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Fibromyalgia
By Mayo Clinic Staff
Jun 25, 2007

You hurt all over, and you frequently feel exhausted. Even after numerous tests, your doctor can't find anything specifically wrong with you. If this sounds familiar, you may have fibromyalgia.

Fibromyalgia is a chronic condition characterized by widespread pain in your muscles, ligaments and tendons, as well as fatigue and multiple tender points ? places on your body where slight pressure causes pain. Fibromyalgia is more common in women than in men. Previously, fibromyalgia was known by other names such as fibrositis, chronic muscle pain syndrome, psychogenic rheumatism and tension myalgias.

Although the intensity of your symptoms may vary, they'll probably never disappear completely. It may be reassuring to know, however, that fibromyalgia isn't progressive or life-threatening. Treatments and self-care steps can improve fibromyalgia symptoms and your general health.

Signs and symptoms
Signs and symptoms of fibromyalgia can vary, depending on the weather, stress, physical activity or even the time of day. Common signs and symptoms include:

  • Widespread pain. Fibromyalgia is characterized by pain in specific areas of your body when pressure is applied, including the back of your head, upper back and neck, upper chest, elbows, hips and knees. The pain generally persists for months at a time and is often accompanied by stiffness.
  • Fatigue and sleep disturbances. People with fibromyalgia often wake up tired and unrefreshed even though they seem to get plenty of sleep. Some studies suggest that this sleep problem is the result of a sleep disorder called alpha wave interrupted sleep pattern, a condition in which deep sleep is frequently interrupted by bursts of brain activity similar to wakefulness. So people with fibromyalgia miss the deep restorative stage of sleep. Nighttime muscle spasms in your legs and restless legs syndrome also may be associated with fibromyalgia.
  • Irritable bowel syndrome (IBS). The constipation, diarrhea, abdominal pain and bloating associated with IBS are common in people with fibromyalgia.
  • Headaches and facial pain. Many people who have fibromyalgia also have headaches and facial pain that may be related to tenderness or stiffness in their neck and shoulders. Temporomandibular joint (TMJ) dysfunction, which affects the jaw joints and surrounding muscles, also is common in people with fibromyalgia.
  • Heightened sensitivity. It's common for people with fibromyalgia to report being sensitive to odors, noises, bright lights and touch.
Other common signs and symptoms include:

  • Depression
  • Numbness or tingling sensations in the hands and feet (paresthesia)
  • Difficulty concentrating
  • Mood changes
  • Chest pain
  • Dry eyes, skin and mouth
  • Painful menstrual periods
  • Dizziness
  • Anxiety
Causes
Doctors don't know what causes fibromyalgia. Current thinking centers around a theory called "central sensitization." This theory states that people with fibromyalgia have a lower threshold for pain because of increased sensitivity in the brain to pain signals. Researchers believe repeated nerve stimulation causes the brains of people with fibromyalgia to change. This change involves an abnormal increase in levels of certain chemicals in the brain that signal pain (neurotransmitters). In addition, the brain's pain receptors (neurons) ? which receive signals from the neurotransmitters ? seem to develop a sort of memory of the pain and become more sensitive, meaning they can overreact to pain signals. In this way, pressure on a spot on the body that wouldn't hurt someone without fibromyalgia can be very painful to someone who has the condition. But what initiates this process of central sensitization isn't known.

It's likely that a number of factors contribute to the development of fibromyalgia. Other theories as to the cause of fibromyalgia include:

  • Sleep disturbances. Some researchers theorize that disturbed sleep patterns may be a cause rather than just a symptom of fibromyalgia.
  • Injury. An injury or trauma, particularly in the upper spinal region, may trigger the development of fibromyalgia in some people. An injury may affect your central nervous system, which may trigger fibromyalgia.
  • Infection. Some researchers believe that a viral or bacterial infection may trigger fibromyalgia.
  • Abnormalities of the autonomic (sympathetic) nervous system. Part of your autonomic nervous system ? the sympathetic, or involuntary, system ? controls bodily functions that you don't consciously control, such as heart rate, blood vessel contraction, sweating, salivary flow and intestinal movements. It?s thought that sympathetic nervous system dysfunction occurs in people with fibromyalgia, particularly at night, which leads to fatigue, stiffness, dizziness and other signs and symptoms associated with the condition.
  • Changes in muscle metabolism. For example, deconditioning and decreased blood flow to muscles may contribute to decreased strength and fatigue. Differences in metabolism and abnormalities in the hormonal substance that influences the activity of nerves may play a role.
  • Psychological stress and hormonal changes also may be possible causes of fibromyalgia.
Risk factors
Risk factors for fibromyalgia include:

