What is fibromyalgia?

The word fibromyalgia means pain ('algia') coming from the muscles ('my') and fibrous tissues ('fibro') such as tendons and ligaments. Most people with fibromyalgia also have other symptoms in addition to the pains - see below. Therefore, fibromyalgia is sometimes called fibromyalgia syndrome, or FMS. It is a chronic (persistent) condition. Fibromyalgia does not affect the joints, and so is not an arthritis.

What causes fibromyalgia?

The cause of fibromyalgia is not known. However, research has shown that people with fibromyalgia have certain subtle changes in some chemicals in the brain and nervous system. For example, there seems to be a minor change in the level of certain brain chemicals called neurotransmitters. These are the chemicals responsible for transmitting messages between nerves and between brain cells. Research studies have also shown that people with fibromyalgia tend to have an increased amount of a chemical called substance P in the fluid that bathes the brain and spinal cord (the cerebrospinal fluid - CSF). This substance may be involved in the way pain messages are transmitted.

A current main theory is that people with fibromyalgia have an oversensitivity to pain signals in the brain. This is called 'central sensitisation'. This may be due to various minor changes in brain chemicals. What triggers or causes these changes is not known.

Note: the term fibromyalgia has been used for a long time. However, because the cause is now thought to be due to the processes described above in the brain and spinal cord, the term 'fibromyalgia' does not accurately describe the condition. That is, there is little evidence that the disease is due to a problem with peripheral tissues such as muscles, tendons and ligaments (although the pain is often felt in these tissues).

Who gets fibromyalgia?

About 1 in 50 people develop fibromyalgia at some stage. It is seven times more common in women than men. In most cases it first develops between the ages of 25 and 55. It is less common in younger adults, and is uncommon in children.

What are the symptoms of fibromyalgia?

The main symptoms are pains felt in many areas of the body, and tiredness. Some people also develop other symptoms. The severity of symptoms varies from person to person.

Pain

Pain can occur in any area of the body. Typically, many areas of the body are affected, and some people feel the pain 'all over'. The neck and back are the sites that are often the most painful. The severity of the pain can vary from day to day. The pains may be made worse by stress, cold or activity. After a night's sleep, you may also feel quite 'stiff' for a few hours. Many areas of the body may also be quite tender.

Tiredness

Tiredness (fatigue) is common, and is sometimes severe. In some cases it is more distressing than the pain. It is also common to have a poor sleep pattern. You may wake feeling exhausted. Many people feel worst first thing in the morning, but improve by the afternoon. Even a small amount of activity may make you tired. The tiredness may cause you to have poor concentration.

Various other symptoms have been reported by people with fibromyalgia. Also, there are a number of other conditions that often occur at the same time as fibromyalgia. As a consequence, quite a number of other symptoms may occur in people with fibromyalgia. The following are perhaps the most common, but it is not an exhaustive list of every possible symptom that may occur:

• Headaches are common.
• Irritable bladder is common - you may need to go to the toilet more frequently than usual.[
• Irritable bowel syndrome occurs commonly in people with fibromyalgia - with abdominal pains, sometimes with diarrhoea, constipation or bloating.
• About 1 in 5 people with fibromyalgia also have restless legs syndrome (see separate leaflet called 'Restless Legs Syndrome' for more detail).
• Painful periods occur in some women with fibromyalgia.
• Pins and needles in fingers and/or toes.
• Some people describe a feeling as if their hands or feet are swollen (although they are not actually swollen).
• Depression or anxiety develop in some people. It is not clear whether these are part of 'fibromyalgia syndrome', or develop as a result of having this condition.
• Some people with fibromyalgia also have CFS/ME (chronic fatigue syndrome/myalgic encephalomyelitis).

How is fibromyalgia diagnosed?

Fibromyalgia is usually diagnosed by the typical symptoms and a doctor's examination.

To make a firm diagnosis, symptoms should include widespread pain involving both sides of the body, above and below the waist, as well as the neck, back and pelvis, and have been present for at least three months.

