Polyarthralgia / fibromyalgia

Fibromyalgia / Polyarthralgia typically causes persistent pains and tenderness in many areas of the body as well as tiredness. You may also have other symptoms. There is no simple 'once and for all' cure. However, various treatments are available that ease symptoms in many cases. Non-drug treatments that may help include exercise, heated pool treatment, and cognitive behaviour therapy. Drug treatments that may help include a painkiller called tramadol, antidepressants (for their pain-relieving action) and some other drugs listed below.

What is fibromyalgia // Polyarthralgia?

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 doesnot affect the joints, and so is not an arthritis.

What causes fibromyalgia/ / Polyarthralgia?

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 / Polyarthralgia?

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 / Polyarthralgia?

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 / Polyarthralgia 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 / Polyarthralgia?

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 does not always help, but studies have shown that it improves symptoms in a good number of cases. If you are able, consider gradually building up to more and more exercise. Aerobic exercises which cause little 'pounding' such as walking, cycling and swimming are thought to be the best form of exercise to improve symptoms. Stretching exercises such as yoga may also help. 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 to 4-5 times a week for at least 20 to 30 minutes a session. However, it may take months to build up to this level.

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.

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

References

• Evidence based recommendations for the management of fibromyalgia syndrome, European League Against Rheumatism (July 2007)

• Gilliland RP; Fibromyalgia; emedicine. January 2007.

• Busch AJ, Barber KA, Overend TJ, et al; Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003786. [abstract]

• Richards SC, Scott DL; Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial. BMJ. 2002 Jul 27;325(7357):185. [abstract]

• McVeigh JG, McGaughey H, Hall M, et al; The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: a systematic review. Rheumatol Int. 2008 Aug 27. [abstract]

• Evcik D, Kizilay B, Gokcen E; The effects of balneotherapy on fibromyalgia patients. Rheumatol Int. 2002 Jun;22(2):56-9. Epub 2002 Mar 29. [abstract]