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What is Fibromyalgia??

 

 

Fibromyalgia

Synonyms and related keywords: fibromyositis, fibrositis, idiopathic myalgia, interstitial myofibrositis, muscular hardening, muscular rheumatism, musculorheumatism, myofibrositis, myogelosis, myositism, nodular rheumatism, nonarticular rheumatism, polymyalgia rheumatica, rheumatic muscle callus, rheumatic muscle hardening, rheumatic myalgia, rheumatic pain modulation disorder, tension myalgia

Author: Regina P Gilliland, MD, Medical Director, Health Link Functional Rehabilitation, Department of Internal Medicine; Division of Rehab Medicine, Baptist Medical Center. Regina P Gilliland, MD, is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Medical Association of the State of Alabama, and Southern Medical Association.
Editor(s): Martin K Childers, DO, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Missouri School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Patrick M Foye, MD, FAAPMR, FAAEM, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; and Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center.

Background: Fibromyalgia is a complex disorder defined only recently, but it is not a recently discovered disorder. Descriptions have been found in the medical literature as far back as the early 17th century. Many physicians prefer not to deal with patients who have this complicated disorder and question the actual existence of the disorder. In the past, poor recognition and lack of treatment for this disorder could be explained by a lack of meaningful research. Today evidence supports the diagnosis of fibromyalgia, as well as the accepted treatments.

Some experts propose that physicians should make a paradigm shift in their approach to patient care to treat patients with fibromyalgia successfully. Since no widely available laboratory tests confirm diagnosis of fibromyalgia, a physician skilled in taking a careful history, listening to the patient's concerns, and performing a thorough examination remains the foundation for diagnosis and treatment of fibromyalgia.

This article reviews synonyms and clinical features of fibromyalgia, as well as an approach to obtaining a medical history, physical examination, and recommended treatment. Treatment suggestions are meant to be a resource for developing a creative treatment program, not a cookbook approach to all patients with fibromyalgia.

A definition of fibromyalgia

Fibromyalgia, a common disorder, is a syndrome composed of a specific set of signs and symptoms. Fibromyalgia long has been considered a "wastebasket" diagnosis, but, in 1987, the American Medical Association (AMA) acknowledged fibromyalgia as a true illness and a potential cause of disability. Fibromyalgia is accepted as a legitimate clinical entity by many well-respected organizations, such as the AMA, National Institutes of Health (NIH), and the World Health Organization (WHO) (Starlanyl, 1996).

Patients with fibromyalgia generally see many physicians before receiving a correct diagnosis. Some report that patients seek medical advice for more than 5 years before a correct diagnosis is made, and over 50% of patients are misdiagnosed and undergo unnecessary surgery.

Nomenclature

Although the syndrome has been known by other names, the word fibromyalgia was first introduced in 1976. This word is derived from the Latin roots "fibro" (fibrous tissue), "my" (muscles), "al" (pain), and "gia" (condition of). Fibromyalgia was known most commonly by the misnomer fibrositis, the "itis" implying an inflammatory component. Chaitrow asserts that no inflammatory process ever has been found to be part of this disease.

Pathophysiology: Although the sequence of events that cause fibromyalgia remains unknown, recent advances and discoveries may help to unravel the mysteries of this disease. Recent research shows biochemical, metabolic, and immunoregulatory abnormalities associated with fibromyalgia. Clinicians' approach to diagnosis and treatment may be enhanced by broadening their knowledge of these biochemical and immunoregulatory abnormalities, which may be involved in the way patients interpret the nociceptive signals to the central nervous system (CNS) and how they respond physiologically to stress. Current understanding of the pathophysiology of fibromyalgia describes the disease as a central pain processing disorder.

The most widely acknowledged biochemical abnormality associated with fibromyalgia is abnormally low serotonin levels. Many studies by researchers have linked serotonin, a neurotransmitter, to sleep, pain perception, headaches, and mood disorders. Lower than normal levels of serotonin have been observed in fibromyalgia patients. Low platelet serotonin is believed to be the cause of the low serum levels. Studies show low serum levels correlate with painful symptoms. Serotonin levels in the CNS are thought to be low due to both low tryptophan (the amino acid precursor to serotonin) and 5-hydroxyindole acetic acid (a metabolic by-product) in spinal fluid. Investigators have proposed a link between low serotonin levels and fibromyalgia symptoms. Moreover, many investigators propose that low serotonin levels may cause fibromyalgia totally or in part.

In support of the idea of a systemic biochemical abnormality in fibromyalgia, 4 independent studies reported elevation by 2-3 times of substance P, the neuropeptide in spinal fluid. Substance P is a neurotransmitter released when axons are stimulated. Increased levels of substance P increase the sensitivity of nerves to pain or heighten awareness of pain. The elevated levels in the spinal cord cause fairly normal stimuli to result in exaggerated nociception. Some authors believe that neither elevated substance P nor low serotonin alone can be primary causative agents but that the dual dysfunction may be responsible for fibromyalgia.

Researchers also have found the existence of low levels of adenosine triphosphate (ATP) in red blood cells of patients with fibromyalgia. Although the significance is unknown, some suggest low platelet serotonin levels could be explained if platelet ATP levels are also low. ATP is necessary to move and then hold serotonin in platelets. More investigation into ATP and the link to serotonin is needed.

Others have studied the neuroendocrine aspects of fibromyalgia and found hypothalamic-pituitary-adrenal (HPA) axis dysfunction in these patients. The HPA is a critical component of the stress-adaptation response. In a normally functioning system, the anterior pituitary is stimulated by corticotropin-releasing hormone (CRH) to release adrenocorticotropic hormone (ACTH). The adrenal cortex then is stimulated by ACTH to produce glucocorticoids, which are powerful mediators of the stress-adaptation response. Circadian regulation and the stress-induced stimulation of the HPA axis are, in part, regulated by serotonin. Serotonin metabolism perturbations (as well as premorbid HPA-axis abnormalities) may explain HPA-axis abnormalities in fibromyalgia.

The effects of abnormal serotonin metabolism may be exaggerated by HPA-axis dysfunction. Low central serotonin actually may be caused by HPA-axis hypoactivity. Some authors have noted the following 5 main measurable neuroendocrine abnormalities associated with HPA-axis dysfunction:

  • Low free cortisol in 24-hour urine
     
  • Loss of the normal circadian rhythm with elevated evening cortisol when it should be at its lowest level
     
  • Insulin-induced hypoglycemia associated with an overproduction of pituitary ACTH
     
  • Low levels of growth hormone
     
  • Stimulated ACTH secretion leading to insufficient adrenal release of glucocorticoids

Growth hormone, produced during delta sleep, is involved in tissue repair. The low levels of growth hormone may be explained by disrupted stage 4 (delta) sleep associated with fibromyalgia. Growth hormone stimulates liver production of insulinlike growth factor I (IGF-I). Some authors have found that low levels of IGF-I are present in most patients with fibromyalgia and that low levels are both specific and sensitive in fibromyalgia.

