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Too much Vitamin A from meat and dairy products can weaken the bones of the elderly. more...  OTHER TOPICS Exercise, nutrition and health |
Fibromyalgia: Real or Imaginary? M. Nergis Alnigenis (Yanmaz), M.D., and Peter Barland, M.D. Dr. Alnigenis is a Visiting Fellow in the Division of Rheumatology, Montefiore Medical Center, Bronx, N.Y. Fibromyalgia Syndrome (FMS), is an illness that causes pain, stiffness and tenderness throughout the body. Sufferers complain they have trouble sleeping and tire easily. 80%-90% of FMS victims are women and most are between 30 and 60 years old. Though FMS may not be well understood, it is far from uncommon. A recent study found that 2% of all North Americans suffer from FMS, 3.4% of women and 0.5% of men.1,2,3,4,5 It is the second most common problem seen by rheumatologists in North America.6,7,8 Some doctors believe that FMS is not a real condition, but, instead, is psychological. What do we actually know about FMS? How FMS Starts A possible clue to the origins of FMS is the fact that sufferers often report that their symptoms began after they came down with another illness or went through some other kind of health problem or personal crisis. The most common of these events are listed in Table 1.
Pain and Fatigue The main symptom of FMS is chronic widespread pain. Generally, the patient "hurts all over," but has difficulty pinpointing the location. The pain typically comes and goes, varying in intensity. Flare-ups often follow unaccustomed exertion, physical injury, a period of sleeplessness, exposure to cold or a stressful event.10 Another common symptom is profound fatigue. This often peaks after getting out of bed in the morning or in the mid-afternoon. Even minor activities can aggravate the pain and fatigue but so can prolonged inactivity. Patients awake in the morning feeling stiff and unrefreshed, even if they have slept 8 or 10 hours. Many patients do not complain of severe sleep disturbances, but do sleep lightly and wake up frequently during the night. The most common FMS symptoms and factors that seem to exacerbate or alleviate these symptoms are listed in Table 2.
FMS cannot be detected in a normal physical exam. Nor does it show up in a neurological exam, x-ray or standard laboratory tests. The symptom that most often leads to the discovery of FMS is the existence of what are called tender point sites. Tender point sites are specific areas of muscle, tendon or other tissue that are painful to the touch. FMS patients are not often aware of the exact location of many of these points.11 Figure 1 shows the 18 tender point sites that have been identified by the American College of Rheumatology (ACR). According to the ACR criteria, FMS is present when a patient suffers widespread pain for at least three months and feels pain in 11 or more of the 18 pressure point sites.  Doctors measure these tender points in one of two ways: by simply pressing the site with a finger or by using a slightly higher-tech method called dolorimetry. In the dolorimetry method, the examiner presses a rubber endplate, attached to a spring-loaded force gauge, into the tender point site with increasing force. Patients are then asked to say when they stop feeling pressure and start feeling pain.12 FMS and Other Disorders Patients with FMS often suffer from associated diseases. The most common of these are listed in Table 3.
Some diseases also mimic FMS and cause confusingly similar complaints. Your doctor will need to run a series of lab tests to rule out these disorders (Table 4) before FMS can be diagnosed.
Also complicating the FMS picture is the fact that FMS sufferers often have a variety of overlapping conditions or syndromes. The most common of these are shown in Table 5.
