Fibromyalgia

From Academic Kids

Fibromyalgia is a debilitating chronic syndrome (constellation of signs and symptoms) characterized by diffuse pain, fatigue, and a wide range of other symptoms. It is not contagious, and recent studies suggest that people with fibromyalgia may be genetically predisposed[1] (http://fmaware.org/fminfo/brochure.htm). It affects more women than men, with a ratio globally of 3-5:1. Fibromyalgia is seen in 3-10% of the general population, and is mostly found between the ages 20 and 50. The nature of fibromyalgia is not well understood, and there is no cure, though it can be managed.

Contents

History

Fibromyalgia has been studied since the early 1800s and referred to by a variety of former names, including muscular rheumatism, neurasthenia and fibrositis. The term fibromyalgia was coined in 1976 to more accurately describe the symptoms, from the Greek my-, meaning muscle, and algia, meaning pain.

Fibromyalgia was once considered an autoimmune disorder, but laboratory results reveal no disturbance of the immune system. It was also once classified as a psychosomatic disorder, although few specialists currently would classify it as such. Because the understanding of this disorder has grown so rapidly in the 1990s and 2000s, many texts on the subject are out of date.

Symptoms

The primary symptom of fibromyalgia is widespread, diffuse pain, often including heightened sensitivity of the skin (that may make the touch of clothing painful), achiness around joints, and nerve pain. Other symptoms often attributed to fibromyalgia (possibly due to another comorbid disorder) are physical fatigue, irritable bowel syndrome, genitourinary symptoms, dermatological disorders, headaches, and symptomatic hypoglycemia. Although it is common in people with fibromyalgia for pain to be widespread, it may also be localized in areas such as the shoulders, neck, back, hips, or other areas. Not all patients have all symptoms.

It can start as a result of some trauma (such as a traffic accident) or illness, but there is no strong correlation between any specific type of trigger and the subsequent initiation of fibromyalgia. Symptoms can have a slow onset, and many patients have mild symptoms beginning in childhood such as growing pains. Symptoms are often aggravated by unrelated illness, or changes in the weather. They can become more tolerable or less tolerable throughout daily or yearly cycles, however, many people with fibromyalgia find that, at least some of the time, the disease prevents them from performing normal activities such as driving a car or walking up stairs. The syndrome does not cause inflammation as is presented in arthritis, nor are there any diagnostically abnormal laboratory findings. Symptoms may present periodically or may be continual.

Diagnosis

When making a diagnosis of fibromyalgia, a practitioner would take into consideration the patient's case history and the exclusion of other conditions such as endocrine disorders, arthritis, and polymyalgia rheumatica. There are also two criteria established by the American College of Rheumatology for diagnosis:

  • A history of widespread pain lasting more than three months —widespread as in all four quadrants of the body, i.e., both sides, and above and below the waist.
  • Tender points —there are 18 designated possible tender points (although a person with the syndrome may feel pain in other areas as well). During diagnosis, four kilograms of pressure[2] (http://www.niams.nih.gov/hi/topics/fibromyalgia/fibrofs.htm#fib_d) is exerted at each of the 18 points; the patient must feel pain at 11 or more of these points for fibromyalgia to be considered. This technique was developed by the American College of Rheumatology as a means of confirming the diagnosis for clinical studies. It is also used in the United Kingdom. Unfortunately, while the vast majority of fibromyalgia patients express pain when these points are pressed, a few patients with a high pain tolerance may not feel exceptional pain during the test.

Since fibromyalgia is a somewhat ill-defined syndrome, with no single cause, causal agent or mechanism, blind tests have been done with people who were suspected to have fibromyalgia, to rule out the possibility that people were faking having the syndrome. Thanks to these tests, fibromyalgia and the tender points diagnostic procedure have now been accepted by official medical associations worldwide.

