Treating Fibromyalgia
Fibromyalgia is an extremely common chronic condition that can be challenging to manage. Although the etiology remains unclear, characteristic alterations in the pattern of sleep and changes in neuroendocrine transmitters such as serotonin, substance P, growth hormone and cortisol suggest that dysregulation of the autonomic and neuroendocrine system appears to be the basis of the syndrome. The diagnosis is clinical and is characterized by widespread pain, tender points and, commonly, comorbid conditions such as chronic fatigue, insomnia and depression. Treatment is largely empiric, although experience and small clinical studies have proved the efficacy of low-dose antidepressant therapy and exercise. Other less well-studied measures, such as acupuncture, also appear to be helpful. Management relies heavily on the physician's supportive counseling skills and willingness to try novel strategies in refractory cases
Fibromyalgia is a rheumatologic condition characterized by spontaneous, widespread soft tissue pain, sleep disturbance, fatigue and extensively distributed areas of tenderness known as tender points. Estimates of prevalence are 3.4 percent for women and 0.5 percent for men
Fibromyalgia can be perplexing to patients and physicians because of the lack of associated abnormalities on readily available diagnostic tests. Despite this, recent findings about the pathogenesis and pathophysiology of fibromyalgia have dispelled the belief that the disorder is psychosomatic. While no laboratory test can confirm fibromyalgia, most patients present with a history of widespread pain, physical findings and comorbid conditions. With experience, the disorder may be diagnosed with confidence on initial presentation or after a period of observation and minimal diagnostic testing. The family physician is ideally suited to treat fibromyalgia because its management calls for a longitudinal relationship, a willingness to try different therapeutic modalities and an understanding of the interrelationship of the biopsychosocial aspects of health.
While the cause of fibromyalgia
remains elusive, substantial findings implicate disturbances in the neuroendocrine axis as central to its etiology.2 This is particularly true of the relationship between the neuroendocrine axis and sleep. The sleep
electroencephalogram of patients with fibromyalgia
indicates disturbance of the non-REM sleep phase by intrusions of alpha waves
with infrequent progression to stage 3 and stage 4 sleep.3 These findings correlate with patient reports of awakening
repeatedly and being "unrefreshed by
sleep."4
The stages of sleep have concomitant hormone release activity. For example, release of growth hormone occurs primarily during stage 3 and stage 4 of non-REM sleep. One third of patients with fibromyalgia have low insulin growth factor (IGF) levels, an indication of low growth hormone secretion. Furthermore, symptoms of fibromyalgia may be created by disturbing non-REM sleep.5
As with other rheumatologic disorders, fibromyalgia:
Is established on the basis of clinical observations.
Is a condition with signs and symptoms that exist on a continuum.
Often requires observation over time to firmly establish the diagnosis.
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History
Widespread pain is characteristic of fibromyalgia. Although not all areas may be involved simultaneously, pain may occur in the occiput, neck, shoulders, thoracic and lumbar spine, paraspinous regions, buttocks, hips, elbows and knees. A careful history will uncover additional areas of pain when the chief complaint lies in one area. It is not unusual for the most significant area of pain to shift over time.
Myofascial Pain and Fibro Myalgia Differences
Myofascial pain syndrome may be confused with fibromyalgia.
To complicate the situation, myofascial pain syndrome
may occur in patients with fibromyalgia. Similar to fibromyalgia, myofascial pain
syndrome is a condition that is diagnosed clinically. With a careful history
and physical examination, the physician should be able to determine whether a
patient has fibromyalgia, myofascial
pain syndrome, or both. While the pain of fibromyalgia
is widespread with changing areas of emphasis, myofascial
pain arises from trigger points in individual muscles. The diagnosis of myofascial pain syndrome should be considered when, by
history, the patient's pain pattern is limited to a particular region over
time.
The definitive differentiation between myofascial pain syndrome and fibromyalgia is made by physical examination. Myofascial pain syndrome is defined by the presence of trigger points. Unfortunately, location alone does not differentiate between trigger points and tender points because they often occur in similar locations. Distinguishing between trigger points and tender points depends on characteristic findings associated with trigger points that are found on physical examination. Trigger points are located within taut bands of muscle, whereas tender points are not. Palpation of trigger points often reproduces the pain radiation pattern experienced by the patient and can elicit a twitch in the muscle. The pain elicited on palpation of a tender point is localized to the area under palpation and does not elicit a jump or twitch. Lastly, trigger points often have a nodular texture described as similar to a pencil eraser, whereas tender points have no palpatory characteristics distinguishing them from surrounding tissue
TREATMENT
Traditional treatments are geared toward improving the quality of sleep and reducing pain. Treatment of fibromyalgia is largely empiric. Although some frequently used approaches, such as antidepressants and exercise, have evidence to support their use, others (such as acupuncture) are less well studied. None of the therapies used in fibromyalgia are based on evidence from larger randomized, double-blind, placebo-controlled trials. This void places a premium on the physician's therapeutic creativity and supportive counselling skills
Exercise. Aerobic and strength-training activities have been associated with significant improvements in pain, tender point counts and disturbed sleep in patients with fibromyalgia.17 Unfortunately, maintenance of exercise regimens tends to be poor in patients with fibromyalgia. Strategies for improving compliance, such as having the patient work out with a companion, can be discussed with the patient.
Acupuncture. A substantial meta-analysis of studies using acupuncture in the treatment of fibromyalgia confirms the empiric finding of medical acupuncturists that acupuncture is an extremely useful adjunctive treatment for many patients with fibromyalgia.18 While not curative, acupuncture can enhance the patient's quality of life. The frequency of acupuncture is individualized and may range from weekly visits to visits once every 10 to 12 weeks
SYMPTOMS
AND ASSOCIATED SYNDROMES
Pain – Temporomandibular Joint Dysfunction Syndrome
Fatigue Sleep
disorder
Irritable
Bowel Syndrome
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 odours, loud noises, bright lights,
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