Overview and Risk Factors
Fibromyalgia is a common but poorly understood and somewhat controversial pain syndrome that affects muscles, tendons, and ligaments. Some reports suggest that in 50% of cases, generalized pain begins after trauma or illness. However, the patient’s history and examination present no explanation for the persistent pain. The condition may be related to an abnormality in pain perception.
Nearly every fibromyalgia patient has fatigue, along with poor sleep quality that may include sleep apnea or other sleep abnormalities. Other common concurrent illnesses include irritable bowel syndrome, depression or anxiety, and headache. Many other nonspecific symptoms may occur, including glosodynia, paresthesias without dermatomal distribution, environmental sensitivity (chemical and allergic), and difficulties in concentrating.
Risk Factors
Gender. The condition is 10 times more common in women than in men.
Age. Prevalence in a Kansas population increased from 2% at age 20 to 8% at age 70.1
Genetic factors. Specific genes relating to abnormal serotonin metabolism and transmission have been identified in fibromyalgia patients.
Diagnosis
Pain symptoms are often symmetric. Screening for psychiatric conditions is appropriate, but a positive diagnosis does not exclude fibromyalgia as a separate diagnosis.
Physical examination reveals characteristic tender points. Palpation causes pain that is disproportionate to the stimulus intensity. Apart from muscle and tendon pain, the examination is otherwise normal except for coexisting conditions, such as rheumatoid arthritis, osteoarthritis, and lupus.
The diagnosis of fibromyalgia requires 11 of 18 bilateral tender points.2 Pressure should be applied gradually and with a dolorimeter (4kg/cm), or by using a finger to the point of whitening of the fingertip.3
The sites of palpation are:
Superolateral quadrant of gluteus maximus.
Supraspinatus origin.
Superior half of trapezius.
Suboccipital insertion.
Sternocleidomastoid (posteroinferior).
Second costochondral junction.
Lateral epicondyle (approximately 2 cm distal).
Greater trochanter.
Medial knee (fat pad).
No abnormal laboratory or imaging findings are diagnostic of fibromyalgia, and inappropriate use of tests can lead to misdiagnosis. Initial laboratory tests that could help rule out other etiologies include erythrocyte sedimentation rate, complete blood count, thyroid function tests, Lyme disease titer, and creatine kinase.
Treatment
Commonly used treatments include both nonpharmacologic and drug therapies:
Nonpharmacologic Interventions4
Low–impact, incremental, cardiovascular exercise programs (3 times weekly).
Muscle strengthening and flexibility programs. Yoga often serves both purposes.
Hypnotherapy, cognitive behavioral feedback, electromyography (EMG) biofeedback, and meditation programs.
Acupuncture, TENS (transcutaneous electro–nerve stimulator) units, and trigger point needling (or injections with lidocaine). These are all under investigation.
Pharmacologic Interventions
Nonsteroidal anti–inflammatory drugs (NSAIDs) are no better than a placebo when used as monotherapy. However, they may be effective in combination with centrally active medications.
Acetaminophen and/or tramadol in medication–naïve patients may be helpful, but efficacy in other clinical scenarios requires further study.
Cyclobenzaprine and tricyclic antidepressants, such as amitriptyline, may benefit a minority of patients. Efficacy may lessen over time. Small doses with gradual increase are advised, due to undesirable side effects (eg, dry mouth, urinary retention). Desipramine may have milder adverse side effects.
Selective serotonin reuptake inhibitors may be effective in treating pain and may act synergistically with tricyclics.5
Duloxetine and milnacipran, which inhibit catecholamine and serotonin reuptake, and carisoprodol (at bedtime), may be beneficial.
Emerging therapeutics, such as anticonvulsants and serotonin receptor blockers, may also be efficacious in treating pain and other symptoms of fibromyalgia.
Narcotics and benzodiazepines are usually contraindicated.
