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•	Fibromyalgia

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Fibromyalgia

Highlights

Risk Factors:

As many as 6 million Americans have fibromyalgia. Risk factors include being female, having had difficult experiences in childhood, having a psychological vulnerability to stress, and coming from a very stressful culture or environment.

Fibromyalgia and PTSD:

Studies have reported a greater number of severe experiences of abuse in patients with fibromyalgia, compared with the general population. This suggests that post-traumatic stress disorder (PTSD) or chronic stress may play a strong role in the development of fibromyalgia in some patients.

Drug Research News

• Milnacipran, an antidepressant not yet approved in the U.S., is in Phase III trials for the treatment of fibromyalgia. Though results from the first Phase III trial did not show a significant benefit for this drug, the manufacturer is undergoing a second, longer, and larger trial.
• Study results, presented in November 2006, show pregabalin cut fibromyalgia pain by at least 50% in 63% of patients, and the effect was long-lasting.
• Pramipexole, a drug used to treat Parkinson’s disease and restless legs syndrome, may cut fibromyalgia-related pain symptoms in half, according to a study published in the journal Arthritis and Rheumatism.

Research:

• A 2004 report, published in the journal Sleep, found that sleep disorders that cause breathing problems are common in women with fibromyalgia.
• Areas in the brain that are responsible for the sensation of pain are different in fibromyalgia patients from the same areas in healthy people, according to research published in the December 2006 issue of Current Pain and Headache Reports.

Introduction

Fibromyalgia is a syndrome of unknown causes that results in lasting, sometimes debilitating, muscle pain and fatigue. Fibromyalgia is also known as fibrositis or fibromyositis.

General Description of Fibromyalgia Symptoms

Pain. The primary symptom of fibromyalgia is pain. The pain can be in one place or all over. The exact locations of the pain are called tender points. The pain of fibromyalgia is often is described as follows:

• Tender point pain occurs in local sites, usually in the neck and shoulders. The pain then spreads out from these areas. The actual pain starts at the muscles. The joints are not affected. There are no lumps or nodes associated with these points of pain, and there are no signs of inflammation (swelling). Those who are diagnosed with fibromyalgia feel pain in at least 11 of 18 specific tender points. [See section on Diagnosis: Criteria for Classifying Fibromyalgia.]
• Widespread pain is similar to that of arthritis and has been described as stiffness, burning, and aching. The pain also radiates, which means it spreads from the original point to nearby areas. Most patients report feeling some pain all the time, and many describe it as "exhausting." The pain can vary depending on the time of day, weather changes, physical activity, and the presence of stressful situations. The pain is often more intense after disturbed sleep.

Fatigue and Sleep Disturbances. Another major complaint is fatigue, which some patients report as being more unbearable than the pain. Sleep disturbances, particularly restless legs syndrome, are also very common. Fatigue and sleep disturbances are, in fact, almost universal in patients with fibromyalgia. Some experts believe that if these symptoms are not present, doctors should seek a diagnosis other than fibromyalgia.

Depression and Mood. Up to a third of patients experience depression. Disturbances in mood and concentration are also very common.

Other Symptoms. The following symptoms may also be present:

• Dizziness
• Tension or migraine headaches
• Tingling or numbness in the hands and feet
• Digestive problems, including irritable bowel syndrome with gas, and alternating diarrhea and constipation
• Urinary frequency caused by bladder spasms
• Painful menstrual periods

Symptoms in Children. Although children and adults have similar fibromyalgia symptoms, some experts suggest that children may not have a set number of pain tender points. In one study, children had an average of 9.7 tender point locations compared to the minimum of 11 in adults. In general, children with fibromyalgia most often experience sleep disorders and widespread pain.

Causes

Fibromyalgia is grouped into two categories:

• Primary (idiopathic) fibromyalgia -- the causes are not known.
• Secondary fibromyalgia -- the causes can be identified.

Primary fibromyalgia is the most common type. Many experts believe that fibromyalgia is not a disease but rather a chronic pain condition brought on by several abnormal body responses to stress. Physical injuries, emotional trauma, or viral infections such as Epstein-Barr may be triggers of the disorder, but none have proven to be a cause of primary fibromyalgia.

Research published in the December 2006 issue of Current Pain and Headache Reports found that the areas in the brain that are responsible for the sensation of pain are different in fibromyalgia patients from the same areas in healthy people.

Chronic Sleep Disturbance

Sleep disturbances are common in fibromyalgia. Both adult and young patients with fibromyalgia have a higher than average rate of a sleep disorder called periodic limb movement disorder (PLMD). PLMD used to be called nocturnal myoclonus. Patients with PLMD involuntarily contract their leg muscles every 20 - 40 seconds during sleep. This may occasionally wake up the patient.

Some experts believe that fibromyalgia does not lead to poor sleeping patterns, but that sleep disturbances come first. Researchers continue to investigate the link between fibromyalgia and sleep.

• In one study, healthy volunteers reported fibromyalgia-like pain after they had been subjected to disrupted deep sleep. Disturbed sleep appears to trigger factors in the immune system that cause inflammation, pain, fatigue, and lower tolerance to pain. A 2004 study found that patients with fibromyalgia have increased rates of cyclic alternating sleep pattern (CAP). Increased CAP produced serious sleep problems, which were strongly linked to symptom severity. Previous studies have also suggested that CAP may be related to PLMD.
• A 2004 report found that sleep disorders that cause breathing problems are common in women with fibromyalgia.
• Other biological measures of troubled sleep, however, such as levels of the hormone melatonin, which helps to regulate circadian rhythms and the sleep-wake cycle, appear to be normal in most fibromyalgia sufferers.

Brain Chemicals and Hormonal Abnormalities

Studies of hormonal, metabolic, and brain chemical activity in fibromyalgia patients have shown numerous abnormalities. Changes appear to occur in several brain chemicals, although no regular pattern has emerged that fits most patients. Some experts believe that the changes are a result of the effects of pain and stress on the central nervous system, and are not a cause of fibromyalgia.

Serotonin. Of particular interest to researchers is serotonin, an important nervous system chemical messenger found in the brain, gut, and other areas of the body. Serotonin plays important roles in feelings of well-being, adjusting pain levels, and promoting deep sleep. Serotonin abnormalities have been linked to many disorders, including depression, migraines, and irritable bowel syndrome. Lower serotonin levels have also been noted in some patients with fibromyalgia.

Stress Hormones. Researchers have also found abnormalities in the hormone system known as the hypothalamus-pituitary-adrenal gland (HAP) axis. The HAP axis controls important functions, including sleep, response to stress, and depression. Changes in the HAP axis appear to produce lower levels of the stress hormones norepinephrine and cortisol. (By contrast, levels of stress hormones in depression are higher than normal.) Deficiencies in the levels of stress hormones produce impaired and weaker responses to psychological or physical stresses. (Examples of physical stress include infection or exercise.)

The hypothalamus is a highly complex structure in the brain that regulates many important brain chemicals.

Click the icon to see an image of the adrenal glands.

