Porter Rheumatology Ltd
Dr David Porter
Rheumatologist
105 Trafalgar St
Nelson 7010
Ph: 03 545 8688
Fax: 03 9280259
Fibromyalgia
Fibromyalgia is not an inflammatory disease. However, the symptoms of fibromyalgia may perfectly mimic those of an inflammatory arthritis and so rheumatologists often see people with fibromyalgia.
The main symptoms of fibromyalgia include widespread pain and stiffness, which can be felt in the joints, muscles or both. The symptoms may be worse at night, early in the morning or after periods of inactivity. Fatigue (often severe) and sleep disturbance are very common. Widespread pins and needles, irritable bowel symptoms and headaches are also common. A very wide range of bodily systems can be affected by symptoms of fibromyalgia, as is shown in the following picture.
The basic problem in fibromyalgia is marked overactivity of the pain system. The function of the pain system function becomes highly disordered so that even innocuous stimuli are felt as major pain. Multiple studies have demonstrated that the pain is real and measurable - both in the peripheral nerve that transmits the signal to the spinal cord and brain, and in the pain centres themselves within the brain. Why such major pain is generated by minor stimuli is not well understood.
Some investigators believe that the primary problem may be a sleep abnormality. Studies have shown that fibromyalgia sufferers have abnormal sleep cycles, so that they do not get down into the deep, restorative phases of sleep that should occur. Interestingly if highly fit young military personnel are systematically sleep-deprived (as has been done in several experiments), they universally end up with severe, widespread pain and stiffness.
There is an enormous volume of data from studies demonstrating a wide variety of abnormalities in the body's chemicals and neurotransmitters (substances that convey information from nerve to nerve) in fibromyalgic patients.
There is no specific test for fibromyalgia. The diagnosis is made by recognising the presence of typical features, the absence of evidence of alternative conditions and the demonstration of an overactive pain system by pressing on a series of so-called fibromyalgia trigger points.
One of the immense frustrations of fibromyalgia is that there is no outward sign of the condition, so that people who often feel very unwell look perfectly well.
It is important to know that fibromyalgia is not a progressive condition, nor does it damage the tissues where the pain is perceived.
Fibromyalgia Management
There is no magic bullet that can cure fibromyalgia. Treatment expectations must be realistic. Unfortunately pain and fatigue are likely to be an ongoing part of the fibromyalgic patient's life. The aim of management is to minimise the symptoms where possible, and to learn to make adjustments where necessary to minimise the impact on the patient's life. Progress will be measured in periods of months rather than days.
a) Medication.
Medication can help, but again, there is no magic bullet. The commonest agents used include:
1. Tricyclic antidepressants. Commonly used drugs include amitriptyline and nortriptyline. The doses used in this context are far lower than the doses utilised when the agents were used for depression in the past. The use of tricyclic antidepressants (it is a historical name) in fibromyalgia has nothing to do with depression. These drugs promote both the amount and the quality of sleep. More time is spent in the restorative phases of sleep when on tricyclics. They are also useful in treating nerve-based pain directly. Tolerability is sometimes an issue - with drowsiness the following day often an issue. This is at its worst in the first week or two of treatment, and can often be taking the medication in the early evening or late afternoon rather than bedtime.
2. Tramadol and Paracetamol. Both of these are painkillers. They act in different ways, and used in combination are synergistic - that is the presence of each one boosts the effect of the other. Sometimes Tramadol is not well tolerated - nausea and "spaced out" feelings can limit its use.
3. Gabapentin. This medication like many others used in a chronic pain (Chronic in medicine means of long duration, and acute means of short duration. Neither term implies anything about severity of pain), is also an anticonvulsant (anti-epileptic) drug. It is similar to Pregabalin which is used in the USA but is not subsidised in NZ. My personal experience with prescribing it has been disappointing and I do not often use it now.
4. Venlafaxine. This is a modern antidepressant. It is the most similar drug available in New Zealand to duloxetine which is used in the USA. It requires a Special Authority number from Pharmac, and is only allowed to be used in severe depression, so its use in the fibromyalgia context is limited.
Avoidance of simply adding more and more pain medications is crucial. It is not uncommon to see patients on 8 or more pain medications that have been gradually introduced with the best of intentions over the years, who still have pain just as bad as it always was but now have multiple side effects to battle with as well.
b) Exercise.
Exercise has been shown in many studies to be beneficial. It is an essential part of of a multi-disciplinary management program. Gentle aerobic exercise (walking), swimming, cycling, or gym-based exercise are all good. Aqua-jogging or Tai Chi may be appropriate. A little every day is important.
It can be extremely hard to get started when you are feeling exhausted and in great pain. To get started, patients can begin with a ridiculously small amount of exercise (eg walk 2 minutes away from the house and back. After a couple of days, go 3 minutes each way. Then 5 minutes, etc. In no time at all, it is possible to build up to 30-60 minutes walking each day.
Exercise leads to a variety of physical and psychological benefits.
Being sedentary reliably leads to worsening of fatigue and pain/stiffness. It is therefore important to do some exercise even if you are feeling terrible on a given day.
It is equally important not to overdo things on a day where you happen to be feeling good. Although it extremely difficult to consciously rein yourself in on a good day, overdoing it is counterproductive. Many are the tales of fibromyalgia patients putting in a fantastic day in the garden on a good day, only to feel extremely unwell for the next fortnight.
3) Psychological management.
Many studies have highlighted the benefit of CBT - cognitive behavioural therapy - in the management of fibromyalgia. Unfortunately publically funded psychology services are extremely limited in the NZ setting, and this aspect of management is usually neglected. Techniques to "fool" the pain centres of the brain into minimising their activity, and exploration of any background issues of stress or depression are very important.
