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Adam Sewell MD

FIBROMYALGIA

The cause of fibromyalgia is uknown and characterized by widespread pain and decreased pain threshold (Nugraha et al, 2011, and CDC, 2009). It affects an estimated 2% of the general U.S. population (Traynor et al 2011), or 5 million Americans age 18 or older (CDC, 2009), and it’s more likely to be found in women (Bartels et al, 2009).

The term is derived from the Latin “fibro-”, which refers to the fibrous connective tissues, the Greek  “myo-,” or “muscle”, and Greek “algos-”, meaning “pain”. “Fibromyalgia” means “connective tissue and muscle pain”. This pain manifests as generalized tenderness,  specific tender points, as well as a range of somatic symptoms.

According to the American College of Rheumatology, the diagnostic criteria for fibromyalgia is: widespread pain, and presence of 11 or more tender points among a possible 18 sites throughout the body.  Fibromyalgia, also, includes sleep disturbances, fatigue, stiffness, hypersensitivity to physical and psychological environmental stimuli, depression and anxiety. In addition, fibromyalgia may coexist with other conditions such as headache, irritable bowel syndrome, chronic fatigue syndrome, temporomandibular joint disorder (TMJ), rheumatoid arthritis, lupus erythematosus, painful menstrual periods, and other pain and autoimmune syndromes (CDC, 2009; Weir et al, 2006;  Calandre & Rico-Villademoros, 2012). The diagnosis of fibromyalgia is considered one of exclusion.

Some patients with fibromyalgia may develop central sensitization, or the overreaction of pain receptors to normal physical sensations. Central sensitization is thought to be a consequence of prolonged pain from any long-term painful condition like fibromyalgia. In central sensitization, low-threshold sensory fibers activated by light touch of the skin trigger neurons in the spinal cord to respond only to painful stimuli. Eventually, even harmless stimuli provoke feelings of pain. This phenomenon is known as allodynia.

Those with fibromyalgia may also experience hyperalgesia, or increased sensitivity to pain.     Although its cause is not yet fully understood, it is thought that both genetic and environmental factors are involved in the development of fibromyalgia (Calandre & Rico-Villademoros, 2012).  Additional research may lead to development of more effective treatments or new preventative measures for chronic pain syndromes like fibromyalgia (Henry et al, 2011).

The NEJM review acknowledges that, for patients experiencing the pain and symptoms of fibromyalgia, there is little doubt that the condition is real, as is the need for relief, and many fibromyalgia patients express dissatisfaction with their quality of life.

Treatment

Although there is no cure for fibromyalgia, symptoms may be lessened, or go through periods of remission, as time passes. It is important to remember that fibromyalgia is not a progressive or life-threatening condition, and that certain treatments can significantly improve the issues, especially the pain and fatigue, associated with the disorder.

There is no cure, so treatment focuses on managing symptoms and improving overall quality of life.  Therapies including medications, physical exercise, and psychological treatment can all be effective approaches (Calandre & Rico-Villademoros, 2012).

First-line drugs used to treat fibromyalgia include, pregabalin used for neuropathic pain, and the serotonin- and norepinephrine-reuptake inhibitors duloxetine and milnacipran for disturbed sleep and depression. These medications were designed, principally, to address pain that stems from the spinal cord and the brain (Crofford, 2008). Evidence from clinical trials indicate these three drugs can have a significant impact on fibromyalgia-related pain, reduce sleep disturbances and fatigue, and improve quality of life and mood (Traynor et al, 2011).

A combination of medications is often necessary to mitigate the symptoms of fibromyalgia, particularly as symptom profiles vary between patients. These include: antidepressants, non-steroidal anti-inflammatory drugs (NSAIDs), sedatives, muscle relaxants, analgesics, sedatives, anticonvulsants, sleep aids, and corticosteroids, depending on each patient’s clinical history, target symptoms, and functional impairments (Han et al, 2011; Moldofsky et al, 2010; Russell et al, 2009; Di Franco et al, 2010). In addition, other therapies may be prescribed to treat specific symptoms like sleep-disturbance, irritable bowel syndrome, and rheumatoid arthritis (Mease et al, 2011).

Opioids (e.g., OxyContin, Vicodin, Percocet), are typically not recommended for the treatment of fibromyalgia, because they have not been shown to provide a long-term benefit for most patients. Though the information is limited, all current guidelines discourage opioid use, because they are habit forming and may not be of benefit to most people with fibromyalgia. They can, in fact, cause greater pain sensitivity, persistence of chronic pain (Ngian et al, 2011), and other long-term effects.

Newer research suggests fibromyalgia patients may have low magnesium levels, and supplementation with magnesium citrate may reduce symptoms of the disorder. It is thought to lower the intensity of fibromyalgia pain, particularly across tender points (Bagis et al, 2012). The same study, also, reported that a combined therapy of amitriptyline plus magnesium citrate not only reduced pain, but improved depression among patients.

Medications are not the only way to treat the symptoms of fibromyalgia. Self-management treatments like, scheduling daily relaxation time, establishing a regular sleeping pattern, getting regular exercise, and educating oneself on fibromyalgia, can all be helpful. ACR also advocates deep-breathing exercises and meditation to help curb stress that can exacerbate symptoms.

Another therapeutic option recommended by ACR is cognitive behavioral therapy (CBR), which can help redefine a person’s perceptions and opinions about illness, teach symptom reduction skills, and help alter a person’s behavioral response to pain. A 2012 randomized controlled trial was conducted to assess the efficacy of an individually administered form of CBR for fibromyalgia (Woolfolk et al, 2012). The study indicated that the patients receiving the experimental treatment reported less pain and overall better functioning than control patients, both at post-treatment and at follow-up.

Several physical treatments have, also, shown tremendous benefit. These include, exercise, yoga, physical therapy, massage therapy and Tai Chi. Strength training and aerobic exercise have beneficial effects on pain in adults with fibromyalgia, as well. One study found that fibromyalgia patients assigned to a yoga program showed significantly greater improvements of symptoms and functioning, including pain, fatigue, and mood and revealed more acceptance, and other coping strategies (Carson et al, 2010).

A growing body of research suggests that Tai Chi produces numerous benefits in the treatment of fibromyalgia, including improved balance and muscle strength, better attentiveness and sleep, and lowered anxiety (Field, 2011). Tai Chi, which consists of gentle, meditative, flowing movements, balance and weight shifting, breathing techniques, and cognitive tools, also promotes positive cardiovascular changes (Field, 2011).

The ACR commonly, also, recommends acupuncture (Itoh & Kitakoji, 2010), transcutaneous electrical nerve stimulation (TENS) (Löfgren & Norrbrink, 2009), massage therapy (Sunshine et al, 1996), and nutritional strategies (Lamb et al, 2011; Dykman et al, 1998). In many cases, these treatments can help individuals with fibromyalgia improve their quality of life. Trigger point injections, membrane-stabilizing infusions and Botox injections have also shown benefit and may decrease pain long enough for patients to resume more conservative therapy (Smith et al, 2002).

Chronic pain causes changes throughout the nervous system that often worsen over time. It has significant psychological and cognitive consequences and can actually cause a separate disease entity (Pizzo & Clark, 2012). Fibromyalgia can be debilitating, causing social and economic impairment and effect the ability of people to work and maintain relationships with family and friends (Firestone et al, 2012). Treatment from an experienced pain management specialist can help fibromyalgia patients obtain the treatment necessary to regain their quality of life.

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