md consult: fibromyalgia: patient education · researchers continue to investigate the link between...

Toronto Polyclinic

Dr. Ramin Safakish, MD, FRCPC

5460 Yonge Street Unit # 204

Toronto, Ontario M2N 6K7

416-250-7171

www.tpclinic.com

www.ChathamPainClinic.com

Special Instructions:

Treatment of FM is not offered by me. The only area I can help is education and IV Lidocaine infusion.

Follow Up:

Fibromyalgia

Highlights

Causes

A history of sexual abuse does not seem to be a risk factor for fibromyalgia. However, women who have

been raped may face a greater risk for the condition.

Treatment

Antidepressants help reduce pain, improve sleep and depressed mood, and improve health-related quality of

life in fibromyalgia patients. Tricyclic antidepressants may be more effective than selective serotonin

reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs), although all three

drug classes show some benefit.

The U.S. Food and Drug Administration (FDA) has approved milnacipran (Savella) for use in fibromyalgia

patients. Studies on the drug have indicated that it significantly improves pain and physical function.

Milnacipran is not approved for use in children.

Psychological therapies may help control fibromyalgia pain in children, although there is no evidence that

they improve disability or mood.

Introduction

Fibromyalgia is a syndrome of unknown causes that results in lasting, sometimes debilitating, muscle pain and

fatigue. Fibromyalgia is also known as fibrositis or fibromyositis.

General Description of Fibromyalgia Symptoms

Pain. The primary symptom of fibromyalgia is pain. The pain can be in one place or all over the body. The exact

locations of the pain are called tender points. Fibromyalgia pain is often described as:

MD Consult: Fibromyalgia: Patient Education http://www.mdconsult.com/das/patient/body/281123306-9/0/10041/9461...

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Tender point pain that occurs in local areas, usually in the neck and shoulders. The pain then spreads out

from these areas. The pain actually starts at the muscles. The joints are not affected, although many patients

feel that the pain is arising from their joints. There are no lumps or nodes associated with these pain points,

and no signs of inflammation (swelling). People who are diagnosed with fibromyalgia feel pain in at least 11

of 18 specific tender points. The skin feels more sensitive to the touch.

Widespread stiffness, burning, and aching pain. The pain also "radiates," or spreads, to nearby areas. Most

patients report feeling some pain all the time, but the intensity of the pain may increase or decrease. Many

describe it as "exhausting." The pain can vary depending on the time of day, changes in the weather,

physical activity or prolonged inactivity, and the presence of stressful situations. The pain is often more

intense after sleep is disturbed.

Fatigue and Sleep Disturbances. Another major fibromyalgia complaint is fatigue. Some patients report that their

fatigue is more distressing than their pain, because it interferes with their ability to enjoy life. Sleep disturbances,

particularly restless legs syndrome (RLS), are also very common. Fatigue and sleep disturbances are almost

universal in patients with fibromyalgia. Many patients complain that they can't get to sleep or stay asleep, and that

they feel tired when they wake up. Some experts believe that if these symptoms are not present, the condition may

not be fibromyalgia.

Depression and Mood. Up to a third of fibromyalgia patients have depression. Disturbances in mood and

concentration are also very common. These conditions often go undiagnosed.

Other Symptoms. The following symptoms may also be present:

Difficulty with memory and concentration

Digestive problems, including irritable bowel syndrome with gas, and alternating diarrhea and constipation

Dizziness

Dry mouth

Painful menstrual periods

Problems with balance

Tension or migraine headaches

Tingling or numbness in the hands and feet

Urinary frequency caused by bladder spasms

Symptoms in Children. In general, children with fibromyalgia most often have sleep disorders and widespread

pain. They may also experience fatigue, stress, depression, and headaches.

Causes

In the most common type of fibromyalgia, the causes are not known. Physical injuries, emotional trauma, or viral

infections such as Epstein-Barr may trigger the disorder, but no one trigger has proven to be a cause of primary

fibromyalgia.

Many experts believe that fibromyalgia is not a disease, but is rather a chronic pain condition brought on by

several abnormal body responses to stress. Areas in the brain that are responsible for the sensation of pain react

differently in fibromyalgia patients than the same areas in healthy people.

People with fibromyalgia have been found to have decreased activity in opioid receptors in parts of the brain that

affect mood and the emotional aspect of pain. This reduced response might explain why fibromyalgia patients are

likely to have depression, and are less responsive to opioid painkillers, researchers say.

Chronic Sleep Disturbance


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Sleep disturbances are common in fibromyalgia. Patients with the condition have a higher-than-average rate of a

sleep disorder called periodic limb movement disorder (PLMD). Patients with PLMD involuntarily contract their

leg muscles every 20 - 40 seconds during sleep, which may occasionally wake them up.

It is not clear whether fibromyalgia leads to poor sleeping patterns, or the sleep disturbances come first.

Researchers continue to investigate the link between fibromyalgia and sleep.

Patients with fibromyalgia have increased rates of cyclic alternating sleep pattern (CAP), which may

produce serious sleep problems and have been strongly linked to symptom severity. CAP may be related to

PLMD.

Sleep disorders that cause breathing problems are common in women with fibromyalgia.

Other biological measures of troubled sleep, such as levels of the hormone melatonin (which helps regulate

circadian rhythms and the sleep-wake cycle) appear to be normal in most people with fibromyalgia.

Brain Chemicals and Hormonal Abnormalities

Many abnormalities of hormonal, metabolic, and brain chemical activity have been described in studies of

fibromyalgia patients. Changes appear to occur in several brain chemicals, although no regular pattern has

emerged that fits most patients. Because there has been no clear cause-and-effect relationship established, it may

be that fibromyalgia is a result of the effects of pain and stress on the central nervous system, which lead to

changes in brain circuitry, rather than a brain disorder itself.

Serotonin. Of particular interest to researchers is serotonin, an important nervous system chemical messenger

found in the brain, gut, and other areas of the body. Serotonin plays important roles in creating feelings of

well-being, adjusting pain levels, and promoting deep sleep. Serotonin abnormalities have been linked to many

disorders, including depression, migraines, and irritable bowel syndrome. Lower serotonin levels have also been

noted in some patients with fibromyalgia.

