| Fibromyalgia Syndrome
Geoff Littlejohn
Fibromyalgia syndrome is the most common cause of persisting aches
and pains in our community. Understanding of this condition has increased
significantly over the last decade and this has resulted in more
appropriate and effective management strategies than we have in the
past.
One in five persons in the community will suffer from long-lasting
[chronic] musculoskeletal pain occurring in a localised part
of the body, say in the neck or back. One in ten persons suffer from
long-lasting, persistent but widespread pain.
Of this group many have fibromyalgia. The exact number affected with
widespread pain in muscles and soft-tissue areas varies according to
how one specifically defines the problem but it is generally considered
that around 3-5% of the community have
generalised fibromyalgia. The condition is more common in
women than men, perhaps in a ratio of 6:1 and it increases as age
increases.
Yet even children and adolescents can develop significant fibromyalgia
and the condition can come on at any time in life. Many have recurring
episodes through their life. Fibromyalgia has been found in all races
and countries where it has been sought out. Current understanding
of fibromyalgia would indicate that the condition is a variation
of normal
bodily functioning, a disorder rather than
a disease in the traditional sense.Top of Page
Fibromyalgia is simply the name applied to a very characteristic, predictable
and reproducible collection of symptoms and signs. The person complains
of generalised aching and pain, usually
accompanied by considerable stiffness in the muscles. This is more prominent
after a period of inactivity, such as in the mornings, or after doing
exercise. The other key symptom is fatigue.
This may be quite profound and sometimes dominate the picture. In these
instances the term chronic fatigue syndrome may be used. There is considerable
overlap between fibromyalgia and chronic fatigue syndrome and many consider
them to be variations on the one disorder.
The symptoms of fibromyalgia fluctuate over
the day, being at their worst in the morning and evenings. Many use
the mid-part of the day as a time to do important activities in order
to avoid aggravating their discomfort. The symptoms also fluctuate
over the weeks and months and years. There may be episodes of fibromyalgia
lasting for some days or weeks and then it may settle, only to return
some years later. Some have the condition every day. Typically the
problem is made worse by changes in weather such as a temperature
drop, a low-pressure system change or in humid weather. Excessive
physical activity or mental strain will also tend to aggravate the
symptoms. Stress of any type is a potent aggravating factor in the
majority.
At times there may be more localised pain, say in the neck or the
back or around a joint, but usually the pain is a generalised
aching discomforting and debilitating pain. Sometimes a feeling
described as “ being hit by a truck” is present on awakening
in the mornings. Hands may feel puffy and
the rings tighten or “pins and
needles” or other unusual, discomforting sensations
are felt in the hands. The neck might become stiff. The muscles and soft
tissues might become quite tender and this might be noticeable
when people touch you on the shoulder or give you a hug. Headaches can
accompany these symptoms, usually a dull tight-feeling type of headache.
Many people with fibromyalgia will have symptoms of irritability
in their bowel with bloating or irregular bowel habits. Women
may complain of premenstrual fluid retention.
Concentration is often poor.
The brain sometimes just doesn’t seem to work properly being
foggy with poor memory retention.
Yet this is often in contrast to the sharp mind that one had before
the whole problem began. The sleep may
become disturbed and be of poor quality, often with shallowness
and frequent wakening. The feeling of being unrefreshed in the morning
is characteristic.
The symptoms of fibromyalgia may range from
very mild and occasional to severe and persistent. Not everyone
with fibromyalgia has the
same degree of problem at any one time. The
symptoms are always reversible – this
is important to remember.
When the health care professional examines someone with fibromyalgia
they may find tight muscles around
the neck or the low back. A physical therapist may treat that area
in order to “loosen things up”, hoping to solve the problem.
This will often give temporary relief but unless the total picture
of all contributing factors to the fibromyalgia disorder are addressed
the symptoms will later return.
Further examination will show that there are areas where there is marked
tenderness on very gentle pressure with the finger. The
middle part of the trapezius muscle, the muscle that links the
neck to the shoulder is a typical area where there is increased
tenderness in fibromyalgia. This is just one of many areas which
are abnormally tender in fibromyalgia and which health care professionals
will know about when they conduct an examination in order to diagnose
the condition. Abnormal tenderness indicates that the amount of
pressure stimulation required to cause pain is less than usual.
This means that the person’s pain
threshold is lower than normal. This lowering of pain threshold
is technically called allodynia and is a characteristic feature
of fibromyalgia. The areas of greatly increased tenderness are
for convenience simply called “tender points”.
