#1 Fibromyalgia Medical Abstracts

Fibromyalgia 

Medical Abstracts

1. What Fibromyalgia Isn’t.
2. Fibromyalgia Tender Points
3. Symptoms
4. Clinical Manifestations of Fibromyalgia

According to the Merck Manual, a standard reference book used in (the failing) allopathic medicine, Fibromyalgia is defined as achy pain and stiffness in soft tissue, including, muscles, tendons and ligaments. Fibromyalgia pain may occur throughout the body or may be restricted in certain locations.  

Fibromyalgia

Fibromyalgia (FM) is the commonest cause of widespread pain (Bennett,1995), yet it may remain undiagnosed for a long time. Uncertainty and frequent misdiagnosis can cause considerable havoc in the lives of patients. Every expert in the field seems to have his or her own estimate of how many people actually have FMS. This confusion will remain until doctors are trained in comprehensive differential diagnosis.

Fibromyalgia is pronounced fie-bro-my-al-jia sind-rome. The word "fibromyalgia" is a combination of the Latin roots fibro (connective tissue fibers), my (muscle), al (pain), and gia (condition of). Fibromyalgia is not a new "fad disease". For many years the medical profession called it by many different names, including "chronic rheumatism" and "fibrositis". Most physicians still lack the skills to diagnose and treat it effectively. FMS, like many other conditions, is not curable right now, but it is very treatable, and there are many ways in which you can considerably improve your health and quality of life. You may come to your doctor with symptoms that seem unrelated. They can run the gamut from mental confusion to burning feet, but are usually accompanied by an over-all flu-like feeling that impacts every aspect of your life. Each chapter in "Fibromyalgia and Chronic Myofascial Pain: A Survival Manual, edition 2" has its own medical journal reference section at the end of the chapter. There is also instruction in how to obtain these reference materials.

Fibromyalgia is definitely not a new illness, and doctors have been aware of this condition for centuries. In 1843, a physician named Robert Froricep described a condition he observed in his patients as “rheumatism with painful hard places.” In the early 1900s, Sir William Gowers observed symptoms in his painful muscular symptoms in his patients, and called this disease fibrositis.

In 1981, the American College of Rheumatology, American Medical Association, The World Health Organization, and the National Institutes of Health have all accepted FMS as a legitimate clinical entity a true physical illness and a major cause of disability. Because of this action, the illness was given an ICD code (International Statistical Classification of Diseases and Related Health Problems).

If your doctor "doesn’t believe in FMS", you are going to the wrong doctor.

At the Travell Focus on Pain Seminar 2000, I. Jon Russell MD, editor of the Journal of Musculoskeletal Pain, mentioned the use of the Functional MRI, which shows the brain in action. In a healthy individual, when you pressed on a tender point, there is minimal response, but in a patient with FMS, "...the result was wild. The whole brain went crazy." Something is happening in the FMS central nervous system that doesn’t happen to healthy people. 

Fibromyalgia can be a source of substantial disability (Kaplan, Schmidt and Cronan, 2000). This is especially true if you have had it for a long period of time without adequate medical support. Nearly everyone with FMS exhibits reduced coordination skills and decreased endurance abilities, although some of this may be due to co-existing chronic myofascial pain (CMP).

Fibromyalgia is a complex syndrome characterized by pain amplification, musculoskeletal discomfort, and systemic symptoms. In FMS, there is a generalized disturbance of the way pain is processed by the body (Morris, Cruwys and Kidd, 1998). I think the definition of FMS as widespread allodynia and hyperalgesia (Russell, 1998) describes it well. Allodynia means nonpainful sensations are translated into pain sensations. Hyperalgesia means that your pain sensations are amplified. These changes in the way your central nervous system processes pain seem to be worse if there is a physically traumatic initiating event.

You may be sensitive to odors, sounds, lights, and vibrations that others don’t even notice. The noise emitted by fluorescent lights might drive you to distraction. Your body may at times interpret touch, light, or even sound as pain. Sleep, or the lack thereof, plays a crucial role in FMS. Sleep disturbances, a swollen feeling, and exercise intolerance are significantly related to FMS (Jacobsen, Petersen and Danneskiold-Samsoe, 1993).

Besides specific tender points, the essential symptom of FMS is pain, except in the case of older patients. Seniors are more troubled by fatigue, soft-tissue swelling and depression (Yunus, Holt, Masi et al. 1988) In younger people, discomfort after minimal exercise, low-grade fever or below-normal temperature, and skin sensitivity are also common (Reiffenberger and L. H. Amundson, 1996).

