Fibromyalgia

Alternative names

Formerly known as: fibrositis, fibromyositis.

Summary

• Fibromyalgia is a chronic condition associated with widespread pain, stiffness and tenderness of the muscles and soft tissues around joints.
• Unlike many other rheumatic conditions, fibromyalgia does not cause inflammation of the affected tissues, and does not lead to joint damage or deformity.
• The cause of fibromyalgia is unknown, but its development is probably due to several different factors, such as stress, trauma and abnormalities of pain-related chemicals in the nervous system.
• Apart from pain, other common symptoms associated with fibromyalgia include fatigue, sleep disturbances and depression.
• There are no tests to help determine the presence of fibromyalgia; diagnosis is based on medical history and physical examination.
• Although there is no cure for fibromyalgia, it can often be managed with a combination of medication, exercise, physical therapy, relaxation techniques and psychological counselling.

Definition

Fibromyalgia is a chronic condition primarily associated with widespread pain, stiffness and tenderness of the muscles and soft tissues around joints.

The pain of fibromyalgia is not accompanied by inflammation in the affected tissues, and therefore does not lead to joint deformity or other tissue damage. In this regard fibromyalgia differs from many other rheumatic conditions (diseases that affect the muscles, joints or associated tissues).

Fibromyalgia may occur in isolation, but many people with the condition also have other musculoskeletal disorders such as rheumatoid arthritis.

Cause

The cause of fibromyalgia is unknown, but medical experts generally agree that a number of different factors contribute to its development and ongoing symptoms.

These factors may include the following:

Sleep disturbances

Disturbed sleep patterns may be a cause rather than only a symptom of fibromyalgia. Studies have shown that people with fibromyalgia have abnormally low levels of the hormone somatomedin C, believed to be essential in rebuilding tissues. Somatomedin C is secreted during the deep restorative stage of sleep, which is often disturbed in fibromyalgia. There is a reduction in stage 4 sleep, with relative reduction in dream phase sleep. People wake up feeling unrested.

Abnormal production and regulation of pain-related chemicalsin the nervous system

Studies indicate that people with fibromyalgia have abnormal levels of the neurotransmitter serotonin (associated with depression, migraines and gastrointestinal problems) and substance P (associated with pain, stress, anxiety and depression) in their central nervous system (brain and spinal cord).

Studies into the responses of the sympathetic nervous system (controls certain involuntary bodily functions and the release of pain-related chemicals epinephrine (adrenaline) and norepinephrine) in people with fibromyalgia report abnormalities such as reduced epinephrine responses to low blood sugar levels and exercise, decreased responses to cold, and altered heart rate and blood pressure responses.

These abnormalities may result in a lower pain threshold, or a heightened perception of pain.

Injury or trauma

Injury to the upper spinal region appears to trigger the development of fibromyalgia in some people. Many people with fibromyalgia report that they began experiencing symptoms after a traumatic event, such as a car accident or fall.

Infection

Fibromyalgia may be triggered by a viral or bacterial infection, although no such agent has yet been identified.

Hormonal, metabolic and immunological abnormalities

For example, tenderness in certain areas may be associated with changes in muscle metabolism, such as decreased blood flow, causing fatigue and weakness.

Psychological stress

Stressful life events may trigger fibromyalgia, or worsen its symptoms. Clinical depression and anxiety precede or accompany fibromyalgia in many cases, and may also contribute to its development. However, fibromyalgia is not simply stress and depression alone. It is a real problem.

Genetic factors

There appears to be a significant increase of  likelihood in families.

Who gets it and who is at risk?

Fibromyalgia is common, affecting an estimated 6-8 million people worldwide. Risk factors for fibromyalgia include:

• Gender and age.Fibromyalgia occurs more commonly in women of childbearing or middle age, although any age and both sexes can be affected. The condition is estimated to occur about seven times more frequently in women than in men: approximately 80 percent of people affected are female. 20 percent are males.
• Family history.You may be more likely to develop fibromyalgia if a relative has the condition.
• Disturbed sleep patterns.It is unclear whether sleep disturbances are a cause or result of fibromyalgia, but people with certain sleep disorders can also develop fibromyalgia.
• Other conditions.Other chronic musculoskeletal disorders, such as rheumatoid arthritis, may increase the risk for developing fibromyalgia.

Symptoms and signs

The severity of fibromyalgia signs and symptoms vary, and occur in different combinations in different individuals, but commonly include the following:

The primary symptom is widespread musculoskeletal pain, which persists for several months and frequently affects the joints, neck and back. The pain is often accompanied by stiffness, which is characteristically worse in the morning and may last all day. Patients often wake up and feel that they have been “run over by a bus”.

