Dick's
Guide to Fibrositis
or Fibromyalgia (or
FMS)
 Books about fibromyalgia
 The Fibromyalgia Help Book: Practical Guide
to Living Better with Fibromyalgia
 Fibromyalgia & Chronic Myofascial Pain
Syndrome: A Survival Manual
 Your Personal Guide to Living Well with
Fibromyalgia
 From Fatigued to Fantastic!: A Manual for
Moving beyond Chronic Fatigue & Fibromyalgia
 Fibromyalgia Survivor
It has been estimated that up to 6 million United States citizens have been
diagnosed with fibromyalgia syndrome. Researchers know little about
its cause, symptoms, or effective treatment. It is hard to know if people
diagnosed with this syndrome really have it, and it's equally clear that
symptomatic patients may not have been correctly diagnosed. According to
the Nurse Practitioner, "FMS may be one of the most common disorders family
health care providers encounter in ambulatory practice; however, it is one
of the most underreported." FMS patients may be told by providers that
there is nothing wrong with them. As FMS causes and symptoms are more clearly
understood, more patients are likely to be diagnosed. It's reported that,
"The average patient with FMS has had the disease for 5 years and has
spent thousands of dollars on medical tests before he or she receives the
diagnosis. In addition, more than half of FMS patients undergo unnecessary
surgery due to misdiagnosis."
Symptoms reported by FMS patients:
persistent pain in the neck, shoulder, low back, and hip;
waking up without feeling rested;
severe fatigue;
waking frequently during the night;
waking with stiffness and achiness;
hypersensitivity to cold and/or heat;
complaints of abdominal pain;
recurrent fronto-occipital headaches;
sensations of numbness or tingling in hands and feet;
constipation and diarrhea; and
anxiety and depression.[1,5]
Other symptoms
spastic colon,
mitral valve prolapse,
bursitis,
chondromalacia,
temporomandibular joint dysfunction,
vertigo,
sinus and
thyroid problems,
concentration problems,
swollen glands, and
tinnitus.
dyspnea,
hypoglycemic- like syndrome,
dysphagia,
vasomotor rhinitis,
mold and yeast sensitivity,
menstrual problems,
memory impairment,
motor coordination problems,
pseudoangina,
conjunctivitis,
carbohydrate craving,
sensitivity to cold,
bloating,
bruising,
tender lymph nodes,
sore throat,
leg cramps,
groin pain,
mottled skin,
muscle twitching,
and lack of endurance.
FMS is a widespread musculoskeletal pain and fatigue disorder with an unknown
etiology. It is unlikely that the majority of patients with FMS are accurately
diagnosed, and few receive any education about the condition. After diagnosis,
it is often difficult to locate a practitioner who will work with the patient
to determine the best way to control the symptoms. This often requires patients
to work out and search for remedies on their own. Due to the chronic
nature of FMS, relationships among family members, friends, and coworkers
can be affected. Because FMS does not involve outwardly visible signs and
symptoms, educating family, friends, and coworkers is crucial to ensure that
the FMS patient receives the support he or she needs.
Diagnosis
In 1990, the Copenhagen Declaration established FMS as a diagnosis. The diagnosis
was incorporated into the International Statistical Classification of Diseases
and Related Health Problems that went into effect on January 1, 1993. The
new document defines FMS as a painful, nonarticular condition predominantly
involving muscles and the most common cause of chronic, widespread
musculoskeletal pain. Onset of symptoms usually occurs between the ages of
20 and 40 years, predominantly in women.
Tender points are the most powerful discriminator between FMS and controls.[10]
They occur in anatomically precise locations and have been shown to have
construct validity when correlated with fibrornyalgia symptoms. The diagnosis
is based mainly on objective testing for the presence of tender points. The
tender points occur in muscles or the area where a muscle joins a tendon.[11]
Diagnostic criteria were defined by the American College of Rheumatology
(ACR) in 1990.[10] The ACR concluded that FMS could be diagnosed by a history
of widespread pain in at least 11 out of 18 specified tender points in muscular
tissue. Pain was described as widespread if it was felt in all of the following
regions: left and right sides of the body, above and below the waist, and
in the axial skeleton (cervical spine, anterior chest, thoracic spine, or
low back).[10] The 18 tender point sites on digital palpation identified
by the ACR are shown in Figure 1.
