Fibromyalgia: A Real Disease

August 26, 2016 / Thomas Cohn, MD

Fibromyalgia is a syndrome that causes diffuse pain throughout the body. Unfortunately, many practitioners still believe it is strictly a psychological disorder and many of the patients are faking symptoms. New research has now been finding objective changes that correlate to the symptoms in fibromyalgia. These findings however are not leading to tests to prove whether a person does or does not have the syndrome.

Diffuse whole body pain with muscle tenderness, abdominal complaints, headaches, fatigue, and sleep issues all are prominent characteristics of fibromyalgia. Currently, the diagnosis is made by history and exam of a patient, then by excluding other diseases such as diabetes, thyroid dysfunction and rheumatoid arthritis. The disease is much more common in females and first becomes symptomatic in the mid- to late-twenties but sometimes as late as the fifties to early sixties. The severity can be highly variable, from mild to disabling. Treatment is basically symptomatic at this time.

New Fibromyalgia Research

Dr. Anne Louise Oaklander of Massachusetts General Hospital studied 27 patients with fibromyalgia as diagnosed with the American College of Rheumatology criteria of the disease, and used a group of 30 matched control subjects. Skin biopsies were taken of the lower leg and 41% of the patients met the criteria of small fiber polyneuropathy. Her team also studied a group of 41 patients who had fibromyalgia begining as a juvenile, and 59% of those had small fiber polyneuropathy as diagnosed with a skin biopsy. Further study of these same patients indicate some of them appeared to have an immune component, like those with rheumatoid or lupus arthritis, and when treated similarly they improved in symptoms. Small fiber polyneuropathy is also seen in diabetes and vascular disease and is associated with the pain these patients experience. Unfortunately, the definitive test for this type of neuropathy is a biopsy (which is a removal of a small patch of skin) and microscopically examining it for nerve fiber endings, which is quite complex.

The importance of this study is that these findings indicate that there is real pathology behind fibromyalgia. It is not psychosomatic or imaginary. It also makes the disease more understandable. The small nerve fibers are those that carry pain sensations. If these fibers are abnormal, the result is pain. These fibers exist throughout the body, in the limbs one would have muscle pain, in the head one would get headaches, and in the trunk one might have stomach problems.

Small fiber neuropathy and peripheral neuropathy are currently best treated with medications that affect nerve cell function. The common medications, know as neuropathics, including gabapentin, Lyrica, Cymbalta, some other antidepressants, and a few miscellaneous medications are helpful. Opioids are very poor medications for this and help very little if at all. Fibromyalgia seems to respond in a similar way, and if it is a small fiber neuropathy, the same treatments would be beneficial.

Improving the understanding of the cause of fibromyalgia and the changes that exist in the body hopefully will lead to better treatment. Not all patients with fibromyalgia have these findings of small fiber neuropathy on biopsy. This syndrome may have different causes, and the treatment may vary due to these differences. Knowing that about half of the patients at least probably have small fiber neuropathy allows physicians to focus treatments that are effective for these problems. Further, the youngest patients with fibromyalgia commonly have immune system dysfunction and treatment for these disorders has also been showing promise. Fibromyalgia is slowly moving from a “psychological” problem to an objective medical syndrome with definitive findings.

Exercises Can Alleviate Fibromyalgia Pain

May 20, 2015 / Thomas Cohn, MD

Research out of Spain confirmed the belief that exercise and physical fitness can help relieve symptoms due to chronic pain and fibromyalgia.

To conduct their experiment, researchers asked participants to refrain from using pain medications for at least 24 hours, then they measured their pain levels using a number of different scales, including the Visual Analog Scale (VAS), the Pain Catastrophizing Scale (PCS) and the Chronic Pain Self-Efficacy Scale. After pain was measured, researchers surveyed patients about their exercise habits. Although the findings don’t prove causation, researchers uncovered:

Patients with higher physical activity exhibited lower levels of pain.

Those who exercised more had a lower psychological overreaction to pain.

Fitness appeared to decrease negative thoughts about chronic pain.

“These results might have implications for future intervention studies in this population,” the investigators wrote in Arthritis Care and Research. “In general, there was a linear (dose-response) relationship so that higher levels of fitness were associated with lower levels of pain and catastrophizing and higher self-efficacy.”

The team concluded that fitness helped improve overall agility, flexibility and mobility. They believe strength conditioning can help increase pain tolerance, while aerobic exercises can help a person with some of the mental aspects of chronic pain and fibromyalgia.

“Our exploratory analyses suggest that muscle strength and flexibility could be the fitness components most strongly associated with pain levels, while aerobic fitness and flexibility could be the fitness components most strongly associated with the psychological experience (i.e. catastrophizing and self-efficacy) of pain,” wrote the authors.

Dr. Cohn Comments

The benefits of exercise for chronic pain have been well documented, so it should come as no surprise that regular exercise can help alleviate problems associated with fibromyalgia.

