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jerry_kit
01-15-2008, 04:03 PM
I have been suffering with Fibromyalgia for several years and it has really taken a toll on me. I still have a very hard time living with the fatigue. I'm going to be 37 in a few days and feel 77....that is my biggest complaint...the pain I can tolerate but just hate being tired all the time.
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krypton6
01-15-2008, 04:11 PM
Why dont you try acupuncture?
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جوري
01-15-2008, 07:18 PM
there are some new meds on the market which may prove beneficial, sis are you in the U.S or England?
I don't know if this will be of help to you? There are some meds on the bottom you may want to ask your health care provider for and some organizations for support...

Patient information: Fibromyalgia
Don L Goldenberg, MD



These materials are for your general information and are not a substitute for medical advice. You should contact your physician or other healthcare provider with any questions about your health, treatment, or care. Please do not contact UpToDate or the physician authors of these materials.

INTRODUCTION — Fibromyalgia is one of a group of chronic pain disorders that affect connective tissue structures, including muscles, ligaments (the tough bands of tissue that bind together the ends of bones), and tendons (which attach muscles to bones). It is a chronic condition that causes widespread muscle pain, or "myalgia," and excess tenderness in certain areas of the body. Many patients also experience fatigue, sleep disturbances, headaches, and mood disturbances, such as depression and anxiety. Despite ongoing research, the cause, diagnosis, and optimal treatment of fibromyalgia are not clear.

WHAT IS FIBROMYALGIA? — Initially reported in France and England during the 19th century, fibromyalgia was previously known as "fibrositis." However, the latter term was felt to be misleading since the suffix "-itis" means "inflammation," and fibromyalgia does not cause tissue inflammation. This condition is now most commonly referred to as "fibromyalgia." The suffix "-algia" denotes pain and "fibr" signifies fibers (as in fibrous tissues).

Fibromyalgia is thought to be the most common cause of generalized musculoskeletal pain in women between the ages of 20 to 75. It is about 6 times more common in women than men. Most patients initially develop symptoms between the ages of 30 and 55.

CAUSES — The cause of fibromyalgia is unknown. However, research suggests that various physical or emotional factors may play a role in triggering symptoms. These triggers include infections, emotional trauma, and/or physical injury. Although the pain is felt in muscles and soft-tissues, there are no permanent pathologic abnormalities at these sites. The muscles and tendons are excessively irritated by various painful stimuli. This is thought to be the result of a change in pain perception, a phenomenon termed "central sensitization".

Research has demonstrated changes in pain sensitive areas in the brain and spinal cord and in neurohormones, brain chemicals that transmit pain signals. These neurohormones also affect energy, sleep, and mood. Such neurohormones include, serotonin, cortisol, norepinephrine, and growth hormone.

SYMPTOMS

Pain — The primary symptom of fibromyalgia is widespread (diffuse), chronic, and persistent pain that may be described as a deep muscular aching, soreness, stiffness, burning, or throbbing. Patients may also feel numbness, tingling, or unusual "crawling" sensations in the arms and legs. Although some degree of muscle pain is always present, it varies in intensity and is aggravated by certain conditions, such as anxiety or stress, poor sleep, exertion, or exposure to cold or dampness. Muscle stiffness is typically present upon awakening and tends to improve as the day progresses. However, in some cases, muscle stiffness can remain throughout the day. A common description is, "It feels as if I always have the flu."

The pain may be confined to specific areas, often the neck or shoulders, early in the course of the disease. Multiple muscle groups may eventually become involved, with most patients experiencing pain within the neck, middle and lower back, arms and legs, and chest wall (show figure 1). Many patients with fibromyalgia feel that their joints are swollen, although there is no visible inflammation of the joints (arthritis).

Other pain symptoms — Patients with fibromyalgia are often affected by additional pain symptoms. About 50 to 75 percent of people with fibromyalgia experience repeated migraines or muscular headaches as well as symptoms of irritable bowel syndrome (IBS).

