Fibromyalgia: Symptoms, Causes, Diagnosis, Treatment
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1. Symptoms
Widespread pain is a chronic pain experienced in the musculoskeletal system which lasts for more than 3 months. Pain and aching are commonly widespread and diffuse and migrates to all parts of the body. Discomfort may intensify at night and may be aggravated by fatigue or weather changes. The patient may experience a deep ache, shooting pain, burning sensation, or intense or unbearable pain in some areas. The degree of severity and the fluctuation of pain may cause the patient to be anxious or depressive and can lead to long-term use of medications such as analgesics and NSAIDs. Fibromyalgia pain and stiffness are often most notable in the morning; that said, morning stiffness and aching are common symptoms that are not restricted to age or gender. Stiffness can vary from mild to very severe and may last from a few minutes to several hours, which restricts movement and flexibility. Joint swelling is not seen, but the stiffness can be so severe that it is mistaken for inflammation of the joint and muscles. Fatigue can be described as a frequent, unrelenting, and unpredictable overwhelming feeling of tiredness, weakness, or exhaustion. At times, fatigue is more of a problem than pain for fibromyalgia sufferers. It affects the patient mentally, physically, and emotively. In most cases, an increased malaise or tiredness is noted after physical or mental exertion. This symptom is connected very closely with disturbances of sleep and will be explored further next.
1.1. Widespread pain
The degree of severity and the impact of fibromyalgia pain are quite variable. Some patients may experience extreme pain and have difficulty performing daily activities, while others may experience moderate pain and still be able to function. It is rare in fibromyalgia for there to be days when there is no pain at all. Fibromyalgia pain is often more noticeable in the morning and late evening. It may be affected by changes in the weather. People with fibromyalgia tend to tire very easily. When the body is pushed beyond its physical limitations, pain and fatigue often intensify.
The cardinal symptom of fibromyalgia is chronic, widespread, diffuse pain. It is described as a deep muscular aching, throbbing, shooting, stabbing, or intense burning. The pain is generally widespread involving both sides of the body. Pain may vary in intensity and location. It may be localized to one or more areas or it may be widespread. Localized to one or more areas is usually described in terms of tender points, which are localized areas of pain and tenderness found in the soft tissue around joints. Though the tender point examination is one way to examine the widespread nature of the pain, not all pain is in the vicinity of a tender point. Tenderness is pain or discomfort when pressure is applied to an area. When a person experiences pain all over (both above and below the waist, and on both the left and right sides of the body) for at least 3 months, it is said to be widespread. This is the important identifying feature.
1.2. Fatigue
Physical, mental, and emotional fatigue in fibromyalgia are closely knit together. Ideally, the body performs physical work using energy that is produced from muscles. Muscle energy is finite and is replaced as it is used. When there is a decrease in muscle energy, fatigue occurs. In fibromyalgia, up to 90% of energy is used to replace muscle cells because of a suboptimal defect in energy metabolism. This decreases the effective energy supply for muscles and produces a sensation of profound physical tiredness. Initial amounts of regular exercise can increase fitness and decrease muscle energy utilization. However, if exercise intensity and repetitions are increased, over-exertion and post-exercise fatigue are still likely to occur. The increased fitness level or "work capacity" attributed to most people after a six-week exercise program is much less in fibromyalgia patients due to their inability to activate anaerobic energy metabolism. Although regular moderate aerobic exercise is beneficial, exceeding the anaerobic threshold and attempting high-impact or strenuous anaerobic exercise will worsen symptoms. Mental and emotional fatigue will be discussed further in subsequent sections.
Fatigue occurs in 90% of patients and is one of the most profound characteristics of fibromyalgia. Patients may be quite vigorous, active, and involved in life before the onset of fibromyalgia, but afterwards they may feel as if their arms are too heavy to lift and their legs are like lead. Whole body fatigue, which is experienced as tiredness or a flu-like illness, can be quite devastating. Many patients compare it to the fatigue of a late-stage cancer patient. This type of fatigue does not improve with rest and sleep and can be quite unpredictable in its intensity. At times, patients may feel very energetic in the morning and by afternoon be too fatigued to do simple daily tasks. When fibromyalgia patients say they feel "tired," that word does not adequately convey the severity of the fatigue.