Low Growth Hormone Levels. Some studies have reported low levels of insulin-like growth factor-1 (IGF-1) in about a third of fibromyalgia patients. IGF-1 is a hormone that is controlled by the adult growth hormone, and promotes bone and muscle growth. Low levels of growth hormone are related to impaired thinking, lack of energy, muscle weakness, and intolerance to cold. Severe growth hormone deficiency has been observed in a subset of fibromyalgia patients. While researchers did not find a link between IGF-1 levels and fibromyalgia, a 2005 study indicates that serum growth hormone levels may be a marker of the disorder.

Abnormal Pain Perception and Substance P. Some studies have suggested that fibromyalgia may involve too much activity in the parts of the central nervous system that process pain (the nociceptive system). Brain scans of fibromyalgia patients have suggested abnormalities in pain processing centers. Of particular interest is research that has detected up to three times the normal level of substance P in the cerebrospinal fluid of fibromyalgia patients. Substance P is a chemical messenger of the nervous system, and is associated with increased pain perception.

Some fibromyalgia patients may also be oversensitive to external stimulation, and overly anxious about the sensation of pain. This increase in awareness is called generalized hypervigilance. One study compared patients with fibromyalgia or rheumatoid arthritis to those without chronic pain. The different groups' responses to pain and noise were measured. Of the three groups, the fibromyalgia patients were least tolerant of and most attentive to such stimuli. However, a 2001 analysis of studies on fibromyalgia found no strong support for the hypervigilance theory.

Immune Abnormalities

Fibromyalgia has some symptoms that resemble those of some rheumatic illnesses, including rheumatoid arthritis and lupus (systemic lupus erythematosus). These are autoimmune diseases in which a defective immune system mistakenly attacks the body's own healthy tissue, producing inflammation and damage. The pain in fibromyalgia, however, does not appear to be due to autoimmune factors, and there is little evidence to support a role for an inflammatory response in fibromyalgia.

Psychological and Social Effects

Although not primary causes, psychological and social factors may contribute to fibromyalgia in three ways:

• They could make individuals susceptible to fibromyalgia.
• They may play some role in triggering the onset of the condition.
• They may perpetuate, or be responsible for, the condition.

Studies have reported a greater number of severe experiences of emotional and physical abuse in patients with fibromyalgia, compared with the general population. Most often, the abuse came from family members or partners. This suggests that post-traumatic stress disorder (PTSD) or chronic stress may play a strong role in the development of fibromyalgia in some patients. PTSD is an anxiety disorder that is a reaction to a specific traumatic event. Symptoms of this condition, which can last for years after the traumatic event, include emotional withdrawal, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle response to noise. There is some evidence that PTSD actually results in changes in the brain, possibly from long-term over-exposure to stress hormones.

Muscle Abnormalities

Some research found muscle abnormalities in fibromyalgia patients. These abnormalities can be classified as follows:

• Biochemical abnormalities: For example, one study reported that fibromyalgia patients had lower levels of the muscle-cell chemicals phosphocreatine and adenosine triphosphate (ATP). Such chemicals regulate the level of calcium in muscle cells. Calcium is an important component in the muscles' ability to contract and relax. If ATP levels are low, calcium is not "pushed back" into the cells and the muscle remains contracted.
• Structural and blood flow abnormalities: Some researchers saw overly thickened capillaries (tiny blood vessels) in the muscles of fibromyalgia patients. The abnormal capillaries could produce lower levels of compounds essential for muscle function, as well as reduce the flow of oxygen-rich blood to the muscles.
• Functional abnormalities: The pain and stress of the disease itself may harm muscle function.

Causes of Secondary Fibromyalgia

Secondary fibromyalgia has the characteristic symptoms of fibromyalgia but, unlike primary fibromyalgia, it has a specific cause. Possible causes include:

• Physical injury: In one study, for example, secondary fibromyalgia developed in over 20% of patients who had neck injuries. The symptoms are identical to those of primary fibromyalgia but are harder to treat. Another study reported a high rate of fibromyalgia in workers who had repetitive stress injuries, although it is not clear which condition came first.
• Ankylosing spondylitis (arthritis affecting the spine)
• Surgery
• Lyme disease

Click the icon to see an image of Lyme disease.

• Hepatitis C

Click the icon to see an image of hepatitis C.

• Endometriosis: According to a 2001 study, about 31% of women with endometriosis go on to develop fibromyalgia or chronic fatigue syndrome, a related illness.

Click the icon to see an image of endometriosis.

Risk Factors

As many as 6 million Americans have fibromyalgia. Some evidence suggests that several factors may make people more susceptible to fibromyalgia. These risk factors include being female, having had difficult experiences in childhood, having a psychological vulnerability to stress, and coming from a very stressful culture or environment.

Women

Nine out of 10 fibromyalgia patients are women. Women may be more prone to develop fibromyalgia during menopause.

Age

The disorder usually occurs in people 20 - 60 years of age, though it can occur at any time. Some studies have noted peaks around age 35. Others note it is most common in middle-aged women. In one trial, cases of fibromyalgia increased with age, and reached a frequency of over 7% among people in their 60s and 70s.

Juvenile Primary Fibromyalgia. This variant of fibromyalgia appears in adolescents, typically after age 13 with a peak incidence at age 14. It is uncommon, but studies indicate that its incidence may be increasing. One study found that 1.2% of school children, all girls, met the criteria for fibromyalgia. Other studies have found an even higher frequency of fibromyalgia in children. Symptoms are similar to adult fibromyalgia, but outcomes appear to be better in young people.

Family Factors

Studies report a higher incidence of fibromyalgia among family members. It is not clear if genetic or psychological factors, or both, are involved.

• One study reported that 28% of the children of mothers with fibromyalgia also develop the disorder. Offspring who developed fibromyalgia were no more likely to have psychological disorders than those who did not.
• Another study noted that 66% of parents of children with fibromyalgia reported some sort of chronic pain, and about 10% had fibromyalgia itself.

Conditions That Commonly Occur in Fibromyalgia Patients

Several conditions overlap or often co-exist with fibromyalgia, and have similar symptoms. It is not clear if these conditions cause fibromyalgia, are risk factors for the disorder, have causes in common with fibromyalgia, or have no relationship at all with it.

Chronic Fatigue Syndrome. There is a significant overlap between fibromyalgia and chronic fatigue syndrome (CFS). In a 2003 study, for example, 43% of CFS patients also had a diagnosis of fibromyalgia. As with fibromyalgia, the cause of CFS is unknown. Both disorders can be diagnosed by a doctor based only on symptoms reported by the patient, and cannot be confirmed by laboratory tests or other objective measures. The two disorders share most of the same symptoms. They are even treated almost identically. The differences are primarily the following:

• Pain with tender points is the primary symptom in fibromyalgia. Some patients with CFS exhibit similar tender pressure points. However, muscle pain is less prominent in patients with CFS.
• Fatigue is the dominant symptom in CFS. It is severe and not relieved by rest or sleep, and it is not the result of excessive work or exercise.

Some doctors believe that fibromyalgia is simply an extreme type of chronic fatigue syndrome. There is some physical evidence, however, that the two disorders are distinct, with treatments that are specific to each.

