Fibromyalgia – Symptoms, Complications, and Epidemiology.

Definition

Fibromyalgia is the most common condition in which a person has long-term, body-wide pain and tenderness in joints, muscles, tendons, and other soft tissue. Fibromyalgia has also been linked to fatigue, sleep problems, headaches, depression, and anxiety. The pain of Fibromyalgia Syndrome is usually described as aching, throbbing or burning and is unpredictable in nature. Its severity varies from day to day and different parts of the body tend to be affected at different times. In some people FMS can be very severe and disabling, while in others it may cause only mild discomfort.

 

How fibromyalgia develops?

Fibromyalgia involves changes in the body’s neurotransmitters – the substances that allow nerve cells to communicate with one another. When produced in adequate amounts and at the right times, neurotransmitters – such as serotonin, noradrenaline, adrenaline, dopamine and many others – ensure proper functioning of the circuitry of the nervous system. When the production of neurotransmitters is altered, the circuits that depend on these substances malfunction, which produces symptoms.

 

This is precisely what happens in your pain pathways: malfunctions in these neurotransmitters lead to a situation in which some stimuli are perceived more strongly than usual, thus producing the characteristic, widespread aches and pains of fibromyalgia.

History: Past to Present

• 180 A.D.: The Greek physician and anatomist Galen (120-200A.D.) attributes symptoms associated with widespread pain to the rheuma. When later interpreted, Galen’s words suggest that rheuma represents “a great fluxion which races to various parts of the body and goes from one to another.”
• 1592: Guillaume de Baillou coins the term rheumatism to describe collective muscle and joint pain.
• 18th century: Physicians begin to distinguish joint rheumatism that is accompanied by signs of deformity from painful, non-deforming musculoskeletal disorders, commonly referred to as muscular rheumatism.
• 1815: British surgeon William Balfour suggests that inflammation in muscle connective tissue is the cause of nodules and pain, and reports for the first time on focal tenderness which he describes as “tender points.”
• 1835: Hans Christian Andersen publishes The Princess and the Pea, a literary fairytale describing a princess who suffered from a heightened state of physical sensitivity that interferes with her ability to sleep.
• 1841: Valleix puts forth the concept of trigger points, and suggests that these points’ proximity to specific nerves indicates that muscular rheumatism is actually a disorder of the nervous system.
• 1904: Sir William Gowers describes diffuse pain as fibrositis and asserts that it results from proliferation and/or inflammation of subcutaneous (i.e., beneath the skin) and fibrous tissue.
• 1968: E. F. Traut offers the first near-modern description of fibrositis, complete with its system-wide manifestations.
• 1972: H.A. Smythe offers the first modern description of fibrositis – including widespread pain and multiple tender points – and proposed working criteria that triggered renewed interest in fibrositis and clinical research
• 1975: H. Moldofsky performs first electroencephalogram (EEG) study to demonstrate sleep-related difficulties in patients with fibrositis
• 1976: P.K. Hench coins the term “fibromyalgia.”
• 1977: H.A. Smythe and H. Moldofsky refine Smythe’s definition of fibromyalgia, requiring the presence of 12 of 14 tender points when 4kg of manual pressure is applied, and requires that the following four signs and symptoms also be present: a history of widespread pain for at least three months, disturbed sleep, tenderness when lightly squeezing the skin at the upper part of the back muscle (trapezius), and normal results on laboratory tests.
• 1981: Yunus and colleagues propose a formal set of criteria for the diagnosis of fibromyalgia, based on the findings of the first controlled clinical study to validate symptoms and tender points in fibromyalgia patients. These criteria require aching, pain, and stiffness for a minimum of three months, in addition to a minimum of five out of 40 possible tender points. 1984: Yunus first describes the concept that fibromyalgia and other syndromes have overlapping features, are mutually associated, and are interconnecte
• 1984: Wolfe reports a high prevalence of fibromyalgia among rheumatoid arthritis patients
• 1985: Yunus publishes the first report of juvenile fibromyalgia by a controlled study
• 1986: Carette et al. and Goldenberg et al. both report on the effectiveness of the tricyclic antidepressant amitriptyline in treating fibromyalgia-related symptoms as demonstrated in a randomized, controlled trial.
• 1987: The American Medical Association recognizes fibromyalgia as a true disease entity.
• 1989: Yunus publishes evidence showing normal results of muscle biopsies in fibromyalgia patients, which shifts the focus of research away from muscle and toward the central nervous system.
• 1990: The American College of Rheumatology (ACR) diagnostic criteria state that in order to receive a diagnosis of fibromyalgia, patients should have widespread pain and at least 11 of 18 possible tender points. Moreover, these criteria assert that a decreased threshold for pain is the hallmark sign of fibromyalgia.
• 1991:The Fibromyalgia Impact Questionnaire (FIQ) is published for the first time. The FIQ is a standardized and validated questionnaire designed to assess the overall impact that fibromyalgia has on the patient’s ability to function, their pain level, fatigue, sleep, mental status, and other domains. It is subsequently translated into 14 languages.
• 1991: The World Health Organization (WHO) incorporates fibromyalgia into their tenth revision of the International Statistical Classification of Disease and Related Health Problems (ICD-10).
• 1993: Researchers demonstrate for the first time that fibromyalgia patients suffer from disordered central sensitization.
• 1995: First United States population-based study reveals 2% prevalence of fibromyalgia.
• 1997: The National Fibromyalgia Association is formed to promote awareness of fibromyalgia and improve its legitimacy.
• 1997: A controlled study implicates the role of trauma (particularly cervical spine injury) in fibromyalgia.
• 2007: Lyrica (pregabalin) becomes the first U.S. Food and Drug Administration (FDA)-approved drug specifically for treating fibromyalgia.
• 2008: Cymbalta (duloxetine hydrochloride) becomes the second FDA-approved drug to treat fibromyalgia.
• 2009: Savella (milnacipran hydrochloride) become the third FDA-approved drug to treat fibromyalgia.
• 2009: The FIQ is replaced by a revised version, the FIQR, which is adjusted to improve the way in which questions are presented to patients, create a more accurate scoring system, and assess a more comprehensive sampling of patient signs and symptoms.
• 2010: The 1990 ACR diagnostic criteria for fibromyalgia are updated in an effort to better standardize the symptom-based aspect of diagnosis and ensure that physicians use similar, if not the same, processes to arrive at a diagnosis of fibromyalgia.