Some studies have found that nerve growth factor was 4 times higher in the spinal fluid of patients with fibromyalgia. This factor is important to the pathophysiology of fibromyalgia, since the process enhances substance P production in the afferent neurons, thereby increasing the sensitivity or awareness to pain. Nerve growth factor also may play a role in spreading or redistributing perceived pain signals.

Increasing evidence suggests the existence of a genetic predisposition for developing fibromyalgia. The inheritance pattern is autosomal-dominant. Some investigators propose that the genetic predisposition requires either reaching a critical age or sustaining an external insult such as trauma or illness.

Although the pathogenesis of fibromyalgia is not understood completely, the currently known abnormalities substantiate the proposal that fibromyalgia can no longer be considered a subjective pain condition. Many research groups suggest that fibromyalgia may be a condition of abnormal central processing of nociceptive pain input.

Frequency:

  • In the US: At any given point in time, conservative estimates suggest that 3-6% of the general population, including children, meet the criteria for diagnosis of fibromyalgia. This assumption makes fibromyalgia over twice as common as rheumatoid arthritis. Physicians may find that approximately 8% of their patients have fibromyalgia. In a rheumatology and physiatry practice, however, as many as 15% of evaluated patients have fibromyalgia. This incidence implies that 1 in every 10 patients evaluated in a medical practice has fibromyalgia.
  • Internationally: Fibromyalgia has been reported by researchers from around the world.

Mortality/Morbidity: The social, emotional, economic, and functional impact of fibromyalgia on an individual's life have been compared, by some authors, to the effects of rheumatoid arthritis. Approximately one third of patients with fibromyalgia have reportedly modified their work to keep their jobs. Some patients have shortened their workdays, their workweeks, or both. Many patients with fibromyalgia have changed to less physically and mentally taxing jobs. Often, this type of job change leads to decreased income and increased financial burdens. One figure suggests that approximately 15% of the people diagnosed with fibromyalgia currently are receiving disability benefits. An estimate of the overall annual cost of this disease to the American economy is over $9 billion.

Race: No racial predilection exists in fibromyalgia. Researchers have reported the condition in all ethnic groups and cultures.

Sex: Studies have shown that fibromyalgia is 4-7 times more common in females. No universally accepted explanation exists for this predilection for females, as there is hardly any difference in incidence among males and females in childhood.

Age: Fibromyalgia may be diagnosed in individuals of all ages. Symptoms usually arise between the ages of 20-55 years, but the condition also may be diagnosed in childhood.

History: Although it may take a little more time to gather a thorough and detailed initial history, the author finds that a good history saves time in the long run, reduces potential for litigation, helps prevent incorrect diagnosis, and eliminates inappropriate or unnecessary treatments.

Start the evaluation with identifying the chief complaint, which usually is related to pain. Although the initial interview starts with the chief complaint, avoid treating patients based on the chief complaint alone. Premature treatment may lead to symptom chasing and ineffective treatment. Patients with fibromyalgia experience a change in symptoms from day to day, which may not reflect the global nature of their disorder.

Next, expand on the chief complaint with specific questions about the pain. Question the patient about the distribution of the pain (eg, ask whether the pain is regional or generalized). Ask about the duration and onset of the pain. Patients usually can remember sudden onset of pain; if there was a gradual onset, determining the exact time of onset is difficult. Inquire about pain aggravating and alleviating factors. Record the description or characteristics of their pain (eg, ask whether the pain is migratory, burning, tender, sore, aching, sharp, radiating).

Thirdly, question the patient about his/her sleep habits and environment. If possible, ask the sleep partner if the patient snores or kicks while asleep. The clinician needs to know how long it takes for the patient to fall asleep and how many times he or she awakens. Ask patients how they feel in the morning.

Pellegrino and the author suggest that physicians obtain information about the patient's diet, particularly caffeine and carbohydrate intake. The history should include any symptoms that may indicate the presence of one or more of the coexisting conditions. Information on medications, exercise, and fatigue also is important. List any allergies and perpetuating factors.

Diagnostic criteria

Unfortunately, no medical test or x-ray can help provide definitive diagnosis of fibromyalgia, although these tests can help evaluate suspected coexisting conditions or rule out other possible diseases. Prior to 1990, there were no guidelines for evaluating and diagnosing fibromyalgia.

To reduce misdiagnosis and confusion, the American College of Rheumatology (ACR) recognized the need to establish a clear definition and guidelines. They sponsored a multicenter study to develop these criteria. In 1992, at the Second World Congress on Myofascial Pain and Fibromyalgia, the diagnostic criteria were expanded and refined.

The diagnostic criteria include 2 basic requirements. The first is the presence of pain in all 4 quadrants of the body, as well as in the axial skeleton on a more or less continuous basis for at least 3 months. The pain often is described as widespread or global. The second criterion is the presence of at least 11 of 18 anatomically specific tender points. A tender point hurts only at the area where pressure (enough to cause the examiner's nail bed to blanch, or about 4 kg) is applied, and there is no referred pain. An instrument known as a dolorimeter can be used to apply exactly 4 kg of pressure over the tender points during the examination. The 18 possible tender points exist as 9 pairs. Tender points may be found in any palpable muscle, but there are 18 sites that have been found to be present consistently in patients with fibromyalgia and are used for diagnosis. The ACR criteria describe 4 pairs of tender points on the anterior of the body and 5 pairs on the posterior of the body.

  • History of pain

    • Widespread pain
       
      • Right and left sides of the body
         
      • Above and below the waist
         
      • Along the axial skeleton
         
    • Duration of pain
       
      • Constant |
         
      • More than 3 months
         
  • Physical examination: Palpate the muscles.
     
    • Use 4 kg of pressure.
       
    • To meet the diagnostic criteria, pain must occur in 11 of 18 paired tender points.

Clinical presentation

Some authors have noted that the typical patient has seen an average of 15 physicians and has been affected for approximately 5 years prior to being diagnosed correctly with fibromyalgia. Many patients are misdiagnosed and endure costly treatments that provide little benefit. At some point, most patients have been told that nothing is medically wrong and that the condition is all in their heads. Many patients are frustrated and skeptical. Although most are relieved when a correct diagnosis finally is made, some patients affirm that the clinician may need to convince the patient that he or she actually knows what is wrong and that there is a treatment plan.

