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Fibromyalgia: A Truly Mysterious Disease

Online Course #9223 - 5 Contact Hours

Author: Maryann Leslie, PhD, RN, CNP, CHES
Excerpts: Shelda L. Shank, RN, BSN, PHN
©2008 National Center of Continuing Education, Inc.

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Instructional Objectives:

Upon completion of this material,the dedicated learner will:

1. Identify the prevalence, gender, and age demographics of fibromyalgia in the general population.
2. Outline the American College of Rheumatology criteria for the classification and diagnosis of the patient with fibromyalgia.
3. List clinical features of fibromyalgia.
4. Define widespread pain as it occurs in the patient with fibromyalgia.
5. State the specific locations identified in the different areas of the body that are tender in the patient with fibromyalgia.
6. Recall emphasis areas to be included in the health history and physical examination of the patient with fibromyalgia.
7. Differentiate between the terms trigger point and tender point.
8. Name other medical conditions that should be included in the differential diagnosis of the patient with fibromyalgia.
9. Summarize the etiological factors proposed in an attempt to explain the clinical findings in fibromyalgia.
10. Identify management strategies for the patient, family and/or significant others in fibromyalgia.
11. Clarify the purposes of drug therapy in the management of the patient with fibromyalgia.
12. Explain the frequency, intensity, and duration of exercise recommended for the patient with fibromyalgia.
13. Describe the effects of physical therapy modalities used in the management of the patient with fibromyalgia
14. Identify terms used to describe fibromyalgia.
15. Name several complementary/alternative therapies that are effective in alleviating fibromyalgia symptoms.

Introduction

Fibromyalgia syndrome is a common chronic musculoskeletal pain syndrome that has been associated with characteristic symptoms such as widespread musculoskeletal pain, the presence of multiple tender points, stiffness, fatigue and sleep disturbances. The word fibromyalgia comes from the Latin term for fibrous tissue (fibro) and the Greek ones for muscle (myo) and pain (algia).
Although fibromyalgia is often considered an arthritis-related condition, it is not truly a form of arthritis (a disease of the joints) because it does not cause inflammation or damage to the joints, muscles, or other tissues. Also like arthritis, fibromyalgia is considered a rheumatic condition.
What exactly does rheumatic mean? Even physicians do not always agree on whether a disease is considered rheumatic. If you look up the word in the dictionary, you’ll find it comes from the Greek word rheum, which means flux—not an explanation that gives you a better understanding. In medicine, however, the term rheumatic means a medical condition that impairs the joints and/or soft tissues and causes chronic pain.
Considerable research has been conducted in the last few decades to delineate the epidemiology, pathophysiology and genesis of this condition. Despite these research efforts, the exact cause of fibromyalgia has yet to be completely defined, and it remains a source of significant controversy among researchers and of confusion among patients.
The majority of patients with fibromyalgia seek assistance from a variety of health care professionals and endure symptoms for several years before receiving an appropriate diagnosis. This is usually experienced as a difficult period for many patients. However, once a diagnosis is established, a practical management plan can be formulated with the patient. The management of fibromyalgia requires a multi-disciplinary approach. It is essential that healthcare professionals possess an understanding of the prevalence of fibromyalgia in the population, the clinical spectrum of the condition, diagnostic criteria, and management strategies.

Evolution of the Concept of Fibromyalgia

One of the major difficulties in the evolution of fibromyalgia has been the use of conflicting and obscure terminology to describe the condition and its clinical findings. For example, prior to 1976, several terms were used to describe the condition. The term fibrositis was introduced during the early 1900’s. It was initially hypothesized that the soft tissues of the patient were inflamed and that the inflammation was the result of some systemic disease process, similar in nature to arthritis. However, researchers have failed to identify any evidence of inflammation in soft tissue. The term psychogenic rheumatism was also employed to describe the condition. Yet, there was no evidence to support the notion that fibromyalgia was a form of hysteria or a psychiatric disturbance. In 1976, the term fibromyalgia was introduced. Currently, fibromyalgia is recognized as a common clinical pain disorder in which a reproducible physical finding, multiple tender points, is associated with characteristic symptoms.
Another area of confusion in the literature has been the haphazard use of the terms tender point and trigger point. Tender points are specific anatomic sites of excessive tenderness that cause pain upon palpation. Fibromyalgia is identified by the presence of multiple tender points, as opposed to trigger points, which have been identified in patients with other soft tissue rheumatism.
Prior to 1986, the diagnosis of fibromyalgia was exclusionary and based primarily on subjective data. In 1986, several researchers from centers in the United States and Canada began a study to provide a consensus definition of fibromyalgia, and to establish new criteria for the classification of the condition. This effort resulted in the eventual publication of criteria for the classification of fibromyalgia by the American College of Rheumatology in 1990. (See Table 1)

The criteria have enabled health care professionals to more easily establish a diagnosis for patients and have provided a clear characterization of the condition. According to the criteria, fibromyalgia can be diagnosed by a history of widespread musculoskeletal pain occurring for longer than 3 months in combination with tenderness at 11 or more of the tender point sites (See Table 2).

The pathogenesis of fibromyalgia remains to be more clearly defined, and researchers have recently postulated that it may be a member of a spectrum of certain disorders that cannot be neatly classified. These disorders include tension and migraine headaches, affective disorders, irritable bowel syndrome, chronic fatigue syndrome, temporomandibular joint syndrome (TMJ) and dysmenorrhea, among others. These disorders share many clinical features and respond to similar medications. Researchers continue to search for a common bio-psychological mechanism.

Prevalence of Fibromyalgia

According to a paper published by the American College of Rheumatology (ACR), fibromyalgia affects 3 to 6 million — or as many as one in 50 — Americans. For unknown reasons, between 80 and 90 percent of those diagnosed with fibromyalgia are women; however, men and children also can be affected. Most people are diagnosed during middle age, although the symptoms often become present earlier in life.
People with certain rheumatic diseases, such as rheumatoid arthritis, systemic lupus erythematosus (commonly called lupus), or ankylosing spondylitis (spinal arthritis) may be more likely to have fibromyalgia, too.
It ranks second to osteoarthritis as the most common problem seen by rheumatologists in the United States. Approximately 80% to 90% of patients with fibromyalgia are women. The most common age group is 40 to 50 years, although fibromyalgia may occur at any age. It is probably common in all racial and ethnic groups but reliable data pertaining to racial and ethnic predisposition are lacking.

What Causes Fibromyalgia?

