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Fibromyalgia is a syndrome that is composed of many symptoms and is characterized by chronic and diffuse body pain. Patients complain of pain that occurs on both sides of the body and is usually worse in the neck and trunk. There are many symptoms associated with fibromyalgia, including headaches, fatigue, unrefreshing sleep, stiffness, decreased physical function, difficulties with short-term memory, and poor concentration.
It is estimated that fibromyalgia occurs in 2% of the population in the United States. Women are at a higher risk than are men (3.4% vs. 0.5%), and there is a steady increase in risk with age. Approximately 12% of women in their 60s have fibromyalgia. Fibromyalgia is the second most common disorder seen by rheumatologists in this country.
Although the cause of fibromyalgia is not clearly understood, the current thinking in the medical community is that abnormalities of sensory processing within the central nervous system result in the amplification of sensory impulses. This process termed central sensitization allows for perception of stimuli as pain that would not normally be perceived as pain. Central sensitization is believed to be responsible for the symptoms of fibromyalgia.
How is fibromyalgia diagnosed?
As outlined in the American College of Rheumatology (ACR) 1990 Criteria for the Classification of Fibromyalgia, the diagnosis of fibromyalgia is based on a history of widespread pain for at least 3 months’ duration. The diffuse pain involves the right and left sides of the body, the upper and lower body, and the axial skeleton. The ACR diagnosis requires the presence of excessive pain on applying pressure to at least 11 of 18 specified tender point sites. There are no laboratory tests and imaging studies that establish a diagnosis of fibromyalgia. However, laboratory and imaging studies are often obtained to rule out other potential pathologies as the source of symptoms.
How is fibromyalgia syndrome treated?
Fibromyalgia is a chronic disorder that is difficult to treat. There is not a single cure, and treatment must be individualized. Treatment involves a lifelong approach consisting of both non-pharmacological therapies and medications to manage the symptoms.
The treatment of fibromyalgia begins with a close relationship between patient and physician. Intensive patient education is very important. Lectures, written materials, and demonstrations provides patients with the knowledge and tools to cope and deal with their illness. Research has shown that education is effective in improving pain, sleep, fatigue, morning tiredness, anxiety, stiffness, and physical capacity.
There is strong evidence demonstrating the effectiveness of aerobic exercise in treating fibromyalgia. Numerous clinical trials demonstrate improvements in sleep, fatigue, global well-being and increase in physical capacity associated with exercise. The tender-point pain pressure threshold also increases with aerobic exercise. The exercise sessions should last 20-60 minutes and occur at least twice per week. Ideal aerobic exercise includes dancing, swimming, cycling, and walking. Physical therapy can be helpful in customizing an exercise regimen. Exercise must be done regularly in order to maintain the positive effects.
Cognitive Behavioral Therapy
Psychological and behavioral therapy can also be effective in treating fibromyalgia. Cognitive behavioral therapy (CBT) focuses on replacing the patient’s coping habits with more effective coping skills. In randomized controlled trials, CBT decreased pain severity and fatigue and improves function and mood. Meditation, relaxation, and stress management also may be helpful in the treatment of fibromyalgia.
Biofeedback, hypnotherapy, and acupuncture have also been investigated with mixed results. More research needs to be conducted before a strong conclusion is drawn.
Hot and/or cold packs may provide some relief for certain patients. Patients with decreased sensation such as with neuropathy should not use hot or cold packs unless under the direct supervision of a physician. If using a hot pack, consider one with herbs built in to add aromatherapy, which some patients find helpful and pleasant.
Currently, there are no medications approved by the US Food and Drug Administration for the treatment of fibromyalgia. The role of pharmacology is to minimize the symptoms and improve general health. Different classes of medications have been used in the treatment of fibromyalgia.
Topical analgesics may be very appropriate for people with fibromyalgia to try. Topical analgesics do not carry the same side effect risks as oral medications. They can be rubbed or sprayed on. Many patients prefer the spray form because it is less messy. A spray with menthol may be preferable so that the odor is pleasant. See the article on Pain Relief for further details.
Of all the pharmacologic treatments being investigated, antidepressants have been the most efficacious in reducing symptoms of fibromyalgia. Patients treated with antidepressants are four times more likely to improve than persons treated with placebo. Improvement is seen in 1 out of every 4 patients treated. Randomized, placebo controlled trials have shown that the tricyclic antidepressant medications, particularly amitriptyline (Elavil), improves pain, sleep, and overall well-being. Cyclobenzaprine (Flexeril), a tricyclic compound that is used as a muscle relaxant, also demonstrates similar beneficial results. These tricyclic medications are taken daily at bedtime. Some side effects include dry mouth, weight gain, constipation, drowsiness, blurred vision, difficulty urinating, and hypotension.
The evidence for the use of other classes of antidepressants such as the serotonin reuptake inhibitors (SSRIs) and the dual-reuptake inhibitors (SNRIs) is less impressive and inconclusive. Some studies have shown that SSRIs are not as effective as tricyclics in the treatment of chronic pain. One trial does demonstrate that the combination of fluoxetine and amitriptyline or cyclobenzaprine is better than either alone. Research on venlafaxine’s (Effexor) efficacy in treating fibromyalgia has been inconsistent, and the evidence for milnacipran (Ixel) and duloxetine (Cymbalta) is limited. Further research is needed to determine the relative efficacy of different classes of antidepressants.
Tramadol (Ultram) incorporates mu-opioid activity with inhibition of serotonin/norepinephrine reuptake. This centrally acting analgesic used with or without acetaminophen has been effective in decreasing fibromyalgia-associated pain in several randomized controlled trials. Tramadol is well tolerated with transient side effects such as nausea, headache, pruritis, dizziness, constipation, and drowsiness. The long-term efficacy and tolerability of tramadol are unknown.
When used alone, non-steroidal anti-inflammatory drugs (NSAIDs) have not been shown to be of benefit in the treatment of fibromyalgia. However, NSAIDS may be beneficial when used in combination with tricyclic antidepressant.
The research on other medications is incomplete and ongoing. When compared with placebo, anticonvulsants such as pregabalin (Lyrica) have shown some promise in reducing the severity of pain and improving the quality of sleep. Growth hormone may improve quality of life and energy level, increase exercise capacity and muscle strength, and enhance cognitive psychometric performance.
Authors: Tom Chen, BA, UMDNJ – Robert Wood Johnson Medical School, Piscataway, NJ
Zinovy, Meyler, DO, New York-Presbyterian Hospital, The University Hospital of Columbia and Cornell, New York, NY