Most patients with fibromyalgia are female and do not appear chronically ill. They may look fatigued or agitated. Their chief complaint is often "I hurt all over all the time." The quality of their constant pain is described as burning, aching, and soreness. They may feel as if they are bruised all over but without visible signs. Although the pain is constant, the location migrates and the intensity varies. Many patients may complain of only a single painful area, such as the low back or neck. A careful history reveals that their pain is not focal in its distribution but global. Initially, they may complain of pain at one site because they tend to be concerned primarily with their worst pain. Since many patients do not understand that the symptoms are connected, they give a fragmented history. The physician must ask the right questions to develop a complete understanding of the patient's pain distribution.

Patients generally do not tell the physician that they have a sleeping disorder. Again, a carefully taken history reveals unrefreshing sleep in about 65% of patients and morning fatigue in about 80% according to recent studies. Patients awaken as tired as they were before sleeping. Most patients awaken frequently throughout the night, and some have difficulty falling asleep. Generally, they finally fall asleep in the early morning hours, describing this as their best sleep. Many patients fall asleep immediately, deny sleep onset problems, and report only infrequent awakenings. Sleep onset this rapid is abnormal and should not be overlooked. Most patients complain of morning stiffness of variable duration. Question the sleeping partner about lower extremity movements. Approximately 20% of fibromyalgia patients have concomitant restless legs syndrome, the presence of which may lead the physician to choose or add medications other than antidepressants to the treatment.

The patients report their fatigue is second only to pain. The fatigue is worse in the morning and early evening. By ten or eleven o'clock in the morning, the fatigue subsides somewhat. Several investigators, including this author, have found patients' fatigue is worsened by poor sleep, physical activity, and diet.

These patients may not admit to feeling depressed or anxious; therefore, the physician must inquire. The source of their emotional stress may be multifactorial.

Several studies show approximately 50% of patients present with complaints of tissues feeling swollen and numbness and tingling in the extremities. These symptoms generally are more common in the upper extremities than in the lower extremities. Objective swelling, sensory changes, and other neurologic findings usually are absent.

Some investigators list many other common complaints, including chronic headaches and tenderness of the scalp to the touch. Complaints of chest pain, shortness of breath, and palpitations are common. Serious cardiac problems should be considered and may require extensive evaluation. Many of these patients' symptoms are related to mitral valve prolapse syndrome. Approximately 40% of patients with fibromyalgia describe symptoms of alternating diarrhea and constipation, bloating, cramping, and an increased urge to defecate. These symptoms most likely are related to irritable bowel syndrome. Some patients also may complain of symptoms that include urgency, frequency, and a sense of incomplete voiding. Pelvic pain and dysmenorrhea may be present as well.

Associated conditions

Several medical conditions and diseases are thought to coexist frequently with fibromyalgia. These coexisting conditions can aggravate and perpetuate symptoms. Left unrecognized, the physician inadvertently might prescribe an ineffective or even harmful treatment regimen, leading to costly and unnecessary testing. Several of the most common conditions are discussed briefly. The most common associated conditions include the following:

  • Irritable bowel syndrome
     
  • Tension/migraine headaches
     
  • Dysmenorrhea
     
  • Nondermatomal paresthesia
     
  • Temporomandibular joint syndrome
     
  • Mitral valve prolapse
     
  • Interstitial cystitis, vulvodynia |
     
  • Female urethral syndrome
     
  • Vulvar vestibulitis
     
  • Hypermobility syndrome
     
  • Restless legs syndrome
     
  • Allergy
     
  • Multiple chemical sensitivity syndrome
     
  • Enthesopathies
     
  • Cognitive dysfunction
     
  • Vestibular disorders
     
  • Esophageal dysmotility
     
  • Ocular disturbances
     
  • Anxiety disorders
     
  • Pulmonary symptoms
     
  • Depression
     
  • Raynaud phenomenon
     
  • Sleep disorders
     
  • Myofascial pain syndrome
     
  • Thyroid dysfunction
     
  • Lyme disease
     
  • Silicone breast implant syndrome
     
  • Rheumatoid arthritis
     
  • Systemic lupus erythematosus
     
  • Sjögren syndrome
     
  • Infections
     
  • Osteoarthritis
     
  • Chronic fatigue syndrome
     
  • Carpal tunnel syndrome
     
  • Hyperventilation
     
  • Premenstrual syndrome (PMS)

Sleep disorders

Sleep is not a state of massive system shutdown, but quite the contrary. During sleep, the brain is very active, constantly communicating with the body. Many neurohormones, antibodies, and other molecules also are synthesized during sleep; therefore, when sleep is disrupted, biochemical abnormalities can occur, leading to multisystem disturbances.

Sleep studies have shown that patients with fibromyalgia have disordered sleep physiology. Most of these patients experience unrefreshing sleep with morning fatigue.

To understand abnormal sleep architecture, it is essential to know the basics of normal sleep. Sleep can be divided into 2 main parts, nonrapid eye movement (NREM) and rapid eye movement (REM) sleep, which alternate cyclically through the night, always starting with NREM sleep. In each successive NREM and REM cycle through the night, the amount of NREM sleep decreases and the amount of REM sleep progressively increases. Each cycle, NREM plus REM, lasts about 90 minutes. NREM is divided even further into 4 stages: stage 1 is initial drowsiness; stage 2 is light sleep; and stages 3 and 4 are progressively deeper levels of sleep.

In stages 3 and 4 of NREM sleep, the electroencephalogram (EEG) shows a pattern called delta waves, which are high-amplitude waves (greater than 75 mV) that move slowly (0.5-2 Hz). Much of the body's regulatory work, as well as synthesis of many substances (eg, antibodies, growth hormone, other neurochemicals), occurs during NREM sleep.

REM sleep has a low-voltage mixed-frequency pattern on EEG and is considered dream sleep. In this stage, the body has a complete loss of muscle tone, known as flaccid paralysis, and cannot move. During this part of sleep, consolidation of memories may occur, but there is still disagreement over exactly what occurs with memory during REM sleep. Some investigators found that during waking hours, the brain generates alpha waves with a frequency of 7.5-11 Hz.

Sleep dysfunction is considered an integral feature of fibromyalgia syndrome. Seventy percent of patients with fibromyalgia recognize a connection with poor sleep and an increased pain, along with feeling unrefreshed, fatigued, and emotionally distressed. Several studies have linked abnormal sleep with these symptoms.

