Back to Information  
Fibromyalgia Syndrome
Geoff Littlejohn

Fibromyalgia syndrome is the most common cause of persisting aches and pains in our community. Understanding of this condition has increased significantly over the last decade and this has resulted in more appropriate and effective management strategies than we have in the past.

Background

One in five persons in the community will suffer from long-lasting [chronic] musculoskeletal pain occurring in a localised part of the body, say in the neck or back. One in ten persons suffer from long-lasting, persistent but widespread pain. Of this group many have fibromyalgia. The exact number affected with widespread pain in muscles and soft-tissue areas varies according to how one specifically defines the problem but it is generally considered that around 3-5% of the community have generalised fibromyalgia. The condition is more common in women than men, perhaps in a ratio of 6:1 and it increases as age increases. Yet even children and adolescents can develop significant fibromyalgia and the condition can come on at any time in life. Many have recurring episodes through their life. Fibromyalgia has been found in all races and countries where it has been sought out. Current understanding of fibromyalgia would indicate that the condition is a variation of normal bodily functioning, a disorder rather than a disease in the traditional sense.Top of Page

What is fibromyalgia?

Fibromyalgia is simply the name applied to a very characteristic, predictable and reproducible collection of symptoms and signs. The person complains of generalised aching and pain, usually accompanied by considerable stiffness in the muscles. This is more prominent after a period of inactivity, such as in the mornings, or after doing exercise. The other key symptom is fatigue. This may be quite profound and sometimes dominate the picture. In these instances the term chronic fatigue syndrome may be used. There is considerable overlap between fibromyalgia and chronic fatigue syndrome and many consider them to be variations on the one disorder.

The symptoms of fibromyalgia fluctuate over the day, being at their worst in the morning and evenings. Many use the mid-part of the day as a time to do important activities in order to avoid aggravating their discomfort. The symptoms also fluctuate over the weeks and months and years. There may be episodes of fibromyalgia lasting for some days or weeks and then it may settle, only to return some years later. Some have the condition every day. Typically the problem is made worse by changes in weather such as a temperature drop, a low-pressure system change or in humid weather. Excessive physical activity or mental strain will also tend to aggravate the symptoms. Stress of any type is a potent aggravating factor in the majority.

At times there may be more localised pain, say in the neck or the back or around a joint, but usually the pain is a generalised aching discomforting and debilitating pain. Sometimes a feeling described as “ being hit by a truck” is present on awakening in the mornings. Hands may feel puffy and the rings tighten or “pins and needles” or other unusual, discomforting sensations are felt in the hands. The neck might become stiff. The muscles and soft tissues might become quite tender and this might be noticeable when people touch you on the shoulder or give you a hug. Headaches can accompany these symptoms, usually a dull tight-feeling type of headache. Many people with fibromyalgia will have symptoms of irritability in their bowel with bloating or irregular bowel habits. Women may complain of premenstrual fluid retention.

Concentration is often poor. The brain sometimes just doesn’t seem to work properly being foggy with poor memory retention. Yet this is often in contrast to the sharp mind that one had before the whole problem began. The sleep may become disturbed and be of poor quality, often with shallowness and frequent wakening. The feeling of being unrefreshed in the morning is characteristic.

The symptoms of fibromyalgia may range from very mild and occasional to severe and persistent. Not everyone with fibromyalgia has the same degree of problem at any one time. The symptoms are always reversible – this is important to remember.

When the health care professional examines someone with fibromyalgia they may find tight muscles around the neck or the low back. A physical therapist may treat that area in order to “loosen things up”, hoping to solve the problem. This will often give temporary relief but unless the total picture of all contributing factors to the fibromyalgia disorder are addressed the symptoms will later return.

Further examination will show that there are areas where there is marked tenderness on very gentle pressure with the finger. The middle part of the trapezius muscle, the muscle that links the neck to the shoulder is a typical area where there is increased tenderness in fibromyalgia. This is just one of many areas which are abnormally tender in fibromyalgia and which health care professionals will know about when they conduct an examination in order to diagnose the condition. Abnormal tenderness indicates that the amount of pressure stimulation required to cause pain is less than usual. This means that the person’s pain threshold is lower than normal. This lowering of pain threshold is technically called allodynia and is a characteristic feature of fibromyalgia. The areas of greatly increased tenderness are for convenience simply called “tender points”.

