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Fibromyalgia

Highlights

Non-Drug Therapies for Fibromyalgia

A combination of non-drug therapies work just as well as medication when it comes to relieving the pain, depression, and disability associated with fibromyalgia. Researchers reporting in the Clinical Journal of Pain compared a program of exercise sessions, stress management, massage, and diet education with standard medication therapy. They concluded that patients can feel better by using several non-drug therapies.

Acupuncture

Some studies have suggested that acupuncture can significantly reduce pain in people with fibromyalgia. However, a large, controlled study published in the July 2005 Annals of Internal Medicine found that inserting needles at fibromyalgia-related pressure points is no better than randomly inserting needles ("sham acupuncture")  at relieving pain for fibromyalgia.

Drug Research News

Pramipexole, a drug used to treat Parkinson’s disease and restless legs syndrome, may cut fibromyalgia-related pain symptoms in half, according to a study published in the journal Arthritis and Rheumatism.

A small study performed in Spain in 2005 suggests that the antipsychotic drug olanzapine (Zyprexa) reduces pain in people with fibromyalgia. Previous research has shown that olanzapine is effective for chronic pain conditions. However, the drug can cause unpleasant side effects. Nearly half of those in the 2005 study dropped out because of severe weight gain.

Introduction

Fibromyalgia is a syndrome of unknown causes that results in chronic, sometimes debilitating, muscle pain and fatigue. Fibromyalgia is also fibrositis or fibromyositis.

General Description of Fibromyalgia Symptoms

Pain. The primary symptom of fibromyalgia is pain. Pain can hurt in one place or all over. Precise locations of pain are called tender points.   The pain of fibromyalgia is often is described as follows:

• Tender point pain occurs in local sites, usually in the neck and shoulders. The pain then spreads out from these areas. The actual pain originates from the muscles. The joints are not affected. There are no lumps or nodes associated with these points and no signs of inflammation such as swelling. Those who are diagnosed with fibromyalgia feel pain in at least 11 of 18 specific tender points. [See section on Diagnosis: Criteria for Classifying Fibromyalgia in this report.]
• Widespread pain is similar to that of arthritis and has been described as stiffness, burning, radiating, and aching. Most patients report feeling some pain all the time, and many describe it as "exhausting." The pain can vary, depending on the time of day, weather changes, physical activity, and the presence of stressful situations. The pain is often more intense after disturbed sleep.

Fatigue and Sleep Disturbances. Another major complaint is fatigue, which some patients report as being more debilitating than the pain. Sleep disturbances, particularly restless legs syndrome, are also very common. Fatigue and sleep disturbances are, in fact, almost universal in patients with fibromyalgia. If these symptoms are not present, then some experts believe that doctors should seek a diagnosis other than fibromyalgia.

Depression and Mood. Up to a third of patients experience depression. Disturbances in mood and concentration are also very common.

Other Symptoms. The following symptoms may also be present:

• Dizziness
• Tension or migraine headaches
• Tingling or numbness in the hands and feet
• Gastrointestinal problems, including irritable bowel syndrome with gas and alternating diarrhea and constipation
• Urinary frequency caused by bladder spasms
• Painful menstrual periods

Symptoms in Children. Although children and adults have similiar fibromyalgia symptoms, some experts suggest that children may not have a set number of pain tender points. In one study, children had an average of 9.7 tender point locations compared to the minimum of 11 in adults. In general, children with fibromyalgia most often experience sleep disorders and widespread pain. 

Causes

Fibromyalgia is grouped into two categories:

• Primary (idiopathic) fibromyalgia -- the causes are not known
• Secondary fibromyalgia -- the causes can be identified

Primary fibromylagia is the most common type. Many experts believe that fibromyalgia is not a disease but rather a chronic pain condition brought on by a number of abnormal body responses to stress. Physical injuries, emotional trauma, or viral infections such as Epstein-Barr may act as triggers for the onset of the disorder, but none have proven to be a cause of primary fibromyalgia.

Chronic Sleep Disturbance

Sleep disturbances are common in fibromyalgia. Both adult and young patients with fibromyalgia have a higher than average rate of a sleep disorder called periodic limb movement disorder (PLMD). PLMD used to be called nocturnal myoclonus. Patients with PLMD involuntarily contract their leg muscles every 20 to 40 seconds during sleep. This may occasionally wake up the patient.

Some experts believe that fibromyalgia does not lead to poor sleeping patterns, but that sleep disturbances come first. Researchers continue to investigate the link between fibromyalgia and sleep.

• In one study, healthy volunteers reported fibromyalgia-like pain after they had been subjected to disrupted deep sleep. Disturbed sleep appears to trigger factors in the immune system that cause inflammation, pain, fatigue, and lower tolerance to pain. A 2004 study published in the journal Rheumatology found that patients with fibromylagia have increased rates of the cyclic alternating sleep pattern (CAP).  The increase CAP produced significant sleep impairment, which was strongly linked to symptom severity. (Previous studies have also suggested that CAP may be related to PLMD.)
• A 2004 report published in the journal Sleep found that sleep-disordered breathing is common in women with fibromyalgia.
• Other biologic measures of troubled sleep, however, such as levels of the hormone melatonin, which helps to regulate circadian rhythms and the sleep-wake cycle, appear to be normal in most fibromyalgia sufferers.

Brain Chemicals and Hormonal Abnormalities

Studies of hormonal, metabolic, and brain chemical activity in fibromyalgia patients have shown a number of abnormalities. Changes appear to occur with a number of brain chemicals, although no consistent pattern has emerged that fits most patients. Some experts believe that the changes are a result of the effects of pain and stress on the central nervous system and are not a cause of fibromyalgia.

Serotonin. Of particular interest to researchers is serotonin, an important nervous system chemical messenger (neurotransmitter) found in the brain, gut, and other areas. Serotonin plays important roles in feelings of well being, modulating pain, and promoting deep sleep. Serotonin abnormalities have been linked to many disorders, including depression, migraines, and irritable bowel syndrome. Lower levels have also been noted in some patients with fibromyalgia.

Stress Hormones. Researchers have also noted abnormalities in the hormone system known as the hypothalamus-pituitary-adrenal gland (HPA) axis, which controls important functions, including sleep, response to stress, and depression. Alterations in the HPA axis appear to produce lower levels of the stress hormones norepinephrine and cortisol. (In depression, stress hormones are higher than normal.) Deficiencies produce impaired and weaker responses to psychological or physical stresses (such as infection or exercise).

The hypothalamus is a highly complex structure in the brain that regulates many important brain chemicals.

Click the icon to see an image of the adrenal glands.

Low Growth Hormone Levels. Some studies have reported low levels of insulin-like growth factor-1 (IGF, also called somatomedin C) in about a third of fibromyalgia patients. IGF is a hormone that is controlled by adult growth hormone and promotes bone and muscle growth. Low levels are associated with impaired thinking, lack of energy, muscle weakness, and intolerance to cold.  Severe growth hormone deficience has been observed in a subset of fibromyalgia patients. In a 2003 study, however, researchers did not find a link between IGF levels and fibromyalgia.