  • Your sex. Fibromyalgia occurs more often in women than in men.
  • Age. Fibromyalgia tends to develop during early and middle adulthood. But it can also occur in children and older adults.
  • Disturbed sleep patterns. It's unclear whether sleeping difficulties are a cause or a result of fibromyalgia ? but people with sleep disorders, such as nighttime muscle spasms in the legs, restless legs syndrome or sleep apnea, can also develop fibromyalgia.
  • Family history. You may be more likely to develop fibromyalgia if a relative also has the condition.
  • Rheumatic disease. If you have a rheumatic disease, such as rheumatoid arthritis, lupus or ankylosing spondylitis, you may be more likely to have fibromyalgia.
When to seek medical advice
See your doctor if you experience general aching or widespread pain that lasts several months and is accompanied by fatigue. Many of the symptoms of fibromyalgia mimic those of other diseases, such as low thyroid hormone production (hypothyroidism), polymyalgia rheumatica, neuropathies, lupus, multiple sclerosis and rheumatoid arthritis. Your doctor can help determine if one of these other conditions may be causing your symptoms.

Screening and diagnosis
Diagnosing fibromyalgia is difficult because there isn't a single, specific diagnostic laboratory test. In fact, before receiving a diagnosis of fibromyalgia, you may go through several medical tests, such as blood tests and X-rays, only to have the results come back normal. Although these tests may rule out other conditions, such as rheumatoid arthritis, lupus and multiple sclerosis, they can't confirm fibromyalgia.

The American College of Rheumatology has established general classification guidelines for fibromyalgia, to help in the assessment and study of the condition. According to these guidelines, to be diagnosed with fibromyalgia you must have experienced widespread aching pain for at least three months and have a minimum of 11 locations on your body that are abnormally tender under relatively mild, firm pressure. In addition to taking your medical history, a doctor checking for fibromyalgia will likely press firmly on specific points on your head, upper body and certain joints so that you can confirm which cause pain.

Not all doctors agree with these guidelines. Some believe that the criteria are too rigid and that you can have fibromyalgia even if you don't meet the required number of tender points. Others question how reliable and valid tender points are as a diagnostic tool.

Complications
Fibromyalgia isn't progressive and generally doesn't lead to other conditions or diseases. It can, however, cause pain, depression and lack of sleep. These problems can then interfere with your ability to function at home or on the job, or maintain close family or personal relationships. The frustration of dealing with an often-misunderstood condition also can be a complication of the condition.

Treatment
In general, treatment for fibromyalgia includes both medication and self-care. The emphasis is on minimizing symptoms and improving general health.

Medications
Medications can help reduce the pain of fibromyalgia and improve sleep. Common choices include:

  • Analgesics. Acetaminophen (Tylenol, others) may ease the pain and stiffness caused by fibromyalgia. However, its effectiveness varies. Tramadol (Ultram) is a prescription pain reliever that may be taken with or without acetaminophen. Your doctor may recommend nonsteroidal anti-inflammatory drugs (NSAIDs) ? such as aspirin, ibuprofen (Advil, Motrin, others) or naproxen sodium (Anaprox, Aleve) ? in conjunction with other medications. NSAIDs haven't proved to be effective in managing the pain in fibromyalgia when taken by themselves.
  • Antidepressants. Your doctor may prescribe antidepressant medications such as amitriptyline, nortriptyline (Pamelor) or doxepin (Sinequan) to help promote sleep. Fluoxetine (Prozac) in combination with amitriptyline has also been found effective. Sertraline (Zoloft) and paroxetine (Paxil) may help if you're experiencing depression. Some evidence exists for a newer class of antidepressants known as serotonin and norepinephrine reuptake inhibitors or dual uptake inhibitors, which regulate two brain chemicals that may transmit pain signals. Studies have found that duloxetine (Cymbalta) may help control pain better than placebo in people with fibromyalgia. Small trials of venlafaxine (Effexor) suggest the same, though more study is needed to confirm these findings.
  • Muscle relaxants. Taking the medication cyclobenzaprine (Flexeril) at bedtime may help treat muscle pain and spasms. Muscle relaxants are generally limited to short-term use.
  • Pregabalin (Lyrica). Pregabalin may reduce pain and improve function in people with fibromyalgia. Pregabalin, an anti-seizure medication that's also used to treat some types of pain, is the first drug approved by the Food and Drug Administration to treat fibromyalgia. Studies show pregabalin reduced signs and symptoms of fibromyalgia in some people. In one study, about half of the participants taking the highest doses of the drug reported at least a 30 percent improvement. Side effects of pregabalin include dizziness, sleepiness, difficulty concentrating, blurred vision, weight gain, dry mouth, and swelling in the hands and feet.
Prescription sleeping pills, such as zolpidem (Ambien), may provide short-term benefits for some people with fibromyalgia, but doctors usually advise against long-term use of these drugs. These medications tend to work for only a short time, after which your body becomes resistant to their effects. Ultimately, using sleeping pills tends to create even more sleeping problems in many people.

