Although fibromyalgia is a relatively recent term, this syndrome has been known by several other names over the past years, including soft tissue rheumatism, fibrositis and non-articular rheumatism.
Symptoms and associated syndromes
Pain – The pain of FMS has no boundaries. People describe the pain as deep muscular aching, throbbing, shooting, and stabbing. Intense burning may also be present. Quite often, the pain and stiffness are worse in the morning and you may hurt more in muscle groups that are used repetitively.
Fatigue – This symptom can be mild in some patients and yet incapacitating in others. The fatigue has been described as “brain fatigue” in which patients feel totally drained of energy. Many patients depict this situation by saying that they feel as though their arms and legs are tied to concrete blocks, and they have difficulty concentrating, e.g., brain fog.
Sleep disorder – Most FMS patients have an associated sleep disorder called the alpha-EEG anomaly. This condition was uncovered in a sleep lab with the aid of a machine which recorded the brain waves of patients during sleep. Researchers found that most FMS patients could fall asleep without much trouble, but their deep level (or stage 4) sleep was constantly interrupted by bursts of awake-like brain activity. Patients appeared to spend the night with one foot in sleep and the other one out of it.
Irritable Bowel Syndrome – Constipation, diarrhea, frequent abdominal pain, abdominal gas, and nausea represent symptoms frequently found in roughly 40 to 70% of FMS patients.
Chronic headaches – Recurrent migraine or tension-type headaches are seen in about 50% of FMS patients and can pose a major problem in coping for this patient group.
Temporomandibular Joint Dysfunction Syndrome – This syndrome, sometimes referred to as TMJ or TMD, causes tremendous jaw-related face and head pain in one quarter of FMS patients. However, a 1997 published report indicated that close to 75% of FMS patients have a varying degree of jaw discomfort. Typically, the problems are related to the muscles and ligaments surrounding the jaw joint and not necessarily the joint itself.
Other common symptoms – Premenstrual syndrome and painful periods, chest pain, morning stiffness, cognitive or memory impairment, numbness and tingling sensations, muscle twitching, irritable bladder, the feeling of swollen extremities, skin sensitivities, dry eyes and mouth, dizziness, and impaired coordination can occur. Patients are often sensitive to odors, loud noises, bright lights, and sometimes even the medications that they are prescribed.
Aggravating factors – Changes in weather, cold or drafty environments, infections, allergies, hormonal fluctuations (premenstrual and menopausal states), stress, depression, anxiety and over-exertion may all contribute to symptom flare-ups. (From Fibromyalgia Network)
Treatments and drugs
In general, treatment for fibromyalgia includes both medication and self-care. The emphasis is on minimizing symptoms and improving general health.
Medications can help reduce the pain of fibromyalgia and improve sleep. Common choices include:
- Analgesics. Acetaminophen (Tylenol, others) may ease the pain and stiffness caused by fibromyalgia. However, its effectiveness varies. Tramadol (Ultram) is a prescription pain reliever that may be taken with or without acetaminophen. Your doctor may recommend nonsteroidal anti-inflammatory drugs (NSAIDs) — such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen sodium (Anaprox, Aleve) — in conjunction with other medications. NSAIDs haven’t proved to be effective in managing the pain in fibromyalgia when taken by themselves.
- Antidepressants. Your doctor may prescribe antidepressant medications such as amitriptyline, nortriptyline (Pamelor) or doxepin (Sinequan) to help promote sleep. Fluoxetine (Prozac) in combination with amitriptyline has also been found effective. Sertraline (Zoloft) and paroxetine (Paxil) may help if you’re experiencing depression.Some evidence exists for a newer class of antidepressants known as serotonin and norepinephrine reuptake inhibitors or dual uptake inhibitors, which regulate two brain chemicals that may transmit pain signals. Studies have found that duloxetine (Cymbalta) may help control pain better than placebo in people with fibromyalgia. Small trials of venlafaxine (Effexor) suggest the same, though more study is needed to confirm these findings.
- Muscle relaxants. Taking the medication cyclobenzaprine (Flexeril) at bedtime may help treat muscle pain and spasms. Muscle relaxants are generally limited to short-term use.
- Pregabalin (Lyrica). Pregabalin may reduce pain and improve function in people with fibromyalgia. Pregabalin, an anti-seizure medication that’s also used to treat some types of pain, is the first drug approved by the Food and Drug Administration to treat fibromyalgia. Studies show pregabalin reduced signs and symptoms of fibromyalgia in some people. In one study, about half of the participants taking the highest doses of the drug reported at least a 30 percent improvement. Side effects of pregabalin include dizziness, sleepiness, difficulty concentrating, blurred vision, weight gain, dry mouth, and swelling in the hands and feet.
Prescription sleeping pills, such as zolpidem (Ambien), may provide short-term benefits for some people with fibromyalgia, but doctors usually advise against long-term use of these drugs. These medications tend to work for only a short time, after which your body becomes resistant to their effects. Ultimately, using sleeping pills tends to create even more sleeping problems in many people.
Benzodiazepines may help relax muscles and promote sleep, but doctors often avoid these drugs in treating fibromyalgia. Benzodiazepines can become habit-forming, and they haven’t been shown to provide long-term benefits.
Doctors don’t usually recommend narcotics for treating fibromyalgia because of the potential for dependence and addiction. Corticosteroids, such as prednisone, haven’t been shown to be effective in treating fibromyalgia.