Abnormal Pain Perception and Substance P. Some studies have suggested that fibromyalgia may involve overactivity in the parts of the central nervous system that process pain (called the nocioceptive system). Brain scans of fibromyalgia patients have suggested abnormalities in pain processing centers. Of particular interest is research that has detected up to three times the normal level of substance P in the cerebrospinal fluid of fibromyalgia patients. Substance P is a neurotransmitter associated with increased pain perception.

Some fibromyalgia patients may also be oversensitive to external stimulation and preoccupied with the sensation of pain. This amplification of sensation is called generalized hypervigilance.  A study compared patients with fibromylagia, rheumatoid arthritis, and those without chronic pain. They were surveyed to assess their response to pain and noise. Of the three groups, the fibromyalgia patients were least tolerant of and most attentive to such stimuli. A 2001 analysis of studies on fibromyalgia, however, found no strong support for the hypervigilance theory.

Immune Abnormalities

Fibromyalgia has some symptoms that resemble a number of rheumatic illnesses, including rheumatoid arthritis and lupus (systemic lupus erythematosus). These are autoimmune diseases in which a defective immune system mistakenly attacks the body's own healthy tissue, producing inflammation and damage. The pain in fibromyalgia, however, does not appear to be due to autoimmune factors, and there is little evidence to support a role for an inflammatory response in fibromyalgia.

Psychological and Social Effects

Although not primary causes, psychological and social factors may contribute to fibromyalgia in three ways:

• They could make individuals susceptible to fibromyalgia.
• They may play some role in triggering the onset of the condition.
• They may perpetuate, or be responsible for, the condition.

Studies have reported a greater incidence of severe experiences of victimization from emotional and physical abuse in patients with fibromyalgia than in the general population. Most often the abuse originated from family or partners. This suggests that post-traumatic stress disorder (PTSD) or chronic stress may play a strong role in the development of fibromyalgia in some patients. PTSD is an anxiety disorder that is a reaction to a specific traumatic event. Symptoms of this condition, which can occur for years after the traumatic event, include emotional withdrawal, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle response to noise. There is some evidence that PTSD actually results in changes in the brain, possibly from long-term overexposure to stress hormones.

Muscle Abnormalities

Some research has detected muscle defects in fibromyalgia patients, which can be classified as follows:

• Biochemical abnormalities. For example, one study reported that fibromyalgia patients had lower levels of the muscle-cell chemicals phosphocreatine and adenosine triphosphate (ATP). Such chemicals regulate the ebb and flow of calcium in muscle cells, an important component in their ability to contract and relax. If ATP levels are low, calcium is not "pushed back" into the cells and the muscle remains contracted.
• Structural and blood flow abnormalities. Some researchers have observed overly thickened capillaries (tiny blood vessels) in the muscles of fibromyalgia patients, which could produce lower levels of certain compounds essential for muscle function as well as reduce the flow of oxygen-rich blood to these tissues.
• Functional abnormalities. The pain and stress of the disease itself may impair muscle function.

Causes of Secondary Fibromyalgia

Secondary fibromyalgia has the characteristic symptoms of fibromyalgia but, unlike primary fibromyalgia, a specific cause can be identified. Possible causes include:

• Physical injury -- In one study, for example, secondary fibromyalgia developed in over 20% of patients who had neck injuries. The symptoms are identical to those of primary fibromyalgia but are harder to treat. Another study reported a high rate of fibromyalgia in workers who had repetitive stress injuries, although it is not clear which condition came first.
• Ankylosing spondylitis
• Surgery
• Lyme disease

Click the icon to see an image of Lyme disease.

• Hepatitis C

Click the icon to see an image of hepatitis C.

• Endometriosis -- According to a 2001 study, about 31% of women with endometriosis go on to develop fibromyalgia or chronic fatigue syndrome, a related illness.

Click the icon to see an image of endometriosis.

Risk Factors

An estimated ten million Americans have fibromyalgia. Some evidence suggests that a number of factors may make people more susceptible to fibromyalgia. These risk factors include being female, having had difficult experiences in childhood, having a psychological vulnerability to stress, and coming from a very stressful culture or environment.

Women

Nine out of 10 fibromyalgia patients are women. Women may be more prone to develop fibromyalgia during menopause.

Age

The disorder usually occurs in people between 20 to 60 years of age, though it can occur at any time. Some studies have noted peaks around age 35; others note it is most common in middle-aged women. In one trial, fibromyalgia increased with age and had a prevalence of over 7% among people in their 60s and 70s.

Juvenile Primary Fibromyalgia. This variant of fibromyalgia appears in adolescents, typically after 13 with a peak incidence at age 14. It is uncommon, but studies indicate that its incidence may be increasing. One study found that 1.2% of school children, all girls, met the criteria for fibromyalgia. Other studies have found an even higher prevalence of fibromyalgia in children. Symptoms are similar to adult fibromyalgia, but outcomes appear to be better in young people.

Family Factors

Studies report a higher incidence of fibromyalgia among family members. It is not clear if genetic or psychological factors, or both, are involved.

• One study reported that 28% of the children of mothers with fibromyalgia also develop the disorder. Offspring who developed fibromyalgia were no more likely to have psychological disorders than those who did not.
• Another study noted that 66% of parents of children with fibromyalgia reported some sort of chronic pain, and about 10% had fibromyalgia itself.

Conditions That Commonly Occur in Fibromyalgia Patients

A number of conditions overlap or often co-exist with fibromyalgia that have similar symptoms. It is not clear if these conditions or others are risk factors for fibromyalgia, are direct causes, have common causes, or have no relationship at all with CFS.

Chronic Fatigue Syndrome. There is a significant overlap between fibromyalgia and chronic fatigue syndrome (CFS). In a 2003 study, for example, 43% of CFS patients also were diagnosed with fibromyalgia. As with fibromyalgia, the cause of CFS is unknown. Both disorders can be diagnosed by a doctor only on the basis of symptoms reported by the patient and cannot be confirmed by laboratory tests or other objective measures. The two disorders share most of the same symptoms. They are even treated almost identically. The differences are primarily the following:

• Pain with tender points is the primary symptom in fibromyalgia. (Some patients with CFS exhibit similar tender pressure points. However, muscle pain is less prominent in patients with CFS.)
• Fatigue is the dominant symptom in CFS. It is severe and not relieved by rest or sleep and not the result of excessive work or exercise.

Some doctors believe that fibromyalgia is simply an extreme variant of chronic fatigue syndrome. There is some physical evidence, however, that the two disorders are distinct, with treatments that are specific to each.

