Fibromyalgia

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Chronic Disease Information

----What Is Fibromyalgia?

Fibromyalgia is a syndrome distinguished by chronic pain in the muscles,

ligaments, tendons, or bursae around joints. It is called a syndrome because it

includes a set of conditions that always occur together.

The term fibromyalgia comes from a combination of three Latin words.

Fibro- (fibrous, for the soft tissues of the body under the skin, especially around the joints, including tendons, and ligaments), my- (myo, for muscles), and -algia (pain) mean pain in the supporting tissues of the body, such as tissues around the knee or muscles around the shoulder.

It is not a new disease but was described as early as the 1700s.

In 1904, it was named fibrositis and in the 1980s renamed fibromyalgia.

People sometimes write about fibrositis and fibromyalgia in the same sentence,

but the terms mean the same thing. It is important, though, to mention that

there is a big difference between generalized fibromyalgia and local pain in

tendons (tendinitis), bursa (bursitis), or muscles (myositis).

These localized areas of pain or inflammation are either secondary to a disease such as rheumatoid arthritis or caused by misuse, overuse, or underuse.

Fibromyalgia syndrome (FMS) is not a true form of arthritis because it does not affect the joints.

It is instead a type of rheumatism of the soft tissues or muscles.

Rheumatism is the term for pain and stiffness associated with arthritis and other disorders of joints, muscles, and bones. FMS is often confused with chronic fatigue syndrome (CFS) because both involve generalized pain and have other symptoms that are similar.

Fibromyalgia is more common in women than in men.

Eighty to 90 percent of persons with FMS are women between the ages of thirty-five and sixty.

There is no cure for fibromyalgia as yet. It can, therefore, persist into old age.

It can also affect children, occurring equally in preadolescent boys and girls. About 20 percent of patients who go to rheumatologists for treatment have fibromyalgia. It is the second most common illness seen by these specialists. Forty percent of persons with FMS have a close relative with similar symptoms.

It may, therefore, be hereditary in nature.

In the past, many believed that fibromyalgia was just a psychological aberration because it has no visible signs and could not be confirmed in laboratory tests. It is often misdiagnosed as arthritis or chronic fatigue syndrome, or diagnosis is delayed because people have symptoms often for as long as six years before receiving a correct diagnosis. FMS is actually more prevalent than RA, epilepsy, or multiple sclerosis.

The attitude toward fibromyalgia is changing. It now appears as a disorder of the neuroendocrine system involving chemicals of the brain and blood that regulate how pain is perceived by the body.

These chemical imbalances are beyond the control of the person who feels the pain.

Recognizing the Symptoms

Based on the research findings of twenty clinical investigators throughout the

United States and Canada, in 1990 the American College of Rheumatology

established guidelines for the diagnosis of fibromyalgia.

The guidelines are simple:

1. - widespread aching that lasts more than three months

2. - local tenderness at eleven of eighteen specified sites.

Laboratory tests and x-rays are not required to establish a diagnosis of fibromyalgia.

Pain is the foremost symptom of fibromyalgia. It occurs in the soft tissue and has been described as burning, gnawing, sore, stiff, shooting, deep aching, or radiating. The pain may vary in intensity according to the time of day, weather, activity level, stress, and sleep patterns. Usually a person is stiff upon awakening and may hurt all over to the point of being unable to function normally. Muscle spasms and cramping, more common at night, often keep a person from sleeping soundly.

Tender points have become the hallmark for diagnosing fibromyalgia.

These are points identical in all persons with fibromyalgia that when pressed are painful.

Eighteen tender points have been identified. All points may not be painful at all times in every person. Tender points hurt only when pressed. Some persons may not realize they have these points until a physician presses on them during examination.

Sleep disturbances occur in 90 percent of persons with FMS. The fourth stage of sleep, deep sleep, which is necessary for muscles and other body tissues to regenerate, is deficient.

Muscle pain occurs, it is believed, because muscles are deprived of proper rest in persons with FMS. The pattern of insomnia varies. Some may have trouble falling asleep, may wake up often during the night and be unable to fall back to sleep, toss, turn, and wake up earlier than is necessary.