Differentials

A number of other disorders can produce essentially the same symptoms as fibromyalgia. Disorders that are known or claimed to produce the same symptoms are:

Treatment

There is no generally accepted cure for fibromyalgia, but many treatment options are available. A patient may try many routes of treatment under the guidance of a physician to find relief. Treatments range from prescription medication to alternative and complementary medicine like herbal medicine and acupuncture[3] (http://www.arthritis.org/resources/arthritistoday/2000_archives/2000_05_06_acupuncture.asp) to exercise therapy.

Conventional analgesics reduce the effects of fatigue and pain. Antidepressants are often prescribed as well to adjust nerve response and help to deal with the psychological effects of constant fatigue and pain. Low doses tricyclic antidepressants like amitriptyline, have also been used to treat the insomnia associated with fibromyalgia, and are believed by many practitioners to help correct sleep problems that may cause or exacerbate the disease. New drugs showing significant efficacy on fibromyalgia pain and other symptoms include SSNRI Cymbalta and GABA analogue Lyrica (pregabalin[4] (http://www.drugdevelopment-technology.com/projects/pregabalin/)).

Studies have found gentle aerobic exercise, such as warm-water pool therapy, improves fitness and sleep and reduces pain and fatigue in people with fibromyalgia[5] (http://www.arc.org.uk/about_arth/booklets/6013/6013.htm). Patients should begin slowly and build their activity level gradually so as to avoid pain and discouragement. However, exercise may be poorly tolerated in more severe cases.

Many patients find temporary relief by applying heat to painful areas. Those with access to physical therapy and/or massage may find them beneficial. Occupational therapy may assist people with fibromyalgia in maintaining employment.

Unfortunately, as with many difficult-to-treat disorders, a large number of opportunistic practitioners are attracted to the treatment of fibromyalgia, and many treatments of dubious validity are often offered to the unsuspecting (and desperate).

Living with fibromyalgia

Fibromyalgia can affect every aspect of a person's life. While it cannot cause death in itself, the chronic pain and depression associated with Fibromyalgia puts its sufferers at risk for suicide, although it is unclear whether there is an increased risk[6] (http://www.cfidsselfhelp.org/artcl_killing_me_softly.htm). However it can severely curtail social activity and recreation, and many people with fibromyalgia are unable to maintain a full-time job.

In the United States, those affected by fibromyalgia may qualify under programs for those whose work is adversely affected by disabilities. Employed Americans may apply for coverage under the Americans with Disabilities Act. Children and college students may be granted more time to take tests, changes in physical education requirements, and college housing closer to class locations.

In the United Kingdom, the Department for Work and Pensions recognizes fibromyalgia as a condition for the purpose of claiming benefits and assistance [7] (http://www.fibromyalgia-associationuk.org/DWP.htm).

Theories on the cause of fibromyalgia

The cause of fibromyalgia is currently unknown. Over the past few decades many theories have been presented, and the understanding of the disorder has changed dramatically. Most current theories explain only a few symptoms of the disorder and are thus incomplete.

Sleep Disturbance Theory

The sleep disturbance theory postulates that fibromyalgia is related to sleep quality. Electroencephalography (EEG) studies have shown that people with fibromyalgia lose deep sleep[8] (http://www.arc.org.uk/about_arth/booklets/6013/6013.htm). Circumstances that interfere with "stage 4" deep sleep (such as drug use, pain, or anxiety) appear to be able to cause or worsen the condition.

According to the sleep disturbance theory, an event such as a trauma or illness causes sleep disturbance and, possibly, some sort of initial chronic pain. These initiate the disorder. The theory supposes that "stage 4" sleep is critical to the function of the nervous system, as it is during that stage that certain neurochemical processes in the body "reset". In particular, pain causes the release of the neuropeptide substance P in the spinal cord, and substance P has the effect of amplifying pain and causing nerves near the initiating ones to become more sensitive to pain. Under normal circumstances this just causes the area around a wound to become more sensitive to pain, but if pain becomes chronic and body-wide then this process can run out of control. The sleep disturbance theory holds that deep sleep is critical to reset the substance P mechanism and prevent this out-of-control effect.

