Close

Fibromyalgia

By Dr. Moghissi - May 2008

What is fibromyalgia?  Does it really exist or are the people who claim to have it crazy or just plain lazy?

Fibromyalgia is a syndrome, which means it is diagnosed by a collection of symptoms (rather than by laboratory tests) and the cause is unknown.  The official diagnosis criteria were created by the American College of Rheumatology and include the following.  You need to have had pain in all 4 quadrants of the body for at least 3 months, and be tender in at least 11 of 18 specific points of the body.  (To see the location of the points go here)  It has been described in medical literature as early as 400 years ago.  It tends to run in families, occurs mostly in women, and often is triggered during times of chronic stress or by some physical or mental trauma.  Many patients have had other issues with more localized pain prior to getting fibromyalgia, such as headaches, menstrual cramps, low back pain and irritable bowel syndrome.  Of note, is that if these symptoms are recent (maybe 3-6 months) some testing should be done.  Basic blood tests including CRP, sed rate, CMP (blood chemistries), CBC, and TSH (thyroid testing) is usually plenty.

The cause of pain of fibromyalgia is thought to be due to a dysfunction in how the nervous system processes pain.  This causes an increase in sensitivity to pain and other stimuli, such as touch, heat, noise and odors.  Every area of the body is more tender than in other people.  It’s like the volume control is broken, so anything and everything can irritate and hurt.  Functional MRI and PET scans have shown that patients with fibromyalgia have hyperactivity in the areas of pain processing.  Research has pointed to abnormal levels of several neurotransmitters in the brain as potential causes.  Drug research and treatment has focused on normalizing those levels. 

In addition to pain, fibromyalgia patients almost always feel fatigued and have sleep disturbances.  They typically awaken frequently during the night, some have difficulty falling asleep, although others fall asleep very quickly (too quickly, which is also abnormal).  Most patients have morning stiffness, and some also have restless leg syndrome.  Sleep cycles are disrupted, and studies have shown an abnormality in stage 4 sleep, which is when synthesis of many neurotransmitters occurs.  The fatigue is usually worse in the morning and early evening, many feel best in the late morning.  Poor sleep, inconsistent physical activity and diet can worsen the fatigue.  In fact, improving sleep has been shown to improve many of the symptoms of fibromyalgia.

So now that we know it exists, how do we treat it?  First, it is important to understand that fibromyalgia cannot be cured, only managed.  Meaning, this is something that the patient will have to live with for the rest of their lives.  Our goal is to improve things as much as possible.  The other thing is that fibromyalgia is not something that can just be treated with a pill.  The majority of the treatment has to be done by the patient through lifestyle changes.  It is also important to diagnose and start those lifestyle changes as early as possible, as many fibromyalgia patients end up misdiagnosed  and over treated with pain medication, causing them to become addicted and nonfunctional in life.
So, to get back to treatment…..The first and most important thing is for the patient to educate themselves (and their families).  There are many excellent websites, a few listed here: WebMD, Mayo Clinic, Medicine Net, and Medline  also contain lots of links to other sites.  The second very important treatment is exercise.  Aerobic exercise has been studied the most, and it has been shown that increasing fitness levels will decrease tenderness.  Remember though, it is important to increase activity slowly, so as to not to temporarily make things worse.  Strength training and stretching  exercising seem to be helpful also.  Cognitive behavioral therapy (see here for an explanation) is considered an important aspect of treatment.  Last would be medications.

I agree with most recommendations that medications should usually be considered last.  I have found that most medications do not work very well with this illness, and the medications used in the past have often made fibromyalgia patients less able to live a normal life.  However, there are newer, less disabling medications available that are often worth trying.  Traditional pain medications do not seem to do work.  NSAIDs (like Advil, Aleve) do not help much with the pain.  Opiods (narcotics) don’t help much either, and as people easily get addicted and develop a tolerance (requiring more medication) it is not recommended for fibromyalgia patients any longer.  There is some evidence however, that the pain medication tramadol may have some effectiveness.  Pregabalin (Lyrica) has an FDA indication for fibromyalgia, and gabapentin (neurontin) is a similar medication which is often used.  These medications work by down regulating the release of pain neurotransmitters.  Although SSRI’s (like Prozac, Zoloft, Paxil, Lexapro) have been used for fibromyalgia, another similar class seems to work better.  It works both on serotonin and norepinephrine, and are therefore called dual acting agents.  Duloxetine ( Cymbalta for depression and diabetic pain ) is in clinical trials to get an indication for fibromyalgia and seems to work well.  A new drug called Milnacipran will hopefully be available in this country within a year.  It is in the FDA approval pipeline specifically to treat fibromyalgia.  Other drugs that have been used with some success are amitriptyline and cyclobenzaprine (Flexeril usually used as a muscle relaxant), generally in low doses and usually only given at night.   Pramipexole (Mirapex for restless leg syndrome) is also currently under investigation.  Of note, there does not seem to be any role for use of steroids in fibromyalgia.

I hope you can see that fibromyalgia really exists; it’s just that we (in the medical profession) don’t understand it very well yet.   Because we don’t understand it, we are not good at treating it either.  One day, hopefully we’ll be better at both.  In the meantime, fibromyalgia sufferers (and they do suffer!) need to understand that they need to make lifestyle changes (physical and mental) to allow them to function as best as possible.  Be wary of treatments that are addictive or make you less able to function.  If you think you or a loved one might have fibromyalgia, please do not hesitate to talk to your doctor about this! 

Jasmine Moghissi, M.D.

