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What is fibromyalgia? – Who is at Risk for Fibromyalgia – Symptoms – Diagnosis – Treatment – Prognosis
What is fibromyalgia?
Fibromyalgia is a complex disease with chronic widespread pain as the main and essential symptom. Pain involves multiple parts of the body and cannot be explained by any other cause.
There are multiple associated symptoms, such as fatigue, cognitive slowing, or “fibro fog”, poor sleep quality, anxiety, and depression. Presence of depression is not essential and depression is not responsible for this pain syndrome.
How common is fibromyalgia?
Prevalence is variable from country to country. For some reason it is more prevalent in Canada. In the US it affects about 2% of the population. Fibromyalgia is much more common in females (3.4%) than in males (0.5%). It tends to develop later in life. The most common age of onset is in 50s.
Fibromyalgia can start in young age. For example, at age 20 fibromyalgia prevalence is 2% and by age 70 it reaches 8%.
Who is at risk for developing fibromyalgia?
People do have pains. We all have injuries and diseases associated with pain. Yet, fibromyalgia chooses to strike only some. Who are they? It is impossible to predict, but there is a strong association with specific symptoms, diseases, gender, age, and genetic predisposition. For example, lupus causes fibromyalgia in 65%. Having first degree family member with fibromyalgia increases fibromyalgia risk to 6.4%.
Those people who experience the following symptoms have higher chance of developing fibromyalgia:
– longstanding pain for any reason
– tendency to have chronic stomach discomfort – pain, diarrhea, constipation, or, what is called, irritable bowel syndrome;
– restless and unrefreshing sleep
– tendency to have different types of discomfort in the body, or numbness, tingling, etc.
– sensation of subjective swelling
Please note, presence of those symptoms does not mean that you have fibromyalgia or you are going to have one. Lack of chronic pain excludes presence of fibromyalgia for a hundred percent! No pain – no fibromyalgia.
Some environmental factors are believed to be able to trigger onset of fibromyalgia. These factors by no means are the causes of the disease. They are acute injury, chronic physical exertion, viral infections, and stressful life events. It is not uncommon to see someone who was heavily working out and had to stop because of chronic pain. Is this exercise responsible for the development of fibromyalgia? I, personally, don’t think so.
Diagnosis of Fibromyalgia
The diagnosis of fibromyalgia is made exclusively on the basis of complaints. No diagnostic tests are available. Diagnostic testing is done in order to rule out any other cause of the pain and the associated symptoms.
Presence of hot and swollen joint, abnormal neurological examination, abnormal MRIs or blood work is not expected in fibromyalgia. The problem arises when someone has, let’s say, rheumatoid arthritis. Joints do hurt in this disease. In fibromyalgia pain will be well beyond the diseased joints and will be causing much more discomfort than the pain due to real arthritis. Symptoms of fibromyalgia are numerous, but they are logical, based on proposed potential mechanisms of this disease. Some diseases may imitate fibromyalgia but unlike fibromyalgia they have additional specific findings.
Multiple sclerosis typically causes chronic fatigue and my cause unpleasant sensation, stiffness, and pain in multiple areas, but it is inevitably produces at least some other symptoms, such as weakness, loss of sensation, balance, change or gait, difficulty holding urine etc.
Myopathy has abnormal blood tests and EMG. Spinal stenosis is seen on MRI. Rheumatoid arthritis causes joint problems, Lupus has an array of symptoms besides the pain. In fibromyalgia, neither diagnostic testing, nor examination are abnormal.
The most confusing is differentiation from depression and anxiety, which are often responsible for multiple body sensations, fatigue, difficulty concentrating, insomnia, and headaches. No depression can produce such a chronic widespread pain syndrome, however.
It is also important to understand that presence of fibromyalgia does not exclude comorbid disorders, which are very common. Patients with fibromyalgia are three times likely to have depression, anxiety, or bipolar disorder. Chance of irritable bowel syndrome is 6.3%, headaches 12.7%. There is an increased chance of rheumatoid arthritis (more males) and lupus (more females). Chance of mood disorders in family members of fibromyalgia patients is 42%.
Symptoms of Fibromyalgia
Pain, pain, pain…
Pain is the main problem. Have you ever had a toothache? I am not talking about a really bad one. Let’s say, it is pain due to failed root canal. It is not so strong, but it is always there. It drives you nuts. It does not let you relax. It has a constant grip on you. It is going on and on and on, day by day, week by week. Then, one day, the pus from the abscess suddenly drains. OMG! You finally realize how bad it was and what it means to live without pain.