1.3. Sleep disturbances
Sleep is essential for overall health and wellbeing. During sleep, the body repairs and regenerates tissues that have been damaged during the day, synthesizes proteins, and releases hormones that are vital to health. It is generally recognized that people with fibromyalgia have intensified symptoms such as pain and fatigue. Fibromyalgia patients often sleep for long periods of time but do not feel rested when they wake up. This is due to light and fragmented sleep. Studies show that compared to the normal population and chronic pain patients, fibromyalgia patients have an abnormal sleep EEG pattern. During the first few sleep cycles, they have an increase in low-frequency delta waves. This suggests light sleep. Also, these patients frequently wake up, particularly when the body transitions from one sleep cycle to another. Often patients are unaware that they are waking up so much during the night, but they become aware of it when these arousals are associated with muscle spasms or pain. An Italian study by Salaffi et al. has found that sleep quality contributes to the severity of fatigue and cognitive dysfunction in fibromyalgia patients. Also, measures of sleep quality correlate with overall disease severity. Since non-restorative sleep affects so much of the later function of fibromyalgia patients, it has been the target of treatments of various medications and cognitive-behavioral therapy measured by sleep improvement and affect on disease severity.
1.4. Cognitive difficulties
Cognitive function has to do with the mental process of thinking, reasoning, and remembering. Most patients with fibromyalgia suffer from mild to moderate cognitive disturbances. Cognitive difficulties in fibromyalgia may be described as "fibro fog" due to the clouding of thought processes. A person may be more forgetful, become easily confused, have difficulty concentrating, and have problems finding the right words to say. Patients often say they have memory problems and cannot think as clearly as they once did. Cognitive difficulties are often more distressing than pain to the patient and can disrupt normal daily activities. Changes in the levels of the hormones serotonin and noradrenaline in fibromyalgia can directly affect cognitive function. The prevalence, ranging from as low as 23% in some studies to as high as 70% in others, may be a distinct feature of fibromyalgia since other chronic pain conditions do not appear to share the same problem to the same degree. There is evidence to suggest that cognitive disturbances in fibromyalgia patients are associated with functional disability and overall psychophysical functioning.
1.5. Headaches
People with fibromyalgia often suffer from headaches and facial pain. These headaches may be the result of muscle tension in the back of the neck and scalp. They can also be the result of the nerves in the brain becoming overly sensitive to pain stimuli. There are two main kinds of headaches which are classified as being "migraine" or "tension-type" headaches. Tension-type headaches are the most common and are usually on one side of the head. They produce a steady, aching pain that is often described as a band-like sensation around the head. Tension-type headache pain is usually mild to moderate, but can be severe. This contrasts with migraine headaches which are less common and usually occur in conjunction with other migraine symptoms. The pain of a migraine headache is usually more severe and is a throbbing pain felt on one side of the head. Sensitivity to light or sound, nausea and vomiting may also accompany the pain, hindering the person's ability to go about their daily activities. Fibromyalgia sufferers meet the classification of either migraine or tension-type headaches and it is these headaches, which are often a major cause of work absenteeism.
2. Causes
Environmental stressors may intensify fibromyalgia symptoms and also contribute to the development of the disorder. Physical or emotional trauma and posttraumatic stress disorder have been noted as precipitating fibromyalgia. The American College of Rheumatology has cited that there is evidence to suggest that patients with fibromyalgia often recall a physically or emotionally traumatic event prior to the onset of the illness. This could change the way in which medical practitioners perceive and diagnose fibromyalgia, taking a more trauma-focused approach. Physical trauma may result in localized or widespread pain which may later develop into fibromyalgia. This could be the result of injury to the body causing abnormal pain processing and the change from acute to chronic pain. Emotional stress may cause psychosocial and behavioral abnormalities in patients, which may lead to the development of fibromyalgia. The stress may cause changes in hormone levels, further affecting the behavior and perception of pain. Life-altering events such as stress at work or motor vehicle accidents can result in disability and financial burden on an individual, which often accompanies fibromyalgia. By studying how environmental factors affect the development and intensity of fibromyalgia, it allows for a better understanding of the changes in the health of those affected and may bring about methods to prevent the occurrence of the disorder when at risk of such stressors. An example may be avoiding an increase in pain through injury or implementing stress-reducing approaches in stress/trauma to lessen the predisposition and intensity of fibromyalgia.
