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Fibromyalgia

What is fibromyalgia?

Fibromyalgia (FM) is a medical condition that is believed to affect the central nervous system. The most common symptom of FM is widespread pain, which can be experienced in one or more places throughout the body. The pain can vary from person to person, may move around the body from time to time and may change in intensity on a daily or even hourly basis. People with FM may also experience other symptoms, such as fatigue, sleep difficulties, lack of concentration and memory, mood swings and gastrointestinal problems (such as constipation or diarrhea) and have a heightened sensitivity to touch and pressure.

FM is a relatively common condition, affecting 2% of Canadians.  Although FM primarily affects women (80 to 90% of people with FM are women), it is also seen in men, teenagers and children.

FM is not a disease of the joints, nor is it an inflammatory or degenerative condition. FM will not cause permanent damage to muscles, bones or joints. What FM does have in common with arthritis is that it can cause pain and fatigue and thus can have a significant impact on a person’s daily life.

Because the symptoms of FM are hard to test for and may change throughout the day or week, FM was often misunderstood and perceived as an “imaginary disease” or something that is “all in your head”. People with FM may look well, but may in fact be experiencing a lot of pain. While more research is needed to fully understand this condition, doctors are now better able to diagnose it and recognize that multiple physiological factors are at play in producing the symptoms.

For many, the cause of their FM cannot be identified. For many, the start of their FM may be pinpointed to a triggering event, such as a severe illness, a traumatic incident or a stressful, emotional experience (such as a car accident or the death of a loved one).

There is currently no cure for FM but medication, exercise, relaxation and stress-reduction measures, as well as other lifestyle changes, may help to reduce symptoms. Most persons with FM will, over time, find some method to reduce symptoms.

Fibromyalgia facts:

  • Fibromyalgia (FM) affects 2% of Canadians
  • Most people with FM are women (80 to 90%)
  • Although painful, FM does not lead to permanent joint damage or deformity
  • People with diseases such as rheumatoid arthritis (RA), systemic lupus erythematosus (commonly called lupus) and ankylosing spondylitis (AS) can also have FM
FAQs

What are symptoms of FM?

Pain is the most common complaint of people with FM. The pain of FM can be felt in one area or in many areas throughout the body. People with FM often find that firm pressure, particularly when applied to soft tissues such as muscles and tendons, can be painful. Pressure that can cause pain may be as gentle as a friendly hug or the weight of a child climbing onto a lap.

Other symptoms that may occur as a result of FM include:

  • Feeling tired and weak
  • Disturbed sleep
  • Irritability
  • Difficulty concentrating (sometimes called “fibro fog”)
  • Memory problems
  • Headaches
  • Gastrointestinal problems (such as constipation, diarrhea and irritable bowel syndrome)
  • Bladder dysfunction
  • Excessive sensitivity to loud sounds, bright light and  smells
  • Temperature sensitivity

Many people with FM feel discouraged; this may lead to depression and anxiety. For some people, symptoms may come and go or may be aggravated by additional stress or even by changes in the weather.

For many people, FM develops gradually and has no known cause. For others, FM may develop after an illness, a traumatic event or a stressful or emotional experience. Researchers are still looking for what triggers FM and why. Recent studies suggest that the body’s pain messages are relayed by the nerve cells in an abnormal way in FM: instead of the pain messages being dampened down over time they are amplified. It can be imagined that the volume control is turned up to high and the nervous system is put into overdrive. The brain has trouble understanding these messages, and this misunderstanding leads to chronic pain: pain that is recurring, long lasting or nearly constant.

Pain is normally an important safety mechanism for the body, but pain associated with FM is not.

How is FM diagnosed?

Your doctor will begin by asking questions about your pain, and taking note of symptoms that are present. Your doctor may ask questions about additional symptoms (such as fatigue and sensitivity to pressure and temperature), perform an examination or request blood tests or X-rays.

What are the risk factors for FM?

