Fibromyalgia, affecting some 5–10 percent of the population, is characterized by tight, tender muscles, usually sore points in the neck, shoulders, chest, back, knees and hips. Insomnia and depression often are associated with the condition. While it is benign and non-progressive, fibromyalgia is chronic. No specific cause is known, although it sometimes appears following trauma. Chronic pain affects some 80 million Americans and, following cancer and heart disease, is the third leading cause of physical impairment in the United States .

Diagnosis of fibromyalgia often involves ruling out other illnesses. Treatment is primarily exercise and may include some kind of medication. From low back pain and herniated discs to carpal tunnel syndrome and tendinitis, physiatrists seek to not only reduce and eliminate chronic pain, but also to prevent its recurrence.

^ Back to top

Fibromyalgia is sometimes categorized as primary or secondary; primary fibromyalgia is the more common form.

The cause or causes of primary fibromyalgia are not known; this condition is also sometimes referred to as idiopathic fibromyalgia. Many experts believe that fibromyalgia is not a disease but rather a dysfunctional disorder caused by a constellation of biologic responses to stress in individuals who are more susceptible to such stress because of negative personal histories or genetic factors.

Family Factors

One recent study reported that 28% of the children of mothers with fibromyalgia also develop the disorder. There were no differences in psychological disorders among those offspring with fibromyalgia and those who did not develop it. Another study noted that 66% of parents of children with fibromyalgia reported some sort of chronic pain--with about 10% reporting fibromyalgia. Close-knit families, oddly enough, were more likely to be associated with severe cases of childhood fibromyalgia.

One noted that the severity of the disorder increased in children whose parents were less able to cope with their children's pain. It is not clear if genetic or psychological factors or both are involved.

Chronic Sleep Disturbance

Some experts believe that disturbed sleeping patterns may be the original precipitating factor for many cases of fibromyalgia pain. In one study, volunteers who did not have fibromyalgia reported fibromyalgia-like pain after they had been subjected to disrupted deep sleep. Disturbed sleep appears to trigger factors in the immune system that cause inflammation and pain.

Abnormalities in the Brain

Studies of hormonal, metabolic, and brain chemical activity in fibromyalgia patients have shown a number of abnormalities. Brain scans of fibromyalgia patients have revealed reduced blood flow to certain regions of the brain related to pain sensation. Of particular interest to researchers are possible abnormalities in the brain system known as the hypothalamus-pituitary-adrenal gland axis, which controls important functions, including growth, sleep, response to stress, and depression. One research target is the hormone somatomedin C (also called insulin-like growth factor), which is produced by the pituitary gland in the brain during deep sleep and is responsible for communicating information about pain-producing stimuli to the brain. Very high levels of somatomedin C have been detected in the spinal fluid of fibromyalgia patients. Such increased levels may cause a heightened sensitivity for pain in such patients, who can experience pain even after mild muscular activity. This causes patients to reduce their physical activity, which, in turn, results in muscle weakness, leading to a perpetual loop of muscle atrophy, and increasing pain with less and less physical exertion. The pain also causes on-going sleep disturbance. Excess somatomedin C may be due to a genetic defect or may be derived from early unhealthy sleep habits that, over time, cause hormonal and brain chemical imbalances.

People with fibromyalgia also tend to have low levels of the neurotransmitter serotonin and its precursor, an amino acid called tryptophan. (A neurotransmitter is a chemical in the brain that serves as a messenger between neurons.) Low levels of both these chemicals are associated with depression and other symptoms of fibromyalgia, including gastrointestinal distress, migraine headaches, and anxiety. Some experts believe that migraine headaches and fibromyalgia are related because of possible defects in the systems that regulate serotonin and another neurotransmitter, epinephrine (commonly called adrenaline). Low levels of magnesium have also been noted in both fibromyalgia and migraine sufferers.

Autoimmunity

Fibromyalgia resembles a number of rheumatic disorders that are known as autoimmune disorders, including rheumatoid arthritis and systemic lupus erythematosus. These diseases occur when a defective immune system produces factors known as autoantibodies, which attack proteins in the body's own tissue, mistaking them as antigens (foreign proteins). Recently, researchers have identified certain autoantibodies in many fibromyalgia patients that affect neurologic and hormonal systems. There is no strong evidence, however, that a faulty immune system is a primary cause of fibromyalgia.

