Fibromyalgia

​Symptoms of fibromyalgia

Fibromyalgia is a condition characterized by widespread pain in the body with diffuse pain in all 4 quadrants of the body. Fibromyalgia occurs more often in women than men with a ratio of 3:1. There is also often a connection with other rheumatic diseases – for example, 25% with rheumatoid arthritis, 50% with Sjögren’s syndrome and 30% with systemic lupus also have fibromyalgia.

Research suggests that fibromyalgia can be explained by abnormal central pain input – i.e. sensitization of pain-modulating systems in the central nervous system. It is the afferent neurons – i.e. those that conduct input back to the nervous system – that become more sensitive, resulting in increased pain sensitivity.

Often, a generally higher level of pain will be accompanied by symptoms such as sleep disturbances, increased fatigue, cognitive dysfunction, headaches, jaw tension, sensory disturbances (either decreased or increased response to stimuli) and symptoms from internal organs such as bowel irritation and bladder irritation. Functional capacity may also be reduced due to pain, which can affect daily life.

It has been documented that patients with fibromyalgia have a reduced threshold for mechanical stimulation of deep tissues and other inputs such as heat and cold.

Sources: Reumatologi 3. Udgave, Pathology and intervention in musculoskeletal rehabilitation second edition, Sundhed.dk

Diagnosing fibromyalgia

Fibromyalgia is diagnosed based on international classification criteria defined in 1990. This is done based on 18 tender points in different places in the body, of which at least 11 must be able to cause pain with a pressure of 4 kg. However, later, with well-treated fibromyalgia, you can have less than 11 points and still have the diagnosis.

In addition to the 11 points, you must have had pain for at least 3 months, and there must be pain on both the right and left sides, as well as both above and below the waist.

Causes and risk factors for fibromyalgia

The causes of fibromyalgia are not fully understood, but there are some connections between the condition and other significant factors:

• There is a link with long-term chronic pain, which has provided nociceptive input to the nervous system for a long period. This can cause biochemical and neuroplastic changes in the nervous system that can lead to hypersensitivity.
• There also seems to be a genetic connection – for example, children of patients with fibromyalgia have an 8-fold greater risk of developing it themselves. A study from the USA has shown a 13-fold greater risk of developing the disease in siblings. Chromosome no. 17 has been shown to contain an area that may predispose to the development of fibromyalgia.
• There is also a connection to psychosocial and environmental factors. External influences probably play a role in the development of the condition, such as physical or psychological trauma, chronic neck or lower back pain, and long-term stress.
• Several studies have also described changes in the hypothalamic-pituitary-adrenal axis and the function of the autonomic nervous system in people suffering from fibromyalgia.
• Changes in levels of pro- and anti-inflammatory cytokines can also be seen, which may explain increased stiffness and sleep disturbances in fibromyalgia.
• A reduced incidence of µ-opioid receptors, which are the ones the body uses to relieve pain, has also been found. This may also explain why pure morphine preparations are not effective in this group, whereas tramadol, which in addition to affecting µ-opioid receptors also has a noradrenergic/serotonergic effect, has been shown to be more effective.

It is recommended that local pain conditions such as herniated discs and tendon problems be addressed quickly so that they do not develop into later increased sensitization and centralization of pain and thereby an increased risk of developing fibromyalgia.

Treatment options and management of fibromyalgia

Although the specific causes are not yet fully known, there are various treatment options for fibromyalgia:

Medical treatment

Pharmacologically, there has been evidence to support the use of antidepressants that affect serotonin and noradrenaline reuptake – and also gabapentanoids such as gabapentin and pregabalin and, as previously mentioned, tramadol. Opioids, paracetamol or NSAIDs have not been shown to be effective.

Research is also being conducted into the use of low-dose naltrexone (LDN) for patients with fibromyalgia. This substance acts as an inhibitor of the µ-opioid receptors. Therefore, when treated with this substance, the body will form more receptors, making you more sensitive to the supply of opioids. This means that the body’s own pain-relieving substances, the endorphins, will work better. Pilot studies have so far shown that LDN can have a beneficial effect on pain, fatigue and improved sleep. The use of medication should be done in consultation with your doctor.

Physical activity

Exercise for people with fibromyalgia makes good sense, especially aerobic exercise such as cycling, walking, swimming and rowing. There is also moderate evidence that exercise in warm water can have a positive effect on pain and quality of life more than 20 weeks after exercise.

The effect of strength training, on the other hand, is not as well documented. It is recommended to proceed slowly based on the principle of “start low, go slow”. In the beginning, it is recommended to start with aerobic training and in any case avoid excessive eccentric and isometric training, as this can result in hyperexcitation of the central nervous system.

Long-term effects and complications of fibromyalgia

There are not many outcome studies that address long-term complications of fibromylagia. However, for example, increased mortality rates have not been recorded in this patient group, but a generally decreased health-related quality of life has been demonstrated compared to other chronic patient groups.

A 1998 study on myofascial pain and whiplash, which can also be present in fibromyalgia, shows that a rehabilitation program has had an effect up to 2 years later, and that it has had a positive effect on coping strategies, joy of life and a reduction in the number of sick days.

For most patients with fibromyalgia, the symptoms are chronic, but most can continue to have a job – 10-15% are, however, declared unable to work. A correlation has been registered here that shows that it helps if you get the right diagnosis early in the process, so that you can work with it properly. Studies from the USA indicate that with the right rehabilitative efforts, you will be better able to maintain your work.

