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A PRACTICAL APPROACH TO FIBROMYALGIA

Tyler Childs Cymet, DO Baltimore, MD
Fibromyalgia is the name given to a collection of symptoms with no clear physiologic cause, The constellation of symptoms are clearly recognizable as a distinct pathologic entity. The diagnosis is made through clinical observations made by the examiner. Differential diagnosis must include other somatic syndromes as well as disease entities like hepatitis, hypothyroidism, diabetes mellitus, electrolyte imbalance, multiple sclerosis, and cancer. Diagnostic criteria are given as guidelines for the diagnosis, not as absolute requirements. Treatment of this condition remains individualized and relies heavily on having a therapeutic relationship with a provider. Treatment of this syndrome needs to be looked at as an ongoing process. Goal oriented treatment aimed at maintaining specific functions can be directed at helping a patient get restorative sleep, alleviating the somatic pains that ail the patient, keeping a person productive, regulating schedules or through goal oriented agreements made with the patient. Since this syndrome is chronic and may effect all areas of a persons functioning the family and social support system of the person being treated need to be evaluated. Patients often seek alternative medical treatments for this problem including diet therapy, acupuncture, and herbal therapy. Treatment must involve more than just the symptoms presented and the patient can only be treated successfully if they are willing to work at changing their own perceptions, and ways of relating to stressors in their world. (J Natl Med Assoc. 2003;95:278-285.)

Key words: Fibromyalgia * tender points/trigger points, somatic syndrome * somatic dysfunction* fibrositis* rheumatism, irritable bowel syndrome * hyperventilation syndrome * hypoglycemia * chronic fatigue syndrome * alternative medicine * elimination diet, magnetic therapy* acupuncture * tricyclic antidepressants * SSRI
© 2003. Assistant Professor of Internal Medicine, Johns Hopkins School of Medicine, Section Head, Family Medicine, Sinai Hospital of Baltimore. Reprint Requests should be sent to Tyler Cymet, DO, Section Head, Family Medicine Sinai Hospital of Baltimore 2435 West Belvedere Ave, Suite 22 Baltimore, Maryland 21215.
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

INTRODUCTION
The fibromyalgia syndrome is seen amongst all socioeconomic classes in most countries, most ethnic groups, and in all types of climates.' It is a common condition frequently seen in primary care settings. An estimated 6 million Americans have fibromyalgia. and between two and six percent of people presenting to a primary care physician's office will have the illness.2 Making an accurate diagnosis of fibromyalgia is important, patients are often relieved that there is a diagnosis which reduces anxiety and tension. Once diagnosed, consultations and laboratory tests can be used in a more judicial manner.
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and the name of the syndrome was 279 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION PRECEDING AND COMORBID CONDITIONS Before the onset of Fibromyalgia a majority of patients reported symptoms of constant gas. Studies have shown patients with fibromyalgia see their primary care provider anywhere from 103 to 22 times a year4and have additional visits to alternative medicine providers. but become "danger signals" in fibromyalgia patients that need immediate attention.FIBROMYALGIA Patients with fibromyalgia are high utilizers of health care resources. anxiety occurs and a fixation on the area of disturbance results. Patients are never symptom free. the concept of inflammation as the cause of the pain was deleted as there was no support.7 It wasn't until 1986 that the American College of Rheumatology established a committee of physicians to determine diagnostic criteria for the syndrome. Such sensations are often no more than minor in most individuals. sleep and balance disturbance.8 Chronic widespread pain not associated with inflammation is considered the hallmark of the disease. cold fingers and feet. 95.7 every six months.5. vibration and smell. depression (stipulated as reactive and not clinical). muscle twitching. HISTORY OF FIBROMYALGIA Muscular pain that limits activity. muscles aches. dry mouth. There is no longterm target organ damage in fibromyalgia. pain. Prescriptions are written for patients with fibromyalgia at the rate of 2. when Guillaume de Baillou published Liber de Rheumatismo describing a case that is currently accepted to be consistent with fibromyalgia. Patients with fibromyalgia have a heightened somatosensory ability. frequency and awareness of urination. SYMPTOMS The most common complaint in people with fibromyalgia is that they "feel bad". Women are mostly effected but men do get the condition. sounds/lights. Which is characterized by a sensitivity and hyperawareness to touch. In 1990. VOL. Desires to get better and full awareness of the abnormalities differentiate this entity from depression. but vary in severity. but at times may reach functional levels in which time they typically see no need for treatment. Table 1. Fibromyalgia is a noninflammatory pain syndrome of unknown etiology. 4. Fibromyalgia Synonyms Fibrositis Myofascial Pain Syndrome Neuromyasthenia Neurashenia Psychalgia Muscular Rheumatism Myofasciitis Myodysneuria Chronic Rheumatism Pressure Point Syndrome changed to fibromyalgia with tender points located in specific areas (see Table 1). APRIL 2003 . NO.9 Chronic fatigue. headache and sore throat are all common symptoms associated with fibromyalgia. Symptoms occur daily." The term fibrositis was first used in the medical literature in 1976 and accepted by the medical community in 1981. If the body does not feel that an adequate response has been made to these stimuli. Symptoms of the condition and the body awareness eventually become a large part of the l°person's life. The term fibrositis was officially coined in 1904 but not accepted by the medical community as a condition worthy of their attention or medical treatment. A search for normalcy and a focus on the symptoms often aggravate intrafamily relationships and get the affected individual labeled as an "emotional vacuum cleaner" and worsen otherwise minor family issues. and it is more common in young to middle age people. Fibromyalgia patients' average one inpatient admission every three years. One third to one half of patients with fibromyalgia relate the onset of the condition to a traumatic experience often can recount the day and time the condition started. impaired memory. but have no observable cause has been noted in the medical literature since 1736.

