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Fibromyalgia

Fibromyalgia  is characterized by musculoskeletal pain and diffuse tender points. Frequently the patients have associated sleep disorder and fatigue. They also have some organ-specific manifestations that are functional in nature. Fibromialgia was eventually used over the older term, fibrositis because there really is no evidence of an inflammatory component. The triggering event is some sort of disruption of sleep which leads to poor rest at night, so you have non-restorative sleep which leads to fatigue, and also presumably the muscles also need to relax. If they don’t, there is muscle pain and that leads to lack of activity. Patients become de-conditioned and poor conditions maybe further begets pain and the pain then, as a sort of positive feedback cycle, disrupts the sleep. Whatever causes it, you get this vicious cycle of muscle pain, fatigue.

People have tried to look at various neurohormonal chemicals, such as insulin-like growth factor 1 was hot for awhile, substance P in the cerebral spinal fluid, serotonin is probably the thing that people latch onto most because we use drugs that affect CNS serotonin metabolism and they seem to help. So maybe there is something in that. Also there may be a predisposition. No genetic component has been found yet but I always wonder, do the patients have some sort of premorbid personality that maybe makes it more likely for them to develop fibromialgia? Unfortunately, every patient I ever asked says, "Oh, before I got sick I was fine, energetic, working hard." And often they are but I haven’t found anything very distinctive in just my cursory evaluation.

I still believe that something that disrupts the sleep can then lead to the symptoms of fibromyalgia. This was taken from the original studies by Moldofsky and this is normal non-REM sleep, or stage IV delta sleep. It’s the real deep sleep when you are almost comatose. I mean someone could kind of come in and remove a digit and you wouldn’t know. You can see it has these slow delta waves, rather large. This is fibromyalgia sleep pattern. This is what this gentleman found and you can see that there is the delta sleep, which is these larger waves, but you can see how it looks very choppy because there’s what they call alpha intrusion. There’s an alpha pattern superimposed on the delta pattern. The alpha pattern is what happens when you are awake. Presumably your brain is a little more active. If you take a healthy person and then give them some stimulus, try to wake them up, you can see what happens. You have the normal delta pattern and the all of a sudden you have this alpha intrusion. This is the fibromyalgia patient without any stimulus. It’s almost like they are not really sleeping. Again, this has not been able to be confirmed in further studies by other groups, whether it was how it was done or the patient selection, is not really clear. I think if you think of fibromyalgia with this diagram in mind it might help you a little bit when you see the patients. It’s not going to get you out of the office any quicker, believe me. Sometimes I see these patients and I think, "I could be having my spleen removed with a warm spoon instead of …" These patients are very trying. I’ll see three or four new fibromyalgia patients in a day, I come home and by 7 o’clock I’m in bed. I’ve had it. And I usually stay up until 12 or 1 o’clock reading, doing work, watching the football game.

But you can see that the central item is the stage IV sleep anomaly which most often, in my experience, you can’t find an identifiable cause but sometimes there are things that cause it. Someone who has muscle or joint pain, someone who has had some physical trauma. Emotional trauma obviously can cause it. Sleep apnea. But these aren’t the things that I usually see in my practice. In general practice you may see these things sometimes. I remember a case - it was one of my fellows’ patients - who had some upper airway obstruction, snored a lot and had some sleep apnea and he had secondary fibromyalgia. When he went to the sleep center they gave him this C-Pak at night and his fibromyalgia, over a period of a few weeks, cleared. So occasionally if you can find an underlying cause you may be able to treat the patient specifically.

