The Facts about Fibromyalgia

Fibromyalgia syndrome is a common, chronic disorder characterized by widespread muscle pain, fatigue, and multiple tender points. Tender points are specific places on the body - on the neck, shoulders, back, hips, and upper and lower extremities - where people with fibromyalgia feel pain in response to slight pressure. In addition to pain and fatigue, people who have fibromyalgia may experience:

• sleep disturbances
• morning stiffness
• headaches
• irritable bowel syndrome
• painful menstrual periods
• numbness or tingling of the extremities
• restless legs syndrome
• temperature sensitivity
• cognitive and memory problems
• a variety of other symptoms

Fibromyalgia is a syndrome rather than a disease. A syndrome is a collection of signs, symptoms, and medical problems that tend to occur together but are not related to a specific, identifiable cause.

According to the American College of Rheumatology (ACR), fibromyalgia affects 3 to 6 million (as many as one in 50) Americans. For unknown reasons, between 80% and 90% of those diagnosed with fibromyalgia are women; however, men and children also can be affected. Most people are diagnosed during middle age, although the symptoms often become present earlier in life.

People with certain rheumatic diseases, such as rheumatoid arthritis, systemic lupus erythematosus (commonly called lupus), or ankylosing spondylitis (spinal arthritis) may be more likely to have fibromyalgia, too.

Several studies indicate that women who have a family member with fibromyalgia are more likely to have fibromyalgia themselves, but the exact reason for this - whether it be hereditary or caused by environmental factors or both - is unknown.

Causes Unknown
The causes of fibromyalgia are unknown, but there are probably a number of factors involved. Many people associate the development of fibromyalgia with a physically or emotionally stressful or traumatic event, such as an automobile accident. Some connect it to repetitive injuries. Others link it to an illness. For others, fibromyalgia seems to occur spontaneously. Many researchers are examining other causes, including problems with how the central nervous system (the brain and spinal cord) processes pain.

Diagnosis
Research shows that people with fibromyalgia typically see many doctors before receiving the diagnosis. One reason for this may be that pain and fatigue, the main symptoms of fibromyalgia, overlap with many other conditions. Therefore, doctors often have to rule out other potential causes of these symptoms before making a diagnosis of fibromyalgia. Another reason is that there are currently no diagnostic laboratory tests for fibromyalgia. Because there is no generally accepted, objective test for fibromyalgia, some doctors unfortunately may conclude a patient's pain is not real, or they may tell the patient there is little they can do.

A doctor familiar with fibromyalgia, however, can make a diagnosis based on two criteria established by the ACR: a history of widespread pain lasting more than 3 months and the presence of tender points. Pain is considered to be widespread when it affects all four quadrants of the body; that is, you must have pain in both your right and left sides as well as above and below the waist to be diagnosed with fibromyalgia. The ACR also has designated 18 sites on the body as possible tender points. For a fibromyalgia diagnosis, a person must have 11 or more tender points.

Treatment
Not all doctors are familiar with fibromyalgia and its treatment, so it is important to find a doctor who is. Fibromyalgia treatment often requires a team approach, with your doctor, a physical therapist, possibly other health professionals, and most importantly, yourself, all playing an active role. It can be hard to assemble this team; when you do, however, the combined expertise of these various professionals can help you improve your quality of life. There are pain clinics that specialize in pain and rheumatology clinics that specialize in arthritis and other rheumatic diseases, including fibromyalgia.

At present, there are no medications approved by the US Food and Drug Administration (FDA) for treating fibromyalgia, although a few such drugs are in development. Doctors treat fibromyalgia with a variety of medications developed and approved for other purposes. Following are some of the most commonly used categories of drugs for fibromyalgia.

Analgesics
Analgesics are painkillers. They range from over-the-counter acetaminophen (e.g., Tylenol) to prescription medicines such as tramadol (Ultram), and even stronger narcotic preparations. For a subset of people with fibromyalgia, narcotic medications are prescribed for severe muscle pain.

Nonsteroidal Anti-Inflammatory Drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, ibuprofen (e.g., Advil, Motrin), and naproxen sodium (e.g., Anaprox, Aleve), are used to treat inflammation and relieve pain. These medications, some of which are available without a prescription, may help ease the muscle aches of fibromyalgia. They may also relieve menstrual cramps and the headaches often associated with fibromyalgia.