soreness. 66% of people with fibromyalgia suffer from allergic rhinitis'3 There may be a relationship between fibromyalgia and hyperventilation syndrome hypoglycemia'4 and hypotension. This last symptom is called fibrofog by the afflicted and is one of the most bothersome symptoms. flowing.'5 Although treatment of fibromyalgia may alleviate the symptoms of these comorbid conditions. Presence of tenderness with application of 4kg/pressure at eleven of these points confirms the diagnosis. APRIL 2003 280 .FIBROMYALGIA bloated feelings. but the patient is clearly able to discern a difference. oftentimes these conditions demand attention and treatment separate from fibromyalgia. multiple chemical sensitivities. Fibromyalgia is a diagnosis of exclusion. temporomandibular joint dysfunction. premenstrual dysphoric disorder or endometriosis. Another frequent complaint is swelling of the hands that is not obvious to the examiner. Besides severe tenderness of the skin and muscle tissue there are few objective findings. Another common theme in these patients is fatigue. Since the disease takes so long to diagnose. and a large majority reported a history of recurrent childhood ear nose and throat infections. The fatigue is severe. irritable bowel. Trigger points are areas of muscle that are painful VOL. and can be shown to not effect the shape and size of the fingers. interstitial cystitis. 95." It has long been noted that people with somatic syndromes such as irritable bowel disease. Almost all patients with fibromyalgia will have some pain in the head and neck area. and fibromyalgia patients are no exception. constipation. On physical examination exclusion of other conditions is the priority. sometimes preventing any movement at all. 4. muscle tendon junction. and there may be mild diffuse abdominal tenderness in varying locations and these sites change during the course of the examination. NO. People wake up feeling like they need eight more hours of sleep. most patients suffer from chronic pain syndrome by the time their symptoms are taken seriously and they have trouble localizing the pain to discrete areas. both above and below the diaphragm. This ensures that the somatic syndrome is a whole body syndrome and can be called fibromyalgia and does not need to be relegated into one of the subspecialty somatic syndromes like migraine headache. clothing. purposes and people who only have 6 areas of tenderness have also been shown to have fibromyalgia'8 HISTORY AND PHYSICAL EXAMINATION The patient most likely to be diagnosed as having fibromyalgia is a women between 25-50 years of age. bursa or fat pad. and chronic fatigue syndrome have overlapping symptom complexes and the diagnosis they get largely depends on the physician who sees them first. aching. regardless of whether the swelling effects the ability to wearjewelry. Bowel sounds are almost always increased. Forgetfulness and an inability to concentrate and think or plan for long term events is also a hallmark of this condition.'7 These criteria were set up for research JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION TENDER POINTS AND TRIGGER POINTS Patients can generally feel and find tender points on their own.. and diffuse. chronic fatigue syndrome or one of the others.'2 Compared to patients with other rheumatologic problems people with fibromyalgia tend to have more lifetime surgical interventions. The pain is described as tingling. The pain must also be present for a minimum of three months. There should also be areas of tenderness checked in 18 areas of the body. It takes an average of 5 years for the diagnosis to be made in a person because of the need to exclude so many other diagnoses'6. Sleep in nonrestful and not restorative. interstitial cystitis. The two criteria that need to be met for the diagnosis of fibromyalgia to be made include pain on the left and right side of the body. Tender points are area of tenderness that can be found in the muscle. DIAGNOSING FIBROMYALGIA It is difficult to diagnose a problem that has mostly subjective findings and few objective ones.

