Ouch: Relief for Fibromyalgia

Part 2 in a series on managing pain

For decades, few physicians acknowledged fibromyalgia as a bona fide disease. Though theterm was first used 20 years ago, it is still a condition about which relatively little is known and for which there is imperfect scientific support.

The history of fibromyalgia dates back to around 1900, when a British physician named Sir William Gowers used the term “fibrositis” to describe a condition whose symptoms he believed were due to inflammation within the muscle fibers. While further study did not support Gowers’s theory, in 1976 Dr. Philip Hench coined what is considered to be a more appropriate term: fibromyalgia, which means pain in the muscles.

Generally speaking, pain is the body’s most common and effective way of communicating that something may be wrong, or that we are being injured by some external entity, as when you touch a hot stove. Pain is also our most frequent complaint to health care providers, yet we still have a lot to learn about it.

As a pain syndrome, fibromyalgia is one of the newest to be studied. The FDA has recently allowed Pfizer pharmaceuticals to claim in a television ad that their novel antidepressant drug, Lyrica (pregabalin), is a suitable treatment for it. Since approval of such drug labeling requires scientific study on human subjects, this lends credence to the condition as a real, diagnostic entity. Things have come a long way for patients with fibromyalgia. There is even a Fibromyalgia for Dummies primer.

Dr. Thomas H. Brannagan III, MD, associate professor of Clinical Neurology at Cornell University in Ithaca, NY, recently outlined the current understanding of fibromyalgia and its treatment in the publication Applied Neurology.

Using defined diagnostic criteria, the disease is found mostly to affect women beginning somewhere between 25 and 40 years old. There may be a genetic predisposition to develop fibromyalgia—along with major mood disorders—among family members. Specific gene defects have been associated with a reduced tolerance to painful stimuli, which is a key aspect of fibromyalgia.

Some of the most important data on the condition comes from functional magnetic resonance imaging (fMRI), which uses magnetic fields to “map” the brain. These diagrams show areas that “light up” when an individual is either performing a task or is subjected to an external stimulus, and indicate increased brain activity.

One study involved pressure applied to the thumbnail of 16 patients with fibromyalgia at the same time that they were undergoing an fMRI of their brain. The same was done to a control group of 16 persons who did not have fibromyalgia. Distinct brain activity in the region that detects pain was noted in the fibromyalgia patients, but not in the control group.

Depression, fatigue, irritable bowel syndrome, headaches and insomnia are also commonly associated with fibromyalgia. It is widely accepted that psychosocial factors, such as physical and emotional stress, can add to an individual’s experience of discomfort.

Though some might discount the feelings of one with fibromyalgia and dismiss the pain as being “all in one’s head,” the truth is that all pain is in our heads because our brains are where we register the sensation of pain.

The first step toward effective treatment of any illness is an accurate diagnosis. But pinpointing this condition can be difficult because the disease is unfamiliar or unacknowledged by many health care providers. That’s because symptoms are vague and vary greatly from one individual to the next. Moreover, the pattern of pain does not fit our highly advanced understanding of human anatomy or physiology.

In truth, vague symptoms are a defining criteria of fibromyalgia. The pain is diffuse and often involves the neck, shoulders, back, hands, knees and hips, or several of these areas at once. To be diagnosed with fibromyalgia, according to the American College of Rheumatology, which studies inflammatory disorders, a patient must be experiencing pain on both sides of the body, above and below the waist. The pain must be chronic and/or ongoing for more than three months. A knowledgeable examiner should be able to identify at least 11 of 18 established “tender points” on various areas of the body.

There is also the challenge of cyclical reasoning: Do the symptoms define the disease or does the disease define the symptoms? Either way, avoid diagnosing yourself and seek out a practitioner who is familiar with current medical literature on the topic and is knowledgeable about the disorder, as there are no definitive diagnostic tests.

Even if one doctor has given you a positive diagnosis, get a second opinion, since fibromyalgia mimics rheumatoid arthritis, polymyalgia rheumatica, Lyme disease, systemic lupus erythematosis, inflammatory myopathy, polyneuropathy, hypothyroidism, degenerative arthritis and irritable bowel syndrome.

Highly-effective treatment for fibromyalgia remains elusive. Cognitive-behavior therapy may help, as may physician-supervised courses of anti-depressant medications. Selective serotonin re-uptake inhibitors (SSRIs) have gained greatly in popularity in recent years. They seem to be more effective for most patients and have few bothersome side effects. The granddaddy of these is Prozac (fluoxetine), which has been proven effective in the treatment of fibromyalgia. The combination of a common tricyclic antidepressant, Amytriptyline, used in combination with Prozac, may even be better than each drug taken separately.

Another new category of anti-depressants proven effective in this regard is the serotonin-norepinephrine re-uptake inhibitors (SNRI’s). The flagship of these is Cymbalta (duloxetine), a medication approved for treating major depression—or neuropathic pain—associated with diabetic neuropathy and generalized anxiety disorder.

Cymbalta was found to improve the symptoms of fibromyalgia in a large, controlled study. While about a third of the subjects also suffered from major depression, the positive effect of the drug also occurred in a majority of subjects without major depression.

Lastly, Lyrica, the only medication approved by the FDA for the treatment of fibromyalgia, has apparently performed well in large, human trials. This does not necessarily mean that it is better than other medications, only that it is better than a placebo, as it was not compared to other drugs.

If one medication or a combination of them seems ineffective after a period of time, another medication or combination should be considered. This requires careful attention and supervision from a physician knowledgeable in managing the pain associated with fibromyalgia.

Some therapies are best avoided because of potential negative side effects. These may include narcotic analgesics and anti-inflammatory steroids. If a potent pain reliever seems vital to a fibromyalgia patient’s treatment, Ultram (tramadol) may prove helpful.

Alternative therapies are worth a try as well. These may include acupuncture or acupressure. Herbal remedies without some scientific support or a reliable track record should be suspect until proven otherwise. If you do choose to use herbs, make sure you are not taking dangerous quantities of potentially harmful substances.

One treatment that has been commonly used, but remains scientifically unproven is trigger-point injections. A physician who offers these can be assumed to have as good an understanding of fibromyalgia as anyone. An aerobic exercise regimen is also recommended.

The good news is that fibromyalgia does not typically progress. In fact, a significant number of patients actually get better after a couple of years.

In our next installment of this series, we will discuss neuropathic pain, which refers to the chronic, atypical variety—in other words pain that is not directly correlated to broken bone, burn or other obvious stimulus. Until next time, keep well.

by Thomas Chappell, MD

Fellow of the American College of Surgeons FACS; Certified American Board of Neurological Surgery; Dr. Chappell specializes in minimally invasive neurosurgery, spine and cranial surgery

ABILITY Magazine
Other articles in the Herschel Walker issue include Green Pages—An Old Fashion Clothesline; Faucet Aerators;Pate—Winter Sports Clinic Highlights; Humor Therapy; Man’s New Best Friend; Headlines—Splel Chceker, Drum Therapy, HBO Film and more; George Covington—Nobody Walks In Texas; Ouch!—Relief for Fibromyalgia; Best Practices—Sprint Has Your Number; A Place Called Home—Disability Legal Rights Center; UCP—A Ride to Raise Funds and Awareness; Ability on Assignment—Qatar, Shafallah Forum; Essay—Spread Respect; ABILITY's Crossword Puzzle; Events and Conferences...subscribe