Fibromyalgia Syndrome

Fibromyalgia, short for what is actually fibromyalgia syndrome, is one of those diagnoses that can often present specific challenges to primary healthcare providers, as it is surrounded by a swirl of controversies; some legitimate, some founded in what many consider “old-fashioned thinking”. Admittedly, when the criteria for defining a medical condition is itself a source of controversy, things get even more complicated. Even today, there are clinicians who debate the existence of a clinical condition that lacks identifiable clinical markers, and whose sufferers could just be considered a group of “chronic complainers” instead of people with a chronic pain condition. After all, people diagnosed with fibromyalgia do say they “hurt all over”– does that make any sense? Is the pain physical, emotional, both, or neither? Does it really occur more in women, or is it under-diagnosed in men? Is it really a diagnosis of exclusion?

Historically, fibromyalgia was once not considered a “real” diagnosis by all clinicians, and it has only been recognized as a bona fide disease by doctors since 1987. In 1990, the American College of Rheumatology established criteria for diagnosis:

  • Widespread pain involving all four quadrants of the body as well as the axial skeleton
  • The presence of 11 of 18 tender points on physical examination

The benefits of this classification was that it enabled studies to be done in a standardized way, and also demonstrated tenderness on examination in addition to complaints of pain. However, how does this translate into every day practice when you have a patient sitting there with pain “all over”? Clinicians have even debated the definition of tenderness, which if at all possible makes things even more blurry.

Science has made some headway in terms of clarification, and although there is no consensus regarding pathogenesis of fibromyalgia, there is general agreement that there is an abnormality in processing of pain; the signals may just be dramatically amplified, and in these patients, the system is oversensitive to stimuli. Some researchers believe there might be a genetic connection indicating a hereditary component, while others think fibromyalgia may provoked by illness or injury that causes the undetected condition to surface. Certainly changes in someone’s psychological status could be a precipitating factor as well. Maybe a better phraseology for fibromyalgia syndrome would be “widespread pain syndrome”. It would certainly be more intuitive.

According to most resources, Fibromyalgia is more common in females (some say 80% of cases occur in women), with an incidence of 3-6 % across the general population of the United States.

Here are some common findings to look for when the diagnosis is included in your differential:

  • – Complaints of widespread pain (head to toe)
    • – These complaints persist for months
    • – Associated with stiffness, especially in the morning
  • – Coincident rheumatic disorder (may be more common in these patients)
  • – Chronic fatigue
  • – Sleep disturbance
  • – Coincident “irritable” conditions:
    • – Irritable bowel
    • – Irritable bladder
    • – Headaches
    • – Facial pain
    • – A generalized impression of hypersensitivity (i.e., sound, light, smells, etc.)
    • – Depression (present in 30-40% percent of cases)
    • – Anxiety

It becomes clear when looking at these signs and symptoms, that the ability to make the diagnosis of fibromyalgia will likely be one of exclusion. Just some of the diagnoses that will need to be eliminated include polymalgia rheumatica, rheumatoid arthritis, and lupus, just to name a few. It is not surprising that the average length of time to making a clinical diagnosis of fibromyalgia syndrome is usually long, and may take a few years. The only advantage the primary care clinician has is the ability to capitalize on the relationship and trust between themselves and their patient, leading to patience on both sides, and in depth investigation of what can potentially be a devastating condition.

Treatment of fibromyalgia syndrome includes common sense approaches, founded on one major, important premise “lifestyle modification”. Without this critical step, it is possible that all of the physical, medical, and alternative approaches may not lead to successful treatment. It is important to help the patient explore ways to modify their lifestyle in ways that don’t further inhibit it, and involves strategies used in treating any other painful condition- assessment, goal-setting, empathy, trust, and communication.

Therapies to treat fibromyalgia include the following, often in combination:

  • – Typical over the counter analgesics such as acetaminophen or non-steroidal medications
  • – Antidepressants have the potential to improve sleep, treat co-morbid depression
  • – Muscle relaxants, such as cyclobenzaprine can help muscle stiffness and spasms
  • – Pregabalin, an anticonvulsant, is the first medication approved by the FDA for treatment of fibromyalgia, and can improve symptoms
  • – Prescription sleep aids, such as zolpidem can improve sleep, mood, and tolerance to pain
  • – Cognitive behavioral therapy has been shown to be quite valuable in stress relief and pain tolerance
  • – Support groups-“suffering in solitude” is counter-productive in fibromyalgia, and sharing stressful, as well as successful stories can be invaluable
  • – Physical therapy
  • Self-care strategies:
    • – Adequate sleep and rest
    • – Stress reduction techniques, such as meditation
    • – Regular exercise
  • Alternative treatments:
    • – Massage
    • – Acupuncture
    • – Yoga

Ultimately, the attempt to treat fibromyalgia requires two important ingredients. First, consideration by the healthcare provider to entertain fibromyalgia as a possible diagnosis and to go through the process necessary to include or exclude it. Second, and just as important, faith and patience on the part of the patient to have a positive outlook, communicate as much information to the healthcare provider as possible, keep detailed records to track the signs and symptoms, and realize that successful treatment will include many solutions, and not one silver bullet.

References

1. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum 1990;33:160—72.

2. Richard E. Harris, PhD, and Daniel J. Clauw, MD 11-22-2006 Journal: Current Pain and Headache Reports. 2006, 10:403-407.

3. Pregabalin for the treatment of fibromyalgia syndrome: Results of a randomized, double-blind, placebo-controlled trial. Crofford LJ, Rowbotham MC, Mease PJ, Russell IJ, Dworkin RH, Corbin AE, Young JP, LaMoreaux LK, Martin SA, Sharma U and the pregabalin 1008-105 study group. Arthritis Rheum (2005 Apr) 52(4):pp 1264-1273.

4. Crofford LJ, Clauw DJ. Fibromyalgia; where are we a decade after the American College of Rheumatology classification criteria were developed? Arthritis Rheum 2002;46:1136-8.