What Is Fibromyalgia?

Bismillaah

Author: Deborah A. Barrett

Diagnostic Criteria

In 1990, the diagnosis of fibromyalgia entered the mainstream in the United States. The American College of Rheumatology (ACR) put forward official criteria to recognize this condition:

widespread pain for at least three months in three quadrants of the body, and
abnormal sensitivity to palpation in at least 11 of 18 specific tender points (as depicted in the illustration).
These diagnostic criteria provide an important empirical basis to diagnose fibromyalgia. During a physical exam, a physician presses lightly (just until the fingernail whitens) on specific tender points as well as control spots and evaluates the patient’s response. People affected by fibromyalgia may not realize they have tender points until someone familiar with the condition applies pressure to them. Wincing, jumping, or any other visible or vocal response of pain depicts excessive tenderness. It has been the case that people with fibromyalgia see an average of five physicians before receiving the proper diagnosis, but as physicians become more familiar with the tender point exam, diagnoses are made more quickly. The number of tender points that elicit pain can vary and someone with widespread pain but only nine or ten tender points should not be ruled out. The diagnosis of fibromyalgia relies not only on tender points, but on a thorough medical history and appropriate lab tests to rule out alternative diagnoses.

Location of Tender Points.
Fibromyalgia is not a new syndrome; evidence for its existence dates back centuries. Until recently, however, the cluster of symptoms that comprise fibromyalgia, or fibrositis one of its former names, were largely considered psychogenic. It is the case that doctors who lack a physiological explanation for symptoms are prone to attribute complaints to mental problems or malingering. This has been the case for fibromyalgia because it lacks a clear test to verify its existence, its sufferers “look fine,” and are predominantly female, a group less likely believed. This skepticism began to change in the late 1970s and early 1980s when more research became available about sleep abnormalities and reproducible tender spots in fibromyalgia. An important group of rheumatologists (the specialty of physicians that treat arthritis) realized that this group of patients did not fit the profile of hypochondriacs. Rheumatologists started to pay more serious attention to the suffering described by these patients, who continue to make up 20% of a rheumatologist’s practice.

The ACR diagnostic criteria for fibromyalgia came about following an extensive study by 25 medical researchers of more than 500 patients in 16 North American studies. Blinded researchers investigated over 300 different factors in patients with various pain complaints. From this study, they concluded that the most reliable predictors of fibromyalgia are the prevalence of tender points and widespread pain (Wolfe et al., 1989).

In the early 1990s, the World Health Organization declared fibromyalgia a significant medical problem and included it in its 10th International Classification of Disease (ICD-10).

Yet “non-believers” still exist. It may be the case that for some doctors, fibromyalgia will not be considered ‘real’ until its cause and cure are discovered. Fortunately these are becoming fewer and farther between. International conferences of experts now meet regularly to share their findings. Publications on fibromyalgia have increased tremendously, bringing us closer to a fuller understanding of this condition. While rheumatologists were the first to treat fibromyalgia, family physicians are becoming more adept at diagnosing and treating this condition. Doctors of physical medicine, or physiatrists, often specialize in the treatment of fibromyalgia and other pain disorders.

Medical Theories
‘Fibromyalgia’ is a descriptive name that may change as we learn more about the condition. It could be the case that various different illnesses with similar symptoms are now being included under the rubric of fibromyalgia, or that fibromyalgia is part of a larger family of pain amplification disorders such as migraines or temporomandibular joint (TMJ).

Numerous theories, supported by empirical findings, try to account for what has gone awry in the fibromyalgia body. The simplest explanation is that as with many other conditions such as allergies, heart disease, diabetes, or cancer, a genetic predisposition makes some people more susceptible than others. Fibromyalgia develops when a ‘triggering incident’ throws the body’s system off track. This could be a virus, physical or emotional trauma, repetitive stress, sleep deprivation, or some combination of these. (A small proportion of people seem to be born with fibromyalgia). Exactly what changes in a fibromyalgia body to cause pain and fatigue is not fully understood. The most recent scientific theories consider the pathology to be located in the central nervous system, where pain signals may be amplified or improperly filtered, causing otherwise innocuous stimuli elicit in severe pain. Researchers have found that people with fibromyalgia have elevated amounts of the neurotransmitters that signal pain responses (Substance P), as well as depressed levels of natural pain killers (serotonin) and hormones that restore muscle regeneration (growth hormone). Other findings include abnormal sleep patterns, mainly a decrease in slow-wave deep-levels of sleep that are most restful to the muscles. These all represent important pieces of the puzzle.