IBS is characterized by frequent abdominal pain and episodes of diarrhea, constipation, or both. In addition, some patients have chronic unexplained pain within the chest wall (sometimes referred to a costochondritis), or a condition referred to as interstitial cystitis/painful bladder syndrome. In those affected by interstitial cystitis/painful bladder syndrome, pelvic pain occurs in association with urinary frequency and urgency. (See "Patient information: Headache causes and diagnosis" and see "Patient information: Irritable bowel syndrome" and see "Patient information: Chronic pelvic pain in women").

According to some reports, up to 40 percent of patients with fibromyalgia are also affected by the Raynaud phenomenon, in which the fingers and toes develop a whitish or bluish discoloration, tingling sensations, numbness, pain, and redness. These episodes are usually triggered by exposure to cold temperatures or strong emotions. (See "Patient information: Raynaud phenomenon").

Some patients with fibromyalgia also have facial and jaw pain or tenderness that may be associated with temporomandibular joint (TMJ) syndrome. Patients with TMJ syndrome may have limited jaw movement, clicking, snapping, or popping sounds while opening or closing the mouth, pain within facial or jaw muscles in or around the ear, and headaches.

TMJ syndrome, as well as interstitial cystitis/painful bladder syndrome, tension headaches, and other localized pain disorders, are sometimes described as forms of myofascial pain syndrome. This syndrome is characterized by pain and tenderness that is confined to a specific area of the body, such as the right side of the neck and shoulder. Many researchers feel that myofascial pain syndrome is a localized or regional form of fibromyalgia.

Fatigue and sleep disturbances — Fibromyalgia is associated with persistent fatigue in more than 90 percent of patients. Unusually light, unrefreshing, or nonrestorative sleep is a common complaint. Difficulties falling asleep, awakening repeatedly during the night, and feeling exhausted upon awakening are also common findings.

There appears to be a close relationship between fibromyalgia and chronic fatigue syndrome (CFS), which is primarily characterized by chronic, debilitating fatigue. Most patients with CFS meet the "tender point" criteria for fibromyalgia, and up to 70 percent of those with fibromyalgia fulfill the criteria for CFS (show table 1 and show table 2). (See "Patient information: Chronic fatigue syndrome").

Other patients may have symptoms that suggest sleep disturbances that can cause excessive daytime fatigue. These include repeated shock-like leg movements that disrupt sleep (known as nocturnal myoclonus), or sleep apnea, characterized by repeated episodes during which there is a temporary cessation of breathing.

Mood and cognitive disorders — Many individuals with fibromyalgia experience mood disorders, particularly depression and anxiety. Fibromyalgia also is also often associated with forgetfulness and difficulty concentrating.

DIAGNOSIS — Individuals are often affected by fibromyalgia for several years before receiving the correct diagnosis. During the diagnostic process, patients may have undergone multiple testing procedures, consulted with numerous specialists, and been incorrectly advised that "nothing appears to be wrong". Although fibromyalgia is not completely understood and can be challenging to diagnose, it is a real illness with bona fide symptoms. Thus, people who have been diagnosed with fibromyalgia should realize that they are not alone; millions of others are affected by this very real illness.

The difficulty in diagnosis arises from the fact that there are no specific laboratory or imaging tests that definitively confirm the diagnosis. Thus, the diagnosis is typically based upon a complete physical or clinical examination, a thorough patient history, and routine tests that assist in excluding conditions with similar symptoms. In 1990, the American College of Rheumatology (ACR), a professional organization of rheumatologists and associated healthcare professionals, developed diagnostic criteria for fibromyalgia. According to the ACR, fibromyalgia may be diagnosed based upon confirmation of the following on physical examination: Widespread musculoskeletal pain Excess tenderness in at least 11 of 18 specific sites known as "tender points" (show figure 1)

As mentioned previously, patients with fibromyalgia also tend to have a history of additional symptoms, including persistent fatigue, headache, additional pain symptoms, and sleep and mood disturbances. Thus, the evaluation may also include the following: Informal or formal evaluation of possible mood disturbances, such as depression or anxiety. If necessary, a patient may be referred to a mental health specialist for further evaluation or treatment. A thorough sleep history. If this suggests a sleep disturbance such as nocturnal myoclonus or sleep apnea, a patient may be referred to a specialized sleep clinic for additional evaluation and treatment.