Fatigue, another symptom, may occur in the early afternoon or all day long preventing normal functioning.

At the end of the day, a person may be completely exhausted and need a good night's sleep but because of sleep disturbances does not get that sleep.

Neurological symptoms occur in about one-fourth of persons with fibromyalgia.

Numbness and tingling in the arms and legs are common. No one knows why these sensations happen and no specific treatment exists. Forty percent of persons with fibromyalgia suffer from often severe tension

headaches as well as migraines.

Irritable bowel syndrome is another symptom that occurs in about 30 percent of fibromyalgia sufferers. Intermittent bouts of diarrhea, constipation, cramps, bloating, gas, and other digestive problems can be managed by adjusting the diet and using over-the-counter medications.

Interstitial cystitis (IC) can also occur in women with fibromyalgia. IC is an inflammatory disorder affecting the bladder wall causing frequent urination, urgent urination, pelvic pain relieved by urination, burning on urination, and difficult urination. When it becomes the major symptom, a patient may be referred to a urologist for treatment.

Some persons with fibromyalgia experience sensations of swelling of the hands, feet, and ankles when no actual swelling is noticeable. Joint pain in the hands, wrists, elbows, neck, chest wall, hip, knees, ankles,

and feet is often reported by persons with FMS. The pain is not actually in the joint but over the joint in the tendon.

One-third of persons with fibromyalgia report pain in the chest wall particularly where the rib cartilage joins the breastbone. Cold temperatures affect around 40 percent of fibromyalgia sufferers. Small blood vessels overrespond to coldness changing the color of the area from white to blue, then red. Tingling, pain, and numbness may also be present.

Investigating the Causes

Standard laboratory tests of the past did not show abnormalities in persons with fibromyalgia. Physicians are now using tests that were formerly only used in clinical trials. These newer tests are revealing and confirming laboratory abnormalities in persons with fibromyalgia.

Chemical analysis of muscle tissue taken from fibromyalgia sufferers reveals that high energy phosphate may be abnormal at the spot in the muscle with the greatest tenderness when pressed.

Where Are the Tender Points in Fibromyalgia?

Tender points are discreet areas of pain in response to palpation on body surfaces. They are in areas of muscles and muscle insertions and do not involve the joint. Some tender points can be identified in many people, but those suffering from chronic pain disorders tend to have more. Fragmented sleep along with lack of sustained delta wave sleep is theorized to be associated with the phenomenon of tender points.

The locations of tender points in people with fibromyalgia syndrome (FMS) are fairly typical, although anecdotal evidence suggests women are more vocal in responding to tender point palpation than men.

Occiput: suboccipital muscle insertion

Low cervical: anterior aspects of the intertransverse spaces of C5-C7

Trapezius: midpoint of the upper border

Supraspinatus: above the medial border of the scapular spine

Gluteal: upper outer quadrants of buttocks

Greater trochanter: posterior to the trochanteric prominence

Second rib: second costochondral junctions

Lateral epicondyle: 2 cm distal to the epicondyle

Knee: medial fat pad proximal to the joint line

One of the 2 criteria for the diagnosis of FMS specifies pain on palpation in at least 11 of these 18 pairs of tender points. Digital palpation should be performed with an approximate force of 4 kg (10 lb per square inch). You can approximate this pressure by placing your thumb pad on a hard surface and pressing so the nail tip just begins to blanch. Either the pad of the thumb or the combined pads of the forefinger and middle finger can be used.

For a tender point to be considered "positive," the subject should volunteer that the palpation was painful. Pressing tender points often elicits grimacing, moaning, and withdrawal.

Ethnic differences should be factored in for this subjective response.

Nontender control points (such as the mid-forehead and the anterior thigh) should be included in the examination although they are not included in the ACR criteria. These control points may be useful in distinguishing FMS from a conversion reaction in which tenderness may be present virtually everywhere.

The second criterion is the history of widespread pain for more than 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia.

FMS is a widespread disorder that involves at least 4% of the population.

The peripheral treatment of muscle pain has not been helpful to date.

Beneficial treatment probably lies in managing the central disorder and improving sleep with nonhabituating soporifics.