A doctor's examination will find tenderness in various parts of the body. During the examination a doctor may press firmly with a thumb on various parts of your body. The amount of pressure used does not cause pain in people without fibromyalgia. However, the pressure typically causes people with fibromyalgia to wince with pain. The increased sensitivity to pressure (being tender to mild pressure) can be in many places in the body, and may be all over. However, a doctor may press on certain specific sites (as shown in the diagram). These sites are generally fairly sensitive areas and the easiest to check for tenderness which is typical in people with fibromyalgia.

Apart from finding areas of tenderness, the examination by a doctor will usually find no other abnormality. There is no laboratory test that confirms the condition. However, tests are advised in some cases to rule out other diseases that can cause similar symptoms. For example, your doctor may do some blood tests to rule out an underactive thyroid, early arthritis, etc.

Is fibromyalgia serious?

Fibromyalgia is not an arthritis, it is not due to cancer, and does not damage any joint or tissue. It does not shorten expected lifespan. In some cases, symptoms ease or go after a few months. However, in many cases it is a chronic (persistent) condition which tends to wax and wane in severity. Quality of life can become affected.

 

What is the treatment for fibromyalgia?

There is no single or simple cure for fibromyalgia. Treatments aim to reduce symptoms as much as possible. Over the years a range of different treatments have been advocated with variable rates of success.

In 2007, a team of experts from 11 countries got together. They looked at the evidence (from research trials, review papers, etc) to determine which treatments should be recommended. Their recommendations were based on the results of research trials that had shown when a treatment had been beneficial to at least some people with fibromyalgia. They published a guideline called 'EULAR evidence-based recommendations for the management of fibromyalgia syndrome'. A number of recommendations were made, and each is briefly mentioned below.

But note: each person is different and has different circumstances and degrees of symptoms. Also, not all treatments help in all cases, and not all treatments may be locally available. Your doctor is likely to discuss the pros and cons of the various options, and help you to decide which is the best option, or options, to try. Indeed, the guideline pointed out that optimal treatment requires a combination of non-drug and drug treatments. Also, that treatment should be tailored to the individual according to pain intensity, function, and whether such features as depression, tiredness and sleep problems are also present.

NON-DRUG TREATMENTS

Exercise

Exercise helps to improves symptoms in a good number of cases. If you are able, consider gradually building up to more and more exercise. 

Walking, cycling and swimming are thought to be the best form of exercise to improve symptoms. 

Stretching exercises such as yoga also helps. 

A doctor or physiotherapist can advise on a suitable programme for your particular circumstances. The aim is to exercise safely and without increased pain. A typical goal to aim for is to build up exercise daily for at least 20 to 30 minutes a session. 

For example, one study published in the British Medical Journal describes how people with fibromyalgia were 'prescribed' an exercise class - mostly walking on treadmills, or using exercise bicycles. 

Each person was encouraged to gradually increase the amount of exercise. When people first started they usually did two sessions of exercise per class lasting about six minutes. By three months some people had increased to doing two sessions in each class lasting 25 minutes. At three months, about 1 in 3 people who did the exercise programme rated themselves as much, or very much, better.

Note: pain and stiffness can get worse for a short while when you first start on an exercise programme.

General measures to help treat fibromyalgia/rheumatoid arthritis/osteoarthritis/spondylitis/spondylosis

Weight control

If you are overweight, try to lose some weight as the extra burden placed on back, hips, and knees can make symptoms worse. Even a modest weight loss can make quite a difference.

Braces or supports may also be helpful for other joints affected by OA. For example, a support around the thumb for painful thumb OA.

Daily walking for 30 to 45 minutes with or without Walking aids

If you have OA of your hip or knee, when walking try using a cane (walking stick). Hold it in the hand on the opposite side of the body to the affected joint. This takes some pressure off the affected joint and helps to ease symptoms in some cases.

Diet - Vitamins, minerals, calcium should be obtained from natural dietary resources and 

not by 'vitamin tablets/capsules' which can increase your risk of 'medicinal side-effects'. 

Fruits, Salads, green vegetables/leaves, Sprouts -250 grammes

Curd/Yoghurt -250 grammes, 

Lemon juice with little salt/sugar.

Water -5-6 lit per day or more, daily slow sustained yoga type physiotherapy exercises as given in website is essential for good health of bones and body.