According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, fibromyalgia can be hereditary; therefore, genetic predisposition could account for the causes of the disorder. Studies have found that there is a high concentration of fibromyalgia in families, so if an individual has relatives with the disorder, they are more likely to contract it. It has been shown that genetic factors may affect the way in which the individual with fibromyalgia feels pain. Research has provided significant support for the hypothesis that there are genes which directly contribute to the development of fibromyalgia. This theory could be significant in that it may lead to further understanding and treatment of the disorder.
2.1. Genetic factors
The genetic determinants of fibromyalgia remain unclear, but several research groups are currently attempting to elucidate the genetic factors that contribute to the development of fibromyalgia. Investigators suspect that repeated painful stimuli or persistent stress may cause the body to change in the way it perceives pain. This can lead to a memory of the pain response in the central nervous system that can result in chronic pain (referred to as neuro-endocrine stress response). This response can cause a change in the levels of certain neurotransmitters and neurohormones (substances that affect the function or activity of nerve cells) and cause the pain signal to be amplified. It is felt that this change in the neuro-endocrine and neurotransmitter/hormone levels can lead to a disturbance in the sleep cycle and can cause the conditioned pain response to be triggered by anything that is associated with a previous painful stimulus. This may start a vicious cycle of pain and fatigue and cognitive dysfunction, and the beginning of fibromyalgia. Although not specific to genetics, this theory can explain how certain environmental factors or physical or emotional trauma can lead to the development of fibromyalgia. It is quite possible that genetic factors can determine who is susceptible to developing the neuro-endocrine response and/or the conditioned pain response. If these people were exposed to certain stressors that result in the above mentioned changes, then it could lead to the development of fibromyalgia. But again, this is only a theory.
2.2. Environmental factors
The development of fibromyalgia as a result of a history of chemical exposure is a topic not heavily looked into but does present interesting possibilities. Endocrine disruptor chemicals are foreign chemicals that interfere with the body's natural hormones, causing adverse developmental, reproductive, neurological, and immune effects. A study by Bellato et al. notes the significant overlap in symptoms between fibromyalgia and various endocrine and hormonal abnormalities, suggesting a possible link.
Exposure to climate and weather changes have also been implicated as contributing factors. Often patients report increases in symptoms during damp or cold conditions. While there is a lack of scientific evidence in this area, a Swedish study exploring the effects of climate on pain in rheumatoid disorders found patients eliminated from a colder, high barometric pressure climate to a warmer, low barometric pressure climate experienced a reduction in perceived pain. This may have implications for fibromyalgia sufferers given the shared symptom of widespread pain.
Stress has been identified as a possible influential factor. Studies in this area, although not specific to fibromyalgia alone, have highlighted the significance of certain major life events. It is apparent that stressful episodes act as triggers which initiate the condition. A study by Clark et al. identified a series of stressful events often associated with the onset of symptoms such as injury, infection, surgery, or the death of a loved one. Dohrenbusch and Berking conducted an experiment comparing sufferers of fibromyalgia with a controlled group to measure the influence of stress and emotion on pain perception. After exposure to a stressful film, patients reported an increase in pain perception in comparison to the controlled group.