Is FMS Really Psychosomatic? As with other diseases whose causes are not understood, some have suggested that FMS may be a psychosomatic illness or even a psychiatric disorder. In the past, FMS patients have been diagnosed as hysterical. It is not hard to understand why: FMS sufferers look well and have normal laboratory test results. Their chief symptom, pain, is quite subjective and is difficult to document. In addition, many FMS symptoms also occur in depression and other psychiatric problems.13 Chronic pain, for example, can accompany anxiety and depression; clinical depression can cause fatigue, sleep disturbance and pain. Some researchers go so far as to question whether FMS even exists as a physical illness. In one study of childhood experiences, FMS patients were found to be much more likely than others to have experienced maltreatment or victimization.16 Though psychiatric problems do not cause tender point sites (the chief distinguishing feature of FMS) and we know that FMS patients who have been cured of depression normally continue to suffer from FMS, there does seem to be a relationship of some kind between FMS and various psychiatric disorders.14,15 Furthermore, studies have found that FMS sufferers, when compared to rheumatoid arthritis patients, are much more likely to have a psychiatric diagnosis at some point in their lives, and are much more likely to experience medically unexplained physical problems. Possible Causes of FMS While we do not know with certainty the causes of FMS, there are several theories.17 These include muscle abnormalities that might account for tender point sites; central nervous system abnormalities that might cause sleep disturbance and sensory problems; and problems with neurohormones (serotonin, endorphins, growth hormone) or other bodily substance that might lead to amplified pain perception. How to Treat and Manage FMS18,19 Recommended treatments include:
Nonsteroidal anti-inflammatory drugs (NSAIDs) Tricyclic antidepressants (TCAD): TCADs can decrease depression, relax muscles, improve sleep, and release endorphins. Side effects include weight gain, constipation, low blood pressure, agitation and morning hangover. Serotonin reuptake inhibitors: morning administration of these drugs may relieve daytime fatigue and fight pain. Muscle relaxants Benzodiazepins: these promote sleep, relax the muscles and help restless leg syndrome. Local injections with lidocaine and steroids. Topical creams: capsaicin 0.25%. Summary FMS is a difficult and poorly understood illness that affects different people in different ways. Accordingly, there are many approaches to its treatment and therapies must be customized to the needs of the individual FMS sufferer.
References As of July, 2002, we have an FMS Update. 1. Wolfe F. Fibromyalgia: the clinical syndrome. Rheum Dis Clin North Am 1989; 15:1-18. return 2. Jacobsson L, Lindgarde F, Manthorpe R. The commonest rheumatic complaints of over six weeks' duration in a twelve-month period in a defined Swedish population. Prevalences and relationships. Scan J Rheumatol 1989; 18:353-60. return 3. Prescott E, Kjoller M, Jacobsen S, Bulow PM, Danneskiold-Samsoe B, Kamper- Jorgensen F. Fibromyalgia in the adult Danish population: I. A prevalence study. Scand J Rheumatol 1993; 22:233-7. return 4. Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum 1995; 38:19-28. return 5. Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia: report of the Multicenter Criteria Committee. Arthritis Rheum 1990; 33:160-72. return 6. Wolfe F. Fibromyalgia: the clinical syndrome. Rheum Dis Clin North Am 1990; 16:681-98. return 7. Reilly PA. Fibromyalgia in the workplace: a management problem. Ann Rheum Dis 1993; 342:906-9. return 8. Goldenberg DL. Fibromyalgia and related syndromes. In: Klippel JH, Dieppe PA, Eds. Rheumatology. London: Mosby, 1998:15.1-15.12. return 9. Wallace DJ. The fibromyalgia syndrome. Ann Med 1997;29:9-21. return 10. Wolfe F. When to diagnose fibromyalgia? Rheum Dis Clin North Am 1994; 20(2): 485-501. return 11. Borg- Stein J, Stein J. Trigger points and tender points: one and the same? Does injection treatment help? Rheum Dis Clin North Am 1996; 22(2): 305-21. return 12. Wolfe F. What use is fibromyalgia control points? J Rheumatol 1998; 25:546-50. return 13. Goldenberg DL. Psychiatric and psychological aspects of Fibromyalgia Syndrome. Rheum Dis Clin North Am 1989;15(1):105-14. return 14. Dunne FJ, Dunne CA. Fibromyalgia syndrome and psychiatric disorder. British Journal of Hospital Medicine 1995;54(5): 194-7. return 15. Walker EA, Keegan D, Gardner G, Sullivan M, Katon WJ, Bernstein D. Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: I. Psychiatric diagnosis and functional disability. Psychosomatic medicine 1997;59:565-71. return 16. Walker EA, Keegan D, Gardner G, Sullivan M, Katon WJ, Bernstein D. Psychosocial factors in fibromyalgia compared with rheumatoid arthritis: II. Sexual, physical, and emotional abuse and neglect. Psychosomatic medicine 1997;59: 572-77. return 17. Bennett R. Fibromyalgia, chronic fatigue syndrome, and myofascial pain. Current opinion in rheumatology 1998; 10:93-103. return 18. Goldenberg DL. Fibromyalgia syndrome a decade later. What have we learned? Arch Intern Med 1999; 159:777-85. return 19. Bradley LA, Alarcon GS. Fibromyalgia. In:Koopman WJ, Ed.Arthritis and allied conditions. A textbook of rheumatology. Baltimore: Williams and Wilkins, 1997:1619-40. return |
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