Some researchers have studied fibromyalgia and sleep, confirming the disordered sleep physiology in fibromyalgia. This abnormality has been identified as an alpha-wave intrusion sleep anomaly, which occurs during NREM stage-4 sleep. This intrusion into deep sleep causes the patient to awaken or to be aroused into a lighter level of sleep.

Some authors describe the altered sleep physiology and somatic symptoms as a nonrestorative sleep syndrome. This sleep dysfunction is believed to be linked to the numerous metabolic disturbances associated with fibromyalgia, including abnormal levels of neurotransmitters (serotonin, substance P) and neuroendocrine and immune substances (growth hormone, cortisol, and interleukin-1). These authors propose that these metabolic imbalances are responsible for the increase in symptoms associated with this alpha-wave intrusion sleep disorder by impairing tissue repair and disturbing the immunoregulatory role of sleep. Studies show that the greatest amount of alpha-wave intrusions occur during the first few hours of sleep, decreasing throughout the night to normal levels by early morning. Some researchers note that this hypothesis correlates well with patients' frequent reporting that their best sleep is obtained in the early morning hours just prior to arising.

Depression

Depression in fibromyalgia is a controversial topic. In support of the contention that fibromyalgia is not a psychiatric illness, some authors believe that no correlation exists between fibromyalgia symptoms and psychological factors; others have determined that fibromyalgia is not a psychiatric disorder. The depression associated with fibromyalgia is believed to result from the pain, sleep deprivation, and dysfunction.

Depression in fibromyalgia may be treated with a regimen that includes nonpharmaceuticals. Antidepressants may help, but the clinician also should address other symptoms, such as fatigue or pain. Modifying diet and practicing good sleep hygiene are crucial. Starting a rehabilitation exercise program also is important. Some authors suggest that behavioral modification techniques and stress management also should be employed.

Myofascial pain syndrome

Fibromyalgia and myofascial pain syndrome may coexist, presenting a complex clinical picture; however, fibromyalgia and myofascial pain syndrome are not one and the same condition. As stated, fibromyalgia is a generalized amplification of pain or hypersensitivity condition and is associated with tender points in the muscles. Tender points are focal areas of muscle tissue that are exquisitely tender to compression. The tender points of fibromyalgia are painful locally at the site where the pressure is applied, without referred pain to distant areas.

By contrast, myofascial pain syndrome is considered in the narrow definition to be a disorder of trigger points. Similar to tender points, trigger points also are discreet areas in muscle tissue and/or its associated fascia that are exquisitely tender to compression; however, unlike tender points, when pressure is applied to the trigger point, pain occurs not only at the site of the applied pressure, but also at a distant site (zone of pain referral). Trigger points are found in taut bands (firm elongated bands) within the muscle fibers and are associated with the local twitch response. This local twitch response is an involuntary transient contraction of the taut band muscle fibers and can be elicited by snapping or pinching the taut band. Some authors assert that both disorders (fibromyalgia and myofascial pain syndrome) can magnify and perpetuate the symptoms of the other.

Several differences have been noted between fibromyalgia and myofascial pain syndrome, and a few mentioned by some investigators are listed below. A more detailed review of the similarities and differences in these 2 syndromes is found in Acupuncture: Trigger Points and Musculoskeletal Pain (1993) by a leading British physician and acupuncturist, DP Baldry.

 

Fibromyalgia

Myofascial pain syndrome

Gender prevalence

 

Mostly affects females No gender difference

Location of pain

Generalized Localized or regional

Association with fatigue

Common No

Other associated conditions

Many systemic diseases or conditions such as mitral valve prolapse, irritable bowel syndrome, and genitourinary disorders No

Prognosis

Generally chronic Can be resolved with manual muscle therapies

Cognitive dysfunction

Central nervous system imbalances have been linked to cognitive dysfunction or "fibrofog." This condition may cause some patients the most disability. According to some investigators, such symptoms include confusion and forgetfulness, inability to concentrate and recall simple words and numbers, and transposing words and numbers. Often, their cognitive functions are so impaired that they are unable to perform their usual activities of daily living (ADL), and the patient may get lost in familiar places or not be able to communicate effectively. Those patients who work face the fear of losing their jobs. Some school-aged patients drop out because of their inability to complete schoolwork.

Advances in noninvasive technology have made it possible to visualize the brain. New methods such as single photon emission computed tomography (SPECT) scanning have helped define some of the abnormalities linked to the cognitive dysfunction. Studies involving SPECT scanning show decreased blood flow in the area of the right and left caudate nuclei and thalami in fibromyalgia patients. Cognitive dysfunction may be caused by abnormal levels of neurotransmitters such as substance P, serotonin, dopamine, norepinephrine, and epinephrine. Some investigators claim that neuroendocrine imbalance of the HPA axis also may play a role in fibrofog. Others studies have implicated yeast overload, water retention, and glial cell abnormalities as causes of cognitive dysfunction in fibromyalgia.

Physical: The goal of the physical examination is to confirm the diagnosis, rule out concomitant systemic diseases, and recognize the presence of common coexisting conditions. The examination should include neurologic, joint, and musculoskeletal evaluations. Note the presence of swelling, deformities, and erythema. Examine the patient's gait, joint range of motion (ROM), and posture for structural asymmetry and skeletal deficiencies. Palpate the soft issues for tone, spasm, and tender points. Also check for taut bands, twitch responses, and trigger points; their presence signals the coexistence of a myofascial pain syndrome.

The standard criterion for diagnosis of fibromyalgia is the presence of 11 of 18 designated tender points. Other tender points may be present and also should be recorded. Some patients may present with less than 11 tender points. Experts contend that fibromyalgia can be diagnosed with as few as 8 or 9 tender points if other symptoms are present, such as sleep problems, fatigue, and any of the characteristic coexisting conditions.

The 1990 ACR criteria for the location of tender points are as follows:

  • Anterior body
    • At the fifth through seventh intertransverse spaces of the cervical spine
    • In the pectoral muscle at the second costochondral junctions
    • Approximately 3 finger breadths (2 cm) below the lateral epicondyle
  • Posterior body
    • At the base of the cranium at the insertion of the suboccipital muscles
    • At the upper border of the shoulder in the trapezius muscle midway from the neck to the shoulder joint
    • At the craniomedial border of the scapula at the origin of the supraspinatus
    • In the upper outer quadrant of the gluteus medius
    • Just posterior to the prominence of the greater trochanter at the piriformis insertion

Causes: No cause for fibromyalgia has been accepted universally, although there are many theories. Some authors suggest that there may even be an inheritance factor. Ongoing research may soon elucidate the cause(s).