2.3. Physical or emotional trauma
There are several environmental factors which have been considered as contributing to the development of fibromyalgia in some people. Post-traumatic physical or emotional events are believed to initiate the development of fibromyalgia in some people. An example of a physical event would be a car accident, especially if it resulted in serious injury and/or chronic pain. A psychological trauma could also predispose to the development of fibromyalgia. One study found that women with a history of repeated sexual abuse in childhood were more likely to develop fibromyalgia than women without such a history. Starting of the fibromyalgia symptoms after a specific traumatic event is known as Etiopathogenesis Delayed onset fibromyalgia. This occurs when fibromyalgia symptoms start after a person has had localized pain in one or more areas due to an event such as surgery, injury, or an episode of joint or muscle inflammation. The person may have continued to have pain in these areas and be more fatigued than usual in the weeks to follow. In some people, this will have triggered the development of fibromyalgia. An alternate form of etiopathogenesis delayed onset fibromyalgia is when a person has had a slow and gradual development of fibromyalgia symptoms without a specific triggering event. An example of this would be an elderly patient with osteoarthritis which changes to general widespread pain and a decline in functioning. Osteoarthritis is considered a type of localized rheumatic disorder and frailer elderly patients with osteoarthritis are more likely to develop fibromyalgia.
The causes of fibromyalgia are currently unknown, although various hypotheses have been proposed. The outline below lists some of the more common ideas on how people may have developed fibromyalgia. As of yet, there have been no studies to prove or disprove any of these ideas. Many researchers feel that fibromyalgia is most likely due to a variety of different factors working together. A genetic predisposition for the disorder is one likely factor as fibromyalgia tends to run in families. In speaking of a genetic predisposition, this is to say that a combination of genes that are necessary for the disorder are passed from parents to their children. In and of themselves, these genes wouldn't cause the disorder, but when combined with other as yet unknown factors would.
2.4. Abnormal pain processing in the brain
Primarily, out of all the abnormalities in pain processing, the most convincing is the theory for central sensitization. This theory states that those with fibromyalgia have a lower threshold for pain because of increased sensitivity in the brain to pain signals. Normally, there is a certain amount of stimuli that is required in order to trigger the "feeling of pain". This is why a light touch would not be considered painful. In fibromyalgia patients, the degree of brain response to pain and the degree of pain intensity are much higher than the amount of stimuli would produce, and often equivalent to that of a higher pain stimulus. This increased sensitivity would explain the widespread pain and multiple tender points experienced in fibromyalgia. Central sensitization is shown in experimental models for pain where the state of the animal and the level of pain do not match the condition, usually being more severe. This is proved by showing that the animal's pain threshold is lowered. In a person, central sensitization would create a great amount of discomfort and pain, as if there were no escape from a pain stimulus.
Small amounts of stimuli can cause severe pain in another theory called central sensitization. Increased blood flow in the brain areas that process pain has been associated with fibromyalgia and may contribute to the symptom of continuous deep muscle pain in the form of poorly localized aching and discomfort. This is complementary to the feeling of pain and tenderness at specific points on the body, known as tender points, which has been localized to those who are affected. Though there is no one cause of fibromyalgia, you can see how the sum of these abnormalities would produce an ongoing cycle of pain.
2.5. Hormonal imbalances
Sleep disturbances are quite common in fibromyalgia and can often be linked back to hormonal imbalances, especially the interruption of deep level sleep. Since this is the stage where the body mends and repairs itself, un-refreshing sleep can cause patients to experience morning stiffness and aching. A sleep cycle that is often disturbed by frequent awakenings can lead to a pattern of night and day reverse. This can be why a number of individuals with fibromyalgia have a hard time getting to sleep at night and tend to be more active during the late hours of the night.
Symptoms involving hormonal imbalances can be vast. This may be one reason why fibromyalgia patients experience such a wide variety of symptoms and why it may be misdiagnosed. Symptoms caused by hormonal imbalances usually mimic those symptoms found in patients with hypothyroidism, including unusual fatigue, inability to cope with stress, depression, cold intolerance, and a feeling of being low in energy. A high percentage of individuals with fibromyalgia also have symptoms of irritable bowel syndrome, which may be related to abnormalities with the release of various gastrointestinal hormones. This can cause disturbance in bowel functioning and motility, as well as pain.
Hormonal imbalances are often identified in both men and women with fibromyalgia. Such imbalances involve the lack of certain hormones and the failure to regulate hormone release. Several hormones have been tested and are found to be abnormal in fibromyalgia. These would include cortisol, the chief hormone the body uses to manage stress. Growth hormone, the regulator of protein synthesis and the repair of the body which occurs mostly during sleep. Several hormones produced in the pituitary and adrenal glands, plus various neurotransmitters which can affect hormonal levels in the bloodstream have also been detected.
