Fibromyalgia: Chronic Pain, Tender Points, No Known Cause

The syndrome known as fibromyalgia can have a devastating impact, as people with it suffer from chronic pain in multiple parts of the body and "tender points" that hurt in response to even slight pressure. Because fibromyalgia has no single known cause and there's no specific laboratory test to detect it, it remains difficult to diagnose and treat.

For example, a patient might be treated for years for chronic hip pain with no relief, only to learn later that they have fibromyalgia. As opposed to a disease, a syndrome involves medical problems, symptoms and signs tending to occur together but not related to a single identifiable cause. Fibromyalgia patients have pain and fatigue, and also may experience sleep disturbances, morning stiffness, numbness or tingling of the extremities, headaches, restless leg syndrome, painful menstrual periods, memory and cognitive problems, or one or more of a variety of other symptoms.

"Fibromyalgia affects a substantial number of individuals, anywhere from two to four percent of the population in the US; I'd say about 6 million people at an absolute minimum," said Nanjappareddy (Muni) Reddy, MD, Medical College of Wisconsin Associate Professor of Physical Medicine and Rehabilitation. Dr. Reddy is Medical Director of Outpatient Physical Medicine and Rehabilitation at the Froedtert & The Medical College of Wisconsin Clinics. He is also the Medical Director of Curative Care Network in Milwaukee, and one of the relatively few Medical College faculty physicians with major interest and experience in evaluating and treating fibromyalgia patients.

"Fibromyalgia is a condition with chronic pain associated with multiple areas of the body, typically with what we call 'tender points' distributed quite frequently in the neck, lower back, and a number of joints, generally speaking in muscle, ligament and tendon areas," said Dr. Reddy. "That's a common presentation. People with fibromyalgia are also commonly experiencing problems with their sleep pattern, have a lot of fatigue, and often uncertainty as to what is causing the problem.

"Fibromyalgia is an easily missed diagnosis because many times people will develop symptoms gradually, and often they present with a localized area of pain. Routine treatment may have failed to give relief. However, on close scrutiny, one might determine that it's not just in one area that they have problems, but they have a number of systemic type complaints and problems. Often signs and symptoms are referred to multiple systems and locations."

The Central Sensitivity Theory
About 80% of those diagnosed with fibromyalgia are women of childbearing age, for reasons that remain unclear, although it also strikes younger and older women, men, and children. Causes being studied by researchers trying to tie the syndrome together include problems with how the central nervous system processes pain, physical or emotional trauma, hereditary factors, underlying diseases, and others.

"The diagnosis for fibromyalgia is substantially clinically-based," said Dr. Reddy, "the reason being that there's no single test that can say 'this is it'. No absolute specific answer can be given to the question of 'what is happening in the body?' in fibromyalgia. We have found that there are a number of things that may be going on. It appears to be some sort of central process of desensitization. In other words, something is going on in the brain or below the brain level, and these changes seem to be such that the person perceives pain to a heightened level. Some research experiments support that 'central sensitivity' theory.

Dr. Reddy stressed that fibromyalgia is not a psychosomatic condition (something the brain says exists but really doesn't, or solely caused by psychological factors or stress). "Many people may think of it that way but it's not. There are physical problems, and there are also some emotional and related issues. But there is more and more suggestion that central sensitivity, altered sensitivity issues, are major factors. That's where a substantial focus is these days."

The American College of Rheumatology (ACR) has established two criteria for fibromyalgia diagnosis: a patient history of widespread pain lasting more than 3 months and the presence of tender points. Pain is considered to be widespread when it affects all quadrants of the body (both right and left sides as well as above and below the waist). The ACR also has designated 18 sites on the body as possible locations for tender points. For a fibromyalgia diagnosis, a person must have at least 11 tender points.

A proper diagnosis can lead to numerous treatment options, important because of the severity of the syndrome. "Fibromyalgia can cause severe impairment in some individuals that inhibits them from doing a number of routine day-to-day activities," said Dr. Reddy. "But a significant proportion of individuals are perfectly functional and active in life despite a diagnosis of fibromyalgia."

