Fibromyalgia (FM)
Introduction
For some, fibromyalgia (FM) is just another complicated word, but for many individuals it is a term known all too well; one that means excruciating, sometimes debilitating pain. FM often has social and psychological consequences, too. Diagnosis, treatment, and understanding of FM can be confusing for both patients and physicians. Read on to learn more about what is known currently about this sometimes dreadful syndrome.
What is it?
Fibromyalgia (FM) is a chronic pain disorder that affects the muscles and the soft fibrous tissues of the body (the ligaments, tendons, and soft tissue in between joints). The word 'fibromyalgia' comes from the Latin words for fibrous tissue (fibro), muscle (myo), and pain (algia). Unlike other chronic painful diseases (e.g. multiple sclerosis), FM is a syndrome. A syndrome is a loose collection of signs and symptoms that characterize a condition. Unlike a disease, the exact cause of FM is still unknown. People with fibromyalgia have "tender points" on the body. Tender points are specific places on the body especially the neck, shoulders, back, hips, arms, and legs. These points hurt when pressure is put on them. Too much exercise or overexertion of muscles can make FM symptoms worse, as can physical inactivity. FM is very hard to diagnose. Patients often experience many signs and symptoms that vary in amount and intensity and can be easily confused with other conditions. This confusion can increase the pain and frustration often felt by a patient with FM.
What causes it?
The exact cause of fibromyalgia (FM) is still unknown. However, recent studies have shown that the central nervous systems (CNS) of patients with FM may interpret, process, and transmit pain signals differently than individuals without the condition. These CNS differences may cause and intensify FM symptoms. It is believed that individuals with FM may have low levels of certain chemicals in the brain such as serotonin and norepinephrine. Low levels of these brain chemicals can cause depression and contribute to the pain and fatigue experienced in FM.
Who has it?
It is estimated that approximately 3-6% of the U.S. population has fibromyalgia. Although both men and women can be affected, the majority (80 to 90%) are women. Most people are diagnosed with FM between 20 and 40 years of age, but the symptoms of disease can become apparent earlier as well as later in life.
What are the risk factors?
Risk factors are characteristics that can make you more likely to develop a condition. Having a risk factor doesn't necessarily mean that you will get a particular disease or condition. However, having more than one risk factor can place you in a higher risk category and may indicate a need to talk to your doctor about your health. The risks associated with developing fibromyalgia include the following:
Although it occurs in both men and women, women are 7 times as likely to develop FM as men.
FM may have a genetic link and having a family member with FM places you at increased risk of developing the syndrome.
Conditions such as arthritis, lupus, and ankylosing spondylitis(a condition that causes chronic inflammation of spine and joints in the lower back) may place you at a greater risk of developing fibromyalgia.
Substance P is a neurotransmitter located in the spinal cord in which transmits pain signals. If you have too much substance P, it will intensify your FM pain pathway, leading to the symptoms of FM.
What are the symptoms?
Along with muscle and soft tissue pain, individuals with fibromyalgia (FM) may experience many other signs and symptoms that can make the disorder unbearable.
Some of the most common symptoms include:
- Chronic headaches and migraines
- Memory problems
- Fatigue
- Gastrointestinal complications (diarrhea, bloating, cramping)
- Morning stiffness
- Memory problems
- Painful menstruation
- Nerve Pain
- Tingling and numbness in the hands and feet
- Temperature sensitivity
- Trouble sleeping
This long list of signs and symptoms often makes it difficult to accurately diagnose fibromyalgia as it is often confused with other diseases and conditions such as arthritis and lupus. It often takes time for a physician to accurately recognize and diagnose fibromyalgia. This can contribute significantly to the pain, frustration, and depression often felt by the individual suffering from FM.
How is it treated?
