What is Fibromyalgia?
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Fibromyalgiais a poorly understood chronic musculoskeletal syndrome involving widespread pain (Abeles et al, 2008). It may affect 2% of the population, or an estimated 200 million or more people worldwide, and is estimated to occur seven times more frequently in females than in males (Bartels et al, 2009).
American College of Rheumatology (ACR) classification criteria for fibromyalgia include widespread pain and presence of 11 or more painful points among a possible 18 sites throughout the body (Yunus & Aldag, 2012). However, in addition to pain, fibromyalgia involves a constellation of symptoms which varies between individual patients, and there are currently no definitive tests or specific diagnostic markers for the condition (Sarzi-Puttini et al, 2011). For these reasons, fibromyalgia is considered a diagnosis of exclusion, or a medical condition reached by process of elimination.
Beyond pain, fibromyalgia patients frequently report fatigue, joint stiffness, and sleep disturbances, which research suggests may be both a cause and a consequence of the disorder (Prados & Miro, 2012). Less frequently, patients with fibromyalgia may report dysphagia (problems with swallowing), bowel and bladder problems, numbness and tingling, and cognitive difficulties. In addition, fibromyalgia is often comorbid with conditions such as depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, temporomandibular joint disorder (TMJ), rheumatoid arthritis, painful menstrual periods, and other pain syndromes (Weir et al, 2006). Not all people with fibromyalgia experience all of the associated symptoms and conditions (Yunus, 1983).
Some patients with fibromyalgia may develop central sensitization, or overreaction of pain receptors in the central nervous system to normal physical sensations. Central sensitization is thought to be a consequence of prolonged pain from any long-term pain condition like fibromyalgia. In central sensitization, low-threshold sensory fibers activated by light touch of the skin trigger neurons in the spinal cord that normally respond only to painful stimuli. Eventually, harmless stimuli provoke feelings of pain, a phenomenon known as allodynia. Fibromyalgia patients may also experience hyperalgesia, or increased sensitivity to pain. The pathogenesis of such peripheral and/or central nervous system changes in chronic pain syndromes is unclear, but peripheral soft tissue changes have been implicated (Staud, 2011). A studying examining the hyper-responsiveness of the central nervous system in patients with fibromyalgia found fibromyalgia patients experienced pain stimuli as more painful than healthy controls (Burgmer et al, 2011). Also, in patients with fibromyalgia, the cerebral pattern corresponding to secondary hyperalgesia was altered, and the correlation between activity in the dorsolateral prefrontal cortex and secondary hyperalgesia was disrupted in comparison to healthy control subjects. The researchers concluded these findings point to an alteration of pain transmission at the central level in fibromyalgia and might be related to changes in cerebral-midbrain-spinal mechanisms of pain inhibition.
Although its pathophysiology is not yet fully understood, it is known that both genetic and environmental factors are involved in the development of fibromyalgia (Calandre & Rico-Villademoros, 2012). According to recent neuroimaging and neurophysiology studies, substantial functional and structural changes, or plasticity, in the central nervous system (CNS) are associated with many chronic pain syndromes. A group of cortical and subcortical brain regions, often referred to as the “pain matrix,” and the motor and sensory homunculus often show abnormalities on functional imaging studies in persons with chronic pain, even with different pain locations and etiologies. Some of these CNS changes return to a normal state upon resolution of the pain. This knowledge may lead to development of more effective treatments or new preventative measures for chronic pain syndromes like fibromyalgia (Henry et al, 2011).
Patients with fibromyalgia may have difficulty with activities of daily living, often due to physical performance limitations. One study found women with fibromyalgia showed deficits in lower limb muscle strength, balance and agility and exhibited decreased knee extension peak torque and rate of torque development (Góes, 2012). In addition, the women showed lower hip adduction and extension peak torque in comparison to the control group. Further, a study comparing the performance of a 6-minute walk (6MWT) test in patients with fibromyalgia and controls and evaluating the relationship between test performance and quality of life, limitations of activities of daily living and physical activity level, found participants with fibromyalgia had higher pain intensity and perceived effort during the test when compared to the control group (Homann, 2011). In addition, patients with fibromyalgia had greater impairment of functional capacity, exacerbation of pain, and exertion during the 6MWT when compared to healthy individuals.
