What is Fibromyalgia?
Fibromyalgia is a condition of chronic widespread muscle pain. It is not inflammation. Studies show that 2-7% of the population have fibromyalgia. It is more common in women than men (9:1). Symptoms usually begin between 30-55 years of age and may start suddenly after a physical or psychological trauma, or begin insidiously over months to years. Fibromyalgia is a complex disorder with varying symptoms. This makes it a challenge for the physician to diagnose and frustrating for patients who may go years without a diagnosis after many tests and doctor visits.
The main symptom of fibromyalgia is pain. Most patients have overwhelming fatigue, difficulty sleeping and memory problems. Patients may also have morning stiffness, anxiety, depression, balance problems, bladder and bowel problems, restless legs syndrome, tingling or numbness. Patients may be very sensitive to noise, light, smells, chemicals (including medications) and extreme hot or cold environments.
Chronic Fatigue Syndrome has many overlapping symptoms to fibromyalgia, with the primary symptom of overwhelming fatigue (rather than pain in fibromyalgia).
Other diseases must be ruled out by the physician that have some of the same symptoms. A physical exam, blood tests and X-rays/CT scans are ordered and in fibromyalgia patients the routine test results are all normal.
The American College of Rheumatology developed diagnostic criteria for fibromyalgia which assist the physician trained in performing these tests in making the diagnosis of fibromyalgia.
Pain has been described as throbbing, shooting, bruised feeling, aching, burning, tingling, stabbing. It may be prolonged pain or very light touch to the skin may be painful.
There is evidence from research studies in the brain and spinal column of fibromyalgia patients showing an increase in chemicals that increase response to pain and a decrease in chemicals that decrease response to pain. The end result is neurotransmitter imbalance causing an increase in pain compared to people without fibromyalgia.
There is evidence from specialized radiology tests (functional MRIs and SPECT scans) in research studies that show changes in the blood flow to areas of the brain that process pain in fibromyalgia patients versus those without fibromyalgia. This data provides objective scientific evidence to support the pain patients have been describing to physicians.
Fibromyalgia patients may describe waking up in the morning feeling more tired than when they went to bed. Repeated nights of poor sleep leads to sleep deprivation that exacerbates the pain and memory impairment.
Sleep studies show that fibromyalgia patients have little or no time in stage 4 (deep sleep) that provides restorative sleep. Throughout sleep, alpha brain waves interrupt deep sleep.
Poor memory or “fibro fog” is common in fibromyalgia patients. Patients may not be able to multi-task as before, may be easily distracted, and forget what they were going to do, forget a word mid-sentence.
Research studies indicate that working memory tests are performed much more poorly compared to age-matched non-fibromyalgia people.
Management of Fibromyalgia
There is no “cure” for fibromyalgia. Management involves a combination of lifestyle changes, non-medication interventions and often medications for pain and sleep. The goal is to improve daily function. Since each patient has differences in their pain and sleep patterns, each patient may respond differently to specific therapeutic interventions.
An internet survey of over 2500 fibromyalgia patients listed what helped them the most in descending order as follows; rest, heat modalities, prescription pain medications, prescription antidepressants, prescription sleep medications, prayer, massage and pool therapy.
The scientific evidence indicates exercise and cognitive behaviour therapy (CBT) are effective interventions. Aerobic exercise must be suited to the fibromyalgia patient. Start small and increase exercise very slowly. Sticking with a routine exercise program improves well-being and physical function. CBT teaches the patient how to think differently about their pain. It therefore affects how to respond to pain. This improves function and decreases pain.
Lifestyle changes are very effective and can be the hardest to implement. With chronic pain there are good days and bad days. It is natural to overextend oneself on good days to compensate for what did not get done on the bad days. But, this usually results in increased pain and fatigue when you have overdone it. One has to learn to listen to what your body is telling you and PACE your activities. Relaxation techniques and stress management, plus eating a healthy diet and adopting a regular sleep routine are very helpful.
Learning what you can about fibromyalgia gives you power and some control. Be wary of internet promises for a “cure” since no cure has been scientifically found in research studies.
Drug Interventions for Pain
The goal is to make pain more manageable and increase physical function to be able to do what you want to do. No drug will take the pain away completely. The type of pain in fibromyalgia has some similarity to nerve pain (neuropathic pain). Medications trialled in fibromyalgia patients have included medications that have been found effective in nerve pain.
The fibromyalgia patient should start with a very low dose of a new medication one drug at a time. The dosage is increased slowly as the patient tolerates it. This will minimize side effects and help determine if the drug is helping decrease pain.
Antidepressants work to decrease pain in fibromyalgia patients by increasing the chemicals (neurotransmitters) which are altering the perception of pain. By modifying these neurotransmitters the sensation of pain is decreased. These effects are separate from the drugs antidepressant effects.
Tricyclic antidepressants such as amitriptyline, nortriptyline, imipramine, doxepin have shown in scientific studies to improve pain and fatigue. Unfortunately this group of drugs have significant side effects. This may include sedation (take at night), decrease in blood pressure, serious heart problems, dry mouth, constipation and retention of urine. Sometimes switching to a different tricyclic may help. Some patients should avoid or use these drugs cautiously. Discuss with your doctor which drug is best for you.
Serotonin-Norepinephrine-Reuptake-Inhibitors such as venlafaxine and duloxetine have been proven effective in scientific studies to reduce pain and fatigue. They are often better tolerated. Side effects may include nausea (take with food), dry mouth, sedation, dizziness, and high blood pressure. Discuss with your doctor what is best for you.
Anticonvulsants gabapentin and pregabalin work as pain-relievers (analgesics) separate from their ability to treat seizures. They work in the brain by decreasing neurotransmitters that increase pain. By blocking this release the pain pathways are altered in the brain to reduce perception of pain.
These drugs have shown in scientific studies to improve pain and fatigue. Side effects of gabapentin may include dizziness, sedation, weight gain and double vision. Pregabalin side effects may include dizziness, sedation, and dry mouth, weight gain, swelling of the hands and feet, and blurred vision. Starting with a low dose and increasing the dose once a week may decrease the side effects.
Discuss with your doctor.
Tramadol works to relieve pain by increasing neurotransmitters in the brain and has weak opioid effects. In a fibromyalgia study where it was combined with acetaminophen as Tramacet® patients showed decreased pain and improved physical function. Side effects included nausea, sedation, dizziness and constipation. Use cautiously in patients with seizures. Discuss with your doctor.
Opioids have shown inconsistent results in fibromyalgia patients. In some patients they are effective in decreasing pain. Discuss this option with your doctor.
Drugs interventions for sleep
Repeated, disrupted, non-restoring sleep is common and increases pain. Zopiclone is a sedative that has shown in scientific studies to improve sleep and decrease fatigue. Side effects may include dry mouth, bitter taste and hangover of sedation. Sodium oxybate is a very strong sedative, new on the market which has been shown effective in improving sleep, pain and fatigue in fibromyalgia patients. Side effects may include headache, nausea, dizziness, tiredness, pain and dependence. It works very quickly and doses must be taken when already lying in bed. Discuss these options with your doctor.
Researchers are getting closer to understanding the cause/s of fibromyalgia which will bring more specific effective drug therapy. Non-drug therapy is paramount to managing fibromyalgia effectively.
Janice E. Sumpton RPh., BScPhm. March, 2009