A doctor’s view: fibromyalgia

Dr Paul Lambden discusses the symptoms, causes and treatments relating to fibromyalgia

Fibromyalgia is a rheumatic condition characterised by muscular or musculoskeletal pain with stiffness and localised tenderness at specific points on the body. Sufferers may hurt all over. It was previously called muscular rheumatism, or fibrositis, but the term fibromyalgia was coined in 1975. It is derived from the Latin word fibra (fibre) and the Greek words myo (muscle) and algos (pain).

Symptoms

It is a much more complex condition than simply muscle-aching and may be accompanied by a disparate range of symptoms. It is a common condition affecting between three and five percent of people. Symptoms tend to develop between the ages of 20 and 60. More women are affected than men and children can also suffer from the condition. The severity of the symptoms varies from person-to-person, and from day-to-day, and they are often more severe in cold weather.

Modern research has identified that the original fibrositis diagnosis – which implied inflammation in muscles and joints – was, in fact, incorrect and the symptoms are not due to tissue damage but to the processing of pain. The principal symptom is pain, usually widespread in the body; common locations are the neck, shoulders and lower back, and it is often very difficult to control. It may be aching, burning, dull or sharp and stabbing. It may be intermittent or persistent. In addition, sufferers experience muscle stiffness (worse after a period of immobility) and tenderness, with increased sensitivity to pain (hyperalgesia),

often with unrelated symptoms such as extreme fatigue, insomnia, nausea,  headaches and difficulty in concentration and undertaking mental activities (a condition sometimes called ‘fibrofog’). Patients may struggle to remember or to concentrate, and even speech may become slowed and confused.

Other symptoms may be present and fibromyalgia may be associated with anxiety and depression (though it is often difficult to decide which came first), restless legs syndrome and irritable bowel, urinary symptoms, visual problems, jaw joint dysfunction, chest pain, dysmenorrhoea and chronic fatigue syndrome. There may also be unrelated, and almost random, nerve symptoms such as numbness, tingling or burning, usually felt in the extremities.  

Fibromyalgia may be associated with a range of arthritic conditions including osteoarthritis, rheumatoid arthritis and ankylosing spondylitis. For many sufferers the pain is so persistent, and difficult to manage, that the depression becomes almost overwhelming and results in inactivity, loss of interest in everything, and even feelings of hopelessness.

The cause of fibromyalgia is not understood, although several mechanisms have been suggested. There is no identifiable damage to muscles or to other tissues – however, there is no doubt that sufferers genuinely feel the pain. Disturbed nerve transmission has been implicated, and an inherited component has also been suspected.

There are no specific changes that a doctor can see, measure or test for to make a diagnosis of fibromyalgia. It is normally diagnosed from the history, and by the exclusion of other musculo-skeletal disorders which may lead to the same symptoms. In order to eliminate other conditions, blood tests, radiographs and scans may be required.

Treatments

The paucity of information about the cause and nature of the condition gives a clue to the reason why a variety of different treatments exist. Some cases are managed in general practice, others by rheumatologists, neurologists or pain clinics.

Medication is a mainstay of the treatment of the condition. Analgesics (painkillers) are extremely important; the type selected will depend on the severity of the pain and the response to treatment. Some patients will obtain adequate relief from a simple analgesic such as paracetamol whilst, for others, more powerful agents – such as codeine, dihydro-codeine, up to fentanyl or even morphine – may be necessary to get reasonable control. The variety of side effects associated with treatment increases with the power of the analgesics and, with all narcotic agents, tiredness, fatigue and constipation are often very troublesome. For other patients treatment with antidepressants, either alone or combined with analgesics, may relieve the symptoms.

Other treatments may include hypnotics (sleeping tablets), muscle relaxants, non-steroidal anti-inflammatory drugs, and some anticonvulsants (normally used in the treatment of epilepsy but known to help some patients with fibromyalgia, such as pregabalin). Exercise –  keeping the affected areas moving – is also very important and so aerobics and swimming may be helpful. For some people cognitive behavioural therapy, psychotherapy, relaxation therapy, acupuncture, massage and aromatherapy may be of help.

Patients with fibromyalgia who want to work may find doing so difficult and challenging; for some, the symptoms compromise the ability to do anything manual or to concentrate on complex activities. Others may need workplace adaptations or additional rest breaks. Such people will need the help of the GP and the presence of a helpful occupational therapist. Although some sufferers will feel that they cannot work, and feel compelled to give up, they should consider very carefully before doing so because working maintains physical ability, mental activity, confidence, self-esteem and social relationships.

Chronic sufferers need much support because the symptoms may be distressing, exhausting and deperately depressing as they continue for day-after-day. Some patients appear well, despite the unremitting pain and, perhaps, lack the sympathy and support to which they are entitled. However, for every sufferer the key to success is the identification of the tailored solution to obtain maximum benefit to relieve the symptoms.

Better understanding of its aetiology may lead to better and more effective treatments.