You hurt all over and you frequently feel exhausted. Even after numerous tests, your doctor can't seem to find anything specifically wrong with you. If this sounds familiar, you may have fibromyalgia, a condition that affects an estimated 3 million to 8 million people in the United States. Approximately 80 percent to 90 percent of affected people are women.
Fibromyalgia is a chronic condition characterized by fatigue and widespread pain in your muscles, ligaments and tendons. Previously, the condition was known by other names such as fibrositis, chronic muscle pain syndrome, psychogenic rheumatism and tension myalgias.
In 1990, the American College of Rheumatology (ACR) identified specific criteria for fibromyalgia. The ACR classifies a patient with fibromyalgia if at least 11 of 18 specific areas of your body are painful under pressure. Also, you must have had widespread pain lasting at least 3 months.
Although the intensity of your symptoms may vary, they'll probably never disappear completely. It may be reassuring to know, however, that fibromyalgia isn't progressive, crippling or life-threatening.
Signs and symptoms of fibromyalgia can vary, depending on weather, stress, physical activity or even just the time of day. Different people experience different signs and symptoms, but common signs and symptoms include:
- Widespread pain. Fibromyalgia is characterized by pain in specific areas of your body when
pressure is applied. These areas include the back of your head, upper back and neck, upper chest,
elbows, hips and knees. The pain generally persists for months at a time and is often accompanied by
stiffness.
- Fatigue and sleep disturbances. People with fibromyalgia often wake up tired and
unrefreshed even though they seem to get plenty of sleep. Some studies suggest that this problem is
the result of a sleep disorder called alpha wave interrupted sleep pattern, a condition in which deep
sleep is frequently interrupted by bursts of brain activity similar to wakefulness. So people with
fibromyalgia miss the deep restorative stage of sleep (stage 4). Nighttime muscle spasms in your legs
(periodic limb movement disorder or nocturnal myoclonus) and restless legs syndrome also may be
associated with fibromyalgia.
- Irritable bowel syndrome (IBS). The constipation, diarrhea, abdominal pain and bloating
associated with IBS are common in people with fibromyalgia.
- Chronic headaches and facial pain. Many people who have fibromyalgia also have recurrent
tension-type headaches that may be related to tenderness in the neck and shoulders. Facial pain is
common, and as many as one-third experience jaw pain — temporomandibular joint (TMJ) dysfunction.
- Heightened sensitivity. It's common for people with fibromyalgia to report being sensitive
to odors, noises, bright lights, touch and changes in weather.
- Depression. As many as one-third of people with fibromyalgia also experience depression.
- Numbness or tingling sensations in the hands and feet (paresthesia).
- Difficulty concentrating and mood changes.
- Chest pain or pelvic pain.
- Irritable bladder.
- Dry eyes, skin and mouth.
- Painful menstrual periods.
- Dizziness.
- Sensation of swollen hands and feet.
Doctors believe that there isn't one single cause of fibromyalgia. Rather, a number of factors may contribute. These factors may include:
- Chemical changes in the brain. Some people with fibromyalgia appear to have alterations in
the regulation of certain brain chemicals called neurotransmitters. This may be particularly true of
serotonin — which is linked to depression, migraines and gastrointestinal distress — and substance P,
a brain chemical associated with pain, stress and anxiety, as well as depression.
- Sleep disturbances. Some researchers theorize that disturbed sleep patterns may be a cause
rather than just a symptom of fibromyalgia. Studies have shown abnormally low levels of a hormone
called somatomedin C in the blood of people with fibromyalgia. Somatomedin C is thought to be
essential for the body to rebuild itself and is secreted only during stage 4 sleep.
- Injury. An injury or trauma, particularly in the upper spinal region, may trigger the
development of fibromyalgia in some people. An injury may affect your central nervous system, which
might trigger fibromyalgia.
- Infection. Some researchers believe that a viral or bacterial infection may trigger
fibromyalgia.
- Abnormalities of the autonomic (sympathetic) nervous system. Your autonomic nervous system
is divided into the sympathetic and parasympathetic systems. Your sympathetic nervous system releases
norepinephrine and influences the release of epinephrine from the adrenal gland. The sympathetic
nervous system also controls bodily functions that you don't consciously control, such as heart rate,
blood vessel contraction, sweating, salivary flow and intestinal movements. Several studies have
looked at the responses of the sympathetic nervous system in people with fibromyalgia. There are
reports of reduced epinephrine responses to low blood sugar levels and exercise. Other reported
abnormalities include decreased responses to cold and altered heart rate and blood pressure responses
during tilt-table testing — a noninvasive procedure normally used to help diagnose a common form of
fainting (syncope). During the test, you lie on a bed that moves from a horizontal to a vertical
position while your blood pressure and heart rate are monitored.
- Changes in muscle metabolism. For example, deconditioning and decreased blood flow may
contribute to decreased strength and fatigue. Differences in metabolism and abnormalities in the
hormonal substance that influences the activity of nerves (neuroendocrine) may play a role.