Cognitive behavior therapy
Cognitive behavior therapy seeks to strengthen your belief in your abilities and teaches you methods for dealing with stressful situations. Therapy is provided through individual counseling, classes, and with tapes, CDs or DVDs, and may help you manage your fibromyalgia.
Programs that combine a variety of treatments may be effective in improving your symptoms, including relieving pain. These interdisciplinary programs can combine relaxation techniques, biofeedback and receiving information about chronic pain. There isn’t one combination that works best for everybody. Your doctor can create a program based on what works best for you.
Most of the research findings in fibromyalgia point to a malfunctioning of the central nervous system (CNS), which includes the brain and spinal cord. Yet, there appear to be a variety of abnormalities occurring in the peripheral soft tissues (muscles and connective tissue) and the peripheral nervous system that communicates with the CNS. This dysfunctional interplay between the CNS and peripheral systems is believed by most investigators to be the source of the many body-wide symptoms. In a way, fibromyalgia could be considered a disease of the CNS.
Central nervous system research on fibromyalgia:
- Alterations in pain-related chemical transmitters have been reported in the spinal fluid (particularly substance P, nerve growth factor, serotonin, norepinephrine, and corticotropin releasing factor)
- Elevated levels of pro-inflammatory cytokines, which are substances that form a communication link between your body’s immune and neurological systems, have been found by many research teams
- Different brain imaging techniques by several research centers have all shown that the blood flow and metabolic processes in the brain are significantly disturbed
- Almost all people with fibromyalgia report difficulties staying asleep (e.g., the natural processes in the brain that maintain sleep appear to be disrupted)
- The autonomic nervous system, whose control center resides at the base of the brain to communicate with the CNS to regulate the peripheral tissues, is not functioning properly
- Research on the primary pain control system in the spinal cord indicates that it is not filtering out or dampening incoming noxious signals from the peripheral tissues
- Several research studies pertaining to memory function tests show that people with fibromyalgia have an impaired ability to concentrate
Research findings show that the peripheral tissues are also involved in producing the symptoms of fibromyalgia:
- Muscles are often tight and knotted with myofascial trigger points (areas in the belly of muscles that refer pain to other regions and cause restrictions in range of motion)
- High levels of a nitric oxide-producing enzyme was documented by one research team to help explain why patients have exercise intolerance
- Excessive levels of oxidative chemicals that irritate the tissues were found in the connective tissues in the tiny space between the muscle fibers
- Reduced blood flow to the muscles as well as a reduction in the number of capillaries supplying nutrients to the tissues were confirmed by different research teams … these findings are hypothesized to be caused by the malfunctioning in the autonomic nervous system
Why do all of the above abnormalities exist in people with fibromyalgia? This is why research in this area is imperative.
- Richard Gracely, Ph.D., and Daniel Clauw, M.D., of the University of Michigan in Ann Arbor, used fMRI to study fibromyalgia patients with and without depression.2 They found that different areas of the brain were activated when patients processed the sensory dimension of pain as opposed to those that were activated for depression (viewed as the affective component of pain because it has to do with how much emotional relevance a person attaches to their pain). They concluded, “Evaluation of these sensory and affective dimensions in patients with chronic pain is likely to improve diagnosis, choice of treatment, and treatment efficacy.”
- The above findings are highly relevant in light of the common prescription of antidepressants for treating fibromyalgia. A 12-week treatment trial of the antidepressant, Effexor, revealed that fibromyalgia patients with depression benefited with improved mood.3 However, the pain of fibromyalgia was unfazed by the drug.
- A separate report by Gracely and Clauw’s team measured the response to experimental pain stimuli in fibromyalgia patients and healthy controls.4 Interestingly, the healthy controls rated the stimuli to be significantly more unpleasant than the patients. Distress, anxiety or depression did not influence the patient’s unpleasantness ratings. The study’s authors suggest that the presence of chronic pain can alter one’s perception of experimental pain (perhaps as part of the brain’s reorganization process), which may pale in comparison to the day-to-day pain of fibromyalgia.
- Ali Gur, M.D., of Turkey found an important cytokine chemical, IL-8, to be elevated in patients with fibromyalgia.5 Correlating this chemical with brain function, he found that fibromyalgia patients with little to no depression had higher IL-8 levels and more impaired brain blood flow than those with severe depression. In keeping with the concept that fibromyalgia and depression cause different alterations in brain function, Gur was able to tease out the chemical change caused by fibromyalgia (IL-8) and the compounding issue of feeling depressed.
In reference to the advances in technology, Apkarian and colleagues write: “We fully expect that the next generation of brain imaging studies of pain will impact clinical practice and thus contribute to decreasing pain in society.”6 How realistic is this projection? Very! Apkarian published a report this year showing how a single dose of an anti-inflammatory drug produced objective improvements in arthritis and a corresponding change in brain chemistry.7
1. Grachev ID, et al. J Neural Transm 109(10):1309-34, 2002.
2. Giesecke T, et al. Arthritis Rheum 52(5): 1577-84, 2005.
3. Sayar K, et al. Psychosomatics 46(4):340-4, 2005.
4. Petzke F, et al. Eur J Pain 9:325-35, 2005.
5. Gur A, et al. Clin Exp Rheumatol 20(6):753-60, 2002.
6. Apkarian AV, et al. Eur J Pain 9(4):463-84, 2005.
7. Baliki MN, et al. Mol Pain 1(1):32, 2005.
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