In addition, because fibromyalgia can cause symptoms that mimic those associated with other disorders, a healthcare provider may perform a general musculoskeletal and neurologic examination to rule out arthritis, other connective tissue disorders, and neurologic conditions.

Routine laboratory tests may also be conducted to help exclude other common conditions. These tests are normal in most patients with fibromyalgia.

Fibromyalgia or another illness? — Determining whether a person's signs and symptoms are related to fibromyalgia or another condition can be a complex and lengthy process. Many illnesses mimic the generalized muscle aches, fatigue, and other common symptoms of fibromyalgia. The following is a sample of disorders that may be considered in the diagnostic process: Systemic connective tissue diseases, such as rheumatoid arthritis and systemic lupus erythematosus (SLE) — Rheumatoid arthritis is a chronic disease that causes inflammation of joints, resulting in pain, swelling, and potential deformity of the affected joints. SLE is also a chronic, inflammatory disorder of connective tissue. Patients may be affected by abnormalities involving multiple organ systems. Although both disorders share many symptoms with fibromyalgia, they have other features that are not usually seen in people with fibromyalgia, including inflammation of the synovial membranes (connective tissue that lines the spaces between bones and joints). (See "Patient information: Systemic lupus erythematosus (SLE)" and see "Patient information: Rheumatoid arthritis symptoms and diagnosis"). Osteoarthritis — Osteoarthritis causes stiffness, tenderness, pain, and potential deformity of affected joints, and most commonly occurs in older individuals. It is differentiated from fibromyalgia based upon a patient's history, clinical examination, and degenerative joint changes usually observed in people with osteoarthritis. (See "Patient information: Features and diagnosis of osteoarthritis").

It is important to note that fibromyalgia commonly coexists with rheumatoid arthritis, SLE, and osteoarthritis. Thus, it may be difficult to determine whether symptoms of chronic pain and fatigue are specifically associated with fibromyalgia or a coexisting connective tissue disorder. Ankylosing spondylitis (AS) — AS is a chronic, progressive, inflammatory disease involving joints of the spine. This condition leads to stiffness, pain, and potential loss of spinal mobility. In contrast, spinal motion is typically normal in patients with fibromyalgia. AS also causes characteristic findings that may be seen on imaging studies, which are absent in people with fibromyalgia. (See "Patient information: Ankylosing spondylitis"). Polymyalgia rheumatica (PMR) — PMR is an episodic, chronic, inflammatory condition that causes muscle stiffness and pain in the shoulders, hips, or other regions. The disorder, which primarily affects individuals over age 50, is frequently associated with inflammation of certain large arteries. PMR is differentiated from fibromyalgia based upon a patient's history, physical examination, and laboratory studies, which typically reveal an elevated erythrocyte sedimentation rate in those with PMR. (See "Patient information: Polymyalgia rheumatica and giant cell (temporal) arteritis"). Hypothyroidism and other endocrine disorders — Decreased activity of the thyroid gland, known as hypothyroidism, may be associated with severe fatigue, sleep disturbances, and generalized aches similar to those associated with fibromyalgia. Thyroid function tests are routinely conducted for those with suspected fibromyalgia to help exclude hypothyroidism. Other endocrine disorders, including increased activity of the parathyroid glands (hyperparathyroidism), can also have symptoms similar to fibromyalgia. Such disorders can be differentiated from fibromyalgia based upon physical examination, a patient's history, and laboratory studies. (See "Patient information: Hypothyroidism" and see "Patient information: Primary hyperparathyroidism"). Muscle inflammation (myositis) or muscle disease due to metabolic abnormalities (metabolic myopathy) — These conditions cause muscle fatigue and weakness, as compared to the widespread pain seen in fibromyalgia. In addition, patients with myositis typically have abnormal levels of muscle enzymes. (See "Patient information: Myositis and other inflammatory diseases of the muscle"). Neurologic disorders — These may include particular disorders of the brain and spinal cord (central nervous system or CNS) or nerves outside the CNS (peripheral nervous system). A thorough neurologic examination may assist in differentiating fibromyalgia from neurologic disease.

