Fibromyalgia

Fibromyalgia (FMS) was first recognized by the American Medical Association as an illness and a cause of disability in 1987. In an article the same year, in the Journal of the American Medical Association, a physician named Don Goldenberg called the syndrome "Fibromyalgia".

The universal symptom of fibromyalgia is pain. FMS is characterized by widespread, debilitating pain involving the muscles, the joints - almost any area of the body.

Usually when the body has pain, inflammation is present. But this not necessarily the case with fibromyalgia. People with FMS can experience pain throughout their entire body without any damage or apparent inflammation of the peripheral tissues.

According to the National Fibromyalgia Association, 10 million Americans suffer from it. Most of them are women.

There is no blood or x-ray test that can diagnose fibromyalgia. The diagnosis is based upon the patient's history and physical examination. Widely accepted criteria created by the American College of Rheumatology define fibromyalgia by two things:

• A history of widespread pain lasting more than 3 months and affecting all 4 quadrants of the body (left side, right side, below the waist, above the waist).
• Upon examination, a finding of pain at 11 or more of 18 "tender points"

Pain and tenderness in the so-called "tender points" are the defining characteristics of fibromyalgia, so medical care providers focus on the features of the pain to distinguish it from other rheumatic disorders.		A posterior view of the "tender points" often used to diagnose fibromyalgia.

(Figures reproduced from the American College of Rheumatology website [1])

While these criteria for classification of patients were originally established for research purposes, they have become the de facto diagnostic criteria.

Fibromyalgia is characterized by diffuse pain, but is often accompanied by other "functional" conditions like irritable bowel syndrome, migraine headaches, chemical sensitivity, Raynaud's phenomenon[2] and chronic fatigue, making it often difficult to reach a definitive diagnosis.

Because of the difficulty of diagnosis, and because so many patients also reported cognitive difficulties, for years the conventional medical community was quick to tell patients that "it's in your head." But patients instinctively knew better. So they shuffled from one doctor to another as they continued to search for what was wrong. Many physicians believed that FMS was mainly a disguised form of psychological distress or depression.

THE PAIN IS FOR REAL

New research since 2003 demonstrates that FMS is indeed real, not imagined.

Daniel Clauw, M.D., of the University of Michigan, recently did much to legitimize the pain of FMS. He used magnetic resonance imaging (MRI) to look into the area of the brain that registers pain. Dr. Clauw observed that the area of the brain that registers pain showed an increase of blood flow when FMS patients were given a low-pressure stimulus. The identical stimulus showed no change in the brains of control group subjects. But when a more intense stimulus was administered to the control group, the blood flow increased in the same way as it had when the FMS group received the low-pressure stimulus. Dr. Clauw says his research finally offers visual proof that FMS patients experience hypersensitivity in the pain processing areas of their brains.

Dr. Clauw's work provided visual evidence that FMS patients really do experience pain differently than people who don't have the disorder. Clauw states:

"Pain is always a subjective matter, but everything that we can measure about the pain in fibromyalgia shows that it is real. We think that one of the primary abnormalities in fibromyalgia is an imbalance between the levels of neurotransmitters in the brain that affect pain sensitivity. Although right now there are no drugs approved to treat fibromyalgia, within three years it its likely that there will be three, if not four, drugs specifically approved to treat the condition. This is not an inflammatory disorder and this is not a primary psychological condition. … A person is about eight times more likely to develop fibromyalgia if one of their relatives has it. But there are also certain environmental triggers. For example, people develop fibromyalgia after motor vehicle accidents, or after certain types of infections or biological stress." [3]

Dr. Clauw is a Professor of Medicine, in the Division of Rheumatology, at the University of Michigan. He is the Executive Director of the Chronic Pain and Fatigue Research Center, and of the Michigan Institute for Clinical and Health Research (MICHR), at the University of Michigan.

In a 2003 paper in the journal Science, the University of Michigan team reported that a small variation in the gene that encodes the enzyme called catechol-O-methyl transferase, or COMT, made a significant difference in the pain tolerance, and pain-related emotions and feelings, of healthy volunteers. Researchers also have found that individual mutations in the COMT gene are related to the future development of temporo-mandibular joint disorder, also known as TMJ, a condition related to fibromyalgia.

