by Thomas Incledon, PhD(c), RD, LD/LN, RPT, NSCA-CPT, CSCS
The aches and pains in her muscles just would not stop. After the car accident, it seemed like everything was going downhill. First she lost her job, then her boyfriend. Sleep hardly ever comes and if it does, the pain and tightness in her shoulders and neck wake her up. After countless visits to a myriad of specialists, she finally got a diagnosis. She thought that she was going crazy, but the rheumatologist said she had fibromyalgia. Learn about this mysterious ailment, the signs and symptoms, the latest theory on the cause, and some treatment options in this article. For an in-depth look at diet and supplementation that may benefit fibromyalgia see the article “Nutritional Strategies For Fibromyalgia.”
Complicated Syndrome
Fibromyalgia (FM) literally means pain in the fibrous connective tissue that surrounds joints, typically the muscle and the tendon that attaches the muscle to the bone. It isn’t a disease, but rather a syndrome, which is a collection of signs and symptoms that occur together. It is a form of soft tissue rheumatism. The American College of Rheumatology defines FM as widespread pain present for at least three months in combination with tenderness at 11 or more of 18 specific tender point sites [1]. .FM used to be called fibrositis, but that erroneous definition meant an inflammatory condition was present, and that is not the case. Because of the difficulty in diagnosing FM and the similarities that FM has to other diseases, many people are not properly diagnosed, or the diagnosis takes much time and effort. Since FM affects 2% of the United States population, with a breakdown of 3.4% in women and 0.5% in men, this is not a rare syndrome [2].
Signs and Symptoms
FM patients usually report that they “hurt all over” and describe their pain as stabbing, aching, or nagging. They also describe feelings of stiffness, especially upon waking up. Pain with palpation is found in 11 of 18 specific points that have been identified around the body. FM patients can suffer from fatigue, sleep disturbances, headaches, abdominal pain, bloating, constipation, diarrhea, bladder urgency and frequency, and skin sensitivity. FM seems to occur in a vicious circle. The lack of sleep leads to sore muscles and fatigue, which leads to less participation in physical activity, which results in depression and further deconditioned muscles, which leads to more pain, which leads to less sleep.
The Central Nervous System Theory
Many researchers now believe that the central nervous system (CNS) plays a large role in the development of this syndrome [3]. The central nervous system is composed of the spinal cord and brain. What investigators think is that an event, either emotionally or physically traumatic, leads to hyperactivity in the CNS. This hyperactivity leads to sleep disturbances, like the increased number of awakenings found in FM patients [4]. The hyperactivity also affects the ratio of excitatory to inhibitory neurotransmitters. Neurotransmitters are chemical messengers that communicate between nerves. In FM, there appears to be larger concentrations of excitatory neurotransmitters (like Substance P) and lower concentrations of inhibitory neurotransmitters (like serotonin). This irregular ratio causes the pain amplification in FM patients [5]. FM patients’ pain perception is normal, but their sensitivity to pain is increased and their tolerance of pain is decreased [6]. The CNS hyperactivity can then lead to problems involving all bodily systems, which explains the seemingly unrelated symptoms of FM. There is even reason to believe that FM may have a genetic component [7].
FM Management
A combination of medication, cognitive behavior therapy, relaxation techniques, exercise, and education is recommended as treatment for FM. Medications that help promote sleep and relaxation have been used, but studies have met with mixed results. Nonsteroidal anti-inflammatory drugs (NSAIDs) aren’t more effective than placebos [8] and corticosteriod injections make FM symptoms worse [9]. Trigger point injections using a local anesthetic can be helpful, but only have temporary effects, and the authors of one study that showed symptom improvement still recommended other forms of treatment [10]. Only one high quality study suggests that real acupuncture is more effective than sham acupuncture [11]. Cognitive behavior therapy, which involves learning affective coping strategies, and stress-reduction programs were proven to be successful in the long term treatment of FM [12].
