgia include:
Rheumatic diseasesDisorders such as rheumatoid arthritis, Sjogren’s syndrome and lupus can begin with generalized aches and pain similar to fibromyalgia. Fibromyalgia often co-occurs (up to 25-65%) with other rheumatic conditions such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and ankylosing spondylitis (AS).5
Mental health problemsDisorders such as depression and anxiety often feature generalized aches and pain.
Neurological disordersIn some people, fibromyalgia causes numbness and tingling, symptoms that mimic those of disorders such as multiple sclerosis and myasthenia gravis. 2
CausesIn some cases, fibromyalgia symptoms begin shortly after a person has experienced a mentally or physically traumatic event, such as a car wreck. People who have post-traumatic stress disorder appear to be more likely to develop fibromyalgia, so inform your healthcare provider if you've experienced any traumatic events recently. Also because this syndrome might be hereditary and a genetic factor appears to be involved in fibromyalgia3, inform your healthcare provider if any other members of your immediate family have experienced similar symptoms.2 Causes and/or risk factors for fibromyalgia are unknown, but some triggers have been loosely associated with disease onset:
- Stressful or traumatic events, such as car accidents, post-traumatic stress disorder (PTSD)
- Repetitive injuries
- Certain diseases (SLE, RA, chronic fatigue syndrome)
- Genetic predisposition
- central sensitization secondary to constant peripheral nociception (pain amplification)
- failure of the descending pain pathway
- mu opioid receptors not functioning properly, possibly contributing to failure of the descending pain pathway.9
Diagnostic CriteriaUnfortunately, it can take years for some people who have fibromyalgia to obtain the correct diagnosis. This can happen for many reasons. The main symptoms of fibromyalgia are pain and fatigue. These are also common symptoms of many other health problems, such as chronic fatigue syndrome, hypothyroidism and arthritis. Until recently, there was no laboratory test that could diagnose fibromyalgia. 3 There was no specific test for fibromyalgia and fibromyalgia could not be easily confirmed or ruled out with a simple laboratory test. It could not be detected in the blood or be seen on an X-ray. Because there was no test for fibromyalgia, healthcare providers relied solely on a group of symptoms to make a diagnosis. 2 Old guidelines required the presence of tender points characterized by pain when firm pressure was applied to specific areas of the body. In the past, at least 11 of 18 spots had to test positive for tenderness to diagnose fibromyalgia.10, 11, 12 However fibromyalgia symptoms can come and go, so a patient might have 11 tender spots one day but only eight tender spots on another day. And because many healthcare providers were uncertain about how much pressure to apply during a tender point exam, new criteria were developed by the American College of Rheumatology in 2012 for use in general practice.
American College of RheumatologyThe American College of Rheumatology (ACR) 2010 guideline is used for the clinical diagnosis and severity classification of fibromyalgia requires that three conditions be met:
- Widespread pain lasting at least three months. "Widespread" is defined as pain on both sides of your body, as well as above and below your waist. This is measured by a Widespread Pain Index (WPI).
- Presence of other symptoms such as fatigue, waking up tired and trouble thinking that have been present at a similar level for at least 3 months. This is measured by a symptom severity scale (SS). Diagnosis is based on: Widespread Pain Index (WPI) >7 and a symptom severity scale (SS) >5, or: WPI 3-6 and SS >9.
- The patient does not have a disorder that would otherwise explain the pain, such as an underlying condition that might be causing the symptoms 2
LaboratoryWhile there is no lab test to confirm a diagnosis of fibromyalgia, your healthcare provider may want to rule out other conditions that may have similar symptoms. Blood tests that may be needed include: 2
- Complete blood count
- Erythrocyte sedimentation rate
- Thyroid function tests
- Vitamin D levels
- CRP if inflammation is present
- CK if muscle diseases are suspected
- ANA & RF if rheumatoid arthritis is suspected
TreatmentThere is no cure for fibromyalgia, but medicine can help you manage your symptoms. Getting enough sleep, exercising, and eating well may also help1. It is important to have a health care team that understands fibromyalgia and has experience treating it. The team will probably include your family doctor, a rheumatologist and a physical therapist. Other health care professionals, like behavior health specialists, may help you manage other symptoms, such as mood or sleep problems2. The most important member of your health care team however, is you. The more active you are in your care, the better you will feel3. Scientific evidence for effective therapies include: pharmacotherapy, aerobic exercise and muscle stretching exercise, education, relaxation therapy and cognitive behavioral therapy5.