Focus - Health Tips » Fibromyalgia

Fibromyalgia

By Dr. Moghissi - May 2008

What is fibromyalgia?  Does it really exist or are the people who claim to have it crazy or just plain lazy?

Fibromyalgia is a syndrome, which means it is diagnosed by a collection of symptoms (rather than by laboratory tests) and the cause is unknown.  The official diagnosis criteria were created by the American College of Rheumatology and include the following.  You need to have had pain in all 4 quadrants of the body for at least 3 months, and be tender in at least 11 of 18 specific points of the body.  (To see the location of the points go here)  It has been described in medical literature as early as 400 years ago.  It tends to run in families, occurs mostly in women, and often is triggered during times of chronic stress or by some physical or mental trauma.  Many patients have had other issues with more localized pain prior to getting fibromyalgia, such as headaches, menstrual cramps, low back pain and irritable bowel syndrome.  Of note, is that if these symptoms are recent (maybe 3-6 months) some testing should be done.  Basic blood tests including CRP, sed rate, CMP (blood chemistries), CBC, and TSH (thyroid testing) is usually plenty.

The cause of pain of fibromyalgia is thought to be due to a dysfunction in how the nervous system processes pain.  This causes an increase in sensitivity to pain and other stimuli, such as touch, heat, noise and odors.  Every area of the body is more tender than in other people.  It’s like the volume control is broken, so anything and everything can irritate and hurt.  Functional MRI and PET scans have shown that patients with fibromyalgia have hyperactivity in the areas of pain processing.  Research has pointed to abnormal levels of several neurotransmitters in the brain as potential causes.  Drug research and treatment has focused on normalizing those levels. 

In addition to pain, fibromyalgia patients almost always feel fatigued and have sleep disturbances.  They typically awaken frequently during the night, some have difficulty falling asleep, although others fall asleep very quickly (too quickly, which is also abnormal).  Most patients have morning stiffness, and some also have restless leg syndrome.  Sleep cycles are disrupted, and studies have shown an abnormality in stage 4 sleep, which is when synthesis of many neurotransmitters occurs.  The fatigue is usually worse in the morning and early evening, many feel best in the late morning.  Poor sleep, inconsistent physical activity and diet can worsen the fatigue.  In fact, improving sleep has been shown to improve many of the symptoms of fibromyalgia.

So now that we know it exists, how do we treat it?  First, it is important to understand that fibromyalgia cannot be cured, only managed.  Meaning, this is something that the patient will have to live with for the rest of their lives.  Our goal is to improve things as much as possible.  The other thing is that fibromyalgia is not something that can just be treated with a pill.  The majority of the treatment has to be done by the patient through lifestyle changes.  It is also important to diagnose and start those lifestyle changes as early as possible, as many fibromyalgia patients end up misdiagnosed  and over treated with pain medication, causing them to become addicted and nonfunctional in life.
So, to get back to treatment…..The first and most important thing is for the patient to educate themselves (and their families).  There are many excellent websites, a few listed here: WebMD, Mayo Clinic, Medicine Net, and Medline  also contain lots of links to other sites.  The second very important treatment is exercise.  Aerobic exercise has been studied the most, and it has been shown that increasing fitness levels will decrease tenderness.  Remember though, it is important to increase activity slowly, so as to not to temporarily make things worse.  Strength training and stretching  exercising seem to be helpful also.  Cognitive behavioral therapy (see here for an explanation) is considered an important aspect of treatment.  Last would be medications.

I agree with most recommendations that medications should usually be considered last.  I have found that most medications do not work very well with this illness, and the medications used in the past have often made fibromyalgia patients less able to live a normal life.  However, there are newer, less disabling medications available that are often worth trying.  Traditional pain medications do not seem to do work.  NSAIDs (like Advil, Aleve) do not help much with the pain.  Opiods (narcotics) don’t help much either, and as people easily get addicted and develop a tolerance (requiring more medication) it is not recommended for fibromyalgia patients any longer.  There is some evidence however, that the pain medication tramadol may have some effectiveness.  Pregabalin (Lyrica) has an FDA indication for fibromyalgia, and gabapentin (neurontin) is a similar medication which is often used.  These medications work by down regulating the release of pain neurotransmitters.  Although SSRI’s (like Prozac, Zoloft, Paxil, Lexapro) have been used for fibromyalgia, another similar class seems to work better.  It works both on serotonin and norepinephrine, and are therefore called dual acting agents.  Duloxetine ( Cymbalta for depression and diabetic pain ) is in clinical trials to get an indication for fibromyalgia and seems to work well.  A new drug called Milnacipran will hopefully be available in this country within a year.  It is in the FDA approval pipeline specifically to treat fibromyalgia.  Other drugs that have been used with some success are amitriptyline and cyclobenzaprine (Flexeril usually used as a muscle relaxant), generally in low doses and usually only given at night.   Pramipexole (Mirapex for restless leg syndrome) is also currently under investigation.  Of note, there does not seem to be any role for use of steroids in fibromyalgia.

I hope you can see that fibromyalgia really exists; it’s just that we (in the medical profession) don’t understand it very well yet.   Because we don’t understand it, we are not good at treating it either.  One day, hopefully we’ll be better at both.  In the meantime, fibromyalgia sufferers (and they do suffer!) need to understand that they need to make lifestyle changes (physical and mental) to allow them to function as best as possible.  Be wary of treatments that are addictive or make you less able to function.  If you think you or a loved one might have fibromyalgia, please do not hesitate to talk to your doctor about this!