Understanding Fibromyalgia

fibromyalgiaFibromyalgia is a “real” condition or syndrome, but it is not really a disease. It is a collection of multiple symptoms primarily with chronic pain (greater than 3 months duration) in multiple regions of the body. The pain is generally is perceived as moderate to severe in intensity throughout the body’s muscles, tendons and joints, with headaches.

It can be described as deep achy, spasm, sharp, stabbing, radiating, and exhausting, with associated symptoms of weakness. It can be intensified with physical activity, emotional stress, inclement weather, cyclic hormonal changes and poor, non-restorative sleep.

Usually there are other associated symptoms including fatigue, swelling, disturbances of sensation, cold intolerance, bowel symptoms including cramping, constipation or diarrhea, indigestion, jaw clenching, sexual dysfunction, menstrual cramps (in women), urinary frequency and/or painful urination, significant anxiety (including fear of activities), and depression.

This condition can be associated with thyroid or rheumatologic problems (Lyme Disease, rheumatoid arthritis, Reynaud’s syndrome or lupus), hypermobility syndrome (Ehlers-Danlos syndrome), neurololgic problems (multiple sclerosis), chemical sensitivity (allergies) as well as following trauma or injury, and emotional stress including abuse.

It is more frequently observed in younger women, and may be inherited. It needs to be differentiated from polymyalgia rheumatic (usually in the elderly with fatigue and temporal headaches), myositis (inflammation of the muscle) from autoimmune (the body reacting against itself), infectious, and medication (statins, cholesterol lowering medicaitons) causes, and certain psychological disorders.

The cause of this condition is multifactorial, and it is believed that the main problem is an amplification of the pain signal in the brain due to altered transmission of the natural neurotransmitters including serotonin, norepinephrine, dopamine, endogenous opioids, substance P. There is an increased brain metabolism in the region of the brain for which the pain is perceived.

FIBRO-pic1

The patient usually has a painful region of the body due to another underlying cause (“pain generator”), usually musculoskeletal in nature, including tendonitis, bursitis, overuse syndromes, “myofascial pain syndromes”, arthritis, “pinched” nerves, injury or trauma that is the “tip of the iceberg” of the “pain generator” for which he or she seeks treatment.

It is rare that I see a patient who only has “fibromyalgia” without any other associated painful problems, although some of the other symptoms may be subtle such as postural abnormalities (ie scoliosis due to leg length discrepancy). Other people may describe their pain as “mild” or temporary, and treat their symptoms with rest or modified activities, over the counter medications including topical creams or patches, braces or splints, heating or cooling modalities, massage and give it time to heal.

However, due to the pain signal amplification, a fibromyalgia patient is more likely to seek care by a health care provider, and receive treatments including prescription medications, and have diagnostic testing. The testing may validate the symptoms such as X rays showing “arthritis”, but they poorly correlate with the intensity of their pain. The fibromyalgia patient may experience additional anxiety due to the intensity of the pain, or heightened concern about the significance of their pain (is it broken?, cancer?), and they are keenly aware of their limitations in activity. There is often a miscommunication in describing their pain to a provider. Therefore, they are more likely to experience frustration and the dismissal by the provider of their complaints.

There are basically two types of fibromyalgia patients that I treat. The first group are patients who generally have an adequate support system, and are “worried well”, usually able to function fairly well with pain that limits some of their activities. Infrequently, many require intermittent use of opioids, as well as adjunctive treatments to improve their pain coping abilities.

They are more likely to have a positive attitude, and are cooperative in receiving education and counseling including involvement of their significant others to understand their pain, and utilize strategies that maintain their continued function. A major goal of treatment is to pro-actively treating them to prevent them from transforming into the other type of fibromyalgia patient, described next.

The second type of patient that I encounter is “dysfunctional” chronic behavior pain syndrome with generalized body pain who, often, are psychologically distressed, unable to tolerate exercises, work or certain self care activities, and passively accepts their condition as their “lot” in life. They present with a “deconditioning syndrome”, resulting in poor posture, reduced exercise tolerance or endurance, functional limitations, generalized weakness with muscle pain and atrophy, and restriction of joint motions throughout their body, with significant depression.