Daily brisk/speed walking for 1 hour, getting enough vitamin D from your diet, sunlight will decrease your risk.

Cycling outdoors and non-gym outdoor exercises such as brisk walking, using stairs at home and office, walk at work bring overall improvement in health, well being besides controlling and curing many diseases such as Hypertension, diabetes, depression, cancer, osteoporosis, arthritis, muscular pains and joint pains. 

Physical activity. Not exercising and being inactive or staying in bed for long periods can increase your risk.

Smoking. Smokers harm their blood circulation, damage all tissues in body by free radicals of smoke and absorb less calcium from their diets.

Medications. Some commonly used medicines can cause loss of bone mass. These include steroids used to control arthritis and asthma; some drugs used to treat seizures; some cancer drugs; and, too much thyroid hormone.

Low body weight. Women who are very thin – and small-boned – are at greater risk for osteoporosis.

Physiotherapy help if unable to follow correct exercises

Sometimes advice or treatment from a physiotherapist is helpful. For example:

• For advice on which exercises to do to strengthen the muscles above the knee (quadriceps) if you have arthritis of the knee. Strengthening the 'quads' has been shown to improve symptoms caused by arthritis of the knee.
• For advice on how to keep active and fit.
• For advice on shoes insoles, knee braces, taping to the knee, and how to use walking aids properly (to make sure you have one of the correct height).

Manipulation and stretching around affected joints may be helpful. This is something that physiotherapists may also be able to help with.

http://www.bbc.com/news/health-24933090

Why I take the stairs at the BBC

Stair climbing is officially classed as "vigorous exercise", burns more calories per minute than jogging and improves cardiovascular fitness and muscle strength.

Apparently you burn one and a half calories for every 10 upward steps and one calorie for every 20 steps down.

http://www.bbc.com/news/health-27904822

Even a small amount of activity can make major health gains, and this is what the population really needs to be taught.
Every action, even a single step on a stair or standing up for a few seconds, can put you on a positive path to better health.

http://www.bbc.com/news/health-28982126

Brain 'can be trained to prefer healthy food'

One study has even found that if you have more plants and flowers around your house you are not only more likely to have a diverse array of bacteria on your skin, you are also less likely to be allergic

http://www.bbc.com/news/health-28934415

http://news.bbc.co.uk/2/hi/uk_news/politics/3669517.stm

People of all ages should be encouraged to take more exercise according to a report by England's chief medical officer.

Sir Liam Donaldson says that exercise is a key factor in reducing the risk of cancer, heart disease and diabetes.

Adults should take 30 minutes of moderate exercise five times a week, children and young people 60 minutes.

Possible activities include walking to work or mowing the lawn.

http://www.bbc.com/news/health-28049568

How can I cut down on sugar?

"We need to reduce sugar intake but should not swap from sugar to fat", said Prof Susan Jebb of the University of Oxford. 

"A greater proportion of our plate should be fruit and vegetables and more fibre-rich carbohydrates and whole grain."

https://in.lifestyle.yahoo.com/world-vegetarian-day-2014-health-094251813.html

Health benefits of a vegetarian diet

Occupational therapy

An occupational therapist may be able to help if you need aids or modifications to your home to cope with any disability caused by OA. Special devices, such as tap turners to help with turning on a tap, may mean that you can carry out tasks around the house more easily.

Other therapies

• Some people have found that TENS (Transcutaneous Electrical Nerve Stimulator) machines help to ease pain from OA. A TENS machine delivers small electrical pulses to the body via electrodes placed on the skin.
• Acupuncture may also help to ease symptoms in some cases.
• Some people find that they can also get some pain relief from using hot or cold packs on the affected joint(s). This is also called thermotherapy. You can use a hot water bottle filled with either hot or cold water and apply it to the affected area. Or, special hot and cold packs that can either be cooled in the freezer, or heated in a microwave, are also available.

Medicines used to treat fibromyalgia/rheumatoid arthritis/osteoarthritis/spondylitis/spondylosis

Paracetamol

Paracetamol is the common medicine used to treat OA. It often works well to ease pain. It is best to take it regularly to keep pain away, rather than 'now and again' when pain flares up. A normal adult dose is two 500 mg tablets, four times a day. It usually has little in the way of side-effects, and you can take paracetamol long-term without it losing its effect.

