Features June 2017 Issue

The Challenge of Fibromyalgia

Fibromyalgia is a recognized medical condition. Effective treatment starts with understanding the array of factors connected to it.

Even though no blood, imaging or other test can confirm a diagnosis of fibromyalgia, it is a real medical condition, afflicting about four million Americans. This chronic pain syndrome causes pain all over the body, fatigue, sleep problems and difficulty with memory and concentration.

While there are drugs to treat fibromyalgia, nondrug therapies are almost always the first step. To understand the rationale for the various treatments for fibromyalgia it helps to have some knowledge about the condition. Recent guidelines by the European League Against Rheumatism (EULAR), published in the Annals of the Rheumatic Diseases (February 2017) make a strong recommendation to educate patients. If you have fibromyalgia, or think you might, here is what you need to know:

What Is Fibromyalgia?

Fibromyalgia Diagnosis

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“Fibromyalgia is diagnosed by a clinician having a conversation with the patient and analyzing the symptoms,” says Cleveland Clinic rheumatologist Carmen Gota, MD. The diagnosis is made if the characteristic symptoms have been present for three or more months. “Usually symptoms have been present for years,” she says.

The pain can be severe. “Patients often describe it in very colorful ways,” says Dr. Gota. Some people report having burning, tingling or stabbing sensations. The pain generally occurs at rest and at night. “It’s better when people start to move, but then it’s worse after exertion,” she says.

The physiologic mechanisms underlying the pain are complex and not completely understood. There are some theories. A term used for fibromyalgia is hypersensitization syndrome. This means that pain stemming from various parts of the body becomes amplified in the brain, making it feel even worse. In addition, pathways that normally inhibit pain signals don’t work properly, further magnifying the feeling of pain.

Fibromyalgia Fingerprint

The reasons this happens are not known. But there’s something called the fibromyalgia fingerprint. These are factors that seem to be connected to the development of fibromyalgia. “They vary in weight from person to person, and most can be addressed,” says Dr. Gota.

1. Genetics. Studies show that some people have a genetic profile that gives them a lower threshold for pain. Genes can’t be changed.

2. Stress. “The majority of people with fibromyalgia have experienced stressful or traumatic events,” says Dr. Gota. This may be emotional or physical. For example, a car accident, an illness, abuse or the stresses of daily living can trigger fibromyalgia. “We can’t reverse certain stressful events, such as a traumatic childhood,” says Dr. Gota. But some sources of stress can be managed.

3. Sleep. Research shows that people with fibromyalgia have disordered sleep, and there are methods to address this.

4. Mood. There is a high association between fibromyalgia and mental health conditions, such as depression, anxiety, and even more complex mood disorders. “If the mental health condition is severe, it must be treated for fibromyalgia to get better,” says Dr. Gota.

Another feature that is important in fibromyalgia is the person’s response to pain. A person may feel helpless or think too much about the pain, or believe things are worse than they are, which can magnify the symptoms. This “catastrophizing” can be addressed with cognitive behavioral therapy (CBT), in which a mental health professional helps the person to dismantle thought processes that amplify pain.

5. Physical activity. Some evidence shows that people with fibromyalgia have higher levels of lactic acid and glutamate in their muscles. This may contribute to the perpetuation of pain. Those levels decrease with exercise.

Yoga

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“Most people with fibromyalgia are not physically active, and they declare that if they move they will feel worse,” says Dr. Gota. This is true, but it is also true that fibromyalgia will get worse without movement. “I tell my patients that fibromyalgia is an exercise deprivation syndrome,” she adds.

Nondrug Treatment First

Once a diagnosis of fibromyalgia is established, the physician will conduct a psychological evaluation and assess the roles of stress, sleep problems and other aspects of the fibromyalgia fingerprint in each individual.

The EULAR guidelines recommend that physicians and patients start by setting goals. “This should not be focused on pain, but rather on obtaining meaningful objectives in terms of function,” says Dr. Gota.

Treatment usually starts with nonpharmacologic measures. There is no other intervention that gets as strong a recommendation by the EULAR guidelines as exercise, which should include both aerobic and muscle-strengthening activities.

People with fibromyalgia should establish a baseline level of activity that doesn’t cause too much discomfort. “They have to build on that level, slowly and gradually,” says Dr. Gota. “But they have to keep moving.” She recommends starting with exercises in a pool. Muscles relax in warm water, making physical activity less painful.

Pain will decrease with regular, long-term physical activity. So don’t give up too soon. A physician or physical therapist can help devise an individualized program.

Other nondrug interventions for fibromyalgia include CBT, acupuncture, good sleep habits and stress management techniques (such as meditation, yoga and massage). Fibromyalgia support groups are helpful for some people.

Nondrug Treatment

- Exercise. Start slowly and work up to moderate physical activity for 30 minutes five days a week.
- Good sleep habits:
- Go to bed and get up at about the same time every day.
- Keep the bedroom quiet, dark and at a comfortable temperature.
- Avoid large meals, alcohol and caffeine before bedtime.
- Manage stress with meditation, yoga, massage or other techniques.
- Treat mental health issues with cognitive behavioral therapy, psychotherapy and/or medications.

Medications

The three drugs that have been FDA-approved to treat fibromyalgia are duloxetine (Cymbalta®), milnacipran (Savella®) and pregabalin (Lyrica®). Several studies have found that about 50 percent of people who take them experience about a 30 percent decrease in pain.

If these drugs fail to work, there is some evidence that the drug tramadol (Ultram®), which is a weak opioid, may help. The EULAR guidelines strongly advise against using stronger opioid drugs, due to lack of evidence that they work and the high risk for side effects and addiction.

When it comes to treating fibromyalgia, “this is an uphill battle for a lot of people, but it is winnable,” says Dr. Gota.

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