Cervical Disc Disease
Cervical Myofascial Pain
Cervical Sprain and Strain
Chronic Pain Syndrome
Complex Regional Pain Syndromes
Hypothyroid Myopathy
Lumbar Degenerative Disc Disease
Lumbar Facet Arthropathy
Mechanical Low Back Pain
Meralgia Paresthetica
Myofascial Pain
Osteoarthritis
Postpolio Syndrome
Rheumatoid Arthritis
Systemic Lupus Erythematosus

Lab Studies:
  • Currently, no clinically available tests accurately identify fibromyalgia. Some investigators mention that laboratory studies are helpful only in ruling out other diseases or diagnosing coexisting conditions.

Imaging Studies:

  • Some investigators state that imaging studies are helpful only in ruling out other diseases or diagnosing coexisting conditions.

Rehabilitation Program:

  • Physical Therapy: The treatment actually begins with a detailed history and a thorough physical examination. Making a correct diagnosis is crucial, and patients need to know that a name exists for the mysterious symptoms that they experience. The physician should inform the patient that no cure exists but that education, lifestyle changes, and proper rehabilitation can help regain control and obtain significant improvement.

    Some investigators believe that a successful rehabilitation program involves a multidisciplinary team of professionals and various modalities individualized for each patient. This team includes the physician, a medical psychologist, physical and massage therapists, and an exercise physiologist. These professionals should have expertise in the treatment of soft tissue disorders. Traditional therapy or rehabilitation actually may worsen the patient's symptoms. Monitor the progress of the patient in rehabilitation. As goals are met and symptoms change, modify the rehabilitation prescription to meet these needs.

    Numerous modalities are available that can reduce pain, including electrotherapy, cryotherapy, and therapeutic heat. Teach patients how and when to use therapeutic modalities as part of their maintenance program. One investigator recommends muscle energy treatments, positional release methods, and massage as part of the rehabilitation program to decrease stiffness and pain.

    Some investigators find daily aerobic and flexibility exercises are an essential component of the rehabilitation program. Begin with gentle warm-up flexibility exercises and progress to stretching all the major muscle groups. Low-impact aerobic exercise is necessary at least 3 times weekly. The author recommends that patients always start at low levels of exercise and progress slowly. The goal is to exercise safely and without increased pain. The patients' target exercise regimen is 4-5 times a week for at least 20-30 minutes, which may take the patient months to achieve.

    Some patients never may be able to achieve this level of exercise, so encourage these people to exercise at the highest level possible without worsening their symptoms. Some investigators believe that aquatic exercise may be the safest and gentlest aerobic conditioning exercise available for them. Aquatic therapy not only provides aerobic conditioning but also flexibility, strengthening, and stretching exercise.

    The rehabilitation program is not complete without psychological intervention therapy. Many fibromyalgia patients experience increased levels of stress and feelings of depression, anxiety, and frustration. Several treatment options are available. According to Buckelew, cognitive behavioral therapy, relaxation training, group therapy, biofeedback, and stress management are some of the most useful options.

Other Treatment (injection, manipulation, etc.):
Trigger point injection

Trigger point injection is an important technique to provide mechanical disruption (myolysis) of the trigger point. Disruption leads to reduction of pain and an increase in ROM, exercise tolerance, and circulation; therefore, it is a valuable tool in the treatment of patients with tender points and trigger points. Long-term outcomes improve when trigger point injections are used in conjunction with physical therapy, massage therapy, or home stretching exercises.

Both dry needling and needling with infiltration are effective in eliminating trigger points and tender points. Many authors report that needling with infiltration is most effective. Patients with fibromyalgia who receive trigger point injections have shown significant improvement in pain intensity and pain threshold and improvement of ROM after trigger point injection. These patients may experience a delayed improvement of their pain but an immediate improvement in ROM following injection. They also experience more severe soreness that develops sooner and lasts longer following injection.

A number of both materials and techniques are used for needling with infiltration. Most physicians prefer either 1% lidocaine without epinephrine or 0.5% procaine. Lidocaine often is chosen over procaine because of fewer allergic reactions, more rapid onset of action, and greater potency. Steroids generally are not indicated or recommended for trigger point injections in patients with fibromyalgia. Sterile saline can be used in patients allergic to local anesthetics.

When performing a trigger point injection, use a sufficiently long needle. Usually an extensive area must be infiltrated, so a relatively large volume (2-12 mL) is injected. Before injecting the local anesthetic, make certain that the needle is in the trigger point. Localization of the trigger point is ascertained when the needle either causes a marked increase in pain with referral pain, a fasciculation is seen or felt, or both.

Several contraindications to trigger point injections must be observed. Avoid trigger point injections in patients with local or systemic infection. Patients with bleeding disorders or who are taking anticoagulation medication should not have trigger point injections without proper medical evaluation and only after the risks and benefits are explained clearly to them.

Fibromyalgia patients have difficulty tolerating regular doses of most medications and supplements; they are very sensitive to medications, and side effects are common. To avoid these problems, use the lowest dose available or perhaps half to a quarter of the lowest recommended dose.

Several medications should be avoided or used very carefully. Most investigators recommend using narcotics sparingly. In fibromyalgia without concomitant rheumatic illnesses, steroids are not helpful and should be avoided.

Avoid complications and confusion by providing written instructions and drug information. These instructions need to be easy to understand. Patients should be instructed to consult their physicians before starting any over-the-counter (OTC) medications or supplements to avoid potentially harmful drug interactions.

Useful medications for treating fibromyalgia

  • Sleep problems
     
    • Antidepressants (eg, trazodone, selective serotonin re-uptake inhibitors [SSRIs], tricyclics)
       
    • Clonazepam
       
    • Zolpidem
       
    • Muscle relaxants (Cyclobenzaprine)
       
  • Depression - Antidepressants
     
  • Pain
     
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
       
    • Cyclo-oxygenase-2 (Cox-2) specific inhibitors
       
    • Muscle relaxants
       
    • Analgesics
       
  • Other
     
    • Vitamins and minerals
       
    • Malic acid and magnesium combination
       
    • Melatonin
       
    • Antioxidants
       
    • Amino acids
       
    • Herbs

Drug Category: Antidepressants -- These drugs are used not only to treat depression, but also to improve sleep and pain. Antidepressants increase CNS serotonin. Delta-wave sleep also improves. The end result is an improvement of the symptoms experienced by patients with fibromyalgia.