Myofascial Pain Syndrome. Myofascial pain syndrome can be confused with fibromyalgia and may also accompany it. Unlike fibromyalgia, myofascial pain tends to occur in trigger points, as opposed to tender points, and typically there is no widespread, generalized pain. Trigger-point pain occurs in tight muscles, and when the doctor presses on these points, the patient may experience a muscle twitch. Unlike tender points, trigger points are often small lumps, about the size of a pencil eraser.

Major Depression. The link between psychological disorders and fibromyalgia is very strong and problematic. Certain studies report that between 50 - 70% of fibromyalgia patients have a lifetime history of depression. Only between 18 - 36% of fibromyalgia patients, however, have concurrent major depression, a severe form of depression. It should be noted that some studies found that people who have both psychological disorders and fibromyalgia are more likely to seek medical help, compared with patients who simply have symptoms of fibromyalgia. If this is the case, study results may be biased, favoring a higher-than-actual association between depression and fibromyalgia.

Depression most likely does not cause fibromyalgia, but it may increase susceptibility. Depressed feelings in people with fibromyalgia can certainly be normal responses to the pain and fatigue caused by this syndrome. Such emotions, however, are related to the situation a person is in, and are temporary. They are not considered to be a depression disorder. However, unlike ordinary periods of sadness, an episode of major depression disorder can last many months. Symptoms of major depression include the following:

• A depressed mood every day
• Significant weight gain or loss (of 10% or more of an individual's typical body weight)
• Insomnia or excessive sleeping
• Restlessness or a sense of being slowed down
• Low energy every day
• Feeling worthless or inappropriately guilty
• An inability to concentrate or make decisions
• Suicidal thoughts

If several of the above symptoms are present, and none of the physical symptoms (particularly the tender points) of fibromyalgia exist, the condition is most likely major depression.

Chronic Headache. Chronic primary headaches such as migraines are common in fibromyalgia patients. Some experts believe that migraine headaches and fibromyalgia may even share common defects in the systems that regulate certain chemical messengers in the brain, including serotonin and epinephrine (adrenaline). Low levels of magnesium have also been noted in patients with both fibromyalgia and migraines. In fact, chronic migraine sufferers who fail to benefit from usual therapies may also have fibromyalgia.

Symptoms of a migraine attack may include heightened sensitivity to light and sound, nausea, vision problems (auras), speech difficulty, and intense pain predominating on one side of the head.

Multiple Chemical Sensitivity. Multiple chemical sensitivity (MCS) is a term that describes conditions in which certain chemicals can cause symptoms similar to CFS or fibromyalgia in some people. It also happens in people with fibromyalgia. Experts have come up with criteria to help recognize MCS.

• The symptoms always happen with repeated exposure to a chemical. (These are often common chemicals found in popular products, such as perfumes, fabric softeners, and air fresheners.)
• The condition is chronic.
• Symptoms can be produced by exposure to the chemical at levels lower than previously or usually tolerated.
• The symptoms improve when the chemical is removed.
• Symptoms can be triggered by multiple substances that are chemically unrelated.
• Symptoms involve multiple organ systems.

Still, as with CFS and fibromyalgia, some experts are uncertain whether MCS is a medical condition or if it is psychologically based. In one study, for example, CFS patients who believed their problem was chemically triggered were exposed to either an active chemical or a placebo (an inactive substance). Both groups reported symptoms, including those exposed only to the placebo. Because everyone is exposed to many chemicals on a daily basis, it is very difficult to determine if chemicals are responsible for specific symptoms.

Restless Legs Syndrome (RLS). About 15% of people with fibromyalgia have restless legs syndrome. RLS is an unsettling and poorly understood movement disorder sometimes described as a sense of unease and weariness in the lower leg that is aggravated by rest and relieved by movement.

Disorders Affected by the Sympathetic (also called Autonomic) Nervous System. Other conditions that commonly accompany fibromyalgia include chest pain and heart palpitations, mitral valve prolapse, and a sudden drop in blood pressure.

Diagnosis

There is no obvious, objective method for diagnosing fibromyalgia. The criteria used for studying fibromyalgia are very helpful, particularly if the patient does not have any accompanying disorder, such as depression or arthritis, which could complicate the diagnosis. Failure to meet the criteria, however, does not rule out fibromyalgia. Fibromyalgia should be suspected in any patient with muscle and joint pain when no identifiable cause has been found.

The 18 fibromyalgia tender points are located throughout the body. According to the American College of Rheumatology, a diagnosis of fibromyalgia requires widespread body pain plus localized pain in 11 of these 18 specific points.

Medical and Personal History

A doctor should always take a careful personal and family medical history, which would include a psychological profile and a history of any factors that might be indicative of disorders other than fibromyalgia. Such factors might include recent weight change, physical injuries, infectious diseases, muscle weakness, rashes, and any instances of sexual, physical, or substance or alcohol abuse. Patients should report any drugs they take, including vitamins and over-the-counter or herbal medications.

Physical Examination

Pressure on Tender Spots. Any physical examination for fibromyalgia requires that the doctor press firmly on all potential tender spots. They must be painful when pressed, not simply tender. In addition, for a doctor to reach a diagnosis of fibromyalgia, these tender sites should normally not show signs of inflammation (redness, swelling, or heat in the joints and soft tissue). The tender points may also change in location and sensitivity over time. A doctor, then, may recheck tender points that do not respond the first time, in patients who have other significant symptoms.

Detection of Other Causes of Symptoms. A physical examination also includes scrutiny of nails, skin, mucous membranes, joints, spine, muscles, and bones to help rule out arthritis, thyroid disease, and other disorders.

Other Tests

There are no blood, urine, or other laboratory tests that can provide a definitive diagnosis of fibromyalgia. If such tests show abnormal results, the doctor should look for other disorders. Tests for specific diseases depend on family histories and other symptoms. They may include thyroid and liver function tests, blood count, tests of certain antibodies, and sedimentation rate. The doctor may suggest follow-up psychological profile testing, if laboratory results do not indicate a specific disease.

Conditions with Similar Symptoms

Between 10 - 30% of all doctors' office visits are due to symptoms that resemble those of fibromyalgia, including fatigue, malaise, and widespread muscle pain. Since no laboratory test can confirm a diagnosis of fibromyalgia, doctors will usually first test for similar conditions. It should be noted that a diagnosis of many of the disorders below may not always rule out fibromyalgia, since it can accompany other common and similar conditions.

Conditions That Do Not Rule Out Fibromyalgia

Chronic fatigue syndrome, myofascial pain syndrome, depression, primary headaches, and certain stress-related disorders commonly occur with fibromyalgia, and have overlapping symptoms. In fact, some experts believe these disorders so often interact that they may all be part of one general condition.

Other conditions may also occur that are similar to fibromyalgia but do not rule out a diagnosis of fibromyalgia. They include:

• Irritable bowel syndrome
• Temporomandibular joint disorders (TMJ)
• Juvenile rheumatoid arthritis (JRA) -- usually diagnosis is clear-cut, but the conditions may coexist. JRA should be considered in children with fibromyalgia if their condition worsens.
• Osteoarthritis -- a common form of arthritis than can coexist with fibromyalgia. The two conditions may be confused, particularly in elderly people. Osteoarthritis, however, causes joint pain, not widespread or generalized pain.

