Diagnosis and Treatment of Fibromyalgia

Fibromyalgia is a poorly understood medical condition characterized by soft tissue pain, fatigue, sleep disturbance and widely distributed areas of tenderness known as tender points. It is a chronic condition with no cure that affects about 3.4% of women and 0.5 % of men.

There is no laboratory test to diagnose fibromyalgia, which previously caused some health care providers to believe the condition to be psychosomatic, or brought on by the individual’s emotions. However, recent research has shown that fibromyalgia patients typically have altered sleep patterns and brain chemistry. Many report awakening repeatedly and not being refreshed by sleep. Furthermore, sleep disturbances (as well as stress) may lead to symptoms of fibromyalgia. One-third of patients with fibromyalgia also have low insulin growth factor levels, which indicates low growth hormone secretion.

Researchers have also found that fibromyalgia patients have elevated levels of a neurotransmitter - cerebrospinal fluid substance P - which is associated with enhanced pain perception. Fibromyalgia patients also have low production of the steroid cortisol in contrast to higher-than-normal levels found in depression patients. These disturbances in the nervous and endocrine systems may cause fibromyalgia. In essence, pain is not caused by inflammation or damage, but is instead associated with a central defect in pain processing. Some speculate that physical or psychological trauma may cause such changes in the central nervous system, leading to fibromyalgia.

Diagnosis
Diagnosis of fibromyalgia is based on symptoms described by the patient, a physical examination and sometimes, observation over time. The American College of Rheumatology established diagnostic criteria, which include unexplained pain or tender points. These are typically located at 11 or more of 18 specific sites on the body, such as the neck, shoulders, lower back, buttocks, hips, elbows and knees. The location of the pain may shift over time and a person may have fibromyalgia even if they don’t meet all the criteria.

Because hypothyroidism can mimic fibromyalgia symptoms, the thyroid-stimulating hormone level should be checked routinely. Another condition, myofascial pain syndrome, may also be confused with fibromyalgia. However, fibromyalgia pain is widespread and changes locations. Myofascial pain is one of the conditions that often accompanies fibromyalgia, along with migraine headaches, irritable bowel syndrome, depression and temporomandibular joint syndrome.

Treatment
Each fibromyalgia patient is different and may require individualized treatment. An active exercise program, low-dose anti-depressants, acupuncture, psychotherapy, behavior modification therapy, chiropractic care, massage and physical therapy, used alone or in conjunction with one another, may provide some relief of symptoms.

In various studies, one-third to one-half of study participants responded to pharmacologic treatment of fibromyalgia. However, in some patients, symptoms may get worse. One study showed that the combination of a tricyclic antidepressant, 25 mg of amitriptyline (Elavil), with a selective serotonin reuptake inhibitor, 20 mg of fluoxetine (Prozac), was twice as effective as either one taken alone.

In patients with fibromyalgia, aerobic exercise and strength-training activities have been associated with significant improvement in pain, tender point counts and disturbed sleep. Maintaining an exercise regimen is often difficult; patients may want to utilize a workout partner or other strategy to stay motivated.

Acupuncture may be an extremely useful addition to fibromyalgia treatment efforts. The frequency of acupuncture sessions ranges widely from patient to patient, but appears to improve quality of life. For patients who have more severe pain and for whom other therapies are ineffective or cannot be utilized, chronic opioid analgesic therapy, involving oral painkillers, may be an option. Nonsteroidal anti-inflammatory agents, such as aspirin and ibuprofen, have not been proven effective, however.

Behavior modification training, including coping skills, relaxation exercises and self-hypnosis may provide relief for some patients. Pain perception is a very complicated phenomenon that may be modified by experience. Finally, growth hormone therapy, though prohibitively expensive for most patients, was shown in one study to reduce symptoms and improve quality of life without significant side effects.

For more information, please see our article in the Oct. 1, 2000, issue of American Family Physician.

Paul J. Millea, MD, MS
Assistant Professor, Family and Community Medicine
Medical College of Wisconsin

Richard L. Holloway, PhD
Professor and Associate Chairman, Family and Community Medicine
Associate Dean, Student Affairs
Medical College of Wisconsin

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