Research has not yet identified the exact cause of FM. It can occur on its own, but links have also been made to the following factors:

  • Age: People between the ages of 20 and 50 years old are most at risk of developing FM
  • Gender: Of those with FM, 80 to 90% are women
  • Family History: People who have a family member with FM may be more likely to have the condition themselves
  • Rheumatic disease: Those who have an existing rheumatic disease, such as rheumatoid arthritis (RA), ankylosing spondylitis (SA) or lupus, may be more likely to develop FM
  • Stressful or traumatic events:  FM is sometimes associated with exposure to a stressful or traumatic event, such as a car accident or death in the family

What body parts are affected by FM?

FM is a condition that causes pain in the soft tissues and muscles throughout the body. FM can also cause tenderness to touch. Areas commonly affected include:

  • Neck
  • Back
  • Chest
  • Arms
  • Legs

Why is treatment for FM so important?

Although there is no single treatment that works for everyone, over time most people with FM will discover, with the help of their health-care team, what gives them the best relief from their symptoms. The most important first step to help relieve symptoms of FM is to remain physically active. Although it might be difficult to begin to be active, regular exercise at a comfortable level has been shown to help decrease pain, fatigue and sleep difficulties and to improve mood.  For most people, medications do little to improve their symptoms, and the benefits of the medications are often outweighed by their side effects. However, good health-related practices, such as regular physical activity, a healthy diet, maintaining a good weight, keeping a routine and pacing and controlling stress, can all help improve FM symptoms. Eliminating all symptoms is rarely possible; therefore, the aim of a treatment plan should be to improve your symptoms as much as possible so that you continue to lead an active and enjoyable life.

Treatment

Medication

What types of medications are used for FM?

Unfortunately, there is no single medication that works extremely well for all people living with FM. Instead, you and your doctor should identify the symptoms that cause you greatest distress.  With most people, these include pain, sleep disturbance, mood disorder and fatigue. There are medications available for the management of the first three symptoms, but as yet there is no recommended treatment for the fatigue associated with FM.

Often treatment for FM is given on a trial basis. It is important for you and your doctor to decide whether a new medication has indeed had a sufficiently positive effect to justify continuing the treatment. If the positive effect is only minimal or, if there are side effects of the medication, then probably that medication should be discontinued and a new medication tried.

Two medications have been approved by Health Canada for treating the symptoms of FM: pregabalin, which is an anti-convulsant drug, and duloxetine, an anti-depressant drug. Other medications, some that have been available for many years, may be suggested by your doctor. Please discuss the use of any medication with your health-care provider.

Pain-relieving medications

For most people with FM, pain-relieving medications, called analgesics, are used either occasionally when symptoms worsen, or on a more regular basis.

Acetaminophen is considered a mild pain-reliever and often takes the edge off FM pain. This medication should be used only at the lowest dose and for as short a period of time as possible, as it may have potentially serious effects on liver function.

Stronger painkillers, including opioids, should only be considered for use in the most severe situations.  Only one opioid, tramadol, has been shown to have some effect for FM pain. Many questions remain regarding the safety of long term use of opioids. If you are using an opioid to treat the pain of FM, it is important to ensure that the benefit of pain relief is not outweighed by negative side effects, such as drowsiness, difficulty concentrating and thinking, sleep disturbance, nausea, loss of appetite and constipation. To justify continued treatment with an opioid, there should be improvement in pain, as well as a clear improvement in function.

Anti-convulsant medications

This category of medications reduces pain by decreasing the activity of nerves that are in overdrive due to FM. They work like the dimmer switch for a light bulb. The most common anti-convulsant medications used in FM are gabapentin and pregabalin. They are safe medications, without serious significant side effects. Their most common side effect is sleepiness. This can actually be an advantage when the medication is taken at night and may help with sleep disturbances often reported by people with FM, but can be troublesome during the day. If combined with alcohol or tranquilizers, however, the negative effect of unsteadiness or sleepiness may be exaggerated and could lead to harm.

Anti-depressant medications

Anti-depressant medications can be used to control pain and have shown some success in treating pain symptoms of FM. Anti-depressants act on pain by boosting the body’s natural mechanisms for reducing pain. Tricyclic anti-depressants were the first medications recommended for the treatment of FM, and still remain a useful drug for some. They have been used for many years and are fairly inexpensive. Tricyclic anti-depressants may help the symptom of poor sleep as well as pain. Newer anti-depressants belong to the group of serotonin norepinephrine reuptake inhibitors (SNRIs). Duloxetine falls into this category. Studies have found that SNRIs may have some modest effect on pain, fatigue and mood in some people with FM.