Epidemiology

Chronic widespread pain, the cardinal symptom of fibromyalgia (FM), is common in the general population, with comparable prevalence rates of 7.3% to 12.9% across different countries. The prevalence of FM in the general population was reported to range from 0.5% to 5% and up to 15.7% in the clinic. The common association of FM with other rheumatic disorders, chronic viral infections, and systemic illnesses has been well documented in several studies. Up to 65% of patients with systemic lupus erythematosus meet the criteria for FM. FM is considered a member of the family of functional somatic syndromes. These syndromes are very common and share a similar phenomenology, epidemiologic characteristics, high rates of occurrence, a common pathogenesis, and similar management strategies. A high prevalence of FM was demonstrated among relatives of patients with FM and it may be attributed to genetic and environmental factors.

Causes

The causes of fibromyalgia are not known. Researchers think a number of factors might be involved. Fibromyalgia can occur on its own, but has also been linked to:

• Having a family history of fibromyalgia
• Being exposed to stressful or traumatic events, such as
• Car accidents
• Injuries to the body caused by performing the same action over and over again (called “repetitive” injuries)
• Infections or illnesses
• Being sent to war

 

Common factors that aggravate Fibromyalgia symptoms

• Sleep difficulties
• Physical deconditioning, muscle overload, poor posture
• Psychological factors: stress, anxiety, depression, poor coping skills
• Environmental factors: hot/cold temperature, humidity, noise
• Occupational factors: repetitive trauma, ergonomic factors
• Physical overuse/unaccustomed exercise
• Coexisting/associated conditions: arthritis, neuritis, restless
• legs syndrome, hypothyroidism, headaches, irritable bowel
• syndrome, irritable bladder syndrome

What are the Symptoms of Fibromyalgia?

The symptoms of Fibromyalgia vary a great deal. People with Fibromyalgia often complain of varying degrees of muscular pain, stiffness and fatigue.

• Pain is present when people are resting but may be worsened by exercise. Pain is felt in all four limbs and almost always in the upper and/or lower parts of the spine, and/or the head, face and jaw.
• Fatigue may be a prominent feature
• Stiffness, body stiffness is a significant problem experienced by most patients. It can occur upon awakening or remaining in one position for prolonged periods. It can also accompany weather changes.
• Increased Headaches or Facial Pain. Headaches are a common complaint for many with FMS. They may be caused by referred pain from tender neck and shoulder areas.
• Abdominal Discomfort, FMS-related symptoms include digestive disturbances, abdominal pain and bloating, constipation, and diarrhea. As a whole, such symptoms are known as irritable bowel syndrome.
• Irritable Bladder, Fibromyalgia patients may notice an increase in urinary frequency or experience a greater urgency to urinate.
• Numbness and Tingling, also known as “paresthesia”, symptoms usually involve a prickling or burning sensation, particularly in the extremities.
• Chest Pain. Persons with FMS sometimes experience a condition called “costochondralgia” which involves muscular pain at the spot where the ribs meet the chest bone. Since costochondralgia mimics cardiac symptoms, it is always a good idea to check with a physician if chest pain occurs.