Stress Hormones. Researchers have also found abnormalities in the hormone system known as the hypothalamus-

pituitary-adrenal gland (HAP) axis. The HAP axis controls important functions, including sleep, stress response,

and depression. Changes in the HAP axis appear to produce lower levels of the stress hormones norepinephrine

and cortisol. (By contrast, levels of stress hormones in depression are higher than normal.) Lower levels of stress

hormones lead to impaired responses to psychological or physical stresses. (Examples of physical stress include

infection or exercise.)


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The hypothalamus is a highly complex structure in the brain that regulates many important brain chemicals.

Low IGF-1 Levels. Some studies have reported low levels of insulin-like growth factor-1 (IGF-1) in about a third

of fibromyalgia patients. IGF-1 is a hormone that promotes bone and muscle growth. Low levels of growth

hormone may lead to impaired thinking, lack of energy, muscle weakness, and intolerance to cold. Studies suggest

that changes in growth hormone likely stem from the hypothalamus in the brain. Although researchers have not

found a link between IGF-1 levels and fibromyalgia, growth hormone levels in the blood may be a marker of the

disorder.

Abnormal Pain Perception and Substance P. Some studies have suggested that people with fibromyalgia may

perceive pain differently than healthy people. Fibromyalgia may involve too much activity in the parts of the

central nervous system that process pain (the nociceptive system). Brain scans of fibromyalgia patients have found

abnormalities in pain processing centers. For example, researchers have detected up to three times the normal

level of substance P (a chemical messenger associated with increased pain perception) in the cerebrospinal fluid of

fibromyalgia patients.

Some fibromyalgia patients may be oversensitive to external stimulation, and overly anxious about the sensation

of pain. This increase in awareness is called generalized hypervigilance.

A conflict between sensory perception and nervous system processing might occur in people with fibromyalgia.

Fibromyalgia patients have been found to have greater awareness of, or less tolerance for, movement problems

(such as tremor) that don't match with their expected sensory feedback. This mismatch in sensory signals might

enhance the perception of pain. Fibromyalgia patients also seem to be more sensitive to sounds.

Immune Abnormalities

Fibromyalgia has symptoms that resemble those of some rheumatic illnesses, including rheumatoid arthritis and

lupus (systemic lupus erythematosus). These are autoimmune diseases in which a defective immune system

mistakenly attacks the body's own healthy tissue, producing inflammation and damage. The pain in fibromyalgia,

however, does not appear to be due to autoimmune factors, and there is little evidence to support a role for an

inflammatory response in fibromyalgia.

Psychological and Social Effects

Although not primary causes, psychological and social factors may contribute to fibromyalgia in three ways:

They could make individuals susceptible to fibromyalgia.

They may play some role in triggering the onset of the condition.

They may perpetuate, or be responsible for, the condition.

Studies have reported higher numbers of severe emotional and physical abuse in patients with fibromyalgia

compared with the general population. Most often, the abusers are family members or partners. A history of sexual

abuse does not seem to be a risk factor for fibromyalgia. However, women who have been raped may face an

increased risk for the disease.

Post-traumatic stress disorder (PTSD) or chronic stress may play a strong role in the development of fibromyalgia

in some patients. PTSD, an anxiety disorder, is a reaction to a specific traumatic event. Some evidence indicates

that PTSD actually results in changes to the brain, possibly from long-term overexposure to stress hormones.

Muscle Abnormalities

Some research has found muscle abnormalities in fibromyalgia patients. These problems can be classified as the


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following:

Biochemical abnormalities: Fibromyalgia patients may have lower levels of the muscle-cell chemicals

phosphocreatine and adenosine triphosphate (ATP). Such chemicals regulate the level of calcium in muscle

cells. Calcium is an important component in the muscles' ability to contract and relax. If ATP levels are low,

calcium is not "pushed back" into the cells, and the muscle remains contracted.

Functional abnormalities: The pain and stress of the disease itself may harm muscle function.

Structural and blood flow abnormalities: Some researchers have seen overly thickened capillaries (tiny

blood vessels) in the muscles of fibromyalgia patients. The abnormal capillaries could produce lower levels

of compounds essential for muscle function, as well as reduce the flow of oxygen-rich blood to the muscles.

To date, none of these abnormalities has a clearly defined relationship with fibromyalgia.

Risk Factors

About 5 million Americans have fibromyalgia. The condition affects women more often than men.

Some evidence suggests that several factors may make people more susceptible to fibromyalgia. These risk factors

include:

Being female

Coming from a very stressful culture or environment

Having a psychological vulnerability to stress

Having had difficult experiences in childhood

Women

Nine out of 10 fibromyalgia patients are women. Women may be more prone to develop fibromyalgia during

menopause.

Age

The disorder usually occurs in people ages 20 - 60, though it can occur at any time. Some studies have noted peaks

at around age 35. Others note that fibromyalgia is most common in middle-aged women. In one study, cases of

fibromyalgia increased with age, and reached a frequency of more than 7% among people in their 60s and 70s.

Juvenile Primary Fibromyalgia. This type of fibromyalgia appears in adolescents, typically after age 13, with a

peak incidence at age 14. It is uncommon, but studies indicate that its incidence may be increasing. Symptoms are

similar to adult fibromyalgia, but outcomes may be better in young people. Girls are affected by fibromyalgia more

often than boys.

Family Factors

Studies report a higher incidence of fibromyalgia among family members. It is not clear whether genetic or

psychological factors, or both, are involved. Studies have found that:

About a third of children whose mothers have fibromyalgia also develop the disorder.

About two-thirds of parents who had children with fibromyalgia report some sort of chronic pain. About

10% of them have fibromyalgia.

Diagnosis


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There is no obvious, objective method (such as laboratory or imaging tests) for diagnosing fibromyalgia. The

criteria used to study fibromyalgia are very helpful, particularly if the patient does not have another disorder, such

as depression or arthritis, that could complicate the diagnosis. Failure to meet the criteria, however, does not rule

out fibromyalgia. Fibromyalgia should be suspected in any person who has muscle and joint pain with no

identifiable cause.

