Latest Update on Fibromyalgia

I hurt all over. I feel like a truck ran over me when I wake up in the morning. These are the most common complaints of patients suffering from a condition known as fibromyalgia. In addition to widespread pain, patients with fibromyalgia also report a wide range of other symptoms such as fatigue, difficulty sleeping, anxiety, depression, stiffness, and mental fog to name just a few.

Patients with fibromyalgia feel sensations like touch and temperature (hot and cold) louder and longer than people who don't have fibromyalgia. Normal sensations feel uncomfortable or even painful to them. And the awareness of those sensations lasts longer than in other folks.

Twenty years ago, fibromyalgia was recognized by the American College of Rheumatology (ACR) as a real biologic problem and not just an imagined or psychologic disorder. That brought an increased attention to this condition. Since then, many studies have been done to understand the underlying basis for the problem and to find a way to effectively treat it.

In this report, two physicians from the University of Pittsburgh School of Medicine present an in-depth update on the latest findings in the diagnosis and treatment of fibromyalgia. Let's start with what causes it. In a nutshell, we still don't know. The pathology has been narrowed down to an abnormal processing of pain signals. It appears that the entire nervous system and its connections to other systems is involved.

Studies have shown there are neuroendocrine, biochemical, and genetic abnormalities. But not all fibromyalgia patients have the same symptoms, responses to pain or other stimuli, genetic links, or altered hormones. So, finding one treatment that will be equally effective for everyone remains a challenge.

Stress seems to have a role in fibromyalgia. Symptoms are certainly aggravated or made worse by emotional, psychologic, or physical stress. There's some evidence that communication between the hypothalamus, pituitary, and adrenal glands is altered in patients with fibromyalgia. The proper functioning of these three areas is essential to a normal response to stress that doesn't lead to physiologic dysfunction.

Most experts agree that a combined approach using medications, cognitive and behavioral therapy, exercise, and complementary approaches is best. This mode of treatment is referred to as multidisciplinary or interdisciplinary. Scientists are still working to identify what form of treatment, in what order, and combined with what other treatments results in the most favorable outcomes.

Physicians are advised to listen to the patient's report of symptoms and choose treatments that will reduce (or eliminate) the most bothersome ones first. So far, studies have shown that exercise is a key therapy for everyone. Too much, too soon can aggravate symptoms. Patients are carefully guided by a physical therapist through a progressive but individualized program of strength training, endurance, and flexibility.

Exercise is combined with medications, cognitive-behavioral therapy, acupuncture or hypnotherapy, and biofeedback/relaxation training. If these methods don't help (or don't help enough), then the patient may want to try chiropractic care, massage therapy, or physical therapy modalities such as ultrasound or electrical stimulation.

There are several different types of medications used with fibromyalgia patients. Most of these work at the level of the nervous system to alter pain signals. These include antidepressants, antiepileptics, analgesics (pain relievers), and sometimes muscle relaxants. It may take some time to find the right drug in the most effective dose to calm symptoms without adding unwanted side effects. The use of vitamin supplements, hormones, herbs, and thyroid medication are under investigation.

Whatever treatment approach is taken, patients must be questioned about results to measure a response to treatment. For example, surveys of pain levels (frequency, intensity, and duration) and assessment of tender points are often used to measure outcomes.

Most treatment is by trial and error. If the chosen treatment isn't having the desired effect(s), then something else can be tried. Any reduction in global pain score and tender points is a step in the right direction. Improved mood, better sleep patterns, fewer headaches, and improved quality of life are all much appreciated by these patients.

Reference: 

Cheryl Bernstein, MD, and Dawn Marcus, MD. Fibromyalgia: Current Concepts in Diagnosis, Pathogenesis, and Treatment. In Pain Medicine News. Special Edition. December 2008. Vol. 6. No. 9. Pp. 8-19.

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