3. Diagnosis
Physical examination can help to further this diagnosis. Studies have found that patients with fibromyalgia often have several abnormal pain responses. This can include an increased sensitivity to painful stimuli, a heightened awareness of pain-related body sensations and a lower tolerance to pain. Patients may also undergo testing to rule out other conditions with similar symptoms.
Medical history can provide some very important clues. Many patients with fibromyalgia report having widespread pain that has been present for a duration exceeding three months. They also report having experienced a number of symmetrical and systemic symptoms. These include sleep disturbances, fatigue, irritable bowel symptoms, headaches and difficulties with memory or concentration. Finally, many fibromyalgia patients recall a specific "triggering" event such as a physical trauma or an illness. The effects of these events often lead into the onset of fibromyalgia.
Fibromyalgia is traditionally diagnosed following a thorough examination to rule out other conditions. Because there are no visible clues to the illness, diagnosis can be rather complicated. As a result, doctors often misdiagnose fibromyalgia. The American College of Rheumatology has established some diagnostic criteria. According to these criteria, a person is considered to have fibromyalgia if they have widespread pain in combination with pain in at least 11 of 18 possible tender point sites. These sites are located all over the body and when pressure is applied with just enough force to cause blanching of the fingernail, the patient expresses pain. Unfortunately, this criterion is still far from foolproof. Fibromyalgia can be diagnosed in a simpler manner, as to save a patient time and money.
3.1. Medical history evaluation
Doctor must first write down a detailed description of the pain, its location, intensity, duration, and factors that make it better or worse. Other symptoms, sleep patterns, depression and stress levels, and response to previous treatments are noted. This is to know what the widespread body pain is and also the associated symptoms. It is said that the pain in fibromyalgia is always chronic. It is diagnosed after 3 months to know that the pain is not because of another or underlying disease. The check for widespread body pain can be done by asking the patient if there is pain in their upper torso (for example, chest or abdominal pain) and lower torso (for example, the back). The pain on the left and right side of the body is also taken into account. Since most patients are known to have some sort of sleep disorder, it is important to ask for detailed sleep-related symptoms. Fibromyalgia patients have stiffness, fatigue, and poor quality sleep. There is a pattern of multiple un-refreshed sleep at nights. Patients usually wake up tired in the morning, with fatigue and stiffness. It can be due to a primary sleep disorder or depression. However, this can also happen in many other diseases. The history of widespread body pain and the associated symptoms will help to differentiate fibromyalgia from others. This is important since fibromyalgia is a diagnosis of exclusion. The patient's mental status is also evaluated because of its high association with major depression or other affective disorders. Fibromyalgia can also be associated with anxiety and panic attacks. Since these symptoms might come from major depressive disorder, it is important to differentiate depressive disorder from pain disorder.
3.2. Physical examination
It is important for a physician to understand the lack of physical findings on examination and the possible negative attitudes towards fibromyalgia patients. A lack of palpable abnormalities may lead to a physician doubting a patient's credibility, particularly when the patient is complaining of severe or widespread pain. This, in turn, can lead to the patient and doctor becoming disillusioned with the consultation. It is necessary to secure a good patient-physician relationship, with the physician showing understanding, empathy, and active listening skills to the patient, and an explanation to the patient on the nature of fibromyalgia and its diagnosis. This will encourage a patient to continue to seek help for their problems on future visits and continue with treatment. A patient-physician relationship involving a patient who always seeks another opinion is likely to cost the healthcare system more money and is not beneficial to the patient who will continue to be passed from physician to physician and very likely to undergo unnecessary tests on various other diagnoses.
A physical examination of a patient with fibromyalgia fails to show any specific abnormality, as opposed to other medically classified disorders. Patients appear to be well, and the physical examination is usually normal, which often leads to a physician concluding that a patient's pain is not real or is psychological in nature. The examination may show signs of associated or coexisting disorders such as hypothyroidism or rheumatoid arthritis. These should not be considered to be the cause of the pain, and if the fibromyalgia is treated, it is likely that these other conditions will improve.