Post-Traumatic Stress Disorder

One study has indicated that the incidence of sexual and physical abuse is higher in female patients with fibromyalgia than in the general population. This could indicate that posttraumatic stress syndrome may play a role in the development of this disorder in some patients. Post-traumatic stress disorder (PTSD) is an anxiety disorder that is a reaction to a specific traumatic event. Symptoms of this condition, which can occur for years after the traumatic event include emotional withdrawal, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle response to noise. There is some evidence that PTSD actually results in changes in the brain, possibly from long-term overexposure to stress hormones.

Hypervigilance

It has been suggested that some factor or a combination of factors, such as a genetic susceptibility, biologic abnormalities, chronic sleep deprivation, or trauma, causes generalized hypervigilance , an amplification of sensation. People with this condition are oversensititive to external stimulation and are preoccupied with the sensation of pain. One study compared three groups of individuals: those with fibromyalgia; patients with rheumatoid arthritis; and people without these disorders. They were given a questionnaire to assess their response to pain and noise. Of the three groups, the fibromyalgia patients were least tolerant and most attentive to such stimuli.

Muscle Cell Abnormalities

Early research suggested that fibromyalgia is basically a muscular disorder. One relatively recent study reported that fibromyalgia patients had lower levels of the muscle-cell enzyme phosphocreatine and adenosine triphosphate (ATP). Such enzymes regulate the ebb and flow of calcium in muscle cells, an important component in their ability to contract and relax. If ATP levels are low, calcium is not "pushed back" into the cells and the muscle remains contracted. Such abnormal enzyme levels could derive from signals in the brain, although some researchers have observed overly thickened capillaries in the muscle tissue of fibromyalgia patients, which could produce lower enzymes levels as well as reduce the flow of oxygen-rich in the muscle tissue. Nevertheless, most research is now showing that fibromyalgia is probably due to abnormalities in nervous or immune systems rather than in muscles.

^ Back to top

Secondary fibromyalgia is caused by specific disorders, including injury, ankylosing spondylitis, or surgery. The symptoms are identical to those of primary fibromyalgia but are harder to treat. In one study, secondary fibromyalgia developed in over 20% of patients who had neck injuries.

Fibromyalgia is the most common cause of widespread muscular pain and affects an estimated 2% of the general population. Two thirds of patients are women, and their symptoms are more severe than men's. An increased incidence of fibromyalgia has been reported in people who have relatives with the disorder, indicating that a genetic component may cause certain people to be more susceptible to fibromyalgia. The disorder usually occurs in people between 20 to 60 years of age and peaks at age 35. In one study, however, fibromyalgia increased with age and had a prevalence of over 7% in patients between 60 and 79 years of age. A condition called juvenile primary fibromyalgia, which appears in children, is uncommon, but studies indicate that its incidence is increasing. One study found that 1.2% of school children--all girls--met the criteria for fibromyalgia. Other studies have found an even higher prevalence of fibromyalgia in children.

Diagnostic Criteria

In spite of increasing evidence that fibromyalgia is a physical disorder, there is no unequivocal objective method for diagnosing the problem. Accordingly to American College of Rheumatology Classification criteria for a diagnosis of fibromyalgia requires the presence of at least 11 of 18 specific areas on the body that are intensely painful (not just tender) when pressed. These trigger points can be found in the following areas:

• on left or right side of the back of the neck, directly below the hairline;
• on left or right side of the front of the neck, above the collar bone (clavicle);
• on left or right side of the chest, right below the collar bone;
• on left or right side of the upper back, near where the neck and shoulder join;
• on left or right side of the spine in the upper back between the shoulder blades (scapula);
• on the inside of either arm, where it bends at the elbow;
  
• on left or right side of the lower back, right below the waist;
  
• on either side of the buttocks right under the hip bones;
  
• on either knee cap.

(Some people also experience tender points at the bottom of their feet.) To confirm the diagnosis, widespread pain, which is experienced in upper and lower and left and right parts of the body and in the spine, must persist for at least three months. Using such criteria is helpful in making a diagnosis of fibromyalgia, but it is not completely reliable and misses about 10% of patients. Because the sensitivity of tender points may vary depending on circumstances, a physician may re-check pressure points that do not respond the first time in patients who have other significant symptoms. Some experts believe that fibromyalgia can be diagnosed if only 8 to 10 tender points are identified but the patient also has at least three other relevant symptoms, including morning stiffness, fatigue, sleep disturbance, numbness or tingling in the hands and feet, or headache.