One theory about muscle abnormalities is that muscles undergo microtrauma during normal daily activities but are repaired during the fourth stage of sleep. In persons with fibromyalgia, restorative fourth stage sleep does not occur properly. In addition, an insulin-like growth factor, secreted by the liver upon release of growth hormone by the brain, is deficient in fibromyalgia. So, muscle repair may be delayed or defective because the fibromyalgia sufferer does not fall into a deep sleep and the insulin like growth factor that repairs the muscle during sleep is deficient.

Other theories about the cause of fibromyalgia involve physical or emotional trauma, such as a car accident or virus, physical or sexual abuse, stress, depression, or neurochemical factors acting as triggers.

Theories about the pain of fibromyalgia focus on the perception of pain and how the message of pain travels to the brain. The pain of fibromyalgia is called alldynia, which means long-standing increase in pain perception. The pain threshold in fibromyalgia appears to be lower. This may result from a

malfunctioning transmission of the pain signal in the nerves, spinal cord, and brain, thereby magnifying the pain signal so a larger amount of pain is felt than actually exists. These are all theories about the causes of fibromyalgia. More research needs to be conducted to determine the actual cause of fibromyalgia and to provide an understanding of how it actually works.

Determining the Prognosis

The good news is that people with fibromyalgia do not generally have serious

long-term arthritis or crippling ailments. In other words, fibromyalgia is not

the beginning of a serious rheumatic disease. You may hurt a lot or incur

chronic fatigue, but you will not have to deal with joints that are damaged later.

Many people who have RA, OA, or something similar may have secondary

fibromyalgia, but the point is that they had RA first and fibromyalgia later,

not the reverse. One puzzling aspect of the prognosis is that when women with

fibromyalgia become pregnant, the symptoms can go away during the pregnancy, just as with RA.

A Course of Treatment

In general, though fibromyalgia waxes and wanes with the years, it stays and stays and stays. This is an important factor for you to understand because there are things you can do to get on with your life:

First, stop feeling sorry for yourself. Take charge of your life and set goals.

Start by getting out of bed, no matter how much it hurts. No matter how tired you are, you can begin doing something. You must begin by building your endurance again. Many folks respond that it's well and good to give a pep talk about getting on with life, and they agree that the pain is bearable.

But -- and this is a big but -- being constantly tired is what prevents normal activity.

So what do you do?

Plan an exercise program -- preferably one with a pool -- and start today.

We recommend swimming every day as the best way to get started.

Next, find a health club with certified exercise trainers. Have your trainer help you create an exercise program, and follow the program every day for half an hour or so.

The fourth thing to do is to make your sleep as comfortable as possible.

You may wish to consider a waterbed. Waterbeds have come a long way in design since the early days; they now have cylinders or tubes of thick vinyl about four inches wide running lengthwise, and you can make them as firm or soft as you want, anytime you want. They also have heaters for each side of the bed, and the cost is about half that of a quality mattress and springs.

A 1989 Gallup poll among waterbed users and regular mattress users revealed that the waterbed won hands down in relieving back pain. Older people, in fact, are now the main buyers of waterbeds. You can rent one at some places to see how you like it.

The purpose, of course, is to see whether you get more rest and wake up rejuvenated instead of nonrejuvenated.

Last, to counter pain, fatigue, and nonrejuvenating sleep, I don't recommend NSAIDs as your primary therapy. For whatever reason, the aspirins, the Advils, the Voltarens, and the Naprosyns don't really seem to work, nor do any of the other fifteen or more NSAIDs on the market. Instead, you have to focus on

exercise. The tricyclic medicines, however, are useful for people with fibromyalgia.

There are several medicines in the tricyclic group, but you can't take all of them.

Ask your doctor about Elavil (amitriptyline) and Sinequan (doxepin); both have several actions and are principally used to help stressed people. They also have physiologic effects on the nervous system that may explain the improvement in fatigue and nonrejuvenating sleep that occurs in many people with fibromyalgia. The medicines are generally taken at night, but you must be supervised by your doctor.

In the long run, though, remember that the only person who can help is yourself.