Criteria for Classifying Fibromyalgia

In 1990, the American College of Rheumatology (ACR) set the following criteria for classifying fibromyalgia:

A. Widespread pain must be present for at least 3 months. This pain must appear in all of the following locations:

Both sides of the body

Above and below the waist

Along the length of the spine

B. Pain in at least 11 of 18 specific areas called tender points on the body. The pain experienced when pressing on

a tender point is very localized and intensely painful (not just tender). Tender points are located in the following

areas:

The left or right side of the back of the neck, directly below the hairline

The left or right side of the front of the neck, above the collarbone (clavicle)

The left or right side of the chest, right below the collarbone

The left or right side of the upper back, near where the neck and shoulder join

The left or right side of the spine in the upper back between the shoulder blades (scapula)

The inside of either arm where it bends at the elbow

The left or right side of the lower back, right below the waist

Either side of the buttocks below the hip bones

Either kneecap

Other Factors. The ACR classification provides a guideline, but doctors will also use a patient's medical history

and other symptoms to reach a diagnosis. Fibromyalgia is often diagnosed after other diseases have been ruled out.

Long-term symptoms that may indicate fibromyalgia include:

Fatigue

Headache

Morning stiffness

Numbness or tingling in the hands and feet

Sleep disturbance


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The 18 fibromyalgia tender points are located throughout the body. According to the American College of

Rheumatology, a diagnosis of fibromyalgia requires widespread body pain plus localized pain in 11 of these 18

specific points.

Medical and Personal History

A doctor should always take a careful personal and family medical history, which includes a psychological profile

and history of any factors that might indicate other conditions, such as:

Infectious diseases

Muscle weakness

Physical injuries

Rashes

Recent weight change

Sexual, physical, or substance or alcohol abuse

Patients should report any drugs they take, including vitamins and over-the-counter or herbal medications.

Physical Examination

Pressure on Tender Spots. Any physical examination for fibromyalgia requires that the doctor press firmly on all

potential tender spots. These spots must be painful when pressed, not simply tender. In addition, for a doctor to

reach a diagnosis of fibromyalgia, these tender sites should normally not show signs of inflammation (redness,

swelling, or heat in the joints and soft tissue). The tender points may also change in location and sensitivity over

time. A doctor may recheck tender points that do not respond the first time in patients who have other significant

symptoms.

Detection of Other Causes of Symptoms. A health care provider will also examine the nails, skin, mucus

membranes, joints, spine, muscles, and bones to help rule out arthritis, thyroid disease, and other disorders.

Other Tests

No blood, urine, or other laboratory tests can definitively diagnose fibromyalgia. If such tests show abnormal

results, the doctor should look for other disorders. Tests for specific diseases depend on family histories and other


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symptoms, and may include:

Blood count

Sedimentation rate

Tests of certain antibodies

Thyroid and liver function tests

The doctor may suggest follow-up psychological profile testing, if laboratory results do not indicate a specific

disease.

Conditions with Similar Symptoms

Between 10% and 30% of all doctor's office visits are due to symptoms that resemble those of fibromyalgia,

including fatigue, malaise, and widespread muscle pain. Because no laboratory test can confirm fibromyalgia,

doctors will usually first test for similar conditions. A diagnosis of many of the disorders below may not always

rule out fibromyalgia, because several conditions may overlap or coexist with fibromyalgia, and have similar

symptoms. Like fibromyalgia, a number of them also cannot easily be diagnosed. It is not clear whether these

conditions cause fibromyalgia, are risk factors for the disorder, have causes in common with fibromyalgia, or have

no relationship at all with it.

Chronic Fatigue Syndrome. There is a significant overlap between fibromyalgia and chronic fatigue syndrome

(CFS). As with fibromyalgia, the cause of CFS is unknown. A doctor can diagnose either disorder based only on

symptoms reported by the patient. The two disorders share most of the same symptoms. They are also treated

almost identically. The main differences are:

Pain with tender points is the primary symptom in fibromyalgia. Some patients with CFS exhibit similar

tender pressure points; however, their muscle pain is less prominent.

Fatigue is the main symptom in CFS. It is severe, is not caused by excessive work or exercise, and is not

relieved by rest or sleep.

Some doctors believe that fibromyalgia is simply an extreme type of chronic fatigue syndrome. Physical evidence,

however, indicates that the two disorders are distinct, and each has its own treatments.

Myofascial Pain Syndrome. Myofascial pain syndrome can be confused with fibromyalgia and may also

accompany it. Unlike fibromyalgia, myofascial pain tends to occur in trigger points, as opposed to tender points,

and typically there is no widespread, generalized pain. Trigger-point pain occurs in tight muscles, and when the

doctor presses on these points, the patient may experience a muscle twitch. Unlike tender points, trigger points are

often small lumps, about the size of a pencil eraser.

Major Depression. The link between psychological disorders and fibromyalgia is very strong. Studies report that

50 - 70% of fibromyalgia patients have a lifetime history of depression. However, only 18 - 36% of fibromyalgia

patients have major depression.

Some studies have found that people who have both psychological disorders and fibromyalgia are more likely to

seek medical help, compared with patients who simply have symptoms of fibromyalgia. If this is the case, study

results may be biased, finding a higher-than-actual association between depression and fibromyalgia.

Depressed feelings in people with fibromyalgia can be normal responses to the pain and fatigue caused by this

syndrome. Such emotions, however, are temporary and related to the condition. They are not considered to be a

depression disorder. Unlike ordinary periods of sadness, an episode of major depression can last many months.

Symptoms of major depression include the following:


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Depressed mood every day

Feeling worthless or inappropriately guilty

Inability to concentrate or make decisions

Insomnia or excessive sleeping

Low energy every day

Restlessness or a sense of being slowed down

Significant weight gain or loss (of 10% or more of an individual's typical body weight)

Suicidal thoughts

If several of the above symptoms are present, and none of the physical symptoms (particularly the tender points)

of fibromyalgia exist, the condition is most likely major depression.

Chronic Headache. Chronic primary headaches, such as migraines, are common in fibromyalgia patients. Some

experts believe that migraine headaches and fibromyalgia may even share common defects in the systems that

regulate certain chemical messengers in the brain, including serotonin and epinephrine (adrenaline). Low levels of

magnesium have also been noted in patients with both fibromyalgia and migraines. Chronic migraine sufferers who

do not benefit from usual therapies may also have fibromyalgia.