Unfortunately, the impact of fibromyalgia on normal activities of daily living leads most patients to report a lowered quality of life. For example, a study found that fibromyalgia patients rated their perceived “present quality of life” at only 4.8 on a scale of 1 to 10 (1 = low to 10 = highest) (Bernard A et al, 2000). Further, adults with fibromyalgia may be 3.4 times more likely to have major depression (Patten et al, 2005) and lower work productivity (McDonald, 2011) than peers without fibromyalgia.
Although there is no cure for fibromyalgia, the intensity and frequency of symptoms may vary as time passes. Some individuals may even experience intermittent symptom-free periods in which they have significantly lower levels of pain. Fortunately, fibromyalgia is not a progressive or life-threatening condition and certain treatments can significantly improve the discomforts associated with the disorder.
Treatment goals for patients with fibromyalgia include improvement of physical pain, increase in daily activities, and restoration of normal sleep cycles. Most treatment plans include medications and non-pharmacological therapies. It has been shown that these types of interdisciplinary treatment programs lead to greater improvements in subjective pain and function than monotherapies (Sarzi-Puttini et al, 2011).
Several medications, including the serotonin and norepinephrine reuptake inhibitors duloxetine and milnacipran, and the α(2)δ modulator pregabalin, have been approved by the Food and Drug Administration (FDA) for the management of fibromyalgia (Mease et al, 2011). Evidence from clinical trials indicates that these three drugs can have a significant impact on fibromyalgia-related pain (Traynor et al, 2011). These drugs also have been shown to beneficially effect global impression of change, function, and other key symptom domains such as fatigue, sleep disturbance and cognition (Mease et al, 2011).
The range of symptoms in fibromyalgia is treated specifically based upon the assortment of symptoms and comorbid conditions, if any, that an individual patient experiences. Treatment of ancillary symptoms may be achieved with appropriate drugs, such as tricyclic antidepressants, selective serotonin-reuptake inhibitors and gabapentin (Traynor et al, 2011). Adjunctive therapies targeted at specific symptom domains, such as sleep, as well as treatments aimed at common co-morbid conditions, such as irritable bowel syndrome, or disease states, such as rheumatoid arthritis, are also considered for the purpose of reducing the patient’s overall symptom burden (Mease et al, 2011).
Opioids (e.g., OxyContin, Vicodin, Percoset), are typically not recommended for the treatment of fibromyalgia as they have not shown to provide long-term benefit for most patients. There is limited information about opioid treatment in fibromyalgia, with all current guidelines discouraging opioid use. Opioids are habit forming, and evidence suggests these drugs may not be of benefit to most people with fibromyalgia and in fact may cause greater pain sensitivity or persistence of chronic pain (Ngian et al, 2011). In addition, concerns about risk-benefit ratio, and possible long-term effects of chronic opioid therapy have been raised. Researchers conducted a chart review of all patients referred to a tertiary care pain center clinic with a referring diagnosis of fibromyalgia to evaluate use of opioid medications, and found opioid use was more commonly associated with lower education, unemployment, disability payments, current unstable psychiatric disorders, history of substance abuse, and previous suicide attempts (Fitzcharles et al, 2011). Since healthcare practitioners have observed negative health and psychosocial effects in fibromyalgia patients using opioids, prolonged use of these drugs in fibromyalgia requires careful evaluation.
Newer research suggests fibromyalgia patients may have low magnesium levels, and supplementation with magnesium citrate may reduce symptoms of the disorder. According to a recent study, supplementation with magnesium citrate lowered the intensity of fibromyalgia pain, particularly across tender points (Bagis et al, 2012). The study also found that combined therapy of amitriptyline plus magnesium citrate not only reduced pain but improved scores on the fibromyalgia impact questionnaire (FIQ) and Beck depression scale among patients. The researchers concluded low magnesium levels might be an etiologic factor for fibromyalgia symptoms.
Beyond taking medications to control fibromyalgia symptoms, several non-pharmacological therapies have had extremely beneficial effects in treating the syndrome. For example, the ACR strongly recommends self-management skills for control of fibromyalgia (Crofford, 2010). ACR suggests that patients schedule daily relaxation time, establish a regular sleeping pattern, get regular exercise, and educate themselves on fibromyalgia. It also advocates deep-breathing exercises and meditation to help curb stress that can exacerbate symptoms.
