What is fibromyalgia?
Fibromyalgia comes from the word "fibrosis" meaning formation of scar tissue. It is a chronic syndrome. It is commonly called as Fibromyalgia, or FMS. It is characterized by musculoskeletal pain, generalized fatigue and a feeling of being tired after sleeping.
Who get’s it?
The Average fibromyalgia patient profile comprises of :
Females are more prone than males. The occurance is 80-90% in females, and they develop it mostly during menopause.
Average age: approximately 40-45 years old.
Average time from onset to diagnosis: 5 to 8 years.
Family factors: A higher incidence among family members. It is not clear if genetic or psychological factors, or both are involved.
Juveniles with fibromyalgia shows subjective swelling, ankle pain and exacerbation by overactivity. Less frequently associated with low back pain, hand pain, and changes in symptoms associated with anxiety or weather.
Types
Broadly categorized as primary and secondary fibromyalgia.
Primary (idiopathic) fibromyalgia is more common. It is a dysfunctional disorder caused by a constellation of biologic responses to stress. It's a condition that causes pain and tenderness at specific body sites along with muscular stiffness, fatigue, and sleep disturbances.
Secondary fibromyalgia occurs as a result, or in conjuction with conditions such as Lupus, Arthritis, Multiple Sclerosis and many other chronic conditions.
Symptoms
Fibromyalgia has common and non-specific symptoms:
Pain is typically wide-spread or generalized.
Stiffness.
Fatigue.
Non-restorative sleep.
And less commonly encountered symptoms like anxiety disorders, irritable bowel syndrome, tension or migraine headaches, dysmenorrhea, irritable bladder and Raynaud’s syndrome.
Fibromyalgia patients generally note exacerbation in symptoms with some or all of the factors like cold, damp weather, stress and overexertion.
Causes
Causes of Primary or Idiopathic Fibromyalgia:
Chronic sleep disturbances: It is common in fibromyalgia. Sleep disturbances in both adult and young patients with a higher than average incidence of a sleep disorder. It is called as periodic limb movement disorder (PLMD). Disturbed sleep appears to trigger factors in the immune system that cause inflammation, pain, fatigue, and a decreased pain threshold.
Brain Chemical and Hormonal Abnormalities: The patients of fibromyalgia shows abnormalities in hormonal, metabolic, and brain chemical activity with alterations in some brain chemicals. Serotonin is an important neurotransmitter found in the brain, gut, and other areas. Serotonin abnormalities include depression, migraines, and irritable bowel syndrome. Lower levels have been noted in some patients with fibromyalgia.
Studies show abnormalities in 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 norepinephrine and cortisol, deficiencies produce impaired and weaker responses to psychological or physical stress.
Low levels of insulin-like growth factor-1 (IGF, also called somatomedin C), a hormone that promotes bone and muscle growth. Release of IGF, is controlled by growth hormone which is released by the brain during deep sleep. Low levels of growth hormone is associated with impaired thinking, lack of energy, muscle weakness, and intolerance to cold.
Research shows upto 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.
Fibromyalgia has some symptoms that resemble certain rheumatic illnesses, like rheumatoid arthritis and lupus (systemic lupus erythematosus). A defective immune system produces factors known as autoantibodies, which mistakenly attack proteins in the body's producing inflammation and damage. However there is little evidence to support a role for an inflammatory response in fibromyalgia.
Psychologic and social effects: These are the contributing factors which could make individuals susceptible to fibromyalgia. They may play some role in triggering or perpetuate the onset of the condition. Most often the abuse originated from family or partners. The post-traumatic stress disorder (PTSD) or chronic stress may play a strong role in the development of fibromyalgia in some patients.
Biochemical, structural or functional muscle abnormalities: One study reported that fibromyalgia patients had lower levels of the muscle-cell chemicals phosphocreatine and adenosine triphosphate (ATP). 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. The pain and stress of the disease itself may impair muscle function. The observed biochemical and structural defects could derive from defective signals in the brain, including hormones produced in the hypothalamus and pituitary that influence the production of stress hormones in the adrenal glands, which sit atop the kidneys. Defects in the hypothalamus-pituitary-adrenal gland (HPA) axis have been reported in fibromyalgia patients.
Causes of Seconday Fibromyalgia:
Secondary fibromyalgia has the characteristic symptoms of fibromyalgia but unlike primary fibromyalgia, a specific cause can be identified. Possible causes include the following:
Physical injury: Symptoms are similar to those of primary fibromyalgia. They are harder to treat.
Ankylosing spondylitis.
Surgery.
Lyme Disease: Some patients with Lyme disease subsequently developed fibromyalgia. They do not respond to the standard Lyme treatment consisting of antibiotics.
Hepatitis C: It may prove to be a trigger for some cases of fibromyalgia.
Endometriosis: According to a study, about 31% of women with the painful condition known as endometriosis go on to develop fibromyalgia or chronic fatigue syndrome, a related illness.
Silicone breast implants: womens are 2.8 times more likely to have fibromyalgia whose implants were made than those whose implants remained intact. It needs further follow-up study.