Myofascial Pain Syndrome. Myofascial pain syndrome can be confused with fibromyalgia and may also accompany it. Unlike fibromyalgia, myofascial pain tends to occur in trigger points, as opposed to tender points, and typically there is no widespread, generalized pain. Trigger-point pain occurs in tight muscles, and when the doctor presses on these points, the patient may experience a muscle twitch. And unlike tender points, trigger points are often small lumps, about the size of a pencil eraser.

Major Depression. The link between psychological disorders and fibromyalgia is very strong and problematic. Certain studies report that between 50 - 70% of fibromyalgia patients have a lifetime history of depression. Only between 18 - 36% of fibromyalgia patients, however, have concurrent major depression, a severe form of depression. It should be noted that some researchers have observed that people who have both psychological disorders and fibromyalgia are more likely to seek medical help than patients who simply have symptoms of fibromyalgia. Such findings may bias study results and favor a higher-than-actual association between depression and fibromyalgia.

Depression most likely does not cause fibromyalgia, but it may increase susceptibility. Depressed feelings in people with fibromyalgia can certainly be normal responses to the pain and fatigue caused by this syndrome. Such emotions, however, are situational and temporary, and are not considered to be a depression disorder. Unlike ordinary periods of sadness, an episode of major depression disorder can last many months. Symptoms of major depression include the following:

• A depressed mood every day
• Significant weight gain or loss (of 10% or more of an individual's typical body weight)
• Insomnia or excessive sleeping
• Restlessness or a sense of being slowed down
• Low energy every day
• Worthless or inappropriately guilty feelings
• An inability to concentrate or to make decisions
• Suicidal thoughts

Major depression is likely to be the responsible condition in the presence of several of these symptoms plus the absence of physical symptoms (particularly the tender points typical of fibromyalgia).

Chronic Headache. Chronic primary headaches such as migraines are common in fibromyalgia patients. Some experts believe that migraine headaches and fibromyalgia may even share common defects in the systems that regulate certain neurotransmitters (chemical messengers in the brain), including serotonin and epinephrine (commonly called adrenaline). Low levels of magnesium have also been noted in patients with both fibromyalgia and migraines. In fact, chronic migraine sufferers who fail to benefit from usual therapies may also have fibromyalgia.

Symptoms of a migraine attack may include heightened sensitivity to light and sound, nausea, vision problems (auras), difficulty of speech, and intense pain predominating on one side of the head.

Multiple Chemical Sensitivity. Multiple chemical sensitivity (MCS) is a term now used to describe conditions in which certain chemicals can cause symptoms similar to CFS or fibromyalgia in some people. It has also been observed in people with fibromyalgia. Experts have come up with criteria to help recognize people with MCS.

• The symptoms are reproducible with repeated exposure to a chemical. (These are often common chemicals found in popular products, such as perfumes, fabric softeners, and air fresheners.)
• The condition is chronic.
• Symptoms can be produced by exposure to the chemical at levels lower than previously or commonly tolerated.
• The symptoms improve when the chemical is removed.
• Symptoms can be triggered by multiple substances that are chemically unrelated.
• Symptoms involve multiple organ systems.

Still, as with CFS and fibromyalgia, some experts are uncertain whether MCS is an actually medical condition or if it is psychologically based. In one study, for example, CFS patients who believed their problem was chemically triggered were exposed to either an active chemical or a placebo (an inactive substance). Both groups reported symptoms, including those exposed only to the placebo. It should be noted that everyone is exposed to many chemicals on a daily basis, and it is very difficult to determine if chemicals are responsible for specific symptoms.

Restless Legs Syndrome (RLS). About 15% of people with fibromyalgia have restless legs syndrome. RLS is an unsettling and poorly understood movement disorder sometimes described as a sense of unease and weariness in the lower leg that is aggravated by rest and relieved by movement.

Disorders Affected by the Sympathetic (also called Autonomic) Nervous System. Other conditions that commonly accompany fibromyalgia include chest pain and heart palpitations, mitral valve prolapse, and a sudden drop in blood pressure.

Diagnosis

There is no unequivocal objective method for diagnosing fibromyalgia. The criteria used for studying fibromyalgia are very helpful, particularly if the patient does not have any accompanying disorder, such as depression or arthritis, which could complicate the diagnosis. Failure to meet the criteria, however, does not rule out fibromyalgia. Fibromyalgia should be suspected in any patient with muscle and joint pain when no identifiable cause has been found.

The 18 fibromyalgia tender points are located throughout the body. According to the American College of Rheumatology, a diagnosis of fibromyalgia requires widespread body pain plus localized pain in 11 of these 18 specific points.

Medical and Personal History

A doctor should always take a careful personal and family medical history, which would include a psychological profile and a history of any factors that might be indicative of disorders other than fibromyalgia. Such factors might include recent weight change, physical injuries, infectious diseases, muscle weakness, rashes, and any instances of sexual, physical, or substance or alcohol abuse. The patient should report any drugs being taken, including vitamins and over-the-counter or herbal medications.

Physical Examination

Pressure on Tender Spots. Any physical examination for fibromyalgia requires that the doctor press firmly on all potential tender spots. They must be painful when pressed, not simply tender. In addition, for a diagnosis of fibromyalgia, these tender sites are not typically accompanied by signs of inflammation, such as redness, swelling, or heat in the joints and soft tissue. The pressure points may also change in location and sensitivity over time. A doctor, then, may recheck pressure points that do not respond the first time in patients who have other significant symptoms.

Detection of Other Causes of Symptoms. A physical examination also includes scrutiny of nails, skin, mucous membranes, joints, spine, muscles, and bones to help rule out arthritis, thyroid disease, and other disorders.

Other Tests

There are no blood, urine, or other laboratory tests that can provide a definitive diagnosis of fibromyalgia. If such tests show abnormal results, then the doctor should look for other disorders. Tests for specific diseases depend on family histories and other symptoms. They may include thyroid and liver function tests, blood count, tests of certain antibodies, and sedimentation rate. Follow-up psychological profile testing may be suggested if laboratory results do not indicate a specific disease.

Conditions with Similar Symptoms

Between 10 - 30% of all doctors' office visits are due to symptoms that resemble those of fibromyalgia, including fatigue, malaise, and widespread muscle pain. Since no laboratory test can confirm a diagnosis of fibromyalgia, doctors will usually first test for similar conditions. It should be noted that a diagnosis of many of these below disorders may not always rule out fibromyalgia, since it can accompany other common and similar conditions.

Conditions That Do Not Rule Out Fibromyalgia

Chronic fatigue syndrome, myofascial pain syndrome, depression, primary headaches, and, certain stress-related disorders commonly occur with fibromyalgia and have overlapping symptoms. In fact, some experts believe these disorders so often interact that they may all be part of one general condition.

Other conditions may also occur that are similar to fibromyalgia but do not rule out a diagnosis of fibromyalgia. They include:

• Irritable bowel syndrome
• Temporomandibular joint disorders (TMJ)
• Juvenile rheumatoid arthritis (JRA) -- usually diagnosis is clear cut, but the conditions may coexist. JRA should be considered in children with fibromyalgia if their condition worsens.
• Osteoarthritis -- a common form of arthritis than can coexist with fibromyalgia. The two conditions may be confused, particularly in elderly people. Osteoarthritis, however, causes joint pain, not widespread or generalized pain.

