David A. Nye MD
January 26, 1999
Fibromyalgia is a common and disabling disorder affecting 2-4% of the population, women more often than men. Despite the condition's frequency, the diagnosis is often missed. Patients with fibromyalgia usually ache all over, sleep poorly, are stiff on waking, and are tired all day. They are prone to headaches, memory and concentration problems, dizziness, numbness and tingling, itching, fluid retention, crampy abdominal or pelvic pain and diarrhea, and several other symptoms.
There are no diagnostic lab or x-ray abnormalities, but a physician can confirm the diagnosis by finding tender points in characteristic locations. Fibromyalgia often runs in families, suggesting an inherited predisposition. It may lie dormant until triggered by an infection, injury, stress, or sleep disturbance. It is closely related to the chronic fatigue and irritable bowel syndromes and to migraines. Some have suggested that these are all just different facets of the same underlying disorder.
Fibromyalgia was once thought to be an inflammatory condition and later a psychiatric one, but neither of these causes now appears likely. No good evidence of inflammation or arthritis has been found. When depression and anxiety occur they are more often the result than the cause of fibromyalgia. Patients with fibromyalgia are no more likely to be depressed than patients with other chronic painful disorders such as rheumatoid arthritis. Spinal fluid levels four times normal of the main pain neurotransmitter substance P suggest that the pain is not imaginary.
We still do not know exactly what causes fibromyalgia, but we know much more than we did a few years ago. Several good theories have been proposed and much scientific data gathered. One leading theory links fibromyalgia with an abnormality of deep sleep. Fibromyalgia patients often note that not getting enough sleep or even just staying up an hour late makes their fibromyalgia symptoms worse the next day. Abnormal brain waveforms have been found in deep sleep in many patients with fibromyalgia. Fibromyalgia-like symptoms and tender points can be produced in normal volunteers by depriving them of deep sleep for a few days. Low levels of growth hormone, important in maintaining good muscle and other soft tissue health, have been found in patients with fibromyalgia. This hormone is produced almost exclusively in deep sleep, and its production is increased by exercise. Daily exercise has been found to be an important part of treatment of fibromyalgia along with steps taken to improve sleep.
Fibromyalgia is also associated with certain immune system changes. These do not appear to be of the auto immune kind seen in some unrelated disorders like multiple sclerosis or rheumatoid arthritis, but rather the immune system appears as if fighting a virus. No virus has been convincingly demonstrated, and the fact that fibromyalgia does not appear to be contagious (for example, it is no more common in spouses of affected patients than in the general population) argues against an infectious cause.
Experimental disturbance of deep sleep in normal volunteers causes similar immune system changes, suggesting that the immune system changes may be secondary to the sleep disorder. Levels of certain cytokines, a class of immune system hormones, are elevated in fibromyalgia. When these same cytokines are given to patients to treat other disorders, fibromyalgia-like side effects are common. Putting this all together, this suggests that fibromyalgia symptoms may be caused by elevated levels of certain cytokines produced by an immune system which is not functioning normally because of a chronic sleep disorder. This explanation is by no means proven, and several other good theories exist.
Neurotransmitter and endocrine changes occur in fibromyalgia, particularly involving serotonin and the pituitary-adrenal axis, but as these same changes can also be produced by experimental deep sleep deprivation, they are probably secondary rather than primary. They may account for some fibromyalgia symptoms, however. Depression and migraine headaches are associated with low serotonin levels, for example, and often respond to medications that boost serotonin.
1) Medication to improve deep sleep.
2) Regular sleep hours and an adequate amount of sleep.
3) Daily gentle aerobic exercise and stretching.
4) Avoidance of over exertion and stress.
5) Treatment of any coexisting sleep disorders.
6) Patient education.
Medication by itself is of little value in treating fibromyalgia. Successful treatment demands the patient's active involvement in treatment as well as lifestyle changes. Each of the six parts of treatment above is important. If any one is omitted, the chance of significant improvement is considerably reduced.
A number of medications have been used to improve sleep in fibromyalgia. The oldest of these is amitriptyline (Elavil), a medication first used to treat depression. Amitriptyline and related medications probably work by improving the quality and depth of deep sleep rather than by any effect on mood. Although it probably works as well as any of the other medications, amitriptyline causes frequent bothersome side effects such as weight gain, dry mouth, daytime tiredness, and trouble concentrating more often than other medications with durations of action more appropriate for sleep so I usually try these other medications first. They include trazodone (Desyrel), diphenhydramine (Benadryl), cyclobenzaprine (Flexeril), alprazolam (Xanax), and carisoprodol (Soma).
