Understanding Fibromyalgia Syndrome

2005: Volume 2, Number 1

C. Jessie Jones, PhD & Lynne Matallana, MA

 

As the medical wellness community professionals participate in efforts to improve health and functional status of people with various medical conditions, one of the most misunderstood conditions, yet increasing in prevalence among all age groups is fibromyalgia syndrome (FMS).

 

While the best diagnostic procedures and treatment options to manage symptoms are being debated it is now evident that an increasing number of people are being diagnosed with FMS (between 6-10 million Americans) with the prevalence increasing with age.1

 

The purpose of this article is to discuss the (1) definition of FMS, (2) causes, symptoms and triggers that worsen symptom of FMS, (3) potential consequences of FMS, and (4) need for a multidisciplinary team effort to provide symptom management strategies for people with FMS.

 

Diagnostic Criteria

The diagnostic criteria for fibromyalgia was established in 1990 by the American College of Rheumatology (ACR).2 ACR defined fibromyalgia as “a painful, but not articular [not present in the joints], condition predominantly involving muscles and is the most common cause of chronic widespread musculoskeletal pain”(p.160). The criteria for fibromyalgia established by the ACR was based on a blinded, multi-center study that evaluated 11 symptom variables including sleep disturbances, frequent headaches, and stress levels.

 

For diagnosis the patient must have a history of widespread pain for more than three months and pain in at least 11 or more tender points upon digital palpation during physical examination. Tender points are areas of muscle or other soft tissues that are extremely sensitive to pressure stimulation. Unlike people with FMS most healthy individuals experience pain in only a small number of tender points.

 

Although these criteria for diagnosis lack a specific “marker” for laboratory testing (e.g., blood test, urine test, x-ray) and have been described as subjective in nature, most researchers agree that the ACR criteria is a beneficial tool for diagnosis of FMS until more highly sophisticated tools are available in the future. It should be noted that many diseases lack specific diagnostic markers (migraine headaches, depression), however this does not negate the existence of these conditions. In the case of FMS, the lack of a marker should only encourage researchers to continue a diligent search for such a tool. Fibromyalgia is classified as a syndrome because it is a collection of symptoms and overlapping conditions.

 

Because FMS can mimic and overlap other illnesses (e.g., myofascial pain syndrome, chronic fatigue syndrome, irritable bowel syndrome, irritable bladder syndrome) or coexist with other some of the inflammatory rheumatic diseases such as systemic lupus erythematosus and rheumatoid arthritis, FMS can be hard to diagnose. 3, 4
 

Causes & Symptoms
Most researchers agree that there are a large number of potential causes of FMS including a genetic component. It is generally accepted that FMS symptoms are the result of disordered sensory processing in the central nervous system.

 

Many people report that their symptoms developed after a triggering event such as an accident or injury, viral infection, surgery, emotional or physical stress, or even exposure to certain drugs or chemicals. Fibromyalgia that has a quick onset after a car accident or physical injury is referred to as post-traumatic fibromyalgia. A large portion of the medical community accepts the current evidence that indicates that 35-65% of people develop fibromyalgia symptoms after experiencing a physical trauma.
 

Whatever the cause, the latest research has identified physiological abnormalities in neurotransmitter and neuroendocrine function which interferes with how the central nervous system processes sensory information for people with FMS.,4, 5

 

The main symptom or chief complaint of FMS is constant widespread pain, above and below that waist and on both sides of the body. Other symptoms include:

• Fatigue

• Stiffness

• Muscle spasms (clustered in neck, shoulders, upper chest wall, and lower back)

• Paresthesia (numbness or tingling)

• Disturbed sleep

• Decreased exercise endurance

• Cognition dysfunction

The intensity of these FMS symptoms are different for people and fluctuates on a daily basis which makes treatment outcomes more difficult to document. Symptoms are aggravated by extreme weather changes, exposure to certain chemicals, emotional and physical stress, hormonal deficiencies, sleep problems, acute illnesses/ infections, too little or too much physical exertion, and nutritional deficiencies.6

 

Individual and Societal Impact
FMS is costly in terms of human dignity and socioeconomic impact. The emotional stress associated with the fluctuating symptoms of FMS is taxing even for the strongest of people. Having been diagnosed with FMS several years ago, we are both personally familiar with the struggle. A search for the “magic” treatment to “cure” FMS or at least minimize symptoms is neverending. Typical consequences for people with FMS include an increased risk for emotional distress, work and family problems, and reduced quality of life. Also, because people with FMS often find it difficult to be physically active, they are at risk for a host of sedentary behavior medical problems (e.g., obesity, sarcopenia, diabetes, cardiovascular disease), difficulty with activities of daily living, and physical disability.7

Every year in the United States at least ten million people seek medical help for pain and it is estimated that $85 billion is spent annually to diagnose and treat chronic pain. It is extremely difficult to accurately report the direct medical costs associated with FMS, however it has been estimated to be approximately $9 billion per year in the US.14). Using a large US health insurance claims database for the year 2000, Berger, Dukes, & Oster (2004)8 reported that health care charges for people with neuropathic disorders (which included people diagnosed with fibromyalgia) were 3-fold higher ($17,355 vs $5,715, respectively) than patients without neuropathic disorders. This cost does not include the thousands of out-of-the-pocket dollars for medical care beyond what the insurance company covers for medications, co-payments, etc., and complementary and alternative therapies for symptom management.9, 10