Pain typically includes multiple “tender points”: localised tender areas that are acutely painful when moderate pressure is applied (e.g. pressing with the thumb until the nail blanches). Tender points may be found on the back of the head, the neck, upper and lower back, shoulders, upper chest, elbows, hips and knees.

Fatigue and sleep disturbances.Fatigue occurs in 90 percent of people with fibromyalgia, and may be related to the disturbed sleep patterns that commonly occur with the condition. Typically, this is experienced as waking in the morning feeling tired and unrefreshed, sometimes with muscle aches.

Some people with fibromyalgia have trouble falling asleep, or may wake repeatedly during the night. Studies suggest that this may be caused by a sleep disorder called alpha-wave interrupted sleep pattern, in which deep sleep is interrupted by bursts of “wakeful” brain activity. Thus people with fibromyalgia often lack the deep, restorative stage of sleep, called “non-rapid-eye-movement” (non-REM) sleep.

Other sleep disorders, such as sleep apnoea, nocturnal myoclonus and restless legs syndrome, may also be associated with fibromyalgia.

About 40 to 70 percent of people with fibromyalgia experience constipation, diarrhoea, abdominal pain and bloating – symptoms associated with irritable bowel syndrome (“spastic colon”).

Chronic headaches and facial pain. Half of people with fibromyalgia have recurrent migraine or tension headaches, which may be related to tenderness in the neck and shoulders. Up to 90 percent experience jaw and facial pain.

Heightened sensitivity. About 50 percent of people with fibromyalgia report increased sensitivity to different sensory stimuli (such as odours, noises, bright lights, certain foods and changes in the weather), and a low pain threshold.

Numbness, tingling or a swollen sensationin the hands and feet

Chest pain or pelvic pain

Irritable bladder, causing frequent painful urination

Dry eyes and mouth

Dizziness

Mental and/or emotional disturbancesoccur in over half of people with fibromyalgia. Such symptoms include poor concentration, forgetfulness, mood changes, irritability, depression and anxiety.

Diagnosis

There are no tests to help determine the presence of fibromyalgia, and diagnosis must be based on a complete medical history and physical examination.

Diagnosis depends on the doctor making the following findings:

• Presence of widespread pain, experienced for at least three months
• Presence of tender points, not accompanied by tissue swelling or inflammation. At least 11 or more of 18 specific locations of the body must be tender. (Patients with fewer than 11 points may still be diagnosed with fibromyalgia if other symptoms and signs are present.)
• Exclusion of other medical conditions that may have similar symptoms

Medical conditions that also cause pain in different areas of the body, or chronic fatigue, include:

• Hypothyroidism (low thyroid hormone level)
• Muscle diseases causing muscle pain (such as polymyositis and polymyalgia rheumatica)
• Bone diseases causing bone pain (such as Paget's disease and rheumatoid arthritis)
• Elevated blood calcium (e.g. as may occur with hyperparathyroidism)
• Certain infectious diseases (such as hepatitis, Epstein Barr virus infection, HIV/AIDS)
• Certain cancers
• Muscle inflammation
• Bursitis (inflammation of the protective tissue between the joints)
• Tendonitis (inflammation of the tendons)
• Neuropathies (diseases of the nerves, such as multiple sclerosis
• Systemic lupus erythematosus (a chronic inflammatory disease of connective tissue that typically involves joint pain)
• Myasthenia gravis (muscular weakness and fatigue)
• Depression. People with fibromyalgia may be misdiagnosed as having depression as their primary underlying problem
• Drug abuse
• Hypoadrenalism (adrenal insufficiency, which leads to weakness and fatigue)
• Parkinson's disease

Blood tests may be important to exclude these medical conditions.

Fibromyalgia may also occur in association with other systemic rheumatic conditions, such as systemic lupus erythamatosus, rheumatoid arthritis, polymyositis and polymyalgia rheumatica. To complicate matters, fibromyalgia may be associated with (Raynauds phenomenon, where the peripheries (fingers, toes) change colour with cold temperature, and with a mild elevation of antinuclear factor antibodies, which can occur in autoimmune rheumatic diseases. Therefore the diagnosis is a clinical one, and not one where the laboratory is of much help.

There are also instances in which fibromyalgia develops in the context of metabolic or infectious diseases such as such as hypothyroidism, drug withdrawal, or bacterial and viral infection.