Drug Name
 
Trazodone (Desyrel) -- Antidepressant most helpful in patients with anxiety and sleep disturbances.
Adult Dose Starting dose: 25 mg qd, preferably at 8 pm with food; increase dose q3wk but only to the lowest effective dose
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions May enhance response to alcohol, barbiturates, and other CNS depressants; digoxin and phenytoin serum levels may increase in patients receiving trazodone concurrently; may decrease hypoprothrombinemic effects of warfarin
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Priapism; some patients may experience orthostatic hypotension and syncope; patients may experience dizziness if this drug is taken on an empty stomach
Drug Name
 
Sertraline (Zoloft) -- Antidepressant that inhibits uptake of serotonin by the neuron. Administered PO qd. Sertraline is used to improve mood and sleep.
Adult Dose Starting dose: 25 mg qam for 1 wk, then, 50 mg qam; not to exceed 200 mg qd
Adjust dose q3wk in 25-mg increments prn
Pediatric Dose Starting dose: 25 mg qam; adjust dose to response in increments of 25 mg
Contraindications Documented hypersensitivity; coadministration with MAOIs
Interactions Increases toxicity of MAOIs, diazepam, tolbutamide, warfarin, and other highly protein-bound drugs
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in preexisting seizure disorders and those who have experienced a recent myocardial infarction, have unstable heart disease, and hepatic or renal impairment
Drug Name
 
Fluoxetine (Prozac) -- Antidepressant that inhibits uptake of serotonin by neurons. Used to improve mood and restore normal sleep patterns.
Adult Dose Starting dose: 10 mg qam for 1 wk, then 20 mg, qam and increase dose q3wk prn in 10-mg increments
Pediatric Dose Not established
Contraindications Documented hypersensitivity; concurrently taking MAOIs or have taken them in the last 2 wk
Interactions Increases toxicity of diazepam and trazodone by decreasing clearance; also increases toxicity of MAOIs and highly protein-bound drugs
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in hepatic impairment and history of seizures; MAOIs should be discontinued at least 14 d before initiating fluoxetine therapy
Drug Name
 
Paroxetine (Paxil) -- Potent selective inhibitor of neuronal serotonin reuptake, unrelated to tetracyclic, tricyclic, and other antidepressants. Also has a weak effect on norepinephrine and dopamine neuronal reuptake. Administered PO qd.
Adult Dose 10 mg qam with or without food for 1 wk, then 20 mg qam
Dose changes should occur q3wk in 10-mg increments
Pediatric Dose Not established
Contraindications Documented hypersensitivity; concurrent administration with MAOIs, or administering within 14 d of discontinuing an MAOI
Interactions Phenobarbital and phenytoin decrease effects of paroxetine; alcohol, cimetidine, sertraline, phenothiazines, and warfarin increase toxicity of paroxetine
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in history of seizures, mania, renal disease, and cardiac disease
Drug Name
 
Amitriptyline (Elavil) -- Sedative tricyclic antidepressant helpful in improving mood and restoring sleep. Inhibits the uptake of both serotonin and norepinephrine.
Adult Dose Starting dose: 5 mg qd at 8pm; increase over 3 wk prn up to lowest effective dose
Pediatric Dose <12 years: Not established
>12 years: 10 mg tid and 20 mg qhs
Contraindications Documented hypersensitivity; patient has taken MAO inhibitors in past 14 d; history of seizures, cardiac arrhythmias, glaucoma, and urinary retention
Interactions Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in elderly patients

Drug Category: Anticonvulsants -- Clonazepam is a benzodiazepine used to control anxiety and improve sleep. Also used to control seizures.

Drug Name
 
Clonazepam (Klonopin) -- Effective drug to improve sleep. Should be titrated to lowest effective dose. When discontinuing drug, slowly taper patient off the drug over 7-14 d.
Adult Dose Starting dose: 0.25 mg PO qd at 8pm; increase to lowest effective dose
Pediatric Dose <18 years: Not recommended except in seizure disorders
>18 years: Administer as in adults
Contraindications Documented hypersensitivity, severe liver disease and acute narrow-angle glaucoma
Interactions Effects of clonazepam may be potentiated by alcohol, narcotics, barbiturates, nonbarbiturate hypnotics, and tricyclic antidepressants
Pregnancy D - Unsafe in pregnancy
Precautions Caution in renal insufficiency and chronic respiratory disease; can cause hypersalivation; caution patients to avoid abruptly discontinuing therapy with clonazepam, especially those on high-dose long-term treatment

Drug Category: Nonbenzodiazepine hypnotic -- Used to improve sleep onset and maintenance

Drug Name
 
Zolpidem (Ambien) -- Safe, effective drug to treat sleep onset problems. Also effective in helping fibromyalgia patients with sleep maintenance.
Adult Dose Starting dose: 10 mg PO qhs
Elderly dose: 5 mg PO qhs
Should be taken on a relatively empty stomach immediately before going to sleep
Pediatric Dose Not recommended
Contraindications Documented hypersensitivity; breastfeeding
Interactions Increases toxicity of alcohol and CNS depressants
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Patients on this medication require adequate (7-8 h) sleep before resuming their activities of daily living; monitor elderly patients for impaired cognitive or motor performance; reduce starting dose to 5 mg

Drug Category: Muscle relaxants -- Helpful in short-term management of muscle spasms along with rehabilitation measures.

Drug Name
 
Cyclobenzaprine (Flexeril) -- Tricyclic amine used for relief of muscle spasms. Benefits fibromyalgia patients by improving sleep and decreasing pain.
Adult Dose 10 mg tid for 2-3 wk
Pediatric Dose Not established
Contraindications Documented hypersensitivity; MAOIs or for 14 days after stopping MAOI; hyperthyroidism, in patients with cardiac conduction disturbances, or in acute recovery phase of myocardial infarction; caution in urinary retention, angle-closure glaucoma, and increased intraocular pressure; patients on anticholinergic drugs should be monitored closely
Interactions Coadministration with MAOIs and tricyclic antidepressants may increase toxicity; cyclobenzaprine may have additive effect when used concurrently with anticholinergics; effects of alcohol, CNS depressants, and barbiturates may be enhanced with cyclobenzaprine
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Mental functions may be impaired by cyclobenzaprine; caution patient about taking cyclobenzaprine and operating machinery, performing hazardous tasks, or driving an automobile
Drug Name
 
Carisoprodol (Soma) -- Treats muscle spasm and pain in fibromyalgia.
Adult Dose 350 mg tid and hs
Treatment should be short term
Pediatric Dose Not recommended
Contraindications Documented hypersensitivity; acute intermittent porphyria
Interactions Increases toxicity of alcohol, CNS depressants, MAO inhibitors, clindamycin, phenothiazines
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Caution in renal and hepatic impairment; mental and physical functions are impaired by Soma

Drug Category: Narcotic analgesics -- These agents should be used for the short-term relief of pain.

