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Overview |
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Definition |
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Fibromyalgia syndrome (FMS) is characterized by three cardinal symptoms:
widespread musculoskeletal pain that persists for at least three months with no
evidence of inflammation or muscle abnormalities; disordered sleep patterns,
especially stage 4 non–rapid eye movement (NREM) sleep;
and multiple tender points (11 of 18 tender points of the American College of
Rheumatology Criteria for Fibromyalgia). However, FMS is not simply a muscle
pain syndrome as most patients present with an array of other symptoms. Long
thought to be a psychosomatic condition, FMS is now regarded as a distinct
clinical disorder. Patients should know that their disease is not deforming,
degenerative, life-threatening, or imaginary, and that there will be flare-ups;
however, treatment is available. |
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Etiology |
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Patients with FMS often attribute a precipitating event to the initial onset
of symptoms. These events include: flu-like illness, human immunodeficiency
virus, Lyme disease, parvovirus B19, persistent stress, chronic sleep
disturbance, and physical trauma. Studies have proposed the causative mechanisms
listed below.
- Disruption of stage 4 NREM sleep by alpha-wave intrusions, which
results in impaired short-term memory (and perhaps low growth hormone
levels)
- Low levels of somatomedin C (mediator of growth hormone function),
which alters muscle homeostasis, predisposing the patient to muscle trauma and
impaired healing
- A deficiency of serotonin, a neurotransmitter that regulates pain and
NREM sleep
- Increased levels of substance P, a neurotransmitter, as a result of
disordered capillary blood flow, which sensitizes peripheral nociceptors to
previously harmless stimuli
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Risk Factors |
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FMS is not unique to any country, ethnic group, or climate, although the
tendency to develop it may be inherited. FMS is more common in women (2% to 5%
of women) and is rare in men (0.5% of men); however, some researchers think that
FMS may simply be underreported in men. The prevalence of FMS increases
progressively from age 18 to 80; approximately 26% of patients with FMS are over
60 years of age. Many patients with FMS report a history of psychiatric
problems, most often depression, anxiety, somatization, and
hypochondriasis. |
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Signs and Symptoms |
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While chronic, widespread musculoskeletal pain that waxes and wanes is the
primary symptom of FMS, features commonly associated with FMS include those
listed below.
- Fatigue
- Paresthesia
- Psychological disturbances
- Postexertional pain
- Allodynia
- Restless leg syndrome
- Irritable bowel syndrome
- Joint pain without erythema and swelling
- Morning stiffness
- Raynaud's phenomenon
- Memory lapses
- Headaches
- Sleep disorders
- Dizziness
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Differential
Diagnosis |
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- Chronic fatigue syndrome
- Polymyalgia rheumatica
- Myofascial pain syndrome
- Multiple chemical sensitivity syndrome
- Systemic lupus erythematosus
- Rheumatoid arthritis
- Malingering
- Hypothyroidism
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Diagnosis |
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Physical Examination |
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The careful patient history should be taken that focuses on the timing and
the conditions surrounding the presentation of symptoms, and a physical
examination should be performed to exclude other disorders. |
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Laboratory Tests |
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Laboratory tests are useful only to exclude some of the disorders listed
above. |
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Other Diagnostic
Procedures |
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Radiographs, blood tests, and a physical examination of the joints should be
performed to show that there are no abnormalities. Because FMS does not have a
recognizable pathophysiolgic basis, a patient is classified as having FMS if
there is a history of the symptoms listed below.
- Widespread pain for at least three months
- Pain reproduced by digital palpation of tender points
- Persistent fatigue
- Generalized morning stiffness
- Nonrestorative sleep disturbance (patients often complain of being
tired on awakening)
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Treatment Options |
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Treatment Strategy |
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There is no single treatment protocol because of the variable patient
presentations. The goal of treatment is simply to maximize functional status.
The nonsteroidal anti-inflammatory drugs and salicylates do not provide complete
or long-lasting pain relief, though they may transiently reduce pain in some
patients during flare-ups. Because FMS is not an inflammatory condition,
glucocorticoids are ineffective. Narcotics may work initially but should only be
used for intense flare-ups and for short periods. |
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Drug Therapies |
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- Sleep disturbances are often treated successfully with low dosages of
tricyclic antidepressants (e.g., amitriptyline, 10 to 35 mg; doxepin, 10 to 25
mg; cyclobenzaprine, 2.5 to 10 mg). Often many different tricyclics must be
tried because of variable response and tolerance of side effects.
Benzodiazepines (e.g., alprazolam) are used if tricyclics do not work but may
result in drug dependence.
- Psychological disturbances can be treated with tricyclic
antidepressants (e.g., fluoxetine, 20 mg) and sedative-hypnotics (e.g.,
alprazolam, 0.5 to 1 mg).
- Musculoskeletal pain may be treated palliatively by lidocaine (1%) or
procaine injections into trigger points. Tramadol (Ultram, 50 to 400 mg) is a
relatively new drug marketed as having a low addiction potential that inhibits
pain neurons; however, as an opiate its use should be limited to flare-ups only.
Capsaicin is a topical agent that can be applied to areas of localized pain.
Ibuprofen (400 to 800 mg bid) along with amitriptyline or cyclobenzaprine are
used to alleviate pain, depression, and
insomnia.
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Complementary and Alternative
Therapies |
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Nutritional support, herbs, and mind-body techniques may be particularly
helpful in reducing symptoms of fibromyalgia and minimizing exacerbations.