3.3. Tender points assessment
The method of assessment is a systematic one to ensure that the examination is thorough and a generalized response to the pain. Use light palpation over the site and then sequentially increase the force of palpation. The patient must confirm that it is their familiar pain and not just a painful response to increasing force. It is also useful to elicit a pain response from a normal non-tender point area to compare it with the level of pain at the tender point being assessed. This minimizes false positive responses. Keep a body chart of the patient for future reference. The examiner should repeat the site palpation as fibromyalgia pain can be intermittent. The few replication steps are important with pressure at both right and left sides of the body, and the above steps are repeated at each tender point site.
This is an essential part of the physical examination for the patient with fibromyalgia. The manual tender point assessment is very easy to do, but the important point is to follow the exact criteria of what consists a tender point in fibromyalgia. The physician must ascertain this and not diagnose just by the presence of pain on light palpation. For those who are not experienced with fibromyalgia patients, it may be helpful to undergo training from a physician who is familiar with the criteria. A brief summary of the criteria for a tender point is localized pain when a 4kg force is applied to the site, and the patient must confirm that the pain is familiar to their usual pain.
3.4. Blood tests
The healthcare provider may want to order a blood test to help make a more accurate diagnosis of fibromyalgia, and to rule out other possible health conditions. There are two common blood tests in use for fibromyalgia, these include the erythrocyte sedimentation rate test and the rheumatoid factor test. The erythrocyte sedimentation rate test is a test which is used to detect the degree of inflammation in the body. A blood sample is taken and studied to see how fast the red blood cells fall to the bottom of a test tube. The faster they fall, the higher the rate of inflammation - although this can be anything from an infection, to arthritis, or it can even be an indication of immune system activity. Many of the overactive immune system manifestations shown in fibromyalgia are not thought to produce an abnormal erythrocyte sedimentation rate result. Usually this test is negative or normal in patients with fibromyalgia. The rheumatoid factor test detects the presence of an antibody which is often secreted by the immune system in rheumatoid arthritis patients, but can indicate the presence of other immune system activity which may be evidenced in a range of other health conditions. The majority of patients with fibromyalgia have a negative rheumatoid factor test, and since this is also often negative in other immune system activity manifestations, a positive result provides little real information with regards to diagnosis.
3.5. Rule out other conditions
General physicians and internists are more apt to give the diagnosis of fibromyalgia than rheumatologists, and this is probably a reflection of the safer diagnosis strategy when unique features may not have yet appeared. This is also probably because a positive clinical diagnosis can generally be made, and specific tissue imaging or laboratory tests are frequently normal or negative. General medical practitioners may not differentiate fibromyalgia from myofascial pain syndrome, which is also due to multiple muscle and soft tissue trigger points but is remediable and, in most cases, curable by treatment. Fibromyalgia is considered more of a functional somatic syndrome, and irreversible chronic phase myofascial pain syndrome can be difficult to distinguish from regional fibromyalgia. Fibromyalgia can sometimes masquerade as various conditions, including multiple regional musculoskeletal disorders and incipient systemic rheumatic disorders. Malignant disease has been simulated, characterized by profound fatigue, weight loss, and diffuse pain. Ali has discussed how fibromyalgia can undercut the true disease status and produce illness by affect. Fibromyalgia may impersonate hypothyroidism; it has been suggested that systemic symptoms are due to hypothalamic-pituitary dysfunction in a mode similar to non-thyroidal illness. Fibromyalgia may also offer a positive diagnosis at times. In a recent study of patients referred to a rheumatologist because it was believed they had rheumatoid arthritis, 30% fulfilled criteria for primary fibromyalgia syndrome while seronegative or undifferentiated connective tissue disease. In an ethnically variant and social security-minded society, the patient may suspect or the physician may consider the possibility of compensation-related malingering. Fibromyalgia is a disability affecting work capability and job loss through functional physical limitations; in sum, it is vital that the diagnosis be correctly and humanely given. The diagnosis of fibromyalgia is commonly associated with a considerable number of coexisting conditions which further compound the clinical picture. Ali has discussed how fibromyalgia can undercut the true disease status and produce illness by affect. Fibromyalgia may impersonate hypothyroidism; it has been suggested that systemic symptoms are due to hypothalamic-pituitary dysfunction in a mode similar to non-thyroidal illness. Fibromyalgia may also offer a positive diagnosis at times. In a recent study of patients referred to a rheumatologist because it was believed they had rheumatoid arthritis, 30% fulfilled criteria for primary fibromyalgia syndrome while seronegative or undifferentiated connective tissue disease, which is characterized by nonspecific symptoms and slow evolution.
