The classic and defining symptoms of fibromyalgia are chronic, widespread pain, fatigue, and heightened pain in response to tactile pressure. Other symptoms may include tingling of the skin, prolonged muscle spasms, weakness in the limbs, nerve pain, muscle twitching, palpitations, functional bowel disturbances, and chronic sleep disturbances.
Many (but not all) patients experience cognitive dysfunction, often characterized by impaired concentration, problems with short and long-term memory, short-term memory consolidation, impaired speed of performance, inability to multi-task, cognitive overload, and diminished attention span. Fibromyalgia is often associated with anxiety, and depressive symptoms.
20–30% of patients with rheumatoid arthritis and systemic lupus erythematosus may also have fibromyalgia.
Currently there is no single diagnostic test for fibromyalgia and there is also considerable debate as to what the key diagnostic criteria for the disease is. The problem is that, in many cases, patients with fibromyalgia symptoms may also have laboratory test results that appear normal and many of their symptoms may mimic those of other rheumatic conditions such as arthritis or osteoporosis. In general, most doctors diagnose patients with a process called differential diagnosis, which means that doctors consider all of the possible things that might be wrong with the patient based on the patient's symptoms, gender, age, geographic location, medical history and other factors. They then narrow down the diagnosis to the most likely one. The most widely accepted set of classification criteria for research purposes was elaborated in 1990 by the Multicenter Criteria Committee of the American College of Rheumatology. These criteria, which are known informally as "the ACR 1990", define fibromyalgia according to the presence of the following criteria:
A history of widespread pain lasting more than three months (where the pain affects all four quadrants of the body)
Tender points on the body. There are eighteen designated possible tender points (although a patient with the disorder may feel pain in other areas as well). The patient must feel pain at eleven or more of these points for fibromyalgia to be considered as a cause).
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There is, unfortunately, no universally-accepted treatment or cure for fibromyalgia. However, developments in the understanding of the underlying pathophysiology of the disorder have led to imporvements in treatment, with integrated treatment plans that incorporated medication, patient education, aerobic exercise and cognitive-behavioural therapy showing efficacy in alleviating pain and other fibromyalgia-related symptoms. Psychological and Behavioural TherapiesCognitive behavioural therapy (CBT) has been shown to be moderately effecitve in trials. Most benefit is seen when CBT is used in combination with exercise. PharmaceuticalsThree compounds have been aproved by the US FAD for treatment of fibromyalgia. Thsee are: pregabalin, approved in June 2007; duloxetine, approved in June 2008 and milnacipran, approved in January 2009. All three chemical compounds are targeted at reducing pain. AntidepressantsAdministering antidepressants in patients with firbromyalgia is associated with improvements in pain, depression, fatigue, sleep disturbances and health-related quality of life, with tricyclic antidepressants being the most effective. TramadolTramadol is a centrally-acting analgesic has been shown to be moderately-effecive in treating fibromyalgia pain. In conjunction with paracetamol it provides, fast, lasting, relief and is more effective tahn either drug alone. Anti-seizure medicationsPregabalin has been approved by the FDA for treatment of fibromyalgia and it has a significant effect on pain management in a minority of patients. Muscle RelaxantsThough typically used for skeletal muscle spasms and pain in acute musculoskeletal conditions, these drugs have been shown to offer some benefit in fibromyalgia. Physical TreatmentsExcersice has been found to be effective in improving fitness and sleep and may reduce pain and fatigue in some fibromyalgia sufferers. Cardiovascular exercise seems to be particularly efficacious. Aquatic therapy is most beneficial, however, as many fibromialgia patients are cold sensitive, such therapy requires a specialised pool facility where both the pool and the air outside are heated. Combination TherapyStudies strongly indicate that the optimal treatment for fibromyalgia would include a combination therapy of appropriate medications in combination with non-pharmacological treatments including physical exercise and cognitive behaviour therapy. However, bacause many sufferers of fibromyalgia do not experience the same combinations of symptoms, it’s important to have treatment options that are adaptive and personalized, not a ‘one size fits all’ treatment. |
Many fibromyalgia patients display anomalous alpha wave activity during non-rapid eye movement (REM) sleep and by disrupting stage IV sleep consistently in young, healthy subjects, the researchers reproduced a significant increase in muscle tenderness similar to that experienced in "neurasthenic musculoskeletal pain syndrome".