Benzodiazepines may help relax muscles and promote sleep, but doctors often avoid these drugs in treating fibromyalgia. Benzodiazepines can become habit-forming, and they haven't been shown to provide long-term benefits.

Doctors don't usually recommend narcotics for treating fibromyalgia because of the potential for dependence and addiction. Corticosteroids, such as prednisone, haven't been shown to be effective in treating fibromyalgia.

Cognitive behavior therapy
Cognitive behavior therapy seeks to strengthen your belief in your abilities and teaches you methods for dealing with stressful situations. Therapy is provided through individual counseling, classes, and with tapes, CDs or DVDs, and may help you manage your fibromyalgia.

Treatment programs
Programs that combine a variety of treatments may be effective in improving your symptoms, including relieving pain. These interdisciplinary programs can combine relaxation techniques, biofeedback and receiving information about chronic pain. There isn't one combination that works best for everybody. Your doctor can create a program based on what works best for you.

Self-care
Self-care is critical in the management of fibromyalgia.

  • Reduce stress. Develop a plan to avoid or limit overexertion and emotional stress. Allow yourself time each day to relax. That may mean learning how to say no without guilt. But try not to change your routine completely. People who quit work or drop all activity tend to do worse than those who remain active. Try stress management techniques, such as deep-breathing exercises or meditation.
  • Get enough sleep. Because fatigue is one of the main characteristics of fibromyalgia, getting sufficient sleep is essential. In addition to allotting enough time for sleep, practice good sleep habits, such as going to bed and getting up at the same time each day and limiting daytime napping.
  • Exercise regularly. At first, exercise may increase your pain. But doing it regularly often decreases symptoms. Appropriate exercises may include walking, swimming, biking and water aerobics. A physical therapist can help you develop a home exercise program. Stretching, good posture and relaxation exercises also are helpful.
  • Pace yourself. Keep your activity on an even level. If you do too much on your good days, you may have more bad days.
  • Maintain a healthy lifestyle. Eat healthy foods. Limit your caffeine intake. Do something that you find enjoyable and fulfilling every day.
Coping skills
Besides dealing with the pain and fatigue of fibromyalgia, you may also have to deal with the frustration of having a condition that's often misunderstood. In addition to educating yourself about fibromyalgia, you may find it helpful to provide your family, friends and co-workers with information.

It's also helpful to know that you're not alone. Organizations such as the Arthritis Foundation and the American Chronic Pain Association provide educational classes and support groups. These groups can often provide a level of help and advice that you might not find anywhere else. They can also help put you in touch with others who have had similar experiences and can understand what you're going through.

Complementary and alternative medicine
Complementary and alternative therapies for pain and stress management aren't new. Some, such as meditation and yoga, have been practiced for thousands of years. But their use has become more popular in recent years, especially with people who have chronic illnesses, such as fibromyalgia.

Several of these treatments do appear to safely relieve stress and reduce pain, and some are gaining acceptance in mainstream medicine. But many practices remain unproved because they haven't been adequately studied. Some of the more common complementary and alternative treatments promoted for pain management include:

  • Acupuncture. Acupuncture is a Chinese medical system based on restoring normal balance of life forces by inserting very fine needles through the skin to various depths. According to Western theories of acupuncture, the needles cause changes in blood flow and levels of neurotransmitters in the brain and spinal cord. In a 2006 Mayo Clinic study, acupuncture significantly improved symptoms of fibromyalgia. Research on the benefits of acupressure ? a similar practice that uses finger pressure on the skin rather than needles ? is inconclusive.
  • Chiropractic care. This treatment is based on the philosophy that restricted movement in the spine may lead to pain and reduced function. Spinal adjustment (manipulation) is one form of therapy chiropractors use to treat restricted spinal mobility. The goal is to restore spinal movement and, as a result, improve function and decrease pain. Chiropractors manipulate the spine from different positions using varying degrees of force. Manipulation doesn't need to be forceful to be effective. Chiropractors may also use massage and stretching to relax muscles that are shortened or in spasm. Because manipulation has risks, always go to properly trained and licensed practitioners.
  • Massage therapy. This is one of the oldest methods of health care still in practice. It involves use of different manipulative techniques to move your body's muscles and soft tissues. The therapy aims to improve blood circulation in the muscle, increasing the flow of nutrients and eliminating waste products. Massage can reduce your heart rate, relax your muscles, improve range of motion in your joints and increase production of your body's natural painkillers. It often helps relieve stress and anxiety. Although massage is almost always safe, avoid it if you have open sores, acute inflammation or circulatory problems.
  • Osteopathy. Doctors of osteopathy go through rigorous and lengthy training in academic and clinical settings, equivalent to medical doctors. They're licensed to perform many of the same therapies and procedures as conventional doctors. One area where osteopathy differs from conventional medicine ? but is similar to chiropractic medicine ? is in the use of manipulation to address joint and spinal problems.
 

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