Osteoarthritis is a chronic disease of the joint cartilage and bone. It is often thought to result from "wear and tear" on a joint, although there are other causes, such as congenital defects, trauma, and metabolic disorders. Joints appear larger, are stiff and painful, and usually feel worse the more they are used throughout the day.

• Chemicals and environmental toxins -- exposure to various chemicals and environmental toxins such as solvents, pesticides, or heavy metals (cadmium, mercury, or lead) can cause fatigue, chronic pain, and other symptoms of fibromyalgia.

Some tests may be positive for one or more of these diseases. However, if the results are uncertain or weak, or if these conditions have been treated successfully, fibromyalgia should not be ruled out if the patient still meets the criteria for it.

Conditions That Usually Rule Out Fibromyalgia

Rheumatoid Arthritis and Other Autoimmune Diseases. Autoimmune diseases are conditions in which the person's immune system attacks the body's own tissues. Many autoimmune conditions resemble fibromyalgia. (Fibromyalgia itself may be an autoimmune disorder.) Autoimmune diseases, like fibromyalgia, also occur more often in women than in men, and early symptoms are often muscle and joint pain, and fatigue. The following are some autoimmune disorders that may be confused with fibromyalgia:

• Rheumatoid arthritis is most likely to resemble fibromyalgia, and the similarities present diagnostic problems in both young people and adults. Symptoms include morning stiffness, fatigue, and tender points. Pressing such points, however, does not produce the intense pain that occurs with fibromyalgia. In addition, abnormal laboratory tests can usually tell this disorder apart from fibromyalgia. Juvenile rheumatoid arthritis may coexist with fibromyalgia.

Click the icon to see an image of rheumatoid arthritis.

• Hashimoto's thyroiditis, a disorder marked by low levels of thyroid hormone, can cause widespread muscle aches, depression, and fatigue, if left untreated. This condition is usually easy to diagnose with thyroid hormone tests.

Click the icon to see an image of Hashimoto's thyroiditis.

• Systemic lupus erythematosus resembles fibromyalgia, although most patients with lupus also have a rash. Doctors can diagnose lupus with a blood test.

Click the icon to see an image of systemic lupus erythematosus.

• Multiple sclerosis (MS) has symptoms similar to those of fibromyalgia. There is no definitive test for diagnosing it. Magnetic resonance imaging (MRI) scans, however, detect patches of injured tissue in the brain. These lesions suggest MS.

Click the icon to see an image of multiple sclerosis.

• Sjogrens syndrome, a condition characterized by dry eyes and mouth, is sometimes mistaken for fibromyalgia.

Autoimmune diseases generally develop slowly. Even if a doctor determines that a patient is most likely to have fibromyalgia, the doctor should keep track of any changes in symptoms over time in case one of these other illnesses is actually present.

Lyme Disease. Lyme disease is a bacterial disease transmitted by ticks. Health care providers can usually diagnose early Lyme disease correctly, but a delayed response or recurrence of this disorder may be mistaken for fibromyalgia. Some experts believe that between 15 - 50% of patients referred to clinics for Lyme disease actually have fibromyalgia. Late Lyme disease can usually (but not always) be ruled out using blood tests that identify the organism that causes this disease. If fibromyalgia patients are incorrectly diagnosed and treated for Lyme disease with prolonged courses of antibiotics, the drugs may have serious side effects.

Drugs and Alcohol. Fatigue is a side effect of many prescription and over-the-counter medications, such as antihistamines. In addition, dependency on or abuse of alcohol or illegal drugs may show as constant fatigue. Medications should be considered as a possible cause of fatigue if an individual has recently started, stopped, or changed medications. Withdrawal from caffeine can produce depression, fatigue, and headache.

Polymyalgia Rheumatica. Polymyalgia rheumatica is a condition that causes pain and stiffness, and generally occurs in older women. Tender points are also present with this disorder, although they almost always occur in the hip and shoulder area. Morning stiffness is common, and patients may also experience fever, weight loss, and fatigue. A higher than normal value of erythrocyte sedimentation rate (ESR) can suggest polymyalgia rheumatica. Elevated ESR, however, also occurs with other conditions. Polymyalgia rheumatica often resolves in about a year, but there is a risk of persistent disease. Worse, it is sometimes associated with a rare condition called temporal arteritis, which may cause blindness if not treated, so an accurate diagnosis of polymyalgia rheumatica is important.

Other Diseases That May Rule Out Fibromyalgia.

• Hepatitis -- Hepatitis C may prove to be a cause of some cases of fibromyalgia.
• Anemia
• Diabetes
• Infections -- For example, infectious mononucleosis is marked by fatigue and swollen glands. It primarily affects adolescents and young adults. Some patients may have lingering fatigue that lasts for many months.
• Cancer
• Neuromuscular diseases such as myasthenia gravis

Prognosis

Fibromyalgia can be mild or disabling, and the emotional toll can be substantial. About half of all patients have difficulty with routine daily activities, or are unable to perform them. Estimates of patients who have had to stop work or change jobs range from 30 - 40%. In a 2003 study, patients with either CFS or fibromyalgia were more likely to suffer losses of jobs, possessions, and support from friends and family than people suffering from other conditions that caused fatigue.

Risk of Negative Behaviors

The pain, emotional consequences, or sleep disturbances that come with fibromyalgia may lead to self-medication and overuse of sleeping pills, alcohol, drugs, or caffeine. One 2001 study also reported a higher incidence of violent deaths, including suicide and accidents, among people with widespread pain.

Long-term Outlook

Outlook in Adults. Some studies show that fibromyalgia symptoms remain stable over the long term, while others report a better outlook, with between 25 - 35% of patients reporting improvement in pain symptoms over time. Studies suggest that regular exercise specifically improves outlook in patients. For example, in one study of adult patients after 4.5 years, those who had adequate exercise had the most promising outcome. Those with a significant life crisis, or who were on disability, had a poorer outcome than others. Outcome was determined by improvements in the patients' ability to work, their own feelings about their condition, pain sensation, and levels of disturbed sleep, fatigue, and depression.

Although the disease is life-long, it does not get worse and is not fatal. Remission -- the absence of any signs of disease activity -- can occur in many patients who participate in disease management programs. Patients with secondary fibromyalgia, particularly one caused by injury, tend to have a more severe and less easily treated condition than those with primary fibromyalgia.

Outlook in Children. Children with fibromyalgia tend to have better outlooks than adults with the disorder. Several studies reported that over half of children with fibromyalgia recover in 2 - 3 years.

Treatment

Fibromyalgia is a mysterious condition whose causes are still largely unknown, as is how it inflicts damage. There is no strong evidence that any single treatment (or combination of treatments) has any significant effect for most patients. Treatment must involve not only relieving symptoms but also changing the patients' attitudes about their disease. Treatment should also teach patients behaviors that help them cope.

Treatments usually use a trial and error, many-sided approach:

• Patients may start with physical therapy, exercise, stress reduction techniques, and cognitive-behavioral therapy.
• If these methods fail to improve symptoms, an antidepressant or muscle relaxant may be added to the treatment. Doctors usually prescribe these drugs for their effects on the central nervous system, which helps improve pain tolerance.
• Patient education and programs that encourage coping skills are an important part of any treatment plan.