Symptoms of a migraine attack may include heightened sensitivity to light and sound, nausea, vision problems

(auras), speech difficulty, and intense pain that is mainly on one side of the head.

Multiple Chemical Sensitivity. Multiple chemical sensitivity (MCS) is a term that describes conditions in which

certain chemicals cause symptoms similar to CFS or fibromyalgia. As with CFS and fibromyalgia, some experts are

uncertain whether MCS is a medical problem or psychologically based condition. Because everyone is exposed to

many chemicals on a daily basis, it is very difficult to determine whether chemicals are responsible for specific

symptoms.

Experts have come up with criteria to help recognize MCS:

Symptoms can be produced by exposure to the chemical at levels lower than the person previously or

usually tolerated.

Symptoms can be triggered by multiple substances that are chemically unrelated.

Symptoms involve multiple organ systems.

The condition is chronic.

The symptoms always happen with repeated exposure to a chemical. (These are often common chemicals

found in popular products, such as perfumes, fabric softeners, and air fresheners.)


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The symptoms improve when the chemical is removed.

Restless Legs Syndrome. About 15% of people with fibromyalgia have restless legs syndrome. Restless legs

syndrome is an unsettling and poorly understood movement disorder that is sometimes described as a sense of

unease and weariness in the lower leg that is aggravated by rest and relieved by movement.

Lyme Disease. Lyme disease is a bacterial disease transmitted by ticks. Health care providers can usually diagnose

early Lyme disease correctly, but a delayed response or recurrence of this disorder may be mistaken for

fibromyalgia. Some experts believe that 15 - 50% of patients referred to clinics for Lyme disease actually have

fibromyalgia. Late Lyme disease can usually (but not always) be ruled out using blood tests that identify the

organism that causes this disease. If fibromyalgia patients are incorrectly diagnosed and treated for Lyme disease

with prolonged courses of antibiotics, the drugs may have serious side effects.

Drugs and Alcohol. Fatigue is a side effect of many prescription and over-the-counter medications, such as

antihistamines. Constant fatigue is also a symptom of drug and alcohol dependency or abuse. Health care

providers should consider medications as a possible cause of fatigue if an individual has recently started, stopped,

or changed medications. Withdrawal from caffeine can produce depression, fatigue, and headache.

Polymyalgia Rheumatica. Polymyalgia rheumatica is a condition that causes pain and stiffness. It generally occurs

in older women. Tender points are also present with this disorder, although they almost always occur in the hip

and shoulder area. Morning stiffness is common, and patients may also experience fever, weight loss, and fatigue.

A higher-than-normal erythrocyte sedimentation rate (ESR) can help diagnose polymyalgia rheumatica. Elevated

ESR, however, also occurs with other conditions. Polymyalgia rheumatica usually responds dramatically to low

doses of a steroid medication such as prednisone. Because polymyalgia rheumatica is sometimes associated with a

rare condition called temporal arteritis, which may cause blindness if not treated, an accurate diagnosis is

important.

Disorders Affected by the Sympathetic (also called Autonomic) ,ervous System. Other conditions that commonly

accompany fibromyalgia include:

Chest pain and heart palpitations

Mitral valve prolapse

Sudden drop in blood pressure

Certain stress-related disorders commonly occur with fibromyalgia, and have overlapping symptoms. In fact, some

experts believe these disorders so often interact that they may all be part of one general condition. Examples are:

Irritable bowel syndrome (IBS) -- IBS and fibromyalgia often coexist. More than half of patients with

fibromyalgia also have IBS, a gastrointestinal disorder that causes cramping, abdominal pain, bloating,

constipation, and diarrhea.

Temporomandibular joint disorders (TMJ) -- TMJ affects the muscles of the face and jaw, leading to pain in

those areas. Most fibromyalgia patients also experience face and jaw pain.

Chemicals and environmental toxins -- exposure to various chemicals and environmental toxins such as

solvents, pesticides, or heavy metals (cadmium, mercury, or lead) can cause fatigue, chronic pain, and other

symptoms of fibromyalgia.


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Osteoarthritis is a chronic disease of the joint cartilage and bone. It is often thought to result from "wear and tear"

on a joint, although there are other causes, such as congenital defects, trauma, and metabolic disorders. Joints

appear larger, are stiff and painful, and usually feel worse the more they are used throughout the day.

Prognosis

Fibromyalgia can be mild or disabling, and the emotional toll can be substantial. People with fibromyalgia

experience greater psychological distress and a greater impact on quality of life than those with other conditions,

such as chronic low back pain. About half of all patients have difficulty with routine daily activities, or are unable

to perform them. An estimated 30 - 40% of patients have had to quit work or change jobs. Patients with either

CFS or fibromyalgia are more likely to lose jobs, possessions, and support from friends and family than are people

suffering from other conditions that cause fatigue.

Risk of ,egative Behaviors

The pain, emotional consequences, or sleep disturbances that come with fibromyalgia may lead to self-medication

and overuse of sleeping pills, alcohol, drugs, or caffeine.

Long-term Outlook

Outlook in Adults. Some studies show that fibromyalgia symptoms remain stable over the long term, while others

report a better outlook, with 25 - 35% of patients reporting improvement in pain symptoms over time. Studies

suggest that regular exercise improves the outlook. People with a significant life crisis, or who are on disability,

have a poorer outcome, as determined by improvements in the patients' ability to work, their own feelings about

their condition, pain sensation, and levels of disturbed sleep, fatigue, and depression. Although the disease is

lifelong, it does not get worse and is not fatal.

Outlook in Children. Children with fibromyalgia tend to have a better outlook than adults with the disorder.

Several studies have reported that more than half of children with fibromyalgia recover in 2 - 3 years.

Treatment

Fibromyalgia is a mysterious condition. Its causes are still largely unknown, as is how it inflicts damage. No strong

evidence indicates that any single treatment (or combination of treatments) has any significant effect for most


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patients.

In 2007 pregabalin (Lyrica) became the first drug FDA-approved for the treatment of fibromyalgia, after a study

showed the medicine reduced fibromyalgia pain in 63% of patients. A year later, the FDA approved the drug

duloxetine (Cymbalta) for fibromyalgia. Cymbalta has been shown to reduce fibromyalgia pain by more than 30%.