The American College of Rheumatology, has devised criteria for classification
of fibromyalgia and this involves finding at least 11 tender points
out of a total of 18 which they have designated as being useful and
important ones. The finding of widespread abnormal tenderness together
with widespread pain has a high accuracy level for diagnosing fibromyalgia.
However, fibromyalgia can occur with lesser numbers of tender points
and a lot of variations do occur. Localised forms of the condition
often affect just one part of the body, such as the neck and arm
or the chest wall or the low back and buttock. These localised forms
are the most common post-injury types of fibromyalgia and are often
mistakenly treated as if the area continues to be damaged rather
than the pain being due to increased
sensitivity of the pain nerves that is the basis for fibromyalgia
and needs different treatment than that for tissue damage.
Other clinical signs include the presence of dermatographia
or the “red-reaction”. This is found on stroking
the fingernail firmly over the upper back. In people without pain
in the area there usually will be a small degree of redness noted
soon after the fingernail pressure but in those with fibromyalgia
this reaction is much more marked than normal. This reaction is
due to release of chemicals from the over-active pain nerves that
in turn make more blood flow into the skin, causing the “red-reaction”.
As mentioned, the soft-tissues, especially muscle, are tenderer
in fibromyalgia but the skin is also overly sensitive. Pinching
a fold of skin between the finger and thumb of the upper back will
induce pain in fibromyalgia – this is not usual in pain-free
people. This indicates a widespread problem with increased pain
sensitivity in many tissues because the
cause of the sensitivity is not in the tender or painful
tissues but rather in the nervous
system itself.
Importantly, there are no clinical
signs to suggest inflammation or degeneration in any of
the tissues of the body that could explain the person’s pain
complaint. Fibromyalgia is not due to an inflammation of the tissues,
it is not due to degeneration in the spine or the muscles or other
regions where the pain might be felt. Nor is there any other immediately
obvious explanation. Blood tests are normal; x-rays show only what
would be expected at that person’s age. Even though the muscles
ache considerably, intensive investigations over the years have
shown that the muscles are in fact structurally normal.Top of Page
Fibromyalgia is basically a problem of overactivity in the pain system.
Pain nerves are distributed throughout the body, more in some areas
than in others. They are waiting to be stimulated and quite a large
stimulus is needed to trigger them off. This is called high threshold.
The pain system is ready to fire in order to warn us about potential
threat to injuring our tissues from some outside source. If a high
threshold stimulus is felt e.g. if a pin pierces the thumb, that message
will be quickly sent to the spinal cord which then will automatically
activate be sent to nerves controlling muscles in that region. This
is a reflex just like the knee-jerk, when you tap the tendon just below
the kneecap and you automatically jerk the leg upwards. The pain nerve
input forms a reflex that induces
the muscles to contract and the arm will pull away from the threatening
pin.
At the same time, the message of pain quickly goes up to the brain
where we feel the pain sensation and
we can then determine the localised spot
from where it came. We can then attend to dealing with the cause
of the problem. When the pain message gets to the brain other input
is put into the sensation of pain and this input comes from our previous
experience with regard to pain, our emotions and our behaviours in
regard to pain. As you well know we all react to pain in different
ways. The localised component of pain
is quite different to the emotional part of pain and yet both
are part of the pain experience. It is for this reason that the World
Health Organization classifies the definition of pain as being “an
unpleasant sensory and emotional experience associated with actual
or potential tissue damage, or described in terms of such damage”.
Now back to fibromyalgia. As mentioned earlier the pain threshold
is lowered in fibromyalgia and this means that the pain
system is ready to fire at a much lower level than would otherwise
be the case. Thus routine activity such as hanging out the washing,
driving the car, making the beds or standing or sitting in the one
position at work will induce pain and discomfort much more readily
than would otherwise be the case. As the pain message is felt with
normal postural activities then so is the message relayed to the
muscles in the area. These muscles contract and tighten. This leads
to stiffness around the area and particularly around the spinal region.
Other reflex actions occur which give rise to some of the clinical
signs that we’ve talked about earlier.
The cause for the lowered pain threshold seems to be an abnormality
occurring in the way the pain system is modified or damped down.
This is the critical link in the fibromyalgia puzzle that is being
worked out at the moment. Many workers think that the cause for
the change in sensitivity in the pain system is due to a change
in one of the pain modifying chemicals that is present in our brains
and nervous system.