Central Sensitization "It is now firmly established that a central nervous system (CNS) dysfunction is primarily responsible for the increased pain sensitivity of fibromyalgia" (Simons, Travell and Simons, 1999 p 17). There is a generalized CNS- mediated deep tissue sensitivity in FMS includes the muscles, which is why so many people mistakenly believe that it is a muscular condition. Anything that results in tissue injury, whether from more obvious physical trauma such as an auto accident or from subtler biochemical damage, can cause hypersensitivity at the site of the injury. If there is repeated or continued trauma, other areas may develop the hypersensitivity (Yaksh, Hua,. Kalcheva et al. 1999). This can lead to a state of "central sensitization", as your nervous system reacts to chronic, long-term pain in several ways.

The tendency to develop FMS may be inherited. Many mothers with FMS have children with FMS. Because psychological and familial factors were not different in children with or without FMS, this may be due to genetics (Yunus, Kahn, Rawlings, et al.1999). In 1989, Pellegrino, Waylonis and Sommer found that FMS might be inherited on an autosomal dominant basis, with a variable latent phase. This means that approximately half of the children of an FMS parent will eventually develop FMS. The sooner FMS is recognized and treated the more easily symptoms can be controlled. In Fibromyalgia and Chronic Myofascial Pain: A Survival Manual, edition 2, there is a chapter dealing with age-related issues, infant to senior citizen, later in the book.

What Fibromyalgia Isn’t.

Fibromyalgia is not musculoskeletal disorder (Simms, 1998). It should have been called "Central Nervous System-myalgia" (New Research). That is where the dysfunction is. It has nothing to do with the fibers of your muscles. In FMS, muscle fibers are not causing the problem, although there may be cellular changes caused by biochemical FMS dysfunction. Fibromyalgia is a biochemical disorder, and these biochemicals affect the whole body. You can’t have FMS only in your back or your hands. You either have it all over or you don’t have it at all. If you have localized complaints, they are probably not caused by FMS, although FMS may be amplifying the local symptoms.

Fibromyalgia is not progressive (Wolfe, Anderson, Harkness et al.1997). If your illness is getting significantly worse with time, there is some perpetuating or aggravating factor or a co-existing condition that has not been addressed. If you identify it and deal with it thoroughly and promptly, your symptoms should ease considerably. Fibromyalgia is not a diagnosis of exclusivity. You may have co-existing conditions, such as MS, arthritis, and/or myofascial pain, and still have FMS amplification.

Fibromyalgia is not a catchall, wastebasket diagnosis. It is a specific, chronic non-degenerative, non-inflammatory syndrome. It is not a disease. Diseases have known causes and well-understood mechanisms for producing symptoms. A syndrome is a specific set of signs and symptoms that occur together are also classified as syndromes. Rheumatoid arthritis, lupus, and many other serious conditions are also syndromes.

Fibromyalgia is not the same as chronic myofascial pain (Gerwin, 1999). It is fundamentally different in an important way (Simons, Travell and Simons, 1999 p 18.) There is no such thing as a fibromyalgia trigger point. Mention of "FMS trigger points" by your doctor or physical therapist should wave a warning flag that there is a serious lack of understanding here. Trigger points (TrPs) are part of myofascial pain, not FMS, and your care provider must understand this.

Fibromyalgia is not the same as CFIDS, although they may be part of the same family of central nervous system dysfunctions. In one study, levels of substance P were determined in the cerebrospinal fluid in 15 patients with CFIDS. All values were within normal. Most patients with FM have increased substance P in the cerebrospinal fluid. The results of this study support the notion that FMS and CFIDS are different disorders in spite of overlapping symptoms (Evengard, Nilsson, Lindh, et al. 1998). Another study points out that "In FMS, there is a condition of physiological hyperarousal. In CFIDS, a blunted response, the exact opposite, occurs" (Crofford, 1998).

Fibromyalgia is not just widespread pain or achy muscles. In the general population, adults who meet the ACR definition of FMS appear to have distinct features compared to those with chronic widespread pain that do not meet those criteria (White, Speechley, Harth et al. 1999a). There are many conditions, which cause widespread pain besides FMS. CMP can cause widespread pain due to trigger point cascades, for example. Side effects of some medications can do the same. Widespread pain is also common in Lyme disease, HIV, hypothyroid and other endocrine abnormalities, and some genetic diseases (Soppi M. and E. Beneforti, 1999).