The American College of Rheumatology, has devised criteria for classification of fibromyalgia and this involves finding at least 11 tender points out of a total of 18 which they have designated as being useful and important ones. The finding of widespread abnormal tenderness together with widespread pain has a high accuracy level for diagnosing fibromyalgia. However, fibromyalgia can occur with lesser numbers of tender points and a lot of variations do occur. Localised forms of the condition often affect just one part of the body, such as the neck and arm or the chest wall or the low back and buttock. These localised forms are the most common post-injury types of fibromyalgia and are often mistakenly treated as if the area continues to be damaged rather than the pain being due to increased sensitivity of the pain nerves that is the basis for fibromyalgia and needs different treatment than that for tissue damage.

Other clinical signs include the presence of dermatographia or the “red-reaction”. This is found on stroking the fingernail firmly over the upper back. In people without pain in the area there usually will be a small degree of redness noted soon after the fingernail pressure but in those with fibromyalgia this reaction is much more marked than normal. This reaction is due to release of chemicals from the over-active pain nerves that in turn make more blood flow into the skin, causing the “red-reaction”. As mentioned, the soft-tissues, especially muscle, are tenderer in fibromyalgia but the skin is also overly sensitive. Pinching a fold of skin between the finger and thumb of the upper back will induce pain in fibromyalgia – this is not usual in pain-free people. This indicates a widespread problem with increased pain sensitivity in many tissues because the cause of the sensitivity is not in the tender or painful tissues but rather in the nervous system itself.

Importantly, there are no clinical signs to suggest inflammation or degeneration in any of the tissues of the body that could explain the person’s pain complaint. Fibromyalgia is not due to an inflammation of the tissues, it is not due to degeneration in the spine or the muscles or other regions where the pain might be felt. Nor is there any other immediately obvious explanation. Blood tests are normal; x-rays show only what would be expected at that person’s age. Even though the muscles ache considerably, intensive investigations over the years have shown that the muscles are in fact structurally normal.Top of Page

What is the cause of fibromyalgia?

Fibromyalgia is basically a problem of overactivity in the pain system. Pain nerves are distributed throughout the body, more in some areas than in others. They are waiting to be stimulated and quite a large stimulus is needed to trigger them off. This is called high threshold. The pain system is ready to fire in order to warn us about potential threat to injuring our tissues from some outside source. If a high threshold stimulus is felt e.g. if a pin pierces the thumb, that message will be quickly sent to the spinal cord which then will automatically activate be sent to nerves controlling muscles in that region. This is a reflex just like the knee-jerk, when you tap the tendon just below the kneecap and you automatically jerk the leg upwards. The pain nerve input forms a reflex that induces the muscles to contract and the arm will pull away from the threatening pin.

At the same time, the message of pain quickly goes up to the brain where we feel the pain sensation and we can then determine the localised spot from where it came. We can then attend to dealing with the cause of the problem. When the pain message gets to the brain other input is put into the sensation of pain and this input comes from our previous experience with regard to pain, our emotions and our behaviours in regard to pain. As you well know we all react to pain in different ways. The localised component of pain is quite different to the emotional part of pain and yet both are part of the pain experience. It is for this reason that the World Health Organization classifies the definition of pain as being “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”.

Now back to fibromyalgia. As mentioned earlier the pain threshold is lowered in fibromyalgia and this means that the pain system is ready to fire at a much lower level than would otherwise be the case. Thus routine activity such as hanging out the washing, driving the car, making the beds or standing or sitting in the one position at work will induce pain and discomfort much more readily than would otherwise be the case. As the pain message is felt with normal postural activities then so is the message relayed to the muscles in the area. These muscles contract and tighten. This leads to stiffness around the area and particularly around the spinal region. Other reflex actions occur which give rise to some of the clinical signs that we’ve talked about earlier.

The cause for the lowered pain threshold seems to be an abnormality occurring in the way the pain system is modified or damped down. This is the critical link in the fibromyalgia puzzle that is being worked out at the moment. Many workers think that the cause for the change in sensitivity in the pain system is due to a change in one of the pain modifying chemicals that is present in our brains and nervous system.