Treatments for Fibromyalgia
The good news about fibromyalgia is that there does not seem to be any underlying pathology that worsens. Treatments therefore focus on alleviating symptoms of pain and sleeplessness. The difficulties of fibromyalgia tend to cycle. When pain is severe, it interferes with sleep, which worsens pain, mood, cognitive ability, and so on. Treatments aim to break this cycle and reverse its direction. In other words, when reducing pain, allows sleep to become easier, which further reduces pain and fatigue, and so on.

The treatments for fibromyalgia sound easy in that they all read like basic practices for good health and well being. They include: (1) a carefully planned exercise program that includes gentle stretching and gradual progression toward aerobic conditioning; and (2) drug therapy, primarily to improve sleep. Physical therapy may be helpful and could include such techniques as heat, ice, massage, whirlpool, and electrical stimulation to help control pain. Some patients benefit from medication for pain relief. However, whatever is wrong with the fibromyalgia body makes things like exercise and sleep a challenge. Nonetheless, with much patience and a good understanding of one’s body’s reactions, people with this condition can improve how they feel.

Exercise may sound to others like an easy antidote. However, when you are in pain, exercise is not easy. Furthermore, people with fibromyalgia do not respond to exercise like other people and need to approach it gradually. But if approached appropriately and gradually, exercise can provide natural painkillers, improve strength, endurance, and fitness. A regular exercise program can decrease pain and improve overall well being, sleep quality, and daily stamina. See my article on exercise.

Good quality sleep is a bedrock of fibromyalgia treatment. Studies have shown that sleep deprivation can induce fibromyalgia-like symptoms. Many people with fibromyalgia suffer from sleep abnormalities and often awake feeling as if they had not slept at all. This is called nonrestorative sleep. There are many different medicines that can improve sleep quality. It may take several tries to find the ones that work best for each individual. The recommended approach is to begin with small doses of medicine to see how they are tolerated, then increase as needed. The goal is to improve sleep without introducing unpleasant side effects. Talk with your doctor about how each medicine works and the expected duration of any side effects. Bedtime routines are also very important for improving sleep. Wind down your day with something soothing such as a hot bath. Try to organize your days to allow yourself the best possible rest. Limit daytime naps. Exercise improves sleep quality, but it is best not to exercise directly before sleep. Make sure your mattress and pillow(s) provide appropriate support and cushion. Earplugs can be very helpful to block disturbing noise. Adjust your sleep environment such as the temperature, humidity, and darkness to your preference. Create a relaxing bedtime ritual and aim for a solid eight hours. Click here for the Mayo Clinic advice on fibromyalgia and sleep.

Pain relief is essential. Understanding what helps you through paintracking allows you to amass strategies to prevent and relieve pain. Heat in various forms soothes aching muscles as does gentle stretching. Earplugs, lightweight but warm clothing (such as silks and polar fleece) and sunglasses can ward off flares from noise, cold drafts, or bright lighting. Meditation, hypnotherapy and self-hypnosis, biofeedback, and diaphragmatic breathing exercises all offer ways to lower the thermostat on pain. For some, massage therapy works wonders. Pain medications help people to feel well enough to do the other things necessary to improve and live a fuller life. Some doctors prescribe pain medications to be taken proactively. The analgesic effects of medications are more effective before pain escalates. Discuss with your doctor short versus longer acting medications. For some, over-the-counter medications may be adequate. For others, stronger medications such as narcotics are needed. Some physicians are reluctant to prescribe narcotics for long-term use, a bias that stems from a fear of addiction. Yet evidence shows that people in pain do not abuse painkillers–we desire to engage in life, not escape it. There is an important distinction between physical dependence and addiction. It is important to keep track of how you take any medication to monitor its effectiveness. Slowly our society is realizing the need for more comprehensive treatments for chronic pain in conditions that are not fatal.

Pacing becomes a very important aspect of living well with fibromyalgia. You may find that taking a break every few hours will allow you to gain a second wind, and maybe even a third or forth. By tracking how you feel and your activity levels, you can learn how to organize your day and weeks to make the most of the energy you have. Creative scheduling can allow people with fibromyalgia to engage in a full life. Knowing when you need to rest and when you can push on make this condition much more manageable.