The causes of fibromyalgia are unknown, but there are probably a number of factors involved. Many people associate the development of fibromyalgia with a physically or emotionally stressful or traumatic event, such as an automobile accident. Some connect it to repetitive injuries. Others link it to an illness. People with rheumatoid arthritis and other autoimmune diseases, such as lupus, are particularly likely to develop fibromyalgia. For others, fibromyalgia seems to occur spontaneously.
Many researchers are examining other causes, including problems with how the central nervous system (the brain and spinal cord) processes pain.
Some scientists speculate that a person’s genes may regulate the way his or her body processes painful stimuli. According to this theory, people with fibromyalgia may have a gene or genes that cause them to react strongly to stimuli that most people would not perceive as painful. However, those genes—if they, in fact, exist—have not been identified.

Clinical Features of Fibromyalgia

In 1990, the American College of Rheumatology (ACR) established criteria for the classification and diagnosis of the patient with fibromyalgia. The criteria have not only enabled health care professionals to more efficiently diagnose patients in a clinical setting, but have provided researchers with a means to identify patients for research purposes. The clinical features of fibromyalgia consist of core features, characteristic features, and several associated features that co-exist or occur concomitantly with the condition (See Table 3).

According to the diagnostic criteria set forth by the ACR, all patients with fibromyalgia exhibit the core features. The characteristic features are present in approximately 60% to 80% of patients with fibromyalgia, and the associated features are present in approximately 25% of patients.
Several studies indicate that women who have a family member with fibromyalgia are more likely to have fibromyalgia themselves, but the exact reason for this — whether it be hereditary or caused by environmental factors or both — is unknown. One study supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is trying to identify if certain genes predispose some people to fibromyalgia.

Core Features

The core features are essential to establishing a diagnosis of fibromyalgia. Widespread musculoskeletal pains along with multiple tender points constitute the core features. Widespread pain is defined as pain that occurs in the axial skeleton (cervical, thoracic or lumbar vertebrae, or anterior chest region), above and below the waist, and on the right and left side of the body. It is one of the most important symptoms from a diagnostic and clinical standpoint. Widespread pain is the most common reason patients seek consultation with a physician.
The pain may occur in one or two regions initially such as the neck or back, and may then spread to several regions. It is usually described as a burning, soreness, aching, or gnawing. However, the patient may use a large number of words in describing the painful experiences. The pain usually arises from muscles, joints, or tendons. It may eventually progress in intensity, severity, or constancy and become disabling and chronic over time. The timing of the pain may vary from patient to patient. For some patients, the pain is worse at the beginning and end of the day. For others, the pain is worse after performing various activities. The pain is often aggravated by cold or damp weather, non-restful sleep, anxiety, stress, infection, and the presence of other arthritic conditions. Trauma, either physical or emotional, may serve as a precipitating factor.
Tender points constitute the second core feature of fibromyalgia. Tender points are specific locations that have been identified in 18 different areas of the body where muscles attach to ligaments or bones and cause pain upon palpation. These tender points comprise a series of nine paired, anatomically discrete sites. More recently, studies have shown that the pain in fibromyalgia is not localized to tender points, and that the patient may have a lower threshold for pain anywhere on the body, not just in tender points.

Characteristic Features

The characteristic features of fibromyalgia include fatigue, musculoskeletal stiffness and non-restorative sleep, and appear in more than 60% of patients. Fatigue is the most common of the characteristic features and the most disabling symptom. It is a global feeling of exhaustion that leaves the patient feeling drained or spent. The patient frequently complains of always being tired or of having decreased endurance while performing routine daily activities. For example, the patient may complain of generalized fatigue after climbing up and down a flight of stairs or completing simple household tasks. The fatigue is especially disconcerting because the patient is often forced to cut back or eliminate activities that have been necessary to function in a particular role. Gradually, the patient may become sedentary and deconditioned.
Musculoskeletal stiffness is another characteristic feature that may be seen in fibromyalgia. It is usually worse in the morning. Researchers have shown that the sites of pain and of stiffness are strongly correlated. The average duration of morning stiffness has been estimated to be 110 minutes.
Sleep disturbances are common characteristic features. Non-restful or non-restorative sleep is said to occur when the patient awakens in the morning feeling fatigued. Trouble staying asleep, sleep apnea, nocturnal myoclonus and restless legs syndrome may also occur in the patient with fibromyalgia. Nocturnal myoclonus is a condition characterized by marked muscle contractions resulting in jerking of one or both legs. The jerking lasts for approximately 30 seconds, is often pronounced and may awaken the patient. In addition, the patient’s sleeping partner may complain of being kicked at night. Restless leg syndrome occurs during the waking state and is characterized by discomfort in the legs when they are immobile or when the patient lies down for more than 15 to 20 seconds. It involves an urge to move the body, particularly the legs, and is relieved by walking. These symptoms may prevent the patient from falling asleep or from falling back to sleep when awakened during the night.

Sleep Disturbances in Fibromyalgia - Nonrestorative or nonrefreshing sleep - Trouble staying asleep - Sleep apnea - Nocturnal myoclonus - Restless legs syndrome

Associated Features

There are several associated features of fibromyalgia. Some of the most common associated features are neurological symptoms, genitourinary symptoms, allergic symptoms, visceral symptoms and affective disorders. Among these, the neurological symptoms occur most frequently. Neurological symptoms include numbness or tingling, or a pins-and-needles sensation of the extremities; chronic headaches; and ocular, auditory and vestibular disorders. Genitourinary symptoms include dysmenorrhea, urinary frequency and urgency, and painful intercourse. In addition, the patient may display a wide array of allergic symptoms ranging from sensitivities to drugs and environmental stimuli to nasal congestion, rhinitis, and lower respiratory symptoms. Disorders of visceral organs including non-cardiac chest pain, heartburn, palpitations, mitral valve prolapse and irritable bowel syndrome, have been known to occur. Dysautonomia of the central nervous system is a likely explanation for much of the symptomatology.
Anxiety and depression are common in fibromyalgia. There is considerable controversy regarding the relationship between fibromyalgia and psychiatric disorders. However, most patients with fibromyalgia do not have an active psychiatric illness. Fibromyalgia is known to occur in association with several other medical conditions such as rheumatoid arthritis, Sjögren’s syndrome, osteoarthritis, systemic lupus erythematosus, hypothyroidism, irritable bowel syndrome and carpal tunnel syndrome. Fibromyalgia may not only precede Lyme disease but may be viewed as a post-Lyme disease syndrome. Misdiagnosis of patients with fibromyalgia as suffering from Lyme disease is not uncommon. It is important to note that there has been no clear clinical relationship established between fibromyalgia and these underlying conditions.