Physicians treat FM with a combination of drugs that are used for other purposes. There are currently no medicines that cure the disease. Drugs commonly used for FM include:
Treating Pain from FM
Analgesics
Analgesics or "pain relievers" interact with receptors in the body to stop the sensation of pain from various sources. Analgesic drugs vary in strength and addiction potential from over-the-counter Tylenol to stronger prescription medications such as propoxyphene/acetaminophen (Darvocet) and tramadol (Ultram). Although narcotic analgesics are prescribed for some FM patients with severe muscle pain, there is no evidence that narcotics are effective for treating chronic FM-associated pain. In addition, addiction and/or dependence may develop with the use of narcotic medications; so they should be used with caution in long-term treatment. Non-steroidal anti-inflammatory drugs (NSAIDs), which are another type of pain reliever, can also be used to treat the symptoms of FM. NSAIDs, such as aspirin, ibuprofen (Advil, Motrin), and naproxen (Anaprox, Aleve) relieve pain and inflammation to help reduce muscle aches, menstrual cramps, and headaches associated with fibromyalgia.
Muscle Relaxants
Muscle relaxants such as cyclobenzaprine (Flexeril) may also be used to help relieve pain and stiffness and muscle spasms.
Muscle Stretching
A physician may also stretch affected muscles that are causing pain. Stretching involves a technique that helps to relax tense muscles prior to an injection. The muscle is then injected with a local anesthetic such as lidocaine to provide longer-lasting pain relief. The downside is that this procedure is initially painful and injections of local anesthetics are not always effective.
Another procedure, called "spray and stretch" involves the same stretching technique and the application of a cooling agent such as ethyl chloride or flouri-methane to the affected area. This works to cool the blood vessels, providing pain relief. The spray and stretch technique must be performed by someone other than the patient, usually a close friend or family member. The benefits of these procedures can last anywhere from a few days to several weeks.
Treating Other Symptoms of FM
Antidepressants
Antidepressants increase the levels of certain chemicals, such as norepinephrine and serotonin, in the brain. Low levels of these chemicals can cause depression and are believed to be associated with the pain and tiredness experienced by FM patients. Sometimes treatment of coexistent conditions such as depression and sleep disorders improve the symptoms of fibromyalgia. Tricyclic anti-depressants (TCAs), which are used in low doses to promote sleep, are usually taken at bedtime. Some of these medicines include amitriptyline (Elavil), doxepin (Prudoxin, Sinequan), and nortriptyline (Aventyl, Pamelor).
If TCAs are not effective at treating the symptoms of FM, doctors may prescribe another type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI). Like TCAs, SSRIs are also prescribed for FM treatment in lower doses than those used to treat depression. SSRIs may improve fatigue, depressive symptoms, and pain by increasing the amount of serotonin in the brain. SSRIs may also increase energy, which can be a problem in FM patients who usually have trouble sleeping.
Combination therapy with more than one type of antidepressant has been shown to be more effective in reducing FM symptoms than using either a TCA or an SSRI alone. As a result, for treating FM, an SSRI is almost always given in combination with a TCA. Currently being researched for FM are antidepressant drugs that increase both serotonin and norepinephrine. Called mixed reuptake inhibitors, these drugs are also believed to be effective in the treatment of FM symptoms. One mixed reuptake inhibitor, duloxetine (Cymbalta), already FDA-approved for depression, has been shown to be effective in the treatment of FM pain symptoms. Venlafaxine (Effexor), another mixed reuptake inhibitor, is also thought to effective but more studies are needed to prove its effectiveness.
Benzodiazepines
Drugs in the benzodiazepine class can help to relax tense, painful muscles as well as improve sleeping difficulties. Many FM patients experience restless leg syndrome (RLS) which is characterized by unpleasant sensations, including muscle twitching in the legs at night. Benzodiazepines have been shown to relieve these symptoms. Due to their potential for addiction, however, benzodiazepines are not usually given until a patient with FM has tried and failed other medicines and therapies. Some benzodiazepines include clonazepam (Klonopin), diazepam (Valium), and lorazepam (Ativan).
Anticonvulsant medications
Pregabalin (Lyrica) is the only medication that has been approved by the FDA for the treatment of fibromyalgia. Prior to its approval, pregabalin had been used to treat pain associated with other conditons. Gabapentin (Neurontin), another anticonvulsant medicine, also used to treat diabetes and nerve related pain following a herpes zoster infection (shingles), has also been investigated for its effectiveness as a treatment for fibromyalgia. The study is called the GIFT trial and was set up to determine if gabapentin was useful for treating the pain associated with fibromyalgia. The study found that at higher doses (1200-2400mg/day) of gabapentin helped reduce the pain with FM.