As you can see, there is a large group of fibromyalgia patients and CFS is chronic fatigue syndrome, which I think are the same. The difference is that infectious disease people see a patient with what they call chronic fatigue syndrome. They are still looking for viral causes because that’s what they do. There is nothing. Take my word for it. Don’t get any viral titers on these patients. Most of the patients present with a long history of musculoskeletal symptoms. It’s not an infection. As far as I’m concerned, they are essentially the same. You can see that there are some patients with fibromyalgia who do not have a specific sleep disorder. You may not get it from their history, they may not even complain of fatigue, although it’s very very common. In conjunction with this you see a lot of organ specific things, like tension headaches, TMJ syndrome, non-cardiac chest pain, irritable bowel syndrome, paroxysmal limb movement disorder, multi-drug sensitivity - that’s a big one. Patient says, "I’m allergic to prednisone and Benadryl." How can you be allergic to that? I mean, they are allergic to everything. And when you ask them what the allergy is, "My arm swells up. I get a pimple on my …" they come up with these crazy manifestations that aren’t IgE mediated allergic reactions. And again, it makes it very difficult to treat these patients because you can’t use any drugs. They want you to really wave a magic wand over them and make them better. But these are some of the features that when you take a complete history you will pick these things up. I would say that better than half of the patients have irritable bowel syndrome. If you talk to gastroenterologists this is the most common thing gastroenterologists hear, irritable bowel syndrome. So I just think when you are taking a history of a patient you think may have fibromyalgia, if you pick up some of these things then it helps confirm your impression. Especially if they look pretty healthy and previous workup hasn’t shown much of anything.

Now the epidemiology of fibromyalgia is; this information is taken from one study center in Boston, which was a rather suburban-type office. My experience is much different because I don’t have suburban patients unless they are going to get in a car and drive to me. But it’s probably the most common rheumatic disease. It’s not necessarily the most common rheumatic disease seen in a rheumatologists office. Because a lot of these patients are certainly managed by non-rheumatologists and some of these patients never go to a doctor at all. They just manage their own symptoms, or just don’t complain about it that much. But a typical rheumatology practice can be 20% fibromyalgia and it’s not that a rheumatologist does any better than a non-rheumatologist, or a primary care physician, but I have primary care physicians, they have very busy practices, they are seeing 60, 80 patients a day. It’s like a factory and they don’t have time to sit and talk. It’s more cost effective, even if they have managed care, refer them to the rheumatologist for their ongoing care so they can go back to their job of seeing patients. It depends definitely on the type of practice that the primary care physician runs, but I’ve had some … sometimes I’ll see the patient and I’ll say, "Return as needed. Start these medications." I’ll write a letter explaining what to do. The patient is back in my office in a week and they have ten referral visits. Obviously that primary care physician does not want to see that patient on a regular interval. I can take a hint. You don't have to drop a hammer on me.

It’s a disease of younger people, although since it is chronic, it increases in prevalence as the population ages. Females definite predominance. I would say in my experience it’s like 98%. Very very common in females. Again, I think it may be as common in males but their symptoms are different or they just don't go to the doctor. Similar to coronary artery disease. Caucasians: now in this group I think 94% were Caucasian. In my experience, I see it very commonly in non-Caucasians, in blacks and Hispanics certainly. In Asians, I’m not sure. There is such a language barrier with the Asian patients that I often see that it’s hard for me to evaluate these more subjective type complaints. The patients often present with a long history of symptoms. I would say generally 2-5 years, at least.

They have a number of different symptoms. All the patients have musculoskeletal symptoms. Pain at multiple sites. They will often describe pain in the neck, the shoulder, the back, the elbows, the knees. Morning stiffness may be present. Pain all over. If you hear them say, "I have pain all over" that almost always is a patient with fibromyalgia. Other non-musculoskeletal findings, fatigue is very very common. These two things, when I see them together with musculoskeletal pain, for me that’s like the triad. There are occasionally patients who don’t have these things, I am less inclined to make the diagnosis. I like to have that there to make me more comfortable with the diagnosis. Paresthesia is very common, although you won’t find any specific findings of carpal tunnel or other entrapment neuropathies. These other associated symptoms; anxiety - I don’t know, everybody is a little anxious I guess - headaches, dysmenorrhea, all the other things that I showed you on that chart. Some of the patients do have sicca symptoms. Be careful though. A lot of the tricyclic and SSRI agents can cause dry mouth and dry eyes, so make sure it’s not due to the medication. And also, Raynaud’s phenomenon, which is obviously very common in women anyway, but people have tried to make a case for this being an autoimmune disease of which there is really no good evidence.

