A syndrome of chronic pain of musculoskeletal origin but uncertain cause. The American College of Rheumatology has established diagnostic criteria that include pain on both sides of the body, both above and below the waist, as well as in an axial distribution (cervical, thoracic, or lumbar spine or anterior chest); additionally there must be point tenderness in at least 11 of 18 specified sites. Syn: fibromyalgia syndrome.
Fibromyalgia is described as inflammation of the fibrous or connective tissue of the body. Widespread muscle pain, fatigue, and multiple tender points characterize these conditions. Fibrositis, fibromyalgia, and fibromyositis are names given to a set of symptoms believed to be caused by the same general problem.
About 5 million Americans have fibromyalgia. The condition affects women more often than men.
The American College of Rheumatology (ACR) set the following criteria for classifying fibromyalgia:
1. Widespread pain must be present for at least 3 months. This pain must appear in all of the following locations:
Both sides of the body.
- Above and below the waist.
- Along the length of the spine.
2. Pain in at least 11 of 18 specific areas called tender points on the body. The pain experienced when pressing on a tender point is very localized and intensely painful (not just tender). Tender points are located in the following areas:
The left or right side of the back of the neck, directly below the hairline.
- The left or right side of the front of the neck, above the collarbone (clavicle).
- The left or right side of the chest, right below the collarbone.
- The left or right side of the upper back, near where the neck and shoulder join.
- The left or right side of the spine in the upper back between the shoulder blades (scapula).
- The inside of either arm where it bends at the elbow.
- The left or right side of the lower back, right below the waist.
- Either side of the buttocks below the hip bones.
- Either kneecap.
Many experts believe that fibromyalgia is not a disease, but is rather a chronic pain condition brought on by several abnormal body responses to stress. Areas in the brain that are responsible for the sensation of pain react differently in fibromyalgia patients than the same areas in healthy people.
People with fibromyalgia have been found to have decreased activity in opioid receptors in parts of the brain that affect mood and the emotional aspect of pain. This reduced response might explain why it patients are likely to have depression, and are less responsive to opioid painkillers, researchers say.
Sleep disturbances are common in fibromyalgia. Patients with the condition have a higher-than-average rate of a sleep disorder called periodic limb movement disorder (PLMD). Patients with PLMD involuntarily contract their leg muscles every 20 - 40 seconds during sleep, which may occasionally wake them up.
Some researchers believe that fibromyalgia does not lead to poor sleeping patterns, but that sleep disturbances come first. Researchers continue to investigate the link between this and sleep.
Many abnormalities of hormonal, metabolic, and brain chemical activity have been described in studies of fibromyalgia patients. Changes appear to occur in several brain chemicals, although no regular pattern has emerged that fits most patients. Since there has been no clear cause-and-effect relationship established, it may be that fibromyalgia is a result of the effects of pain and stress on the central nervous system, which lead to changes in brain circuitry, rather than a brain disorder itself.
Serotonin: Of particular interest to researchers is serotonin, an important nervous system chemical messenger found in the brain, gut, and other areas of the body. Serotonin plays important roles in creating feelings of well-being, adjusting pain levels, and promoting deep sleep. Serotonin abnormalities have been linked to many disorders, including depression, migraines, and irritable bowel syndrome. Lower serotonin levels have also been noted in some patients with fibromyalgia.
Stress Hormones: Researchers have also found abnormalities in the hormone system known as the hypothalamus-pituitary-adrenal gland (HAP) axis. The HAP axis controls important functions, including sleep, stress response, and depression. Changes in the HAP axis appear to produce lower levels of the stress hormones norepinephrine and cortisol. (By contrast, levels of stress hormones in depression are higher than normal.) Lower levels of stress hormones lead to impaired responses to psychological or physical stresses. (Examples of physical stress include infection or exercise.)
Some fibromyalgia patients may be oversensitive to external stimulation, and overly anxious about the sensation of pain. This increase in awareness is called generalized hypervigilance.