Many people with FM also experience symptoms of depression or anxiety. When these symptoms are sufficiently serious to affect your well-being, your doctor may decide to prescribe a medication to improve your mood. Depending on the anti-depressant medication chosen, there may be the added effect of calming anxiety, promoting sleep or improving energy.

Therapy

Physiotherapy

Physiotherapy is a science-based practice that aims to enhance or restore function of different systems of the body. Physiotherapists are trained to diagnose musculoskeletal complaints and are able to plan a treatment for joint and muscle problems using physical remedies, such as massage, specialized exercise programs, stretching, hydrotherapy and breathing techniques. These treatments can help relieve pain, improve posture and strength and allow you to become more independent and active over time.

Occupational therapy

Occupational therapy is a form of therapy for those recuperating from physical or mental illness. It encourages rehabilitation through the performance of day-to-day activities. An occupational therapist may offer you guidance on how to pace yourself, change the way you work, modify your environment and/or use labour-saving gadgets.

Self-Management  

There is no single treatment that works for everyone. Over time, most people with FM will find the balance of treatments that gives them the best relief. Eliminating all symptoms is rarely possible, but a management plan can help you contain your symptoms so that you can lead an active and enjoyable life. Your first and most important step is to become an active participant in your treatment and develop coping strategies to manage your FM. It is also important to learn more about your condition and share that information with family and friends, so they can understand how you feel physically and emotionally.

Non-medication therapies, such as physical activity, stress management and relaxation techniques, are a very important part of treating FM.

Sleeping

Fatigue is a key symptom of FM so getting enough and proper sleep is important when it comes to managing your condition. Sleep can help to decrease not only the fatigue but also the pain of FM. It is also important that you do not spend extended hours in bed as too much rest and sleep can also be harmful to you both physically and emotionally.

Tips to help you get a good night’s rest:

  • Avoid caffeine in the evening (including soft drinks, alcohol, coffee and caffeinated tea)
  • Avoid smoking
  • Avoid watching TV or using electronic devices (such as mobile devices and laptops) late at night
  • Develop a regular routine to help you wind down before bedtime
  • Go to bed and wake up at the same time each day
  • Ensure your bedroom is dark, quiet and a comfortable temperature

Physical activity

Although pain and fatigue can make exercise difficult; it is important to be as physically active as much as possible. Research shows that regular physical activity is one of the most effective treatments for FM.

Regular physical activity can reduce pain and fatigue, improve mobility and sleep issues as well as alleviate depression. Overall, it can help someone with FM to lead a more productive and enjoyable life. An exercise program designed for you by a professional is ideal, but participation in an appropriate community-based program is fine too.

People living with FM may experience muscle stiffness. This stiffness cannot be reduced by rest. On the contrary, inactivity can cause muscle weakness and worsens the stiffness: so try to get up and exercise.  However, it is important to always listen to your body and if you are in a lot of pain, reduce or perform only light range of motion exercise.

There are different types of exercises you can do to lessen your pain and stiffness:

  • Range of motion (also called stretching or flexibility exercises): Ideally, these exercises should be done daily. Also, watch our “Simple Stretches” video.
  • Strengthening: Exercises that maintain or increase muscle tone. These exercises include weight training movements that can be done with your own body weight, or with a set of “free” weights or with a weight machine.
  • Endurance: Exercises that strengthen your heart, give you energy, control your weight and help improve your overall health. These exercises include walking, swimming and cycling. It is best to avoid high-impact exercises like step aerobics, jogging or kickboxing unless you are very well-conditioned.
  • Low-impact: There are many low-impact exercise options that can benefit people living with FM. Consult your health-care provider to find exercises that are suitable to you and your particular condition.
  • Tai chi: An ancient Chinese martial art, tai chi is a combination of movements performed in a slow, focused manner. Though it has many variations and styles, Tai chi is a low-impact exercise and is similar to both yoga and meditation. Tai chi can reduce pain and increase physical function in some people, as well as reduce depression and contribute to health-related quality of life.
  • Yoga: Studies have shown some benefits of yoga for people living with FM. The practice of breath control, simple meditation and stretching can improve a person’s state of mind and help them better manage their pain. Regular yoga under the guidance of a certified instructor can also boost your general health and increase your energy levels.
  • Water and aerobic exercise: Water exercises, such as swimming and water aerobics, are excellent for people living with FM and suitable for all ages and fitness levels. Water can help you move in ways that would otherwise be painful. Other low-impact aerobic exercises that can get your heart pumping include biking and walking. All these exercises can help improve your sleep, keep weight under control and help to alleviate stress and depression that is sometimes linked to FM.