================================================


	Chronic Disease Information \| home Fibromyalgia \| Chronic Fatigue Syndrome \| How Do I Cope \| Insomnia \| Pain Management \| What is Stress \| Depression \| Interstial Cystitis \| Nutritional Supplements \| How Can I Manage \| Hypoglcemia \| Hypotension \| Hypertension \| Herbal Information \| Swimming Can Help \| Walking Program \| Tips For Dealing with Chronic Diseases \| Getting Started \| Exercises \| Nutritional Information \| Irritable Bowel Syndrome Chronic Disease Information ----What Is Fibromyalgia? Fibromyalgia is a syndrome distinguished by chronic pain in the muscles, ligaments, tendons, or bursae around joints. It is called a syndrome because it includes a set of conditions that always occur together. The term fibromyalgia comes from a combination of three Latin words. Fibro- (fibrous, for the soft tissues of the body under the skin, especially around the joints, including tendons, and ligaments), my- (myo, for muscles), and -algia (pain) mean pain in the supporting tissues of the body, such as tissues around the knee or muscles around the shoulder. It is not a new disease but was described as early as the 1700s. In 1904, it was named fibrositis and in the 1980s renamed fibromyalgia. People sometimes write about fibrositis and fibromyalgia in the same sentence, but the terms mean the same thing. It is important, though, to mention that there is a big difference between generalized fibromyalgia and local pain in tendons (tendinitis), bursa (bursitis), or muscles (myositis). These localized areas of pain or inflammation are either secondary to a disease such as rheumatoid arthritis or caused by misuse, overuse, or underuse. Fibromyalgia syndrome (FMS) is not a true form of arthritis because it does not affect the joints. It is instead a type of rheumatism of the soft tissues or muscles. Rheumatism is the term for pain and stiffness associated with arthritis and other disorders of joints, muscles, and bones. FMS is often confused with chronic fatigue syndrome (CFS) because both involve generalized pain and have other symptoms that are similar. Fibromyalgia is more common in women than in men. Eighty to 90 percent of persons with FMS are women between the ages of thirty-five and sixty. There is no cure for fibromyalgia as yet. It can, therefore, persist into old age. It can also affect children, occurring equally in preadolescent boys and girls. About 20 percent of patients who go to rheumatologists for treatment have fibromyalgia. It is the second most common illness seen by these specialists. Forty percent of persons with FMS have a close relative with similar symptoms. It may, therefore, be hereditary in nature. In the past, many believed that fibromyalgia was just a psychological aberration because it has no visible signs and could not be confirmed in laboratory tests. It is often misdiagnosed as arthritis or chronic fatigue syndrome, or diagnosis is delayed because people have symptoms often for as long as six years before receiving a correct diagnosis. FMS is actually more prevalent than RA, epilepsy, or multiple sclerosis. The attitude toward fibromyalgia is changing. It now appears as a disorder of the neuroendocrine system involving chemicals of the brain and blood that regulate how pain is perceived by the body. These chemical imbalances are beyond the control of the person who feels the pain. Recognizing the Symptoms Based on the research findings of twenty clinical investigators throughout the United States and Canada, in 1990 the American College of Rheumatology established guidelines for the diagnosis of fibromyalgia. The guidelines are simple: 1. - widespread aching that lasts more than three months 2. - local tenderness at eleven of eighteen specified sites. Laboratory tests and x-rays are not required to establish a diagnosis of fibromyalgia. Pain is the foremost symptom of fibromyalgia. It occurs in the soft tissue and has been described as burning, gnawing, sore, stiff, shooting, deep aching, or radiating. The pain may vary in intensity according to the time of day, weather, activity level, stress, and sleep patterns. Usually a person is stiff upon awakening and may hurt all over to the point of being unable to function normally. Muscle spasms and cramping, more common at night, often keep a person from sleeping soundly. Tender points have become the hallmark for diagnosing fibromyalgia. These are points identical in all persons with fibromyalgia that when pressed are painful. Eighteen tender points have been identified. All points may not be painful at all times in every person. Tender points hurt only when pressed. Some persons may not realize they have these points until a physician presses on them during examination. Sleep disturbances occur in 90 percent of persons with FMS. The fourth stage of sleep, deep sleep, which is necessary for muscles and other body tissues to regenerate, is deficient. Muscle pain occurs, it is believed, because muscles are deprived of