Osteoarthritis is a chronic disease of the joint cartilage and bone. It is often thought to result from "wear and tear" on a joint, although there are other causes such as congenital defects, trauma, and metabolic disorders. Joints appear larger, are stiff and painful, and usually feel worse the more they are used throughout the day.

• Chemicals and environmental toxins -- exposure to various chemicals and environmental toxins such as solvents, pesticides, or heavy metals (cadmium, mercury, or lead) can cause fatigue, chronic pain, and other symptoms of fibromyalgia.

Some tests may be positive for one or more of these diseases. However, if the results are ambiguous or weak or if they have been treated successfully, fibromyalgia should not be ruled out if the patient still also meets the criteria for it.

Conditions That Usually Rule Out Fibromyalgia

Rheumatoid Arthritis and Other Autoimmune Diseases. Autoimmune diseases are conditions in which the person's immune system attacks the body's own tissues. Many autoimmune conditions resemble fibromyalgia. (Fibromyalgia, itself, may be an autoimmune disorder.) These diseases, like fibromyalgia, also occur more often in women than in men, and early symptoms are often muscle and joint pain and fatigue. The following are some autoimmune disorders that may be confused with fibromyalgia:

• Rheumatoid arthritis is most apt to mimic fibromyalgia, and the similarities present diagnostic problems in both young people and adults. Symptoms include morning stiffness, fatigue, and tender points. Pressing such points, however, does not produce the intense pain that occurs with fibromyalgia, and abnormal laboratory tests can usually differentiate this disorder from fibromyalgia. Juvenile rheumatoid arthritis may coexist with fibromyalgia.

Click the icon to see an image of rheumatoid arthritis.

• Hashimoto's thyroiditis, a form of hypothyroidism marked by low levels of thyroid hormone, can cause widespread muscle aches, depression, and fatigue if left untreated. This condition is usually easily identifiable with thyroid hormone tests.

Click the icon to see an image of Hashimoto's thyroiditis.

• Systemic lupus erythematosus resembles fibromyalgia, although most patients with lupus also have a rash. Lupus can be diagnosed with a blood test.

Click the icon to see an image of systemic lupus erythematosus.

• Multiple sclerosis has similar symptoms. There is no definitive test for diagnosing it. Magnetic resonance imaging scans, however, detect patches of injured tissue (lesions) in the brain that suggest MS.

Click the icon to see an image of multiple sclerosis.

• Sjogren's syndrome, a condition characterized by dry eyes and mouth, is sometimes mistaken for fibromyalgia.

Autoimmune diseases generally evolve slowly. Even if a doctor determines that a patient is most likely to have fibromyalgia, he or she should keep track of any changes in symptoms over time in case one of these illnesses is actually present.

Lyme Disease. Early Lyme disease can usually be correctly diagnosed, but a delayed response or recurrence of this disorder may be mistaken for fibromyalgia. Some experts believe that between 15 - 50% of patients referred to clinics for Lyme disease actually have fibromyalgia. Late Lyme disease can usually (but not always) be ruled out using blood tests that identify the infectious organism that causes this tick-borne disease. If fibromyalgia patients are incorrectly diagnosed and treated for Lyme disease with prolonged courses of antibiotics, the drugs may have serious side effects.

Drugs and Alcohol. Fatigue is a side effect of many prescription and over-the-counter medications, such as antihistamines. In addition, dependency on or abuse of alcohol or illicit drugs may manifest as persistent fatigue. Medications should be considered as a possible cause of fatigue if an individual has recently started, stopped, or changed medications. Withdrawal from caffeine can produce depression, fatigue, and headache.

Polymyalgia Rheumatica. Polymyalgia rheumatica is a condition that causes pain and stiffness and generally occurs in older women. Tender points are also present with this disorder, although they almost always occur in the hip and shoulder area. Morning stiffness is common, and patients may also experience fever, weight loss, and fatigue. High blood levels of erythrocyte sedimentation rates (ESR or sed rates) can suggest polymyalgia rheumatica. Elevated sed rates, however, also occur with other conditions. Polymyalgia rheumatica often resolves in about a year, but there is a risk of persistent disease. Worse, it is associated with a rare condition called temporal arteritis, which causes blindness if not healed, so an accurate diagnosis of polymyalgia rheumatica is important.

Other Diseases That May Rule Out Fibromyalgia.

• Hepatitis -- Hepatitis C, in fact, may prove to be a cause of some cases of fibromyalgia
• Anemia
• Diabetes
• Infections -- For example, infectious mononucleosis is marked by fatigue and swollen glands. It primarily affects adolescents and young adults. Some patients may have lingering fatigue that last for many months.
• Cancer
• Neuromuscular diseases such as myasthenia gravis

Prognosis

Fibromyalgia can be mild or disabling, and the emotional repercussions can be substantial. About half of all patients have difficulty with or are unable to perform routine daily activities. Estimates of patients who have had to stop work or change jobs range from 30 - 40%. In a 2003 study, patients with either CFS or fibromyalgia were more likely to suffer losses of jobs, possessions, and support from friends and family than people suffering from other conditions that caused fatigue.

Risk of Negative Behaviors

The pain, emotional repercussions, or sleep disturbances may lead to self-medication and overuse of sleeping pills, alcohol, drugs, or caffeine. One 2001 study also reported a higher incidence of violent deaths, including suicide and accidents, among people with widespread pain.

Long-term Outlook

Outlook in Adults. Some studies indicate that fibromyalgia symptoms remain stable over the long term, while others report a better outlook, with between 25 - 35% of patients reporting improvement in pain symptoms over time. Studies suggest that regular exercise specifically improves outlook in patients. For example, in one study of adult patients after four and a half years, those who had adequate exercise had the most promising outcome. Those with a significant life crisis or who were on disability had a poorer outcome than others. Outcome was determined by improvements in the patients' capacity to work, their own feelings about their condition, pain sensation, disturbed sleep, fatigue, and depression.

Although the disease is chronic, it is neither progressive nor fatal, and remission can occur in many patients who participate in disease management programs. Patients with secondary fibromyalgia, particularly when it is caused by injury, tend to have a more severe and less easily treated condition than those with primary fibromyalgia.

Outlook in Children. Children with fibromyalgia tend to have better outlooks than adults. Several studies have reported that over half of children with fibromyalgia recover in 2 to 3 years.

Treatment

Fibromyalgia is a mysterious condition whose causes and basic disease mechanisms are still largely unknown. There is no strong evidence that any single treatment or combination has any significant effect for most patients. Treatment must involve not only relieving symptoms but also changing the patients' perceptions of their disease and helping them to develop behaviors that enable them to cope.