Fibromyalgia has many features that overlap with chronic fatigue syndrome. The relationship between these two syndromes is not well established.

Treatment

There is no known cure for fibromyalgia. However, the condition can be managed successfully in many cases by using a combination of medication, exercise, physical therapy, relaxation techniques and, if necessary, psychological counselling.

As the symptoms of fibromyalgia are diverse and variable, the treatment programme should be tailored to the individual and based on several factors, including overall health, medical history, number of tender points, severity of pain and the presence of other symptoms.

Treatment typically includes the following:

Medication

Medications that decrease pain and improve sleep:

Low doses of antidepressant medication (usually tricyclic antidepressants) taken at bedtime may help to promote restful sleep. They may also help to elevate mood, relax the muscles and reduce fatigue. Examples of tricyclic antidepressants commonly used in treating fibromyalgia include amitriptyline (Tryptanol) and imipramine (Tofranil).

A recent study suggests that adding fluoxetine (Prozac) to amitriptyline can further reduce muscle pain, anxiety and depression, and promote restful sleep and a sense of well-being.

No currently existing medications completely relieve fibromyalgia pain. However, acetaminophen (such as Tylenol) is helpful and safer than other analgesics (pain-relieving medications). Some studies indicate that the pain-reliever tramadol (Ultram) may be useful in fibromyalgia pain treatment.

The nonsteroidal anti-inflammatory drugs (NSAIDs), while very helpful in treating other rheumatic conditions, are usually ineffective in treating fibromyalgia pain. Narcotic pain relievers and cortisone medications have also not been shown to be beneficial.

Exercise

Aerobic exercise for at least 30 minutes three times a week improves muscle fitness and significantly reduces muscle pain and tenderness, and also promotes deep restful sleep. Low-impact aerobic exercises, such as walking, cycling, swimming and water aerobics are good activities to choose when starting your exercise programme. Muscle building exercises are not shown to be beneficial.

Coping with stress

Identifying stress factors and learning ways to cope with or modify these where possible may help improve fibromyalgia symptoms.

Relaxation techniques can be used to relieve muscle tension and reduce stress. Professionals trained in stress management can teach you these techniques, which might include modifying your lifestyle to reduce stress factors, biofeedback (learning to have greater control over aspects of the involuntary nervous system), relaxation tapes and psychological counselling.

Anxiety and depression are often major contributors to stress and, if present, must be treated concurrently with fibromyalgia.

Other treatments

A physiotherapist can advise you as to other treatments that may help to ease fibromyalgia pain – such as heat treatments, occasional cold application, massage, and stretching and range-of-motion exercises.

Avoiding alcohol and caffeine before bedtime can help promote restful sleep.

Outcome

Fibromyalgia is a chronic condition, but it is not progressive or life-threatening, nor is it associated with muscle, nerve or joint injury, or any serious tissue damage or disease. People with fibromyalgia are not at greater risk for other musculoskeletal diseases.

Although fibromyalgia symptoms will probably never disappear completely, they often improve with treatment. Medications that can alter the balance of pain-producing chemicals, such as anti-depressants, improve symptoms by about 30 percent. When other forms of therapy such as acetominophen and aerobic exercise are added, even greater improvement can be expected.

Sometimes, if the situation that caused the initial stress is improved, fibromyalgia may improve spontaneously and medications may be unnecessary.

A minority of people with fibromyalgia (about 5%) become chronically disabled by the condition.

When to call the doctor

Consult your doctor if you experience general aching or widespread pain that persists for several months.

It is important to find a doctor who has a sound knowledge of fibromyalgia, feels empathy for chronic pain sufferers, is willing to try different treatment combinations and, if necessary, will refer you for specialist evaluation. Although most fibromyalgia cases can be successfully handled by a GP, about 30% are referred to a rheumatologist (a specialist dealing with muscle and joint conditions).

It is important to educate families about the condition. Most patients are accused of neurosis or of being hypochondriacs. In fact people need to understand that the pain is real and that the condition is not simply stress or depression. Patients, however, need to be focussed on being positive and to try and maintain an active lifestyle and not to simply lie back and give in to the disease.

Reviewed by Dr David Gotlieb, rheumatologist, MBChB FCP(SA)

Reviewed by the Arthritis Foundation, September 2011

The information provided in this article was correct at the time of publishing. At Mediclinic we endeavour to provide our patients and readers with accurate and reliable information, which is why we continually review and update our content. However, due to the dynamic nature of clinical information and medicine, some information may from time to time become outdated prior to revision.