Diagnosis of Fibromyalgia

Research shows that people with fibromyalgia typically see many doctors before receiving the diagnosis. One reason for this may be that pain and fatigue, the main symptoms of fibromyalgia, overlap with many other conditions. A complete health history and physical examination remain the cornerstones of evaluating the patient. In most cases, there is some disruption in the patient’s quality of life. It is important to emphasize that the patient is in pain, worried about the future, and wants an explanation for the symptoms. It is not uncommon for the patient to have been referred from one specialist to another without getting any information. It is extremely important that the health history emphasize the following areas: activities of daily living, sleep habits, physical activity patterns, satisfaction with relationships and roles, and the strategies used by the patient to cope with symptoms. The physical exam may be negative in the patient with fibromyalgia. Low frequency sensorineural hearing loss has been reported. Although the patient may complain of fatigue and stiffness, muscle weakness is usually absent and there is usually no evidence of joint swelling, periarticular wasting or limitation of movement. It is possible that the musculoskeletal and neurological exams may be entirely normal.
The finding of multiple tender points is essential to diagnosis. However, researchers have indicated that a diagnosis of fibromyalgia syndrome should not be categorically ruled out if a patient exhibits fewer than 11 tender points. All of the clinical findings should be taken into consideration when attempting to establish a diagnosis. Tender points should not be confused with trigger points. Although these two terms have been used interchangeably throughout the literature, they refer to two separate and distinct anatomical entities. Trigger points are nodular, hyperirritable spots located deep within a taut band of skeletal muscle. They are painful upon compression and give rise to referred pain and autonomic -phenomena such as lacrimation, sweating or “goose bumps.” The formation of trigger points usually relates to some form of damage to muscle cells or from microtrauma that occurs from repetitive muscular tension. Trigger points are often found in muscles that lie within referred pain zones of inflamed joints or near inflamed nerve roots. The most commonly involved muscles are those involved in maintaining posture. In contrast, the etiology of tender points is unknown and there is no associated nodule or taut band of skeletal muscle.
The assessment of tender points is made by applying firm pressure over a neutral area such as the forehead or wrist. This provides the examiner with an indication of the patient’s pain threshold. There is some evidence to suggest that the patient may have a lower general threshold for pain on palpation of body locations other than tender points. The tender points are palpated bilaterally at each site using the pulp of the thumb or the first two fingers of one hand. A steady, uniform pressure of 4 kilograms should be applied; this amount of pressure should cause blanching of the examiner’s thumbnail upon palpation. The examiner applies increasing pressure until the patient:

1. tells the examiner to stop because of pain,
2. withdraws from the pain, or
3. grimaces because of the pain.

The tender points are then examined for erythema or redness. For a tender point to be considered positive, the patient must state that the palpation was “painful,” not “tender”. The severity of tenderness to palpation can be graded on an intensity scale or described according to the patient’s response.

Table 4

Pain Intensity Scale

0 = no tenderness
1 = tenderness with no withdrawal
2 = tenderness and withdrawal
3 = tenderness and exaggerated withdrawal
4 = untouchable

These observations may be documented in the patient’s medical record. The severity of tenderness experienced by the patient can be compared to tenderness experienced during subsequent medical visits as a means of monitoring patient progress before and after the institution of management strategies. There is no one definitive laboratory test or radiographic abnormality attributable to fibromyalgia. In attempting to establish a diagnosis, it is reasonable for the health care professional to obtain a complete blood count, an erythrocyte sedimentation rate, blood chemistries, and thyroid function studies. The results of these tests should be within normal limits unless there is another underlying disorder. Isotope scans of bones and joints and electromyographic studies are usually not necessary to make a diagnosis.

Related Conditions

There are other medical conditions whose symptoms may mimic those of fibromyalgia. The most common medical conditions include myofascial pain syndrome, chronic fatigue syndrome and polymyalgia rheumatica.
Myofascial pain syndrome is a muscular pain disorder involving pain referred by trigger points, stiffness, fatigue and impaired sleep. Speculations concerning the cause of myofascial pain syndrome have focused upon microtrauma from a traumatic injury in which muscles are damaged either by repetitive muscle strain or overload. As with fibromyalgia, the results from laboratory studies and diagnostic imaging studies indicate that there is no systemic disease process. When treated with moist heat, massage, deep stretching techniques, and anti-inflammatory drugs, myofascial pain syndrome has an excellent prognosis.
Chronic fatigue syndrome is a disorder of unknown etiology characterized by persistent, debilitating fatigue and other neuropsychiatric symptoms such as mood disturbances and sleep disturbances. There is a close similarity between these symptoms and the symptoms experienced by the patient with fibromyalgia syndrome. Chronic fatigue syndrome is often associated with muscle pains, pharyngitis and lymphadenopathy. As with fibromyalgia, chronic fatigue syndrome occurs mostly in women although the proportion is not quite as great. Furthermore, in both conditions, the symptoms usually occur in individuals who characterize themselves as previously healthy and active. The presence of symptoms has caused major changes in their lives.
Polymyalgia rheumatica is a common syndrome seen in patients after age 50. It is characterized by widespread pain in the neck, shoulders, back, and hips, and pronounced morning stiffness. There is shoulder tenderness and limited shoulder motion. These findings suggest an inflammatory process in synovial tissues.

Pathogenesis of Fibromyalgia

The pathogenesis of fibromyalgia remains to be completely defined. The two most common etiological factors that have been set forth in an attempt to explain the clinical findings include 1) a deprivation of restorative sleep, and 2) neurotransmitter abnormalities.

Deprivation of Restorative Sleep
It has been proposed that the patient with fibromyalgia experiences a disruption in stage IV (non-rapid eye movement) sleep which may be related in some way to the generalized aching, stiffness, and fatigue. The usual electroencephalogram pattern in Stage IV sleep is characterized by high amplitude, low frequency delta waves. In some patients with fibromyalgia, a sleep pattern disruption has been shown to occur. This disruption is characterized by a superimposed alpha wave intrusion. This pattern of sleep, referred to as “alpha EEG NREM” sleep, is commonly associated with fibromyalgia syndrome but is not a specific indicator for the condition. Researchers have been able to successfully reproduce the sleep disruption in normal subjects by disrupting stage IV sleep with an auditory stimulus. The exact nature of this sleep disruption and its relationship to symptoms experienced by the patient continues to be a fruitful area of investigation.

