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Look Up > Conditions > Fibromyalgia
Fibromyalgia
Overview
Definition
Etiology
Risk Factors
Signs and Symptoms
Differential Diagnosis
Diagnosis
Physical Examination
Laboratory Tests
Other Diagnostic Procedures
Treatment Options
Treatment Strategy
Drug Therapies
Complementary and Alternative Therapies
Patient Monitoring
Other Considerations
Prevention
Complications/Sequelae
Prognosis
Pregnancy
References

Overview
Definition

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.


Etiology

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

Risk Factors

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.


Signs and Symptoms

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

Differential Diagnosis
  • Chronic fatigue syndrome
  • Polymyalgia rheumatica
  • Myofascial pain syndrome
  • Multiple chemical sensitivity syndrome
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
  • Malingering
  • Hypothyroidism

Diagnosis
Physical Examination

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.


Laboratory Tests

Laboratory tests are useful only to exclude some of the disorders listed above.


Other Diagnostic Procedures

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)

Treatment Options
Treatment Strategy

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.


Drug Therapies
  • 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.

Complementary and Alternative Therapies

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.


Nutrition

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.

Herbs

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.


Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency.


Physical Medicine

Epsom salts baths: Adding two to four cups of Epsom salts to a warm bath can soothe aching muscles.


Acupuncture

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.


Massage

Therapeutic massage is helpful in reducing stress-related symptoms, improving circulation, and increasing the overall sense of well-being.


Patient Monitoring

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.


Other Considerations
Prevention

Symptoms are worsened by emotional stress, anxiety, medical illness, trauma, cold damp weather, overexertion, and surgery.


Complications/Sequelae

Chronic FMS may predispose the patient to greater psychological disturbances, particularly depression, anxiety, panic attacks, and poor coping mechanisms.


Prognosis

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.


Pregnancy

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.


References

Abraham GE, Flechas JG. Management of fibromyalgia: rationale for the use of magnesium and malic acid. J Nutr Med. 1992;3:49-59.

Caruso I, Sarzi Puttini P, Cazzola M, et al. Double-blind study of 5-hydroxytryptophan versus placebo in the treatment of primary fibromyalgia syndrome. J Int Med Res. 1990;18:201-209.

Chaitow L. Fibromyalgia: the muscle pain epidemic. Part I. Available at: www.healthy.net/library/articles/chaitow/fibromy/fibro1.htm.

Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:1955-1957.

Holland NW, Gonzalez EB. Soft tissue problems in older adults. Clin Geriatr Med. 1998;14:601-603.

Kelley WN, ed. Textbook of Rheumatology. 5th ed. Philadelphia, Pa: WB Saunders Co; 1997:511-518.

Koopman WJ. Arthritis and Allied Conditions: A Textbook of Rheumatology. 13th ed. Baltimore, Md: Williams & Wilkins; 1993:1619-1635.

Nicolodi M, Sicuteri F. Fibromyalgia and migraine, two faces of the same mechanism. Serotonin as the common clue for pathogenesis and therapy. Adv Exp Med Biol. 1996;398:373-379.

Romano TJ, Stiller JW. Magnesium deficiency in fibromyalgia syndrome. J Nutr Med. 1994;4:165-167.

Russell IJ. Fibromyalgia syndrome: formulating a strategy for relief. J Musculoskel Med. 1998;November:4-21.

Starlanyl D, Copeland M. Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survival Manual. Oakland, Calif: New Harbinger Publications Inc; 1996:215-224, 227-235.

Tyler VE. Herbs of Choice: The Therapeutic Use of Phytomedicinals. Binghamton: Pharmaceutical Products Press; 1994.

Wolfe F, Smyth HA, Yunus MB, et al. American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia: report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33:160-172.


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.