Fibromyalgia is not homogenous. The cause of muscle pain and allodynia may not be the same in all persons fulfilling the American College of Rheumatology (ACR) criteria for FMS (Henriksson, 1999). Fibromyalgia seems to include patients with different pain processing mechanisms (Sorensen, Bengtsson, Ahlner, et al.1997). There are many subsets of FMS. One study has separated some subsets into meaningful categories (Eisinger, Starlanyl, Blatman, 2000), and this separation may help decide which treatment regimens are more likely to help specific patients.

Fibromyalgia is not autoimmune (Wittrup, Wiik, Danneskiold-Samsoe, 1999). The presence of antinuclear antibodies and other connective tissue disease features is similar in patients with fibromyalgia and healthy controls (Yunus, Hussey and Aldag, 1993). Some FMS patients may develop co-existing autoimmune conditions, and patients with immune conditions may develop FMS, but this does not show a causal relationship. There is a subset of people with FMS who test positive for antinuclear antibodies (Smart, Waylonis and Hackinshaw, 1997). We don’t yet know what this means. A response to antipolymer antibodies is associated with a subset of patients with FMS (Wilson, Gluck, Tesser et al. 1999).

Fibromyalgia is not a mental illness, and must not be categorized as such. Some people with FMS also have mental illness. Some people with sniffles have mental illness too, but that doesn’t mean that sniffles are caused by mental illness. Studies have shown that the incidence of mental problems is no higher with FMS patients than with any other type of chronic pain syndrome (Goldenberg, 1989; Merskey, 1989 ). "There is now clinical evidence that FMS represents a distinct rheumatic disorder and should not be regarded as a somatic illness secondary to psychiatric disorder" (Dunne and Dunne 1995). "Psychiatric Diagnostic Interview data failed to discriminate in any major way between primary fibromyalgia syndrome (a disorder with no known organic etiology) and rheumatoid arthritis (a disorder with a known organic etiology). Therefore, these data do not support a psychopathology model as a primary explanation of the symptoms of primary fibromyalgia syndrome" (Ahles, Khan, Yunus et al. 1991).

Fibromyalgia is not infectious. Infection from many causes can start the neurochemical cascade of FMS. This does not mean that FMS itself is infectious. Both FMS and CMP can be brought on by triggers, such as stress, infections, pollution, and diet. There is a great deal of financial and other stress in dealing with a chronic illness, so it is not surprising that some partners of patients with FMS develop the same illness.

Tender points hurt where pressed, but they do not refer pain. In other words, pressing a tender point does not cause pain in some other part of the body. The examiner must use enough pressure to whiten the thumbnail, which is about 4 kg pressure. The official definition further requires that tender points must be present in all four quadrants of the body, that is, the upper right and left and lower right and left parts of your body. Tender points occur in pairs, so the pain is usually distributed equally on both sides of the body.

Fibromyalgia Tender Points

On the back of your body, tender points are present in the following places:Along the spine in the neck, where the head and neck meet;On the upper line of the shoulder, a little less than halfway from the shoulder to the neck;about three finger widths, on a diagonal, inward from the last points;On the back fairly close to the dimples above the buttocks, a little less than halfway in toward the spine;

Below the buttocks, very close to the outside edge of the thigh, about three finger widths.On the front of your body, tender points are present in the following places:

On the neck, just above inner edge of the collarbone;On the neck, a little further out from the last points, about four finger widths down;On the inner (palm) side of the lower arm, about three finger widths below the elbow crease;On the inner side of the knee, in the fat pad.

The tender point count may decrease with proper medical treatment and self-care, but that doesn’t mean that the FMS has been cured. It simply means that you have learned to deal with the perpetuating factors and co-existing conditions and have them under control.

In FMS, we believe that there is often an initiating event that activates biochemical changes, causing a cascade of symptoms. For example, unremitting grief of six months or longer can trigger FMS. In many ways, FMS is sort of like a Survivor’s Syndrome. Cumulative trauma, protracted labor in pregnancy, open-heart surgery, and even inguinal hernia repair have all been initiating events for FMS. The start of each case of FMS probably has multiple causes (Bennett and Jacobsen,1994. Not all cases of FMS cases have a known triggering event that initiates the first obvious flare. During a flare, current symptoms become more intense, and new symptoms frequently develop.

Fibromyalgia seems to be the result of many neurotransmitter cascades (Fibromyalgia Advocate, Chapter 2). A neurotransmitter cascade is like a waterfall that starts at the top and bounces off rocks and ridges on the way down, wearing down rock, moving gravel, and changing the river as it goes. The neurotransmitter cascade can cause changes throughout your body, and many of these changes start cascades of their own. Once they get going, a combination of peripheral and central factors join in to make the changes chronic, and the result is what we call fibromyalgia. Every patient may have different "informational substances" disrupted in different ways".