Psychological stress and hormonal changes also may be possible causes of fibromyalgia.
Risk factors for fibromyalgia include:
- Sex. It's estimated that fibromyalgia occurs much more often in women than in men.
- Age. Fibromyalgia tends to develop in people between the ages of 20 and 60. But it can
occur in children.
- Disturbed sleep patterns. It's unclear whether sleeping difficulties are a cause or a
result of fibromyalgia, but people with sleep disorders such as nighttime muscle spasms in the legs,
restless legs syndrome or sleep apnea can also develop fibromyalgia.
- Family history. You may be more likely to develop fibromyalgia if a relative also has the
condition.
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When to seek medical advice
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See your doctor if you experience general aching or widespread pain that lasts several months and is accompanied with fatigue. Many of the symptoms of fibromyalgia mimic those of other diseases such as low thyroid hormone production (hypothyroidism), polymyalgia rheumatica, neuropathies, systemic lupus erythematosus, multiple sclerosis and rheumatoid arthritis. Your doctor can help determine if one of these other conditions may be causing your symptoms.
Diagnosing fibromyalgia is difficult because there isn't a single, specific diagnostic laboratory test. In fact, before receiving a diagnosis of fibromyalgia, you may go through several medical tests, such as blood tests and X-rays, only to have the results come back normal. Although these tests may rule out other conditions, such as rheumatoid arthritis, lupus and multiple sclerosis, they can't confirm fibromyalgia.
The American College of Rheumatology has established some general classification guidelines for fibromyalgia, to help in the assessment and study of the condition. These guidelines require that you have widespread aching for at least 3 months and have a minimum of 11 locations on your body that are abnormally tender under relatively mild pressure. In addition to taking your medical history, a doctor checking for fibromyalgia will press firmly on specific points on your head, upper body and certain joints so that you can confirm which cause pain.
However, not all doctors agree with the guidelines. Some believe that the criteria are too rigid and that you can have fibromyalgia even if you don't meet the required number of tender points. Others question how reliable and valid tender points are as a diagnostic tool.
Fibromyalgia isn't progressive and generally doesn't lead to other conditions or diseases. It can, however, cause pain, depression and lack of sleep. These problems can then interfere with your ability to work at home or on the job, or maintain close family or personal relationships. The frustration of dealing with an often-misunderstood condition also can be a complication of the condition.
In general, treatment for fibromyalgia is with a combination of medication and self-care. The emphasis is on minimizing symptoms and improving general health.
Medications
Medications can help reduce the pain of fibromyalgia and improve sleep. The ones most commonly recommended by doctors include:
- Aspirin, ibuprofen (Advil, Motrin, others) or acetaminophen (Tylenol, others). These
over-the-counter pain relievers may ease the pain and stiffness caused by fibromyalgia. However,
their effectiveness varies with individuals. In addition, frequent or long-term use of aspirin and
ibuprofen, also known as nonsteroidal anti-inflammatory drugs (NSAIDs), can cause serious side
effects, including stomach pain, bleeding or ulcers. Overuse of acetaminophen may lead to kidney or
liver damage.
- Antidepressants. Your doctor may prescribe antidepressant medications, such as
amitriptyline (Elavil), nortriptyline (Pamelor), trazodone (Desyrel) or doxepin (Sinequan) to help
promote sleep. Fluoxetine (Prozac) in combination with amitriptyline has also been found effective.
Sertraline (Zoloft) and paroxetine (Paxil) also are effective if you're suffering from depression.
These medications may be beneficial by affecting serotonin levels in the brain. Side effects of
antidepressants include dry eyes and mouth, constipation and increased appetite.
- Muscle relaxants. Taking the medication cyclobenzaprine (Flexeril) at bedtime may help
treat muscle pain and spasms.
- Benzodiazepines. In the early to mid-1990s, there were a few short-term studies with a
small number of fibromyalgia patients using benzodiazepines, some in combination with NSAIDs, and the
results were variable. Usually, doctors avoid benzodiazepines in treating fibromyalgia since they
haven't been shown to have long-term benefit and have the potential for drug dependence.
Prescription sleeping pills, such as zolpidem tartrate (Ambien), may provide short-term benefits for some people with fibromyalgia, but doctors usually advise against long-term use of these drugs. These medications tend to work for only a short time, after which your body becomes resistant to their effects. Ultimately, using sleeping pills tends to create even more sleeping problems in people with fibromyalgia.
Doctors don't usually recommend narcotics for treating fibromyalgia because of the potential for dependence and addiction. Corticosteroids, such as prednisone, haven't been shown to be effective in treating fibromyalgia.
Cognitive-behavioral therapy
Cognitive-behavioral therapy seeks to increase your belief in your own abilities and teaches you methods for dealing with stressful situations. Therapy can be provided via individual counseling, audiotapes or classes, and may help you manage your fibromyalgia.
