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Multiple approaches best treatment for Fibromyalgia
06-Jul-2007
S. VARMA
Norwich Bulletin
Many people suffer from the debilitating effects of fibromyalgia, which
involves chronic widespread muscular pain, fatigue and tenderness. Many
people with fibromyalgia also experience symptoms such as fatigue,
headaches, irritable bowel syndrome, irritable bladder, cognitive and
memory problems (called "fibro fog"), temporomandibular joint disorder,
pelvic pain, restless leg, sensitivity to noise and temperature,
anxiety and depression. It is second only to osteoarthritis in
frequency of visits to rheumatology clinics, and about 5 percent of
women and 0.5 percent of men in the United States will be affected. The
majority will be between 30 to 50 years old.
Although we still have much to learn about fibromyalgia, it is believed
patients with it experience pain amplification because of abnormal
sensory processing in the central nervous system. This is supported by
studies showing multiple physiological abnormalities in patients,
including increased levels of substance P in the spinal cord, low
levels of blood flow to the thalamus region of the brain and low levels
of serotonin.
It has also been suggested fibromyalgia might relate to an abnormality
in deep sleep. Abnormal brain waveforms have been found in deep sleep
in some patients. Tender points can be produced in normal volunteers by
depriving them of deep sleep for a few days. Recent studies show
genetics might also be a factor.
Here is some information on diagnosis and treatment from rheumatology.org and uptodate.com:
Diagnosis
Unfortunately, there are no "objective markers" -- evidence on X-rays,
blood tests or muscle biopsies -- for this condition, so patients have
to be diagnosed based on the symptoms they are experiencing.
The American College of Rheumatology has established general
classification guidelines for fibromyalgia. These guidelines require
widespread aching for at least three months and a minimum of 11 out of
18 tender points. However, not all physicians and researchers agree
with these guidelines. Some believe the criteria are too rigid and
fibromyalgia can be present even if the required number of tender
points is not met, while others question how reliable and valid tender
points are as a diagnostic tool.
Treatment
Fibromyalgia must be managed as a chronic condition, and should include
both medication and non-medication treatments for symptoms. Drug
therapy for fibromyalgia largely treats symptoms. Studies indicate the
best pharmacological approach for treating pain, and improving
disrupted sleep, is low doses of tricyclics including cyclobenzaprine
(Flexeril) and amitriptyline (Elavil). Positive results also have been
shown with dual reuptake inhibitors (Effexor), duloxetine (Cymbalta),
tramadol (Ultram) that work similarly.
Conversely, long-acting opioids are typically not recommended for the
treatment of fibromyalgia unless patients are resistant to other
therapies. This is not because of issues with dependence, but rather
because anecdotal evidence suggests these drugs are not of great
benefit to most people with fibromyalgia.
Anti-inflammatory medications will generally work if
the patients have associated arthritis. Recently, researchers studying
antiepileptics such as pregabalin (Lyrica) have found these drugs may
prove promising for fibromyalgia.
Other therapies
Complementary and alternative therapies can be useful
for pain, although these treatments have generally not been well
tested. Therapeutic massage to manipulate the muscles and soft tissues
of the body may alleviate pain, discomfort, muscle spasms and stress.
Similarly, myofascial release therapy, which works on a broader range
of muscles, can gently stretch, soften, lengthen and realign the
connective tissue to ease discomfort.
The bottom line is if you have fibromyalgia, a multi-modal approach to managing it is probably best.
Sandeep Varma, M.D., is a rheumatologist and medical
director of the Backus Arthritis Center at the Backus Outpatient Care
Center in Norwich. This column should not replace advice or instruction
from your personal physician. E-mail Varma and all of the Healthy
Living columnists at healthyliving@wwbh.org
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