Anti-inflammatory painkillers

You may find that a topical preparation of an anti-inflammatory painkiller that you rub onto the skin over affected joints is helpful instead of, or in addition to, paracetamol tablets. This may be particularly helpful if you have knee or hand OA. Compared to anti-inflammatory tablets, the amount of the drug that gets into the bloodstream is much less with topical preparations, and there is less risk of side-effects (see below).

Anti-inflammatory painkillers that are taken by mouth are not used as often as paracetamol. This is because there is a risk of serious side-effects, particularly in older people who take them regularly. However, one of these medicines is an option if paracetamol or topical anti-inflammatories do not help. Some people take an anti-inflammatory painkiller for short spells, perhaps for a week or two when symptoms flare up. They then return to paracetamol or topical anti-inflammatories when symptoms are not too bad. There are many different brands of anti-inflammatory painkillers. If one does not suit, another may be fine.

Side-effects may occur in some people who take anti-inflammatory painkillers:

• Bleeding from the stomach is the most serious possible side-effect. This is more of a risk if you are over 65, or have had a duodenal or stomach ulcer, or if you are also taking low-dose aspirin. Stop the medicine and see a doctor urgently if you develop indigestion, upper abdominal pain, or if you vomit or pass blood. Read the leaflet that comes with the medicine for a list of other possible side-effects. You doctor can prescribe another medicine that can help to protect your stomach if you are taking anti-inflammatory painkillers in the long-term. You should discuss this with them.
• Some people with asthma, high blood pressure, kidney failure, and heart failure may not be able to take anti-inflammatory painkillers.

Codeine

Codeine is sometimes combined with paracetamol for added pain relief. Constipation is a common side-effect from codeine. To help prevent constipation, have lots to drink and eat a high fibre diet.

Capsaicin cream

This cream is made from chilli peppers and it works by blocking the nerve signals that send pain messages to the brain. It may be helpful if you have knee or hand OA. It takes a while for the effects of this cream to build up and may take around one month to get the maximum benefit. You should rub in a pea-sized amount of cream around the affected joint four times a day, and not more often than every four hours.

Don't use this cream on broken or inflamed skin. You may notice some burning after you apply the cream but this tends to improve the longer you have used it. Avoid having a hot bath or shower, before, or after, applying the cream because it may make the burning sensation worse. Also, be careful to wash your hands after applying the cream. Because it is made from chilli peppers, it can cause burning if it gets into your eyes, mouth or around your genital area.

An injection of antiinflammatory medicine

An injection directly into a joint is useful if a joint becomes badly painful / inflamed.

Treatments that are not normally recommended

Glucosamine, cartilage regenerative drugs are Usually not helpful in long term as no reliable studies on them. besides they may affect liver function and kidneys.

Hyaluronic acid

The use of regular injections of hyaluronic acid directly into a joint is a relatively new treatment that has been tried for OA. The theory is that it may help with 'lubrication' and 'shock absorption' in a damaged joint. It may produce a small beneficial effect in some people. However, the National Institute for Health and Clinical Excellence (NICE) has looked at the use of hyaluronic acid as a possible treatment for OA and does not recommend its use. This is because there is little evidence that it is effective.

Chondroitin

This is another food supplement that has become popular as a potential treatment for OA. It is a chemical that is part of the make-up of normal cartilage. A recent big study showed that chondroitin has little, or minimal, effect on reducing symptoms in people with OA. Also, NICE does not recommend the use of chondroitin for the treatment of OA. This is because they could find no clear evidence from studies to show that it is an effective treatment.

Surgery for osteoarthritis/spondylitis/fibromyalgia/rheumatoid arthritis/osteoarthritis/spondylitis/spondylosis

Most people with OA/spondylitis do not have it badly enough to need surgery. However, OA of a joint may become severe in some cases. Some joints can be replaced with artificial joints. Hip and knee replacement surgery has become a standard treatment for severe OA of these joints. Some other joints can also be replaced.