In 2006, The University of Michigan team concluded:

"It is increasingly clear that fibromyalgia is a central nervous system disorder and that patients experience hypersensitivity to pain. There also appears to be a fairly strong genetic component to fibromyalgia and related conditions. These studies indicate that fibromyalgia patients have abnormalities within their central brain structures. … It is time for us to move past the rhetoric about whether these conditions are real, and take these patients seriously as we endeavor to learn more about the causes and most effective treatments for these disorders."[4]

National Fibromyalgia Association president and founder Lynne Matallana said that doctors who treat fibromyalgia patients face a unique challenge. "This is a new paradigm for medical professionals to understand," she says. "It isn't a tumor or something else that you can see. It is a problem within the pain-processing center of the central nervous system." [5]

AND IT'S MORE THAN JUST PAIN

People with FMS can be sensitive to changes in barometric pressure and temperature. Rain beating on the windowpane may feel as if it were beating on the walls of your cells. Noise emitted by fluorescent lights can be very irritating, and you may have to avoid overcrowded areas such as malls. FMS sensitizes nerve endings as well as the rest of the autonomic nervous system. The actual ends of the nerve receptors may have changed shape, turning touch and other receptors into pain receptors. Pain signals then bombard your brain. Your brain knows pain is a danger signal — an indication that something is wrong and needs attention — so it mobilizes its defenses. Then, when those defenses aren't used, the brain becomes anxious.

If you have FMS, you may have insomnia or a host of other sleep-related problems. You may have sleep apnea, or your heightened sensitivity does not allow you to sleep deeply. Our body heals and many neurotransmitters are balanced during deep sleep, and without it we soon suffer from the effects of sleep deprivation.

You may experience skin mottling. Your finger and toe nails may have vertical ridges — a typical sign of endocrine imbalance. Fingernails may break off, often in crescent-shaped pieces. If nails do grow, some may start to curve under (beaking).[6]

You may experience "brain fog" and so you have a cognitive overload, memory dysfunction, and an inability to do more than one thing at once. The brain "feel good" chemical, serotonin, is typically low in patients with fibromyalgia. Since a firm diagnosis of fibromyalgia is difficult, and no confirmatory laboratory tests are available, FMS patients are often misdiagnosed as depression patients.

People with rheumatoid arthritis and other autoimmune diseases are particularly likely to develop fibromyalgia. To the good, patients with fibromyalgia do not develop deformity as happens with rheumatoid arthritis. Fibromyalgia also does not cause damage to internal body organs. Therefore, fibromyalgia is different from many other rheumatic conditions.

Many medical conditions can cause pain in different areas of the body, mimicking fibromyalgia. These conditions include:

• low thyroid hormone level (hypothyroidism)
• parathyroid disease (causing elevated blood calcium level)
• muscle diseases causing muscle pain (polymyositis)
• bone diseases causing bone pain (Paget's Disease)
• infectious diseases)

Even though there is no blood test for fibromyalgia, blood tests are important to exclude other medical conditions.

IS FIBROMYALGIA SOMETIMES LYME DISEASE?

Many people with Lyme disease suffer the same widespread pain and tender points as fibromyalgia sufferers do. There is no good test for Lyme disease, so things get confusing. According to some in the Lyme community, as many as half the people diagnosed with fibromyalgia actually have Lyme disease.

Lyme Disease and fibromyalgia have very similar symptoms. Lyme disease is an infection caused by the bacterium borrelia burgdorferii, a spirochete originally transmitted to animals and then humans by ticks. Lyme disease can cause a host of different symptoms because it affects a number of different systems within the body, including the heart, brain, and musculoskeletal systems.

San Diego news reporter Brooke Landau speaks about her battle with Lyme disease.

One school of thought says that many fibromyalgia patients have unrecognized infections with atypical bacteria or viruses, including mycoplasma, chlamydia, Lyme disease and HHV-6. They claim beneficial results from long-term antibiotics. Several studies support these claims, but none were large or well-designed enough to put skepticism to rest. Breakthrough research on HHV-6 virus as a cause of chronic fatigue syndrome was reported recently. Transfer Factor, a cow's milk colostrum especially immunized to produce antibodies against HHV-6, was reported to help about two thirds of patients. This same approach, in theory, could also help fibromyalgia.[7]

Fibromyalgia can affect every aspect of a person's life. The chronic pain associated with fibromyalgia is pervasive and persistent and can severely curtail social activity and recreation. As many as 30% of those diagnosed with fibromyalgia are unable to maintain full-time employment. Like others with disabilities, individuals with FMS often need accommodations to fully participate in their education or remain active in their careers.