Miscellaneous Therapies
Other drugs include those that are given to treat the specific symptoms of FM. One of these is called alosetron (Lotronex) which are used to treat gastrointestinal symptoms such as diarrhea, cramping, bloating, and constipation or Irritable Bowel Syndrome (IBS), which are often seen with fibromyalgia. Tegaserod (Zelnorm), another medication that has been used to treat gastrointestinal symptoms, was recently removed from the market due to an increased risk of side effects; however, Zelnorm may still be available for certain individuals who do not get gastrointestinal symptom relief with any other medication.
The treatment of FM usually involves a strategy for each patient that is specific to his or her symptoms and can involve many healthcare professionals such as physicians, psychiatrists, and physical therapists. Many times a rheumatologist (a physician who specializes in conditions, such as arthritis, that affect the joints and soft tissues) is required to treat fibromyalgia. To learn more about the medications used to treat symptoms of FM, click on the drug class links below.
Helping Yourself
If you have fibromyalgia (FM), here are some practical steps you can take to help improve your condition:
- Make sure you regularly get enough sleep (at least 8 hours per night) If you have trouble sleeping, be sure to assess the nature of your sleeping problem. You can learn more about sleep disorders by returning to the "Conditions and Treatments" tab on DrugDigest. Also, to help assess the presence of a sleep disorder, take our interactive quizzes that can be found in the "Interactive Tools" tab on DrugDigest.
- Develop a daily exercise or activity regimen that you can tolerate. This will help to improve your overall health and the pain associated with FM. The most important thing is to recognize your limitations and not to exceed them as this can worsen the condition. Avoid excessive activity or exercise. Remember, exercise in moderation does help.
- Avoid situations that cause you stress. Stress has been shown to worsen FM symptoms and trigger pain episodes. Use techniques such as breathing exercises, meditation, and yoga to help you relax.
- Eat a healthy well-balanced diet with a daily multi-vitamin and avoid alcohol, caffeine, and candy.
- Acupuncture may be an extremely useful addition to FM treatment efforts. The frequency of acupuncture sessions ranges widely from patient to patient, but appears to improve quality of life.
- Behavior modification training, including coping skills, relaxation exercises, and self-hypnosis may provide relief for some patients.
- If you smoke, consider quitting. You can learn more about Smoking Cessation by returning to the "Conditions and Treatments" tab on DrugDigest. Also, to help assess the severity of nicotine addiction, take our interactive quiz that can be found in the "Interactive Tools" tab on DrugDigest.
- Develop a daily journal for your condition. This information can be shared with your physician to help guide your treatment. It will also help you to understand your condition better and give you more control over your symptoms. Write down a daily report of your symptoms and how you feel that day. You can also write a daily report of your activity and exercise routine.
- Get the support and encouragement of friends and family in dealing with your condition. You can't overcome fibromyalgia alone. Consider joining a fibromyalgia support group with others who are dealing with the same condition.
Here are some websites that may help you to find a support group:
http://www.fibrohugs.com/
http://www.immunesupport.com/supportgroups/
What is on the horizon?
Researchers are working to determine exactly how individuals with fibromyalgia (FM) perceive pain. One of the problems believed to be associated with FM is a difference in the way FM patients interpret and process pain signals. This difference may lead to increased pain sensitivity. Understanding this difference will help researchers create new medicines and ways to treat FM.
The relationship between fibromyalgia and family history is also being studied. Research is being performed to determine if a gene or genes predispose a person to fibromyalgia. Researchers are also investigating whether fibromyalgia is more common in patients with other existing conditions or characteristics. This will help us to understand fibromyalgia better and point to other risk factors for FM.
Fibromyalgia patients often have erratic and irregular sleep patterns. A current trial is researching the efficacy of EEG biofeedback (brain electricity) on the reduction of FM symptoms.
Research is also being done on kainic acid (this acid is similar to an amino acid agonist). A single injection of this to the vagus nerve (one of the nerves in the brain that supplies nerve fibers to the organs of the chest and the abdomen) was found to enhance long-term pain sensitivity. The researchers can't say how closely the syndrome they have created in the lab rats mimics FM, but comparing what is happening in their model to what is happening in FM should give them important information about both. The eventual goal is to use the model not only to better understand chronic pain in patients with FM, but also to develop new treatments for FM.