In Denmark, approximately 50% of the patient group receives some form of social benefit as an expression of generally reduced working capacity.

Fibromyalgia and Lifestyle: Exercise, Diet, and Sleep

Various things can worsen the symptoms of fibromyalgia, so it is important to focus on, for example, diet, ergonomics at work, in the car or in your own home, and posture. Below is a number of tips that can be useful to keep in mind:

• Aerobic exercise has a good effect on pain intensity, so moderate physical exercise will be beneficial.
• Environmental or psychosocial factors such as stress, depression or anxiety can also worsen the pain experience, which is why it may make sense to work on coping strategies beforehand so that you can better regulate it yourself. This can also be through mind-body techniques such as meditation, mindfulness or yoga.
• Regarding diet, it suggests that an anti-inflammatory diet may have a beneficial effect on chronic pain. Therefore, a more plant-based diet may make sense, as vegetables are high in various antioxidants.
• Another recommendation is vitamin D. Vitamin D deficiency is linked to symptoms of fibromyalgia, according to the National Institutes of Health.
• For patients with fibromyalgia, it may be a good idea to limit the intake of foods high in saturated fat, such as full-fat dairy products. Here, you can switch to light products instead. There are also various studies that indicate that it may also be a good idea to limit gluten in the diet if you have fibromyalgia.
• In addition, one study found a 30% reduction in symptoms in patients who avoided the additives MSG (monosodium glutamate) and the sweetener aspartame.
• Sleep is also an important factor in pain, so it’s a good idea to get 8-9 hours of sleep a night. Sleep affects the secretion and regulation of cortisol, the body’s stress hormone.

This advice probably won’t eliminate all the symptoms associated with fibromyalgia, but it does have the potential to alleviate them.

Psychological aspects of living with fibromyalgia

It is a well-known fact that there is a link between depression and anxiety and chronic pain. The rate of depression and anxiety in patients with chronic pain is 40-60% for people affiliated with treatment centers, but in more population-based studies, a 7.1% risk of depression in relation to fibromyalgia has been registered, which is not much higher than for the rest of the population (4.1%).

Cognitive behavioral therapy has been shown to be effective in building coping strategies and counteracting inappropriate thinking and behavior related to chronic pain. Again, studies indicate that the best results occur if cognitive behavioral therapy is combined with other treatments and interventions.

As previously mentioned, there has also been success in using cognitive therapy and mind-body techniques to reduce stress. Psychological stress has been associated with increased numbers of myofascial trigger points and thus possible increased pain experience.

Recent research findings on fibromyalgia

Studies from 2011 and 2015 have shown that treatment of connective tissue in particular can be beneficial – e.g. myofascial release. This suggests that it can have a beneficial effect on fatigue, stiffness in the body, pain perception and quality of life. Manual lymphatic drainage can also have an effect on stiffness, depression and quality of life. The studies have shown improvement after treatment up to 6 months after, after which the effect decreases when measured again one year after the treatment. It must therefore be a recommendation that when you are well treated, you receive follow-up treatment every six months, for example.

As previously mentioned, however, it makes good sense to work multifactorially with a focus on, for example, environmental stressors, diet and lifestyle – possibly also with mind-body techniques such as yoga, tai-chi and biofeedback. It is also recommended to treat local pain-causing conditions such as tendinitis, bursitis and radiating pain in order to reduce the nociceptive input to the central nervous system.

Myths and misconceptions about fibromyalgia

Fibromyalgia is a recognized diagnosis by the WHO with an international disease classification, so it is misunderstood that it is just a diagnosis of exclusion. It is also not just psychological when patients with fibromyalgia have pain. The pain experience is real enough, but as previously mentioned, the nervous system itself is sensitized, so small stimuli are experienced more strongly than in other people. As previously mentioned, there is a connection between chronic pain and the psyche, just as during periods of stress one can experience increased pain, but this does not mean that the pain is just something psychological or simply stems from a stressful period.

The symptoms of fibromyalgia can be confused with symptoms of myofascial pain syndrome, as this can also cause pain in different parts of the body. With myofascial pain syndrome, a tight/tense structure in a muscle can often be felt, which can cause referred pain. However, this does not necessarily have to be the case with fibromyalgia. Furthermore, pain associated with myofascial pain syndrome may not necessarily be found both above and below the waist and in all 4 quadrants of the body.

Other differential diagnoses may include joint dysfunction, muscle arthritis, neurogenic diseases or neuropathies, inflammation of local tendon junctions, degenerative changes in the disc, referred pain from organs or mechanical stress, e.g. due to scoliosis or leg length discrepancy. Other underlying conditions that may resemble the symptoms may also include a lack of various vitamins or minerals or anxiety and depression.

As previously mentioned, some of these conditions can also be present along with fibromyalgia, but they can also be present even if you do not meet the criteria for the diagnosis.

Complementary and alternative therapies for fibromyalgia

• The effects of classical massage and classical acupuncture do not appear to be long-lasting for patients with fibromyalgia. However, massage has been shown to be more effective if combined with stretching exercises.
• Using dry needling techniques has been effective in treating myofascial trigger points, but results in subsequent soreness after treatment.
• Using ultrasound as a treatment has not been shown to have a long-term effect on symptoms.
• It appears that forms of electrotherapy such as TENS and FREMS have had a longer-lasting effect on myofascial pain, which can also be present in people with fibromyalgia.