It is helpful to the patient to be reassured by a well-informed physician that their symptoms are not attributable to a possibly progressive or destructive disease that requires specific treatment. No important difference was found when comparing the diagnosis made by a rheumatologist and the family practitioner. One in six of the rheumatologist's diagnoses was fibromyalgia, compared with one in eight for the family practitioner. On the other hand, the family practitioner was less likely to diagnose rheumatoid arthritis. Diagnostic agreement between the patient and their own family physician was moderate at best, reflecting the complexity and lack of diagnostic markers in this syndrome. The diagnosis of fibromyalgia is usually made by the family practitioner and only referred to a rheumatologist if difficulties or uncertainties arise. One survey showed that general practitioners were poorly informed about this syndrome, but another showed that both general practitioners and specialist physicians are equally knowledgeable.
4. Treatment
After the diagnosis of fibromyalgia, the first step in treatment is education. This is an important aspect in empowering patients to learn effective self-management skills. Education should address the nature of the problem, the biological, psychological, and social consequences of the symptoms, the patient's concerns, and the potential for coping and learning. Information and treatment recommendations should be relayed in a supportive manner, and healthcare providers should help patients identify treatments that are realistic, affordable, and that will help improve their quality of life.
The identification, treatment, and acceptance of fibromyalgia have links to different health professionals and other patients. In diagnosing, a common way to determine disease cause and progression is through the use of cognitive interviews. Healthcare providers use this type of interview to assess any changes in one's cognitive function and to help better understand the patient's symptoms and monitor the effects of treatment. It also helps in disease progression to identify days when certain symptoms are worse. This type of data is meaningful and in the long run can be used as markers in assessing treatment effectiveness. Cognitive interviews carry much significance as they help establish clinical meaning. This data can also be correlated with daily logs of pain and symptoms. An example of a daily diary provides information that is useful in determining treatment effectiveness and disease progression. Fibrocenter is a web-based tool that is a self-report assessment developed from the cognitive interviews with the intent of monitoring symptoms, progression, and treatment outcomes for healthcare providers.
4.1. Medications
Dopaminergic agents: Dopamine is a neurotransmitter in the brain that is involved in controlling movement and aiding the flow of information to the frontal lobe. Gabapentin is thought to increase levels of dopamine in the brain, and there is evidence to suggest that increasing dopamine function can help to improve pain and other symptoms in patients with fibromyalgia.
Pregabalin and gabapentin: Pregabalin is an anticonvulsant drug that was the first medication to be approved by the US Food and Drug Administration specifically for the treatment of fibromyalgia. The exact way in which these medications work is not fully understood, but it is thought they calm overactive pain signals in the brain. Both medications have been shown to be effective in reducing pain, improving sleep quality, and fatigue and are now considered a first-line treatment for fibromyalgia. Side effects of pregabalin and gabapentin can include dizziness, drowsiness, weight gain, and edema.
Antidepressant drugs: There are a number of antidepressant medications that can be used in the treatment of fibromyalgia. Antidepressants are used in smaller doses than when treating depression and are thought to work by increasing the levels of certain neurotransmitters in the brain. Tricyclic antidepressants such as amitriptyline at doses of between 10-75mg per day have been shown to be effective in treating pain, fatigue, and sleep disturbance. Selective serotonin reuptake inhibitors (SSRIs) may also be used in treating fibromyalgia and can help to improve mood, pain, fatigue, sleep quality, and cognitive function. Serotonin and noradrenaline reuptake inhibitors (SNRIs) are a newer form of antidepressant that has been found to be useful in the treatment of fibromyalgia by acting on both serotonin and noradrenaline. Studies have shown that duloxetine and milnacipran can help to improve pain, mood, fatigue, sleep, and cognitive function in patients with fibromyalgia.