A multidisciplinary approach that includes physical therapy, good sleep hygiene, and mental health specialists may be indicated for optimal treatment, because concomitant depressive symptoms and adjustment problems are often present. Patients also benefit from knowing that a hidden condition is not the cause of their symptoms.
Nutritional Considerations
Fibromyalgia is considered a rheumatic disease, one in which inflammatory cytokines (eg, interleukin–6) may be involved in triggering or increasing inflammation and its symptoms.6 Indications of increased oxidative stress (malondialdehyde, advanced glycosylation end products)7 and lower levels of the antioxidant enzyme superoxide dismutase have been found in patients with fibromyalgia.8 Dietary manipulation can reduce oxidative stress and cytokine production (see Rheumatoid Arthritis chapter), but such treatments have yet to be tested in fibromyalgia patients. Limited evidence suggests that a vegan diet may improve subjective experience of joint pain and stiffness.9,10 However, this impression requires confirmation in additional controlled clinical trials.
Fibromyalgia patients also have disturbed sleep and may have lower nocturnal melatonin production, which can increase daytime fatigue and pain perception.11 Limited evidence indicates that supplemental melatonin (3 mg at bedtime) reduces tender points, pain severity, and sleep disturbances, and results in improvement in both patient and physician assessment of global improvement.12 Further studies are needed to assess the effects of diet changes and melatonin supplements on the condition.
Orders
Exercise prescription: Patient should be given an appropriate, sustainable, and enjoyable exercise routine.
What to Tell the Family
Fibromyalgia is a poorly understood condition that is treated symptomatically. General recommendations for a healthy exercise routine may be helpful to the patient and the entire family. Concomitant depression or other mental illness should be treated, but fibromyalgia is not an imaginary illness. Good sleep hygiene is also very important. Limited evidence suggests that some patients may respond well to a low–fat, vegan diet, and diet changes are easier to adopt when all family members make the change.
References
1. Wolfe F, Ross K, Anderson J, et al. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. 1995;38:19.
2. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multicenter criteria committee. Arthritis Rheum. 1990;33:160-172.
3. Okifuji A, Turk DC, Sinclair JD, Starz TW, Marcus DA. A standardized manual tender point survey. I. Development and determination of a threshold point for the identification of positive tender points in fibromyalgia syndrome. J Rheumatol. 1997;24:377-383.
4. Goldenberg DL, Burckhardt C, Crofford L. Management of fibromyalgia syndrome. JAMA. 2004;292:2388-2395.
5. Goldenberg DL, Mayskiy M, Mossey CJ, et al. A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum. 1996;39:1852.
6. Wallace DJ, Linker-Israeli M, Hallegua D, Silverman S, Silver D, Weisman MH. Cytokines play an aetiopathogenetic role in fibromyalgia: a hypothesis and pilot study. Rheumatology (Oxford). 2001;40:743-749.
7. Hein G, Franke S. Are advanced glycation end-product-modified proteins of pathogenetic importance in fibromyalgia? Rheumatology (Oxford). 2002;41:1163-1167.
8. Bagis S, Tamer L, Sahin G, et al. Free radicals and antioxidants in primary fibromyalgia: an oxidative stress disorder? Rheumatol Int. 2005;25:188-190.
9. Donaldson MS, Speight N, Loomis S. Fibromyalgia syndrome improved using a mostly raw vegetarian diet: an observational study. BMC Complement Altern Med. 2001;1:7.
10. Hanninen O, Kaartinen K, Rauma AL, et al. Antioxidants in vegan diet and rheumatic disorders. Toxicology. 2000;155:45-53.
11. Wikner J, Hirsch U, Wetterberg L, Rojdmark S. Fibromyalgia--a syndrome associated with decreased nocturnal melatonin secretion. Clin Endocrinol (Oxf). 1998;49:179-183.
12. Citera G, Arias MA, Maldonado-Cocco JA, et al. The effect of melatonin in patients with fibromyalgia: a pilot study. Clin Rheumatol. 2000;19:9-13.