They frequently have other habits that can result in medical problems including tobacco/ nicotine dependency and obesity, and they are more likely to have other medical problems (ie sleep apnea) or frequent surgeries. Often, they are physically dependent on medications (opioids, benzodiazepines or carisoprodol), may be at a higher risk for non-compliance including misusing their medications or relying on medications for all their symptoms (chemical coping). They may be resistant to change their outlook or behaviors, have limited goals, and often, their stated intention of applying or qualifying for disability.

These patients require closer monitoring, a structured environment, with supportive psychological counseling, education and professional guidance (including attention to their significant others) to become more self empowered and confident to change their lifestyle, and become more active, despite their fear that this will further aggravate their condition. Ultimately, it is the patient’s coping style to their condition that correlates with their success in treatment using multiple modalities in a coordinated fashion (interdisciplinary approach). These patients can improve their condition slowly over time, but they are very challenging, and require patience and additional expertise.

fibro-pic2

The best overall recommendations for fibromyalgia is reassurance, and education to recognize the conditions that can aggravate their other painful symptoms, and make pro-active adjustments to their lifestyle including “pacing” themselves, with psychological counseling including “cognitive behavioral” therapy as well as lifestyle modification for tobacco or alcohol cessation, sleep hygiene, and prioritize proper eating habits including specialized preservative free or anti-oxidant diets for healthy weight changes.

Relaxation training or biofeedback may also be considered. The patient may use non-habituating pre-medications (acetaminophen, anti-inflammatories or muscle relaxants) in anticipation strenuous activities with, warm ups or stretches, or make changes in their work station or ergonomic modification. The patients need to continue performing postural exercises, stretches, low impact aerobic conditioning including aquatics, walking or stationary bicycling, and gentle strengthening on a daily basis.

Physical medicine modalities may be passively applied to the most painful regions that represent the superimposed painful condition, including hot or cold packs, ultrasound, electrical stimulation, massage, stretching, therapeutic exercises, joint, tendon or nerve mobilization or manipulation (osteopathic or chiropractic), aquatics, acupuncture, or other complementary/ alternative medicine approaches.

Then there is an active exercise phase with rehabilitation to improve their posture, flexibility, endurance, and strength and transitioning the patient to an independent individualized program of home exercises, which allows the muscles/ tendons/ ligaments/ joints to operate at greatest efficiency, thus improving function and preventing painful recurrences. Other treatments can be considered including TENS (transcutaneous electrical nerve stimulation), trigger point injections or other interventional blocks, which are mainly treating the pain generator.

Adaptive equipment may also be used including sitting cushions, back braces, heel lifts, foot orthotics, splints or elastic wraps, traction units and walking aides.
Certain medications are prescribed for the “diagnosis” of fibromyalgia including selective serontonin/ norephinephrine reuptake inhibitors (ie antidepressants including duloxetine, milcaprin, amitrypitene and others), which improves the brain’s ability to suppress the pain signals, and calcium channel modulators (ie pregabalin, or gabapentin), which prevents the amplification of the pain signal transmission from the spine to the brain.

Other adjunctive medications can be used to reduce the pain generator component including anti-inflammatories, acetaminophen, muscle relaxants, other anticonvulsants, anesthetics, and topical medications. Some patients require anti-histamines because there is an associated release of histamine under the skin in the region of muscle spasm that can cause additional muscle soreness.

There some over the counter supplements including vitamins (especially Vitamin D), amino acids, sleep aides, or herbal medications that may also be tried. It is controversial whether opioids taken chronically will result in meaningful improvements of fibromyalgia. Therefore, it is prescribed and monitored carefully in those patients who demonstrate responsible use (without dose escalation once it is properly titrated), medication security, with improvement or stabilization of their pain and function, without significant limiting side effects, or changes in their personality (medication taking aberrancy). Additional research is currently being done for more effective medications with less side effects or risk of dependency, misuse or addiction.

The care that is required for successful treatment of fibromyalgia is individualized, and goal oriented to improve function, not cure. The treatment provides a foundation of support that nurtures the confidence, or guiding the patient to improve their overall lifestyle and level of fitness. This encourages the patient to go beyond their perceived boundaries to a higher level of “wellness”, while at the same time legitimately validating their current pain generators as a significant reason for their overall condition. Other reasonable goals may include stabilization of their pain complaints, depression, anxiety, sleep disorder, maintenance of activities or function, prevention of worsening of condition, prevent unnecessary urgent care visits, procedures or surgery by adequately managing their pain, prevent the adverse effects of inactivity.