Diagnosis
The criteria used for studying fibromyalgia is very helpful, particularly if the patient does not have any accompanying disorder, such as depression or arthritis, that could complicate the diagnosis.
Failure to meet the criteria, however, does not rule out fibromyalgia. A psychological profile and a history of any might include recent weight change, physical injuries, infectious diseases, muscle weakness, rashes etc. The patient should report any drugs being taken, including vitamins and over-the-counter or herbal medications. Physical examination which includes the tender spots test must be conducted in case of fibromyalgia patient. The tender spots must be pressed firmly. They must be painful when pressed. 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. Scrutiny of nails, skin, mucous membranes, joints, spine, muscles, and bones should be done to help rule out arthritis, thyroid disease, and other disorders.
Other Tests
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.
Treatment
Medicine
Fibromyalgia (FM) is the most common of all rheumatic conditions. Allopathic medicine is only able to relieve the discomforts and pains with analgesic and antidepressant drug. Although antidepressants do not work for all fibromyalgia patients, antidepressants can also help relieve pain, fatigue, and insomnia.
Some doctors prescribe very low doses of an antidepressant such as amitriptyline (Elavil) or nortriptyline (Aventyl, Pamelor) for people with fibromyalgia. As these drugs can cause side effects including dry mouth, confusion, high or low blood pressure, heart palpitations, rashes, numbness, tingling, tremors, blood abnormalities, nausea, vomiting, diarrhoea, abdominal pain, and liver damage the dose prescribed is generally low.
Techniques for reducing stress and mind-body therapies are the most effective ways to treat fibromyalgia.
There are two main classes of antidepressants used for fibromyalgia.
The tricyclics and selective serotonin-reuptake inhibitors (SSRIs).
Tricyclics help relieve depression, reduce sleeplessness and muscle pain. 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. 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.
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.
Common side effects are agitation, nausea, and sexual dysfunction.
Trazodone (Desyrel) is an antidepressant that might be specifically helpful for fibromyalgia sufferers. Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. It is related to the tricyclic antidepressants and has similar side effects, the most common being dry mouth, drowsiness, and dizziness.
Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) may improve sleep with a lower risk for dependence than older sleeping drugs.
Because fibromyalgia may develop when a woman reaches menopause, some experts believe that estrogen replacement therapy may have special benefits for fibromyalgia patients. Women who take estrogen therapy seem to fall asleep faster, have longer periods of REM sleep, have fewer wakeful periods, and sleep longer than those not taking estrogen. Taking estrogen shortly before going to bed is most helpful.
Pain relief is of major concern for patients with fibromyalgia.
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.
Some physicians prescribe opioids such as oxycodone (Roxicodone) or morphine sulfate (Duramorph) for patients who require ongoing relief.
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.
Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has helped some people and was thought not to be addictive, although dependence and abuse have been reported. It can cause nausea.
The anesthetic lidocaine, which can offer pain relief when injected into tender muscle points during "trigger point injections", may also offer benefits when it is infused into the veins.
Other Drugs: Some treatments being tried for fibromyalgia are experimental and have potentially toxic side effects and interactions with other drugs.
Patients should inform their physicians of any other drugs, including so-called natural remedies, that they are taking. Tropisetron (Navoban) is an agent used to reduce vomiting during chemotherapy. Studies suggest it may also help patients with fibromyalgia, including reducing pain, dizziness, and depression and improving sleep. Gastrointestinal upset and headaches were the most common side effects.
Preliminary studies are reporting some improvement in morning stiffness and physical function when fibromyalgia patients take small doses of oral interferon-alpha, an agent used for chronic hepatitis.
Drug therapy consists of antidepressants and pain relievers and is aimed at improving sleep and relieving pain. Any ongoing drug regimen should be administered in combination with physical and cognitive behavioral therapies. 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 technique used for muscle relaxation and pain reduction in fibromyalgia, however, are different and employ injections or cooling agents to inactivate the pressure points so that muscles can be stretched.
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. Possible alternative treatments that may help include chiropractic therapy, hypnosis, or acupuncture.
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. Patients must begin all treatments with the attitude that they are trial and error. No physician, even an expert, has a clear treatment solution, because little significant research has been conducted on this disorder.
Alternative Medicine
Aromatherapy: Essential oils have a long history of treating pain, insomnia, headache, digestive and urinary tract symptoms, skin rash, anxiety and depression. Proposed causes that include dysfunction involving neuroendocrine / neurotransmitters, blood flow to the thalamus, levels of serotonin and tryptophan, certainly bring fibromyalgia into the territory where essential oils are known to operate.
Oils of Rosa mosqueta or jojoba can be used for massage. The effect of this formulation is to improve circulation and increase diuresis, hence diminishing irritability, memory and concentration lapses, and other common symptoms due to lack of oestrogens and progesterone that have a direct relationship with the onset of the menopause.
Soothing aromatherapy baths and massages can help to ease muscle and joint pain. Individual or combination of essential oils can be used. Basil, black pepper, elemi, eucalyptus, myrrh, peppermint, and pine. And juniper oil, rosemary oil, tea tree oil may also be used for massage.