Although symptoms are similar in children, some experts suggest that they often have no set number of pain trigger points. In one study, children had an average of 9.7 trigger point locations compared to the minimum of 11 in adults. In general, children with fibromyalgia most often experienced sleep disorders and diffuse pain, and less frequently headache, general fatigue, and morning stiffness.

Medical and Personal History

A physician should always take a careful personal and family medical history, which would include a psychological profile and a history of any factors that might be indicative of disorders other than fibromyalgia, including recent weight change, physical injuries, infectious diseases, muscle weakness, rashes, and any instances of sexual, physical, or substance or alcohol abuse. The patient should report any drugs being taken, including vitamins and over-the-counter or herbal medications.

Physical Examination

Any physical examination for fibromyalgia requires that the physician press firmly on all potential trigger spots. It also includes scrutiny of nails, skin, mucous membranes, joints, spine, muscles, and bones to help rule out arthritis, thyroid disease, and other disorders.

Other Tests

In most cases of fibromyalgia, laboratory tests tend to be normal; if they are abnormal, then other disorders should be suspected. Tests for specific diseases may be given if a family history or symptoms of other disorders are present. Sometimes blood tests, such as thyroid and liver function tests, blood count, tests of certain antibodies, and sedimentation rate, are recommended. Follow-up psychological profile testing may be suggested if laboratory results do not indicate a specific disease. One study found high levels of an autoantibody called antipolymer antibody in nearly half of fibromyalgia patients but not in patients with autoimmune diseases, such as rheumatoid arthritis. A test for this antibody is in development, and may help differentiate between fibromyalgia and these other, sometimes similar, disorders.

Between 10% and 30% of office visits are due to symptoms that resemble those of fibromyalgia, including fatigue, malaise, and general muscle pain. No laboratory test can confirm a diagnosis of fibromyalgia, and if tests for tender spots are ambiguous, physicians will rule out other conditions, including various physical diseases, chronic fatigue syndrome, sleep disturbances, medications, toxins, and psychological causes. It should be noted that a diagnosis of any of these disorders may not always rule out fibromyalgia, which can accompany other common and similar conditions.

Chronic Fatigue Syndrome

About 75% of patients fit the diagnosis for both fibromyalgia and chronic fatigue syndrome (CFS). As with fibromyalgia, the cause of CFS is unknown and its course is chronic. Both disorders can be diagnosed by a physician only on the basis of symptoms reported by the patient and cannot be confirmed by laboratory tests or other objective measures. The two disorders share most of the same symptoms; some patients with CFS even exhibit similar tender pressure points, although muscle pain is less prominent in patients with CFS. The two disorders are even treated almost identically. Fatigue is the dominant symptom in CFS and pain with tender points is predominant in fibromyalgia. Some physicians believe that fibromyalgia and CFS are the same and define fibromyalgia as an extreme variant of chronic fatigue syndrome. One physician described the relationship between fibromyalgia and chronic fatigue as similar to one between a migraine and a headache. There is some physical evidence, however, that the two disorders may be distinct, which offers the possibility for treatments that are specific to each. Some research indicates, for example, that patients with fibromyalgia may have high levels of a compound called substance P in their spinal fluid while CFS patients may not. Levels of substance P change in response to pain.

Other Myalgias

Myalgia is the common term for muscle pain. A number of disorders of unknown causes may be similar to fibromyalgia. Polymyalgia rheumatica is one such disorder; it causes pain and stiffness in the neck and shoulders and in the hip and thigh. Morning stiffness is common and patients may also experience fever, weight loss, and fatigue. Tender points with this disorder almost always occur in the hip and shoulder area. It also usually develops in women over 50. A blood test called the erythrocyte sedimentation rate (ESR or sed rate) often shows elevated results in polymyalgia rheumatica. It is important to rule out polymyalgia rheumatica because, although the condition often resolves in about a year, there is a risk of persistent disease and, worse, it is associated with a rare condition called temporal arteritis, which causes blindness if not healed.