Therapies generally employ a trial and error, multi-faceted approach:

• Patients may start initially with physical therapy, exercise, stress reduction techniques, and cognitive-behavioral therapy.
• If non-pharmacologic methods fail to improve symptoms, then an antidepressant or muscle relaxant may be added to the treatment regimen. These drugs are typically prescribed for their effects on the central nervous system that help to improve pain tolerance. Because many fibromyalgia patients have difficulty sleeping, the drowsiness that these drugs produce can be beneficial.
• Patient education and programs that bolster coping skills are an important part of any treatment plan.

According to a 2005 study published in the Clinical Journal of Pain, a combination of non-drug therapies (exercise, stress management, massage, and dietary therapy) work just as well as drug therapy in improving pain, depression, and disability. In 2004, the Journal of the American Medical Association published an evaluation of various fibromyalgia treatments. Based on clinical trial data reported in medical journals, the researchers assessed and ranked the evidence supporting the efficacy of these treatments.

Non-Drug Treatments:· 

• Strongest evidence: Cardiovascular exercise; cognitive-behavioral therapy; patient education groups; combinations of these treatments.
• Moderate evidence: Strength training; acupuncture, hypnotherapy; biofeedback; balneotherapy. 
• Weak evidence: Chiropractic; massage therapy; electrotherapy; ultrasound.
• No evidence: Trigger point injections; flexibility exercise.

Drug Treatments:

• Strongest evidence: Amitriptyline; cyclobenzaprine.
• Moderate evidence: Tramadol; fluoxetine; venlafaxine; milnacipran; duloxetine; pregabalin.
• Weak evidence: Growth hormone; 5-HT; tropisetron; SAMe.
• No evidence: Opioids; corticosteroids; NSAIDs; benzodiazepine and non-benzodiazepine hypnotics; melatonin; calcitonin; thyroid hormone; guaifenesin; DHEA; magnesium.

These evidence-based rankings were determined from published clinical trials. However, some treatment modalities have not been as extensively studied as others and have less available published evidence. Doctors’ recommendations and individual patients’ experiences in the real world of clinical practice may differ from clinical trial results.

Preparation for Treatment

Patients must have realistic expectations about the long-term outlook and their own individual capabilities. It is important to understand that the condition can be managed and patients can live a full life. The following tips may be helpful in embarking on a treatment program for fibromyalgia:

• The goal of therapy is to relieve symptoms, not to cure them.
• Treatment must be individualized, and a combination approach is often needed.
• Patients must begin all treatments with the attitude that they are trial and error.There is no clear treatment solution. Patients and doctors need to work together to make the best choices for individual symptoms and concerns.
• Therapies are prolonged, in some cases life-long, and patients should not be discouraged by relapses.
• Enlisting family, partners, and close friends, particularly with exercise and stretching programs, can be helpful.
• Becoming involved with support groups of fellow-patients has also benefited many patients. Support groups may also benefit family members, particularly parents of children with fibromyalgia. One study noted that the severity of the disorder increased in children whose parents were less able to cope with their child's pain.
• Improvement is subjective, and some patients are pleased with only a 10% reduction in pain and other symptoms.

Lifestyle Changes

Many studies have shown that exercise is the most effective component in managing fibromyalgia, and patients must expect to undergo a long-term exercise program. Physical activity prevents muscle atrophy, increases a sense of well being, and, over time, reduces fatigue and pain.

Graded Exercise. The basic approach used for fibromyalgia is called graded exercise. Graded exercise means you slowly increase the amount of your physical activity. In a well-conducted 2002 study, 35% of patients who engaged in graded aerobic exercise reported feeling much better or very much better after 3 months. Only 18% of patients who performed relaxation and flexibility exercises reported the same results. At the end of a year, more than half of the exercise group was no longer diagnosed with fibromyalgia compared to only 34% of the relaxation group.

In general, graded exercise involves:

• Exercises such as walking, swimming, and using equipment like treadmills or stationary bikes. Swimming and water therapy, which eliminate weight-bearing, appear to be excellent choices for getting started. In one 2002 study, patients who engaged in water exercise therapy for six months still reported improvements in symptoms and functioning two years after they had completed the program.
• A very gradual incremental program of activity, beginning with mild exercise and building over time, is important to help patients comply with exercise. For example, in one successful exercise study, patients started with two weekly sessions that lasted for only six minutes each. By week 12, they were performing exercises that lasted 25 minutes each with sufficient intensity to produce some sweating while still allowing them to talk comfortably.
• Patients should do stretching exercises before engaging in physical activity. A daily stretching routine can also help relax tense muscles and prevent muscle soreness.

Patients who attempt strenuous exercise too early actually experience an increase in pain and are likely to become discouraged and quit. Even walking 2 or 3 times a week is helpful.

Every patient must be prepared for relapses and setbacks, but this should be discouraging. Patients who do not respond to one type of exercise might consider experimenting with another form.

Physical therapy can be very helpful. Studies suggest that physical therapy may reduce muscle overload, lessen fatigue from poor posture and positioning, and help condition weak muscles.

Establish Regular Sleep Routines

Sleep is essential, particularly since pain is aggravated by disturbed sleep. Many patients with fibromyalgia sleep poorly and have difficulty achieving a restful and restorative night’s sleep. Improvement is low in those who are unable to sleep consistently and at night. Swing shift work, for example, is extremely hard on fibromyalgia patients. Poor sleep habits can contribute to sleep problems. “Sleep hygiene” tips include:

• Establish a regular time for going to bed and getting up in the morning. Maintain this schedule even on weekends and during vacation.
• Use the bed only for sleep and sexual relations.
• If unable to fall asleep after 15 or 20 minutes, go into another room and engage in quiet activity. Return to bed when feeling sleepy.
• Minimize light and maintain a comfortable, moderate temperature in the bedroom. Keep the bedroom well ventilated. 
• Avoid naps, especially in the evening or late afternoon.
• Avoid exercising within 6 hours of bedtime.
• Avoid caffeine or alcohol within 4 to 6 hours of bedtime.
• Avoid drinking fluids directly before bedtime so that sleep is not disturbed by the need to urinate.
• Avoid large meals before bedtime. A light snack, however, may help promote sleep.

[For more information see In-Depth Report #27: Insomnia.]

Diet

Fibromyalgia patients should maintain a healthy diet low in animal fat and high in fiber, with plenty of whole grains, fresh fruits and vegetables. Although everyone should be careful about calories in fats, some are healthy.

Omega-3 Fatty Acids. Oils containing omega-3 fatty acids are of particular interest for arthritic pain. Such oils are found in cold water fish and can be purchased as supplements called EPA-DHA or omega 3.

Omega-3 fatty acids are a form of polyunsaturated fat that the body gets from food. Omega-3s are known as essential fatty acids (EFAs) because they are important for good health. These healthy fatty acids can be found in certain fish, dark green leafy vegetables, and some oils. Omega-3 fatty acids have anti-inflammatory properties, which help prevent blood clots, lower cholesterol and triglyceride levels, and reduce blood pressure. Omega-3s may also reduce the risks and symptoms for diabetes, stroke, rheumatoid arthritis, asthma, inflammatory bowel disease, ulcerative colitis, some cancers, and mental decline.