According to a 2005 study published in the Clinical Journal of Pain, a combination of non-drug therapies works just as well as drug therapy in improving pain, depression, and disability. This combination includes exercise, stress management, massage, and diet. In 2004, the Journal of the American Medical Association published an evaluation of various fibromyalgia treatments. Based on clinical trial data reported in medical journals, the researchers assessed and ranked the evidence supporting the usefulness of these treatments.

Non-Drug Treatments:

• Treatments with the strongest evidence for usefulness: Cardiovascular exercise, cognitive-behavioral therapy, patient education groups, and combinations of these treatments

• Moderate evidence: Strength training, acupuncture, hypnotherapy, biofeedback, balneotherapy
• Weak evidence: Chiropractic, massage therapy, electrotherapy, ultrasound therapy
• Treatments with no evidence of usefulness: Trigger point injections, flexibility exercise

Drug Treatments:

• Strongest evidence: Amitriptyline, cyclobenzaprine
• Moderate evidence: Tramadol, fluoxetine, venlafaxine, milnacipran, duloxetine, pregabalin
• Weak evidence: Growth hormone, 5-HT, tropisetron, SAMe

• No evidence: Opioids, corticosteroids, NSAIDs, benzodiazepine and non-benzodiazepine hypnotics, melatonin, calcitonin, thyroid hormone, guaifenesin, DHEA, magnesium

These evidence-based rankings were determined from published clinical trials. However, some treatments have not been as extensively studied as others and have less available published evidence. Doctors' recommendations and individual patients' experiences may differ from clinical trial results.

Preparation for Treatment

Patients must have realistic expectations about the long-term outlook of their condition, and their own individual abilities. It is important to understand that fibromyalgia can be managed, and patients can live a full life. The following tips may be helpful when starting a treatment program for fibromyalgia:

• The goal of therapy is to relieve symptoms not cure them.
• Treatment must be tailored to each patient, and a combination approach is often needed.
• Patients must begin all treatments with the attitude that these treatments are trial and error. There is no clear treatment solution. Patients and doctors need to work together to make the best choices for individual symptoms and concerns.
• Treatments are long-lasting, in some cases life-long, and patients should not be discouraged by return of symptoms (relapses).
• Enlisting family members, partners, and close friends, particularly to help with exercise and stretching programs, can be helpful.
• Becoming involved with support groups of fellow patients also benefits many patients. Support groups may also benefit family members, particularly parents of children with fibromyalgia. One study noted that the severity of the disorder increased in children whose parents were less able to cope with their child's pain.

The definition of improvement is personal. For example, some patients are pleased with only a 10% reduction in pain and other symptoms.

Lifestyle Changes

Many studies have shown that exercise is the most effective component in managing fibromyalgia, and patients must expect to take part in a long-term exercise program. Physical activity prevents muscle wasting, increases a sense of well-being, and, over time, reduces fatigue and pain.

Graded Exercise. The basic approach used for fibromyalgia is called graded exercise. Graded exercise means you slowly increase the amount of your physical activity. In a well-conducted 2002 study, 35% of patients who engaged in graded aerobic exercise reported feeling much better or very much better after 3 months. Only 18% of patients who performed relaxation and flexibility exercises reported the same results. At the end of a year, more than half of the exercise group no longer had symptoms of fibromyalgia, compared to only 34% of the relaxation group.

In general, graded exercise involves:

• Walking, swimming, and using equipment such as treadmills or stationary bikes are excellent choices for starting an exercise program. Swimming and water therapy are also good because they eliminate putting weight on joints. In one 2002 study, patients who engaged in water exercise therapy for 6 months still reported improvements in symptoms and functioning 2 years after they had completed the program.
• A very gradual program of activity, beginning with mild exercise and building in intensity over time, is important to help patients do their exercise as directed. For example, in one successful exercise study, patients started with 2 weekly sessions that lasted for only 6 minutes each. By week 12, they were performing exercises that lasted 25 minutes each, with enough intensity to produce some sweating. However, they were still able to talk comfortably.
• Patients should do stretching exercises before exercising. A daily stretching routine can also help relax tense muscles and prevent muscle soreness.

Patients who try hard exercises too early actually experience an increase in pain, and are likely to become discouraged and quit.

Every patient must be prepared for relapses and setbacks, but this should not be discouraging. Patients who do not respond to one type of exercise might consider experimenting with another form.

Physical therapy can be very helpful. Studies suggest that physical therapy may reduce muscle overload, lessen fatigue from poor posture and positioning, and help condition weak muscles.

Establishing Regular Sleep Routines

Sleep is essential, particularly since sleep disruptions make pain worse. Many patients with fibromyalgia have trouble getting a restful and healing night's sleep. Improvement in fibromyalgia is low in those who are unable to sleep consistently and at night. Swing shift work, for example, is extremely hard on fibromyalgia patients. Poor sleep habits can adds to sleep problems. Tips for good sleep habits include:

• Establish a regular time for going to bed and getting up in the morning. Maintain this schedule even on weekends and during vacation.
• Use the bed only for sleep and sexual relations.
• If you are unable to fall asleep after 15 or 20 minutes, go into another room and engage in quiet activity. Return to bed when you feel sleepy.
• Minimize light and maintain a comfortable, moderate temperature in the bedroom. Keep the bedroom well ventilated.
• Avoid naps, especially in the evening or late afternoon.
• Avoid exercising within 6 hours of bedtime.
• Avoid caffeine or alcohol within 4 - 6 hours of bedtime.
• Avoid drinking fluids directly before bedtime so that sleep is not disturbed by the need to urinate.
• Avoid large meals before bedtime. A light snack, however, may help promote sleep.

[For more information see In-Depth Report #27: Insomnia.]

Diet

Fibromyalgia patients should maintain a healthy diet low in animal fat and high in fiber, with plenty of whole grains, fresh fruits, and vegetables. Although everyone should be careful about calories from fats, some are healthy.

Omega-3 Fatty Acids. Oils containing omega-3 fatty acids are of particular interest for arthritic pain. Such oils are found in cold-water fish. You can also purchase these oils as supplements called EPA-DHA or omega 3.

Omega-3 fatty acids are a form of polyunsaturated fat that the body gets from food. Omega-3s are known as essential fatty acids (EFAs) because they are important for good health. These healthy fatty acids can be found in certain fish, dark green leafy vegetables, and some oils. Omega-3 fatty acids have anti-inflammatory properties, which help prevent blood clots, lower cholesterol and triglyceride levels, and reduce blood pressure. Omega-3s may also reduce the risks and symptoms for diabetes, stroke, rheumatoid arthritis, asthma, inflammatory bowel disease, ulcerative colitis, some cancers, and mental decline.

Vegetarian Diet. A vegan diet has no meat, dairy, or eggs and includes uncooked fruits, vegetables, nuts, and germinated seeds. In two small studies, a vegan diet was associated with improved symptoms including reduced pain, stiffness, and increased quality of sleep. In addition, the diet was associated with lower weight and cholesterol levels. However, a 2000 study found no significant decline in symptoms, except for some improvement in pain. This improvement was not as great as the one seen with a tricyclic antidepressant.