Many of these chemicals come from the higher parts of the brain
where emotion, mood and stress effects also act. These chemicals
in turn react on other control systems that can change the sensitivity
of our pain system. In addition other parts of our body’s “homoeostatic” [or
control systems] can be altered and these might include changes
in the hormonal system and immune system of our bodies. There are
certainly changes in these systems that can be measured using current
technology in patients with fibromyalgia. It is considered these
changes are not the cause of the problem but are a result of the
problem. But they may cause some of the non-pain symptoms of fibromyalgia,
such as fatigue or dizziness.
Fibromyalgia may come on quickly, say after a frightening accident
or may come on slowly and there may be no obvious cause seen. However,
many times there is a stress event in the person’s life that
might be near to the onset of the fibromyalgia. Sometimes the stress
event goes completely but the fibromyalgia continues just as if the pain
system has been set at a new level.
Currently there is no antidote to fibromyalgia – no medication
that reverses the situation and thus we rely on other tactics to manage
the problem.
Anyone with fibromyalgia, be it generalised and widespread or be it localised,
needs to work out a management strategy to deal with the problem. As
indicated above, the condition is not due to something wrong in the area
where the pain is felt. This is merely the pain nerves being activated
but without any local reason for this. Excessive physical therapies or
investigations into a cause in the painful tissues do not help the problem.
There is no need for ongoing scans, blood tests or seeking our numerous
specialists to find the “magic answer” to the chronic pain
problem. Fibromyalgia should be the end of the trail. The diagnosis of
fibromyalgia should not be given if there is another explanation for
the pain and naturally a certain number of tests will be required to
eliminate that possibility if present. However, the diagnosis of fibromyalgia
should be the start of a new management plan.Top of Page
A person with fibromyalgia should consider
the following:
- The condition is always potentially
reversible.
-
Psychological factors
are important in
management. Managing everyday stresses, dealing with ongoing
life problems and working out the best strategies for dealing
with the
pain problem are all necessary. This may just require readjustment
in thinking and life strategies or may require the help of a
professional who deals with this problem all the time. This
might be a clinical
psychologist, another health care professional or a doctor who
deals with chronic pain. The catch-cry “learn to live with
it” implies that the situation is hopeless and irreversible.
This is not the case.
-
Strategies which include relaxation therapy,
meditation and movement treatment such as Feldenkrais, yoga, tai
chi, pilates and the like are all useful in dealing with the emotional
and muscle tightness problems which accompany fibromyalgia.
-
If there is a lot of localised muscle tightness
then some physical therapy may well be necessary but this should not be relied
on as the only way to deal with the problem.
-
Exercise is extremely important
and one should try to start moving the body even if it is painful.
The pain of fibromyalgia does not mean that there is damage occurring
in the painful area. A programme that encourages exercises, i.e.
the establishment of an aerobic fitness programme, should follow
physical therapy. One should not rush into this, as this will tend
to cause some discomfort at first start. This can be best done
under supervision of a health care professional or doctor. A person
with fibromyalgia may take three-times longer than normal to achieve
fitness but it is still achievable.
-
Simple analgesics, such as
paracetamol/acetaminophen are preferred to any other medication
-
Low dose tricyclic
medications are
given in the evenings to help the sleep disturbance, fatigue and
pain – around 40% of people gain benefit. If there is an
associated mood disturbance such as depression then routine antidepressant
medications may be needed. Medical advice helps in this regard.
-
The emphasis on management of fibromyalgia
is self-management.
When the condition is severe one usually requires input from a
health care professional to get the right path set up. When the
problem is mild the health care professionals have a minimal role.
Perhaps a check of the diagnosis and then establishment of an appropriate
programme might be all that is required.
-
Finally, it should be remembered that fibromyalgia is a problem
of the pain system. This can occur in people with rheumatoid arthritis,
osteoarthritis, disc troubles or other health problems. Or it can
occur by itself. When it occurs along
with other painful musculoskeletal diseases then the fibromyalgia
may be mistakenly put down to that other condition. At all times
discussion with a health-care professional will ensure that treatment
approaches encompass both options. Top of Page
Fibromyalgia is a common everyday problem. Usually mild, self-limiting
and not disabling, the condition can be managed by the person with
the problem. When the pain is more severe and the person is more disabled
then more professional input is required to help deal with the problem.
The above notes are a general guide
to fibromyalgia based on the author’s opinion and
specific approaches for individuals may at times differ
from that contained in this information sheet. At all
times advice from health-care practitioners, including
your doctor,
needs to be taken into consideration.
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