To meet ACR diagnostic criteria for FMS, digital palpation with an approximate
force of 4 kilograms of pressure must produce a report of pain in at least
11 of these 18 tender points. Bilateral palpation with moderate pressure
of 11 thumbs (examiner's thumbnail should blanch)[12] should produce pain
in the tender point areas. Unaffected patients may also be slightly tender
at these points, but fibrornyalgia patients will exhibit a reduced pain tolerance
symmetrically at the tender points.[10,12,13] The tenderness should be localized
to the tender points rather than diffuse aching. Tender points must be present
on both sides of the body, above and below the waist, and in the midline.
Pain in the tender point areas must have been present for at least 3 months.
Some clinicians accept a diagnosis of fibrornyalgia with fewer than 11 tender
points, if several associated symptoms are present.[10]
The Copenhagen Declaration divided ACR's definition into a pragmatic and
clinical perspective: "The diagnosis is commonly entertained in the presence
of unexplained widespread pain or aching, persistent fatigue, generalized
(morning) stiffness, nonrefreshing sleep, and multiple tender points. A variable
proportion of otherwise typical patients may have less than 11 tender points
at the time of the examination." The document continues to state that FMS
is often "part of a wider syndrome encompassing headaches, irritable bowel,
dysmenorrhea, cold sensitivity, Raynaud's phenomenon, restless legs, atypical
patterns of numbness and tingling, exercise intolerance and complaints of
weakness." [9]
The Copenhagen Declaration emphasized the fact that patients with FMS should
not be considered hypochondriacs. Although the etiology of FMS is unknown,
members of the consensus panel ruled out psychologic distress as a cause
of the muscular pain and tenderness. In fact, the document states, it could
be the other way around. The psychologic state may be a result of the patient
attempting to cope with the pain.[9]
Although the terms tender points and trigger points have been used
interchangeably, they are now considered separate entities and are associated
with different syndromes.[14] Tender points are localized areas of exaggerated
tenderness at anatomically reproducible sites. A trigger point, when palpated,
produces pain referred to a distant site, such as when pressure applied to
the neck produces pain down the arm. Trigger points are associated with syndromes
of localized myofascial pain, and in some cases, possible nerve root compression.
The pain may or may not be related to the tender points of FMS.[15]
Tender points became the cardinal feature of FMS after Smythe and Moldofsky
published their article in 1977.[16] They proposed criteria of chronic aching,
a nonrestorative sleep pattern with marked morning stiffness and fatigue,
an electroencephalographic (EEG) finding of alpha intrusion in non-rapid
eye movement (non-REM) sleep, localized tenderness at 12 of 14 specific sites,
and marked skin-fold tenderness in the upper scapular region. They introduced
the symptom complex identified with FMS today that led to several quantitative
and controlled trials.
Historical Perspectives
The concept of FMS has evolved, and in the minds of many, differs from the
view of the disorder 30 to 50 years ago.[10] These changes, in part, are
the result of diagnostic criteria that defined the syndrome. Thus, the emphasis
on irritable bowel syndrome and modulating factors added a dimension to FMS.
Some investigators have suggested that FMS is a psychologic disorder, or
perhaps a myofascial pain syndrome. This disarray in construct has led to
confusion regarding the nature of the disorder and to the consequent idea
that FMS means something different to every observer.
The first controlled study on FMS was published in 1981.[17] Previous to
this study, the condition was described as having pain, fatigue, and tender
points. The study identified many more symptoms besides pain that patients
with FMS had in common. Documentation concluded that fibromyalgia is actually
a syndrome. [18]
Many researchers were quick to criticize the study. They stated that one
could not demonstrate FMS objectively, or show any neurologic damage or swelling.