TREATMENT — The treatment of fibromyalgia requires a comprehensive, multidisciplinary approach in which patients, physicians, physical therapists, mental health professionals, and other healthcare professionals actively participate in the management of the disease [1]. Fibromyalgia is essentially a benign disease. It is not a degenerative or deforming condition, nor does it result in life-threatening complications. However, treatment of chronic pain and fatigue are challenging and there are no "quick cures." Treatments are available. Medications may be helpful in alleviating pain, improving the quality of sleep, and elevating mood. Antidepressants, anticonvulsants and analgesics have been found to be helpful in clinical trials. Exercise, stretching programs, and other activities are important in helping to manage symptoms. Understanding fibromyalgia may help to improve response to treatment. As an example, some patients believe that their illness is due to an undiagnosed infectious agent, although there is no evidence indicating that fibromyalgia (or chronic fatigue syndrome) is related to persistent infection. Those who know the facts concerning this issue generally tend to have more effective results with treatment. Realistic expectations are important concerning the ability to function and the overall long-term management of the condition. Symptoms may wax and wane over time, yet some degree of muscle pain and fatigue generally persist. Nevertheless, many people with fibromyalgia have improvement of their condition and most patients lead full, active lives.

Medications — A variety of medications have been used in an effort to alleviate symptoms associated with fibromyalgia. Such agents include anti-inflammatory medications, pain relieving drugs (analgesics), and medications that act on the brain, such as antidepressants and muscle relaxers.

**Anti-inflammatory drugs and analgesics — Because fibromyalgia is not associated with tissue inflammation, it is not surprising that anti-inflammatory agents provide only modest relief. However, when used in combination with medications that act upon the central nervous system, non-steroidal anti-inflammatory drugs (NSAIDs) may have some benefit. The analgesic drug tramadol, either alone or combined with acetaminophen, has been found to be helpful in alleviating the pain associated with fibromyalgia.

**Antidepressants — In some patients, the administration of antidepressants, particularly tricyclic medications, such as low-dose amitriptyline or cyclobenzaprine before bedtime, may promote deeper sleep and alleviate muscle pain. In addition, this treatment may improve depression. Although cyclobenzaprine is considered to be a muscle relaxant, its chemical structure and mode of action are very similar to that of amitriptyline. Studies have shown that treatment with these tricyclic antidepressants results in significant improvement in about 25 to 45 percent of patients with fibromyalgia, although the effectiveness may lessen over time [1,2]. (See "Patient information: Depression").

Therapy with tricyclic antidepressants is typically started at low doses and slowly increased to find the most effective and tolerable dose. However, even with low doses, side effects are common, including dry mouth, weight gain, constipation, and lack of concentration. Thus, it is essential to keep your healthcare provider informed about side effects or any other concerns.

Other antidepressants also may be effective in fibromyalgia, including selective serotonin-reuptake inhibitors (SSRIs), such as fluoxetine. SSRIs are a group of antidepressant drugs that work to increase the concentration of available serotonin in the brain [3,4]. Serotonin is a naturally produced chemical that regulates the delivery of messages between nerve cells. Some reports suggest that combining various drugs, such as fluoxetine in the morning and amitriptyline before bedtime, may be more effective for patients with fibromyalgia than any single medication [3,4].

A new class of antidepressants called dual reuptake inhibitors have been promising in fibromyalgia treatment trials. Two are currently available, venlafxamine and duloxetine. These medications affect two brain neurotransmitters, serotonin and norepinephrine, in a balanced fashion [5].

**Other medications — Anticonvulsants (drugs used primarily for treating epilepsy) have been studied for treatment of fibromyalgia, and preliminary evidence suggests that they may relieve pain and help sleep. Gabepentin has been used to treat pain disorders for years, and pregabalin has been used as a result of promising clinical trial in patients with fibromyalgia [6]. Patients with sleep disorders, such as nocturnal myoclonus, may also benefit from low doses of certain medications such as benzodiazepines or dopamine agonists. These drugs are typically administered at bedtime. Benzodiazepines act on the central nervous system and may be helpful in relaxing muscles, reducing restlessness, and promoting sleep.