Medication is started at a low dose and gradually increased until you sleep well at night and feel good during the day, encounter unacceptable side effects, or reach the prescribed maximum dose. Starting low and slow helps minimize initial side effects such as dizziness, nausea, and morning grogginess. By two to four weeks, most patients find that the side effects are settling down and the fibromyalgia symptoms are starting to improve.
It often takes a lot of fiddling with the dose to get it exactly right. It may be necessary to try several medications in succession or sometimes in combination. Some patients find that certain of these medications cause stimulation rather than sedation, as if one has had too many cups of coffee. When this "paradoxical effect" occurs it will be necessary to switch to another medication. Some medications may become less effective over time and the dose may then need to be increased slightly. Most patients will need to continue medication indefinitely, although sometimes the dose can be reduced once a good response to treatment has been achieved.
Some patients report that they find various herbal and other "alternative" remedies helpful. While I can't recommend such treatments because they haven't been adequately studied for efficacy or long term harm, I don't discourage patients from using them if they find them helpful. I would encourage you to try treatments for which there is scientific proof of efficacy first, though. The large majority of alternative treatments appear to be of no use or have no more than a placebo effect and are simply a waste of money.
Patients with fibromyalgia must try to get to bed by the same time every night and get an adequate amount of sleep (anywhere from 1 to 12 hours depending on the individual). Staying up just one hour late may cause an exacerbation that lasts for several days. Many patients with fibromyalgia are worse with the change to or from Daylight Savings time. To avoid this problem, try to make the switch in fifteen minute increments every few days instead of by one hour over one night. I have had little success getting patients truly feeling well who work shifts that prevent them from having a consistent bedtime or require that they sleep during the day.
Both daily gentle aerobic exercise and stretching exercises are important. While patients who try to do too much exercise too soon or of the wrong type will make themselves temporarily worse, most patients who don't begin a daily aerobic exercise regimen will never notice much improvement. Aerobic exercise is defined as exercise that gets your heart rate up to a target heart rate for the duration of the exercise period. It is very important to count your pulse and not just guess. If your pulse is too low or too high, you may be just wasting your time or even causing harm.
Heart rates are measured in beats per minute. It is accurate enough for our purposes just to take your pulse for 6 seconds and multiply by 10. Your aerobic target heart rate is calculated from the following formula:
(220 - age - rhr) x .6 + rhr
where age is your age in years and rhr your resting heart rate, determined by taking your pulse when you wake up but before getting out of bed. Good places to feel your pulse are at the side of your neck or at the end of your forearm just the base of the thumb-wrist turned palm up, next to the large bone on the thumb side at the end of your forearm. If you are exercising hard enough you should be able to feel your heart beating and can just count that. For most people, the aerobic target heart rate is at about the point where they can no longer sing but can still talk comfortably.
Exercise seems not to work through conditioning of muscles but rather through a direct, possibly hormonal effect on pain and sleep, which explains why you don't need to exercise painful muscles for the pain in them to decrease. Daily exercise is essential. Patients who have been exercising regularly and then miss a day usually find that their fibromyalgia symptoms are worse for the next day or two. If you are only exercising every other day you may never notice any benefit.
It may take trying several different kinds of exercise before finding one or more types that agree with you. Popular kinds include walking, a water exercise program, regular or exercise bicycles, other exercise equipment, and *gentle* aerobic dance. Jogging, vigorous aerobic dance, and weight lifting are too strenuous for most patients. If your pain is mainly in your legs or back, exercise just your arms or try exercising in the water. You may need to cut back on exercise on days that you are feeling worse.
While many patients may get a lot of exercise at work, doing housework, or in their yard, it is rarely the helpful kind. Effective exercise must result in a sustained elevation of the heart rate, and these incidental kinds of exercise are usually stop and go and may instead increase your pain. You need to set aside a time specifically for daily exercise.
Particularly if you are out of shape, start out with just 3-5 minutes of exercise and gradually increase as tolerated, shooting for twenty to thirty minutes. Take a few minutes to stretch your muscles, then start out slowly, increasing to full speed after a minute or two. Slow down again for the last minute or two and repeat the stretches. Here are five recommended stretches, each done for 20 seconds a side. They should be gentle and painless. Hold onto a tree or post for support for #s 3-5:
1) Shrug your shoulders in a circular motion.