The serotonin-norepinephrine reuptake inhibitor (SNRI) milnacipran (Savella) has now also been approved for this

condition.

Many patients with fibromyalgia are treated first with medication; however, the American Pain Society

Fibromyalgia Panel recommends a combined approach using cognitive-behavioral therapy, education, medication,

and exercise. Treatment usually involves not only relieving symptoms, but also changing a patient's attitude about

the disease. Treatment should also teach patients behaviors that help them cope.

Treatments usually involve trial and error:

Patients may start with physical therapy, exercise, stress reduction techniques, and cognitive-behavioral

therapy.

If these methods fail to improve symptoms, an antidepressant or muscle relaxant may be added to the

treatment. Doctors usually prescribe these drugs because they may improve pain tolerance.

Patient education and programs that encourage coping skills are an important part of any treatment plan.

A combination of non-drug therapies appears to work just as well as drug therapy in improving pain, depression,

and disability. This combination includes exercise, stress management, massage, and diet.

Preparation for Treatment

Patients must have realistic expectations about the long-term outlook of their condition, and their own individual

abilities. It is important to understand that fibromyalgia can be managed, and patients can live a full life. The

following tips may be helpful when starting a treatment program for fibromyalgia:

The goal of therapy is to relieve symptoms, not cure them.

Treatment must be tailored to each patient, and a combination approach is often needed.

Patients must begin all treatments with the attitude that these treatments are trial-and-error. There is no

clear treatment solution. Patients and doctors need to work together to make the best choices for individual

symptoms and concerns.

Treatments are long-lasting, in some cases lifelong, and patients should not be discouraged by the return of

symptoms (relapses).

Enlisting family members, partners, and close friends, particularly to help with exercise and stretching

programs, can be helpful.

Becoming involved with support groups also benefits many patients. Support groups may also help family

members, particularly parents of children with fibromyalgia. One study noted that the severity of the

disorder increased in children whose parents were less able to cope with their pain.

The definition of improvement is personal. For example, some patients are pleased with only a 10% reduction in

pain and other symptoms.

Lifestyle Changes

Many studies have shown that exercise is the most effective component in managing fibromyalgia, and patients

must expect to take part in a long-term exercise program. Physical activity prevents muscle wasting, increases

well-being, and, over time, reduces fatigue and pain. Many studies have also demonstrated that exercise can

improve physical and emotional function, as well as reduce symptoms, including pain.


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Programs often combine aerobic, strength-training, and flexibility exercises with self-management education.

Some studies have shown improvements lasting for up to 9 months after the exercise program ends.

Graded Exercise. The basic approach used for fibromyalgia is called graded exercise. Graded exercise means you

slowly increase the amount of your physical activity.

In general, graded exercise involves:

A very gradual program of activity, beginning with mild exercise and building in intensity over time.

Stretching exercises before working out. A daily stretching routine can help relax tense muscles and prevent

soreness.

Walking, swimming, and using equipment such as treadmills or stationary bikes. Swimming and water

therapy are good because they don't require putting weight on the joints.

Patients who try difficult exercises too early actually experience an increase in pain, and are likely to become

discouraged and quit.

Every patient must be prepared for relapses and setbacks, but they should not get discouraged. Patients who do

not respond to one type of exercise might consider experimenting with another form.

Physical therapy can be very helpful. Studies suggest that physical therapy may reduce muscle overload, lessen

fatigue from poor posture and positioning, and help condition weak muscles.

Establishing Regular Sleep Routines

Sleep is essential, particularly because sleep disruptions worsen pain. Many patients with fibromyalgia have

trouble getting a restful and healing night's sleep. Those who are unable to sleep consistently have little

improvement in symptoms. Swing shift work, for example, is extremely hard on fibromyalgia patients. Poor sleep

habits can add to sleep problems. Tips for good sleep habits include:

Avoid caffeine or alcohol 4 - 6 hours before bedtime.

Avoid drinking fluids right before bedtime so that you do not have to wake up to urinate.

Avoid exercising 6 hours before bedtime.

Avoid large meals before bedtime. A light snack, however, may help you sleep.

Avoid naps, especially in the evening or late afternoon.

Establish a regular time for going to bed and getting up in the morning. Maintain this schedule even on

weekends and during vacations.

If you are unable to fall asleep after 15 or 20 minutes, go into another room and start a quiet activity. Return

to bed when you feel sleepy.

Minimize light and maintain a comfortable, moderate temperature in the bedroom. Keep the bedroom well

ventilated.

Use the bed only for sleep and sexual relations.

[For more information see In-Depth Report #27: Insomnia.]

Diet

Fibromyalgia patients should maintain a healthy diet low in animal fat and high in fiber, with plenty of whole

grains, fresh fruits, and vegetables. Although everyone should be careful about calories from fats, some are

healthy.

Omega-3 Fatty Acids. Oils containing omega-3 fatty acids are of particular interest for arthritic pain. Such oils are

found in cold-water fish. You can also purchase these oils as supplements called EPA-DHA or omega 3.


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Omega-3 fatty acids are a form of polyunsaturated fat that the body gets from food. Omega-3s are known as

essential fatty acids (EFAs) because they cannot be produced by the body. These healthy fatty acids can be found

in certain fish, canola oil, flax seeds, and walnuts. Omega-3 fatty acids have anti-inflammatory properties, which

help prevent blood clots, lower cholesterol and triglyceride levels, and reduce blood pressure. Omega-3s may also

reduce the risks and symptoms of diabetes, stroke, rheumatoid arthritis, asthma, inflammatory bowel disease,

ulcerative colitis, some cancers, and mental decline.

Vegetarian or Vegan Diet. A vegan diet has no meat, dairy, or eggs and includes uncooked fruits, vegetables,

nuts, and germinated seeds. The actual benefit of various vegetarian diets remains unproven.