Vegetarian Diet. A vegan diet has no meat, dairy, or eggs and includes uncooked fruits, vegetables, nuts, and germinated seeds. In two small studies a vegan diet was associated with improved symptoms including pain, stiffness, and quality of sleep. In addition, the diet was associated with lower weight and cholesterol levels. A 2000 study found no significant decline in symptoms except some improvement in pain, but not as much as with a tricyclic antidepressant.

Stress Reduction Techniques

Relaxation and stress-reduction techniques are proving to be helpful in managing chronic pain. There is certainly evidence that people with fibromyalgia have a more stressful response to daily conflicts and encounters than those without the disorder. A number of relaxation and stress-reduction techniques have proven to be helpful in managing chronic pain:

• Deep breathing exercises
• Muscle relaxation techniques
• Meditation
• Hypnosis
• Biofeedback
• Massage therapy

Biofeedback. Evidence suggests that biofeedback techniques may be helpful for fibromyalgia patients. During biofeedback, electric leads are taped to a subject's head. The person is encouraged to relax using any method that works. Brain waves are measured and an auditory signal is emitted when alpha waves are detected, a frequency that coincides with a state of deep relaxation. By repeating the process, subjects associate the sound with the relaxed state and learn to achieve relaxation on their own.

Meditation. Meditation, used for many years in eastern cultures, is now widely accepted in this country as an effective relaxation technique. A number of studies are reporting its benefits for fibromyalgia patients who practice on a sustained and regular basis. The practiced meditator can achieve the following physical benefits:

• Improvements in well being
• Improved sleep -- some research has reported an increase in melatonin levels in experienced meditators. This brain hormone is important in regulating the sleep-wake cycle.
• Less pain, possibly from reductions in levels of cortisol, a stress hormone
• A reduction in heart rate, blood pressure, adrenaline levels, and skin temperature while meditating

An important goal for both religious and therapeutic meditative practices is to quiet the mind, essentially to relax thought. This redirection of brain activity from thoughts and worries to the senses disrupts the stress response and prompts relaxation and renewed energy. A number of meditation techniques are available; some may be more or less useful for fibromyalgia.

• Fixed point meditation involves focuse on a stationary object, mental image (such as a candle flame), or internal sound (such as a mantra). When the mind begins to wander, the meditator gently brings concentration back to the central image or sound. This exercise promotes focus but it is often experienced as a thinking exercise. A popular variety of this type of meditation is known as transcendental meditation, or TM.
• Breath meditation. Other meditative forms involve focusing on the present moment and observing (but not attending to or judging) ones thoughts. During breath meditation, one sits upright with the spine straight with the eyes closed. The subject begins to breathe regularly and continues to observe the outward (exhalation) of the breath. As the mind wanders, one simply notes the thoughts as a fact and returns to the breath. A variant of this technique called mindfulness meditation has been helpful for fibromyalgia patients. It involves focusing on the present moment and letting thoughts pass without the accompanying breathing exercises.
• Mini-meditation. This method involves heightening awareness of the immediate surrounding environment. One should first choose a simple routine activity when alone. For example, while washing dishes concentrate on the feel of the water and dishes; allow the mind to wander to any immediate sensory experience, such as sounds outside the window, smells from the stove, or colors in the room. If the mind begins to think about the past or future, abstractions or worries, redirect it gently back.

People who try meditation for the first time should understand that it can be difficult to quiet the mind, and should not be discouraged by lack of immediate results. Some recommend meditating for no longer than 20 minutes in the morning after awakening and then again in early evening before dinner. Even once a day is helpful. (One should probably not meditate before going to bed, which causes some people to wake up in the middle of the night, alert and unable to return to sleep.)

Hypnosis. In one controlled study, hypnosis was more effective than physical therapy in improving function and reducing pain.

Massage Therapy. Massage therapy is thought to stimulate the parasympathetic nervous system, which slows down the heart and relaxes the body. In a 2002 study, patients who were given 30 minute sessions twice a week experienced lower stress and anxiety and less pain after 5 weeks compared to a group receiving an alternative therapy called transcutaneous electrical stimulation (TENS).

Alternative Treatments

Because of the difficulties in treating fibromyalgia, many patients seek alternative therapies. Everyone should be wary of those who promise a cure or urge the purchase of expensive but potentially dangerous treatments. Major analyses have indicated that mind-body therapies, such as biofeedback or hypnosis, are more effective than no treatment at all but less effective than moderate to intense exercise. In one analysis, evidence was weakest on the advantages of so-called manipulative ("hands-on") approaches such as massage and chiropractic treatments.

Acupuncture.  Studies continue to report conflicting results on acupuncture's ability to relieve pain. Several small studies suggest it offers some benefit, especially those who can not take medicines because of their side effects. However, a large controlled study published in the July 2005 Annals of Internal Medicine found that inserting needles at fibromyalgia-related pressure points was no better than randomly inserting needles ("sham acupuncture") at relieving pain for fibromyalgia.

Click the icon to see an image of acupuncture.

Chiropractic or Osteopathic Manipulation. Chiropractic or osteopathic manipulation may also help some patients. In one study 21 patients improved after 4 weeks of chiropractic spinal manipulation compared to those receiving only medications. It may be less effective in older patients with severe symptoms. Other studies have reported pain relief and improved sleep with osteopathic manipulation. Osteopathic techniques may include manipulation of the spine or muscle tissue release. It should be noted that there is always some very small risk for adverse effects from any of these techniques. (For example, in rare cases manipulation of the neck has been known to cause stroke or damage to the arteries.)

Hydrotherapy and Similar Treatments. Hydrotherapy, also called balneotherapy, involves soaking in water, such as hot tubs, pools, or baths to help relieve pain. In one 2002 study, hydrotherapy using a daily 20-minute bath reduced tender-point pain.

Herbal or Natural Remedies. Some alternative agents are being investigated for fibromyalgia:

• S-adenosylmethionine (SAMe) is a natural substance that has antidepressant, anti-inflammatory, and analgesic properties. It has shown some benefit in controlled studies.
• Melatonin, a natural hormone associated with the sleep-wake cycle, may have benefits for some patients with fibromyalgia.
• In one 2000 study, collagen hydrolysat, a food supplement, significantly decreased pain in fibromyalgia patients with accompanying temporomandibular joint problems.

It is extremely important for patients to realize that any herbal remedy or natural medicine that has positive effects most likely has negative side effects and toxic reactions, just as any conventional drug does. Everyone is strongly advised to consult a doctor before using any untested products or dietary supplements, and to discuss potential interactions with any medications being taken.