Rheumatoid Arthritis and Other Autoimmune Diseases

Some diseases that cause symptoms similar to fibromyalgia are known as autoimmune disorders, in which the person's immune system attacks the body's own tissues. Like fibromyalgia, many of these diseases are more common in women than in men. Rheumatoid arthritis is most apt to mimic fibromyalgia and includes morning stiffness, fatigue, and tender points. Pressing such points, however, does not produce the intense pain that occurs with fibromyalgia, and abnormal laboratory tests can usually differentiate this disorder from fibromyalgia. Another autoimmune disease is Hashimoto's thyroiditis, a form of hypothyroidism (low levels of thyroid hormone), which, if undetected, can cause widespread muscle aches, depression, and fatigue. Other autoimmune disorders with similar symptoms and with a higher prevalence in women than men are systemic lupus erythematosus (SLE) and multiple sclerosis. Fibromyalgia symptoms, in fact, are very common in SLE patients, although the two conditions are thought to be distinct. Autoimmune diseases evolve slowly, and even when physicians diagnosis fibromyalgia, they should keep track of any changes in symptoms over time in order to rule out these other illnesses, which require different treatments.

Other Medical Conditions

Many diseases, both benign and serious, can cause general muscle aches and prolonged fatigue, including chronic hepatitis, anemia, infections, various forms of cancer, gout, neuromuscular diseases, and diabetes. Physicians can usually distinguish these diseases from fibromyalgia after a clinical evaluation and laboratory testing. Patients and physicians should not overlook even previously treated diseases, since they may not have been completely resolved and may cause residual symptoms.

Major Depression Disorder

Like chronic fatigue syndrome, some physicians still believe that fibromyalgia is not a physical illness but a result of an emotional disorder. The link between psychological disorders and fibromyalgia is problematic because so many of the symptoms overlap. Fatigue, listlessness, poor concentration, memory deficits, agitation, and sleep disorders can all be manifestations of either depression or fibromyalgia. Depression is very common, affecting up to a fifth of all Americans at some point in their lives; the odds are, then, that a similar high percentage of fibromyalgia patients will also experience depression independent of the muscular disorder. In addition, depressed feelings in people with fibromyalgia are often reactions to the pain and fatigue caused by this syndrome. They may often experience deep feelings of rejection and alienation if their symptoms are disregarded by those close to them or by their physicians. Such emotions, however, are situational and temporary, not part of chronic depression. Criteria have been established to help physicians differentiate between normal discouragement experienced by everyone, including fibromyalgia patients, and major depression disorder. Unlike ordinary periods of sadness, an episode of depression usually lasts many months. Symptoms of depression include (1) a depressed mood everyday, (2) significant weight gain or loss (more than 10% of an individual's normal body weight), (3) insomnia or excessive sleeping, (4) restlessness or a sense of being slowed down, (5) low daily energy, (6) worthless or inappropriate guilty feelings, (7) an inability to concentrate or to make decisions, and (8) suicidal thoughts. The presence of several of these symptoms suggests depression, rather than fibromyalgia, particularly if the tender points typical of fibromyalgia are not also present.

Sleep Disturbances

Another symptom of fibromyalgia is sleep disturbance, which may actually be due to sleep disorders, including chronic insomnia, restless legs syndrome, or obstructive sleep apnea syndrome, a breathing disorder often marked by loud snoring and thrashing in bed. A person may have sleep apnea and not realize it unless it is brought to his or her attention by a bed partner or observer.

Drugs and Alcohol

Fatigue is a side effect of many prescription and over-the-counter medications, such as antihistamines. In addition, dependency on or abuse of alcohol or illicit drugs may manifest as chronic fatigue. Medications should be considered as a possible cause of fatigue if an individual has recently started, stopped, or changed medications. Withdrawal from caffeine can produce depression, fatigue, and headache.

Chemicals and Other Toxins

Exposure to various chemicals and environmental toxins such as solvents, pesticides, or heavy metals (cadmium, mercury, or lead) can cause fatigue, chronic pain, and other symptoms of fibromyalgia.

Fibromyalgia can be mild or disabling, and the emotional repercussions can be substantial. There are estimates that 30% to 40% of patients have had to stop work or change jobs. About half of all patients have difficulty with or are unable to perform routine daily activities. There is some indication that such patients are at higher risk for carpal tunnel syndrome and osteoporosis. The pain, emotional repercussions, or sleep disturbances may lead to self-medication and overuse of sleeping pills, alcohol, drugs, or caffeine. Desperation may encourage a belief in false cures and potentially dangerous use of herbal or so-called natural remedies.

Although the disease is chronic, it is neither progressive nor fatal, and remission can occur in many patients who participate in disease management programs. Children with fibromyalgia tend to have a better outlook than adults. In adult patients who were studied for four and a half years, those who had adequate exercise had the most promising outcome; those with a significant life crisis or who were on disability had a poorer outcome than others. Outcome was determined by improvements in the patients' capacity to work, their own feelings about their condition, pain sensation, disturbed sleep, fatigue, and depression.