Neurotransmitter Abnormalities
The increased tenderness seen in the patient with fibromyalgia may be a manifestation of generalized pain intolerance related to abnormalities within the central nervous system. The most common central nervous system abnormalities that have been documented in the patient with fibromyalgia are alterations in neurotransmitters or neuromodulators. Substance P is a neuropeptide stored in sensory nerves and released upon stimulation. Substance P has a variety of functions and acts to increase smooth muscle tone and vascular permeability. It is also a mediator of neurogenic inflammation. There is evidence that cerebrospinal fluid levels of substance P are markedly elevated in patients with fibromyalgia. Despite high cerebrospinal fluid levels, serum levels of substance P are normal in fibromyalgia. Higher levels of substance P in the patient could amplify the perception of pain.
Serotonin might be involved in the pathogenesis of fibromyalgia syndrome. Serotonin is an important neurotransmitter whose functions appear to involve control of appetite, sleep, memory, learning, temperature regulation, mood, -behavior, cardiovascular function, and many other diverse effects. It is found in three main areas of the body: the intestinal wall, blood vessels and the central nervous system. Serum concentrations of both tryptophan, a precursor of serotonin, and serotonin have been shown to be significantly lower than normal in the patient with fibromyalgia syndrome. Serotonin may also serve as a regulator of pain perception through its effect on the release of substance P.
It is not entirely clear what role stress plays in the etiology of fibromyalgia syndrome. Patients often report the onset of symptoms following an acute stressor or a period of intense stress. In addition, symptoms are often exacerbated during periods of stress, and patients report a high level of daily stress. A number of investigations have shown that there is blunting of the stress response in individuals with fibromyalgia. Other investigations have noted a dysfunction of the hypothalamic-pituitary-adrenal stress axis.

Other Findings
Another hormone referred to as insulin-like growth factor or somatomedin C has been shown to be low in fibromyalgia patients. It is a major mediator of growth hormone anabolic action and is a prerequisite for normal homeostasis. Other hormones such as prolactin and thyroid hormones have been the focus of investigations. There have been a number of observations suggestive of mild immune dysfunction in fibromyalgia. Although traditional laboratory tests for inflammation such as the erythrocyte sedimentation rate and C-reactive protein are normal, nonspecific abnormalities of the immune system have been identified in subsets of patients. The primary abnormality is that of decreased natural killer cell function. Clearly, there is need for further research in this area.

Management Strategies

Although its cause remains obscure, strategies can be employed to assist the patient to better manage symptoms. There continues to be a trend in the literature toward a multidisciplinary approach to patient management that encompasses four primary components: patient education, medication, physical therapy and aerobic exercise. Physical therapists, occupational therapists, nurses, physicians, chiropractors, and exercise physiologists are just a few of the health professionals that may be involved in the care of the patient. The patient with fibromyalgia may feel as though something can be done to improve or change the severity of symptoms but that additional information is needed before action can be taken. In all cases, the patient should be made an active participant in formulating the plan of care.
The patient should be assisted in making a commitment to assume a major responsibility for rehabilitation, pain control and improved function. The patient along with family members or significant others should be included in the education sessions and in formulating the plan of care. Encouragement and support from loved ones is beneficial. In this way, the patient does not feel alone in the struggle to regain control of the situation.

Medications
Several symptoms of fibromyalgia syndrome may respond to specific drug therapy. However, drug therapy alone may be insufficient in modifying or alleviating symptoms. Therefore, this should be combined with nonpharmacologic approaches when formulating a plan of care for the patient.
In June 2007, the U.S. Food and Drug Administration approved Lyrica* (pregabalin) as the first drug to treat fibromyalgia. Doctors also treat fibromyalgia with a variety of medications developed and approved for other purposes. Manufactured by: Pfizer Inc., Lyrica is approved for treating fibromyalgia in adults who are 18 years and older.
How it works: Lyrica reduces pain and improves function in patients with fibromyalgia. The mechanism of action is unknown, but there is some data suggesting that it has effects on the release of neurotransmitters in the brain. Neurotransmitters are chemicals in the brain that transmit signals from one neuron to another. People with fibromyalgia experience pain differently than people who don’t have the condition. Treatment with Lyrica reduces the level of pain in some patients.
Effectiveness: The effectiveness of Lyrica in treating fibromyalgia was established in two randomized, placebo-controlled trials of approximately 1800 people. These trials showed that treatment with Lyrica in doses of 300-450 mg per day reduced pain and improved function in patients with fibromyalgia. They also demonstrated that symptoms of fibromyalgia worsened when Lyrica was withdrawn.
Safety: The most common side effects of Lyrica include dizziness and sleepiness, blurry vision, weight gain, trouble concentrating, swelling of the hands and feet, and dry mouth. Allergic reactions can also occur. These are rare, but potentially serious. FDA advises patients to talk with their doctors about whether using Lyrica will impair their ability to drive.
*Brand names included in this course are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Center. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
Following are some of the most commonly used categories of drugs for fibromyalgia:

Analgesics
Analgesics are painkillers. They range from over-the-counter acetaminophen (Tylenol) to prescription medicines, such as tramadol (Ultram), and even stronger narcotic preparations. For a subset of people with fibromyalgia, narcotic medications are prescribed for severe muscle pain. However, there is no solid evidence showing that narcotics actually work to treat the chronic pain of fibromyalgia, and most doctors hesitate to prescribe them for long-term use because of the potential that the person taking them will become physically or psychologically dependent on them.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
As their name implies, nonsteroidal anti-inflammatory drugs, including aspirin, ibuprofen (Advil, Motrin), and naproxen sodium (Anaprox, Aleve), are used to treat inflammation. Although inflammation is not a symptom of fibromyalgia, NSAIDs also relieve pain. The drugs work by inhibiting substances in the body called prostaglandins, which play a role in pain and inflammation. These medications, some of which are available without a prescription, may help ease the muscle aches of fibromyalgia. They may also relieve menstrual cramps and the headaches often associated with fibromyalgia.

Antidepressants
Perhaps the most useful medications for fibromyalgia are several in the antidepressant class. Antidepressants elevate the levels of certain chemicals in the brain, including serotonin and norepinephrine (which was formerly called adrenaline). Low levels of these chemicals are associated not only with depression, but also with pain and fatigue. Increasing the levels of these chemicals can reduce pain in people who have fibromyalgia. Doctors prescribe several types of antidepressants for people with fibromyalgia, described below.