Drug Name
 
Hydrocodone -- Opioid analgesic used for short-term relief of acute pain in fibromyalgia. Indicated for use during first few days of a flare-up or first few visits of rehabilitation program.
Adult Dose 5-10 mg q6-8h for 5-7 d
Pediatric Dose Not recommended
Contraindications Documented hypersensitivity
Interactions Toxicity increases when taken with TCAs, MAOIs, and CNS depressants
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Controlled substance with potential for abuse and dependence; patient's mental and physical functions may be affected when taking this drug; caution when taking this drug and driving an automobile, operating machinery, or performing dangerous tasks

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDS) -- Used to help control the pain associated with fibromyalgia. Although effects in treatment of pain tend to be patient specific, ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Drug Name
 
Ibuprofen (Ibuprin, Advil, Motrin) -- DOC for mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult Dose 200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric Dose 6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults
Contraindications Documented hypersensitivity to ibuprofen, other NSAIDs, or aspirin; avoid in peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding
Interactions May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity of NSAIDs
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Drug Name
 
Flurbiprofen (Ansaid) -- May inhibit cyclo-oxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult Dose 200-300 mg/d PO divided bid/qid
Pediatric Dose Not established
Contraindications Documented hypersensitivity
Interactions May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity of NSAIDs
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia rarely occurs, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug
Drug Name
 
Ketoprofen (Oruvail, Orudis, Actron) -- For relief of mild to moderate pain and inflammation. Small doses are indicated initially in patients with small body size, elderly patients, and those with renal or liver disease.
Doses >75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult Dose 25-50 mg q6-8h prn; not to exceed 300 mg/d
Pediatric Dose 3 months to 12 years: 0.1–1 mg/kg q6-8h
>12 years: Administer as in adults
Contraindications Documented hypersensitivity
Interactions May decrease effects of loop diuretics with coadministration; coadministration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity of NSAIDs
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Drug Name
 
Naproxen (Anaprox, Naprelan, Naprosyn) -- For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which is responsible for prostaglandin synthesis.
Adult Dose 500 mg PO, followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric Dose <2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Contraindications Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Interactions Probenecid may increase toxicity of NSAIDs; coadministration with ibuprofen may decrease effects of loop diuretics; coadministration with anticoagulants may prolong PT (watch for signs of bleeding); NSAIDs may increase serum lithium levels and risk of methotrexate toxicity (eg, stomatitis, bone marrow suppression, nephrotoxicity)
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia rarely occurs, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrant further evaluation and may require discontinuation of drug

Complications:

  • Symptoms of fibromyalgia vary. Patients may experience few symptoms one day and many the next. Some investigators describe a flare-up as a time when the patient experiences an acute intense increase in symptoms that last more than a day. The pain may be amplified to such intense levels that the patient becomes bedridden. Flares-ups usually are triggered by a stressor. The stressor may be infection, trauma, or changes in medication, sleep, or exercise. Onset of allergies, changes in diet, and a change in usual activity may bring on a flare-up.

    Teach patients what brings on flare-ups. Occasionally, no trigger can be identified. Patients must understand what their identifiable flare-up triggers are and what measures to take to decrease their symptoms.

  • Some tips for avoiding and managing flare-ups
    • Educate the patient on flare-ups.
    • Treat infection quickly.
    • Avoid changes in diet.
    • Exercise as prescribed (ask patients not to increase their routines without consulting a physician).
    • Moderate changes in activity.
    • Avoid unnecessary life changes.
    • Treat changes in mood or sleep early and aggressively.
    • Always start new medications at the lowest possible dose.
       
    • Prepare for situations that have caused flare-ups in the past (eg, increases in sleep medications or help with caring for children and housework).
       
    • Encourage the patient not to overdo anything.

Prognosis:

  • Fibromyalgia is not a life-threatening, deforming, or progressive disease. The symptoms are variable. Without proper diagnosis and treatment, the patient may have the illusion of disease progression. This illusion does not occur as a result of disease, but as a result of sleep deprivation and physical deconditioning. Some investigators state that, with the proper treatment and a caring informed physician, patients with fibromyalgia should be able to improve their function and reduce their pain.

Patient Education:

  • Although fibromyalgia has no cure, patients should be reassured that the illness is not life-threatening. Some authors suggest explaining the chronic fluctuating nature of this disorder to patients. When patients with fibromyalgia fully understand the nature of the disease, they are more compliant with treatment and more likely to take an active role in managing their disease. At the initial visit, give them educational materials on fibromyalgia, including a list of resources such as books, videotapes, newsletters, and brochures. Some authors recommend encouraging patients to attend their local fibromyalgia support group. Provide education and support to the patient's significant family members.
  • Sleep

    Fibromyalgia symptoms are worsened and perpetuated by poor sleep, so aggressive treatment is indicated. Searle asserts that most patients understand very little about the nature of sleep, so provide instruction on the basics of sleep, along with proper sleep hygiene. This educational tool is one of the most helpful interventions.

    This author suggests asking the patient to keep a sleep diary for 2 weeks before starting any new medications. The diary should include a list of current medications taken during the 2 weeks, time of retiring to bed, approximate time when the patient falls asleep, the number of awakenings, the time he or she got out of bed, and a general description of how rested he or she felt. The sleep diary gives the physician useful information for choosing medications.

    The physician should suggest a few helpful dietary and behavioral changes to the patient. Instruct the patient to avoid caffeine and large evening meals; avoiding alcohol is also helpful. Teach the patient basic relaxation techniques to use before bed. If urinary frequency is problematic, restrict fluids in the evenings. If these techniques are not helpful, a few patients may need sleep studies.

    The physician needs to consider using appropriate medications to improve the patient's sleep. The author feels the most effective medication for improving sleep onset problems is Zolpidem. The patient must be given instructions in the proper dosing of this medication. Sleep maintenance disorders are more difficult to manage. Generally, the antidepressants are most helpful because of their effect on serotonin. The criterion standard is amitriptyline, but many patients cannot tolerate this medication. Trazodone is an inexpensive, well-tolerated, and effective medication. The starting dose is 25 mg, and it should be taken at 8 pm. The dose can be titrated up slowly, if needed. If the patient is still not staying asleep, adding an SSRI usually is helpful. Clonazepam may be the drug of choice, if the patient has concomitant restless legs syndrome or mitral valve prolapse syndrome. The starting dose is 0.125 mg or 0.25 mg taken at 8 pm; titrate the dose to the lowest effective dose.

