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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. Fibromyalgia 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 fibromyalgia? 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 - which is usually about when it ends.

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.

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.