Symptoms

symptoms of fibromyalgia can include:

headache or facial pain, often as a result of neck, shoulder or jaw muscle stiffness,

disturbed sleep or tiredness upon waking,

irritable bowels or bladder, leading to an increased need to pass urine, diarrhoea, constipation, or feeling bloated,

tingling, numbness, prickling or burning sensations in the hands and feet (paresthesia),

dry eyes, skin or mouth,

unusually painful periods,

restlessness in the legs, particularly at night,

increased sensitivity to smells, noise, bright lights or touch,

poor concentration or memory lapses,

anxiety, and

depression.

Symptoms sometimes get better or worse depending on factors such as the weather, stress levels, and what types of activity the person is doing. Many people find that symptoms are worse first thing in the morning and last thing at night.

Full recovery from fibromyalgia is uncommon, although there may be long periods of time when symptoms disappear completely. Most people have to learn to live with the condition long-term. However, fibromyalgia is not life-threatening and does not reduce life expectancy. None of the common symptoms of fibromyalgia are outwardly visible and someone with the condition may appear perfectly well. As a result, fibromyalgia is sometimes referred to as 'the invisible disability' or the 'irritable everything syndrome'.

Causes

The cause of fibromyalgia is unknown, although there are several theories.

Research has shown that people with fibromyalgia have lower than normal levels of a chemical called serotonin. Serotonin plays an important part in controlling pain and regulating sleep. One of the leading theories is that a low level of serotonin causes fibromyalgia.
 However, research has also shown that people with fibromyalgia tend to have disturbances in their deep sleep. Some experts believe that disturbed sleep patterns may be a cause of fibromyalgia, rather than just a symptom. Other theories about the cause include viral infection (although no virus has been identified), physical injury, altered pain perception, lack of growth hormone and hereditary factors. It is possible that there is no single cause, and that several factors combine to cause the condition.

Diagnosis

Diagnosing fibromyalgia can be difficult - there is no specific test that can diagnose the condition and the symptoms of fibromyalgia can vary from person to person.

Treatment

There is no cure for fibromyalgia, so treatment aims to ease the symptoms as much as possible and to improve your quality of life.