PharmacologicPrimary fibromyalgia is difficult to treat because patients commonly have significant hypersensitivity to the prescribed medications. Nonsteroidal anti-inflammatory medicines (ibuprofen, aspirin and naproxen) are not usually effective in treating fibromyalgia when taken alone3. People with fibromyalgia typically turn to pain medicines, antidepressants, muscle relaxants, and sleep medicines.
Anti-seizureIn June 2007, Lyrica (pregabalin) became the first FDA-approved drug for specifically treating fibromyalgia. Lyrica, marketed by Pfizer Inc., was previously approved to treat seizures, as well as diabetic peripheral neuropathy and for the pain of shingles. Side effects of Lyrica including sleepiness, dizziness, blurry vision, weight gain, trouble concentrating, swelling of the hands and feet, and dry mouth. Allergic reactions, although rare, can also occur. 3, 6, 9
Anti-depressantJune 2008, Cymbalta (duloxetine hydrochloride) became the second FDA-approved drug for specifically treating fibromyalgia. Cymbalta, marketed by Eli Lilly, was previously approved to treat depression, anxiety, and diabetic peripheral neuropathy. The side effects of Cymbalta include nausea, dry mouth, sleepiness, constipation, decreased appetite, and increased sweating. Like some other antidepressants, Cymbalta may increase the risk of suicidal thinking and behavior in people who take the drug for depression. Some people with fibromyalgia also experience depression. Savella (milnacipran) is another FDA approved anti-depressant to treat fibromyalgia6. Both Lyrica and Cymbalta reduce pain and improve function in people with fibromyalgia. The mechanism by which these drugs produce their effects is unknown. There is some data suggesting that these drugs affect the release of neurotransmitters in the brain. Treatment with Lyrica or Cymbalta may reduce the level of pain experienced by some people with fibromyalgia. These drugs should be started low and slowly titrated in fibromyalgia patients.
Physical Therapy & ExerciseOne of the best things to do if you have fibromyalgia is engage in moderate exercise on a regular basis. Exercise can reduce your pain, give you more energy, reduce stress and help you sleep better. If you’re not used to exercising, be sure to talk to your healthcare provider before you start. If you have a physical therapist on your health care team, he / she can help you develop an exercise routine that’s right for you. It is usually best to start with low-impact aerobic exercise, like walking or water aerobics for a short period of time a few days a week. As your pain decreases and your energy increases, you can gradually increase the intensity and frequency of your exercise3.
Behavioral HealthFibromyalgia is a chronic condition. It affects patients over a long period of time – possibly their entire life. There will be times when fibromyalgia may “flare up” and the symptoms will be worse. Other times patients may feel much better. The good news is that the symptoms can be managed3. Multidisciplinary treatment for fibromyalgia is recommended, and that includes screening and treatment for depression. A behavior health provider can perform this screening and develop an effective treatment plan2. The following are ways a behavioral health provider may you take an active role in managing your fibromyalgia symptoms:
Maintain a healthy outlookWork with the health care team to choose realistic, short-term goals to manage your symptoms. Focus on what you can do today to feel better. Tell your healthcare provider if you have been feeling depressed or anxious. These feelings are common among people who live with the pain and frustration of fibromyalgia. Your provider may suggest cognitive behavioral therapy, which helps you replace negative thoughts with positive thoughts.
Find supportDon’t be afraid to ask for the help you need to deal with fibromyalgia. Support can come from your health care team, as well as friends and family members. For example, you could ask a friend to be your exercise buddy. There are also support groups specifically for people who have fibromyalgia.
Recognize stress and take steps to reduce itBecause stress makes the symptoms of fibromyalgia worse, it’s important to recognize when you’re feeling stressed. Signs of stress may include a feeling of tension in your shoulders or neck, an upset stomach or a headache. Unfortunately, there isn’t a way to completely get rid of stress in your life. However, you can focus on changing the way you react to stress. For example, you might set aside time each day to practice deep-breathing techniques or meditation.
Establish healthy sleep habitsLack of sleep can make your fibromyalgia symptoms worse. And increased pain makes it hard to get restful sleep. To avoid getting caught in this cycle, try to have healthy sleeping habits. Avoid caffeine and alcohol before bedtime, go to bed and wake up at the same time each day, including weekends, and limit naps during the day.
Get into a routineMany people who have fibromyalgia do better when their schedule follows a routine pattern. This usually means that each day they have meals at the same times, go to bed and get up at the same times, and exercise at the same time. Try to keep your weekend and holiday schedules as similar to your weekday schedule as possible.
Make healthy lifestyle choicesBy making healthy choices, you will have more energy, feel better and lower your risk for other health problems. Eat a healthy, balanced diet. Limit the amount of alcohol you drink. If you use tobacco products, stop. Lose weight if you are overweight3.