Stress Reduction Techniques

Relaxation and stress-reduction techniques are proving to be helpful in managing chronic pain. There is certainly evidence that people with fibromyalgia have a more stressful response to daily conflicts and encounters than those without the disorder. A number of relaxation and stress-reduction techniques have proven to be helpful in managing chronic pain:

• Deep breathing exercises
• Muscle relaxation techniques
• Meditation
• Hypnosis
• Biofeedback
• Massage therapy

Biofeedback. Evidence suggests that biofeedback techniques may be helpful for fibromyalgia patients. During a biofeedback session, electric leads are taped to a subject's head. The person is encouraged to relax using any method that works. Brain waves are measured and an audio signal sounds when alpha waves are detected. Alpha waves are brain waves that occur with a state of deep relaxation. By repeating the process, people using biofeedback connect the sound with the relaxed state, and learn to achieve relaxation on their own.

Meditation. Meditation, used for many years in eastern cultures, is now widely accepted in this country as an effective relaxation technique. A number of studies are reporting its benefits for fibromyalgia patients who practice on a continued and regular basis. The practiced meditator can achieve the following physical benefits:

• Improvements in well-being
• Improved sleep -- some research has reported an increase in melatonin levels in experienced meditators. Melatonin is important in regulating the sleep-wake cycle.
• Less pain, possibly from reductions in levels of cortisol, a stress hormone
• A reduction in heart rate, blood pressure, adrenaline levels, and skin temperature while meditating

An important goal for both religious and therapeutic meditation practices is to quiet the mind, essentially to relax thought. This redirection of brain activity from thoughts and worries to the senses disrupts the stress response and prompts relaxation and renewed energy. Several meditation techniques are available. Some may be more useful for fibromyalgia than others.

• Fixed point meditation involves focusing on a stationary object, mental image (such as a candle flame), or internal sound (such as a mantra). When the mind begins to wander, the meditator gently brings concentration back to the central image or sound. This exercise promotes focus, but it is often experienced as a thinking exercise. A popular variety of this type of meditation is known as transcendental meditation, or TM.
• Breath meditation. Other meditative forms involve focusing on the present moment and observing (but not examining or judging) one's thoughts. During breath meditation, one sits upright with the spine straight with the eyes closed. The subject begins to breathe regularly and continues to observe the outward (exhalation) of the breath. As the mind wanders, one simply notes the thoughts as a fact and returns to the breath. A variant of this technique called mindfulness meditation has been helpful for fibromyalgia patients. It involves focusing on the present moment and letting thoughts pass without the accompanying breathing exercises.
• Mini-meditation. This method involves heightening awareness of the immediate surrounding environment. One should first choose a simple routine activity when alone. For example, while washing dishes concentrate on the feel of the water and dishes. Allow the mind to wander to any immediate sensory experience, such as sounds outside the window, smells from the stove, or colors in the room. If the mind begins to think about the past or future, abstractions or worries, redirect it gently back.

People who try meditation for the first time should understand that it can be difficult to quiet the mind, and should not be discouraged by lack of immediate results. Some recommend meditating for no longer than 20 minutes in the morning after awakening and then again in early evening before dinner. Even once a day is helpful. A person should probably not meditate before going to bed, since it causes some people to wake up in the middle of the night, alert and unable to return to sleep.

Hypnosis. In one controlled study, hypnosis was more effective than physical therapy in improving function and reducing pain.

Massage Therapy. Massage therapy is thought to stimulate the parasympathetic nervous system, which slows down the heart and relaxes the body. In a 2002 study, patients who were given 30-minute sessions twice a week experienced lower stress and anxiety and less pain after 5 weeks compared to a group receiving an alternative therapy called transcutaneous electrical stimulation (TENS).

Alternative Treatments

Because of the difficulties in treating fibromyalgia, many patients seek alternative therapies. Everyone should be wary of those who promise a quick cure or urge the purchase of expensive but potentially dangerous treatments. Major analyses have indicated that mind-body therapies, such as biofeedback or hypnosis, are more effective than no treatment at all but less effective than moderate to intense exercise. In one analysis, evidence was weakest on the advantages of so-called manipulative ("hands-on") approaches such as massage and chiropractic treatments.

Acupuncture. Studies continue to report conflicting results on acupuncture's ability to relieve pain. Several small studies suggest it offers some benefit, especially to those who can not take medicines because of their side effects. However, a large controlled study published in the July 2005 Annals of Internal Medicine found that inserting needles at fibromyalgia-related pressure points was no better at relieving pain for fibromyalgia than randomly inserting needles ("sham acupuncture").

Click the icon to see an image of acupuncture.

Chiropractic or Osteopathic Manipulation. Chiropractic or osteopathic manipulation may also help some patients. In one study, 21 patients improved after 4 weeks of chiropractic spinal manipulation compared to those receiving only medications. It may be less effective in older patients with severe symptoms. Other studies have reported pain relief and improved sleep with osteopathic manipulation. Osteopathic techniques may include manipulation of the spine or muscle tissue release. Note that there is always some very small risk for adverse effects from any of these techniques. For example, in rare cases manipulation of the neck has caused stroke or damage to the large blood vessels in the neck.

Hydrotherapy and Similar Treatments. Hydrotherapy, also called balneotherapy, involves soaking in water, such as hot tubs, pools, or baths, to help relieve pain. In one 2002 study, hydrotherapy using a daily 20-minute bath reduced tender-point pain.

Herbal or Natural Remedies. Some alternative agents are being investigated for fibromyalgia:

• S-adenosylmethionine (SAMe) is a natural substance that has antidepressant, anti-inflammatory, and analgesic properties. It has shown some benefit in controlled studies.
• Melatonin, a natural hormone associated with the sleep-wake cycle, may have benefits for some patients with fibromyalgia.
• In one 2000 study, collagen hydrolysat, a food supplement, significantly decreased pain in fibromyalgia patients who had temporomandibular joint problems. The temporomandibular joint connects the lower jaw to the skull.

It is extremely important for patients to realize that any herbal remedy or natural medicine that has positive effects most likely has negative side effects and toxic reactions, just as any conventional drug does. You should consult a doctor before using any untested products or dietary supplements. You should also discuss with your doctor any potential interactions between the supplements and any medications you take.

Behavioral Therapy

Studies continue to show that when fibromyalgia patients deal with the specific conditions of their disorder and their lives, they feel better. Cognitive-behavioral therapy (CBT) enhances a patients' belief in their own abilities and helps them develop methods for dealing with stressful situations. CBT, also called cognitive therapy, is a known effective method for dealing with chronic pain from arthritic conditions. Some evidence also suggests that cognitive-behavioral therapy can help some patients with fibromyalgia. In one study, 1 in 4 patients achieved long-lasting improvement.

The Goals of CBT. The primary goals of CBT are to change any unclear or mistaken ideas and self-defeating behaviors. Using specific tasks and self-observation, patients learn to think of pain as something other than a negative factor that controls their life. Over time, the idea that they are helpless against the pain goes away and, instead, they learn that they can manage the pain.