Surgery

Seldom is surgery used to treat spondylosis. Most patients respond well to non-surgical treatment for spinal osteoarthritis.

Heated pool treatment with or without exercise

Heated pool treatment (balneotherapy) has been shown to improve symptoms in some cases. Some trials that looked into this included exercise in addition to heated pool treatment, and some did not. Both with and without exercise seemed to help in some cases.

For example, in one study of 42 fibromyalgia patients, half received 20 minutes bathing, once a day, five times per week, for three weeks (total of 15 sessions). Half did not have this treatment. The patients were evaluated by the number of tender points, and symptom severity (mainly pain). The evaluation was initially straight after the therapy, and then after six months. The results showed that, on average, the treated group had significantly less tenderness and pain - even six months after the treatment had finished.

Your doctor or physiotherapist may recommend a locally based heated hydrotherapy pool. However, if non is available, a heated swimming pool, or jacuzzi may suffice, or simply lying in a warm bath for 20 minutes per day may be of benefit.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) may be of benefit to some people with fibromyalgia. CBT is one type of psychotherapy ('talking treatment'). It is used as a treatment for various mental health and physical problems. Unlike other types of psychotherapy it does not involve 'talking freely', or dwelling on events in your past. CBT tends to deal with the 'here and now' - how your current thoughts and behaviours are affecting you now. CBT is problem-focused and practical. CBT may actually help to ease pain symptoms. But it can also help you to take control of the extent to which pain, tiredness, or other symptoms interfere with your life.

Other therapies

The guideline recommended that other therapies may be useful, depending on the individual person’s needs. The therapies thought to be useful included relaxation, physiotherapy, and psychological support.

DRUG TREATMENTS

Painkillers

Painkillers such as paracetamol, anti-inflammatory painkillers such as ibuprofen, or codeine may help to ease pain. However, they often do not work very well in fibromyalgia.

Tramadol is a stronger painkiller and is recommended if the above painkillers are not helpful. Research studies have shown the benefit of tramadol in people with fibromyalgia.

Very strong opiate painkillers such as morphine are not recommended. This is because fibromyalgia is a long-term condition. It is unwise to take strong opiates long-term due to problems with drug dependence.

Antidepressants

An antidepressant drug is a common treatment for fibromyalgia. Research studies have confirmed that antidepressants are often helpful for easing pain and improving overall function. They may also help with disturbed sleep. Although they are called antidepressants, they are not used in fibromyalgia to treat depression. Tricyclic antidepressants ease pain separately to their action on depression. Antidepressant drugs are used to treat various conditions apart from depression.

There are various antidepressants and your doctor will advise on one, if needed. A trial of 4-6 weeks is often advised, and continued if found to be helpful. Low doses are often used (compared to a dose that may be used to treat depression). However, if you have depression in addition to fibromyalgia, then a 'full strength' dose would be appropriate to treat both the pain of the fibromyalgia and the depression.

Other drugs

Drugs called pramipexole, and pregabalin have been recently studied in people with fibromyalgia. These drugs are usually used for other conditions (pramipexole for Parkinson's disease, and pregabalin for nerve pain). So far, the studies looking into their effect on easing pain in people with fibromyalgia have been promising. They seem to reduce pain in some people with fibromyalgia. One of these drugs may be advised if other treatments have not helped very much. Further research is needed to clarify their role in fibromyalgia and to study their long-term effects.

Other treatments

Some people try complementary or alternative treatments such as acupuncture, aromatherapy, massage, etc. There is little evidence that such treatments relieve the core symptoms of fibromyalgia. However, some people find that certain treatments help them to relax, feel less stressed, and feel better in themselves which helps them to cope better with their condition.

Note: sleeping tablets are not often used as they do not help with fibromyalgia, and can be addictive. See separate leaflet called 'Insomnia - Poor Sleep' which gives tips on getting a good night's sleep and may be of benefit if you have difficulty sleeping.

Further information and support

Fibromyalgia Association UK

PO Box 206, Stourbridge, West Midlands, DY9 8YL
Tel: 0845 345 2322 Web: www.fibromyalgia-associationuk.org

FibroAction

46 The Nightingales, Newbury, RG14 7UJ
Web: www.fibroaction.org