Complementary Alternative MedicineMuch of the research on complementary health approaches for fibromyalgia is still preliminary, and evidence of effectiveness is limited. However, some mind and body practices, such as tai chi, meditation, and massage therapy, may be helpful for fibromyalgia symptoms. Other alternative approaches like dietary supplements and herbs, lack sufficient research and scientific evidence to support their use. Tell your health care providers about any complementary health approaches you use. Give them the complete picture of what you do to manage your health, to help ensure coordinated and safe care7.
Tai ChiResearch suggests that tai chi—a practice originating in China that involves moving the body slowly, gently, and with awareness—may provide a benefit to patients with fibromyalgia. A 2010 study compared the effects of a tai chi program with a wellness education and stretching program for managing fibromyalgia over a 12-week period7. The researchers found that the participants in the tai chi group had significant improvements in symptoms such as pain, sleep quality, depression, and quality of life, and maintained these benefits for up to 24 weeks. A larger follow-up study of tai chi for fibromyalgia is underway. A 2009 review examined the use of qi gong—a Chinese practice involving physical movement, mental focus, and breathing techniques. The reviewers found that qi gong may improve symptoms related to fibromyalgia7.
MassageA 2009 study compared the effects of manual lymph drainage therapy and connective tissue massage in women with fibromyalgia. The researchers found that both types of massage helped to reduce pain, improve quality of life, and increase the pain pressure threshold. Manual lymph drainage therapy had a greater effect on the participants’ overall health7.
ReikiThe National Center for Complementary and Alternative Medicine funded a study to examine the use of Reiki, a practice based on an Eastern idea that energy supports the body’s natural healing abilities. The study showed no effect of Reiki on pain or any of the other outcomes measured in the study; (physical and mental functioning, medication use, and visits to health care providers)7.
AcupunctureA 2010 systematic review of acupuncture for fibromyalgia concluded that acupuncture had a small pain-relieving effect. However, this effect might have been due to biases in the acupuncture studies7.
OtherResearch evidence is insufficient to draw conclusions about the effectiveness of chiropractic care, hypnosis, or magnet therapy for fibromyalgia. A 2009 systematic review found that balneotherapy, bath therapy treatment, may provide some benefit to patients with fibromyalgia, particularly for decreasing pain. However, because of variations in study design and small sample sizes, definite conclusions about the value of balneotherapy cannot be reached based on the current evidence7.
Nutritional SupplementsBe aware that some complementary health approaches, particularly dietary supplements, may interact with conventional medical treatments. Small studies have examined various natural products; such as topical creams containing capsaicin or dietary supplements like S-adenosyl-L-methionine. A 2010 systematic review concluded that there is not enough evidence to determine whether these products provide a health benefit7.
Areas of ResearchRecent National Center for Complementary and Alternative Medicine sponsored studies has investigated new CAM treatments for fibromyalgia including:
- The effectiveness of traditional Chinese medicine for treating fibromyalgia
- The mechanisms of fibromyalgia pain, as revealed by brain-imaging techniques
- The effectiveness of a form of electroencephalograph (EEG) biofeedback in addressing fibromyalgia symptoms7.
- Researchers are investigating whether low magnesium levels contribute to fibromyalgia and if magnesium supplements might help to reduce symptoms
Linkshttp://www.nlm.nih.gov/medlineplus/fibromyalgia.html http://www.mayoclinic.com/health/fibromyalgia-symptoms/AR00054 http://familydoctor.org/familydoctor/en/diseases-conditions/fibromyalgia.printerview.all.html http://www.niams.nih.gov/Health_Info/Fibromyalgia/default.asp http://www.cdc.gov/arthritis/basics/fibromyalgia.htm http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm107802.htm http://nccam.nih.gov/ http://www.theacpa.org/uploads/FibroHandbook.pdf http://www.empr.com/fibromyalgia-a-diagnosis-of-exclusion-no-longer/article/310074/
- NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases
- Mayo Foundation for Medical Education and Research
- American Academy of Family Physicians
- National Institute of Arthritis and Musculoskeletal and Skin Diseases
- Centers for Disease Control and Prevention
- Food and Drug Administration
- National Center for Complementary and Alternative Medicine
- EpicGenetics, Inc. 1640 S. Sepulveda Blvd., Suite 214 Los Angeles, CA. 90025
- Monthly Prescribing Reference, 09/04/ 2013. Fibromyalgia: A Diagnosis of Exclusion No Longer
- American Chronic Pain Association
- Goldberg, DL. Clinical Management of Fibromyalgia, 2009 NY. Professional Communications
- Starz, TW & Turk, DC. Diagnosing Fibromyalgia. 2010