Cognitive therapy is particularly helpful in defining and setting limits -- a behavior that is extremely important for these patients. Many fibromyalgia patients live their lives in extremes. They first become heroes or martyrs, pushing themselves too far until they collapse. This collapse reverses the way they view themselves, and they then think of themselves as complete failures, unable to cope with the simplest task. One important aim of cognitive therapy is to help such patients discover a middle route. Patients learn to prioritize their responsibilities, and drop some of the less important tasks or delegate them to others. Learning these coping skills can eventually lead to a more manageable life. Patients learn to view themselves and others with a more flexible attitude.

The Procedure. Cognitive therapy is usually of short duration, typically 6 - 20 sessions that last 1 hour. Patients are also given homework, which usually includes keeping a diary and trying tasks that they have avoided because of negative attitudes.

A typical cognitive therapy program may involve the following measures:

• Keep a Diary. Patients are usually asked to keep a diary, and it is usually a key part of cognitive therapy. The diary serves as a general guide for setting limits and planning activities. Patients use the diary to track any stress factors, such as a job or a relationship that may be making the pain worse or better.
• Confront Negative or Discouraging Thoughts. Patients are taught to challenge and reverse negative beliefs. For example, "I'm not good enough to control this disease, so I'm a total failure" becomes the coping statement "Where is the evidence that I can control this disease?"
• Set Limits. Limits are designed to keep both mental and physical stress within manageable levels, so that patients do not become discouraged by getting "in over their heads." For example, tasks are broken down into incremental steps, and patients focus on one at a time.
• Seek out Pleasurable Activities. Patients list a number of enjoyable low-energy activities that they can conveniently schedule.
• Prioritize. Patients learn to drop some of the less critical tasks or delegate them to others.
• Accept Relapses. Over-coping and accomplishing too much too soon can often cause a relapse of symptoms. Patients should respect these relapses and back off. They should not consider them a sign of failure.

Support Organizations and Group Therapy

Cognitive therapy may be expensive and not covered by insurance. Alternative and effective approaches that are free or less costly include strong, intelligently managed support groups or group psychotherapy. In one center, educational discussion groups were as effective, or even more so, than a cognitive therapy program. Such results are not typical in all centers, of course. Therapeutic success varies widely depending on the skill of the therapist.

Medications

To date, the FDA has not approved any drug for specific treatment of fibromyalgia. The first choice in drug treatments usually consists of an antidepressant or a muscle relaxant. The goal is improving sleep and pain tolerance. Medications from other drug classes (sleeping aids, anti-convulsants, pain relievers) may also be prescribed. Patients receive drug treatments in combination with exercise, patient education, and behavioral therapies.

Antidepressants

The main classes of antidepressants used for treating fibromyalgia are tricyclics, selective serotonin-reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Although these drugs are antidepressants, doctors prescribe them to improve a patient's sleep and relieve pain in non-depressed patients with fibromyalgia. The dosages used for managing fibromyalgia are generally lower than dosages prescribed for treating depression. If a patient has depression in addition to fibromyalgia, higher doses may be required.

Tricyclics. Tricyclic antidepressants cause drowsiness and can be helpful for improving sleep. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but which can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), and nortriptyline (Pamelor, Aventyl).

Generally, only small doses are necessary for relief of fibromyalgia. Therefore, although tricyclics have several side effects, these side effects may be less frequent in fibromyalgia patients than in those taking tricyclics for depression. Side effects most often reported include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty in urinating, disturbances in heart rhythm, drowsiness, and dizziness. Like all medications, tricyclics must be taken as directed. Overdose can be life-threatening.

Unfortunately, not all patients respond to tricyclics, and their effects wear off in some patients, sometimes after only a month.

Selective Serotonin-Reuptake Inhibitors (SSRIs). Selective serotonin-reuptake inhibitors (SSRIs) increase serotonin levels in the brain, which may have specific benefits for fibromyalgia patients. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Studies suggest they may improve sleep, fatigue, and well-being in many patients. Studies are mixed on whether they improve pain. In any case, they do not have any significant effect on tender points. SSRIs should be taken in the morning, since they may cause insomnia. Common side effects are agitation, nausea, and sexual dysfunction, including delay or loss of orgasm and low sex drive.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs). These drugs are also known as dual inhibitors because they act directly on two chemical messengers in the brain -- norepinephrine and serotonin.

• Duloxetine (Cymbalta) is gaining attention as a treatment for fibromyalgia. In a 2004 study, 207 patients with fibromyalgia were randomized to receive either duloxetine 60 mg twice a day or placebo for 12 weeks. Duloxetine significantly improved pain and tenderness and was effective for both depressed and non-depressed patients. Duloxetine was most effective for women, but very few men were enrolled in this trial.
• Venlafaxine (Effexor) is similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. As with the SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Although clinical trials have shown that the drug is safe and effective in most people, there have been reports of changes in blood pressure. There have also been reports of problems with the electrical system of the heart when taking this drug. These side effects may cause serious problems in elderly patients. Some patients report severe withdrawal symptoms, including dizziness and nausea.
• Milnacipran (Ixel) is under investigation and is not yet approved in the U.S. It is specifically being researched for helping people with fibromyalgia and similar pain syndromes. A first Phase III trial evaluating its use as a potential treatment for fibromyalgia was completed in July 2005. While the results of this trial were not statistically significant, the manufacturer is now conducting a longer, larger Phase III trial. Results are expected to be announced in 2007. In a 2004 study of 125 patients, milnacipran improved fibromyalgia pain and other symptoms, including fatigue, sleep, and depression.

Muscle Relaxants

Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. Drowsiness is the most common side effect. Cyclobenzaprine is related to the tricyclic antidepressants and has similar side effects including dry mouth and dizziness. A 2004 review of five randomized controlled trials found that patients who received cyclobenzaprine were three times more likely to report improvement in fibromyalgia symptoms than patients who received placebo.

Sleep Medications

Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) and eszopiclone (Lunesta) may improve sleep for patients who suffer from insomnia.

Pain Relievers

Pain relief is of major concern for patients with fibromyalgia.

• Tramadol (Ultram), used alone or in combination with acetaminophen (Tylenol), is commonly prescribed for relief of fibromyalgia pain. Its most common side effects are drowsiness, dizziness, constipation, and nausea. Tramadol should not be used in combination with tricyclic antidepressants.
• For relief of mild pain, acetaminophen is most often recommended. Anti-inflammatory drugs, which are commonly used for arthritic conditions, are less useful for the pain of fibromyalgia, since the pain is not caused by muscle or joint inflammation. Anti-inflammatory drugs include corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil), and others.
• Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers. Capsaicin is helpful in relieving painful areas in other disorders. It may have some value for fibromyalgia patients.
• Opioids, or narcotics, may be used occasionally for certain patients with moderate-to-severe pain, or those with significant problems performing everyday tasks. Narcotics should be used by such patients only if they cannot find relief with other, less potent treatments. Some patients may get combinations of narcotic pain relievers and acetaminophen for periodic pain. Some physicians prescribe opioids such as oxycodone (Roxicodone) or morphine sulfate (Duramorph) for patients who need ongoing relief. However, the benefit of opioids in fibromyalgia treatment is highly controversial. Physicians should take a careful medical and psychological profile of the patient before prescribing opioids. The patients should be evaluated periodically for continuing pain relief, side effects, and indications of dependence.
• Pramipexole, a drug used to treat Parkinson’s disease and restless legs syndrome, may help relieve pain and fatigue in people with fibromyalgia, according to a 2005 study published in Arthritis and Rheumatism. Pramipexole stimulates production of dopamine, a chemical messenger in the brain. For the randomized controlled study, researchers compared pramipexole with a dummy pill (placebo). After 3.5 months, 36% of those who took pramipexole said they felt much better, compared to 9% of those received a dummy pill. Overall, patients had a 50% or greater decrease in pain.
• A small 2005 study conducted in Spain suggests that the atypical antipsychotic olanzapine (Zyprexa) may be a beneficial add-on therapy for patients with fibromyalgia. Although proven effective for some chronic pain conditions, olanzapine causes unpleasant side effects. Eleven of the 25 patients in the 2005 study dropped out due to weight gain.