Fibromyalgia patients many have heighterend sensitivity of the nociceptive system (this senses pressure, heat, cold, electrical and chemical stimulation of the body). Fibromyalgia sufferers also display an exaggerated wind-up in response to repetitive stimulation.
Fibromyalgia sufferers may demonstrate alterations of normal endocrine function. This is typically characterized by hypocortisolemia, hyperreactivity of pituitary adrenocorticotropin hormone release in response to challenge, and glucocorticoid feedback resistance. Low insulin-like growth factor 1 (IGF-1) levels in some fibromyalgia patients have led to the theory that these patients may actually have a different, treatable syndrome, adult growth hormone deficiency.
Patients with fibromyalgia have demonstrated disturbed activity of their autonomic system characterized by hyperactivity of the sympathetic nervous system, with sympathoadrenal reactivity in response to a variety of stressors including physical exertion and mental stress. Fibromyalgia patients demonstrate lower heart rate variability, an index of sympathetic/parasympathetic balance, indicating sustained sympathetic hyperactivity, especially at night. In addition, plasma levels of neuropeptide Y, which is co-localized with norepinephrine in the sympathetic nervous system, have been reported as low in patients with fibromyalgia.
One of the most reproduced laboratory finding in patients with fibromyalgia is an elevation in cerebrospinal fluid levels of substance P, a putative nociceptive neurotransmitter. Metabolites for the monoamine neurotransmitters serotonin, norepinephrine, and dopamine—all of which play a role in natural analgesia—have been shown to be lower, while concentrations of endogenous opioids (i.e., endorphins and enkephalins) appear to be higher. There is also evidence for increased excitatory amino acid release within cerebrospinal fluid, with a correlation demonstrated between levels for metabolites of glutamate and nitric oxide and clinical indices of pain.
Functional neuroimaging of the brain indicated decreased blood flow within the thalamus and elements of the basal ganglia and mid-brain (i.e., pontine nucleus). Differential activation in response to painful stimulation has also been demonstrated. Brain centers showing hyperactivation in response to noxious stimulation include such pain-related brain centers as the primary and secondary somatosensory cortices, anterior cingulate cortex, and insular cortex. Patients also exhibit neural activation in brain regions associated with pain perception in response to nonpainful stimuli in such areas as the prefrontal, supplemental motor, insular, and cingulate cortices. Evidence of hippocampal disruption indicated by reduced brain metabolite ratios has been demonstrated by studies using single-voxel magnetic resonance spectroscopy (1H-MRS). A significant negative correlation was demonstrated between abnormal metabolite ratios and a validated index of the clinical severity (i.e. the Fibromyalgia Impact Questionnaire). Correlations between clinical pain severity and concentrations of the excitatory amino acid neurotransmitter glutamate within the insular cortex have also been demonstrated using 1H-MRS.
As a disease, Fibromyalgia continues to be a disputed diagnosis. Ineed, mainly due to the laci of abnormalities on physical examination, and the absence of objective diagnostic tests many members of the medical community do not consider fibromyalgia to be a disease per se.
The validity of fibromyalgia as a unique clinical entity is also a matter of contention because no discrete boundary separates syndromes such as FMS, chronic fatigue syndrome, irritable bowel syndrome, or chronic muscular headaches. Because of this considerable symptomatic overlap, some researchers have proposed that fibromyalgia and other syndromes with overlapping symptoms be classified as functional somatic syndromes for some purposes.
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