but it is the tender points that are diagnostic. Clustering of fibromyalgia has been noted. 4. Hepatitis. but are not useful in all patients suspected of having fibromyalgia. exercising past the point of exhaustion. and from the healthcare world there is disappointment. ESR. Other triggers include surgery. PSYCHOLOGICAL FACTORS/GENETIC FACTORS Physicians caring for fibromyalgia patients should notice a distinct personality type. hyponatremia have all been found in people who claim to have self diagnosed fibromyalgia. living in warm or dry weather and maintaining a moderate activity schedule. Sleep apnea can be found even in thin women who are not considered to have the typical body build to have sleep disturbances. and what they can expect from the healthcare world are very clear to the patient. even the activation/infection of HIV or Lyme disease can trigger fibromyalgia. Both may exist together in patients with fibromyalgia. Muscle biopsies. NO. and allowing oneself to become severely phys281 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION . 95. but must be done by a sleep center that evaluates for fibromyalgia. If rheumatologic disorders like SLE. hypothyroidism. medical illness. creatinin kinase and a urineanalysis. Hepatitis panel. Trigger points feel like taut bands of tissue. When those expectations are not met by their bodies. Cognitive factors and a persons expectations of how they should feel.FIBROMYALGIA to palpation and usually not noted by the patient until pointed out by the practitioner. hyperparathyroidism. TSH. Lifestyle patterns involving sleep. Sleep studies are also a useful test. While clustering does not confirm a genetic role in fibromyalgia. humid weather or a rapid change in temperature can bring on an exacerbation of fibromyalgia. Symptoms of anxiety and depression almost always accompany fibromyalgia. PMR. and not just pulmonary proW lems that arise from sleep disturbances.21 This does not make fibromyalgia a psychogenic disorder. diabetes. worry and a sense of having been failed by either their bodies or the medical profession. ically or mentally fatigued can cause a flare-up in the syndrome20. chemistry profile. APRIL 2003 AGGRAVATING AND ALLEVIATING FACTORS Fibromyalgia patients do not respond uniformly to external factors. This is not a universal response and in different populations different responses to these stimulii can be found.22 The search for a HLA association are ongoing with both positive and negative reports found in the literature. Malignancy also needs to be considered and evaluated for before a physician can be comfortable that the person has fibromyalgia. The protective factors are considered to be staying on a strict schedule.23. but they know that you won't be able to do anything to help them. Finding a treatable condition in a person who claims to have fibromyalgia can be a tremendous benefit to a patient. hypokalemia.24 VOL. It is common to hear from a new fibromyalgia patient that they are coming to a physician for help. remaining inactive for long periods of time. It is generally accepted that cold weather. it has been noted that twenty six percent of first degree relatives of people with fibromyalgia also have fibromyalgia. hypothyroidism.'9 DIFFERENTIAL DIAGNOSIS Fibromyalgia is often self diagnosed with the aid of the internet or friends. MRI's may be needed to address other issues. and environmental factors may be the reason for such findings. missing sleep or meals. Many of the symptoms are part of any syndrome where a person has chronic pain. Workup includes a laboratory analysis of a complete blood count. anxiety. EMG's. which has led to a search for genetic factors in this syndrome. RA and polymyositis need to be considered then an ANA and RF should also be done. There is a tendency to discontinue coping strategies quickly and a subsequent anticipation of failure.

The Internet has become a major source of information with over 100. which has made this a very attractive area for alternative medicine providers who often claim to have successful treatments. Polarity workers redirect energy with crystals. who perform acupuncture. NO. moxibustion and combine treatments with therapy to balance the body humors do well in treating this condition.25 Several therapies have become standard fare for the fibromyalgia patient seeking alternative care. In one study relief lasted for twenty months after acupuncture in 46% of patients. APRIL 2003 282 . eyes. Besides the harmonic balancing of elements (earth. whereby modern processed foods are removed from the diet and replaced with the paleolithic equivalents. Lifestyle changes are a key part of this treatment as well as gaining a mastery over ones environment by turning inward.28 Acupuncture may be effective because it has been noted to cause an increase in seratonin levels in the serum. or ears are felt to have corresponding areas to the organs and body. even without any JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION monitoring of the effect that these magnets have on people. An "oligoantigenic" diet is another method of food therapy. Through manipulation of these zones healing is felt to occur in the corresponding body areas. Zone Therapy (reflexology/iridology/auriculotherapy)-Areas of the feet. Polarity Therapy-Works to balance the energy forces in the body to the environment surrounding it. 4.000 sites showing up on an alta vista search. 95. Massage and pressure point treatment of these areas is done. and ether). The shiny magnets sold are usually no stronger or different than the ones we keep on our refrigerators. water. VOL. Acupuncture-Oriental medical practitioners. a rotation of foods with close attention to effects may be attempted. and sixty nine percent said that they were able to significantly reduce the medications they were taking while receiving acupuncture. They also give love and caring to people who may have been abandoned by other friends and may not have adequate social support.29 Ayurvedic Medicine-Indian health care philosophy based on a balance of physical and spiritual factors. Pet Therapy-Give people a need outside of themselves. It is this electromagnetic sensitivity that throws people off balance and maintains the constant level of discomfort. enemas and therapeutic vomiting. can cost hundreds of dollars. Guaifenasin-This Internet based hypothesis posits that fibromyalgia is a "retention disease similar to gout. Pets do not listen to excuses and force people to be more scheduled and regimented. other expressions of this philosophy include purging. Elimination Diet-In order to identify and avoid "irritant" foods for which people may have a "subclinical" allergy. Guaifenasin and water taken in large doses is the treatment espoused here. The following are some of the more common treatments that fibromyalgia patients use. Specific foods are introduced into the diet at the rate of one per five days. Patients with fibromyalgia are more likely than the general population to seek out alternative medicine.FIBROMYALGIA NON-SCIENCE BASED THERAPEUTIC INTERVENTIONS (ALTERNATIVE MEDICINE) Physicians do not have successful treatments for fibromyalgia. touch or other modalities felt to have energy flow.27 However oriental medical providers consider acupuncture an adjunctive therapy and not as a curative or definitive treatment. Herbal Therapy-Too many herbs claim benefit in fibromyalgia to review in this article. but with phosphate that has accumulated in the tissue. with up to ninety one percent of these patients seeing alternative providers. A double blind placebo controlled study showed no benefit of this treatment at all26 Magnetic Therapy-A multi-level-marketing business that strives to convince people with fibromyalgia that they can "feel" electromagnetic fields. but as medical treatments. air. hands. fire. Since phosphate is a normal cation in the body there is no inflammation of the tissue.