Associations Abound
"At least from what we know, there may be a substantial amount of emotional stress associated with fibromyalgia," said Dr. Reddy. "We know that the altered sleep pattern, in some cases, does not allow adequate recovery of the muscular and ligament structures and patients often feel a lot of fatigue because of that. And they feel pain that is very bothersome and frustrating.

"Also, a number of other associations have been found. Some individuals seem to have had no prior physical trauma that can be explained. Many, though, may have had some sort of disease process or trauma (such as a bad accident) predisposing them to fibromyalgia. Examples of conditions associated with fibromyalgia include rheumatoid arthritis, lupus, AIDS, or chronic fatigue syndrome.

"And there is some suggestion that people who have had cervical injuries, as in an automobile or other accident, can develop features of fibromyalgia over time. There appears to be a reduced level of growth hormone secretion in these individuals. But again, it's not everyone. And there appears to be some neurochemical changes, such as altered levels of noradrenalin and serotonin."

The societal cost of fibromyalgia is huge, Dr. Reddy said, both in lost productivity and in care costs. "It's a pretty expensive condition nationally," he said. "People lose a lot of workdays. And there is a lot of cost involved in the medical care, the reason being they are looking for clarity, a clear diagnosis, and solutions. So it is quite common for individuals to go through a variety of tests, sometimes finding nothing wrong that is specific. A variety of numbers have been thrown around; I've seen some estimates that are quite staggering, putting the health care costs alone at about $80 billion a year.

"The complexity of fibromyalgia makes treatment difficult. Many times it is very hard to deal with all their complaints and concerns in a typical short primary care clinic visit. We generally end up seeing fibromyalgia patients in specialty clinics such as Physical Medicine and Rehabilitation, rheumatology, and quite often in pain clinics. Patients need a fairly comprehensive initial visit and a physician who understands this condition well. There are still skeptics about this diagnosis, but it's a well-described condition accepted in the medical world. There's a tendency ignore the condition. Clinics can be overwhelmed and send the patient on to somebody else."

Treatment and More Research
Patients he has initially diagnosed with fibromyalgia first get a comprehensive specialty medical assessment, Dr. Reddy said. "I also want to be sure there's nothing else that is an underlying condition that's significant enough that it should be treated first. When I'm reasonably certain that the diagnosis is clear, I identify the problem areas, such as the areas of pain, and offer local and systemic approaches of care.

"These can include physical exercise programs; modalities such as heat, cold, and electrical stimulation; medical management including medications to help with pain control and sleep problems; and also management for stress and other psychologic difficulties. Often I refer individuals not only to a physical therapist but also to a psychologist for specific treatment as well as to learn cognitive coping techniques for chronic pain."

Some medications developed for other purposes are now more accepted for treating fibromyalgia, Dr. Reddy said, for example anti-seizure medications and newer antidepressant drugs seem to hold promise.

Dr. Reddy is in the very early stages of developing a research project or projects (along with a professor at Marquette University) to look at the practice of medicine in an academic setting as it relates to fibromyalgia. "There are clinicians who don't want to touch it," he said. "There are others who want to do a lot. But the majority don't seem to have a level of comfort to work with these people. We'd like to determine what the factors are that influence how we handle them and how we work with these individuals, and maybe another project directed at improving outcomes.

"When someone comes in with elbow pain, the doctor treats the elbow pain. That's not wrong, but not enough attention may have been paid to other questions that weren't asked and other issues to look into. I've had many individuals who were treated for many years for a localized (e.g., elbow or back pain) problem, even had exploratory surgery without finding anything, and the patient wasn't getting any better.

"One of the reasons that people may not be responding is that one area is being treated but the whole picture that may indicate fibromyalgia is being ignored. That's not an uncommon problem. My experience with these people for many years has been that if you properly manage them, the majority of them can make significant progress in coping with their pain more effectively, functioning more effectively, minimizing the disabling type of conditions, and carry on with a good quality of life."

Dan Ullrich
HealthLink Contributing Writer

For a detailed overview of fibromyalgia, see the HealthLink article The Facts about Fibromyalgia.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.