Fibromyalgia Article

FIBROMYALGIA - chronic pain, general fatigue, poor sleep, depression

written by: Dr. Dan Umberger, DO and reviewed by JP Saleeby, MD

written for JIVE Magazine on: 07/16/2004

Fibromyalgia is a chronic pain syndrome in part characterized by general fatigue, poor sleep, depression, and diffuse muscle and joint aches and pains. Fibromyalgia Syndrome (FMS) affects an estimated 6 million Americans, with a prevalence from 2 – 7%. Women are affected at an incidence approximately 7 times that of men, with peak incidence from ages 45 – 60 (1).

There are no accepted indicators specific for FMS; it remains a diagnosis of exclusion. The American College of Rheumatology (ACR) instituted criteria for diagnosis of FMS in 1990. To meet diagnostic criteria, a patient must have 11 of 18 specific sites of tenderness, distributed both above and below the waist. These points are bilateral at the neck, shoulders, chest, ribcage, low back, thighs, knees, elbows, and buttocks. Upon pressure over these sites, a non-radiating pain needs be elicited. In addition, the patient must exhibit at least three of the following: fatigue, sleep disturbance, anxiety, irritable bowel syndrome, headaches, or paresthesia (2).

In using the above criteria diagnosticians were able to separate out FMS patients from a control group consisting of patients with other chronic pain conditions with a specificity of 88% (3). However, the ACR criteria are undergoing critique. There appear to be several subgroups within the designation of FMS, including approximately 29% with significant depressive symptomatology (4) and those with differences in processing pain (5). Studies indicate that treatment programs for FMS patients have no reliable predictors in part due to the heterogenicity of the classification (6). Further studies concerning the pathophysiology of FMS are likely to influence the ACR criteria.

There are no known causative agents for FMS. Among proposed etiologies are viral or bacterial infection, disturbances in the inhibitory control system of pain, neuroendocrine dysfunction, heavy metal exposure, sleep disturbances, and low human growth hormone levels.

Disrupted sleep patterns, in particular disrupted slow wave sleep, was found to give a 24% reduction in pain threshold in otherwise healthy middle aged women after only three days of sleep interference. The subjects also showed an increase in inflammatory flare response of their skin (7).

In a study performed by Berglund et al in Sweden, patients with FMS were shown to have decreased threshold to perceived cold-pain or heat-pain, using significantly more frequent pain related descriptors for cold and tactile stimulation than controls. Additionally, cold was perceived as heat or other dysethesias in the majority of FMS patients, while perception of warmth or tactile stimulation was not misread. They posit that this could be indicative of pathophysiology at a particular level of integration, and may be generic to FMS. FMS patient’s dyasthenic response to cold may prove valuable as an additional criteria (8). Furthermore, Staud et al. reported increased wind-up in FMS patients compared with controls, indicating possible pathology in the processing of central nociceptive pathways (9).

Paiva found a link between FMS and a decreased post exercise rise of human growth hormone. In his study, levels of insulin like growth factor (IGF-1) and cortisol levels were checked in FMS patients and control subjects before, during, and after exercise. One month later, the study was repeated with the FMS patients receiving pyridostigmine – a drug that decreases the level of serum somatostatin, a hormone that in turn inhibits growth hormone secretion. Three findings were reported: 1) FMS patients have a reduced growth hormone response to exercise, 2) pyridostigmine reverses this impaired response, and 3) defective growth hormone secretion in patients with FMS can occur in patients with normal IGF-1 levels. It is surmised that the decreased growth hormone response to exercise in patients with FMS results from increased levels of somatostatin (10).

Treatment options to-date remain palliative. These options include 1) reassurance and education, 2) evaluation and eradication of mechanical stressors, 3) symptomatic analgesic drug therapy, and 4) moderate individually adapted exercises.

NSAIDs and other analgesics have been found to ameliorate pain to varying degrees in various patients, due in part perhaps to the different pathological basis in the various subgroups. Glucocorticoids should be avoided (11).