An interesting aspect of the sleep disturbance/substance P theory is that it explains "tender points" that are characteristic of fibromyalgia but which are otherwise enigmatic, since their positions don't correspond to any particular set of nerve junctions or other obvious body structures. The theory posits that these locations are more sensitive because the sensory nerves that serve them are positioned in the spinal cord to be most strongly affected by substance P. This theory does not explain slow-onset fibromyalgia, fibromyalgia present without tender points, or patients without heightened pain symptoms. It also does not address the multitude of non-pain symptoms present in the disorder.

Also of interest is a possible connection between this theory and the theory that chronic fatigue syndrome and post-polio syndrome are due, at least in part to damage to the ascending reticular activating system of the reticular formation. This area of the brain, in addition apparently controlling the sensation of fatigue, is known to control sleep behaviors and is also believed to produce some neuropeptides, and thus injury or imbalance in this area could cause both CFS and sleep-related fibromyalgia, explaining why the two disorders so often occur together.

The Deposition Disease Theory

Another theory involves phosphate and calcium accumulation in cells that eventually reaches a level to impede the ATP process, possibly caused by a kidney defect or missing enzyme that prevents the removal of excess phosphates from the blood stream. This theory posits that fibromyalgia is an inherited disorder, and that phosphate build up in cells is gradual (but can be accelerated by trauma or illness). Calcium is required for the excess phosphate to enter the cells. The additional phosphate slows down the ATP process; however the excess calcium prods the cell to continue producing ATP[9] (http://www.fibromyalgia-associationuk.org/Are%20phosphates%20the%20hidden%20enemy%20(1).pdf) (76.7kb pdf).

Diagnosis is made with a specialized technique called mapping that is a gentle palpitation of the muscles to detect lumps and areas of spasm that are thought to be caused by an excess of calcium in the cytosol of the cells. This mapping approach is specific to deposition theory, and is not related to the trigger points of myofascial pain syndrome.

While this theory does not identify the causative mechanism in the kidneys, it proposes a treatment known as guaifenesin therapy. This treatment involves administering the drug guaifenesin to a patient's individual dosage, avoiding salicylic acid in medications or on the skin, and, if the patient is also hypoglyemic, a diet designed to keep insulin levels low.

The phosphate build-up theory explains many of the symptoms present in fibromyalgia and proposes an underlying cause. The guaifenesin treatment, based on this theory, has received mixed reviews, with some practitioners claiming many near universal success and others reporting no success. Only one controlled clinical trial has been conducted to date, and it showed no evidence of the efficacy of this treatment protocol. This study was criticized for not limiting the salicylic acid exposure in patients, and for studying the only effectiveness of guaifenesin, not the entire treatment method. As of 2005, further studies to test the protocol's effectiveness are in the planning stages, with funding for independent studies largely collected from groups which advocate the theory.

Other Theories

Other theories relate to various toxins from the patient's environment, viral causes, growth hormone deficiencies, neurotransmitter disruptions in the central nervous system, and erosion of the protective chemical coating around sensory nerves. Due to the multi-systemic nature of illnesses such as fibromyalgia and chronic fatigue syndrome (CFS/ME), an emerging branch of medical science called psychoneuroimmunology (PNI) is looking into how the various theories fit together.

Comorbid Diseases

Cutting across several of the above theories is a theory that proposes that fibromyalgia is almost always a comorbid disorder, occurring in combination with some other disorder that likely served to "trigger" the fibromyalgia in the first place. This concept fits especially well with the sleep disturbance theory.

By this theory, some other disorder (or trauma) occurs first, and fibromyalgia follows as a result. In some cases the original disorder abates on its own or is separately treated and cured, but the fibromyalgia remains. In other cases the two disorders coexist. This theory would explain why such a wide variety of symptoms are often ascribed to fibromyalgia, since there are potentially a wide variety of comorbid disorders. It also helps explain why fibromyalgia is so hard to treat, since the fibromyalgia is unlikely to abate while the comorbid condition is untreated.

Commonly proposed comorbid/trigger disorders are:

References

External links

Other resources

es:Fibromialgia nl:Fibromyalgie

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