They professed that the symptoms were really manifestations of depression
or the stress of society.
A study in 1982 may have contributed to the early emphasis on psychologic
factors.[19] Thirty hospitalized primary fibromyalgia syndrome patients (PFS)
were compared with 30 rheumatoid arthritis (RA) patients using the Minnesota
Multiphasic Personality Inventory (MMPI). The results revealed significantly
elevated scores in the PFS group in several areas. Based on the results,
researchers concluded that PFS patients are psychologically disturbed.
Further studies have refuted those findings. Stringent analysis with various
psychologic models has found no correlation between any of the symptoms and
the mental status of patients. A subsequent study extended the work of the
earlier study, but the design differed in that ambulatory PFS patients were
studied and a normal comparison group was included in addition to the RA
group.[20] Additionally, researchers sought to examine the presence of
subpopulations of PFS patients based upon responses to the MMPI, as well
as to assess the association of stressful life events and social skills in
PFS. Their results found fewer differences between the PFS and RA patients.
Two potential explanations can be offered for the differences from the earlier
study: (1) ambulatory patients, in general, display a lower level of psychologic
disturbance than hospitalized patients; and (2) the inclusion of the normal
comparison group revealed that some of the differences between PFS and RA
patients found in the early study may be explainable by a depression of the
RA scale means rather than an elevation of PFS means (i.e., the RA patients'
means may be lower than a healthy population and the PFS means may be similar
to a healthy population).
In a second study by the same researcher, the instrument used was the Psychiatric
Diagnostic Interview.[21] It was concluded that the instrument failed to
discriminate any major differences between PFS (a disorder with no known
organic cause) and RA (a disorder with a known organic cause); therefore,
a psychopathologic explanation could not be considered as a primary cause
of the symptoms of PFS.
Subsequent studies found the psychologic aspects of patients with FMS were
similar to those with chronic pain.[22] Three groups (chronic pain, nonchronic
pain, and FMS) were compared using a stand ardized interview and two psychologic
questionnaires. Researchers concluded that the chronic pain group and nonchronic
pain group could be easily distinguished from each other. The scores of the
FMS group and the chronic pain group were very similar. This led to the
conclusion that many psychologic aspects of FMS can be considered as psychologic
aspects of chronic pain.
An additional study had similar findings.[23] Researchers hypothesiezed that
there is a correlation between the sites of pain and the sites of symptoms.
Their report confirmed that the pain and symptoms are centrally modulated
and not determined by psychologic status.
Etiology/Pathogenesis
The etiology and pathogenesis of FMS are unknown. A variety of mechanisms
have been postulated. Researchers have focused on the fibrositic tender point,
possible electromyographic response, and tissue histology and chemistry.
Light microscopic abnormalities in tissues obtained under tender point muscle
biologies are not specifically different, but occur in greater numbers in
FMS patients than in normal controls. However, differences in immunoglobulin,
cytokine, tissue metabolism, capillary permeability, as well as increases
in central nervous system substance P levels and tissue changes analogous
with experimental interleukin-2 infusion, were significant enough to suggest
a definite abnormality in the immunologic system.[24]
Using light microscopes, researchers could not find any evidence of an
inflammatory process in either tendon or muscle tissues.[25] However, with
an electron microscope, they detected severe damage and even dissolution
of myofilaments. They propose that in FMS there are two totally different
tissues affected: (1) the bradytrophic collagenous connective tissue that
requires little oxygen and (2) the highly active skeletal muscles, made up
of muscle cells that require a high amount of oxygen. The way these two tissues
react to disorders is also different. The collagenous tendon and capsular
tissues react to lack of oxygen and overstrain by excessive formation of
fibroblasts and dissolution of collagen fibers. Muscle tissue reacts to nerve
irritations by pathologic muscle changes in extensive areas in the body.[25]
A consistent loss of stage 3 to 4 non-REM sleep has been observed in patients
with fibromyalgia and with other diseases associated with aching and stiffness.