Sleep disturbances may be addressed by physical exercise, melatonin, or TCAs and muscle relaxants. Fluoxetine was found to decrease pain, fatigue, and depression scores on the Fibromyalgia Impact Questionnaire (FIQ) (12).

The new studies by Paiva indicate that medical therapy utilizing either human growth hormone, somatastatin modifying drugs, or a combination of the two may prove beneficial.

Aerobic exercise has been found to improve function, and decrease pain and depression, independent of gains made in aerobic capacity (13). Moderate, non-flare producing exercise has a beneficial impact on FMS patients. One year follow-up of FMS patients who had undergone aerobic exercise conditioning showed that the benefits were either maintained or improved, with fewer patients meeting ACR criteria, with fewer tender points and lower scores on the FIQ.

A study by Berman et al. indicates that acupuncture has a beneficial effect on patients with FMS. They note a lack of high quality studies and state that high quality randomized trials are needed (14).

In conclusion, fibromyalgia is an exclusionary diagnosis with a heterogenous population. Treatment is multi faceted and needs to be tailored to the individual, as different subgroups within the population do not evidence the same symptoms, and those with similar symptoms do not necessarily respond similarly to the same treatment. Additional indicators such as response to thermal input may help in clarifying the existence of these subsets.


Reference:

1) Guler M et al.: Clinical characteristics of patients with fibromyalgia. Isr J Med C 1992,28:20-23.
2) Wolfe F, et al.: The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia.Arthritis Rheum 1990, 33:160-172.
3) Ibid
4) Ahles T, et al.: Is chronic pain f variant of depressive disease? Pain 1987, 29:105-11.
5) Sorensen J, et al.: Fibromyalgia: are there different mechanisms in the processing of pain? J Rheumatol 1997, 24:1615-1621.
6) King SJ, et al.: Predictors of success of intervention programs for persons with fibromyalgia. J Rheumatol 2002, 29:1034-40.
7) Lentz MJ. : Effects of selective slow wave sleep disruption on musculoskeletal pain and fatigue in middle aged women. J Rheumatol 1999 Jul;26:1586-92
8) Berglund B et al.:Quantitative and qualitative perceptual analysis of cold dysesthesia and hyperalgesia in fibromyalgia. Pain 2002 Mar;96(1-2):177-87.
9) Staud R, et al.: Abnormal sensitization and temporal summation of second pain in patients with fibromyalgia syndrome. Pain 2001 Mar;91:165-75.
10) Paiva ES et al.: Impaired growth hormone secretion in fibromyalgia patients. Arthritis Rheum 2002, 46:1344-1350.
11) Gordon S, Morrison C: Fibromyalgia and its primary are implications. Medsurg Nursing. 1998, 7:207-216.
12) Arnold L, et al.: A randomized, placebo-controlled, double-blind, flexible-dose study of fluoxetine in the treatment of women with fibromyalgia. Am J Med 2002, 112:191-197.
13) Valim V et al.:Aerobic fitness effects in fibromyalgia. J Rheumatol 2003 May:30(5):1060-9.
14) Berman B et al.: Is acupuncture effective in the treatment of fibromyalgia? J FAM Pract 1999 Mar:48(3):213-8.

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Dr. Dan Umberger was an Osteopathic Resident in training (St. Barnabas Hospital, Bronx, NY) who rotated through The Saleeby Longevity Institute in March 2004 at the time of this writing. Dr. Umberger's interests include FMS and neuromusculoskeletal medicine. For information please call (912) 201-9464.

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Article Submitted to JIVE Magazine by Health Columnist JP Saleeby, MD, Saleeby Longevity Institute, Savannah, GA. JP Saleeby, MD is medical director of the Saleeby Longevity Institute (www.longevity-institute.com) and Assistant Medical Director of the Emergency Department at Liberty Regional Medical Center in Hinesville, GA. He can be reached for comment at jpsaleeby@aol.com.