Stress Reduction Techniques

Relaxation and stress-reduction techniques are proving to be helpful in managing chronic pain. Evidence shows

that people with fibromyalgia have a more stressful response to daily conflicts and encounters than those without

the disorder. Several relaxation and stress-reduction techniques may be helpful in managing chronic pain,

including:

Biofeedback

Deep breathing exercises

Hypnosis

Massage therapy

Meditation

Muscle relaxation techniques

Biofeedback. During a biofeedback session, electric leads are taped to a subject's head. The person is encouraged

to relax using any method that works. Brain waves are measured and an audio signal sounds when alpha waves are

detected. Alpha waves are brain waves that occur with a state of deep relaxation. By repeating the process, people

using biofeedback connect the sound with the relaxed state, and learn to relax on their own. Evidence from

controlled trials does not suggest that biofeedback techniques are very helpful for fibromyalgia patients.

Meditation. Meditation, used for many years in Eastern cultures, is now widely accepted in this country as an

effective relaxation technique. A number of studies are reporting its benefits for fibromyalgia patients who

practice on a continued and regular basis. The practiced meditator can achieve the following physical benefits:

Reduced heart rate, blood pressure, adrenaline levels, and skin temperature while meditating.


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Improved well-being.

Better sleep -- some research has reported an increase in melatonin levels in experienced meditators.

Melatonin is important in regulating the sleep-wake cycle.

Less pain, possibly from reductions in levels of cortisol, a stress hormone.

An important goal for both religious and therapeutic meditation practices is to quiet the mind -- essentially to relax

thought. This redirection of brain activity from thoughts and worries to the senses disrupts the stress response and

prompts relaxation and renewed energy.

People who try meditation for the first time should understand that it can be difficult to quiet the mind, and they

should not be discouraged by a lack of immediate results. Some experts recommend meditating for no longer than

20 minutes in the morning after awakening and then again in the early evening before dinner. Even once a day is

helpful. Do not meditate before going to bed, because it causes some people to wake up in the middle of the night,

alert and unable to return to sleep.

Hypnosis. In one small, short-term controlled study, hypnosis was more effective than physical therapy in

improving function and reducing pain.

Massage Therapy. Massage therapy is thought to stimulate the parasympathetic nervous system, which slows the

heart and relaxes the body. In one study, patients who were given 30-minute massage sessions twice a week

experienced lower stress and anxiety and less pain after 5 weeks compared to a group receiving an alternative

therapy called transcutaneous electrical stimulation (TENS).

Alternative Treatments

Because of the difficulties in treating fibromyalgia, many patients seek alternative therapies. Although some

studies have reported a benefit from these treatments, there is not enough evidence to recommend them.

Acupuncture. Studies continue to report conflicting results on acupuncture's ability to relieve pain. Several small

studies suggest that it offers some benefit, especially to people who cannot take medicines because of side effects.

Acupuncture also seems to help relieve pain when added to treatment with tricyclic antidepressants and exercise,

and the improvements last for a few months after treatment ends. Other studies have not found enough evidence

to support the use of acupuncture for fibromyalgia.

Chiropractic or Osteopathic Manipulation. Chiropractic or osteopathic manipulation may also help some

patients. While some studies have reported pain relief and improved sleep with osteopathic manipulation, larger

controlled studies are needed to clearly identify whether manipulation is an effective treatment. Osteopathic

techniques may include manipulation of the spine or muscle tissue release. There is always a very small risk for

adverse effects from any of these techniques. For example, in rare cases manipulation of the neck has caused

stroke or damage to the large blood vessels in the neck.

Herbs and Supplements

Some alternative remedies are being investigated for fibromyalgia. Examples include: melatonin, a natural

hormone associated with the sleep-wake cycle; and S-adenosylmethionine (SAMe), a natural substance that has

antidepressant, anti-inflammatory, and analgesic properties. Studies have shown benefits for some patients with

fibromyalgia, but trials done so far have not been well designed.

Generally, manufacturers of herbal remedies and dietary supplements do not need approval from the U.S. Food

and Drug Administration to sell their products. It is extremely important for patients to realize that any herbal

remedy or natural medicine that has positive effects most likely has negative side effects and toxic reactions, just

as any conventional drug does. There have been a number of reported cases of serious and even deadly side


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effects from herbal products.

Consult a doctor before using any untested products or dietary supplements. Also discuss with your doctor the

potential interactions between the supplements and any medications you take.

Behavioral Therapy

Studies show that fibromyalgia patients feel better when they deal with the consequences of the disorder on their

lives. Cognitive-behavioral therapy (CBT) enhances a patient's belief in their own abilities and helps them develop

methods for dealing with stressful situations. CBT, also called cognitive therapy, is known to be an effective

method for dealing with chronic pain from arthritic conditions. Evidence also suggests that CBT can help some

patients with fibromyalgia.

Although the effects of CBT and other non-medication treatments for fibromyalgia do not always last over the

long-term, they may help certain groups of people, particularly those with a high level of psychological stress.

CBT may be particularly useful for addressing insomnia, one of the hallmark symptoms of fibromyalgia. In studies,

patients who received CBT for insomnia woke up 50% less often at night, had fewer symptoms of insomnia, and

had improved mood.

The Goals of CBT. The primary goals of CBT are to change any unclear or mistaken ideas and self-defeating

behaviors. Using specific tasks and self-observation, patients learn to think of pain as something other than a

negative factor that controls their life. Over time, the idea that they are helpless goes away and they learn that

they can manage the pain.

Cognitive therapy is particularly helpful for defining and setting limits, which is extremely important for these

patients. Many fibromyalgia patients live their lives in extremes. They first become heroes or martyrs, pushing

themselves too far until they collapse. This collapse reverses the way they view themselves, and they then think of

themselves as complete failures, unable to cope with the simplest task. One important aim of cognitive therapy is

to help such patients discover a middle route. Patients learn to prioritize their responsibilities and drop some of the

less important tasks or delegate them to others. Learning these coping skills can eventually lead to a more

manageable life. Patients also learn to view themselves and others with a more flexible attitude.

The Procedure. Cognitive therapy usually does not last long. It typically consists of 6 - 20 one-hour sessions.

Patients also receive homework, which usually includes keeping a diary and trying tasks they have avoided in the

past because of negative attitudes.