Experts recommend a multi-faceted approach for treating fibromyalgia that involves exercise to reduce pain and strengthen muscles, regular sleep routines, drug therapies to improve sleep and other symptoms, and psychological tools for coping with the emotional disorders caused by the disease and for reducing stress that can exacerbate pain. One study compared three treatment options (biofeedback and relaxation techniques; exercise; and a combination of the other two) with a passive educational approach used as a control. After two years, the combination approach proved to be most beneficial and the passive control approach was the least. Another study also found that interdisciplinary treatment programs were effective in significantly improving pain in 42% of patients. Improvements in pain and other symptoms, including depression and sense of physical capability, persisted for at least six months, although patients tended to become fatigued again. The effectiveness of the treatments tended to depend on how depressed the patients were, the sense of their own disability, personal support networks, and if the cause was unknown. The severity of the pain at the start of treatment had little to do with outcome. Patients must realize that such therapies are prolonged---in some cases, lifelong--and they should not be discouraged by relapses. Enlisting family, partners, and close friends, particularly with exercise and stretching programs, and becoming involved with support groups of fellow-patients are very helpful. Patients must have realistic expectations about the long-term outlook and their own individual capabilities. Improvement is subjective, and some patients are pleased with only a 10% reduction in pain and other symptoms. It is important to understand that the condition can be managed and patients can live a full life.

Exercise

Many studies have indicated that exercise is the most effective component in managing fibromyalgia, and patients must expect to undergo a long-term exercise program. Some patients of fibromyalgia avoid exercise for fear it will exacerbate their pain. However, according to studies, any pain caused by exercising subsides within 30 minutes. Physical activity prevents muscle atrophy, increases a sense of well being, and, over time, reduces fatigue and pain itself.

Aerobic Exercise. Regular low-impact aerobic exercises are the most helpful for raising the pain threshold, although it may take months to perceive benefits. A very gradual incremental program of activity, beginning with mild exercise and building over time is important; patients who attempt strenuous exercise too early actually experience an increase in pain and are likely to become discouraged and quit. Every patient must be prepared for relapse and setbacks, which are nearly universal, but this should not dissuade the patient from exercising. Rather, they should experiment with various forms of physical activity that can be tolerated using their available energy levels. Desirable exercises are walking, swimming, and using stationary bikes. Swimming and water therapy, which eliminate weight-bearing, appear to be excellent choices for getting started.

Some experts recommend the use of a training index for gauging progress and establishing a goal. This index is the product of three calculations: the duration of exercise in minutes, number of days per week that the patient exercises, and the percentage of maximum heart rate. [See Box.] People just beginning an exercise program should start with an index of 10 to 25 and aim over time for at least 42. As examples for achieving these goals, an initial index of 15 may be achieved with a maximum heart rate percentage of 60% during exercise performed for 5 minutes 5 times a week (.60 x 5 x 5); the later goal of an index of 42 could be achieved with a maximum heart rate percentage of 70% that occurs with 20-minute exercises three days a week (.70 x 20 x 3 = 42). (Stretching exercises should be performed for about 10 minutes before aerobic exercise, but they are not considered part of the total exercise time that the patient uses in calculating the index goal.)

Determining Percentage of Maximum Heart Rate

1. Determine the maximum heart rate by subtracting one's age from 220.
   
2. Determine the heart rate by measuring the pulse either at the carotid artery on the neck or on the inside of the wrist during a workout. It's easiest to count pulse beats for 10 seconds, then multiply by six for the per-minute total.
   
3. Calculate the percentage of maximum heart rate, by dividing the exercise heart rate by the maximum heart rate and multiply by 100.

Stretching Techniques

Much of the pain experienced by patients occurs where muscles join tendons or bones, particularly when the muscles are stretched. Stretching, or flexibility exercises, are part of the warm-up and cool-down routines of any regular program, but the stretching technique used for muscle relaxation and pain reduction must be performed by a person other than the patient, usually a family member or close friend. One such technique is known as "spray and stretch." Using this method, the tender points are located by pressing on the suspected areas, which are then targeted and sprayed with either ethyl chloride (Chloroethane) or Fluori-Methane, which are chemicals that cool the blood vessels in the skin. The patient must be in a comfortable position and the face covered if the spray is being used near the head. The spray bottle is held upside-down about 12 to 18 inches from the targeted area. The spray is not used as an anesthetic but to inactivate the tender points so that the patient's partner can slowly stretch the affected muscle. (Anesthetic skin creams do not appear to be effective for this treatment.) After the procedure, the muscle should feel looser, and the patient should have a greater range of motion with that muscle.

