FIBROMYALGIA: Arthritis Foundation

Fibromyalgia syndrome is a common cause for persisting aches and pains in our community. Understanding of this condition has increased significantly over the last decade and this has allowed us to use more appropriate and effective management strategies than we have in the past.

One in five persons in the community will suffer from chronic musculoskeletal pain occurring in a localised part of the body. One in ten persons suffers from longstanding persistent but widespread pain. Of this group many have fibromyalgia. This number varies according to how one defines the problem but it is generally considered that around 3-5% of the community have generalised fibromyalgia. The condition is more common in women than men, perhaps in a ratio of 6:1 and it increases as age increases. Yet even children and adolescents can develop significant fibromyalgia and the condition can come on at any time in life. Many have recurring episodes through their life. Fibromyalgia has been found to be present in all races and countries in which it has been looked for. The evolving understanding of this condition would indicate that it is a variation on normal rather than being representative of a disease in the traditional sense.

What is Fibromyalgia

Well, what is fibromyalgia? Fibromyalgia is merely the name applied to a constellation of symptoms and signs. The patient complains of generalised aching and pain, often accompanied by fatigue and considerable stiffness in the muscles, more prominent after inactivity such as in the mornings. The third key symptom is fatigue. This may be quite profound and dominate the picture. In these instances the term chronic fatigue syndrome is often used. There is considerable overlap between fibromyalgia and chronic fatigue syndrome and many consider them to be variations on the one condition.

The symptoms of fibromyalgia fluctuate over the day, being at their worst in the morning and evenings and it is recommended that people use the mid-part of the day to do most of their activities to avoid aggravating their discomfort. The symptoms also fluctuate over the weeks and months and years. There may be episodes of fibromyalgia lasting for some days or weeks and the situation may settle only to return some years later. Some have the condition every day. Typically the problem is made worse by changes in weather such as a temperature drop or a change coming in. Excessive physical activity or mental strain will also tend to aggravate the symptoms.

At times there may be more localised pain say in the neck or the back or around a joint but usually the pain is a generalised aching discomforting and debilitating pain. Sometimes you feel as though you have been hit by a truck when you waken in the morning. You may feel your hands puffy and the rings tighten or you may feel pins and needles through the hands. The neck might be stiff. The muscles and soft tissues might become quite tender and you might even notice this when other people touch you on the shoulder or give you a hug. Headaches can accompany these symptoms usually a dull tension type of headache. Many people with fibromyalgia will have symptoms of irritability in their bowel with bloating or irregular bowel habits. Women may complain of premenstrual fluid retention. Concentration is often poor. The brain sometimes just doesn't seem to work properly being foggy with poor memory retention. Yet this is often in contrast to the sharp mind that one had before the whole problem began. The sleep may become disturbed and be of poor quality often with shallowness and frequent wakening. The feeling of being unrefreshed in the morning is characteristic.

The symptoms of fibromyalgia may range from very mild and occasional to severe and persistent. Not everyone with fibromyalgia has the same degree of problem at any one time. The symptoms are always reversible - this is important to remember.

When the health care professional examines someone with fibromyalgia they may find tight muscles around the neck or the low back and a physical therapist may go to work at that area to loosen things up hoping to solve the problem. This will often give temporary relief but unless the total picture is addressed the symptoms will again return. Further examination will show that there are areas where there is marked tenderness on very gentle pressure with the finger. The middle part of the trapezius muscle, the muscle that links the neck to the shoulder is a typical area where there is increased tenderness in fibromyalgia. There are many other areas which health care professionals will know about and will search for in order to help diagnose the condition. This lowering of pain threshold is called hyperalgesia and is a characteristic feature of fibromyalgia. The areas of increased tenderness are simply called tender points. The American College of Rheumatology has devised criteria for classification of fibromyalgia and this involves finding at least 11 tender points out of a total of 18 which they have designated as being important ones. This finding together with widespread tenderness has a high accuracy level for diagnosing the condition. However, fibromyalgia can occur with lesser numbers of tender points and a lot of variations do occur in everyday clinical practice. Even localised forms of the condition can occur affecting just one part of the body such as the neck and arm of the chest wall or the low back and buttock. These localised forms are the most common post-injury types of fibromyalgia and are often mistakenly treated as if the area continues to be injured rather than being one of increased pain sensitivity alone.

Other clinical signs include the presence of dermatographia or the "red-reaction". This is found on stroking the finger nail firmly over the upper back. Usually a small degree of redness will be quickly seen but with fibromyalgia this is much more marked than normal. Often pinching a fold of skin between the finger and thumb of the upper back will induce pain in fibromyalgia - this is not usual in pain-free people.

Importantly, there are no clinical signs to suggest inflammation or degeneration in any of the tissues of the body which could explain the pain compliant that the person has. Fibromyalgia is not due to an inflammation of the tissues, it is not due to degeneration in the spine or the muscles or other regions where the pain might be felt. Nor is there any other immediately obvious explanation. Blood tests are normal, x-rays show only what would be expected at that person's age. Even though the muscles ache considerably, intensive investigations over the years have shown that the muscles are in fact structurally normal.

What causes Fibromyalgia?

