Health for Women, March 2005

Fibromyalgia Better Understood, Experts Say

Fibromyalgia is now accepted as a diagnosable illness, and as more is understood about the syndrome, better treatment becomes available, experts say.

A simple description of fibromyalgia is that it is a chronic syndrome characterized by widespread muscle pain and fatigue.

For still unknown reasons, people with fibromyalgia have increased sensitivity to pain that occurs in areas called their "tender points."

Common tender points are the front of the knees, the elbows, the hip joints, the neck, and spine. People may also experience sleep disturbances, morning stiffness, irritable bowel syndrome, anxiety, and other symptoms.

Women Are Affected in Greatest Numbers

According to the American College of Rheumatology, fibromyalgia affects 3 million to 6 million Americans, 80 percent to 90 percent of whom are women. The condition is most often diagnosed during middle age, but at least one of its symptoms appears earlier in life.

But is there a psychological tie-in strong enough to differentiate fibromyalgia from other similar diseases and conditions? Apparently not.

"Fibromyalgia patients are such a diverse group of patients, they cannot all be the same," says Dr. Thorsten Giesecke, a University of Michigan research fellow.

Dr. Giesecke and his colleagues evaluated 97 fibromyalgia patients, including 85 women and 12 men. The patients underwent a two-day series of tests, answering questions about their coping strategies and personality traits - particularly their emotional well-being. They were also tested for sensitivity to pressure and pain.

"It's generally been thought that fibromyalgia patients who have higher distress have higher pain sensitivities," notes Dr. Giesecke.

In other words, it was believed that those with fibromyalgia who were prone to emotional difficulties such as depression and anxiety were more likely to experience greater physical pain.

But his study did not bear that out. In fact, patients in one of the three groups in the study who had the highest pain levels had the lowest anxiety.

The term fibromyalgia comes from the Latin word for fibrous tissue (fibro) and the Greek ones for muscle (myo) and pain (algia). Tender points are specific locations on the body - 18 points on the neck, shoulders, back, hips, and upper and lower extremities - where individuals with fibromyalgia feel pain in response to relatively slight pressure.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) states that fibromyalgia patients often experience combinations of many other chronic and frustrating symptoms, including:

• sleep disturbances
• morning stiffness
• headaches
• irritable bowel syndrome
• painful menstrual periods
• numbness or tingling of the extremities
• restless leg syndrome
• temperature sensitivity
• cognitive and memory problems, sometimes referred to as "fibro fog"

Latest research indicates that fibromyalgia is the result of internal biochemical imbalances that cause physical symptoms such as pain, weakness, and mental impairment.

Because it is a syndrome - a collection of signs and symptoms - rather than a disease, fibromyalgia cannot be diagnosed by an invariable set of specific symptoms or reproducible lab findings.

Even with the findings about relatively small psychological influence, practical experience seems to indicate that stress may play a role.

Roger H. Murphree, a Birmingham, Ala., chiropractor who specializes in treating patients with fibromyalgia and chronic fatigue syndrome, said he has seen a link between stress and the intensity of fibromyalgia.

"Most of us live in a world of stress," Murphree says. "Something has to give, and it's usually sleep. Meanwhile, we subsist on junk food, caffeine, alcohol, and prescription medications. Such a lifestyle isn't good for anyone. But for an unlucky few, the toll is severe."

Dr. Jacob Teitelbaum, whose practice in Annapolis, Md., led him to do research into fibromyalgia and the closely related chronic fatigue syndrome, concluded that the body's endocrine system could hold the clue to treatment. It's a matter of how the body's energy is marshaled, he says.

"Fibromyalgia is like the body blowing a fuse," he explains. "The hypothalamus serves as humans' internal fuse box. When the demands of living build up, stress increases and the hypothalamus shuts down. Because the circuit is overtaxed and the fuse is blown, the body simply can't generate enough energy."

"That causes muscles to cease functioning in a shortened position, resulting in pain all over the body and a general feeling of fatigue or weariness," Dr. Teitelbaum says.

Murphree's experience with hundreds of patients confirms Dr. Teitelbaum's analogy. Most, he says, are either "Type A" perfectionists or "Type B" caregivers.

"Type A fibromyalgia patients work and work and work until they burn out," says Murphree. "Type B patients give and give and give - nurturing their spouses, children, family, and friends - until they break down. Anyone whose lifestyle includes very little downtime is at risk."

Help Is on the Way

Dr. Teitelbaum recommends a four-pronged approach to repair the "blown fuse" and turn the body's current back on:

• Restoration of sleep - at a minimum, eight to nine hours every night, using appropriate medications, as needed
• Restoration of a normal hormone balance, including thyroid, adrenal, and reproductive hormones
• Appropriate treatment for infections that may be present as a consequence of the body's depleted immune function
• Nutritional support, particularly with B complex vitamins, magnesium, zinc, and malic acid

Dr. Teitelbaum uses the acronym SHIN to summarize his treatment regimen. "S is for sleep, H for hormone balance, I for infection control, and N for nutrition," he explains. "The important thing is that all four should be implemented in concert with one another for maximum therapeutic effect."

Always consult your physician for more information.

Online Resources

(These links are provided for the education and convenience of our Neighbors. AAMC is not responsible for the content of Internet sites.)

American College of Rheumatology

Arthritis Foundation

Centers for Disease Control and Prevention (CDC)

HealthierUS.Gov

National Institute of Arthritis and Musculoskelatal and Skin Diseases

National Institutes of Health (NIH)

National Library of Medicine

National Women's Health Information Center

Office of Research on Women's Health

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Treating Fibromyalgia

According to the American College of Rheumatology (ACR), there is no known cure for fibromyalgia.

Patients may be reassured that the condition, while painful, does not damage tissues and that it can be managed successfully in many cases.

The ACR states that the most successful treatment of fibromyalgia is a comprehensive team approach focusing on cognitive behavioral therapy, stress reduction, and medication to help with sleep.

Physical therapies, such as heat treatments, cold application, and massage, can provide some temporary relief from symptoms but they should not be the focus of treatment.

Gentle and regular stretching can be used to decrease tight muscles.

Strength training activities help support the areas that have pain to help make muscles work more efficiently, since those areas may be weak from inactivity.

Supervised aerobic conditioning exercises are valuable since most people are deconditioned (out of shape).

These endurance activities can help facilitate sleep, which often improves fatigue.

The aquatic environment provides another option since the water allows you to tolerate more activity due to the effects of buoyancy. Aquatic exercises or swimming laps can be used.

ACR suggests starting very gradually with any of these activities so you don’t set yourself back from ‘overdoing’ it. Moderation is the key to finding the balance between rest and activity.

Occupational therapy, including the use of adaptive devices and instruction in lifestyle modification, energy conservation, pacing, and relaxation training can improve functional performance.

Learning better coping skills and eliminating negative self-talk are beneficial.

Attention to mental health, including psychological consultation, is also important, since depression may precede or accompany fibromyalgia.

Certain medications have an important role, say ACR experts. Various medications to improve sleep and relax muscles, such as amitriptyline and cyclobenzaprine, are widely used.

Antidepressant medications may be appropriate, according to physicians at ACR.

Local anesthetic or corticosteroid injections may be appropriate for painful local tender points.

Pain may also be managed by non-steroidal anti-inflammatory drugs (ibuprofen, naproxen, and others) or tramadol.

A psychologist is often helpful in utilizing cognitive-behavioral techniques and relaxation training to reduce the pain.

Psychological consultation may also identify an underlying component of depression, which can then be treated, suggests the ACR.

Always consult your physician for more information.