proper rest in persons with FMS. The pattern of insomnia varies. Some may have trouble falling asleep, may wake up often during the night and be unable to fall back to sleep, toss, turn, and wake up earlier than is necessary. Fatigue, another symptom, may occur in the early afternoon or all day long preventing normal functioning. At the end of the day, a person may be completely exhausted and need a good night's sleep but because of sleep disturbances does not get that sleep. Neurological symptoms occur in about one-fourth of persons with fibromyalgia. Numbness and tingling in the arms and legs are common. No one knows why these sensations happen and no specific treatment exists. Forty percent of persons with fibromyalgia suffer from often severe tension headaches as well as migraines. Irritable bowel syndrome is another symptom that occurs in about 30 percent of fibromyalgia sufferers. Intermittent bouts of diarrhea, constipation, cramps, bloating, gas, and other digestive problems can be managed by adjusting the diet and using over-the-counter medications. Interstitial cystitis (IC) can also occur in women with fibromyalgia. IC is an inflammatory disorder affecting the bladder wall causing frequent urination, urgent urination, pelvic pain relieved by urination, burning on urination, and difficult urination. When it becomes the major symptom, a patient may be referred to a urologist for treatment. Some persons with fibromyalgia experience sensations of swelling of the hands, feet, and ankles when no actual swelling is noticeable. Joint pain in the hands, wrists, elbows, neck, chest wall, hip, knees, ankles, and feet is often reported by persons with FMS. The pain is not actually in the joint but over the joint in the tendon. One-third of persons with fibromyalgia report pain in the chest wall particularly where the rib cartilage joins the breastbone. Cold temperatures affect around 40 percent of fibromyalgia sufferers. Small blood vessels overrespond to coldness changing the color of the area from white to blue, then red. Tingling, pain, and numbness may also be present. Investigating the Causes Standard laboratory tests of the past did not show abnormalities in persons with fibromyalgia. Physicians are now using tests that were formerly only used in clinical trials. These newer tests are revealing and confirming laboratory abnormalities in persons with fibromyalgia. Chemical analysis of muscle tissue taken from fibromyalgia sufferers reveals that high energy phosphate may be abnormal at the spot in the muscle with the greatest tenderness when pressed. Where Are the Tender Points in Fibromyalgia? Tender points are discreet areas of pain in response to palpation on body surfaces. They are in areas of muscles and muscle insertions and do not involve the joint. Some tender points can be identified in many people, but those suffering from chronic pain disorders tend to have more. Fragmented sleep along with lack of sustained delta wave sleep is theorized to be associated with the phenomenon of tender points. The locations of tender points in people with fibromyalgia syndrome (FMS) are fairly typical, although anecdotal evidence suggests women are more vocal in responding to tender point palpation than men. Occiput: suboccipital muscle insertion Low cervical: anterior aspects of the intertransverse spaces of C5-C7 Trapezius: midpoint of the upper border Supraspinatus: above the medial border of the scapular spine Gluteal: upper outer quadrants of buttocks Greater trochanter: posterior to the trochanteric prominence Second rib: second costochondral junctions Lateral epicondyle: 2 cm distal to the epicondyle Knee: medial fat pad proximal to the joint line One of the 2 criteria for the diagnosis of FMS specifies pain on palpation in at least 11 of these 18 pairs of tender points. Digital palpation should be performed with an approximate force of 4 kg (10 lb per square inch). You can approximate this pressure by placing your thumb pad on a hard surface and pressing so the nail tip just begins to blanch. Either the pad of the thumb or the combined pads of the forefinger and middle finger can be used. For a tender point to be considered "positive," the subject should volunteer that the palpation was painful. Pressing tender points often elicits grimacing, moaning, and withdrawal. Ethnic differences should be factored in for this subjective response. Nontender control points (such as the mid-forehead and the anterior thigh) should be included in the examination although they are not included in the ACR criteria. These control points may be useful in distinguishing FMS from a conversion reaction in which tenderness may be present virtually everywhere. The second criterion is the history of widespread pain for more than 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia. FMS is a widespread disorder that involves at least 4% of the population. The peripheral treatment of muscle pain has not been helpful to date. Beneficial treatment probably lies in managing