• Tricyclic antidepressants — When taken at bedtime in dosages lower than those used to treat depression, tricyclic antidepressants can help promote restorative sleep in people with fibromyalgia. They also can relax painful muscles and heighten the effects of the body’s natural pain-killing substances called endorphins.
Tricyclic antidepressants have been around for almost half a century. Some examples of tricyclic medications used to treat fibromyalgia include amitriptyline hydrochloride (Elavil, Endep), cyclobenzaprine (Cycloflex, Flexeril, Flexiban), doxepin (Adapin, Sinequan), and nortriptyline (Aventyl, Pamelor). Both amitriptyline and cyclobenzaprine have been proved useful for the treatment of fibromyalgia. Cyclobenzaprines have a structure similar to the tricyclic antidepressants but is used primarily as a skeletal muscle relaxant. It has been shown to reduce the pain experienced by the patient, increase total sleep time and decrease evening fatigue. The recommended dose is 10 mg to 30 mg. However, it is often very sedating, and may be initially given at bedtime in doses of 5 mg.

• Selective serotonin reuptake inhibitors—If a tricyclic antidepressant fails to bring relief, doctors sometimes prescribe a newer type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). As with tricyclics, doctors usually prescribe these for people with fibromyalgia in lower dosages than are used to treat depression. By promoting the release of serotonin, these drugs may reduce fatigue and some other symptoms associated with fibromyalgia. The group of SSRIs includes fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).
SSRIs may be prescribed along with a tricyclic antidepressant. Doctors rarely prescribe SSRIs alone. Because they make people feel more energetic, they also interfere with sleep, which often is already a problem for people with fibromyalgia. Studies have shown that a combination therapy of the tricyclic amitriptyline and the SSRI fluoxetine resulted in greater improvements in the study participants’ fibromyalgia symptoms than either drug alone.

• Mixed reuptake inhibitors—Some newer antidepressants raise levels of both serotonin and norepinephrine, and are therefore called mixed reuptake inhibitors. Examples of these medications include venlafaxine (Effexor) and nefazadone (Serzone). Researchers are actively studying the efficacy of these newer medications in treating fibromyalgia.

• Benzodiazepines
Benzodiazepines help some people with fibromyalgia by relaxing tense, painful muscles and stabilizing the erratic brain waves that can interfere with deep sleep. The benzodiazepines are widely prescribed drugs and have limited side effects. Two of the most common side effects are drowsiness and confusion. Researchers have shown that over half of the patients with fibromyalgia syndrome who were treated with alprazolam plus ibuprofen showed a greater than 30 percent improvement in anxiety and pain.

• Benzodiazepines also can relieve the symptoms of restless legs syndrome, which is common among people with fibromyalgia. Restless legs syndrome is characterized by unpleasant sensations in the legs as well as twitching, particularly at night. Because of the potential for addiction, doctors usually prescribe benzodiazepines only for people who have not responded to other therapies. Benzodiazepines include clonazepam (Klonopin) and diazepam (Valium).

• Other medications
In addition to the previously described general categories of drugs, doctors may prescribe others, depending on a person’s specific symptoms or fibromyalgia-related conditions. For example, in recent years, two medications — tegaserod (Zelnorm) and alosetron (Lotronex) — have been approved by the FDA for the treatment of irritable bowel syndrome. Gabapentin (Neurontin) currently is being studied as a treatment for fibromyalgia. Other symptom-specific medications include sleep medications, muscle relaxants, and headache remedies.
People with fibromyalgia also may benefit from a combination of physical and occupational therapy, from learning pain-management and coping techniques, and from properly balancing rest and activity.

Complementary and Alternative therapies

More than Medicine. Many people with fibromyalgia also report varying degrees of success with complementary and alternative therapies, including hydrotherapy, massage, movement therapies (such as Pilates and the Feldenkrais method), chiropractic treatments, acupuncture, and various herbs and dietary supplements for different fibromyalgia symptoms.

Herbs

Rhodiola rosea (Golden Root, Roseroot) is a plant in the Crassulaceae family that grows in cold regions of the world. These include much of the Arctic, the mountains of Central Asia, the Rocky Mountains, and others. Rhodiola rosea is effective for improving mood. Russian research shows that it improves both physical and mental performance, and reduces fatigue.
Substances like these are referred to as adaptogens. They differ from stimulants, and do not have the same health consequences as nicotine, etc.
In Russia, Rhodiola rosea, also known as golden root, has been used for centuries to cope with the cold Siberian climate and stressful life. It has also been used for centuries in Scandinavia, both by the Vikings and the Sámi.

Rundown on Rhodiola
 you decide to try rhodiola, it won’t take long to determine if it will work for you, say experts familiar with the herb. “Most of the people I’ve seen respond within a couple of weeks,” says psychiatrist Sharon Sageman, who prescribes it both as a general tonic to enhance energy and ease stress and to treat specific conditions, such as depression, anxiety, or the unwanted symptoms of menopause. Here are some guidelines for giving it a try:

• Make sure the label lists Rhodiola rosea. Some brands include other forms of rhodiola, which are not nearly as well studied.
• Choose a brand of pure root extract standardized to 3 to 4 percent rosavins and 0.8 to 1 percent salidrosides, widely regarded as the ideal ratio for the two most important constituents.
• Start with one 100-milligram capsule once a day, taken 20 to 30 minutes before breakfast. If you don’t notice benefits after three days, gradually increase the dosage. Most people respond to daily doses in the 200 to 600 mg range; don’t take more than 400 mg a day without medical supervision.
• Take a little extra rhodiola when you’re under either emotional or physical stress. The hallmark of adaptogens is their ability to arm the body to resist the negative effects of stress.
• If the herb makes you feel jittery, reduce the dosage.

Ribose, Malic acid, and Magnesium. “A major component of what people consider arthritis pain comes from the shortening of the small muscles and not from the joints themselves,” says Jacob Teitelbaum, MD, medical director of the fibromyalgia and Fatigue Centers and author of From Fatigued to Fantastic! (Penguin/Avery, 2007) and Pain Free 1-2-3: A Proven Program to Get You Pain Free! (McGraw-Hill, 2006). For the muscles to lengthen, they need to relax. And that requires energy. “A key, but underappreciated, factor in physiology is that it takes much more energy for muscles to relax than to contract,” Teitelbaum explains. When taken in a combination formula, “d-ribose, malic acid, and magnesium all dramatically increase the body’s energy production and, thus, promote relaxation.” Early research is exciting, but you need all three supplements to get the effect. “It’s like building a house,” says Teitelbaum. “Ribose is the lumber, malic acid the hammers, and magnesium the workers. You need all three of them for the house to go up, and you need all of these supplements to make energy.” Typical dosage: 5 grams of ribose, at least 600 mg of malic acid, and 40 mg of magnesium, three times a day for three to four weeks, and then go to twice a day. Cut back the dose of magnesium if it loosens your stools too much. A recent pilot study may have found a remedy. 