In some cases, injections of lidocaine, called "trigger-point injections," may be used for particularly painful tender points as an aid to stretching. The injection causes intense, transient pain in the trigger point, but after the medication has taken effect, the ability to stretch the muscle is greatly enhanced. After an injection, the spray may be used on the whole muscle to inactivate less severe tender points. In some cases, injections may be needed two or three times over six to eight weeks. There is some soreness afterward, which can be severe, and the benefits of the treatment may not be apparent immediately.

With use of either injections or the spray, the benefits may last from a few days to weeks. Neither the spray nor the injection is useful without muscle stretching.

Cognitive Therapy

Studies continue to show that when fibromyalgia patients increase their psychological capacity to deal with the specific conditions of their disorder and their lives, they are more apt to experience physical improvement. Behavioral cognitive therapy is an effective method for enhancing patients' belief in their own abilities and to develop methods for dealing with stressful situations. A specific goal of cognitive therapy is to change the distorted perceptions that patients have of the world and of themselves; for fibromyalgia patients, this means that they learn to think differently about their pain. Many fibromyalgia patients live their lives in extremes. They first become heroes or martyrs, doggedly pushing themselves past the point of endurance until they collapse and withdraw. This inevitable backlash reverses their self-perception, and they then view themselves as complete failures, unable to cope with the simplest task. One important aim of cognitive therapy is to help such patients discover a middle route, whereby they can prioritize their responsibilities and drop some of the less important tasks or delegate them to others. Such behavior will eventually lead to a more manageable life and to less of an absolutist perspective on themselves and others. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that pain is only one negative and, to a degree, a manageable experience among many positive ones. Fulfilling experiences and many areas of control are still available. Cognitive therapy may be expensive and not covered by insurance. It should be noted that, in one center, educational discussion groups were as effective, or even more so, than a cognitive therapy program. Such results cannot necessarily be applied to all centers; therapeutic success varies widely depending on the skill of the therapist. The studies do indicate, however, that patients who cannot afford cognitive therapy may do as well with strong, intelligently managed support groups.
Maintaining a Healthy Lifestyle

Establishing Regular Sleep Routines. Sleep is essential, particularly since pain is aggravated by disturbed sleep. Improvement is low in those who are unable to sleep consistently and at night. Swing shift work for example, is extremely hard on fibromyalgia patients.
Diet. Fibromyalgia patients should maintain a healthy diet low in animal fat and high in fiber, with plenty of fresh fruits and vegetables. There is no evidence that any specific dietary factor is effective in managing fibromyalgia; taken in moderation, vitamins and most nutritional supplements are probably not harmful, but megadoses of vitamins and even certain supplements may be toxic.

Stress Reduction Techniques

There is some evidence that people with fibromyalgia have a more stressful response to daily conflicts and encounters than those without the disorder. A number of relaxation and stress-reduction techniques have proven to be helpful in managing chronic pain.
Deep Breathing. Inhale slowly and deeply to the count of ten, making sure that the stomach and abdomen expand. Inhale through the nose and exhale slowly and completely, also to the count of ten. To help quiet the mind, concentrate fully on breathing and counting through each cycle. Repeat five to ten times and make a habit of doing the exercise several times each day, even when not feeling stressed.

Progressive Muscle Relaxation

After lying down in a comfortable position without crossing the limbs, concentrate on each part of the body, beginning with the top of the head and progressing downward to focus on all the muscles in the body. Be sure to include the forehead, ears, eyes, mouth, neck, shoulders, arms and hands, fingers, chest, belly, thighs, calves and feet. (Some individuals even imagine tensing and releasing internal muscles once the external review is complete.) A slow, deep breathing pattern should be maintained throughout this exercise. Tense each muscle as tightly as possible for a count of five to ten and then release it completely; experience the muscle as totally relaxed and lead-heavy. Continue until the feet are reached. In the beginning it is useful to have a friend or partner check for tension by lifting an arm dropping it; the arm should fall freely. Practice makes the exercise much more effective and produces relaxation much more rapidly.