A conflict between sensory perception and nervous system processing might occur in people with fibromyalgia. Fibromyalgia patients have been found to have greater awareness of, or less tolerance for, movement problems (such as tremor) that don't match with their expected sensory feedback. This mismatch in sensory signals might enhance the perception of pain. This patients also seem to be more sensitive to sounds.
Fibromyalgia has symptoms that resemble those of some rheumatic illnesses, including rheumatoid arthritis and lupus (systemic lupus erythematosus). These are autoimmune diseases in which a defective immune system mistakenly attacks the body's own healthy tissue, producing inflammation and damage. The pain in fibromyalgia, however, does not appear to be due to autoimmune factors, and there is little evidence to support a role for an inflammatory response in fibromyalgia.
List of Fibromyalgia Symptoms Include:
Causes and Risk factors:
- Widespread pain for more than 3 months.
- Tenderness in the neck, shoulder, knee, elbow, or upper buttocks or thigh areas.
- Trouble sleeping.
- Tiredness in the morning or late in the day.
- Mood changes.
- Irritable bowel syndrome.
- Headaches, sometimes migraines.
- Difficulty concentrating.
- Numbness and tingling in hands, arms, feet, legs or face.
- Abdominal pain.
In the most common type of fibromyalgia, the causes are not known. Physical injuries, emotional trauma, or viral infections such as Epstein-Barr may trigger the disorder, but no one trigger has proven to be a cause of primary fibromyalgia.
Investigators are constantly looking at various explanations for the occurrence of fibromyalgia. Some, for example, are exploring hormonal disturbances and chemical imbalances that affect nerve signaling. Other experts believe this with its deep muscle pain is linked to stress, illness, or trauma. Still others think there is a hereditary cause or say there is no explanation at all. But while there is no clear consensus about what causes fibromyalgia, most researchers believe fibromyalgia results not from a single event but from a combination of many physical and emotional stressors.
Some have speculated that lower levels of serotonin in the blood leads to lowered pain thresholds or an increased sensitivity to pain. Serotonin is a neurotransmitter in the brain. It's associated with a calming, anxiety-reducing reaction. The lowered pain thresholds may be caused by the reduced effectiveness of the body's natural endorphin painkillers and the increased presence of a chemical called "substance P." Substance P amplifies pain signals.There have been some studies that link fibromyalgia to sudden trauma to the central nervous system. Keep in mind, though, theories about what causes fibromyalgia are merely speculative.
Another theory states that fibromyalgia is caused by biochemical changes in the body and may be related to hormonal changes or menopause. In addition, some (but not all) people with fibromyalgia have low levels of human growth hormone, which may contribute to the muscle pain.
Some scientists used to believe that because fibromyalgia was accompanied by low-grade depression, there may be a link between the two illnesses. Today, mental health issues are no longer thought to cause fibromyalgia. However, chronic pain can cause feelings of anxiety and depression, which may worsen fibromyalgia symptoms.
Like other rheumatic diseases, this could be the result of a genetic tendency that's passed from mother to daughter. Some researchers believe that a person's genes may regulate the way his or her body processes painful stimuli. These scientists theorize that people with fibromyalgia may have a gene or genes that cause them to react intensely to stimuli that most people would not perceive as painful. To date, these genes have not been isolated or identified.
It's thought that when a person with this genetic tendency is exposed to certain emotional or physical stressors -- such as a traumatic crisis or a serious illness -- there is a change in the body's response to stress. This change can result in a higher sensitivity of the entire body to pain.
Psychological and Social Effects:
Although not primary causes, psychological and social factors may contribute to fibromyalgia in three ways:
They could make individuals susceptible to fibromyalgia.
- They may play some role in triggering the onset of the condition.
- They may perpetuate, or be responsible for, the condition.
Some evidence suggests that several factors may make people more susceptible to fibromyalgia. These risk factors include:
- Coming from a very stressful culture or environment.
