I come across numerous patients who have had body aches for years. They have made many visits to the doctor to find out what causes tiredness, lack of sleep, headaches, depression, forgetfulness and painful muscles and joints. Arthritis has been ruled out in many among them, but what actually is the reason for all these symptoms? Fibromyalgia might explain all of the above.
Fibromyalgia is a condition that mainly affects the muscles and sometime the joints. It’s a collection of various symptoms and is a diagnosis made after ruling out more obvious reasons for joint pain like arthritis. Fibromyalgia might lead to significant problems at one’s work place and is common among ladies.
In the following article I will explain some of the features of fibromyalgia, ways to diagnose this condition and some common mimics and methods of treatment. It’s a common disorder affecting almost one in every twenty-five adults.
The exact trigger for fibromyalgia is unknown. We think that it’s a combination of neurological, psychological and sometimes external factors that initiate the symptoms. Pain is a defensive response to any form of injury. It makes any living form withdraw from the stimuli. When we feel pain we try to get away from the harmful source and this itself protects our body from further damage. In fibromyalgia, there is no visible cause for the pain. The patients simply feel pain without any reason. Some research shows that patients who have fibromyalgia are more sensitive to pain compared to others. When the body repairs the damaged organ/part in a healthy person, pain tends to diminish or disappear. But in fibromyalgia, as there is no exact cause for pain, it tends to last longer.
Sleep disturbance is also associated with this condition and we believe that the patients never experience deep sleep. This could be because of the continuous pain. Not feeling refreshed upon awakening is a result of this haphazard sleep pattern.
Depression is associated with pain in any healthy person. As the pain tends to last longer, patients with fibromyalgia are more depressed. This could in turn affect sleep and vice versa. Normal pressure over healthy muscles/joints/parts of the body can cause severe pain and this was earlier used as a test to diagnose the condition. Unlike in arthritis when we examine the joints we do not find features of wear and tear or inflammation (red, hot, swollen joints).
Most patients with fibromyalgia feel very tired. As this is again a long standing complaint we call it chronic(long standing) fatigue (undue tiredness). Healthy people get tired after physically demanding tasks, but fibromyalgia patients feel tired even after periods of rest. There is a different condition called chronic fatigue syndrome which usually happens after a viral infection. This should not be confused with fibromyalgia.
A condition where the bowel habits become irregular with constipation and diarrhoea is called irritable bowel syndrome (IBS). IBS can be associated with fibromyalgia.
Certain diseases need to be ruled out before diagnosing fibromyalgia. For an example lack of blood particles (haemoglobin) can cause a condition called anaemia. Anaemia leads to breathlessness, tiredness, difficulty in concentrating etc. Treatment for anaemia is with iron or nutrients. Lack of thyroid hormones can cause lethargy, slowness, hoarse voice, weight gain, muscle aches, joint pain and constipation. This ‘Hypothyroidism’ requires hormone supplements.
Arthritis is the commonest cause for joint pain. Some patients who have arthritis have muscle involvement with swelling. This could cause severe muscle pain and tenderness (pain when being pressed upon). Treatment for arthritis differs from the medication given for fibromyalgia.
Before explaining the methods of treatment I would like to say a few words about the long-term outlook of fibromyalgia. The strange conclusion is that fibromyalgia doesn’t actually cause any damage to either bones, muscles or joints. Having said that, it does cause severe mental agony. This is because it is a long lasting condition.
Fibromyalgia affects different patients in different ways. In some it is just a body ache which one could cope up with, but in others it leads to failure in life events and work. So as specialists we need to identify how severely this affects the individual patient, hence the need to individualise treatment.
Earlier we used to diagnose fibromyalgia using eighteen different areas of the patient’s body. When pressure is applied over those areas it leads to a diagnosis of fibromyalgia. Now the method of diagnosis is different.
Patients with fibromyalgia should have widespread pain lasting three months or more, fatigue, waking up not feeling refreshed and problems with the thought processes like memory and understanding (cognitive symptoms).
The widespread pain is checked over nineteen areas of the body. And then a score is given between zero to nineteen. Fatigue, not wake refreshed and cognitive symptoms are again given a score between zero to four. This is based on how bad things are. Somatic symptoms are considered next and given a score between zero to four. Some examples for somatic symptoms are headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression and constipation. After the scores are obtained we figure out whether the patient has fibromyalgia or not. But the most important task is to exclude serious underlying illnesses. There is no blood test or scan to diagnose fibromyalgia, so it is a challenge diagnosis to make sometimes.
I prefer to simply divide the treatment strategies to ones involving medication and therapies that don’t introduce medication. It is strongly advised to combine both methods to provide the best benefits to the patient.
There are various drugs used for fibromyalgia out of which antidepressants take centre stage. Usually antidepressants are given to treat low mood, but in fibromyalgia these are proven to help reduce the pain. Sometimes patients need to take these for a longer duration for the best results to be achieved. Some common examples of antidepressants used are amitriptyline and duloxetine.
Another category of drugs used are gabapentin and pregablin. These are also called neuropathic drugs and change the way we perceive pain. We start these with a very low dosage and gradually observe how the symptoms subside. A common sideeffect of these drugs is drowsiness. But as most fibromyalgia patients suffer from insomnia, this side effect is sometimes considered as an advantage.
Tablets which have a mixture of paracetamol and codeine are sometimes useful, but usually the normal pain killers and ointments are ineffective in treating fibromyalgia.
If we consider alternative therapy, I find exercise one of the best remedies for fibromyalgia. Exercise doesn’t mean that patients have to run one or two kilometres a day. Brisk walking for about twenty minutes a day or climbing a staircase rapidly are also good forms of exercise that might be very soothing to the body. There are also stretching exercises that could be done without mobilising yourself too much.
Sometimes referral to physiotherapy and occupational therapy is beneficial in fibromyalgia. In the United Kingdom we used to refer patients to a pain clinic attended by physiotherapists and psychologists. One might wonder what a psychologist has to offer in fibromyalgia. I would say the psychologist can do a lot, considering all the emotional aspects of pain and its consequences. Relaxation techniques are also proven to be useful when treating fibromyalgia.
In Sri Lanka some patients have found Yoga as a useful remedy for pain relief. The same principals apply in a martial arts form named Tai Chi. In China I have witnessed this common sight before office hours or even at parks, where groups of individuals practice Tai Chi to bring down the stress levels. Both Yoga and Tai Chi involve gradual movement of limbs in a methodical manner.
I always advice patients with fibromyalgia to practice good sleep hygiene techniques. Sleep hygiene is not just maintaining cleanliness, but various other factors such as food, beverages, natural light, ventilation etc. which have a collective effect in improving sleep.
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