Meditation

Meditation, used for many years in eastern cultures, is now widely accepted in this country as an effective relaxation technique. For example, one recent study reported that patients who performed qigong, an Oriental technique, reported reduced pain, fatigue, and sleeplessness and improved function, mood, and general health after eight weeks. The practiced meditater can achieve a reduction in heart rate, blood pressure, adrenaline levels, and skin temperature while meditating. A number of organizations, both religious and nonreligious, teach meditation; the names of these organization along with instructional books can be found at public libraries. The goal of all meditative procedures, both religious and therapeutic, is to quiet the mind, essentially to relax thought. The first step is to be as physically comfortable as possible in a quiet place, preferably in a semi-dark room isolated from noise or distraction. One should be sitting up with the eyes closed and concentrating on a simple image or sound. Some methods suggest imagining a point of light behind the forehead and between the eyes. Other techniques, such as transcendental mediation, assign "mantras," words that have particular chanting sounds, which are repeated silently. (Anyone can make up a word or a sound; the only condition is that the word or sound not be associated with a real thing, which can distract the meditater from the internal process.) When the mind begins to wander, the meditater gently brings concentration back to the central image or sound. Some recommend meditating for no longer than 20 minutes in the morning after awakening and then again in early evening before dinner. Even once a day is helpful. When successful, the meditater experiences deep relaxation and renewed energy. (One should probably not meditate before going to bed; some people who meditate before sleep wake up in the middle of the night, alert and unable to return to sleep.)

One technique requiring little adaptation of the daily schedule has been termed mini-meditation. The method involves heightening awareness of the immediate surrounding environment. One should first choose a routine activity when alone. For example, while washing dishes concentrate on the feel of the water and dishes; allow the mind to wander to any immediate sensory experience, such as sounds outside the window, smells from the stove, or colors in the room. If the mind begins to think about the past or future, abstractions or worries, redirect it gently back. This redirection of brain activity from thoughts and worries to the senses disrupts the stress response and prompts relaxation. It also helps promote an emotional and sensual appreciation of simple pleasures already present in a person's life.

Biofeedback

During biofeedback, electric leads are taped to a subject's head. The person is encouraged to relax using methods such as those described above. Brains waves are measured and an auditory signal is emitted when alpha waves are detected, a frequency that coincides with a state of deep relaxation. By repeating the process, subjects associate the sound with the relaxed state and learn to achieve relaxation by themselves.

Massage Therapy

Massage therapy is thought to stimulate the parasympathetic nervous system, which slows down the heart and relaxes the body. Rather than causing drowsiness, massage actually increases alertness; the reduction of stress and anxiety levels and the resulting relaxation, however, do contribute to better sleep. A number of massage therapies are available for relaxing muscles, including the following:

1. shiatsu, which applies intense pressure to parts of the body, can be painful but people report deep relaxation at the end,
2. reflexology manipulates hands and feet using Eastern techniques, and
3. Swedish massage has been available for years and some experts believe is still the best method for relaxation.

Other Procedures

Because of the difficulties in treating fibromyalgia, many patients seek alternative treatments. Everyone should be wary of those who promise a cure or urge the purchase of expensive but useless and potentially dangerous treatments. Acupuncture. Acupuncture may be effective for some patients. One study measured blood levels of the chemicals serotonin and substance P, which change in response to pain or its cessation. After acupuncture, the blood levels of these chemicals increased, which paralleled the reduction in fibromyalgia pain.

Magnet Therapy

Magnet therapy has received some attention and one study using magnets that were only slightly more powerful than refrigerator magnets showed some benefits .

The primary goal of drug therapy is to improve sleep, but many of the medications may relieve other symptoms of fibromyalgia, including depression and low energy.

Tricyclics

antidepressants known as tricyclics are commonly prescribed for fibromyalgia patients primarily to reduce sleeplessness and muscle pain; treating depression is a secondary benefit for those suffering from both depression disorder and fibromyalgia. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep). Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), trazodone (Desyrel), and nortriptyline (Pamelor, Aventyl). Side effects are fairly common with these medications, although generally only small doses are necessary for relief of fibromyalgia. Side effects most often reported include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty in urinating, disturbances in heart rhythm, drowsiness, and dizziness. Blood pressure may drop suddenly when sitting up or standing. Like all medications, tricyclics must be taken as directed; overdose can be life threatening.