- Having a psychological vulnerability to stress.
- Having had difficult experiences in childhood.
Women: Nine out of 10 fibromyalgia patients are women. Women may be more prone to develop fibromyalgia during menopause.
Age: The disorder usually occurs in people ages 20 - 60 years, though it can occur at any time. Some studies have noted peaks at around age 35. Others note that fibromyalgia is most common in middle-aged women. In one study, cases of fibromyalgia increased with age, and reached a frequency of more than 7% among people in their 60s and 70s.
Juvenile Primary Fibromyalgia: This type of fibromyalgia appears in adolescents, typically after age 13, with a peak incidence at age 14. It is uncommon, but studies indicate that its incidence may be increasing. Symptoms are similar to adult fibromyalgia, but outcomes may be better in young people.
Family Factors: Studies report a higher incidence of fibromyalgia among family members. It is not clear whether genetic or psychological factors, or both, are involved. Studies have found that:
About a third of children whose mothers have fibromyalgia also develop the disorder. About two-thirds of parents who had children with fibromyalgia report some sort of chronic pain. About 10% of them have fibromyalgia.
There is no obvious, objective method for diagnosing fibromyalgia. The criteria used for studying this are very helpful, particularly if the patient does not have an accompanying disorder, such as depression or arthritis, that could complicate the diagnosis. Failure to meet the criteria, however, does not rule out fibromyalgia. Fibromyalgia should be suspected in any person who has muscle and joint pain with no identifiable cause.
A doctor should always take a careful personal and family medical history, which includes a psychological profile and history of any factors that might indicate other conditions, such as:
- Muscle weakness.
- Physical injuries.
- Recent weight change.
- Sexual, physical, or substance or alcohol abuse.
- Patients should report any drugs they take, including vitamins and over-the-counter or herbal medications.
Physical Examination: Any physical examination for fibromyalgia requires that the doctor press firmly on all potential tender spots. These spots must be painful when pressed, not simply tender. In addition, for a doctor to reach a diagnosis of fibromyalgia, these tender sites should normally not show signs of inflammation (redness, swelling, or heat in the joints and soft tissue). The tender points may also change in location and sensitivity over time. A doctor may then recheck tender points that do not respond the first time in patients who have other significant symptoms.
Detection of Other Causes of Symptoms: A health care provider will also examine the nails, skin, mucus membranes, joints, spine, muscles, and bones to help rule out arthritis, thyroid disease, and other disorders.
Other Tests: No blood, urine, or other laboratory tests can definitively diagnose fibromyalgia. If such tests show abnormal results, the doctor should look for other disorders. Tests for specific diseases depend on family histories and other symptoms, and may include:
- Blood count.
- Sedimentation rate.
- Tests of certain antibodies.
- Thyroid and liver function tests.
The doctor may suggest follow-up psychological profile testing, if laboratory results do not indicate a specific disease.
Fibromyalgia is a mysterious condition. Its causes are still largely unknown, as is how it inflicts damage. No strong evidence indicates that any single treatment (or combination of treatments) has any significant effect for most patients.
The U.S. Food and Drug Administration approved pregabalin (Lyrica) as the first drug treatment for fibromyalgia after a study showed the medicine reduced fibromyalgia pain in 63% of patients. A year later, the FDA approved the drug duloxetine (Cymbalta) for fibromyalgia. Cymbalta has been shown to reduce fibromyalgia pain by more than 30%.
Treatments usually involve trial and error:
Patients may start with physical therapy, exercise, stress reduction techniques, and cognitive-behavioral therapy.
- If these methods fail to improve symptoms, an antidepressant or muscle relaxant may be added to the treatment. Doctors usually prescribe these drugs because they may improve pain tolerance.
- Patient education and programs that encourage coping skills are an important part of any treatment plan.