As far as we can tell, fibromyalgia is basically a multi-system functional disorder, whereas irritable bowel syndrome is a functional disorder of the bowels, fibromyalgia is just multiple areas. On examination, the examination should be very normal. The patient may have a depressed affect, may be anxious, may be very hopeful. They are holding that you are the last great salvation and the examination is otherwise benign except for these tender points. The joints have full range of motion. The patient may complain of pain. There is no synovitis, no skin rash, no nothing except for these tender points that are rather consistent. Patients with fibromyalgia will have the same tender points, so in that regard, to me it is something real. The patients are having pain, they are not making it up and it’s very consistent from patient to patient. These are the classic sites of the pain; occipital area, the cervical region, the parasternal area - second rib - the trapezius is probably the best one. Don’t squeeze too hard. If you push on your trapezius muscle hard enough anybody’s will be tender. It’s a rather sensitive muscle. But these patients, if you give just a little squeeze like you are massaging them, they’ll be uncomfortable. Around the scapula. The gluteal region. The trochanteric region, the buttocks, the anserine region of the knee. The elbow. But the patient can have pain anywhere, in their fingers and their toes. There is one area that the open circles are controlled. I would say that the forehead is a pretty good control. These patients won’t be tender there. And sometimes won’t be tender over the mid-thigh. But that is not as useful. The pain is really very variable. But in a given patient it is consistent.

One thing to note is that patients with fibromyalgia … there was a very good study done where they sort of did a population-based study looking at fibromyalgia - and they identified patients who had fibromyalgia but didn’t seek medical attention and these patients generally had much better adaptive skills and coping skills. The patients who sought medical attention with fibromyalgia had a lot of psychiatric overlay; depression, anxiety, poor coping skills, and the like.

When you do your laboratory evaluation, normal. If I’m seeing a patient for the first time, I will usually get a CBC, an ESR, an ANA and a TSH. The ANA is variable. If the exam is completely benign I am pretty sure they have fibromyalgia. I do want to rule out an underlying inflammatory disease, particularly spondyloarthropathies can sometimes be rather subtle and sometimes an elevated ESR will help you think of that. Also the TSH because hypothyroidism can present in a similar fashion; fatigue and muscle aches and pains. Although I’ve picked that up much more in other diseases than in a patient I thought had fibromyalgia. I don’t think I’ve ever seen hypothyroidism once. But it’s even common in the general population so I think it’s worth doing in a patient that has this cluster of symptoms.

If you find an abnormality, and you still think the patient has fibromyalgia, it’s not due to fibromyalgia. Or possibly you have the wrong diagnosis. The diagnostic criteria for fibromyalgia are really more for study purposes. When you are doing a study you want them to fulfill these criteria. I don’t go around and count 11 points. If I find 3 points and I get the history, especially if I get the list, that’s good enough for me. They have fibromyalgia. But these are the classic points and if you are going to include patients in a study you want 11 of these points. Obviously, some of them are bilateral and that’s why there’s not 18 listed. And of course, the history of widespread pain for three months.

Differential diagnosis includes connective tissue diseases, particularly lupus, also a disease of young women. So you have to think of lupus in your history. Hypothyroidism. In an older patient maybe polymyalgia rheumatica. Although these patients generally have a lot of systemic features. Maybe a low grade fever and often a rather abrupt onset. They don’t come in after five or six years of symptoms. Sometimes widespread OA, widespread tendonitis, bursitis, myofascial pain syndromes and psychogenic pain. Myofascial pain is a term that is commonly used by osteopaths and also physiatrists. I’m starting to use it because a lot of patients come with localized pain syndromes that is not going to show up on x-ray or anything, and it seems to be due to abnormalities of the muscles or the muscles and tendons in conjunction. There are some differences between myofascial pain, one is it is equal in males and females. It is usually regional, often above the diaphragm so the neck and shoulder are very common areas. Systemic features like fatigue are unusual. Sleep disturbance, if it occurs, is usually related to the fact that they have this pain and it’s hard for them to get comfortable. Treatment is usually myofascial therapy, spray and stretch, sometimes local injections of lidocaine are helpful, and the prognosis is generally good, as opposed to fibromyalgia where, if we could use a multidisciplinary approach I think that would be helpful. I think with managed care, and also some patients just don’t have the wherewithal to go and do different things, it’s not often practically useful. Of course in these patients there is chronic relapsing. Some patients with myofascial pain syndromes can go on to generalized and become fibromyalgia patients. What the link is, your guess is as good as mine.