Normal individuals deprived of stage 4 sleep develop a fibromyalgia like
syndrome.[15]
Several hypotheses have been identified, including sleep disturbance, infectious
agent(s), stress, and trauma from accidents or surgery. Metabolic factors
including neurotransmitters, hormones, enzymes, immune system chemicals,
energy compounds, products produced by the body's cells, and the breakdown
products of foods have been identified as possible etiologic factors of FMS.[26]
Nonrestorative sleep has a well -established association with FMS, but the
role it plays in the pathophysiology of the syndrome has not been clarified.
The sleep disorder most frequently identified with FMS patients is the stage-4
sleep anomaly.[27] Growth hormone secretions may be disrupted by the poor
quality of sleep seen in FMS patients. Growth hormone is released almost
exclusively in stage-4 sleep. It has been theorized that FMS is a disorder
of nonrestorative sleep with a specific neurochernical abnormality common
to pain, sleep disturbance, and depression.[28] They suggest an abnormality
in serotonin metabolism. Serotonin is important in deep sleep and in central
and peripheral pain mechanisms. Amitriptyline, the most commonly used medication
for treating FMS, blocks serotonin reuptake and increases deep sleep.[29]
Other studies have suggested the possible involvement of substance P and
catecholamines.[30] In one additional study, patients with FMS were shown
to have a neurotransmitter profile similar to those in other chronic pain
states.[31] The sleep problem associated with FMS varies from sleep fragmentation
to alpha-wave intrusion into deep level sleep (awake-like brain waves interfering
with deep sleep).[32] Two different hypotheses on the function of sleep are
relevant to FMS: (1) sleep is necessary for tissue restoration or bodily
renewal, and (2) sleep is necessary for regulating many neuroendocrine and
immune functions.[32]
An infectious cause of FMS has been hypothesized based upon the observed
similarity of this entity and chronic fatigue syndrome. A careful search
for viral infections in FMS patients whose symptoms appear following a "flu-like"
illness is warranted.[33] An infectious disease component may be responsible
for FMS.[34] Suspected agents have included Epstein-Barr, cytomegalovirus,
human herpesvirus 6, enteroviruses, B. burgdorferi, and HIV. Some of these
agents have been ruled out as actual causative agents, but it is thought
that "the manipulative nature of these infectious agents might lead susceptible
people into an altered immune system state of reduced natural killer cell
function and increased interferon activity."[34]
It is suspected that the pain and other symptoms of FMS are transmitted through
the central nervous system by many chemicals called neurotransmitters. Substance
P is known to play a role in pain transmission while serotonin, norepinephrine,
dopamine, and other chemical transmitters work in an inhibitory fashion to
reduce or modulate the effects of pain signals coming from the central nervous
system.[18]
There have been suggestions that psychogenic factors may contribute to FMS,
but research has not supported the hypothesis.[15] The literature revealed
that there were not any psychologic abnormalities or certain personality
types found in patients with FMS. This was important in ruling out a psychologic
etiology for FMS. Since the etiology is unknown and there are not easily
demonstrative objective abnormalities, FMS becomes a prime target for psychologic
or somatiform etiologies.[35] Study results argue against such a mechanism
playing a role in the perpetuation of FMS. A number of other findings, including
the response of pain to weather fronts, the marked stiffness comparable to
other rheumatic diseases, the consistent location of the fibrositic tender
points, the occasional finding of palpable nodules with electromyographic
and histologic abnormalities, and the disturbance of sleep all suggest a
peripheral or, at least, nonpsychogenic component of the syndrome. Despite
this, there is a common clinical impression that a number of these patients
are psychologically abnormal. Longstanding or severe pain and disability
may result in the development of emotional abnormalities like those seen
in patients with RA and other chronic diseases.[35]
Researchers continue to study FMS patients to determine the etiology of the
illness and to validate or disprove the many theories postulated about the
cause of FMS.