A team of researchers headed by Jacob E. Teitelbaum, MD, medical director of the national fibromyalgia and Fatigue Centers (www.fibroandfatigue.com), gave 36 CFS/FMS suffers a total of 280 grams (5grams three times a day) of d-Ribose, a readily available supplement, in an attempt to boost their energy levels. Earlier studies had shown that d-Ribose, a five-carbon sugar that’s a component of adenosine triphosphate (ATP), the primary energy source for all living cells, improved heart function, energy levels, and quality of life for people with congestive heart failure. 

At the end of Teitelbaum’s study, the patients reported improvement in energy, sleep, mental clarity, pain intensity, and well-being, with 66 percent of them saying they felt either “somewhat” or “much” better. The researchers concluded that the d-Ribose “significantly reduced” the clinical symptoms of CFS/FMS.

Not Just Mud in Your Eye. Various hydrotherapies have proven effective in some cases, which led researchers in Italy to wonder about the healing powers of mud baths, a therapy that reached its heyday in the last half of the 19th century. The researchers took a group of 80 patients who had primary FS (i.e., no known cause) but found little or no relief from medication and gave half of them a cycle of 12 full-body mud-pack treatments, combined with thermal baths. The remaining 40 received no treatment. Upon completion of the therapy, the mud-bath group showed a significant improvement in every FS evaluation measure compared to the control group. And perhaps more importantly, the mudders maintained these improvements in a 16-week follow-up examination.

Topical remedies. Users of Epsom Salts in the gel form (Magnesium Sulfate), have reported significant and lasting relief from pain associated with fibromyalgia. Epsom Salts have long been touted for its ability to reduce pain and swelling.

Take a little needling. Many people with FMS get hooked on acupuncture, and for good reason. Numerous studies show the positive benefits of acupuncture for pain relief. One landmark study appeared in the June 2006 Mayo Clinic Proceedings. This randomized, controlled trial, led by David P. Martin, MD, an anesthesiologist from the Mayo Clinic College of Medicine in Rochester, Minnesota, reports on 50 FMS patients, half of whom received acupuncture; the remaining 25 received sham acupuncture, which involved needles inserted at non-therapeutic points. After just six treatments spread over three weeks, the acupuncture patients reported significant improvement in symptoms, particularly fatigue and anxiety, lasting up to seven months. One month after treatment, those treated with “true” acupuncture had less fatigue and fewer anxiety symptoms than the sham acupuncture group.
These remedies are just the tip of the iceberg. For more information on complementary and contact the National Center for Complementary and Alternative Medicine or visit Live Extension Foundation at www.lef.org

Aerobic Conditioning

The patient with fibromyalgia is usually deconditioned and can benefit from a program of aerobic conditioning. Some authors have reported that deconditioned muscles use energy sources poorly, contributing to fatigue, and are believed to be susceptible to microtrauma, which may contribute to pain. According to this hypothesis, deconditioning may play a role in perpetuation of the syndrome. Other authors claim that this assumption has no factual basis and advocate regular aerobic exercise because of its beneficial effects. Among these effects are increased strength, improved sleep, reduced anxiety levels and improvement in depression.
The patient should avoid impact-loading exercises such as jogging, basketball, volleyball or any other activity that involves jumping up and down. Non-impact loading exercises such as walking, swimming, and riding a stationary bicycle have been recommended. Aquatic therapy is often recommended as a desirable activity -because it permits a tremendous amount of upper-body and endurance activity without putting undue demands on the trunk. Aquajogging is a form of aquatic therapy that involves the use of a buoyancy belt. The belt is fastened around the chest and allows the patient to stand up in a swimming pool and walk against the resistance of the water.

Exercise guidelines for the patient with fibromyalgia syndrome should include the following components:

1. a frequency of three times per week
2. a long-term exercise intensity goal of 85% of the target heart rate for age
3. a long-term exercise duration goal of 40 minutes,
4. a program of controlled stretching exercises

Because the patient has most likely become sedentary, it may be necessary to set a much lower intensity and duration goal. For example, it may be necessary to begin with exercise sessions of no more than five to ten minutes and then increase the duration of activity by one minute per session every three to four days. As with any behavioral change program, supervision of activity and positive reinforcement are essential ingredients for long-term adherence.

Physical Therapy

Physical therapy is often reserved for flare-ups of symptoms rather than administered on a continuous basis. Moist hot packs, heating pads, whirlpools, warm showers or baths, and hot packs increase local blood flow and decrease muscle spasm and tension. Cold modalities such as ice packs, ice massage and cool baths anesthetize localized areas of pain and break the pain cycle. Gentle massage therapy may promote muscle relaxation. However, vigorous massage may aggravate pain and should be avoided.

Other Management Approaches

Biofeedback training, acupuncture and hypnotherapy may be useful approaches and are deserving of future study as treatment mo- dalities. Cognitive-behavioral approaches that employ a combination of gentle stretching, breathing exercises, imagery and stress reduction skills may also be beneficial in the overall plan of care.

Patient Education
Reassure the patient that fibromyalgia is a benign condition; it is not life-threatening or deforming. Although the symptoms may last for days, months, or years, they may eventually disappear. Improved function and quality of life usually can be achieved.
Perhaps, more controversy surrounds fibromyalgia and its relationship to emotional and psychological disorders than any other issue. The patient should be reassured that fibromyalgia is not a psychiatric disturbance. They will most likely experience a feeling of relief to know that the symptoms are not imagined and that certain steps can be taken to deal with them.
Patient education includes explaining how various circumstances and factors in the patient’s life can contribute to symptoms. For example, stressors such as cold, damp weather or an argument with a spouse can aggravate pain and stiffness. The patient should be encouraged to identify factors that may induce stress and avoid or modify these situations, if possible.
Educate the patient that certain physical activities may take longer to complete than they used to. Some activities may have to be cut back. Other activities may have to be delegated to family members. The patient should be encouraged to participate in activities that have provided the greatest enjoyment in the past.
One of the most important management strategies in fibromyalgia involves assisting the patient to obtain quality sleep. Improved sleep often means improved symptoms; therefore the patient should be encouraged to avoid daytime naps and maintain regular bedtime hours. Sleep hygiene encompasses the use of a firm mattress; the cessation of alcohol, nicotine and caffeine consumption; and the cessation of any medication that may be contributing to disturbances of sleep. Specific measures to promote sleep such as listening to music, consuming a warm beverage, reading or taking a bath may serve to promote relaxation and induce sleep. An effort should be made to remove possible distractions and excessive noise. Televisions, stereos, children and pets all have the potential to disrupt sleep.
Another important beneficial measure is conserving body heat by dressing appropriately in cool environments. Some patients experience a hypersensitivity to cold temperatures. The addition of extra clothing helps to keep the body warm and prevent muscle tensing that may accompany body cooling.