Cognitive-behavioral therapy, support groups, meditation, visualizations,
progressive muscle relaxation, tai chi, yoga, and gentle exercise may alleviate
concurrent depression and/or anxiety, as well as improve coping skills, sleep,
and sense of well-being. |
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Nutrition |
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Eliminate all food allergens from the diet. The most common allergenic foods
are dairy, soy, citrus, peanuts, wheat, fish, eggs, corn, and tomatoes. An
elimination/challenge trial may be useful in uncovering sensitivities. Remove
suspected allergens from the diet for two weeks. Reintroduce foods at the rate
of one food every three days. Watch for reactions that may include
gastrointestinal upset, mood changes, flushing, fatigue, and exacerbation of
symptoms.
A rotation diet, in which the same food is not eaten more than once every
four days, may be helpful in reducing sensitivities.
Decrease overall intake of carbohydrates. Eat protein as part of each meal
and include moderate amounts of fat. The ideal ratio is approximately 30/30/40
(protein/fat/carbohydrate). Eating this way will help improve insulin
sensitivity and normalize metabolism. Eliminate inflammatory foods such as
refined foods, sugar, saturated fats (meat and dairy products), alcohol, and
caffeine. Eat whole foods such as vegetables, whole grains, fruits, protein, and
essential fatty acids (cold-water fish, nuts, and seeds).
- Vitamin C (1,000 mg tid to qid) reduces inflammation and supports
immune function.
- Coenzyme Q10 (50 to 100 mg one to two times/day) improves oxygenation
of tissues and has antioxidant activity.
- Chromium picolinate (200 mcg with meals) may reduce reactive
hypoglycemia which may exacerbate symptoms.
- Magnesium (200 mg bid to tid) with malic acid (1,200 mg one to two
times/day) helps to relieve pain, tenderness, and fatigue.
- 5-Hydroxytryptophan (100 mg tid) is a precursor to L-tryptophan and
may help alleviate concurrent depression and insomnia. May take up to one week
to be effective.
- B vitamins help reduce the effects of stress: B-complex (50 to 100
mg/day), niacinamide (100 mg/day), and B6 (100 mg/day).
- Melatonin (0.5 to 3 mg one time before bed) is a neurotransmitter
secreted by the pineal gland. It is a precursor to serotonin and is needed for
sound sleep.
- Zinc (30 mg/day) is essential for immune function.
- Phosphatidyl choline and phosphatidyl serine (300 mg/day) may
counteract the stress-induced activation of the hypothalamic-pituitary-adrenal
axis and improve depression and memory.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Note: Herbs containing salicylates may exacerbate symptoms of
fibromyalgia.
Some herbs, known as adaptogens, may help increase resistance to stress and
strengthen the immune system. These herbs include Siberian ginseng
(Eleutherococcus senticosus), schizandra berry (Schizandra chinensis),
ashwaganda root (Withania somnifera), gotu kola (Centella
asiatica), and astragalus root (Astragalus membranaceus). Use ginseng
alone or with equal parts of 2 to 3 herbs. Take 20 to 30 drops bid to tid.
Herbs that alleviate pain and nervous tension include the following: black
cohosh (Cimicifuga racemosa), kava kava (Piper methysticum),
skullcap (Scutellaria lateriflora), passionflower (Passiflora
incarnata), lavender (Lavandula angustifolia), and valerian
(Valeriana officinalis). Combine equal parts and take as a tincture 20 to 30
drops bid to tid.
Essential oils of jasmine, lemon balm, rosemary, and clary sage relieve
nervous exhaustion and may be used in aromatherapy. Place several drops in a
warm bath, an atomizer, or cotton ball. |
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and
potency. |
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Physical Medicine |
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Epsom salts baths: Adding two to four cups of Epsom salts to a warm bath can
soothe aching muscles. |
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Acupuncture |
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Fibromyalgia may be related to deficiencies in multiple organ systems which
can be addressed with acupunture treatment that stimulates circulation and
promotes a sense of well-being. |
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Massage |
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Therapeutic massage is helpful in reducing stress-related symptoms, improving
circulation, and increasing the overall sense of
well-being. |
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Patient Monitoring |
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A multidisciplinary team approach is essential because management of patients
with FMS is extremely demanding. The importance of self-help to maximize the
benefit of any treatment should be emphasized. Support groups can help patients
to take control of their lives and their
condition. |
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Other
Considerations |
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Prevention |
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Symptoms are worsened by emotional stress, anxiety, medical illness, trauma,
cold damp weather, overexertion, and surgery. |
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Complications/Sequelae |
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Chronic FMS may predispose the patient to greater psychological disturbances,
particularly depression, anxiety, panic attacks, and poor coping
mechanisms. |
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Prognosis |
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The prognosis for a full recovery for most patients with FMS is generally
poor, with the severity of the disease waxing and waning over time, and only
rarely remitting completely. In some cases, simple treatment of poor sleep
habits may bring positive results. |
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Pregnancy |
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Fibromyalgia may be exacerbated in pregnancy. Dietary changes may be safely
followed in pregnancy; however, nutritional supplements and herbs should be used
only with caution. |
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References |
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magnesium and malic acid. J Nutr Med. 1992;3:49-59.
Caruso I, Sarzi Puttini P, Cazzola M, et al. Double-blind study of
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Chaitow L. Fibromyalgia: the muscle pain epidemic. Part I. Available
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Holland NW, Gonzalez EB. Soft tissue problems in older adults. Clin
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Romano TJ, Stiller JW. Magnesium deficiency in fibromyalgia syndrome. J
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Starlanyl D, Copeland M. Fibromyalgia and Chronic Myofascial Pain
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Tyler VE. Herbs of Choice: The Therapeutic Use of Phytomedicinals.
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |