2012-06-23 / Columnists

Maintaining Your Health on Mackinac

Fibromyalgia Education Provides Doctors, Patients Better Understanding of Condition
By Yvan Silva, M.D.

Fibromyalgia is a chronic, musculo-skeletal pain condition. Pain is experienced all over the body, in the muscles, tendons, and ligaments. Pain is associated with fatigue and abnormal sleep. FMS (Fibromyalgia Syndrome) and the previously used term for similar symptom patterns, CFS (Chronic Fatigue Syndrome) may be the same. There is a wide spectrum of symptoms that physicians have difficulty diagnosing because of the subjectivity and variability of findings that are not always measurable. Fibromyalgia is becoming more discernible, and direct-to-consumer marketing for certain approved medications is adding to increased public education and understanding of the problem by patients and physicians. The diagnoses and management of this complex syndrome is a rapidly growing area of research, the goals being an individualized approach to the nature of symptoms and their severity, the level of the causative stressors, and the presence of coexisting medical and psychological morbidities.

The author of the story of the famed equine legend Seabiscuit recalls how she was misdiagnosed by several physicians, some of whom said she had an attitude problem, and that she was trying to get out of schoolwork. She suffered for several years before a doctor finally told her she had CFS, and started treating her. FMS affects more women than men, usually between the ages of 25 and 55, and is estimated to affect 2% of the United States population. It’s a frustrating condition that can be difficult to diagnose and effectively treat.

The causes of fibromyalgia are not clear and may indeed be multifactorial. There may be a genetic predisposition, and the emergence of the syndrome frequently follows an acute infectious illness, or an episode of emotional or physical trauma. There is also an elevated frequency of depressive symptoms and emotional disorders in patients diagnosed with FMS.

Pain is a predominant symptom and is believed to be associated with aberrant processing of pain signals by the central nervous system so that there is a heightened response to painful stimuli and indeed, in some cases, from otherwise normally non-significant stimuli. Pain is described as deep muscular throbbing, aching and intense, more in muscle groups that are commonly used. The American College of Rheumatology has defined criteria for fibromyalgia – identification on physical examination, tenderness in 11 out of 18 specific sites of the body, but some patients may have tenderness to pressure pain all over the body. Chronic fatigue can range from mild to incapacitating, with patients feeling “drained” of energy. Most patients suffer from sleep disorders – sleep starts relatively normally, but the “deep level” of sleep – Stage IV – is frequently interrupted, resulting in severe tiredness. Research in fibromyalgia patients in “sleep laboratories” has uncovered a host of other sleep disorders such as sleep apnea (interrupted upper airway resistance), restless leg syndrome, teeth grinding, and periodic limb movements that interrupt normal sleep. Diagnosis of this component of the overall condition is best addressed by referral to a sleep center for laboratory tests.

In addition to pain and fatigue, patients may experience digestive problems, headaches, difficulty concentrating, numbness and tingling in the extremities, mood changes and increased sensitivity to noise, odors, bright lights, and in many patients, varying degrees of pain in the jaw and face owing to tension in the muscles. The combination of symptoms in any given patient is variable and not consistent. Diagnosis is difficult because there is not a specific test to rule out or to confirm it. There are overlaps with several other known conditions – Lyme disease, depression, sleep apnea, multiple sclerosis, under active thyroid, and psychosocial problems. Generally, diagnosis is made by a process of exclusion and a thorough evaluation of symptoms and physical and psychological testing. The consensus for fibromyalgia diagnosis is the widespread pain lasting at least three months and the identification of excess tenderness in at least 11 out of 18 specific sites of the body.

The American Pain Society published guidelines for the treatment of fibromyalgia in 2004. The initial step is clearly the confirmation of the diagnosis. Individual education about fibromyalgia and how to manage the symptoms personally is the primary step. Exercise is recommended, but compliance can be difficult because of the severity of pain and fatigue. The level of fitness should be evaluated before exercise is undertaken, and with time and medical treatment, exercise can be gradually increased, as tolerated, for the positive impact on fitness, pain pressure thresholds, well being, and improved physical function. Studies have reported that group therapy may be more successful than home-based exercise regimens. Reducing stress – deep breathing exercises, meditation, and learning to establish a comfortable daily routine is advised. Cognitive behavior therapy outlined in counseling can assist in managing anger, anxieties, and stress associated with FMS. Massage, chiropractic treatments, acupuncture, and other physical therapy treatments may help in relieving pain and stress.

Medications play an important role in the management of FMS. Initially, medication to alleviate pain is started as a trial for effectiveness. Commonly used drugs like acetaminophen, tramadol, and non-steroidal anti-inflammatory drugs are prescribed. But they don’t work as well, or have already been tried. When depression is a concern, counseling and antidepressant medications may be recommended. Muscle relaxants, anti-seizure medication, and some that are recommended for Parkinson’s disease may be used in combinations for optimal management of pain, sleep, muscle spasms, and other symptoms. Careful monitoring with the treating physician is essential to ensure efficacy and also untoward side effects. Narcotic medications are generally not indicated, except in extreme situations.

In summary, fibromyalgia is a chronic and complex painful condition and major depression commonly co-occurs. Treatment options vary with the degree of disabilities. Based on current knowledge, a stepwise program of education, certain medications, physical exercise, and cognitive therapy are indicated. Patients who require comprehensive care may well be served by a pain specialist or a fibromyalgia treatment facility.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.

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