HOW TO TREAT

For FMS, the recommended prescription drugs typically are:

• Tricyclic antidepressants (e.g. Elavil/amitryptiline, Pamelor/nortriptyline)
• Desyrel/trazadone, a different form of anti-depressant
• Serotonin Re-uptake Inhibitor Antidepressants (e.g. Prozac)
• Sleeping Medicines (Ambien/zolpidem, Klonopin/clonazepam)
• Muscle relaxants (Flexeril/cyclobenzaprine)
• Various pain medicines

Traditionally, the most effective drugs have been the tricyclic antidepressants. In treating fibromyalgia, tricyclic antidepressants are taken at bedtime in doses that are a fraction of those used for treating depression. Tricyclic antidepressants appear to reduce fatigue, relieve muscle pain and spasm, and promote deep restorative sleep in patients with fibromyalgia. Scientists believe that tricyclics work by interfering with serotonin.

In reality, the degree of benefit differs very much for each individual.

Several drug companies are testing new drugs for the treatment of fibromyalgia; they target the central nervous system. These drugs fall into two general classes. One class raises the levels of neurotransmitters that normally stop the spread of pain, while another class lowers the levels of neurotransmitters that normally increase the spread of pain.

In 2007, pregabalin (Lyrica) became the first drug approved specifically for treating fibromyalgia.

Local injections of analgesics and/or cortisone medication into the trigger point areas can also be helpful in relieving painful soft tissues, while breaking cycles of pain and muscle spasm.

Non-Pharmaceutical Treatments

Limit the dietary stimulants. Just say no to caffeine and sugar. Avoid excitotoxins , especially MSG (monosodium glutamate) and artificial sweeteners like aspartame. Both glutamate (in MSG) and the amino acid, aspartic acid (in aspartame) stimulate pain augmenting receptors within the spinal cord. These are called NMDA receptors. Some individuals with Fibromyalgia improve very much on a Fibromyalgia diet that avoids MSG and aspartame. Occasionally, people with Fibromyalgia improve with the elimination of foods to which they personally are sensitive. Wheat/gluten, milk, yeast, and sugar can be culprits.

One of our patients had been diagnosed with fibromyalgia since 1996. In 2007 he came to us. One week after we took him off gluten, his pain was completely gone. Gluten, the protein in wheat, is notorious for creating chronic inflammation in many people.

Acupuncture is effective in treating some patients with fibromyalgia. The University of Michigan team is attempting to quantify just how helpful it is.

Exercise helps many patients. While exercise improves the symptoms of FMS, pain and fatigue often prevent individuals from beginning an exercise regimen in the first place. Because of the known benefits of exercise on FMS, it is important to find new ways for individuals with FMS to increase their physical activity. Lifestyle physical activity, which involves any type of moderate-intensity activity such as walking, housecleaning, shopping, and gardening, may be more doable than structured exercise like what you find at a gym.

As is true with so many autoimmune diseases, stress plays a big role and learning how to handle stress can make living with the disease easier. As is true with so many autoimmune diseases, stress plays a big role. Hypnosis can be extremely helpful to learn how to defuse stress.

One thing which may distinguish fibromyalgia is a particular brain wave pattern, as measured by Brain State Technologies.[8] It does appear that people with fibromyalgia have a hyperactive pain sensitivity, with significant elevations of substance P, a pain neurotransmitter, in the cerebro-spinal fluid.[9] Differences in blood flow to specific areas of the brain have been noted in patients with fibromyalgia.[10]

FMS dysfunctions may be simply points on a spectrum of chemical sensitivity or autonomic nervous system imbalance[11], through a mechanism called "neurogenic switching"[12] . This is a process whereby a signal from the brain, in response to an inflammation from a given site in the body, causes inflammation at a second site elsewhere in the body, apparently not related to the first site. Fibromyalgia is an excellent example of the "switching" phenomenon – we may ingest a food which causes inflammation in the intestinal tract, sending signals to the brain, which are then expressed as diffuse pain in the muscles. This phenomenon happens because the body uses many of the same neurotransmitters and hormones to activate pathways in many different organ systems. It is not surprising that, with an overwhelming stimulus, the system itself may become overwhelmed.[13]

To read more about brain training for treatment of fibromyalgia, see www.brainstatetech.com.

To make an appointment for evaluation at the Arizona Center for Advanced Medicine, call 480-240-2600.