the positive response does not last at least two weeks. Almost all patients feel better for some short period of time ranging from 3 hours to 3 days. low repetition and focus on strengthening. but have minimal effect of the pain symptoms. Cognitive Behavioral Therapy-Focuses mainly on relaxation and coping strategies. TREATMENT-NONPHARMACOLOGIC MODALITIES Education-Patients with fibromyalgia seem to be comforted once the diagnosis is confirmed by a healthcare professional. Exercise-As muscles atrophy.32 Counterstrain is the technique of choice. Symptom improval may take 4-6 weeks and a course of at least three months should be tried before a full evaluation of the therapy can be done. and when pain develops exercise should stop. Compliance with this therapy has been poor. Explanations vary. I discontinue manipulation. NO. stretching. the pain worsens and prospects for full recovery diminish.. APRIL 2003 . Much of what we can do is to "witness" the disease along with the patient. The goal of these treatments is to minimize fatigue and maintain functional ability. valerian root. then the effect is not alleviating the underlying pathology of the disorder. meditation. Maintaining muscle tone needs to be a priority in treating fibromyalgia. Water aerobics are particularly well tolerated.FIBROMYALGIA SAM-e is currently in vogue. Exercises should be low load. Initial dose of amitriptyline is 10 mg given at bedtime. Relaxation and breathing exercises can be used to help a person maintain their functional ability at work.31 Physical Therapy Modalities-Heat. massage. Specific goals need to be set. studies on specific herbs are rare and the change in herbal treatment makes it difficult to complete studies before new mixtures are developed. teatree oil. There are strong positive reinforcements for healthy behaviors.30 Hypnosis-Hypnosis has shown promise in relieving pain symptoms. Patients should be warned that these medications do cause a "hungover" feeling particularly for the first week of use. 34 SSRI-Fluoexetine is the most widely studied and has some benefit in treatment. Biofeedback-There are a number of studies that show biofeedback successfully lessening the number of tender points. what will worsen it. If the response does not last. Hypnosis was shown to be more effective than physical therapy in re283 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION lieving pain in a controlled study of 40 patients with fibromyalgia. In my practice if. after an initial weekly treatment for three weeks. and how long the exacerbations will last. Even though we do not have successful treatments we can help people understand the disease process. If aerobics are done they should be low impact. People also do better when they are given some part in their recovery. It does not help in curing the condition or alleviate the return of symptoms. An adequate trial of this medication is a minimum of two months. body work. none juice and multiple other treatments. Manipulation-People with fibromyalgia both subjectively and objectively have been shown to benefit from manipulation. can all be used to maintain the functional ability of a person with fibromyalgia. Effects of biofeedback have been shown to last up to six months after treatment has been instituted..33 TREATMENT-PHARMACOLOGIC MODALITIES Tricyclic antidepressants-Low doses of amitriptyline and trazodone have been shown to help with sleep. 4. Exercise programs need to start off with stretching. Treatments have included pycnogenol. There also is benefit in "uncoupling" of the sensory component of the pain and the cognitive appraisal of the pain. Pain limits should not be exceeded.35 Seratonin/Norepi Reuptake Inhibitor-Venlafaxine is the only medication in this class and at high doses it does increase norepi and doVOL. decreasing overall pain and decreasing morning stiffness. 95.

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