 

Symptom Management
Symptom management is critical in order to reduce the onset of physical frailty and to promote an active life expectancy. The optimal treatment for symptom management for people with FMS is unclear and comprehensive evidence-based guidelines have not been reported by experts in the field.10

 

However, current evidence suggests that the most efficacious approach to symptom management at this time is based on a biopsychosocial model (a multifaceted pharmaceutical and nonpharmaceutical approach) including certain pharmacological medications, patient education, physical and occupational therapy, exercise (e.g., yoga, tai chi, aerobic, strength conditioning, aquatic programs), cognitive-behavioral therapy, dietary modifications, stress management techniques, (e.g., relaxation training, coping strategies, meditation, electomyographic biofeedback training, activity pacing, guided imagery, hypnosis), and certain alternative therapies (e.g., acupuncture, massage therapy, chiropractic or osteopathic manipulation, herbal remedies and dietary supplements).12

FMS is a serious chronic medical condition that warrants research that
will guide us to a better understanding and new treatment modalities. Current off-label pharmacological therapies are often ineffective, and people with fibromyalgia tend to experience drug sensitivities and intolerable adverse reactions. In order to address these issues, patients need to work closely with their health-care professionals to evaluate at what dosage level and what kind of medications are going to be not only tolerable, but also helpful in symptom reduction.

However, with the increase of new research evidence regarding the neurobiology of chronic pain, hopefully new, safe medications will be developed to complement an integrated approach to symptom management for people with FMS, with an emphasis on having the person with FMS be actively involved with decision concerning the therapeutic regimen by health care providers.

 

In closing, we would be remiss not to share our keys to easing FMS symptoms which include having a strong support system; staying educated about FMS; taking care of the mind, body, and spirit; living a balanced lifestyle; keeping faith and hope; and maintaining a positive attitude—the brain has an amazing effect on the body!

Resources
American College of Rheumatology
American Academy of Pain Management
American Fibromyalgia Syndrome Association
American Pain Foundation
Arthritis Foundation

International Myopain Society
National Fibromyalgia Association
National Fibromyalgia Research Association
Oregon Fibromyalgia Foundation
 

References
1. Jones, K.D., Burckhardt, C.S., & Bennett, J.A. Motivational interviewing may encourage exercise in persons with fibromyalgia by enhancing self efficacy. Arthritis Rheumatology, 51, 864-7.
2. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. (1990). The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the multi-center criteria committee. Arthritis Rheum, 33, 160-72.
3. Matallana, L. (2005). The complete idiot's guide to fibromyalgia. New York: Penguin Group Inc.
4. Russell, J. (Spring, 2003). New developments in the management of fibromyalgia syndrome. ACR 2002 Annual Meeting [On-line information]. http:// www.medscape.com/viewarticle/445110
5. Clauw, D. J. & Crofford, L. J. (2003). Chronic widespread pain and fibromyalgia: What we know, and what we need to know. Best Practice & Research Clinical Rheumatology, 17, 685-701.
6. Leventhal, L. J. & Bouali, H. (2003). Fibromyalgia: 20 Clinical pearls: Finding ways to confirm the diagnosis and deal with a difficult condition. (Anniversary Special Series). The Journal of Musculoskeletal Medicine, 20,
7. Chaitow, L. (2000). Chronic widespread pain and fibromyalgia: what we know, and what we need to know. Best Practice & Research Clinical Rheumatology, 17, 685 – 701.
8. Cedraschi, C., Desmeules, J., Rapiti, E., Baumgartner, E., Cohen, P., Finckh, A., et. al (2004). Fibromyalgia: A randomized, controlled trail of a treatment programme based on self management. Annals of the Rheumatic Diseases, 63, 290-296.
9. Berger, A., Dukes, E.M, & Oster, G. (2004). Clinical characteristics and economic costs of patients with painful neuropathic disorders. The Journal of Pain, 5, 143-149.
10. Panush R.S. (2000). American College of Rheumatology Position Statement. Complementary and Alternative Therapies for Rheumatic Disease. Rheumatic Disease Clinics of North America, 26: 189-192.
11. Wassem, R. & Hendrix, T.J. (2003). Direct and indirect costs of fibromyalgia to patients and their families. Journal of Orthopedic Nursing, 7, 26-32.
12. Goldenberg, D.L., Burckhardt,C., & Crofford, L. (2004). Management of fibromyalgia syndrome. Journal of the American Medical Association, 292, 2388-2395.
13. Crofford, L. Appleton, B.F. (2001). Complementary and alternative therapies for fibromyalgia, Current Rheumatology Reports, 3, 147-156
14. Wallace, D. J. & Wallace, J (1999). Al about fibromyalgia. New York: Oxford University Press.