Now, you should understand what life with fibromyalgia feels like. Pain, like an ugly clawy hand from some horror movie, has a constant hold on the body. Sometimes it lets go for a day or two, or even a week… But this is just a trick. The ugly hand will tighten its grip some time later.
People suffering fibromyalgia often have difficulty describing the quality of pain. It is rather dull, achy and is hard to pinpoint. This pain can’t be localized to any particular joint or specific area. The reason is simple. This pain does not come from the joint, or muscle, or skin. Nothing is damaged. This pain is a ghost living in the brain with very loose connection to the real body parts.
The pain is always there but it moves from place to place. Patients usually state that the whole body is hurting. When asked about recent pain, they may say that today the wrists, the back and the lower jaw are hurting. This pain may stay in the same area for a while or may move to the chest and neck or legs. In some patients this pain stays in the same, but multiple areas for years.
Headaches are common as well. Migraine is common in fibromyalgia but these are two independent conditions. They are just more likely to happen in the same person due to shared disease mechanisms.
Another puzzle is the intensity of pain. What is 10 out of 10 pain intensity? I think it is surgery without anesthesia. The closest to 10 out of 10 is passing a kidney stone or, may be, cluster headache. Giving birth is considered a strong pain, but women usually don’t rate it 10 out of 10.
After this introduction, please imagine a young lady quietly talking to you and stating that she has a constant pain that she rates 8 out of 10. After clarification that the worst pain rating is surgery without anesthesia she might drop a point. Is she exaggerating? No, she is not. There is no absolute pain scale. Pain, which is felt by one person, can’t be perceived by another. What matters, however, how bad the personal perception of the pain is. Chronic pain is exhausting! This lady simply included all these years of pain in her rating. Not sure, if it makes any sense to you. Meanwhile, if pain is felt as severe, it is severe and there is no point disputing this.
Besides having chronic pain, a mere perception of pain produced by natural mechanisms is amplified as well. Experiments show that fibromyalgia patients need stimulus 50% less intense than in average person in order to produce a painful sensation. Fibromyalgia is associated with increased heat, cold, and pressure sensitivity.
Cause of Pain in Fibromyalgia
So, where the pain is coming from in fibromyalgia? Under normal circumstances, pain is an alarm system that prevents the body from serious damage. Like any other sensation, it is regulated and is controlled by the brain. It may be not the best example, but severe injuries such as gunshot wounds or bone fractures are not felt as pain initially. Pain comes later. It happens due to total system shut down to prevent an overload. Otherwise, such a strong pain might be life-threatening by itself.
In fibromyalgia both, pain production and pain extinguishing, are malfunctioning. There is some evidence that pain related information is unreasonably amplified at the spinal cord level even before it gets processed in the brain and perceived. People with fibromyalgia have elevated levels of substance P and Glutamate in the cerebrospinal fluid. These neurotransmitters are involved in pain transmission process in the spinal cord.
Pain modulating system of the brainstem has capacity to control and inhibit pain transmission in the spinal cord. There are 2 major neurotransmitters utilized by this system, which are serotonin and norepinephrine. Cerebrospinal fluid in fibromyalgia patients has decreased metabolite levels of both of them. The reason is not clear, but there is a suspicion that some genetic variants of serotonin transporter and COMT genes may predispose to fibromyalgia. The same genes are believed to be involved in depression. So, it is not surprising that both disorders frequently happen in the same person. Brain processing of pain differs in fibromyalgia patients, which can be demonstrated by fMRI.
Considering likelihood of serotonin and norepinephrine involvement in fibromyalgia, presence of below described associated symptoms and diseases as well as treatment options are logical. Most of them have something to do with the same neurotransmitters.
Fatigue in Fibromyalgia
Chronic fatigue is almost invariably present in fibromyalgia (87%) and it is not attributed to any other cause. Neuroendocrine abnormalities are typical. Lightheadedness upon rising is common because of inadequate heart rate regulation in response to change of body position.
Sleep Disturbance in Fibromyalgia
It is very common in fibromyalgia (72%). Insomnia pattern is similar to the one in anxiety and depression. Rather than falling asleep, staying asleep is the major challenge. Sleep is shallow with frequent interruptions and early awakenings. Feeling drained and unrefreshed upon awakening follows. In spite of chronic sleep deprivation fibromyalgia patients don’t nap. It is all like in depression, but presence of depression is not mandatory. Only 38% of patients with fibromyalgia have depression. Anxiety disorders are more common in fibromyalgia and it affects about 60%.