Selective Serotonin-Reuptake Inhibitors

Selective serotonin-reuptake inhibitors (SSRIs) are antidepressants that keep levels of serotonin increased in the brain. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), Paroxetine (Paxil), and Fluvoxamine (Luvox). Such drugs are often prescribed for fibromyalgia patients who also suffer from major depression. They do not appear to have any specific benefit for fibromyalgia itself. One study indicated that a combination of low doses of Prozac along with the tricyclic Elavil was effective in reducing depression, improving sleep, and reducing pain, although the added benefits from Prozac may have only been to increase the potency of Elavil. SSRIs should be taken in the morning, since they may cause insomnia. Studies are indicating that SSRIs are generally safe for pregnant women although any medication must be taken with caution during pregnancy. Patients on SSRIs report a higher level of efficiency, more energy, and enhanced relationships with other people. Common side effects are agitation, nausea, and sexual dysfunction, including delayed or loss of orgasm and low sexual drive. High doses or interactions with other drugs may cause hallucinations, confusion, changes in blood pressure, stiffness, and irregular heartbeats. Very serious drug interactions can occur with other older antidepressants, particularly those known as monoamine oxidase inhibitors.

Cyclobenzaprine

Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. It is related to the tricyclic antidepressants and has similar side effects, the most common being dry mouth, drowsiness, and dizziness.

Because fibromyalgia often develops when a woman reaches menopause, some experts believe that estrogen replacement therapy may have special benefits for fibromyalgia patients, in addition to protection against heart disease, osteoporosis, and, possibly, Alzheimer's disease. Women who take estrogen therapy seem to fall asleep faster, have longer periods of REM sleep, have fewer wakeful periods, and sleep longer than those not taking estrogen. Taking estrogen shortly before going to bed is most helpful.

Acetaminophen

For relief of pain, acetaminophen is recommended. Anti-inflammatory drugs, such as corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), which include aspirin ibuprofen, and others, are less useful for the pain of fibromyalgia, since the pain is not caused by muscle inflammation. A number of patients are prescribed opioids such as codeine or codeine combinations for pain relief. One study indicated that many doctors prescribe opioids primarily because of the patients' expressions of pain not from any objective criteria, such as cause, duration, pain severity, and physical findings. Physicians are urged to take a careful medical and psychological profile of the patient before prescribing them and periodically evaluate the patient for continuing pain relief, side effects, and indications of abuse.

Other Drugs

Among other drugs used for various symptoms of fibromyalgia are the antianxiety drug alprazolam (Xanax) and the over-the-counter antihistamine diphenhydramine (Benadryl). Some treatments being tried for fibromyalgia are experimental and have potentially toxic side effects and interactions with other drugs. Patients should be sure to inform their physicians of any other drugs, including so-called natural remedies, that they are taking. An interesting area of research is the use of very powerful chemicals, including saporin and a toxin called substance P, that block pain signals to the brain. In animal studies, this combination was injected into the spinal cords of rats that were hypersensitive to pain; it relieved pain without affecting any nearby cells. Some patients have been treated with recombinant growth hormone and have experienced improvement.

References:

• Massachuesetts Medical Handbook
• Fibromyalgia syndrome in children and adolescents: Clinical features at presentation and status at follow-up. Pediatrics,
March 1998
• Magnets Attract new interest. The Back Letter, March 1998
• Why do doctors prescribe opioids for chronic pain. The Back Letter, April 1998
• Pain in children with juvenile primary fibromyalgia syndrome: Parental pain history and family environment. Clinical Journal of
Pain, 1998 Vol.14
• Psychiatric disorders in patients with fibromyalgia. Psychosomatics, January/February 1999, Vol.40
• Unraveling a mysterious cause of pain. Johns Hopkins Med Lett Health After 50, 1998 Jun;10(4):3 Board of Editors
• Harvey Simon, MD, Editor-in-Chief, Massachusetts Institute of Technology; Physician, Massachusetts General Hospital
• Masha J. Etkin, MD, Gynecology, Harvard Medical School; Physician, Massachusetts General Hospital
• John E. Godine, MD, PhD, Metabolism, Harvard Medical School; Associate Physician, Massachusetts General Hospital
• Daniel Heller, MD, Pediatrics, Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active
Staff, Children's Hospital
• Irene Kuter, MD, D. Phil, Oncology, Harvard Medical School; Assistant Physician, Massachusetts General Hospital
• Paul C. Shellito, MD, Surgery, Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital
• Theodore A. Stern, MD, Psychiatry, Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service,
Massachusetts General Hospital
• Carol Peckham, Editorial Director
• Cynthia Chevins, Publisher