It is important to note that regular physical activity at a comfortable level is good for your overall health and will not cause you harm or damage to your body.  Sometimes keeping a diary over several weeks is a good way to encourage yourself to keep up a regular routine. A diary can also help you keep track of the connection between your FM symptoms and your daily activities, which can help you and your doctor manage your FM.

Healthy eating

Although no specific diet has been proven to help FM, healthy eating will give you the energy to complete your daily activities as well as contribute to a strong immune system, and bone and tissue health.

Three ways to improve your nutrition include:

  • Reduce sugar intake: Sugar added to foods contributes calories, but few other nutritional benefits. Sugar refers to white, brown, cane and raw sugar as well as syrup and honey. Instead, use dried fruits such as raisins or dates to sweeten food since they provide vitamins, minerals and fibre. Although artificial sweeteners contain few calories, it is better to minimize their use and just get used to food being less sweet.
  • Eat more vegetables and fruit: Vegetables and fruit should make up the largest component of your diet. Try to have at least one vegetable or fruit at every meal and as a snack. Besides being an excellent source of energy, vegetables and fruit boost your fibre intake. Fibre makes you feel full and so helps you to control how much you eat.
  • Choose “healthy fats”: The type and amount of fat you eat is important. You need some fat in your diet, but too much can be bad for your health. Fat is high in calories and some types of fat (saturated and trans fats) may increase your risk of developing heart disease. Polyunsaturated and monounsaturated fats are recommended as the main source of fat in your diet. Monounsaturated fat is found naturally in olive and canola oil, avocadoes and nuts like almonds, pistachios and cashews. Polyunsaturated fats, especially omega-3 and omega-6 fatty acids, can be found in cold-water fish (such as char, mackerel, salmon and trout), walnuts, sunflower seeds and flaxseeds. Fats that should be limited include trans fats, which are found in fried and processed foods, and saturated fats, which mainly come from animal sources of food, such as red meat, poultry and full-fat dairy products. Choose healthier dairy products (such as skim, 1 or 2% milk, low-fat yogurt and low-fat cheese).

Complementary medicine

People with a chronic condition like FM may decide to try complementary and alternative therapies to help them manage the symptoms of their condition.

Before you try any of these treatments, always inform your health-care provider of any complementary and alternative therapies you are taking, receiving or would like to try. Your health-care provider can offer valuable advice about these treatments, especially how they may affect other medications and treatments.

Massage

Massaging of muscles and other soft tissues, by a professional massage therapist, may lead to a short-term decrease in stiffness and pain. Other benefits may include a reduction in stress and anxiety as well as improved sleep patterns.

Meditation

Meditation is a mind-body practice intended to quiet the mind by focusing on your breathing. Some studies have found that meditation, if practiced regularly, can ease pain and anxiety in individuals with FM. It can also offer people a heightened sense of calmness and control.

Acupuncture

Acupuncture, an ancient Chinese therapy for alleviating pain and treating various physical and mental health conditions, involves pricking the skin with needles. While studies on the effectiveness of acupuncture for FM symptoms are somewhat mixed, you may wish to try this treatment. It is important to find a certified practitioner.

What Now

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Contributors

This information was last updated September 2017, with expert advice from:

Mary-Ann Fitzcharles, MB ChB, MRCP (UK), FRCPC
Associate Professor, Division of Rheumatology, Alan Edwards Pain Management Unit, McGill University Health Centre

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