2) Reach your arm over your head and bend to the opposite side.
3) Bend forward with your legs straight.
4) Pull your foot toward your buttock with your hand while standing on the other leg.
5) With your feet flat on the ground and one foot ahead of the other, lean forward, bending just the front knee.
Exercise is most effective if done in the late afternoon or early evening. If you absolutely can't do it then, exercising earlier in the day is better than not exercising at all, but you will probably need to exercise longer for the same effect. Don't exercise just before bed as this may interfere with sleep.
Some patients find that exercise provides an immediate benefit, making them feel more alert and comfortable for several hours. If you experience this effect, you may want to try exercising on awakening and at noon as well. Some patients for whom this works may eventually not need medication.
Stretching exercises such as those described above are often very helpful to decrease muscle stiffness and pain. When fibromyalgia patients have been immobile for long periods, for example in bed at night or on long car rides, their muscles tend to get stiff and painful. Stretching exercises and heat can be particularly helpful at these times. Massage may also be very beneficial. Many patients find that weekly massages greatly help the pain and stiffness, but unfortunately insurance usually does not cover massage therapy.
Too much physical activity of the wrong kind will make you feel worse. Rather than doing housecleaning, yard work, or other physical activity all on one day, break up the task so that you do a half hour or an hour every day until it is done. While it is difficult to learn to do this, it is essential that you be able to sense when you have reached your limit and stop. By pacing yourself, you will be more productive overall. You need to be able to say no to family and friends when you are not up to some outing or other activity. Don't take on extra responsibilities if you can avoid it.
Stress also worsens fibromyalgia symptoms. If you have ongoing problems with depression or anxiety, consider seeking help for them from your family doctor or a psychiatrist. Anxiety and depression may arise as symptoms of fibromyalgia and in turn cause insomnia, leading to worsening of the underlying problem. Relaxation techniques or a chronic pain program can also help lower your stress level and are of proven benefit in treating fibromyalgia.
Several other sleep disorders besides insomnia may aggravate fibromyalgia. Almost half of men with fibromyalgia and some women have obstructive sleep apnea. In this condition the patient snores loudly and has periodic pauses in breathing after which he starts breathing again with a snort. Periodic limb movements of sleep is a condition in which patients jerk or kick every 30 to 90 seconds for long periods during the night and is also frequent in FMS. Patients may be completely unaware of either of these conditions until the spouse complains. Not only will it be difficult to get fibromyalgia symptoms to improve without treating other sleep disorders, but if sleep apnea is left untreated it may lead to injury or even premature death. Be sure to tell your physician about these problems if you notice them.
Other common sources of repeated sleep disturbance are a spouse's snoring and young children. If the spouse drinks alcohol in the evenings or is overweight, then avoidance of alcohol after supper or weight loss may eliminate snoring. Avoiding sleeping on the back will often help. At the very least, the patient can wear earplugs. Children are harder to put off but fortunately most soon outgrow their need for care at night.
It is important to avoid prescription tranquilizers and sleeping medications of the benzodiazepine group other than alprazolam (Xanax) as well as alcohol in the evening. While these may help you get to sleep, they suppress deep sleep and therefore often make fibromyalgia symptoms worse the next day. Narcotic pain medications have the same effect and should be avoided -- they may help the pain but they also may keep you from getting better. Even anti-inflammatory medications like ibuprofen interfere with sleep a little, which may explain why they haven't been shown to help fibromyalgia in controlled studies. Tylenol and Ultram have the least effect on sleep and are preferred for pain.
Some patients have noticed that certain foods may trigger fibromyalgia symptoms much as they may migraines. Some have found that a diet low in fats, fried foods, and simple sugars helps. If you suspect that some food make you worse, try avoiding it and see if that makes a difference.
Patients with fibromyalgia should probably give up caffeine completely. Even one cup in the morning can sometimes disrupt sleep at night and may directly increase muscle pain and headaches. If you are drinking more than a cup a day you should taper yourself off caffeine-containing beverages over two weeks or so to prevent headaches and other withdrawal symptoms.
Patients who make the effort to learn as much as possible about this disorder usually do better than those who don't. I recommend that you keep this handout handy and re-read it periodically. Fibromyalgia sufferers often elicit less sympathy and support than they deserve from family, friends, and employers because of the lack of outward evidence of disease. Many have been told by physicians that there is nothing wrong with them or that it is "all in your head" which can be very demoralizing. For these reasons, and just because it is good to know that you are not alone, attending a support group can be valuable. There are local support groups in most areas now. Two large national support organizations produce good newsletters and can help you find a local support group or physician:
Fibromyalgia Alliance of America, Inc.