Antidepressants
Perhaps the most useful medications for fibromyalgia are several in the antidepressant class. Antidepressants elevate the levels of certain chemicals in the brain, including serotonin and norepinephrine. Increasing the levels of these chemicals can reduce pain in people who have fibromyalgia. Doctors prescribe several types of antidepressants for people with fibromyalgia:

• Tricyclic antidepressants. When taken at bedtime in dosages lower than those used to treat depression, tricyclic antidepressants can help promote restorative sleep in people with fibromyalgia. They also can relax painful muscles and heighten the effects of the body's natural pain-killing substances, called endorphins.
• Selective serotonin reuptake inhibitors. If a tricyclic antidepressant fails to bring relief, doctors sometimes prescribe a selective serotonin reuptake inhibitor (SSRI). As with tricyclics, doctors usually prescribe these for people with fibromyalgia in lower dosages than are used to treat depression. By promoting the release of serotonin, these drugs may reduce fatigue and some other symptoms associated with fibromyalgia. The group of SSRIs includes fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). SSRIs may be prescribed along with a tricyclic antidepressant. Doctors rarely prescribe SSRIs alone. Because they make people feel more energetic, they also interfere with sleep, which often is already a problem for people with fibromyalgia.
• Mixed reuptake inhibitors. Some newer antidepressants raise levels of both serotonin and norepinephrine, and are therefore called mixed reuptake inhibitors. Examples of these medications include venlafaxine (Effexor) and nefazadone (Serzone). Researchers are actively studying the efficacy of these newer medications in treating fibromyalgia.

Benzodiazepines
Benzodiazepines help some people with fibromyalgia by relaxing tense, painful muscles and stabilizing the erratic brain waves that can interfere with deep sleep. Benzodiazepines also can relieve the symptoms of restless legs syndrome, which is common among people with fibromyalgia. Restless legs syndrome is characterized by unpleasant sensations in the legs as well as twitching, particularly at night. Because of the potential for addiction, doctors usually prescribe benzodiazepines only for people who have not responded to other therapies. Benzodiazepines include clonazepam (Klonopin) and diazepam (Valium).

Other Medications
Doctors might also prescribe other drugs, depending on a person's specific symptoms or fibromyalgia-related conditions. For example, in recent years, two medications - tegaserod (Zelnorm) and alosetron (Lotronex) - have been approved by the FDA for the treatment of irritable bowel syndrome. Gabapentin (Neurontin) currently is being studied as a treatment for fibromyalgia. Other symptom-specific medications include sleep medications, muscle relaxants, and headache remedies.

People with fibromyalgia also may benefit from a combination of physical and occupational therapy, from learning pain-management and coping techniques, and from properly balancing rest and activity.

Complementary and Alternative Therapies
Many people with fibromyalgia also report varying degrees of success with complementary and alternative therapies, including massage, movement therapies such as Pilates and the Feldenkrais method, chiropractic treatments, acupuncture, and various herbs and dietary supplements for different fibromyalgia symptoms. Though some of these supplements are being studied for fibromyalgia, there is little, if any, scientific proof yet that they help. If you are using or would like to try a complementary or alternative therapy, you should first speak with your doctor, who may know more about the therapy's effectiveness, as well as whether it is safe to try in combination with your medications.

Prognosis
Fibromyalgia is a chronic condition, meaning it lasts a long time - possibly a lifetime. However, it is not a progressive disease, it is never fatal, and it won't cause damage to your joints, muscles, or internal organs. In many people, the condition does improve over time.

Self-Care
Besides taking medicine prescribed by your doctor, there are many things you can do to minimize the impact of fibromyalgia on your life. These include:

• Getting enough sleep. Getting enough sleep and the right kind of sleep can help ease the pain and fatigue of fibromyalgia. Even so, many people with fibromyalgia have problems such as pain, restless legs syndrome, or brain-wave irregularities that interfere with restful sleep.
• Exercising. Though pain and fatigue may make exercise and daily activities difficult, it's crucial to be as physically active as possible. Research has repeatedly shown that regular exercise is one of the most effective treatments for fibromyalgia. People who have too much pain or fatigue to do vigorous exercise should begin with walking or other gentle exercise and build their endurance and intensity slowly.
• Making changes at work. Most people with fibromyalgia continue to work, but they may have to make big changes to do so; for example, some people cut down the number of hours they work, switch to a less demanding job, or adapt a current job. If you face obstacles at work, such as an uncomfortable desk chair that leaves your back aching or difficulty lifting heavy boxes or files, your employer may make adaptations that will enable you to keep your job. An occupational therapist can help you design a more comfortable workstation or find more efficient and less painful ways to lift.
  If you are unable to work at all due to a medical condition, you may qualify for disability benefits through your employer or the Federal Government. Social Security Disability Insurance (SSDI) and Supplemental Security Insurance (SSI) are the largest Federal programs providing financial assistance to people with disabilities. For information about the SSDI and SSI programs, contact the Social Security Administration.
• Eating well. Although some people with fibromyalgia report feeling better when they eat or avoid certain foods, no specific diet has been proven to influence fibromyalgia. Of course, it is important to have a healthy, balanced diet. Not only will proper nutrition give you more energy and make you generally feel better, it will also help you avoid other health problems.

This information is made available by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.