Growth hormone therapy, though very expensive for most patients, was shown in one study to reduce symptoms and improve quality of life without significant side effects. As persons with FM may not make enough growth hormone when they exercise, pyridostigmine (Mestinon) is currently being studied to determine if the medication can stimulate production of growth hormone. It is thought that increasing growth hormone to a normal level may improve the symptoms of FM.
References
- American Fibromyalgia Syndrome Association Update. Treatment trials. American Fibromyalgia Syndrome Association. August 2003. Available at: http://www.afsafund.org/update0803.htm#TrmtTrials. Accessed July 2005, June 2006, April 2007, and March 26, 2008.
- What is Fibromyalgia? Health Topics. National Institute of Arthritis and Musculoskeletal and Skin Diseases. March 2005. Available at: http://www.niams.nih.gov/hi/topics/fibromyalgia/fffibro.htm. Accessed July 2005, June 2006, April 2007, and March 26, 2008.
- Fibromyalgia. Questions and Answers about?. National Institute of Arthritis and Musculoskeletal and Skin Diseases. June 2004. Available at: http://www.niams.nih.gov/hi/topics/fibromyalgia/Fibromyalgia.pdf. Accessed July 2005, June 2006, and April 2007.
- Fibromyalgia and CFS Basics.Fibromyalgia Network. July 22,2005. Available at: http://www.fmnetnews.com/. Accessed July 2005, June 2006, April 2007, and March 26, 2008.
- Risk Factors for Fibromyalgia. Health Information.Aurora Health Online. March 9,2005. Available at: http://www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp?URLhealthgate=%2219456.html%22. Accessed July 2005, June 2006, April 2007, and March 26, 2008.
- New Treatment for Fibromyalgia. Press Release. American College of Rheumatology, Available at: http://www.rheumatology.org/press/2004/fibro0904.asp. Accessed July 2005, June 2006, April 2007, and March 26, 2008.
- Patient Education for Fibromyalgia. http://www.rheumatology.org/publications/primarycare/number1/hrh0002-98.asp. Accessed July 2005 and June 2006.
- Fibromyalgia Syndrome Diagnostic Criteria. National Fibromyalgia Research Association. Available at: http://www.nfra.net/Diagnost.htm. Accessed July 2005, June 2006, April 2007, and March 26, 2008.
- United States National Institute of Health: Clinical Trials Registry: Gabapentin in Fibromyalgia Trial (GIFT). June 30, 2005. Available at: http://www.clinicaltrials.gov/ct/show/NCT00057278?order=10. Accessed July 2005, June 2006, April 2007, and March 26, 2008.
- United States National Institute of Health: Clinical Trials Registry: Effectiveness of Brainwave Biofeedback in the Treatment of Fibromyalgia. June 30,2005. Available at: http://www.clinicaltrials.gov/ct/show/NCT00080184?order=7 Accessed July 2005, June 2006, April 2007, and March 26, 2008.
- Support for Fibromyalgia. Avaliable at: http://www.fibrohugs.com. Accessed July 2005, June 2006, April 2007, and March 26, 2008.
- Immune Support. Support Group listings Available at: http://www.immunesupport.com/supportgroups/. Accessed July 2005, June 2006, April 2007, and March 26, 2008.
- X-Plain Fibromyalgia Reference Summary. Medline Plus Interactive Tutorial. 2004. Available at: http://www.nlm.nih.gov/medlineplus/tutorials/fibromyalgia/id309101.pdf. Accessed July 2005 and June 2006.
- United States National Institute of Health: Clinical Trials Registry: Testing Mestinon and Exercise in Fibromyalgia. Available at: http://www.clinicaltrial.gov/ct2/show/NCT00535587?term=fibromyalgia&rank=8. Accessed March 26, 2008.
- Bennet, R. Growth Hormone Deficiency in Fibromyalgia. Available at: http://www.myalgia.com/growth_hormone_deficiency_in_fib.htm. Accessed June 2006, April 2007, and March 26, 2008.
- Arnold LM, Goldenberg DL, Stanford SB, et al. Gabapentin in the treatment of fibromyalgia: A randomized, double-blind, placebo-controlled, multicenter trial. Arthritis Rheum. 2007 Apr;56(4):1336-44.
Fibromyalgia (FM) Health Condition Last Updated: March 2008
Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.