Treatment Recommendations
Treatment for fibrornyalgia necessitates a multifaceted approach to control
symptoms in several areas. Interventions to aid sleep, relieve pain, and
control headaches and gastrointestinal disturbances, as well as gentle exercise
to aid in muscle conditioning are all utilized to treat the FMS patient.
Since FMS patients differ greatly in their symptoms and their severity, it
is critical to tailor a treatment regimen to each individual patient.
Medications
The medication needs of patients with FMS must be addressed. Health care
providers and patients with FMS should be educated on the latest research
on effective medications and treatments. There is a great deal of difficulty
and confusion in identifying the best way to medically manage the FMS patient.
Patients and their health care providers must work together closely, on a
one-on-one basis, to identify the medications and treatment that are appropriate.
Medications such as tricyclic antidepressants have been utilized as therapeutic
agents since Moldofsky described an alpha-delta sleep disturbance in 1975.
In the FMS patient, antidepressants work to increase non-REM stage 4 sleep
by increasing serotonin levels, rather than in an anti-depressive manner.
Amitriptyline is the most commonly used medication to treat FMS. Controlled
studies by several researchers have shown significant improvement following
use of amitriptyline.[36- 39] Other tricyclic antidepressants shown to be
effective in controlled studies are cyclobenzaprine (Flexeril),[40-42] and
imipramine (Tofranil).[43] Trazodone (Desyrel) was effective in increasing
slow wave sleep, normalizing REM latency, and reducing the alpha-delta
pattern.[44]
Serotonin reuptake inhibitors like fluoxetine (Prozac) are also beneficial.
Fluoxetine (Prozac) can be stimulating and contribute to sleep disturbances,
so a combination of a bedtime tricyclic and a morning medication like fluoxetine
(Prozac) may work better for the patient fighting fatigue. A randomized,
double-blinded, crossover study compared fluoxetine (Prozac) alone, amitriptyline
alone, and a combination of amitriptyline and fluoxetine (Prozac). The
combination therapy significantly reduced pain, improved sleep, and increased
patient functionality and sense of overall well-being. Individual effects
of amitriptyline and fluoxetine (Prozac) were comparable, but not as good
as the combination.[45] Venlafaxine (Effexor) and bupropion (Wellbutrin)[46]
can be tried as well, although more clinical studies are needed to substantiate
the favorable effect for FMS patients.
Zolpidem (Ambien) has been found to be helpful in treating sleep difficulties
and improving daytime energy in FMS patients, although it did not alter pain
levels.[47] The drug is marketed as a short- term insomnia aid and should
be limited to two to three nights per week.[48] Alprazolam (Xanax) can also
be used as a sleeping aid. Alprazolam (Xanax) was shown to be significantly
beneficial in a study by Russell.[49]
Muscle relaxants can be used to treat muscle spasms and to control pain.