Exercise programs that emphasize cardiovascular fitness seem to be the tool for breaking the circle of pain [13]. FM patients are deconditioned from avoiding exercise. This can lead to further pain from shortened and tight muscles. Many doctors recommend a balanced program of flexibility, gentle strengthening, and aerobic conditioning [14]. Exercise should be thought of as health training, not sports training. The intensity and duration should begin slowly, but become a part of the FM patient’s lifestyle. Pool exercises are a good place to start with a gradual progression to land exercises. Physical therapists can help design exercise and stretching programs. The Arthritis Foundation recommends also learning progressive muscle relaxation techniques in addition to exercise and stretching.
The Good News
FM is not a life threatening disease, nor is it physically deforming. Symptoms do not usually get worse and may be lessened with appropriate interventions. Although researchers are still working on a complete explanation for the syndrome, progress is advancing rapidly. Without a definitive treatment for every FM patient, an individualized approach and experimentation with different methods should be utilized. In a study of FM patients who still had symptoms after ten years of onset, 66% of patients reported that their symptoms were a little or a lot better, 55% said they felt well or very well, and only 7% felt they were doing poorly [15]. Of course, education about the syndrome is the first step to understanding and beginning a treatment program. For more information, visit the American College of Rheumatology website at www.rheumatology.org or The Arthritis Foundation website at www.arthritis.org. You can call Fibromyalgia Alliance of America, Inc., (614) 457-4222 and Fibromyalgia Network info line: (520) 290-5508. A newsgroup devoted to fibromyalgia can be found at alt.med.fibromyalgia.
References
1. Wolfe, F., et al., The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee [see comments]. Arthritis Rheum, 1990. 33(2): p. 160-172.
2. Wolfe, F., et al., The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum, 1995. 38(1): p. 19-28.
3. Clauw, D.J., The pathogenesis of chronic pain and fatigue syndromes, with special reference to fibromyalgia. Med Hypotheses, 1995. 44(5): p. 369-378.
4. Jennum, P., et al., Sleep and other symptoms in primary fibromyalgia and in healthy controls. J Rheumatol, 1993. 20(10): p. 1756-1759.
5. Wallace, D.J., The fibromyalgia syndrome. Ann Med, 1997. 29(1): p. 9-21.
6. Gibson, S.J., et al., Altered heat pain thresholds and cerebral event-related potentials following painful CO2 laser stimulation in subjects with fibromyalgia syndrome. Pain, 1994. 58(2): p. 185-193.
7. Buskila, D., et al., Familial aggregation in the fibromyalgia syndrome. Semin Arthritis Rheum, 1996. 26(3): p. 605-611.
8. Yunus, M.B., A.T. Masi, and J.C. Aldag, Short term effects of ibuprofen in primary fibromyalgia syndrome: a double blind, placebo controlled trial [published erratum appears in J Rheumatol 1989 Jun;16(6):855]. J Rheumatol, 1989. 16(4): p. 527-532.
9. Clark, S., E. Tindall, and R.M. Bennett, A double blind crossover trial of prednisone versus placebo in the treatment of fibrositis. J Rheumatol, 1985. 12(5): p. 980-983.
10. Hong, C.Z. and T.C. Hsueh, Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia [see comments]. Arch Phys Med Rehabil, 1996. 77(11): p. 1161-1166.
11. Berman, B.M., et al., Is acupuncture effective in the treatment of fibromyalgia? J Fam Pract, 1999. 48(3): p. 213-218.
12. White, K.P. and W.R. Nielson, Cognitive behavioral treatment of fibromyalgia syndrome: a followup assessment. J Rheumatol, 1995. 22(4): p. 717-721.
13. McCain, G.A., et al., A controlled study of the effects of a supervised cardiovascular fitness training program on the manifestations of primary fibromyalgia. Arthritis Rheum, 1988. 31(9): p. 1135-1141.
14. Bennett, R.M., Fibromyalgia: the commonest cause of widespread pain. Compr Ther, 1995. 21(6): p. 269-275.
15. Kennedy, M. and D.T. Felson, A prospective long-term study of fibromyalgia syndrome. Arthritis Rheum, 1996. 39(4): p. 682-685.
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