4.2. Physical therapy
Physical therapy is often helpful for people with fibromyalgia. Physical therapists are trained to help people with musculoskeletal problems. Often, fibromyalgia patients have damage to the muscle and tissue around a joint. The muscles can be a source of tremendous pain in fibromyalgia, and they can also cause many joint problems. A physical therapist can help you strengthen the muscles to help the joint and take away the pain. Physical therapy will use a combination of exercises, massage, and avoidance of trigger points. It is important to find a knowledgeable physical therapist, one who is knowledgeable about trigger points and fibromyalgia. If done too aggressively, physical therapy can cause a flare-up in pain and fatigue for a fibromyalgia patient. A knowledgeable physical therapist will know when your body has had enough and act within your limitations. Unfortunately, finding a good physical therapist can be difficult. But perseverance can pay off with a decrease in pain and an increase in functioning.
4.3. Exercise and stretching
You should start slowly and gradually increase the frequency and duration of the exercise. Do not overdo it. It is important to strike a balance between exercise and not exercising. Usually, stay at each stage for a week before increasing exercise activity. If you experience moderate to strong pain that lasts for an hour after the exercise, you have done too much. Decrease the exercise and increase it again in the future but at a slower pace. You should always exercise to your own ability. Do not be persuaded by family or friends to exercise more than you are able to. This will only make symptoms worse.
Gentle forms of exercise may include walking, swimming, cycling, or aquaerobics. During the acute phases when pain and fatigue are at their worst, gentle stretching can be helpful. Tai chi is a form of exercise based on the eastern philosophy of the movement of the body and has been found to provide pain relief and fatigue for some fibromyalgia sufferers. Yoga is a gentle form of exercise that consists of specific postures, which help mobility, flexibility, and strength. It may also bring about a sense of feeling relaxed while improving pain and mental function in some fibromyalgia sufferers. Tai chi and yoga are often available at community colleges or adult education centers. They are taught in almost every large city in the country and neither has an age limit. If you can, begin with a beginner’s class. Approach the instructor after class and talk about fibromyalgia. Instructors are often willing to modify their teaching methods in order to help individual students.
Exercise can improve fitness, reduce pain, and improve the quality of sleep. It may also increase pain tolerance and mental function. Thus, many people with fibromyalgia try to maintain a regular program of gentle exercise.
4.4. Stress management techniques
Stress does not cause fibromyalgia. Pain and fatigue are part of the disease process and ongoing. When pain and fatigue are relentless, it is difficult to deal with the daily stress of life. The added stress makes symptoms worse and creates a vicious cycle. It is important for people with fibromyalgia to avoid or limit added stress whenever possible. Although not all stress is avoidable, it is possible to change reactions to stress. The biggest obstacle for all people is changing their personal understanding of stress. Understanding stress is an important aspect of stress management. Cognitive therapy and/or insight therapy can be helpful with this. Learning skills such as time management and relaxation techniques have the potential to change harmful stress behaviors. Techniques such as psychotherapy, massage, self-hypnosis tapes, and deep breathing exercises can also be beneficial in reducing stress. When stress is reduced, symptoms are known to improve.
4.5. Complementary and alternative therapies
Some common forms of mind and body techniques include: - Deep breathing exercises. - Progressive muscle relaxation. - Meditation. - Yoga. - Prayer. - Use of imagery.
Relaxation techniques. Many people with fibromyalgia turn to mind and body techniques for relaxation and stress reduction. These techniques help them cope with the pain and other symptoms.
Some people with fibromyalgia also consider turning to complementary and alternative therapies to help relieve their symptoms. When the treatments are used in combination with your traditional medicine treatment plan, it's called complementary medicine. The techniques are deemed alternative when they are used instead of traditional medicine. Researchers are studying how safe and effective some of these therapies are so they can better understand if they can help people with fibromyalgia.