the central disorder and improving sleep with nonhabituating soporifics. One theory about muscle abnormalities is that muscles undergo microtrauma during normal daily activities but are repaired during the fourth stage of sleep. In persons with fibromyalgia, restorative fourth stage sleep does not occur properly. In addition, an insulin-like growth factor, secreted by the liver upon release of growth hormone by the brain, is deficient in fibromyalgia. So, muscle repair may be delayed or defective because the fibromyalgia sufferer does not fall into a deep sleep and the insulin like growth factor that repairs the muscle during sleep is deficient. Other theories about the cause of fibromyalgia involve physical or emotional trauma, such as a car accident or virus, physical or sexual abuse, stress, depression, or neurochemical factors acting as triggers. Theories about the pain of fibromyalgia focus on the perception of pain and how the message of pain travels to the brain. The pain of fibromyalgia is called alldynia, which means long-standing increase in pain perception. The pain threshold in fibromyalgia appears to be lower. This may result from a malfunctioning transmission of the pain signal in the nerves, spinal cord, and brain, thereby magnifying the pain signal so a larger amount of pain is felt than actually exists. These are all theories about the causes of fibromyalgia. More research needs to be conducted to determine the actual cause of fibromyalgia and to provide an understanding of how it actually works. Determining the Prognosis The good news is that people with fibromyalgia do not generally have serious long-term arthritis or crippling ailments. In other words, fibromyalgia is not the beginning of a serious rheumatic disease. You may hurt a lot or incur chronic fatigue, but you will not have to deal with joints that are damaged later. Many people who have RA, OA, or something similar may have secondary fibromyalgia, but the point is that they had RA first and fibromyalgia later, not the reverse. One puzzling aspect of the prognosis is that when women with fibromyalgia become pregnant, the symptoms can go away during the pregnancy, just as with RA. A Course of Treatment In general, though fibromyalgia waxes and wanes with the years, it stays and stays and stays. This is an important factor for you to understand because there are things you can do to get on with your life: First, stop feeling sorry for yourself. Take charge of your life and set goals. Start by getting out of bed, no matter how much it hurts. No matter how tired you are, you can begin doing something. You must begin by building your endurance again. Many folks respond that it's well and good to give a pep talk about getting on with life, and they agree that the pain is bearable. But -- and this is a big but -- being constantly tired is what prevents normal activity. So what do you do? Plan an exercise program -- preferably one with a pool -- and start today. We recommend swimming every day as the best way to get started. Next, find a health club with certified exercise trainers. Have your trainer help you create an exercise program, and follow the program every day for half an hour or so. The fourth thing to do is to make your sleep as comfortable as possible. You may wish to consider a waterbed. Waterbeds have come a long way in design since the early days; they now have cylinders or tubes of thick vinyl about four inches wide running lengthwise, and you can make them as firm or soft as you want, anytime you want. They also have heaters for each side of the bed, and the cost is about half that of a quality mattress and springs. A 1989 Gallup poll among waterbed users and regular mattress users revealed that the waterbed won hands down in relieving back pain. Older people, in fact, are now the main buyers of waterbeds. You can rent one at some places to see how you like it. The purpose, of course, is to see whether you get more rest and wake up rejuvenated instead of nonrejuvenated. Last, to counter pain, fatigue, and nonrejuvenating sleep, I don't recommend NSAIDs as your primary therapy. For whatever reason, the aspirins, the Advils, the Voltarens, and the Naprosyns don't really seem to work, nor do any of the other fifteen or more NSAIDs on the market. Instead, you have to focus on exercise. The tricyclic medicines, however, are useful for people with fibromyalgia. There are several medicines in the tricyclic group, but you can't take all of them. Ask your doctor about Elavil (amitriptyline) and Sinequan (doxepin); both have several actions and are principally used to help stressed people. They also have physiologic effects on the nervous system that may explain the improvement in fatigue and nonrejuvenating sleep that occurs in many people with fibromyalgia. The medicines are generally taken at night, but you must be supervised by your doctor. In the long run, though, remember that the only person who can help is yourself. ================================================