I’ve even written about how exercise has helped me control my pain condition. If you’re suffering from chronic pain, try to squeeze in some regular exercise. Even 15 minutes of walking can do wonders for your mind and body. If some exercises are too trying, try to find an activity that works for your condition. Whether it’s running, walking or swimming find an activity that works for you!

Fibromyalgia Pain Treatment Options

October 2, 2013November 17, 2015 / Thomas Cohn, MD

Fibromyalgia is a painful condition in which the body hurts all over. It is more common in women, and often comes with other problems such as:

Stomach acid issues
Irritable bowels
Sleep issues
Depression
Headaches

Treatment is aimed at managing the symptoms and understanding the disease. Fibromyalgia treatment begins with making an accurate diagnosis, and educating the patient on the best treatment options.

A Team Approach to Treatment

The most effective approach to treatment is attacking the condition with a team of medical professionals consisting of:

Nurses
Physical therapists
A Psychologist
A Physical Medicine Doctor

A multi-disciplinary approach is helpful to shift the patient away from a perception of helplessness, defeat, and frustration and toward a positive and active lifestyle. Psychology is beneficial in changing attitudes from defeat and depression to understanding and self-motivation. Psychologists use a variety of techniques including cognitive behavioral therapy and biofeedback to influence changes. Physical therapy is necessary to teach the patient to go from being inactive, to exercising. Nursing is helpful to work with sleep problems, diet, nutrition, and understanding lifestyle and medication issues.

Medications & their Effectiveness

Pharmacologic strategies include prescription and non-prescription medications. There are three drugs approved for Fibromyalgia, and many others that have limited affects. The most commonly used drugs that are approved are Cymbalta and Lyrica. They both decrease the sensitivity of the nervous system to excessive signals that influence pain. Amitriptyline and Nortriptyline at low doses also have similar affects and are helpful with sleep. Narcotics and anti-inflammatory medications are not effective in management and usually lead to more problems than solutions.

Nonprescription medications have varied success rates and the research is not solid to support their effectiveness. S-adenosine-L-methionine(SAM-e) has been used for joint pain and general pain, and is commonly used in Europe. Tryptophan and melatonin may improve sleep and help with mood. Fish oil is felt to help with joint and spine pain, and may help control cholesterol levels. Glucosamine and chondroitin sulfate have been used to help control joint pain. These supplements are generally felt to be safe. Whether they are going to be helpful is open to question but they should not cause problems.

Fibromyalgia is best treated by a knowledge team of practitioners, headed by an experienced Physical Medicine pain physician. The goal of treatment is to improve function and activity level, and manage pain symptoms. Education and psychological well-being are important. Fibromyalgia is a real syndrome, when treated appropriately can be successfully managed.

Fibromyalgia: Symptoms & Pain Management Options

August 26, 2013September 27, 2016 / Thomas Cohn, MD

Fibromyalgia is a disorder characterized by diffuse musculoskeletal pain throughout the whole body. It is often accompanied by sleep issues, jaw pain, headaches, stomach problems, and depression. There is no special test, blood work, nerve or muscle test, or X-ray that confirms the diagnosis. Rather, diagnosis of Fibromyalgia is based on a patient’s history, medical exam, and the exclusion of other diseases that may cause similar problems.

Symptoms of Fibromyalgia

There are 2 core symptoms of fibromyalgia:

Diffuse muscle pain
Fatigue

With diffuse muscle pain even a light touch of the skin produces pain. Typical locations of muscle pain include all four extremities, head and trunk. Muscle pain often interferes with sleep, and contributes to fatigue and depression. This constellation of problems is thought to be driven by an over-active nervous system, which is hypersensitive to sensory inputs.

Treatment Options

Treatment of fibromyalgia is aimed at minimizing symptoms and maximizing function. People with fibromyalgia often greatly diminish activity and withdraw from normal interactions. A comprehensive strategy that teaches a person to understand the physical and mental aspects of the disease is often helpful. A multidisciplinary team that includes medical management, lifestyle, psychology, and physical therapy is one of the most effective strategies. Physical Medicine based pain clinics often coordinate such programs.

Medication Management

Medication management of fibromyalgia is aimed at modifying symptoms. There are 3 drugs now approved specifically for fibromyalgia. All these medications are considered neuropathics. They reduce the sensitivity of the nervous system so that stimuli are not perceived as intensely. Analgesics can be helpful when used judiciously, especially acetaminophen, anti-inflammatories, and occasionally tramadol. Symptom treatment for depression, and sleep management is also extremely important.

Fibromyalgia is a disorder that affects the whole body and every aspect of daily function. At this time, there is not a known cause and no definitive cure. Management of symptoms is the key to treatment. An experienced pain physician with a multidisciplinary team will often lead to the most beneficial personalized treatment strategy.