Fibromyalgia

Overview: Fibromyalgia

Fibromyalgia is a common cause of pain that is spread throughout the body, affecting muscles, ligaments, and tendons. Outside of pain, Fibromyalgia may also be associated with fatigue, mood difficulties, and sometimes cognitive difficulties.

Fibromyalgia is relatively common, present in about 2 to 3 percent of people. The incidence tends to increase with age. It affects women more than men, typically between the ages of 20 and 55 years old.Other conditions tend to cluster with Fibromyalgia, including irritable bowel syndrome and migraine.

What causes Fibromyalgia?

In this condition, there is no direct evidence of inflammation in the affected tissues and there is no obvious structural abnormality. While this diagnosis has been controversial and a precise cause has not been identified, the latest research suggests that fibromyalgia is a disorder of pain regulation and processing. It is thought that the nervous system becomes over sensitized to pain signal input.

Features of Fibromyalgia

The fundamental symptoms of fibromyalgia include widespread pain for at least 3 months, fatigue, and sleep difficulties. These symptoms must not be explained by an alternative medication condition

  • Multi-site pain
    • Usually, at least 6 spots of the body have pain
    • This may include the legs, arms, chest, abdomen, back, neck, shoulders, and head
    • The pain may be perceived in the muscles or the joints
    • Common areas for tenderness on exam are the trapezius muscle, outside portion of the elbow, between the upper ribs in the chest, or the bony hip. There is no true swelling or redness.
    • Some criteria suggest the person must have pain in at least four of the following areas:
      • Left upper region: shoulder, arm, jaw
      • Right upper region: shoulder, arm, jaw
      • Left lower region: hip, buttock, leg
      • Right lower region: hip, buttock, leg
      • Axial region: neck, back, chest, abdomen
    • Fatigue
      • Even minor exertion or activity may result in fatigue
      • A person may feel unrefreshed even in the morning after quality sleep
    • Sleep difficulties
      • Sleep may be “light” with frequent waking during the early morning
    • Other symptoms
      • Other common symptoms include a mental “fog” mild cognitive impairment, depression, anxiety, headache, tingling sensation, or other non-specific symptoms

Diagnosis

A Neurologist will take a detailed history and physical exam. The provider will ensure that there is no alternative diagnosis that is causing the symptoms. At times, simple blood work may be pursued to rule out inflammatory conditions, rheumatoid arthritis, lupus, thyroid disease, or others. At this point, the diagnosis of Fibromyalgia can be met without necessarily needing other invasive or expensive testing. At times, referrals may be pursued with other specialists including Sleep Medicine or Psychiatry, if assistance is needed with addressing sleep difficulties or mood symptoms.

Treatment

In Fibromyalgia, the treatment is targeted at symptom control. This often involves medications and non-medication-based approaches. People with Fibromyalgia often benefit from a multidisciplinary treatment that is individualized to the particular case.

  • Patient Education
    • Patient education itself has been shown to improve quality of life and symptom control.
    • This includes educating the patient about the condition, explaining the concept of centralized pain processing, discussing various treatment options, addressing good sleep hygiene.
    • Many times, the education should also be provided to support people in the patient’s life, so that all are aware and involved.
    • The importance of movement and activity – such as with exercise – should be reinforced, as being inactive can worsen fibromyalgia symptoms.
    • Maladaptive behavior is actions that are in response to symptoms that may actually worsen the symptoms. People with Fibromyalgia are at risk for maladaptive behavior, such as catastrophizing the symptoms and having this make the pain or fatigue appear worse.
  • Cognitive behavioral Therapy (CBT)
    • CBT is a therapy program that can be done individually or in a group setting. This helps a person know how to best and most healthfully respond to fibromyalgia symptoms. CBT has been shown to be the most cost-effective treatment for fibromyalgia.
    • CBT can be helpful with stress management
  • Address co-existing conditions
    • Comorbidities, such as sleep or mood difficulties, headache, irritable bowel syndrome, or vitamin D deficiency may exist at high rates alongside fibromyalgia. These conditions have many similar risk factors and overlaying symptoms.
    • These conditions should be actively screened for and managed. If they are not found and treated, the fibromyalgia symptoms may not be improved as well.
  • Exercise
    • In inactive lifestyle has been associated with worse symptoms of fibromyalgia.
    • Low-impact aerobic exercise such as biking, swimming, water exercise, or walking may be most successful.
    • The person should be aware that muscle cramping or pain may be a part of effective exercise and does not mean that injury is being done.
    • Tai Chi or yoga may also offer benefit in fibromyalgia
  • Physical therapy
    • A supervised physical therapy program can help improve symptoms
  • Medications
    • Tricyclic Antidepressants (TCA) are generally the first line medications for fibromyalgia, as they offer pain control, can assist with sleep, and can help with mood difficulties. Options include Elavil, Pamelor, or others.
    • Other options include SNRIs (such as Cymbalta), anticonvulsants (such as Lyrica or Gabapentin), or muscle relaxers (such as Flexeril)
    • The Neurologist will take a detailed history, evaluate for comorbidities, and address possible side effects when tailoring the medical treatment
  • Complementary and Alternative medicine
    • Some complementary and alternative therapies can be considered with fibromyalgia
    • Acupuncture, massage therapy, yoga, and tai chi may be implemented
  • Referrals
    • While often able to be managed by a single provider, in some cases fibromyalgia may benefit from a multidisciplinary approach
    • This may include the Primary Care Provider, Neurologist, Rheumatologist, Psychiatry, Physical Medicine and Rehab doctor, and/or Pain Management specialist.

Prognosis

Fibromyalgia is a chronic life-long condition for which there are many treatments that can help control the symptoms. It is non-life threatening. It is not due to any underlying infectious or inflammatory process. While most people with fibromyalgia continue to have some degree of chronic pain and fatigue, many people can be effectively treated to continue to live productive and independent lives with quality of life.

Further Resources

https://www.cdc.gov/arthritis/basics/fibromyalgia.htm
https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia
https://www.niams.nih.gov/health-topics/fibromyalgia
https://www.mayoclinic.org/diseases-conditions/fibromyalgia/symptoms-causes/syc-20354780