 

• Cognitive Disorders. Frequent complaints, which vary from day to day, include difficulty concentrating “spaciness”, “Fog”, memory lapses, word mix-ups when speaking or writing, type of stuttering (difficulty getting words out) and clumsiness or dropping things.
• FMS patients also experience dizziness and balance problems. Typically, there is no classical, spinning vertigo. Rather difficulties in orientation occur when standing, driving or reading.
• Environmental Sensitivity. Allergic-like (but not true allergies, i.e. non immune mediated), reactions to a variety of substances are common, including sinusitis, as are sensitivities to light, noise, voice (when tension head/headache is present) odors, and weather patterns. Dryness of the skin, eyes and mouth is also common.
• Other Symptoms. Fibromyalgia Syndrome is often described as the”Irritable Everything Syndrome” increasingly, additional symptoms (see the extended list of symptoms in this folder) and syndromes are being associated with FM.

Diagnosis

In the past, doctors would check 18 specific points on a person’s body to see how many of them were painful when pressed firmly. Newer guidelines don’t require a tender point exam. Instead, a fibromyalgia diagnosis can be made if a person has had widespread pain for more than three months — with no underlying medical condition that could cause the pain.

Blood tests

While there is no lab test to confirm a diagnosis of fibromyalgia, your doctor may want to rule out other conditions that may have similar symptoms. Blood tests may include:

• Complete blood count
• Erythrocyte sedimentation rate
• Cyclic citrullinated peptide test
• Rheumatoid factor
• Thyroid function tests

Treatment

Medical attention is needed, because fibromyalgia can be difficult to manage. As it is a syndrome, each patient will experience a different set of symptoms, and an individual treatment plan will be necessary.

Treatment will usually include some or all of the following:

• An active exercise program
• Low-dose anti-depressants
• Acupuncture
• Psychotherapy
• Behavior modification therapy
• Chiropractic care
• Massage
• Physical therapy

Drugs for fibromyalgia

Drugs may be recommended to treat certain symptoms.

• These may include over-the counter (OTC) pain relievers, such as non-steroidal anti-inflammatories (NSAIDs).
• Antidepressants, such as duloxetine, or Cymbalta, and milnacipran, or Savella, may help reduce pain. Anti-seizure drugs, such as gabapentin also known as Neurontin, and pregabalin, or Lyrica, may be prescribed.

Exercise

• A combination of aerobic exercise and resistance training, or strength training, has been linked to a reduction in pain, tenderness, stiffness, and sleep disturbance, in some patients.
• If exercise is helping with symptoms, it is important to maintain consistency in order to see progress. Working out with a partner or personal trainer may help to keep the exercise program active.

Acupuncture

• Some patients have experienced improvements in their quality of life after starting acupuncture therapy for fibromyalgia. The number of sessions required will depend on the symptoms and their severity.

 

Behavior modification therapy

• Behavior modification therapy is a form of cognitive behavioral therapy (CBT) that aims to reduce negative, stress- or pain-increasing behaviors and improve positive, mindful behaviors. It includes learning new coping skills and relaxation exercises.

Prevention and management of fibromyalgia

Fibromyalgia cannot be prevented. Proper treatment and lifestyle changes can help reduce the frequency and severity of your symptoms. People with fibromyalgia attempt to prevent flare-ups rather than trying to prevent the syndrome itself. There are many things you can do to prevent aggravation of your symptoms.

Get adequate sleep

Lack of restorative sleep is both a symptom of fibromyalgia and a cause of flare-ups. Poor sleep creates a cycle of more pain, making it harder to sleep, which causes more pain, and so on. You may be able to break the cycle by going to bed at the same time every night and practicing good sleep habits.

Try relaxing one hour before bed by shutting off the television and other electronic devices. Reading, taking a warm bath, or meditating are all good ways to unwind and prepare for deeper sleep. Your doctor may prescribe a sleep aid if you have persistent problems falling or staying asleep.