Anti-Seizure Agents (Anti-Convulsants)

Anti-seizure drugs, also called anti-epileptics or anticonvulsants, affect the chemical messenger gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing. Studies have shown that gabapentin (Neurontin), an anti-seizure medication also approved for postherpetic neuralgia, affects pain transmission pathways and may relieve the pain associated with fibromyalgia. Phase II and III clinical trials are underway.

Pregabalin (Lyrica) is an anti-epileptic drug closely related to gabapentin. The FDA approved pregabalin in 2004 for treatment of nerve pain and diabetic peripheral neuropathy. It is currently in late-stage trials for treatment of fibromyalgia. A 2005 study of 529 patients with fibromyalgia reported that 450 mg per day of pregabalin reduced pain and improved sleep quality and fatigue symptoms. Dizziness and drowsiness were the most common side effects. Study results presented in November 2006 show pregabalin cut fibromyalgia pain by at least 50% in 63% of patients, and the effect was long- lasting. The study, lasting 6 months, was one of the longest controlled studies of pregabalin in fibromyalgia, to date.

Other Investigative Drugs

Tropisetron. Tropisetron (Navoban) is a drug used to reduce vomiting during chemotherapy. European studies are suggesting it may also help patients with fibromyalgia by reducing pain, dizziness, and depression, and by improving sleep. Fatigue and dizziness are the most common side effects.

Targeting Pressure Points and Stretching Techniques

Much of the pain experienced by patients occurs where muscles join tendons or bones, particularly when the muscles are stretched. Stretching or flexibility exercises are part of the warm-up and cool-down routines of any regular program. Stretching techniques may also employ injections or cooling agents to inactivate the pressure points so that muscles can be more effectively stretched. These techniques must be performed by a person other than the patient, usually a family member or close friend. With use of either injections or the spray, the benefits may last from a few days to weeks. Neither the spray nor the injection is useful without muscle stretching.

Spray and Stretch. One such technique is known as "spray and stretch." This method uses the following approach:

• The patient must be in a comfortable position.
• The partner presses on suspected tender points and the patient reports any pain.
• The points, when targeted, are sprayed with either ethyl chloride (Chloroethane) or Fluori-Methane. These chemicals are not numbing medicines. They cool the blood vessels in the skin to inactivate the tender points. Numbing skin creams do not appear to be effective for this treatment.
• The spray bottle is held upside-down about 12 - 18 inches from the targeted area. The patient's face should be covered if the spray is being used near the head.
• The patient's partner then slowly stretches the affected muscle.

After the procedure, the muscle should feel looser, and the patient should have a greater range of motion with that muscle.

Trigger-Point Injections. In some cases, "trigger-point injections" of a numbing drug such as lidocaine may be used for particularly painful tender points as an aid to stretching.

• The injection causes intense, but brief, pain in the trigger point. After the medication has taken effect, however, the muscle's ability to stretch is much greater.
• There is some soreness afterward, which can be severe. After an injection, spraying the whole muscle with cooling agents may inactivate less severe tender points.
• In some cases, injections may be needed several times over 6 - 8 weeks.

Resources

• www.rheumatology.org -- American College of Rheumatology
• www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
• www.arthritis.org -- Arthritis Foundation
• www.fmaware.org -- National Fibromyalgia Foundation
• www.fmpartnership.org -- National Fibromyalgia Partnership
• www.fmnetnews.com -- Fibromyalgia Network
• www.aapainmanage.org -- American Academy of Pain Management
• www.ampainsoc.org -- American Pain Society
• www.medicalacupuncture.org -- American Association of Medical Acupuncture
• www.asch.net -- American Society of Clinical Hypnosis
• www.aabt.org -- Association for Advancement of Behavior Therapy
• www.clinicaltrials.gov -- Find a clinical trial

References

Cypress Bioscience, Inc. Milnacipran: Results of first Phase III Trial. Last accessed on 29 November 2006.

Crofford L. J., Simpson S., Young Jr, J. P., et al. A Six-month, Double-blind, Placebo-controlled, Durability of Effect Study of Pregabalin for Pain Associated With Fibromyalgia. American College of Rheumatology Annual Meeting, Presentation # L44.

Harris RE and Clauw DJ. How Do We Know That the Pain in Fibromyalgia Is "Real"? Current Pain and Headache Reports. 2006;10:403-7.

Denko CW, Malemud CJ. Serum growth hormone and insulin but not insulin-like growth factor-1 levels are elevated in patients with fibromyalgia syndrome. Rheumatol Int. 2005;25(2):146-51.

National Institute of Arthritis and Musculoskeletal and Skin Diseases. Fast Facts: What is Fibromyalgia? Last accessed on 29 November 2006.

Gill JM, Quisel A. Fibromyalgia and Diffuse Myalgia. Clin Fam Pract. 2005; 7(2); 181-190.

Lemstra M, Olszynski WP. The effectiveness of multidisciplinary rehabilitation in the treatment of fibromyalgia: a randomized controlled trial. Clin J Pain. 2005; 21(2): 166-74.

Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol Suppl. 2005;32(10):2063

Zheng L, Faber K. Review of the Chinese medical approach to the management of fibromyalgia. Curr Pain Headache Rep. 2005;9(5): 307-12.

Assefi NP, Sherman KJ, Jacobsen C, Goldberg J, Smith WR, Buchwald D. A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. Ann Intern Med. 2005; 143(1): 10-9.

Harris RE, Tian X, Williams DA, et al. Treatment of fibromyalgia with formula acupuncture: investigation of needle placement, needle stimulation, and treatment frequency. J Altern Complement Med. 2005; 11(4): 663-71.

Holman AJ, Myers RR. A Randomized, Double-Blind, Placebo-Controlled Trial of Pramipexole, a Dopamine Agonist, in Patients With Fibromyalgia Receiving Concomitant Medications. Arthr Rheum. 2005; 52(8): 2495-2505.

Rico-Villademoros F, Hidalgo J, Dominguez I, García-Leiva JM, Calandre EP. Atypical antipsychotics in the treatment of fibromyalgia: a case series with olanzapine. Prog Neuropsychopharmacol Biol Psychiatry. 2005; 29(1): 161-4.

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