Behavioral Therapy

Studies continue to show that when fibromyalgia patients deal with the specific conditions of their disorder and their lives, they feel better. Cognitive-behavioral therapy (CBT) enhances a patients' belief in their own abilities and helps them develop methods for dealing with stressful situations. CBT is a known effective method for dealing with chronic pain from arthritic conditions. Some evidence also suggests that cognitive-behavioral therapy can help some patients with fibromyalgia. In one study, 25% of patients achieved long-lasting improvement.

The Goals of CBT. The primary goals of CBT (also called cognitive therapy) are to change any distorted perceptions and self-defeating behavoirs. Using specific tasks and self-observation, patients learn to think of pain as something other than a negative factor that dominates their life. Over time, the idea that they are helpless against the pain goes away and, instead, they learn that they can manage the pain.  

Cognitive therapy is particularly helpful in defining and setting limits -- a behavior that is extremely important for these patients. Many fibromyalgia patients live their lives in extremes. They first become heroes or martyrs, doggedly pushing themselves past the point of endurance until they collapse and withdraw. This inevitable backlash reverses their self-perception, and they then view themselves as complete failures, unable to cope with the simplest task. One important aim of cognitive therapy is to help such patients discover a middle route, whereby they can prioritize their responsibilities and drop some of the less important tasks or delegate them to others. Learning these coping skills can eventually lead to a more manageable life and to less of an absolutist perspective on themselves and others.

The Procedure. Cognitive therapy is usually of short duration, typically 6 to 20 sessions that last 1 hour. Patients are also given homework, which usually includes keeping a diary and attempting tasks that they have avoided because of negative attitudes.

A typical cognitive therapy program may involve the following measures:

• Keep a Diary. The patient is almost always asked to keep a diary, and it is usually a key component of cognitive therapy. The diary serves as a general guide for setting limits and planning activities. The patient uses the diary to track any stress factors, such as a job or a relationship that may be making the pain worse or better.
• Confront Negative or Discouraging Thoughts. Patients are taught to challenge and reverse negative beliefs ("e.g., I'm not good enough to control this disease, so I'm a total failure.") to using coping statements ("Where is the evidence that I can control this disease?").
• Set Limits. Limits are designed to keep both mental and physical stress within a manageable framework so that patients do not get discouraged by forcing themselves into situations in which they are likely to fail. For example, tasks are broken down into incremental steps, and patients focus on one at a time.
• Seek out Pleasurable Activities. List a number of enjoyable low-energy activities that can be conveniently scheduled.
• Prioritize. Patients learn to drop some of the less critical tasks or delegate them to others.
• Accept Relapses. Over-coping and accomplishing too much too soon can often cause a relapse of symptoms. Patients should respect these relapses and back off. They should not consider them a sign of treatment or self-failure.

Support Organizations and Group Therapy

Cognitive therapy may be expensive and not covered by insurance. Alternative and effective approaches that are free or less costly include strong, intelligently managed support groups or group psychotherapy. In one center, educational discussion groups were as effective, or even more so, than a cognitive therapy program. Such results cannot necessarily be applied to all centers, of course. Therapeutic success varies widely depending on the skill of the therapist.

Medications

To date, the FDA has not approved any drug for specific treatment of fibromyalgia. First-line drug therapy usually consists of an antidepressant or a muscle relaxant and is aimed at improving sleep and boosting pain tolerance. Medications from other drug classes (sleep agents, anti-convulsants, pain relievers) may also be prescribed. Drug therapy is administered in combination with exercise, patient education, and behavioral therapies.

Antidepressants

The main classes of antidepressants used for treating fibromyalgia are tricyclics, selective serotonin-reuptake inhibitors (SSRIs), and serotonin/norepinephrine reuptake inhibitors (SNRIs). Although these drugs are antidepressants, they are used to improve sleep and relieve pain in non-depressed patients with fibromyalgia. The dosages used for managing fibromyalgia are generally lower than dosages prescribed for treating depression. If a patient has depression in addition to fibromyalgia, then higher doses may be required.

Tricyclics. Tricyclic antidepressants cause drowsiness and can be helpful for improving sleep. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but which can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), and nortriptyline (Pamelor, Aventyl).

Generally only small doses are necessary for relief of fibromyalgia, so, although tricyclics have a number of side effects, they may occur less frequently in fibromyalgia patients than in those taking tricyclics for depression. Side effects most often reported include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty in urinating, disturbances in heart rhythm, drowsiness, and dizziness. Like all medications, tricyclics must be taken as directed; overdose can be life threatening.

Unfortunately, not all patients respond to tricyclics and their effects wear off in some patients, sometimes after only a month.

Selective Serotonin-Reuptake Inhibitors (SSRIs). Selective serotonin-reuptake inhibitors (SSRIs) increase serotonin levels in the brain, which may have specific benefits for fibromyalgia patients. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Studies suggest they may improve sleep, fatigue, and well-being in many patients. Studies are mixed on whether they improve pain. In any case, they do not have any significant effect on tender points. SSRIs should be taken in the morning, since they may cause insomnia. Common side effects are agitation, nausea, and sexual dysfunction, including delayed or loss of orgasm and low sexual drive.

Serotonin/Norepinephrine Reuptake Inhibitors (SNRIs). These drugs are also known as dual inhibitors because they act directly on two neurotransmitters---norepinephrine and serotonin.

• Duloxetine (Cymbalta) is gaining attention as a treatment for fibromyalgia. In a 2004 study, 207 patients with fibromyalgia were randomized to receive either duloxetine 60 mg twice a day or placebo for 12 weeks. Duloxetine significantly improved pain and tenderness and was effective for both depressed and non-depressed patients. Duloxetine was most effective for women, but very few men were enrolled in this trial.
• Venlafaxine (Effexor) is similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. As with the SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Although clinical trials have shown that the drug is safe and effective in most people, there have been reports of changes in blood pressure and heart conduction abnormalities, which may cause serious problems in elderly patients. Some patients report severe withdrawal symptoms, including dizziness and nausea.
• Milnacipran (Ixel) is under investigation and is not yet approved in the U.S. It is specifically being researched for helping people with fibromyalgia and similar pain syndromes. A Phase III trial evaluating its use as a potential treatment for fibromyalgia is underway. In a 2004 study of 125 patients, milnacipran improved fibromyalgia pain and other symptoms, including fatigue, sleep, and depression.

Muscle Relaxants

Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. Drowsiness is the most common side effect. Cyclobenzaprine is related to the tricyclic antidepressants and has similar side effects including dry mouth and dizziness. A 2004 review of five randomized controlled trials found that patients who received cyclobenzaprine were three times more likely to report improvement in fibromyalgia symptoms than patients who received placebo.

Sleep Medications

Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) and eszopiclone (Lunesta) may improve sleep for patients who suffer from insomnia.

Pain Relievers

Pain relief is of major concern for patients with fibromyalgia.