  • Diet

    Fibromyalgia symptoms are worsened by a poor diet; an investigator suggests that this deterioration may be due to impaired glycolysis and carbohydrate metabolism. Dietary changes are both essential to improvement of symptoms and challenging to achieve. Although there are many diet possibilities, many are as unhealthy as the patient's current diet. No dietary approach has been accepted universally, so the physician must choose an approach that is balanced and safe.

    Start by having the patient keep a food journal for 2 weeks. Determine the types of foods the patient normally eats. Eliminate caffeine, alcohol, and tobacco from the diet. Help the patient set reasonable and attainable goals. Wean the patient slowly off caffeine. Abruptly stopping caffeine causes increased fatigue and pain, headaches, anxiety, and worsens the sleep disturbance. Some authors suggest that all alcohol must be avoided for at least 6 months; then, if the patient's symptoms are stable, he or she may consume no more than 2 alcoholic drinks a day. Lastly, remove chemical-laden foods and refined sugars from the diet, including sugar and white flour.

    Most patients with fibromyalgia consume enormous amounts of carbohydrate-rich foods, which may contribute to their symptoms. Some investigators suggest a diet high in fresh vegetables, fish, and fiber. Green leafy and yellow vegetables are preferable because of their low carbohydrate content. Also choose fruits carefully; some are more glycemic than others. Some authors suggest it is better to eat fruits such as citrus, apples, berries, cantaloupe, and peaches. The rate of carbohydrate absorption decreases if the patient combines a food with fiber or some fat in it. A small amount of white or lowfat cheese with 1-2 high-fiber crackers works well. Ask the patient to avoid junk foods or processed snack foods, which usually contain large amounts of sugar or salt.

    Physicians must acquaint themselves with the available research on diet and metabolism. Investigate the trendy diets available and make informed choices and recommendations to each patient on an individual basis. Help patients set attainable goals for dietary modification.

  • Buckelew SP: Behavioral Interventions and Fibromyalgia. J Musculoskelet Pain 1994; 2: 153-161.
  • Chaitow L: In: Fibromyalgia and Muscle Pain. 1995:1-205.
  • Chaitow L: Conditions associated with fibromyalgia. In: Fibromyalgia Syndrome: A practitioner's Guide to Treatment. Edinburgh: Churchill Livingston; 2000:31-59.
  • Clauw DJ: Fibromyalgia: more than just a musculoskeletal disease. Am Fam Physician 1995 Sep 1; 52(3): 843-51, 853-4[Medline].
  • Crofford LJ: Neuroendocrine Aspects of Fibromyalgia. J Musculoskelet Pain 1994; 2: 125-133.
  • Eisinger J, Plantamura A, Ayavou T: Glycolysis abnormalities in fibromyalgia. J Am Coll Nutr 1994 Apr; 13(2): 144-8[Medline].
  • Fischer AA: New Approaches in Treatment of Myofascial Pain. Phys Med Rehabil Clin North Am 1997; 8: 153-169.
  • Gilliland RP: A medical perspective on fibromyalgia. In: Fibromyalgia Syndrome: A Practitioner's Guide to Treatment. Edinburgh: Churchill Livingston; 2000:111-119.
  • Goldstein JA: In: Betrayal by the Brain. NY: Haworth Medical Press; 1996.
  • Griep EN, Boersma JW, de Kloet ER: Altered reactivity of the hypothalamic-pituitary-adrenal axis in the primary fibromyalgia syndrome. J Rheumatol 1993 Mar; 20(3): 469-74[Medline].
  • Hong CZ, Hsueh TC: Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil 1996 Nov; 77(11): 1161-6[Medline].
  • Imamura ST, Fischer AA, Imamura M: Pain Management Using Myofascial Appoach When Other Treatment Failed. Phys Med Rehabil Clin North Am 1997; 8: 179-196.
  • Ingber RS: Position Paper on Trigger Point Injections. Available at: http://www.dringber.com/tpoint.html[Full Text].
  • Lue FA: Sleep and Fibromyalgia. J Musculoskelet Pain 1994; 2: 89-100.
  • Moldofsky H: A chronobiologic theory of fibromyalgia. In: Musculoskeletal Pain, Myofascial Pain Syndrome, and Fibromyalgia Syndrome. 1993:49-59.
  • Pellegrino M: Physical Medicine and a Rehabilitation Approach to Treating Fibromyalgia. Fibromyalgia Syndrome: A Practitioner's Guide to Treatment. Edinburgh: Churchill 2000; 121-130.
  • Russell IJ: Biochemical Abnormalities in Fibromyalgia Syndrome. J Musculoskelet Pain 1994; 2: 101-115.
  • Russell IJ: Fibromyalgia Syndrome: Diagnosis, Pathogenesis, and Management. Phys Med Rehabil Clin North Am 1997; 8: 213-226.
  • Russell IJ, Orr MD, Littman B: Elevated cerebrospinal fluid levels of substance P in patients with the fibromyalgia syndrome. Arthritis Rheum 1994 Nov; 37(11): 1593-601[Medline].
  • Searle: In: Easy Steps to Help You Sleep. Chicago: Searle; 1994:1-34.
  • Sears B, Lawren B: The Zone. 1st ed. 1995.
  • Simms RW: Muscle Studies in Fibromyalgia Syndrome. J Musculoskelet Pain 1994; 2: 117-123.
  • Starlanyl D, Copeland ME: In: Fibromyalgia and Chronic Myofascial Pain Syndrome: A Survivors Manual. 1996:7-264.
  • Teitelbaum J: For physicians. In: From Fatigued to Fantastic! Avery Publishing; 1995:93-115.
  • Travell JG, Simons DG: In: Myofascial Pain and Dysfunction: The Trigger Point Manual. Baltimore: Lippincott Williams & Wilkins; 1983.
  • UCLA Sleep Research Society: Basics of Sleep Behavior: What is Sleep. 1997; Available at: http://www.sleephomepages.org/sleepsyllabus.[Full Text].
  • Vecchiet L, Giamberardino MA: Referred Pain: Clinical Significance, Pathophysiology, and Treatment. Physical Medicine and Rehabilitation Clinics of North America 1997; 8: 119-136.
  • Wolfe F, Smythe HA, Yunus MB, et al: The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum 1990 Feb; 33(2): 160-72[Medline].
  • Yunus MB: Fibromyalgia Syndrome: Clinical Features and Spectrum. J Musculoskelet Pain 1994; 2: 5-21.
  • Zohn DA: Relationship of Joint Dysfunction and Soft-Tissue Problems. Phys Med Rehabil Clin North Am 1997; 8: 69-86.
  • Source:  eMedicine - Fibromyalgia : Article by Regina P Gilliland, MD http://www.emedicine.com/pmr/topic47.htm#section~workup

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