Fibromyalgia is basically a problem of overactivity in the pain system. Pain nerves are distributed throughout the body, more in some areas than in others. They are waiting to be stimulated and quite a large stimulus is needed to trigger them off. This is called high threshold. The pain system is ready to fire in order to warn us about potential threat to injuring our tissues from some external source. If a high threshold stimulus is felt, eg if the thumb is pierced by a pin, that message will quickly relay to the spinal cord which will automatically activate reflexes which induce the muscles to contract and the arm will pull away from the threatening pin. At the same time the message of pain quickly goes up to the brain where we feel the sensation and localise where it came from. We can then attend to dealing with the cause of the problem. When the pain message gets to the brain other input is put into the sensation of pain and this input comes from our previous experience with regard to pain, our emotions and our behaviours in regard to pain. As you well know we all react to pain in different ways. The localised component of pain is quite different to the emotional part of pain and yet both are part of the pain experience. It is for this reason that the World Health Organisation classifies the definition of pain as being "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage".

As mentioned earlier the pain threshold is lowered in fibromyalgia and this means that the pain system is ready to fire at a much lower level than would otherwise be the case. Thus routine activity such as hanging out the washing, driving the car, making the beds or standing or sitting in the one position at work will induce pain and discomfort much more readily than would otherwise be the case. As the pain message is felt with normal postural activities then so is the message relayed to the muscles in the area. These muscles contract and tighten. This leads to stiffness around the area and particularly around the spinal region. Other reflex actions occur which give rise to some of the clinical signs that we've talked about earlier.

The cause for the lowered pain threshold seems to be an abnormality occurring in the way the pain system is modified or damped down. This is the critical link in the fibromyalgia puzzle which is being worked out at the moment. Many workers think that the cause for the change in sensitivity in the pain system is due to a change in one of the pain modifying chemicals which is present in our brains and nervous system.

Many of these chemicals come from the higher parts of the brain where emotions, mood and stress effects are also noted. These chemicals in turn react on other systems which can change the sensitivity of our pain system. Also other parts of our body's homoeostasis can be altered and these might include changes in the hormonal system and immune system of our bodies. There are certainly changes in these systems which are measured using current technology in patients with fibromyalgia. It is considered these changes are not the cause of the problem but are just a result of the problem.

Relationship with Stress

Fibromyalgia may come on quickly say after a frightening accident or may come on slowly and there may be no obvious cause seen. However, many times there is a stress event in the person's life which might be near to the onset of the fibromyalgia. Sometimes the stress event goes completely but the fibromyalgia continues just as if the pain system has been set at a new level. Currently there is no antidote to fibromyalgia - no medication that reverses the situation and thus we rely on other tactics to manage the problem.

Managing Fibromyalgia

Anyone with fibromyalgia, be it generalised and widespread or be it localised, needs to work out a management strategy to deal with the problem. As indicated above, the condition is not due to something wrong in the area where the pain is felt. This is merely the pain nerves being activated but without any reason to be. Excessive physical therapies or investigations into a cause do not help the problem. There is no need for ongoing scans, blood tests or seeking out numerous specialists to find the "magic answer" to the chronic pain problem. Fibromyalgia should be the end of the trail. The diagnosis of fibromyalgia should not be given if there is another explanation for the pain and naturally a certain number of tests will be required to eliminate that possibility if present. However, the diagnosis of fibromyalgia should be the start of a new management plan.

A person with fibromyalgia should consider the following:

The condition is always potentially reversible. Psychological factors are important in management. Managing everyday stresses, dealing with ongoing life problems and working out the best strategies for dealing with the pain problem are all necessary. This may just require readjustment in your own thinking and life strategies or you may require the help of a professional who deals with this problem all the time. This might be a clinical psychologist, another health care professional or a doctor who deals with chronic pain. You should not listen to the people who tell you to "learn to live with it". This implies that the situation is hopeless and irreversible. This is not the case.

Relaxation Techniques

Strategies which include relaxation therapy, meditation and movement treatment such as Feldenkrais, yoga, tai chi and the like are all useful in dealing with the emotional and muscle tightness problems which accompany fibromyalgia.

Physical Therapy and Exercise

If there are a lot of localised muscle tightness problems then some physical therapy may well be necessary but this should not be relied on as being the only way to deal with the problem. Exercise is extremely important and one should try to start moving the body even if it is painful and later moving into a programme which encourages exercises, ie the establishment of an aerobic fitness programme. One should not be rushing into this as this will tend to cause some discomfort when you first start. This can be best done under supervision of a health care professional or doctor.

Simple analgesics are preferred to any other medication and sometimes low dose tricyclic medications are given in the evenings to help the sleep disturbance. If there is an associated mood disturbance such as depression then antidepressant medications may be needed.

Self Management Techniques

The emphasis on management of fibromyalgia is self-management. When the condition is severe one usually requires input from a health care professional to get the right path set up. When the problem is mild the health care professionals have a minimal role. Perhaps a check of the diagnosis and then establishment of an appropriate programme might be all that is required. Consider the Better Health Self Management Course offered through Arthritis Victoria.

The support than can be gained from other people with fibromyalgia can be really important. Support Groups can be a useful source of peer support. Consider joining one of Arthritis Victoria's Fibromyalgia Support Groups. Remember the support you can offer other people is just as important as the support you might receive from others.

Fibromyalgia is a common everyday problem in our society. Usually mild, self-limiting and not disabling, the condition can be managed by the person with the problem. When the pain is more severe and the person is more disabled then more professional input is required to help deal with this problem.

Finally, it should be remembered that fibromyalgia is a problem of the pain system. This can occur in people with rheumatoid arthritis, osteoarthritis, disc troubles or other health problems. Or it can occur by itself. When it occurs in the context of other musculoskeletal diseases then the fibromyalgia may be mistakenly put down to that other condition. You need to discuss this with your doctor to ensure that your treatment approach encompasses both options.