PO Box 21990
Columbus, OH 43221-0990
(614) 457-4222 Phone
(614) 457-2729 Fax
PO Box 31750
Tucson, Az. 85751-1750
info line: (520) 290-5508
fax: (520) 290-5550
For those of you with internet access, a good place for on-line information and support is alt.med.fibromyalgia, a Usenet newsgroup devoted to fibromyalgia. Be aware though that there is much misinformation on the internet and even in some books on fibromyalgia. Of the several good books available for fibromyalgia patients, two of the best in my opinion are:
The Fibromyalgia Survivor by Mark Pellegrino MD, Anadem Press (1-800-633-0055 to order). Lots of valuable practical advice. Dr. Pellegrino, a physiatrist and FMS researcher who himself has FMS, has written several other books about FMS, all good.
The Fibromyalgia Help Book by Jenny Fransen RN and I. Jon Russell MD, PhD, Smith House Press (1-888-220-5402 to order). Comprehensive and scientifically accurate with lots of useful references yet easily readable. Dr. Russell is a FMS researcher and editor of the Journal of Musculoskeletal Pain. Jenny Fransen is a nurse clinician with special expertise in FMS.
While fibromyalgia is not curable, most patients with a little work can make it to the point where they feel substantially better most of the time. Even with good results from treatment however occasional relapses are common, perhaps caused by staying up as little as one hour late one evening, skipping exercise for a day, a disruption in your daily routine, increased stress, a storm front moving in, or often for no apparent reason. You will do best if you give in to it when this happens and try to get extra rest. Hot baths and massage may also be helpful at these times. Try not to stop exercising during relapses, even if you have to back off on the amount a little, and continue stretching. Once you have had a period of feeling relatively well, it is usually possible to get back to that point again by identifying what derailed you and correcting the problem.
To qualify for a diagnosis of fibromyalgia, patients must ache all over and have tenderness in at least 11 of these 18 spots when 4 kgs. of pressure are applied.
__ __ / \ / \ Location of FMS tender points: | | | OO | | | | __ | \__/ \ / 1) Attachment of neck muscles at 11 -- the base of the skull _2_||_2_ _2_88_2_ / \ / \ 2) Midway between neck and shoulder | 3 3 | | | | | | 99 | 3) Muscle over upper inner shoulder | | | | | | | | blade | | | | | | | | | | | | | | /\ | | 4) 2 cms below side bone at elbow | | | | |_| / \ |_| |@| |@| | | | | 5) upper outer buttock 4 |\ /| 4 | |\ /| | | |/ \| | | |/ \| | 6) Hip bone | ||5 5|| | | || || | | |6 6| | | |6 6| | 7) Just above knee on inside | || )( || | | || /\ || | ( )| || |( ) ( )| || |( ) 8) Lower neck in front | || | | || | | || | | || | 9) Edge of upper breast bone |-77-| |@77@| | || | | || | | || | | || | | || | | || | | || | | || | _| || |_ _| || |_ (___/\___) (___/\___)
If you are not one of the lucky few whose primary doctor is knowledgeable about fibromyalgia or at least willing to work with you and learn about it, you should look for a fibromyalgia specialist. Unfortunately, this is often difficult to do. Most fibromyalgia specialists are rheumatologists or physiatrists, (physical medicine rehabilitation specialists), but you can't assume that any given rheumatologist or physiatrist will be knowledgeable and helpful. Other fibromyalgia specialists may be internists, anesthesiologists, neurologists, or belong to other specialties.
The best way to find a fibromyalgia specialist is to send for lists of recommended physicians from the national fibromyalgia organizations mentioned above, and also go to a local fibromyalgia support group meeting and ask for recommendations. It is best to do both because the doctor lists are incomplete. Those of you out there who already have good fibromyalgia specialists please let the list-keepers know. A fibromyalgia specialist will be able to perform a tender point exam (without which it is impossible to make the diagnosis accurately), will tell you that it is not possible to cure fibromyalgia but that most patients can be helped substantially, usually will not order a large number of tests, will recommend treatment similar to that described above, and will seem to enjoy treating fibromyalgia.
David A. Nye MD (email@example.com)* Midelfort Clinic, Eau Claire, WI