Actually, in my practice, most of the patients with myofascial pain usually it’s low back. But I think in general, if you talk to physiatrists, orthopedists or primary care physicians, probably neck and shoulder is more common. But it can be in either location.

Psychogenic pain is something I do not see a lot of. I don’t know if it is just where I am located, or my patients. I’ve seen like one patient every year or so, which is fine with me. These are patients who really, for their own reasons, aren’t going to get better. They are actually … once you do your evaluation you should be pretty comfortable with the fact that these patients have psychogenic pain. Remember, in fibromyalgia patients, the pain and tender points are reproducible whereas with psychogenic pain it’s very variable, inconsistent, even sometimes you go back in the room five minutes later and you get a different history and physical. Fibromyalgia patients - I’ve made some jokes - but they are very cooperative patients. They are usually very appreciative patients, even though they are not getting better. So I don’t mind taking care of them. It’s just that in the long run I realize that I’m not doing a tremendous amount for them, from a medical standpoint. But if you ask them questions, they are trying to help you. They have a good cooperative approach to the therapy. You can make a good therapeutic relationship with these patients. With the patient with psychogenic pain, they are almost defying you. "You can’t make me better. Nah, nah, nah." That’s their attitude a lot of times. For some reason they require this pain to be part of their daily life and they are not going to get better. The fibromyalgia patients, even if they are depressed, their demeanor is appropriate for their level of symptoms. Whereas the psychogenic pain patient seems bizarre. You just hope they don’t bring a machine gun. They are very strange patients. When they talk about their pain they have a little smile. They are just very different from fibromyalgia patients. You should be able to differentiate them. It’s almost a waste of time for a non-psychiatrist to try and make these people better. I think they probably do pretty poorly even with psychotherapy. I just don’t think that this is a syndrome that we understand well enough to really help.

Prognosis: Most of the patients have symptoms for many years. There was a recent study where after ten years they looked at a group of fibromyalgia patients. Most of the patients had noted some improvement, although continuation of their symptoms. So whatever it is, the natural history, the treatment, the patients do get better over time in many instances. The longer a period of time the patients have symptoms, the less likely it is to go away. I think that’s true for almost any chronic pain. Severe symptoms that limit their activities; the patient who has quit work or stopped gardening, you’ve got a tough road ahead. Work disability due to fibromyalgia, another difficult situation. Fibromyalgia starting after a physical injury, particularly if they have a lawyer. I’m not saying that facetiously but there’s almost disincentive for them to get better. They can make money, and that’s what this country is about, making money. But these are patients that are not likely to do well no matter what you do.

We just try and treat the symptoms. The one thing you can do is make a firm diagnosis and don’t keep getting blood tests. "Oh, maybe it’s this." I’ve seen patients who have had thousands of dollars of weird endocrinologic and infectious disease titers and the patient is actually more anxious because they thought, "Hey, my doctor thinks something’s wrong. They keep ordering all these blood tests. Maybe I’m dying." You make your diagnosis and you stick with it. Obviously, if something changes - like the patient develops a big swelling in their abdomen - you would address it appropriately, but don’t keep looking for other connective tissue disease or underlying problem. Sometimes I do get lab tests if the patient that is on a treatment that might require some occasional monitoring. I think that helps to allay some anxiety. Obviously, patient education is important to explain what they have as best you can. Explain that not a lot is known about it, although it is very common and that it is treatment