A combination of non-drug therapies appears to work just as well as drug therapy in improving pain, depression, and disability. This combination includes exercise, stress management, massage, and diet.
It is important to understand that fibromyalgia can be managed, and patients can live a full life. The following tips may be helpful when starting a treatment program for fibromyalgia:
The goal of therapy is to relieve symptoms, not cure them.
Medicine and medications:
Anti-Seizure Agents (Anti-Convulsants)
- Treatment must be tailored to each patient, and a combination approach is often needed.
- Patients must begin all treatments with the attitude that these treatments are trial-and-error. There is no clear treatment solution. Patients and doctors need to work together to make the best choices for individual symptoms and concerns.
- Treatments are long-lasting, in some cases life-long, and patients should not be discouraged by the return of symptoms (relapses).
- Enlisting family members, partners, and close friends, particularly to help with exercise and stretching programs, can be helpful.
- Becoming involved with support groups also benefits many patients. Support groups may also help family members, particularly parents of children with this. One study noted that the severity of the disorder increased in children whose parents were less able to cope with their pain.
: Pregabalin is an anti-epileptic. Also called anti-seizure drugs and anti-convulsants, these medicines affect the chemical messenger gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing. Research is indicating it may improve sleep quality, fatigue symptoms, and fibromyalgia pain.
: The main classes of antidepressants used for treating fibromyalgia are tricyclics, selective serotonin-reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Although these drugs are antidepressants, doctors prescribe them to improve sleep and relieve pain in non-depressed patients with fibromyalgia. The dosages used for managing fibromyalgia are generally lower than dosages prescribed for treating depression. If a patient has depression in addition to fibromyalgia, higher doses may be required.
: Tricyclic antidepressants were the first drugs to be well-studied for this. They cause drowsiness and can be helpful for improving sleep. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), and nortriptyline (Pamelor, Aventyl).
Side effects most often reported include:
- Difficulty urinating.
- Dry mouth.
- Heart rhythm disturbances.
- Sexual dysfunction.
- Weight gain.
: Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. It helps relieve fibromyalgia symptoms. Cyclobenzaprine is related to the tricyclic antidepressants and has similar side effects, including drowsiness, dry mouth, and dizziness.
: Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) and eszopiclone (Lunesta) may improve sleep in patients with insomnia.
: Pain relievers for fibromyalgia include:
Tramadol (Ultram), used alone or in combination with acetaminophen (Tylenol), is commonly prescribed for relief of fibromyalgia pain. Its most common side effects are drowsiness, dizziness, constipation, and nausea. Tramadol should not be used in combination with tricyclic antidepressants.
- Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers. Capsaicin is helpful for relieving painful areas in other disorders. It may also have some value for fibromyalgia patients.
- Opioids, or narcotics, may be used occasionally by certain patients with moderate-to-severe pain, or those with significant problems performing everyday tasks. Such patients should use narcotics only if they cannot find relief with other, less potent treatments. Patients may get combinations of narcotic pain relievers and acetaminophen for periodic pain. Some physicians prescribe opioids, such as oxycodone (Roxicodone) or morphine sulfate (Duramorph), for patients who need ongoing relief. However, the benefit of opioids in fibromyalgia treatment is highly controversial. Physicians should take a careful medical and psychological profile of the patient before prescribing opioids, and then should evaluate those patients periodically for continuing pain relief, side effects, and signs of dependence.
- Pramipexole, a drug used to treat Parkinson's disease and restless legs syndrome, may help relieve pain and fatigue in people with fibromyalgia. Pramipexole stimulates the production of dopamine, a chemical messenger in the brain.
- The atypical antipsychotic drug olanzapine (Zyprexa) may be a beneficial add-on therapy for patients with fibromyalgia. Although proven effective for some chronic pain conditions, olanzapine and other antipsychotics cause unpleasant and potentially serious side effects.
: The following drugs and medications are in some way related to, or used in the treatment. This service should be used as a supplement to, and NOT a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.