Many of these chemicals come from the higher parts of the brain where emotion, mood and stress effects also act. These chemicals in turn react on other control systems that can change the sensitivity of our pain system. In addition other parts of our body’s “homoeostatic” [or control systems] can be altered and these might include changes in the hormonal system and immune system of our bodies. There are certainly changes in these systems that can be measured using current technology in patients with fibromyalgia. It is considered these changes are not the cause of the problem but are a result of the problem. But they may cause some of the non-pain symptoms of fibromyalgia, such as fatigue or dizziness.

Fibromyalgia may come on quickly, say after a frightening accident or may come on slowly and there may be no obvious cause seen. However, many times there is a stress event in the person’s life that might be near to the onset of the fibromyalgia. Sometimes the stress event goes completely but the fibromyalgia continues just as if the pain system has been set at a new level.

How to manage fibromyalgia

Currently there is no antidote to fibromyalgia – no medication that reverses the situation and thus we rely on other tactics to manage the problem.
Anyone with fibromyalgia, be it generalised and widespread or be it localised, needs to work out a management strategy to deal with the problem. As indicated above, the condition is not due to something wrong in the area where the pain is felt. This is merely the pain nerves being activated but without any local reason for this. Excessive physical therapies or investigations into a cause in the painful tissues do not help the problem. There is no need for ongoing scans, blood tests or seeking our numerous specialists to find the “magic answer” to the chronic pain problem. Fibromyalgia should be the end of the trail. The diagnosis of fibromyalgia should not be given if there is another explanation for the pain and naturally a certain number of tests will be required to eliminate that possibility if present. However, the diagnosis of fibromyalgia should be the start of a new management plan.Top of Page

A person with fibromyalgia should consider the following:

  • The condition is always potentially reversible.
  • Psychological factors are important in management. Managing everyday stresses, dealing with ongoing life problems and working out the best strategies for dealing with the pain problem are all necessary. This may just require readjustment in thinking and life strategies or may require the help of a professional who deals with this problem all the time. This might be a clinical psychologist, another health care professional or a doctor who deals with chronic pain. The catch-cry “learn to live with it” implies that the situation is hopeless and irreversible. This is not the case.
  • Strategies which include relaxation therapy, meditation and movement treatment such as Feldenkrais, yoga, tai chi, pilates and the like are all useful in dealing with the emotional and muscle tightness problems which accompany fibromyalgia.
  • If there is a lot of localised muscle tightness then some physical therapy may well be necessary but this should not be relied on as the only way to deal with the problem.
  • Exercise is extremely important and one should try to start moving the body even if it is painful. The pain of fibromyalgia does not mean that there is damage occurring in the painful area. A programme that encourages exercises, i.e. the establishment of an aerobic fitness programme, should follow physical therapy. One should not rush into this, as this will tend to cause some discomfort at first start. This can be best done under supervision of a health care professional or doctor. A person with fibromyalgia may take three-times longer than normal to achieve fitness but it is still achievable.
  • Simple analgesics, such as paracetamol/acetaminophen are preferred to any other medication
  • Low dose tricyclic medications are given in the evenings to help the sleep disturbance, fatigue and pain – around 40% of people gain benefit. If there is an associated mood disturbance such as depression then routine antidepressant medications may be needed. Medical advice helps in this regard.
  • The emphasis on management of fibromyalgia is self-management. When the condition is severe one usually requires input from a health care professional to get the right path set up. When the problem is mild the health care professionals have a minimal role. Perhaps a check of the diagnosis and then establishment of an appropriate programme might be all that is required.
  • Finally, it should be remembered that fibromyalgia is a problem of the pain system. This can occur in people with rheumatoid arthritis, osteoarthritis, disc troubles or other health problems. Or it can occur by itself. When it occurs along with other painful musculoskeletal diseases then the fibromyalgia may be mistakenly put down to that other condition. At all times discussion with a health-care professional will ensure that treatment approaches encompass both options.Top of Page

Summary

Fibromyalgia is a common everyday problem. Usually mild, self-limiting and not disabling, the condition can be managed by the person with the problem. When the pain is more severe and the person is more disabled then more professional input is required to help deal with the problem.

The above notes are a general guide to fibromyalgia based on the author’s opinion and specific approaches for individuals may at times differ from that contained in this information sheet. At all times advice from health-care practitioners, including your doctor, needs to be taken into consideration.

Top of Page Back to Information
All Rights Reserved ® 2003