It's also important to get enough sleep to reduce the effects of fatigue, and to eat a healthy, balanced diet to help with energy levels. Full recovery from fibromyalgia is uncommon. Although symptoms may vary in severity over time, and may even disappear completely for periods, they usually return

~~~~~~~~~~~~~~

Symptoms

In fibromyalgia, generalized, widespread muscular pain and tender points (see figure 1) may be present. Pain is generally felt all over, although it may start in one region, such as the neck and shoulders, and seems to spread over a period of time. Fibromyalgia pain has been described in a variety of ways including: burning, radiating, gnawing, sore, stiff, and aching. It often varies according to time of the day, activity level, weather, sleep patterns, and stress levels. Most people with fibromyalgia say that some degree of pain is always present. They sense that the pain is mainly in their muscles and often note that fibromyalgia feels like a persistent flu. About 90 percent of people with fibromyalgia describe moderate or severe fatigue with lack of energy, decreased exercise endurance, or the kind of exhaustion felt with the flu or with lack of sleep. Often the fatigue is more of a problem and more troubling than the pain. Generally, people with fibromyalgia wake up feeling tired, even after sleeping throughout the night. They may be aware that their sleep has become lighter and that they wake up during the night. Scientific studies have demonstrated that most people with fibromyalgia have an abnormal sleep pattern, especially an interruption in their deep sleep. The fatigue in fibromyalgia is similar to that in another condition called chronic fatigue syndrome (CFS). Some people with fibromyalgia have symptoms of CFS, and vice versa. For example, many people with CFS have the tender points and symptoms considered to be diagnostic of fibromyalgia. Changes in mood and thinking are common in fibromyalgia. Many individuals feel "blue" or "down," although only about 25 percent are truly depressed at the time of diagnosis. Mood disorders share many similar symptoms with fibromyalgia and vice versa.

As with other chronic illnesses, people with fibromyalgia may report difficulty concentrating or performing simple mental tasks. There is no evidence that these problems become more serious. Similar problems have been noted in many people with sleep disturbances of all kinds or with mood changes. People with fibromyalgia may have feelings of numbness and tingling in their hands, arms, feet, legs, or sometimes in their face. These feelings can suggest other disorders such as carpal tunnel syndrome, neuritis, or even multiple sclerosis. Therefore, people with fibromyalgia often undergo numerous tests for such conditions, only to find that the test results are normal. Headaches, especially muscular (tension) and migraine headaches are common in fibromyalgia. Abdominal pain, bloating, and alternating constipation and diarrhea are also common. This may resemble irritable bowel syndrome or "spastic colon." Similar bladder spasms and irritability may cause urinary urgency or frequency.

Causes and effects

Most people with fibromyalgia do not remember any specific event that lead to their symptoms. Some people feel that fibromyalgia was triggered by stresses such as an illness, emotional trauma, or hormonal changes. These stresses may precipitate the generalized pain, fatigue, and sleep and mood problems that characterize fibromyalgia.  Physical or emotional trauma could precipitate fibromyalgia in a number of ways. For example, a physical trauma such as having an infection or flu could lead to certain hormonal or chemical changes that promote pain and worsen sleep..

Diagnostic tests

Your health care provider will usually check a series of blood tests to look for other possible conditions that might mimic fibromyalgia. Low thyroid hormone (hypothyroidism), typically causes fatigue, cold intolerance, muscle aches and pain, and weight gain. Anemia also may lead to fatigue, and exercise intolerance. People with abnormally high or low levels of calcium in their blood may also have similar symptoms. Several muscle disorders may mimic fibromyalgia and can be checked with a blood test called the CPK

Condition research

Much research is now being done to try to understand both the psychological aspects and biological aspects of fibromyalgia with the hope that a holistic understanding will lead to a holistic treatment approach. Certain brain chemicals and pain receptors have been found to be altered in people with fibromyalgia and chronic pain in general. Research is being directed toward trying to modify these abnormalities to relieve the pain and fatigue.

You may have feelings of numbness or tingling in parts of your body, or a feeling of poor blood flow in some areas. Many people are very sensitive to odors, bright lights, loud noises and even medicines. Headaches and jaw pain are also common. In addition, you may have dry eyes or difficulty focusing on nearby objects. Problems with dizziness and balance may also occur. Some people have chest pain, a rapid or irregular heartbeat, or shortness of breath. Digestive symptoms are also common in fibromyalgia and include difficulty swallowing, heartburn, gas, cramping abdominal pain, and alternating diarrhea and constipation. Some people have urinary complaints, including frequent urination, a strong urge to urinate and pain in the bladder area. Women with fibromyalgia often have pelvic symptoms, including pelvic pain, painful menstrual periods and painful sexual intercourse. 

Clinical Manifestations of Fibromyalgia

Pain is the hallmark of fibromyalgia. The pain radiates diffusely from the axial skeleton and is localized to muscles and muscle-tendon junctions of the neck, shoulders, hips, and extremities. Fibromyalgia patients describe the pain with such terms as exhausting, miserable, or unbearable. Generalized hyperalgesia is a cardinal feature. Patients frequently complain that even gentle touch is unpleasant, a manifestation of allodynia.

Fibromyalgia patients also experience severe fatigue, insomnia, and low mood or depression. In fibromyalgia, fatigue occurring most times of the day on most days, together with subjective weakness and nonrestorative sleep, is almost universal. Cognitive complaints, such as difficulties with concentration and memory, may be prominent. Depression, anxiety disorders, and personality disorders contribute to ongoing psychological distress. Other complaints result from somatization, which can be defined as translating psychological distress into somatic symptoms (which are considered more socially acceptable) and seeking care for those symptoms. Functional impairment is usually present, at least in patients with fibromyalgia who seek care. Patients report difficulty doing usual activities of daily living and lack of exercise—indeed, they actually fear and avoid exercise.

Regional pain syndromes, such as headache, temporomandibular joint disorder, or irritable bowel syndrome, are often present in fibromyalgia patients. It is essential that the physician not automatically attribute all such symptoms to fibromyalgia, however, because fibromyalgia frequently coexists with other disorders of defined structural pathology, such as SLE and rheumatoid arthritis. Optimum therapy requires recognition of both fibromyalgia and comorbid disease.

~~~~~~~~~~~~~~~~~~~~

Reference Winfield JB: XIII Fibromyalgia. 15 Rheumatology. ACP Medicine Online. Dale DC, Federman DD, Eds. WebMD Inc., New York, 2006.

http://www.nhsdirect.nhs.uk/encyclopaedia

http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=449&sectionId=21431&PrintPage=1

http://www.orthop.washington.edu/Default.aspx