Fibromyalgia

Fibromyalgia

Fibromyalgia is a syndrome characterized by widespread pain and tenderness at specific points across the body. It occurs most commonly in the 4th and 5th decade and affects women 10 times more commonly than men. Overall about 3-4 % of the US population is affected. Associated symptoms include fatigue, stiffness, insomnia, headache, abdominal pain and poor concentration. Fibromyalgia is often associated with other chronic conditions such as  Temporomandibular Joint Syndrome (TMJ), Irritable Bowel Syndrome (IBS), Chronic Fatigue Syndrome (CFS)  and depression.

The cause of fibromyalgia is unknown but there appears to be  a problem with the central pain processing center in the brain. This problem results in the sensory signals coming to the brain being magnified. It is this magnification that turns a relatively innocuous sensation  into a painful sensation. Thus, a sensation with a 2-3 (out of 10) pain level become a 8-9 level. How this happens is unclear but does appear to involve some of the deeper sensory centers of the midbrain. The American College of Rheumatology has published a set of criteria used to make the diagnosis of fibromyalgia. The criteria are :

  1. History of widespread pain for greater than 3 months duration
  2. Pain along the spine and in all four quadrants of the body (right/left and above/below the waist)
  3. Tenderness in at least 11 out of 18 standard points throughout the body to pressure of 4 kilograms (9 pounds).

Testing for fibromyalgia with lab and radiological testing is unnecessary and not part of the diagnostic criteria used to make the diagnosis. However, these tests are often very useful in excluding other painful disorders. Appropriate testing may include:

  • Complete Blood Count (CBC)
  • Thyroid Panel (TSH and free T4)
  • Sed rate
  • Rheumatoid Tests (RA or CCP)
  • Antinuclear Antibody (ANA)
  • C-reactive Protein (CRP)
  • Creatinine Phosphokinase (CPK)

Radiological testing has a very limited use in the diagnosis or treatment of fibromyalgia.

Treatment of fibromyalgia is difficult due to the diffuse presentation of the symptoms. Also, there is no treatment for the underlying cause of fibromyalgia. Psychotherapy is useful in dealing with the emotional response people have to the pain and limitation in function.  Physical therapy and exercise programs with a graded program that slowly increases the intensity and the duration of the exercise is extremely useful. Patients should set realistic but progressive goals. A flexibility and stretching program is useful in maintaining function. A patient log to monitor progress is useful to demonstrate improvement or identify a problem.

Medications have been shown to useful in most patients with fibromyalgia.  However, the degree of pain reduction with medication alone is 35-50%.  The main groups of medication used for treatment are:

  1. Tricyclic antidepressants – Elavil and Pamelor
  2. Selective serotonin reuptake inhibitors  (SSRIs)- Zoloft, Celexa, Prozac and Lexapro
  3. Selective serotonin and norepinephrine  reuptake Inhibitors – Effexor and Cymbalta
  4. Anticonvulsants – Neurontin and Lyrica.

Many of these medications are now available generically (7 of the 10 medications listed.)

Narcotic pain medications are seldom suggested for use in fibromyalgia due to their high addiction potential. These medications may worsen cognitive function and increase depressive mood changes. However, there are certain patients for which the antidepressants and the anticonvulsants are inappropriate or simply do not work. These patients may need pain medications to maintain their activities of daily living especially as the disease progresses. Tramadol is a medication that works in  a similar fashion to the narcotics. However, it is not a true opioid narcotic and not as physically addicting as the narcotics. Tramadol appears to a slightly beneficial effect on serotonin and norepinephrine.  It is a useful medication in the treatment of fibromyalgia. The nonsteroidal anti-inflammatory medications are marginally useful in this condition but are cheap and nonaddicting.

Fibromyalgia is a common chronic pain syndrome that has the potential to incapacitate people. There is no cure for this problem and response to treatment varies from patient to patient. The best treatment appears to be multifactorial ,  often requiring psychotherapy, physical/exercise therapy, education, a supportive family, motivation by the patient’s doctor and appropriate medication.