Another non-drug therapeutic option recommended by ACR is cognitive behavioral therapy (CBR), which can help redefine a person’s perceptions and opinions about illness, and teaches symptom reduction skills, which may help alter a person’s behavioral response to pain. A 2012 randomized controlled trial was conducted to assess the efficacy of an individually administered form of CBR for fibromyalgia (Woolfolk et al, 2012). In an additive design, 76 patients diagnosed with fibromyalgia were randomly assigned to either CBR, 10 individual sessions, one per week, administered concurrently with treatment-as-usual or to a normal treatment-as-usual plan. Statistical analysis conducted at the end of treatment (3 months after the baseline assessment) and at a follow-up (9 months after the baseline assessment) indicated that patients receiving the experimental treatment reported less pain and overall better functioning than control patients, both at post-treatment and follow-up.
Several physical treatment modalities have shown tremendous benefit in the management of fibromyalgia. These include exercise, yoga, physical therapy, massage therapy and Tai Chi. Strength training and aerobic exercise have beneficial effects on pain in adults with fibromyalgia, according to a 2012 study by the Mayo Clinic College of Medicine (Hooten et al, 2012). And a randomized, controlled trial found fibromyalgia patients assigned to a yoga program showed significantly greater improvements on standardized measures of fibromyalgia symptoms and functioning, including pain, fatigue, and mood, and in pain catastrophizing, acceptance, and other coping strategies (Carson et al, 2010). Also, a systematic review and meta-analysis of the efficacy and safety of meditative movement therapies in fibromyalgia found yoga had short-term beneficial effects on some key domains of fibromyalgia (Langhorst et al, 2012).
A growing body of methodologically strong research suggests Tai Chi produces many benefits in the treatment of fibromyalgia, including improved balance and muscle strength, better attentiveness and sleep, and lowered anxiety (Field, 2011). Tai Chi, a gentle, an ancient Chinese martial art that consists of gentle, meditative, flowing movements, balance and weight shifting, breathing techniques, and cognitive tools (e.g., imagery and focused internal awareness), also promotes positive cardiovascular changes including decreased heart rate and blood pressure, increased vagal activity, and decreased cholesterol (Field, 2011). A study by Tufts University published in the New England Journal of Medicine found that a single-blind, randomized trial of fibromyalgia patients assigned classic Yang-style Tai Chi, as compared with a control intervention consisting of wellness education and stretching, produced clinically important improvements in the FIQ total score and quality of life among patients assigned to Tai Chi (Wang et al, 2010). Improvements were maintained at 24 weeks, and no adverse events were observed. These results parallel those of small studies of Tai Chi in other patient populations (Yeh et al, 2010).
In addition to the therapies endorsed by ACR, other treatment options commonly recommended for treatment of fibromyalgia include acupuncture (Itoh & Kitakoji, 2010), transcutaneous electrical nerve stimulation (TENS) (Löfgren & Norrbrink, 2009), massage therapy (Sunshine et al, 1996), and nutritional strategies (Lamb et al, 2011; Dykman et al, 1998). In many cases, these treatments can help individuals with fibromyalgia safely and effectively improve their quality of life. Trigger point injections, membrane-stabilizing infusions and Botox injections have also shown benefit in many cases. A review noted that although not used as first-line therapy for pain relief, Botox injections may decrease pain long enough for patients to resume more conservative therapy (Smith et al, 2002).
The average fibromyalgia patient sees five different healthcare providers over an eight-year period before receiving a fibromyalgia diagnosis (Firestone et al, 2012). In fact, a study found that over 27% of patients reported feeling that their healthcare provider did not view fibromyalgia as a “very legitimate” disorder (Firestone et al, 2012), and research on United States-based primary care physicians (PCPs) in seven cities found 46% of PCPs reported some uncertainty when diagnosing fibromyalgia (Hadker et al, 2011). The results of these and other studies suggest that patients experiencing fibromyalgia symptoms should seek advice from a pain management specialist familiar with treatment of fibromyalgia syndrome. A pain management specialist is trained in a range of newer pain relief techniques and can tailor a treatment plan to meet individual needs.
- Fibromyalgia – PainDoctor.com
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