A typical cognitive therapy program may involve the following measures:

Keep a Diary. Patients are usually asked to keep a diary, a key part of cognitive therapy. The diary serves as

a general guide for setting limits and planning activities. Patients use the diary to track any stress factors,

such as a job or relationship that may be improving or worsening the pain.

Confront Negative or Discouraging Thoughts. Patients are taught to challenge and reverse negative beliefs.

For example, "I'm not good enough to control this disease, so I'm a total failure" becomes the coping

statement, "Where is the evidence that I can control this disease?"

Set Limits. Limits are designed to keep both mental and physical stress within manageable levels, so that

patients do not become discouraged by getting in over their heads. For example, tasks are broken down into

incremental steps, and patients focus on doing one step at a time.

Seek out Pleasurable Activities. Patients list a number of enjoyable low-energy activities that they can

conveniently schedule.

Prioritize. Patients learn to drop some of the less critical tasks or delegate them to others.

Patients should learn to accept that relapses occur, and that over-coping and accomplishing too much too soon can


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often cause a relapse. Patients should respect these relapses and back off. They should not consider them a sign of

failure.

Research also shows that patient education can be effective in treating fibromyalgia, especially when combined

with CBT, exercise, and other therapies. Educational programs can take the form of group discussions, lectures, or

printed materials, although there isn't any clear evidence that one type of education works best.

Treatment of Fibromyalgia in Children

Medications such as pregabalin and milnacipran are recommended for adults, but they have not been well tested in

children. Analgesics and NSAIDs are not very effective in children. Psychological therapies may help control pain

in children, although there is no evidence that they improve disability or mood. Experts say the treatment of

fibromyalgia in children should begin with non-drug therapies, including exercise and cognitive behavioral

therapy.

Support Organizations and Group Therapy

Cognitive therapy may be expensive and not covered by insurance. Other effective approaches that are free or

less costly include support groups or group psychotherapy. In one study, educational discussion groups were as

effective, or even more so, than a cognitive therapy program. Such results are not typical in all centers.

Therapeutic success varies widely depending on the skill of the therapist.

Medications

Pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran (Savella) are approved specifically for treating

fibromyalgia. However, many other drugs are used to treat the condition, including antidepressants and muscle

relaxants. There is no consensus over which treatment is most useful, or whether a combination of treatments

works best. The goal with medication has been to improve sleep and pain tolerance. Medications from other drug

classes (such as sleeping aids and pain relievers) may also be prescribed. Patients receive drug treatments in

combination with exercise, patient education, and behavioral therapies.

Anti-Seizure Agents (Anti-Convulsants)

Pregabalin is an anti-epileptic medicine. Also called anti-seizure drugs and anti-convulsants, these medicines

affect the chemical messenger gamma aminobutyric acid (GABA), which helps prevent nerve cells from

over-firing.

Research is indicating that pregabalin may improve sleep quality, fatigue symptoms, and fibromyalgia pain. One

study found that three different doses of pregabalin -- 300 mg, 450 mg, and 600 mg -- were effective at improving

pain and sleep, and all were well tolerated by patients. The most common side effects include mild-to-moderate

dizziness and sleepiness. Pregabalin can impair motor function and cause problems with concentration and

attention. Patients should talk to their doctor about whether pregabalin may affect their ability to drive.

Studies have shown that another anti-convulsant, gabapentin (Neurontin), which is approved for the treatment of

postherpetic neuralgia, affects pain transmission pathways and may relieve pain associated with fibromyalgia.

Patients who took gabapentin also reported that they slept better and were less tired.

Antidepressants

The main classes of antidepressants used for treating fibromyalgia are tricyclics, selective serotonin-reuptake

inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Although these drugs are


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antidepressants, doctors prescribe them to improve sleep and relieve pain in non-depressed patients with

fibromyalgia. The dosages used for managing fibromyalgia are generally lower than dosages prescribed for treating

depression. If a patient has depression in addition to fibromyalgia, higher doses may be required.

Tricyclics. Tricyclic antidepressants were the first drugs to be well-studied for fibromyalgia. They may be more

effective than SSRIs and SNRIs for fibromyalgia symptoms, although all three drug classes seem to show some

effectiveness. Tricyclics cause drowsiness and can be helpful for improving sleep. Research finds that they are

also effective for reducing pain, and improving depressed mood and quality of life. The tricyclic drug most

commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain and

sleep, but can lose effectiveness over time. Other tricyclics include nortriptyline (Pamelor, Aventyl), desipramine

(Norpramin), doxepin (Sinequan), imipramine (Tofranil), and amoxapine (Asendin).

Generally, only small doses of tricyclic antidepressants are needed to relieve fibromyalgia. Therefore, although

tricyclics have several side effects, these side effects may be less frequent in fibromyalgia patients than in those

taking tricyclics for depression. Side effects most often reported include:

Blurred vision

Difficulty urinating

Dizziness

Drowsiness

Dry mouth

Heart rhythm disturbances

Sexual dysfunction

Weight gain

As with all medications, tricyclic antidepressants must be taken as directed. An overdose can be life-threatening.

Unfortunately, not all patients respond to tricyclics, and the effects wear off in some patients, sometimes after

only a month.

Selective Serotonin-Reuptake Inhibitors. Selective serotonin-reuptake inhibitors (SSRIs) increase serotonin levels

in the brain, which may have specific benefits for fibromyalgia patients. Commonly prescribed SSRIs include

fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Studies suggest they may

improve sleep, fatigue, and well-being in many patients. Studies are mixed on whether they improve pain. SSRIs

should be taken in the morning, since they may cause insomnia. Common side effects are agitation, nausea, and

sexual dysfunction, including a delay or loss of orgasm and low sex drive.

Serotonin-,orepinephrine Reuptake Inhibitors. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also

known as dual inhibitors because they act directly on two chemical messengers in the brain -- norepinephrine and

serotonin. These drugs appear to have more consistent benefits for fibromyalgia pain than SSRIs.

SNRIs include:

Duloxetine (Cymbalta) has been approved by the FDA for treating fibromyalgia. In studies, it reduced

fibromyalgia pain by more than 30%. The most common side effects with this medication are nausea, dry

mouth, constipation, decreased appetite, sleepiness, increased sweating, and agitation. It may also increase

the risk of hemorrhage in patients taking NSAIDs, aspirin, or blood thinners.