Other Body Sensations
Pain is not the only type of sensation produced by fibromyalgia. Tingling sensation is common (54%). Tingling and other unpleasant sensations might be perceived in any part of the body and, similar to “fibro-pain”, they don’t to stay in one place.
A very strange sensation of subjective swelling affects about 52%. I perceive it as relatively specific for fibromyalgia. As an example, the hands are felt swollen but no swelling can be noticed by an outside observer.
The most common discomfort in fibromyalgia, other than pain, is sensation of body parts being stiff (75%). At the same time, neurological examination reveals no abnormally increased muscle tone.
Irritable Bowel Syndrome
Irritable bowel syndrome-like picture is a frequent associate of fibromyalgia. Patient often confirm having unexplained stomachaches, bloating, diarrhea, or constipation.
Neuropsychological testing reveal that patients with fibromyalgia are functioning as if they are 20 years older than their biological age. We all age and loose our nerve cells. This loss of “hardware” translates into slowing of the processing speed, difficulty multitasking, and “forgetfulness”. It is often called “senility”. Such as looking for glasses that are sitting on the forehead or going to another room and forgetting about the purpose. People with fibromyalgia express it as “memory loss”, dizziness, or “not feeling sharp”. It is sometimes called “fibro fog”. Cognitive symptoms present in 70%. Fibromyalgia is not a sign of premature aging and is not associated with widespread nerve cell loss like in Alzheimer’s disease, but it is just felt this way.
Treatment of Fibromyalgia
A few important points first.
There is no cure. It is a lifetime condition, once occurred, and the treatment is directed to lessening of pain and associated symptoms.
To be realistic, adequate treatment should reduce the pain intensity about 50%. The most effective medications are antidepressants, which decrease pain severity about 30%.
It is very important to understand that pain in fibromyalgia IS NOT caused by depression and fibromyalgia and depression are different diseases. Antidepressants work because both conditions are associated with low levels of serotonin and norepinephrine in the brain and they increase those levels.
Patients with fibromyalgia tend to tolerate medications poorly, so it makes sense to start with low dose and increase it slowly. For the same reason it is better to use multiple medications with different mechanisms of action at low doses, rather than using one at a high dose.
Treatment is expected to alleviate other symptoms of fibromyalgia at least to some extent.
Some medications are FDA approved for the treatment of fibromyalgia, such as Pregabalin (Lyrica), Duloxetine (Cymbalta), and Milnacipran (Savella). Other medications are used off label but it does not mean that they are less effective.
Antidepressants in Fibromyalgia
Stone-age old tricyclic antidepressants such as Amitriptyline and Doxepin are pretty effective and are typically used in small doses. They are not recommended in the elderly, or people with heart disease and narrow angle glaucoma. Common side effects are dry mouth, constipation, low blood pressure, and sleepiness during the day.
Duloxetine (Cymbalta) is an antidepressant that increases both serotonin and norepinephrine. It might cause increased blood pressure but it does not commonly occur.
Milnacipran (Savella) increases mostly norepinephrine, so elevated blood pressure as a side effect is common. It is not effective in depression. Common issues are nausea, dry mouth, constipation. It may produce withdrawal symptoms if stopped abruptly.
Calcium Channel Ligands
They are Gabapentin (Neurontin) and Pregabalin (Lyrica). These drugs probably work at the spinal cord level and prevent pain “amplification” and transmission. Additionally, they may decrease anxiety and improve sleep. Maximum pain control in fibromyalgia is about 20%.
The problem is that effective doses have to be high in order to achieve a substantial pain control. Common issues are weight gain, fatigue, dizziness.
Nonpharmacological Treatment of Fibromyalgia
Exercise decreases pain, anxiety, and depressive symptoms. Aerobic exercise is, probably, the most reasonable one. It is recommended to start slowly and gradually increase the intensity.
There are “good” days and “bad” days in fibromyalgia, so it is highly recommended not to overdo on the “good” days because it might make the “bad” days worse.
Massage helps with pain reductions, which was proven in a few studies. People report that massage works for a day or two. Then the pain comes back.
Some studies demonstrated beneficial effects of meditation and biofeedback.
Acupuncture may be marginally effective but it is expensive, uncomfortable, and cumbersome for long term use.
No supplements were proven to be effective.
No diet is effective but weight loss might be helpful.
In conclusion, fibromyalgia is a chronic condition with no known cure.
Nevertheless, there are measures available to substantially decrease the intensity of pain and severity of associated symptoms.