Many essential oils help to reduce stress which is a major contributor of fibromyalgia. Elemi, frankincense, geranium, jasmine, lavender, myrrh, and neroli oils are also useful.
A growing number of health professionals consider essential oils to be medicine.
The oils of following can be used to treat some of the symptoms also benefitial in cases of fibromyalgia as discussed below:
Cypress (Cupressus sempervirens) oil is beneficial for decongesting the circulatory and lymphatic systems, and may help edema, cellulite, varicose veins, and water retention. It is anti-infectious, antibacterial, and antimicrobial.
Frankincense (Boswellia carterii) is anticatarrhal, prevents scarring, antitumoral, immune-stimulating, and antidepressant.
Helicrysum (Helichrysum italicum) oil regenerates tissue, reduces tissue pain and may help to improve skin conditions and circulatory function. It is anticoagulant, prevents phlebitis, helps regulate cholesterol, stimulates liver cell function, is ant catarrhal, mucolytic, expectorant, antispasmodic, and reduces scarring and discoloration.
Lemon Grass (Cymbopogon flexuosus) oil works well for purification. It may be beneficial for the digestive system, and has been reported to help regenerate connective tissue. It is a vasodilator, anti-inflammatory, sedative and supportive to the digestive system.
Ravensara aromatica has been shown to be useful for Fibromyalgia. Calophyllum inophyllum can be mixed with Ravensara aromatica and Petitgrain as a good external application.
Fibromyalgia may respond to gentle exercise, particularly walking and massage. Acupuncture or acupressure stimulation of tender points and trigger points can also be helpful.
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.
Collagen hydrolysat, a food supplement, significantly decreases pain in fibromyalgia patients. 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.
It is strongly advised to consult a physician before using any untested products or dietary supplements, and to discuss potential interactions with any medications being taken.
St. John's wort is an herb that has been used for centuries for medicinal purposes, including to treat depression. St. John's wort (Hypericum perforatum in Latin) is a long-living plant with yellow flowers. It contains many chemical compounds. Some are believed to be the active ingredients that produce the herb's effects, including the compounds hypericin and hyperforin. St. John's wort has been used for centuries to treat mental disorders as well as nerve pain. St. John's wort is used by some people to treat mild to moderate depression, anxiety, or sleep disorders.
Minerals like magnesium and Other natural supplements like Maleic acid, 5-HTP and the dietary guidelines can help patients suffering from fibromyalgia.
Include plenty of fluids in your diet, especially fresh vegetable and fruit juices. Food rich in saturated fats are harmful, so keep away from them as well as red meat, fatty food, tomatoes, vinegar, potatoes, green pepper and eggplant.
Light exercise and Yoga may be helpful.
Inhalation of any of the Firs, Pines, or Spruces is useful especially when mixed with Rosemary pyramidalis.
Studies indicate that exercise is effective in managing fibromyalgia, and patients must expect to undergo a long-term exercise program. The basic approach is called a graded exercise which begins with mild exercise and building over time. Patients who do not respond to one type of exercise might consider experimenting with other forms of physical activity. It should be noted that some patients are so disabled that they experience no benefits over time. Establish regular sleep routines, particularly since pain is aggrevated by disturbed sleep. Relaxation and stress-reduction techniques are proving to be helpful in managing chronic pain. Deep breathing exercises, muscle relaxation techniques, meditation, hypnosis, acupuncture and magnet therapy etc may also be tried.
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.
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.
Some studies then have suggested that a vegetarian diet may be helpful. Study shows that elimination of common food allergens (corn, wheat, dairy, citrus, soy, and nuts) from the diet help control fibromyalgia. Patients may try this elimination diet approach to see if it helps. The substances called excitotoxins stimulate neurotransmitters and in excess, may damage nerve cells. Better research is needed to confirm these findings, although there is no harm in eliminating the additives if patients include them in their diets.
Precautions: Any substance that can affect the body's chemistry can, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies or conventional medicine, more work in this area is needed (20, 36).
Conclusion
Because little significant research has been conducted on Fibromyalgia. Patients and doctors need to work together to make the best choices for individual symptoms and concerns. Since the symptoms of the disease vary from patient to patient, the treatment program should be suggested keeping in view the requirement of the patient.
Therapies are prolonged and in some cases life-long. No doubt, Fibromyalgia is a chronic medical problem that can be a daunting challenge for anyone who has it. Although along with the medical treatment, exercise stretching programs and support groups can be helpful. Its the need of an hour and a challenge for the medicine and alternative medicine professionals to come together and find solution to this problem.
Acknowledgement
The authors would like to show their gratitude to Dr Vipin Kumar (Chief Coordinator), Mr Dhaval Vyas (Coordinator, Validation and Value Addition to Indigenous Knowledge), Dr Deepak Acharya and colleagues at Natural Product Laboratory, SRISTI Ahmedabad, for their constant encouragement and support. We also wish to thank those associated with the inspirational suggestions made in this article.
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