FIBROMYALGIA

Fibromyalgia is relatively common disorder affecting primarily women in the 25-45 year age group. It is frequently a diagnosis of exclusion where the symptoms cannot be attributed to other causes. Normally it has a slow onset, and although non-fatal and non-degenerative, it causes chronic long-term difficulties and may, in rare instances, become debilitating.

Uniform diagnostic criteria for fibromyalgia were established by the American College of Rheumatology in 1990. These require the patients to have widespread pain in combination with at least 11 of 18 tender points and for at least 3 months in duration. Sites of tenderness are bilaterally over the suboccipital muscle insertion at the base of the skull, the anterior aspect of the intertransverse process spaces at C5-C7, the midpoint of the upper border of the trapezius muscle, above the scapular spine near the medial border of the scapula, the second costochondral junction, the lateral epicondyle, the upper outer quadrant of the buttock, the posterior aspect of the trochanteric prominence, and the medial fat pad of the knee. Skinfold tenderness may be present particularly over the upper scapular region. Subcutaneous nodules may be felt at sites of tenderness. Nodules in similar locations are present in normal persons but are not tender. (1)

The tender points of fibromyalgia are distinguished from the trigger points of myofascial pain syndrome. In fibromyalgia the points are exquisitely more tender than adjacent areas, causing pain only at that site. Pressure over trigger points normally causes pain to be referred to a nearby site. With fibromyalgia, patients often feel the sites are swollen and inflamed, however, in physical exams no swelling can be found and no evidence of inflammation is normally found in either lab values or biopsies.

The severity of related symptoms and of the pain and accompanying tenderness may vary greatly from day to day. Related symptoms are fatigue, which may be overwhelming, non-refreshing sleep, irritable bowel syndrome, headache, Raynaud's-like symptoms, paresthesias, and depression. The non-refreshing sleep is characterized by the intervention of alpha waves into the normal delta waves of stage 4 sleep, referred to as alpha-delta sleep. The alpha-delta sleep pattern can be induced in normal individuals by repetitive arousal during sleep, causing the development of pain and tenderness similar to those of patients with fibromyalia. Interestingly, this pattern of sleep deprivation did not induce symptoms of fibromyalgia in aerobically conditioned individuals. (2)

Conventional treatment of fibromyalgia includes the use of tricyclic antidepressants, non-steroidal anti-inflammatories such as aspirin and ibuprofen and local injections of either steroids or lidocaine. Serotonin as a neurotransmitter in blocking pain pathways has led to an increased use of the amino acid L-tryptophan. (3) Local measures such as heat, massage, and acupuncture are considered to provide only temporary relief of symptoms.

Although the causes of fibromyalgia are unknown, it currently affects as many as 3 million Americans of which 89 to 90 percent are women. It appears to be related to environmental and emotional stress in patients with inadequate coping mechanisms due to poor diet, insufficient exercise, and lack of knowledge or use of stress reducing regimes. Cardiovascular fitness training or aerobic exercise programs, biofeedback training, and deep massage have been effective. A holistic approach including massage, somato-emotional release, aerobic conditioning, diet counseling, meditation, and bio-feedback would appear to have the best chance of success in reversing this painful and depressing condition.

1. Harrison's Principles if Internal Medicine, Thirteenth Edition, editors Kurt J. Isselbacher…(et al.), 1994 McGraw-Hill, Inc., pp. 1688-89, 1707.
2. Scientific American Medicine, editors David C. Dale and Daniel D Federman, 1996, Scientific American, Inc., Chapter 15 Rheumatology, section VI, Idiopathic Inflammatory Myopathies, pp. 7-9.
3. Wallace, Daniel J., M.D., Fibromyalgia: A newly defined arthritis of aches and pains that used to fool the doctors., Arthritis Foundation: Headlines, Southern California Chapter, Vol XXVI, No. 3, Fall 1983., pp. 4-5