Other approaches to disease management — The management of fibromyalgia may include the use of localized injectable or topical therapies that provide temporary pain relief in some patients. Localized areas of severe pain or tenderness can be injected with a local anesthetic, such as one-percent lidocaine solution. In addition, limited research has examined the use of injections with saline or botulinum toxin (BTX). Five-percent lidocaine skin patches may provide temporary pain relief in small areas.

Non-medicinal therapy — Regular cardiovascular exercises, such as walking, swimming, or biking, is helpful in reducing muscle pain and improving muscle strength and fitness in fibromyalgia [7]. Muscle pain and fatigue often seem to worsen when beginning to exercise. Nevertheless, engaging in supervised and gradually increased aerobic exercises typically improves symptoms. Consider working with a physical therapist to develop an appropriate, individualized exercise program that can provide the greatest benefit. Eventually, a person should exercise for a minimum of 30 minutes 3 times weekly. (See "Patient information: Exercise").

In selected patients with fibromyalgia, participating in stress-reduction programs, learning relaxation techniques, or participating in hypnotherapy, biofeedback, or cognitive behavioral therapy may help to alleviate certain symptoms. Hypnotherapy uses hypnosis in the treatment of disease. Hypnosis induces a trance-like state (similar to daydreaming) of altered awareness and perception, during which there may be heightened responsiveness to suggestions. During biofeedback, patients use information about typically unconscious bodily functions, such as muscle tension or blood pressure, to help gain conscious control over such functions. Cognitive behavioral therapy is based on the concept that individuals' perceptions of themselves and their surroundings affect their emotions and behavior. The goal of such therapy is to essentially change the way a person views or thinks about their pain—and to enable them to increase their ability to positively deal with illness.

PROGNOSIS — With currently available treatments, many patients with fibromyalgia have moderate or marked improvement. In one study, 47 percent of women who were given "standard care" improved substantially, while a little more than one-half were either no better or worse after three years of standard treatment [8].

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two patients are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.patients.uptodate.com). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable. National Library of Medicine

****** (www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Arthritis, Musculoskeletal, and Skin Diseases

******(www.niams.nih.gov/, search for "fibromyalgia")
National Fibromyalgia Research Association

******(www.nfra.net)
National Fibromyalgia Association

****** (www.fmaware.org)
The Arthritis Foundation

******(www.arthritis.org)



Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1.*Goldenberg, DL, Buckhardt, C, Crofford, L. Management of fibromyalgia syndrome. JAMA 2004; 292:2388.
2.*Arnold, LM, Keck, PE Jr, Welge, JA. Antidepressant treatment of fibromyalgia. A meta-analysis and review. Psychosomatics 2000; 41:104.
3.*Goldenberg, DL, Mayskiy, M, Mossey, CJ, et al. A randomized, double-blind crossover trial of fluoxetine and amitriptyline in the treatment of fibromyalgia. Arthritis Rheum 1996; 39:1852.
4.*Arnold, LM, Hess, EV, Hudson, JI, et al. A randomized, placebo-controlled, double-blind, flexible-dose study of fluoxetine in the treatment of women with fibromyalgia. Am J Med 2002; 112:191.
5.*Arnold, LM, Lu, Y, Crofford, LJ, et al. A double-blind, multi-center trial comparing duloxetine with placebo in the treatment of fibrommyalgia patients with or without major depressive disorder. Arthritis Rheum 2004; 50:2974.
6.*Crofford, LJ, Rowbotham, MC, Mease, PJ, et al. Pregabalin for the treatment of fibromyalgia syndrome: results of a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2005; 52:1264.
7.*Gowans, SE, deHueck, A, Voss, S, et al. Effect of a randomized, controlled trial of exercise on mood and physical function in individuals with fibromyalgia. Arthritis Rheum 2001; 45:519.
8.*Fitzcharles, MA, Costa, DD, Poyhia, R. A study of standard care in fibromyalgia syndrome: a favorable outcome. J Rheumatol 2003; 30:154.

:w:

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samuel.july
01-16-2008, 11:21 AM
Hi, I would like to say one think that treating the pain associated with Fibromyalgia can be a difficult task since cures that help one person might not help you. Have you heard about http://www.fibromyalgiacured.com/ There is a list of popular and common pain remedies that should help your symptoms.
Take care, bye!
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