What Can I Do To Try To Feel Better?

Besides taking medicine prescribed by your doctor, there are many things you can do to minimize the impact of fibromyalgia on your life. These include:


1. Getting enough sleep—Getting enough sleep and the right kind of sleep can help ease the pain and fatigue of fibromyalgia. (See Tips for Good Sleep.) Even so, many people with fibromyalgia have problems such as pain, restless legs syndrome, or brain-wave irregularities that interfere with restful sleep.

2. Exercising—Though pain and fatigue may make exercise and daily activities difficult, it’s crucial to be as physically active as possible. Research has repeatedly shown that regular exercise is one of the most effective treatments for fibromyalgia. People who have too much pain or fatigue to do vigorous exercise should begin with walking or other gentle exercise and build their endurance and intensity slowly. Although research has focused largely on the benefits of aerobic and flexibility exercises, a new NIAMS-supported study is examining the effects of adding strength training to the traditionally prescribed aerobic and flexibility exercises.

3. Making changes at work—Most people with fibromyalgia continue to work, but they may have to make big changes to do so; for example, some people cut down the number of hours they work, switch to a less demanding job, or adapt a current job. If you face obstacles at work, such as an uncomfortable desk chair that leaves your back aching or difficulty lifting heavy boxes or files, your employer may make adaptations that will enable you to keep your job. An occupational therapist can help you design a more comfortable workstation or find more efficient and less painful ways to lift.
If you are unable to work at all due to a medical condition, you may qualify for disability benefits through your employer or the Federal Government.
Social Security Disability Insurance (SSDI) and Supplemental Security Insurance (SSI) are the largest Federal programs providing financial assistance to people with disabilities. Though the medical requirements for eligibility are the same under the two programs, the way they are funded is different. SSDI is paid by Social Security taxes, and those who qualify for assistance receive benefits based on how much an employee has paid into the system; SSI is funded by general tax revenues, and those who qualify receive payments based on financial need. For information about the SSDI and SSI programs, contact the Social Security Administration

4. Eating well—Although some people with fibromyalgia report feeling better when they eat or avoid certain foods, no specific diet has been proven to influence fibromyalgia. Of course, it is important to have a healthy, balanced diet. Not only will proper nutrition give you more energy and make you generally feel better, it will also help you avoid other health problems

Tips for Good Sleep

• Keep regular sleep habits. Try to get to bed at the same time and get up at the same time every day — even on weekends and vacations.
• Avoid caffeine and alcohol in the late afternoon and evening. If consumed too close to bedtime, the caffeine in coffee, soft drinks, chocolate, and some medications can keep you from sleeping or sleeping soundly. Even though it can make you feel sleepy, drinking alcohol around bedtime also can disturb sleep.
• Time your exercise. Regular daytime exercise can improve nighttime sleep. But avoid exercising within 3 hours of bedtime, which actually can be stimulating, keeping you awake.
• Avoid daytime naps. Sleeping in the afternoon can interfere with nighttime sleep. If you feel you can’t get by without a nap, set an alarm for 1 hour. When it goes off, get up and start moving.
• Reserve your bed for sleeping. Watching the late news, reading a suspense novel, or working on your laptop in bed can stimulate you, making it hard to sleep.
• Keep your bedroom dark, quiet, and cool.
• Avoid liquids and spicy meals before bed. Heartburn and late night trips to the bathroom are not conducive to good sleep.
• Wind down before bed. Avoid working right up to bedtime. Do relaxing activities, such as listening to soft music or taking a warm bath, that get you ready to sleep. (An added benefit of the warm bath: It may soothe aching muscles.)

Investigational treatments

Milnacipran, a serotonin-norepinephrine reuptake inhibitor (SNRI), is available in parts of Europe where it has been safely prescribed for other disorders. On May 22nd, 2007, a Phase III study demonstrated statistically significant therapeutic effects of Milnacipran as a treatment of fibromyalgia syndrome. At this time, only initial top-line results are available and further analyses will be completed in the coming weeks. If ultimately approved by the FDA, Milnacipran could be distributed in the United States as early as summer, 2008.

In summary, fibromyalgia is a common, chronic musculoskeletal pain syndrome that affects approximately 2%-6% of the population. Although it is defined by its musculoskeletal features, it is associated with several non-musculo- skeletal symptoms. In attempting to establish a diagnosis, the health history and physical examination remain the cornerstone for evaluating the patient. The pathogenesis of fibromyalgia has yet to be fully elucidated, and there is no one definitive laboratory test or radiographic abnormality attributable to the condition. Management strategies require a multidisciplinary approach and include patient education, medication, physical therapy, and aerobic exercise. In all cases, the patient should be made an active participant in the management plan.

Fibromyalgia Syndrome: A Case Study

Gloria, a 38-year-old mother of seven children, presented to the family nurse practitioner because she had experienced muscle “achiness” in both of her upper arms and lower legs for the past three to four months. She had complained of this discomfort during prior visits. It was difficult for her to pass food at the table or pour a cup of milk for her children. Her legs ached along the anterior shins and she reported awakening several times during the night with jerking movements of her legs. She admitted to feeling fatigued during the day and especially upon awakening in the morning.

Background information: Gloria was a high-school graduate who lived with her husband of 16 years and their seven children. They owned and operated a large dairy farm and practiced Mennonite religious traditions.

Family history: The patient’s mother had a positive history for hypothyroidism but presently was in good health. The patient had no knowledge of her father or his medical background. She had no brothers or sisters. All of her children were healthy and attended school on a regular basis.

Past medical history: Gloria’s past medical history included seven uncomplicated pregnancies and vaginal deliveries. She had no previous hospitalizations for acute or chronic illnesses. Her history was negative for accidents, injuries, abuse, and musculoskeletal or neurological diseases. She had no known allergies. In June of 1996, results from thyroid function tests indicated she was hypothyroid. A goiter was detected upon physical examination and she was prescribed Synthroid 0.1 mg daily. She was instructed to return annually for evaluation of thyroid function studies.

Upon returning for these annual visits, all of the thyroid function tests were found to be within normal limits. However, she was noted to have complained about a variety of symptoms reminiscent of fibromyalgia. A synopsis of her medical record appears below:

April 2006 – extreme fatigue upon walking up and down stairs while doing laundry; generalized fatigue throughout the day; alternating constipation and diarrhea for three to four days.

October 2007 – tired for two weeks; aching discomfort in her upper arms and lower legs; some morning fatigue and stiffness that disappeared after two hours.