Treatment programs
Interdisciplinary treatment programs may be effective in improving your symptoms, including relieving pain and depression. These programs can combine a variety of treatments, such as relaxation techniques, biofeedback and receiving information about chronic pain. There isn't one combination that works best for everybody. Your doctor can create a program based on what works best for you.
Self-care is critical in the management of fibromyalgia. Important aspects of self-care include taking these actions:
- Reduce stress. Develop a plan to avoid or limit overexertion and emotional stress. Allow
yourself time each day to relax. That may mean learning how to say no without guilt. But don't change
your routine totally. People who quit work or drop all activity tend to do worse than those who
remain active. Try stress reduction techniques, such as deep-breathing exercises or meditation.
- Get enough sleep. Because fatigue is one of the main effects of fibromyalgia, getting
sufficient sleep is essential. In addition to allotting enough time for sleep, practice good sleep
habits, such as going to bed and getting up at the same time each day and limiting daytime napping.
- Exercise regularly. At first, exercise may increase your pain. But doing it regularly
often improves symptoms. Appropriate exercises include walking, swimming, biking and water aerobics.
A physical therapist may help you develop a home exercise program. Your doctor may recommend that you
aim for at least 20 to 30 minutes of exercise four or more times a week. Stretching, good posture and
relaxation exercises also are helpful.
- Pace yourself. Keep your activity on an even level. If you do too much on your good days,
you may have more bad days.
- Maintain a healthy lifestyle. Try to eat a balanced diet, limit your caffeine intake, work
on smoking cessation, get adequate rest, exercise regularly, and do something that you find enjoyable
and fulfilling.
- Use eyedrops as needed. If you experience dry eyes, you can use over-the-counter drops for
relief. These preparations resemble your own tears and contain substances that hold water in your
eye. Choose one that's preservative-free.
Besides dealing with the pain and fatigue of fibromyalgia, you may also have to deal with the frustration of having a condition that's often misunderstood. In addition to educating yourself about fibromyalgia, you may find it helpful to provide your family, friends and co-workers with information.
It's also helpful to know that you're not alone. Organizations such as the Arthritis Foundation and the American Chronic Pain Association provide educational classes and support groups. These groups can often provide a level of help and advice that you might not find anywhere else. They can also help put you in touch with others who have had similar experiences and can understand what you're going through.
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Complementary and alternative medicine
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Complementary and alternative therapies for pain and stress management aren't new. Some, such as meditation and yoga, have been practiced for thousands of years. But their use has become more popular in recent years, especially with people who have chronic illnesses, such as fibromyalgia.
Several of these treatments do appear to safely relieve stress and reduce pain, and some are gaining acceptance in mainstream medicine. But many practices remain unproved because they haven't been adequately studied.
Some of the more common complementary and alternative treatments promoted for pain management, and the current thinking about their effectiveness and safety, include:
- Chiropractic care. This treatment is based on the philosophy that restricted movement in
the spine may lead to reduced function and pain. Spinal adjustment (manipulation) is one form of
therapy chiropractors use to treat restricted spinal mobility. The goal is to restore spinal movement
and, as a result, improve function and decrease pain. Chiropractors manipulate the spine from
different positions using varying degrees of force. Manipulation doesn't need to be forceful to be
effective. Chiropractors may also use massage and stretching to relax muscles that are shortened or
in spasm. Because manipulation has risks, always use properly trained and licensed practitioners.
- Massage therapy. This is one of the oldest methods of health care still in practice. It
involves use of different manipulative techniques to move your body's muscles and soft tissues. The
therapy aims to improve circulation in the muscle, increasing the flow of nutrients and eliminating
waste products. Massage can reduce your heart rate, relax your muscles, improve range of motion in
your joints and increase production of your body's natural painkillers. It often helps relieve stress
and anxiety. Although massage is almost always safe, avoid it if you have open sores, acute
inflammation or circulatory problems.
- Osteopathy. Doctors of osteopathy go through rigorous and lengthy training in academic and
clinical settings. They're licensed to perform many of the same therapies and procedures as
traditional doctors. One area where osteopathy differs from conventional medicine — but is similar to
chiropractic medicine — is in the use of manipulation to address joint and spinal problems. Again,
this is an area of controversy, but many studies support osteopathic techniques for many joint and
muscle conditions.
- Acupressure and acupuncture. Both acupressure and acupuncture stem from the Chinese belief
that 14 invisible pathways, called meridians, lie beneath your skin. In this belief, when the life
force that runs through these meridians is interrupted, you become ill. Practitioners restore the
flow of the energy by applying pressure with their fingers (acupressure) or by inserting very fine
needles (acupuncture) into the skin. Research on the benefits of acupressure is inconclusive. But
according to the National Institutes of Health, acupuncture to help control pain associated with
fibromyalgia may be effective.
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April 24, 2003 —