• Tramadol (Ultram), used alone or in combination with acetaminophen, is commonly prescribed for relief of fibromyalgia pain. Its most common side effects are drowsiness, dizziness, and constipation, and nausea. Tramadol should not be used in combination with tricyclic antidepressants.
• For relief of mild pain, acetaminophen (Tylenol) is most often recommended. Anti-inflammatory drugs, which are commonly used for arthritic conditions, are less useful for the pain of fibromyalgia, since the pain is not caused by muscle or joint inflammation. Such drugs include corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil), and others.
• Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers that has been helpful for relieving painful areas in other disorders. It may have some value for fibromyalgia patients.
• Opioids, or narcotics, may be used occasionally for certain patients with moderate to severe pain or significant functional impairment who cannot find relief with other, less potent treatments. Some may be given combinations of narcotic pain relievers and acetaminophen for periodic pain. Some physicians prescribe opioids such as oxycodone (Roxicodone) or morphine sulfate (Duramorph) for patients who require ongoing relief. However, the benefit of opioids for fibromyalgia management is highly controversial. Physicians should take a careful medical and psychological profile of the patient before prescribing opioids and periodically reevaluate the patient for continuing pain relief, side effects, and indications of dependence.
• Pramipexole, a drug used to treat Parkinson’s disease and restless legs syndrome, may help relieve pain and fatigue in people with fibromyalgia, according to a 2005 study published in Arthritis and Rheumatism. Pramipexole stimulates production of dopamine, a neurotransmitter in the brain. For the randomized controlled study, researchers compared pramipexole with a dummy pill (placebo). After three and a half months, 36% of those who took pramipexole said they felt much better, compared to 9% of those received a dummy pill. Overall, patients had a 50% or greater decrease in pain. 
• A small 2005 study conducted in Spain suggests that the atypical antipsychotic olanzapine (Zyprexa) may be a beneficial add-on therapy for patients with fibromyalgia. Although proven effective for some chronic pain conditions, olanzapine causes unpleasant side effects. Eleven of the 25 patients in the 2005 study dropped out due to weight gain.  

Anti-Seizure Agents (Anti-Convulsants)

Anti-seizure drugs, also called anti-epileptics or anticonvulsants, affect the neurotransmitter gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing. Studies have shown that gabapentin (Neurontin), an anti-seizure medication also approved for postherpetic neuralgia, affects pain transmission pathways and may relieve the pain associated with fibromyalgia. Phase II and III clinical trials are underway.

Pregabalin (Lyrica) is an anti-epileptic drug closely related to gabapentin. The FDA approved pregabalin in 2004 for treatment of nerve pain and diabetic peripheral neuropathy. It is currently in late-stage trials for treatment of fibromyalgia. A 2005 study of 529 patients with fibromyalgia reported that 450 mg/day of pregabalin reduced pain and improved sleep quality and fatigue symptoms. Dizziness and drowsiness were the most common side effects.

Other Investigative Drugs

Tropisetron. Tropisetron (Navoban) is a 5-HT3 receptor blocker used to reduce vomiting during chemotherapy. European studies are suggesting it may also help patients with fibromyalgia by reducing pain, dizziness, and depression and improving sleep. Fatigue and dizziness are the most common side effects.

Targeting Pressure Points and Stretching Techniques

Much of the pain experienced by patients occurs where muscles join tendons or bones, particularly when the muscles are stretched. Stretching or flexibility exercises are part of the warm-up and cool-down routines of any regular program. Stretching techniques may also employ injections or cooling agents to inactivate the pressure points so that muscles can be more effectively stretched. These techniques must be performed by a person other than the patient, usually a family member or close friend. With use of either injections or the spray, the benefits may last from a few days to weeks. Neither the spray nor the injection is useful without muscle stretching.

Spray and Stretch. One such technique is known as "spray and stretch." This method uses the following approach:

• The patient must be in a comfortable position.
• The partner presses on suspected tender points and the patient reports any pain.
• The points, when targeted, are sprayed with either ethyl chloride (Chloroethane) or Fluori-Methane. (These chemicals are not anesthetics. They cool the blood vessels in the skin to inactivate the tender points. Anesthetic skin creams do not appear to be effective for this treatment.)
• The spray bottle is held upside-down about 12 to 18 inches from the targeted area. (The patient's face should be covered if the spray is being used near the head.)
• The patient's partner then slowly stretches the affected muscle.

After the procedure, the muscle should feel looser, and the patient should have a greater range of motion with that muscle.

Trigger-Point Injections. In some cases, "trigger-point injections" of an anesthetic such as lidocaine may be used for particularly painful tender points as an aid to stretching.

• The injection causes intense, transient pain in the trigger point. After the medication has taken effect, however, the ability to stretch the muscle is greatly enhanced.
• There is some soreness afterward, which can be severe. After an injection, spraying the whole muscle with cooling agents may inactivate less severe tender points.
• In some cases, injections may be needed several times over 6  to 8 weeks.

Resources

• www.rheumatology.org -- American College of Rheumatology
• www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
• www.arthritis.org -- Arthritis Foundation
• www.fmaware.org -- National Fibromyalgia Foundation
• www.fmpartnership.org -- National Fibromyalgia Partnership
• www.fmnetnews.com -- Fibromyalgia Network
• www.aapainmanage.org -- American Academy of Pain Management
• www.ampainsoc.org -- American Pain Society
• www.medicalacupuncture.org -- American Association of Medical Acupuncture
• www.asch.net -- American Society of Clinical Hypnosis
• www.aabt.org -- Association for Advancement of Behavior Therapy
• www.clinicaltrials.gov -- Find a clinical trial

References

Gill JM, Quisel A. Fibromyalgia and Diffuse Myalgia. Clin Fam Pract. 2005; 7(2); 181-190.

Lemstra M, Olszynski WP. The effectiveness of multidisciplinary rehabilitation in the treatment of fibromyalgia: a randomized controlled trial. Clin J Pain. 2005; 21(2): 166-74.

Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol Suppl. 2005;32(10):2063

Zheng L, Faber K. Review of the Chinese medical approach to the management of fibromyalgia. Curr Pain Headache Rep.  2005;9(5): 307-12.

Assefi NP, Sherman KJ, Jacobsen C, Goldberg J, Smith WR, Buchwald D. A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. Ann Intern Med. 2005; 143(1): 10-9.

Harris RE, Tian X, Williams DA, et al. Treatment of fibromyalgia with formula acupuncture: investigation of needle placement, needle stimulation, and treatment frequency. J Altern Complement Med. 2005; 11(4): 663-71.

Holman AJ, Myers RR. A Randomized, Double-Blind, Placebo-Controlled Trial of Pramipexole, a Dopamine Agonist, in Patients With Fibromyaglia Receiving Concomitant Medications. Arthr Rheum. 2005; 52(8): 2495-2505.

Rico-Villademoros F, Hidalgo J, Dominguez I, García-Leiva JM, Calandre EP. Atypical antipsychotics in the treatment of fibromyalgia: a case series with olanzapine. Prog Neuropsychopharmacol Biol Psychiatry. 2005; 29(1): 161-4.

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