Fibromyalgia Syndrome

Fibromyalgia syndrome (FMS), previously called fibrositis, is a diffuse pain syndrome and one of the most common causes of chronic musculoskeletal pain. FMS is observed in up to 15% of patients seen in a general rheumatology practice and 5% of general medicine clinic patients. It's characterized by diffuse musculoskeletal pain, daily fatigue, and poor-quality sleep, along with multiple tender points on examination (in specific areas). Women are affected much more often than men, and although FMS may occur at almost any age, the peak incidence is in people ages 20 to 60.

FMS has also been reported in children, who have more diffuse pain and a higher incidence of sleep disturbances than adult patients. They may have fewer tender points and often improve after 2 to 3 years of follow-up.

Causes

Although the cause of fibromyalgia is unknown, researchers believe there may be a link with sleep disturbance, psychological stress, or immune, endocrine, or biochemical abnormalities. Fibromyalgia mainly affects the muscles and the points at which the muscles attach to the bone (at the ligaments and tendons).

Symptoms

The most common symptoms of fibromyalgia are muscle and joint pain, stiffness and fatigue. The pain may move from one part of the body to another, and is most common in the neck, shoulders, chest, arms, legs, hips, and back. The pain may last for years, though the severity of it may change over time. Other symptoms include tension headaches, difficulty swallowing, recurrent abdominal pain, diarrhea, and numbness or tingling of the extremities. Stress, anxiety, depression, or lack of sleep can increase symptoms.

Diagnostic tests

Diagnostic testing in FMS that isn't associated with an underlying disease is generally negative for significant abnormalities. Examination of joints doesn't reveal synovitis or significant swelling, the neurologic examination is normal, and no laboratory or radiologic abnormalities are common to FMS patients.

Tender points are elicited by applying a moderate amount of pressure to a specific location. This examination can be fairly subjective, but many FMS patients with true tender points wince or withdraw when pressure is applied to an appropriate intensity. Non­tender control points, such as midforehead, distal forearm, and midanterior thigh, can also be tested to assess for conversion reactions (psychogenic rheumatism), in which patients hurt everywhere or exhibit other psychosomatic illnesses.

Treatment

The most important aspect in FMS management is patient education. Patients must understand that although FMS pain can be severe and is often chronic, the syndrome is common and does not lead to deforming or life-threatening complications.

A regular, low-impact aerobic exercise program can be effective in improving muscle conditioning, energy levels, and the patient's overall sense of well­being. The FMS patient should be taught pre-exercise and postexercise stretching to minimize injury and should begin a program, such as walking, bicycling, or swimming, at a low intensity with slow, gradual increase as tolerated.

A physical therapist may assist in the management of FMS through the use of education, injection of tender points, massage therapy, and ultrasound treatments for particularly problematic areas. In a few studies, acupuncture and phototherapy have been somewhat beneficial.

Medications are typically used to improve sleep and control pain. A bedtime dose of amitriptyline, nortriptyline, or cyclobenzaprine may be useful to improve sleep, but tricyclic antidepressants can be associated with anticholinergic adverse effects and daytime drowsiness. Hypnotic agents, such as many benzodiazepines, are less useful because they generally don't prevent frequent awakening through the night. The combination of a tricyclic antidepressant at bedtime and a daytime dose of a serotonin uptake inhibitor, such as fluoxetine, may be useful.

Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are typically not effective against FMS pain, although NSAIDs may be used for coexisting tendinitis or arthritis. Narcotics to control the chronic pain of FMS should be used only with extreme caution, preferably under the guidance of a pain clinic.

Prevention

There is no proven prevention for this disorder. However, over the years, the treatment and management of the disease has improved.

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