April 2008 – discomfort in legs has lessened but occasionally awakens her during the night after feeling a jerking movement of her legs; still fatigued while doing light chores around the farm; intermittent constipation and diarrhea.

History of present illness: On this visit, Gloria complained of bilateral, non-radiating aching in her upper arms and anterior lower legs that began three to four months ago. She could recall having similar episodes during the past four years but they were not as severe. She could not recall exactly what she was doing when she first noted the discomfort. She denied performing new physical activities or strenuous lifting.

The aching was intermittent and occurred three to four times each week at all hours of the day. Each episode lasted from ten minutes to five hours. On a scale of one to ten, with ten being the worst pain ever experienced, this aching rated an eight. Gloria admitted that the pain was similar to having the flu where her arms and legs ached or similar to having a charley horse. The aching was more severe during the winter months and was aggravated by cold, damp, rainy weather. It was relieved somewhat by warm baths and gentle massage. Aspirin and other over-the-counter pain medications were taken on occasion but did not relieve the discomfort to any significant degree. Gloria also complained of feeling fatigued during the day to the extent that she would have to take frequent rest periods. The fatigue was aggravating because she had always considered herself to be a young active mother. Gloria worried that the fatigue was slowing her down. “I can’t do anything quickly anymore,” she reported.

Activities of daily living: A typical day for Gloria involved arising at 5:30 a.m. with her husband. She would prepare breakfast for the family, pack the lunches for the children and assist them on their way to school. There were several chores to be completed such as laundry, mending, cleaning, shopping, cooking and participating in weekly church activities. In addition, she was responsible for maintaining 20 acres of strawberries on the farm.

Sleep habits: Gloria retired at 11:00 p.m. every night. She admitted to waking during the night because of the aching in her arms and legs. These episodes occurred approximately three times a week. Eventually, she would fall back to sleep but felt stiffness and fatigue upon awakening in the morning.

Relationships and roles: Although it was a challenge to fulfill the roles of wife, mother, and property owner, Gloria described her relationships with her family as very positive. Her husband’s family lived nearby, and she received much emotional support from friends at church.

Physical examination: The practitioner performed a complete physical exam with an assessment of tender points. The clinical findings from the exam were unremarkable with the exception of the presence of multiple painful tender points bilaterally at the following locations: at the midpoint of the upper border of the trapezia, distal to the epicondyles, posterior to the trochanteric prominences, at the medial fat pads of the knee, at the suboccipital muscle insertions, and at the upper outer quadrants of the buttocks.

Diagnostic studies: Hematology studies, blood chemistries, an erythrocyte sedimentation rate and thyroid studies were performed from a blood sample.

Discussion of Case Study

This case study illustrates the profound impact fibromyalgia had on all dimensions of the patient’s life. Gloria reported experiencing pain that occurred during most of the day and night, fatigue, and a loss of stamina. As a 38-year-old mother of seven children, these symptoms were interfering with her ability to carry out responsibilities associated with her roles as wife and mother. The muscular pain was severe and a major source of anxiety. The intensity of the pain varied considerably from one day to the next and was unpredictable. The results from the hematology studies, blood chemistries, erythrocyte sedimentation rate and thyroid studies were within normal limits. In attempting to establish a diagnosis of fibromyalgia syndrome, other competing diagnoses had to be ruled out. These competing -diagnoses included myofascial pain syndrome, chronic fatigue -syndrome, and polymyalgia rheumatica.
Among the most important criteria used for differentiating myofascial pain syndrome from fibromyalgia were findings obtained from the history and physical exam. There was no prior history of trauma, overuse, or prolonged spasm of muscles. Upon examination, there were no trigger points, nodules, taut bands of skeletal muscle or areas of referred pain that would be characteristic of myofascial pain syndrome.
The second diagnosis that had to be ruled out was chronic fatigue syndrome. Although the patient experienced frequent episodes of fatigue, it was not totally disabling. She was able to complete most of her usual activities of daily living. There was no past medical history or findings suggestive of pharyngitis or lymphadenopathy.
The final diagnosis that had to be considered was polymyalgia rheumatica. The patterns of pain experienced by the patient were not consistent with a diagnosis of polymyalgia rheumatica. The patient, who was a young adult woman, experienced pain that was limited to her arms and legs. She did not complain of persistent neck, shoulder or hip discomfort. There was no shoulder tenderness or limited range of motion on the physical examination. A diagnosis of polymyalgia rheumatica was not supported by the physical findings.
Based upon the patient’s past medical history of hypothyroidism, intermittent changes in bowel habits, musculoskeletal pain, fatigue, sleep disturbances, and the presence of multiple tender points, a working diagnosis of fibromyalgia -syndrome was established. A management plan was initiated with the patient and her husband at the next visit.

Formulation of Plan of Care

The patient and her husband were informed regarding the nature of fibromyalgia, its prevalence, clinical features, diagnosis, and management strategies. They were provided with pamphlets and a videotape to augment the verbal instruction. They were also provided with the name of a contact person for a fibromyalgia support group in their neighborhood.

In addition, the patient was given a prescription for amitriptyline 10 mg to be taken every night at bedtime. She was cautioned about the potential side effects of the medication and encouraged to take it as prescribed. A program of systematic exercise was initiated that included 10 minutes of controlled stretching exercises to be performed prior to 20 minutes of brisk walking three times each week. She was instructed to keep an exercise log of her activity. Specific instructions were provided regarding the need to pace activities with rest periods. Her husband agreed to hire someone to assist with household chores.

Since warm baths and gentle massage had been helpful in relieving her pain in the past, she expressed an interest in continuing with these therapeutic interventions. A referral was made to a physical therapist who had experience caring for patients with fibromyalgia syndrome. The patient and her husband verbalized a basic under-standing of the disorder and agreed to return for a follow-up appointment in six weeks.

Resources

Advocates for Fibromyalgia
Phone: 847-362-7807
Fax: 847-680-3922
Email: info@affter.org
Website: http://www.after.org

Fibromyalgia Network
Toll Free: 800-853-2929
Website: http://www.fmnetnews.com

Suggested Readings

Dell DD “Getting the point about fibromyalgia.” Nursing 2007 Feb; 37(2): p61-4

Karper WB, Jannes CR, Hampton JL “Fibromyalgia syndrome: the beneficial

effects of exercise.” Rehabil Nurs 2006 Sep-Oct; 31(5): p193-8

Cunningham MM, Jillings C “Individuals’ descriptions of living with fibromyalgia.” Clin Nurs Res 2006 Nov; 15(4): p258-73

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