Cyclobenzaprine (Flexeril) is an antidepressant with muscle relaxant
qualities.[40-42] Tramadol (Ultram) and topical anesthetics are effective
in some patients in the treatment of pain, although controlled trials are
needed to substantiate the claim.[50]
Clinicians must be willing to adjust dosages and try different medications
in different combinations to identify the most effective medications for
each patient.[45]
Interdisciplinary Approach
Several researchers have found that an interdisciplinary approach to the
treatment of FMS is beneficial to the FMS patient.[51-54] One study involved
a group of 36 patients who completed a 6-month program including education,
support groups, stress reduction, cognitive restructuring, antidepressants,
trigger point therapy, and aerobic conditioning. Improvements were noted
in the areas of functional impairment, quality of life, pain analog scores,
number of tender points, total myalgic score, attitudes index, pain behavior,
and Beck depression and anxiety. The study was not blinded; however, the
improvements seen over the 6-month trial were much greater than the placebo
response reported in previous studies.[51]
Another study demonstrated improvements in social function, fatigue, and
vitality in a study of 35 patients with a diagnosis of FMS and/or chronic
fatigue syndrome who participated in a treatment regimen that included education,
counseling, development of self-management techniques, and acupuncture.[53]
Patients were followed for 6 months after a treatment program including
education, aerobic exercise, stretching exercise, pain control, stress
management, pacing, and body mechanics. Significant improvements were seen
in pain severity, life control, affective distress, perceived support, and
perceived interference.[54]
Exercise
Exercise is the primary nonpharmacologic treatment of FMS. Research studies
have confirmed the benefits of exercise in the FMS patient.[55- 57]
A randomized, controlled study of 42 patients who participated in a 20-week
program of either cardiovascular fitness training or simple flexibility exercises
determined modest improvements in both objective and subjective pain
measurements.[55] Significant improvements in cardiovascular fitness, pain
threshold scores of tender points, and both patient and physician global
assessment scores were demonstrated. In addition, there was a trend toward
decreased intensity of pain in the cardiovascular group.
Other studies demonstrated positive benefits from exercise. Forty- one patients
demonstrated improvements in walk distance, well-being, and fatigue following
a 6-week program of aquafit classes and group education.[56] An additional
study of 36 patients who participated in a 6-month program that included
aerobic conditioning and flexibility exercises showed that FMS patients can
be motivated to exercise, that exercise does not cause an increase in pain
when appropriate levels are followed, and enhanced flexibility and endurance
are dependent upon exercising at the prescribed level.[57]
Self-management
Patients with FMS would also benefit from education on effective self- care
treatment options (see Patient Education). They should be taught techniques
that they can use at home to decrease pain, muscle spasm, and tightness and
improve sleep.[11] Patients and their family members should be educated in
these treatment techniques, with self-management being the ultimate goal.
Self-treatment strategies should include heat therapy, stretching techniques,
massage, relaxation techniques, and the benefits of walking for exercise.
Heat therapy should include information regarding the use of moist hot packs,
heating pads, whirlpool baths, and warm baths or showers.[12]
Flexibility stretching techniques should emphasize the involved body areas
and the need to stretch slowly, gently, and gradually, starting out with
several repetitions and then working to increase tolerance.[58] Massage should
be taught for its relaxation and physiologic benefits. When learning massage,
the patient would benefit from self- massage techniques and instruction to
his or her significant other about how to properly massage the patient with
FMS. The benefits of both massage and transcutaneous electrical nerve stimulation
were tested in a group of 30 FMS patients and found to be beneficial.[59]
Relaxation techniques should include such activities as deep breathing,
visualization, biofeedback, meditation, autogenic training, and progressive
relaxation.[60] Walking should be emphasized for its importance to maintain
heart and lung conditioning and to help increase circulation and maintain
muscle strength. Demanding exercise should be avoided, with walking beginning
in a gradual fashion and increasing as tolerated.[11, 58] Other therapies
found to be beneficial for some patients include acupuncture,[61]
acupressure,[58] spray-and-stretch techniques,[58, 62] and stress reduction.[60]
Patients with FMS should be made aware of methods to manage their sleep disorder
and cope with their fatigue.[62] If patients with FMS are able to manage
their sleep disturbance, they may be able to have better control over fatigue
and pain levels.
Conclusion
Prompt diagnosis of the patient exhibiting symptoms of FMS will prevent years
of unnecessary suffering. Effective treatments are available to increase
the quality of life of FMS patients and their families. Together, the health
care provider and patient can plan a beneficial, multifaceted treatment regimen.
Source: Maurizio, Sandra J.; Rogers, Janet L., Recognizing and treating
fibromyalgia. (Continuing Education, with test)., Vol. 22, The Nurse
Practitioner, 12-01-1997, pp 18(12).
Website for:
USA Fibromyalgia Association
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