Fibromyalgia

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Fibromyalgia: Donald R. Tanenbaum, DDS, MPH

Fibromyalgia has been termed a type of non-articular (bony) rheumatism. It is characterized by widespread musculoskeletal aching that has persisted beyond a three month duration, and is often continuous and unremitting in its presence. Pain is the most dominant complaint noted by patients and often encompasses all four limbs, and the upper and lower back. At times patients state that they, “hurt all over”. Other common symptoms include fatigue which is reported by 85% of patients, a poor sleeping pattern, a sense of swollen body parts and numbness often in the extremities. Frequently a patient with fibromyalgia has associated headaches, irritable bowel syndrome, and primary dysmenorrhea.

Fibromyalgia can be classified as primary in nature, when the signs and symptoms do not appear to have an underlying cause. Fibromyalgia can also be secondary in nature when the signs and symptoms are caused by an underlying condition such as rheumatoid arthritis, and hypothyroidism. With secondary fibromyalgia, when the primary medical condition is treated successfully, the constellation of symptoms inclusive of pain, stiffness, fatigue, and a sense of swelling and numbness go into remission

Fibromyalgia at times has been called fibrositis, but in reality this is an inaccurate term as the tissues involved are not characterized by inflammation. Fibromyalgia has been determined not to be a psychiatric condition.

Females outnumber males at an almost eight to two ratio. Most frequently symptoms are reported between the ages of forty and fifty. Caucasians appear to be the most affected race.

As previously noted, pain is the most dominant chief complaint. Two thirds of patients at times report severe pain. The descriptions used to characterize the pain are inclusive of radiating, shooting, pressing, pricking, and nagging. The areas most affected are the back, neck, shoulders, arms, knees, hands, hips, thighs, legs, and feet. At times the TMJ region and the anterior chest can be affected. The symptoms of pain appear to be increased with anxiety, cold temperature, humid conditions, and/or stress. Symptoms are most dominant early in the morning and late a night. Patients frequently feel tired all the time with an associated sense of weakness throughout multiple muscular parts. Sleep patterns are poor with morning fatigue, frequent awakenings during the night, and difficulty falling asleep. Though patients often report swelling in their limbs and numbness in their fingers and/or feet, there are no objective findings on physical examination.

The typical physical examination for patients with fibromyalgia reveals multiple tender points throughout the body, often numbering eleven to eighteen spots. Joints are often tender, and range of motion is often restricted due to pain. Laboratory tests, however, inclusive of blood chemistry, complete blood count, erythrocyte sedimentation rate, and rheumatoid factor are negative. Sleep studies at times show a lack of restorative sleep.

The origins of fibromyalgia have remained unclear. It has most recently been postulated that central pain mechanisms are involved whereby neurotransmitters and neurohormones have been altered in their production and regulatory functions. These aberrations in neuroendocrine balance often sensitize peripheral tissues producing reports of pain. Though research has been extensive, there does not appear to be a genetic predisposition. Though psychiatric factors aggravate symptoms, fibromyalgia is not a primary psychiatric condition.

Most frequently patients with fibromyalgia also report other dysfunctional problems inclusive of irritable bowel syndrome, chronic headaches, and dysmenorrhea. The reasons for this constellation of syndromes is unclear.

Treatment to date has not been clearly defined. The problem with managing fibromyalgia is that it is a continuous unremitting pain condition accompanied by fatigue and poor sleeping patterns. Such a wide variety of symptoms have been found to be unresponsive to most therapies. To date, primary therapies include medication, cardiovascular training, and physical exercise. The medications most commonly used are muscle relaxants, tricyclic antidepressants, and analgesics. Approximately one third of patients report a moderate benefit from these medications. Unfortunately, however, many of these medications are poorly tolerated, and the fibromyalgia patient typically can have severe adverse reactions. Physical exercise and cardiovascular training have shown to at times diminish pain perception, increase self esteem, and increase social support for these patients. These types of therapies often give the fibromyalgia patient a sense of control, and this is a critical component of pain management strategies. Physical exercise programs typically work to increase muscle strength and flexibility. Despite the fact that fibromyalgia patients may suffer during physical workouts, this does not lead to a progression of their problem overtime. In an effort to provide patients with coping strategies to control their pain, emg biofeedback training, and cognitive behavioral strategies are often put into place during the course of this illness process.

In summary, fibromyalgia continues to plague millions of individuals throughout the world. Fortunately multiple experimental study designs are underway which will hopefully shed light on this significant musculoskeletal pain problem, leading many disbelieving physicians to understand that these problems are real, impact on our society, and disrupt the lives of individuals in a dramatic way.