From the Archives of the Massachusetts Medical Society

(many thanks to Jeff Comeau for sending this along to me.)

Fibromyalgia, which has no known cause or cure, is both frustrating and
confusing for the three to six million Americans who struggle with this
chronic pain disorder. But in recent years, researchers have gained a better
understanding of the underlying problems that trigger fibromyalgia symptoms.

There's evidence that a combination of medication and non-drug approaches
such as exercise can help many patients feel better, according to an article
in the December 7, 1999 Annals of Internal Medicine.

Fibromyalgia isn't a disease per se, but rather a spectrum of symptoms that
can also include fatigue, stiffness upon waking, headaches, crampy abdominal
or pelvic pain and diarrhea, memory and concentration problems, and
dizziness. Fibromyalgia syndrome, or FMS, as it is also called, falls under
the rubric of rheumatology, which includes various conditions that affect
the joints or other parts of the musculoskeletal system.

According to the American College of Rheumatology's criteria for diagnosing
FMS, a person must have a history of chronic, widespread pain (on both sides
of the body as well as both above and below the waist) for at least three
months. The person must also report tenderness in 11 of the 18 tender point sites when a doctor presses on those points.

But many experts acknowledge that not everyone diagnosed with FMS will meet these exact criteria.

One aggravating aspect of the condition stems from a widespread perception
among the general public (including some health care providers) that fibromyalgia is a psychosomatic problem - the old "it's all in your head" argument. While it's true that people with FMS are often anxious and
depressed, most experts believe those feelings are the result rather than the cause of the problem. Although FMS can occur at any age, it usually shows up in midlife and is far more common in women.


Diagnostic Dilemma

There is no specific blood test, X-ray, or other high-tech image of the body
that clearly indicates a person has FMS. But compared with healthy people,
many people with the disorder have measurable differences in certain
substances in their bodies. For instance, they tend to have higher levels of
substance P, a chemical involved in pain transmission, and lower amounts of
serotonin, a brain chemical that's key to sleep, mood, and pain regulation.
People with FMS have also been shown to have abnormal brain waves during deep
sleep, when our bodies normally produce growth hormone. The level of growth
hormone, which is important for keeping muscles and other soft tissues
healthy, is also lower in some people with FMS.

But most experts believe that the primary problem in FMS is a
still-unresolved anomaly in how the body processes sensory information, says Daniel Clauw, MD, who directs the Chronic Pain and Fatigue Research Center at Georgetown University. "People with fibromyalgia aren't just sensitive to pain; they also find loud noises, odors, and bright lights aversive," he says. This hypersensitivity is probably due in part to genetic differences.

FMS and certain related health problems, including irritable bowel syndrome,
migraine headaches, and mood disorders, do tend to run in families.
But environmental influences such as stress also probably have an influence.

In fact, some - but not all - cases of FMS appear to be triggered by
mentally and physically traumatic events, such as a car accident or serious
infections (mononucleosis or influenza, for example). This may help explain
why people with FMS and related problems are more likely to have a history
of sexual abuse, domestic violence, and alcoholism, as some experts have
noted.

Finding the Right Doctor

Some primary care providers are familiar with FMS and know how to treat it,
though some refer their patients to rheumatologists to make sure the problem isn't lupus, arthritis, or polymyalgia rheumatica - conditions with symptoms that can overlap with FMS. Hypothyroidism can also mimic FMS; the same is also true for sleep apnea and hepatitis C infection, especially among men.

Sometimes, people with FMS have chronic low-grade fevers along with aches
and pains, so they're referred to infectious disease specialists. They may
also end up seeing neurologists, since FMS symptoms have been mistaken for
multiple sclerosis or even Parkinson's disease. While some people do well
with primary care physicians or rheumatology experts, those who don't
respond well to standard treatments often end up at specialized fibromyalgia
or chronic pain clinics, usually located in major academic hospitals in big
cities.

Treatment Strategies

When it comes to treatment, experts agree that a multifaceted approach, using a combination of drugs and non-drug treatments, is the way to go.
There aren't any specific drugs for treating FMS, but many different
medications have been tested, and studies of several new ones are under way.

The first step is treating sleep problems. One of the most commonly used
drugs is the antidepressant amitriptyline (Elavil), which also improves
sleep. But side effects such as weight gain, dry mouth, and daytime
sleepiness can be a problem. Other antidepressants for FMS include
venlafaxine (Effexor), trazodone (Desyrel), and fluoxetine (Prozac).
The tranquilizer alprazolam (Xanax) is another drug shown to be helpful in
FMS. Cyclobenzaprine (Flexeril), a drug that's mainly used as a muscle
relaxant, appears to both promote sleep and reduce pain.
To lessen the side effects of all drugs, the key is to start with a low dose
and increase it slowly, says David A. Nye, MD, a fibromyalgia specialist at
Midelfort Clinic in Eau Claire, Wisconsin. It often takes a lot of fiddling
to get it right, he adds.

Nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin) don't appear
to be very effective in fighting fibromyalgia pain, nor is prednisone or
other steroids. Some people find relief with injections of lidocaine, a drug
that temporarily numbs nerves, into the tender points. Another beneficial
drug is tramadol (Ultram), which seems to address both the altered brain
chemicals and pain signals of fibromyalgia. Pregabalin, an experimental drug
related to gabapentin (Neurontin), which is used for epilepsy and certain chronic pain conditions, will soon be tested in people with fibromyalgia and arthritis. Unlike other drugs for fibromyalgia that focus on serotonin, pregabalin targets pain pathways in the spinal cord-brain connection.

Alternative and Non-Drug Therapies

Many people with FMS turn to alternative therapies, according to the Annals
study. One popular supplement, 5-hydroxytryptophan (a precursor to
serotonin) showed minor benefits in one study, and several reports revealed
modest improvements in pain and depression with S-adenosyl-L-methionine
(SAM-e), a naturally occurring derivative of an amino acid found throughout
the body. While most doctors don't specifically recommend these supplements, many advise people who want to try them to experiment with one supplement at a time (keeping all other variables the same) to see which one, if any, helps them feel better. Exercise, which keeps muscles from weakening further, can be helpful.

Dr. Nye recommends starting with just three to five minutes of gentle aerobic exercise and stretching daily, gradually building to 20 to 30 minutes per day. Walking, swimming, and bicycling are good choices.

Other non-drug treatments include biofeedback, hypnotherapy, and cognitive
behavioral therapy, all of which focus on teaching strategies to help people
relax and achieve some degree of mental control over symptoms. Acupuncture is yet another option for treating pain; in fact, the National Institutes of Health lists FMS as one of the few conditions that acupuncture may help.

Finally, finding an empathetic health care provider and a support group -
both of which can offer a listening ear and advice on fine-tuning a
treatment strategy - can make a real difference in keeping FMS symptoms under control.

-The Editors
For more information: The Fibromyalgia Alliance
of America, 888-717-6711,
and the Fibromyalgia Network, 800-853-2929.