Venlafaxine (Effexor) is similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. As

with SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Although clinical

trials have shown that the drug is safe and effective in most people, there have been reports of changes in

blood pressure. There have also been reports of problems with the electrical system of the heart in people

taking this drug. These side effects may cause serious problems in elderly patients. Some patients report

severe withdrawal symptoms, including dizziness and nausea.


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The FDA has approved milnacipran (Savella) for use in fibromyalgia patients. Studies of the drug have

indicated that it significantly improves pain and physical function. Milnacipran is not approved for use in

children. The label includes a boxed warning that it may increase the risk of suicidal thoughts and behaviors

in children and adolescents. Savella is also not appropriate for patients who are taking monoamine oxidase

inhibitors, and for those with uncontrolled narrow-angle glaucoma.

Muscle Relaxants

Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function.

It helps relieve fibromyalgia symptoms. Cyclobenzaprine is related to the tricyclic antidepressants and has similar

side effects, including drowsiness, dry mouth, and dizziness.

Sleep Medications

Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) and eszopiclone (Lunesta) may

improve sleep in patients with insomnia.

Pain Relievers

Pain relief is of major concern for patients with fibromyalgia. Pain relievers for fibromyalgia include:

Tramadol (Ultram), used alone or in combination with acetaminophen (Tylenol), is commonly prescribed for

relief of fibromyalgia pain. Its most common side effects are drowsiness, dizziness, constipation, and nausea.

Tramadol should not be used with tricyclic antidepressants. Patients may become dependant on this drug,

and potentially abuse it.

For relief of mild pain, acetaminophen is most often recommended. Anti-inflammatory drugs, which are

commonly used for arthritic conditions, are less useful for the pain of fibromyalgia, because the pain is not

caused by muscle or joint inflammation. Anti-inflammatory drugs include corticosteroids and nonsteroidal

anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil). New guidelines from the

American Geriatrics Society do not recommend the use of NSAIDs for older adults with chronic pain,

because the cardiovascular and gastrointestinal risks outweigh the benefits of using these drugs.

Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers. Capsaicin is

helpful for relieving painful areas in other disorders. It may also have some value for fibromyalgia patients.

Opioids, or narcotics, may be used occasionally by certain patients with moderate-to-severe pain, or those

with significant problems performing everyday tasks. Such patients should use narcotics only if they cannot

find relief with other, less potent treatments. Patients may get combinations of narcotic pain relievers and

acetaminophen for periodic pain. Some physicians prescribe opioids, such as oxycodone (Roxicodone) or

morphine sulfate (Duramorph), for patients who need ongoing relief. However, the benefit of opioids in

fibromyalgia treatment is highly controversial. Physicians should take a careful medical and psychological

profile of the patient before prescribing opioids, and then should evaluate those patients periodically for

continuing pain relief, side effects, and signs of dependence.

Pramipexole, a drug used to treat Parkinson's disease and restless legs syndrome, may help relieve pain and

fatigue in people with fibromyalgia. Pramipexole stimulates the production of dopamine, a chemical

messenger in the brain.

The atypical antipsychotic drug olanzapine (Zyprexa) may be a beneficial add-on therapy for patients with

fibromyalgia. Although proven effective for some chronic pain conditions, olanzapine and other

antipsychotics cause unpleasant and potentially serious side effects.

Other Investigative Drugs

,abilone. A synthetic drug derived from marijuana may be another effective addition to fibromyalgia treatment,


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according to early studies. In one study, nabilone (Cesamet), which is also used to treat severe nausea and

vomiting in chemotherapy patients, significantly relieved fibromyalgia pain compared to placebo. There are some

challenges to using nabilone for fibromyalgia, however. First, it is a controlled substance that can become

addictive, and researchers say it is so expensive that it would be cost-prohibitive to use for a chronic disease such

as fibromyalgia.

Resources

www.rheumatology.org -- American College of Rheumatology

www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases

www.arthritis.org -- Arthritis Foundation

www.fmaware.org -- National Fibromyalgia Foundation

www.fmpartnership.org -- National Fibromyalgia Partnership

www.fmnetnews.com -- Fibromyalgia Network

www.aapainmanage.org -- American Academy of Pain Management

www.ampainsoc.org -- American Pain Society

www.medicalacupuncture.org -- American Association of Medical Acupuncture

www.asch.net -- American Society of Clinical Hypnosis

www.clinicaltrials.gov -- Find a clinical trial

References

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Bennett RM. Clinical manifestations and diagnosis of fibromyalgia. Rheum Dis Clin ,orth Am.

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Buskila D. Pediatric fibromyalgia. Rheum Dis Clin ,orth Am. 2009;35(2):253-261.

Eccleston C, Palermo TM, Williams AC, Lewandowski A, Morley S. Psychological therapies for the management

of chronic and recurrent pain in children. Cochrane Database Syst Rev. 2009 Apr 15 (2):CD003968.

Geisser ME, Glass JM, Rajcevska LD, Clauw DJ, Williams DA, Kileny PR. A psychophysical study of auditory

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Gusi N, Tomas-Carus P. Cost-utility of an 8-month aquatic training for women with fibromyalgia: a randomized

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Hassett AL, Gevirtz RN. Nonpharmacologic treatment for fibromyalgia: Patient education, cognitive-behavioral

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Hauser W, Bernardy K, Uceyler N, Sommer C. Treatment of fibromyalgia syndrome with antidepressants. JAMA.

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Lawrence RC, Felson DT, Helmick CG, Arnold LM, Choi H, Deyo RA, et al. Estimates of the prevalence of

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Paras ML, Murad MH, Chen LP, Goranson EN, Sattler AL, Colbenson KM, et al. Sexual abuse and lifetime

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Schweinhardt P. Fibromyalgia: a disorder of the brain? ,euroscientist. 2008;14:415-421.

Targino RA, Imamura M, Kaziyama HH, Souza LP, Hsing WT, Furlan AD, et al. A randomized controlled trial of

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Verbunt JA, Pernot DH, Smeets RJ. Disability and quality of life in patients with fibromyalgia. Health Qual Life

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Review Date: 1/13/2010

Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School;

Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director,

A.D.A.M., Inc.

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