Muscle pain, fatigue and tenderness are just some of the symptoms of this baffling condition

Fibromyalgia syndrome (FS) literally means muscle pain. It is a common chronic disorder characterised by widespread musculoskeletal pain, fatigue, multiple tender points and poor sleep.

'Tender points' refers to tenderness that occurs in precise, localised areas, particularly in the neck, spine, shoulders and hips. People with FS may also experience morning stiffness, fatigue, irritable bowel syndrome, depression, anxiety and cognitive symptoms such as troubles with concentration, short-term memory and handling multiple tasks.

Diagnosis of FS has been controversial because there are no specific laboratory tests. Until the 1990s, many doctors thought FS was largely psychosomatic, in part because the disease is often associated with depression. In recent years, however, scepticism has largely given way to interest in more fully characterising the syndrome and its effective treatment.

FS is more common in women of childbearing age, but children, the elderly and men can also be affected. It can be disabling: one survey of fibromyalgia patients found that 70 per cent considered themselves disabled and 26 per cent were receiving at least one form of disability payment.

Symptoms
Known as fibrositis, rheumatism and many other names since it was first described in 1816, fibromyalgia causes pain and/or a burning sensation in soft tissue throughout the body. Unlike arthritis, however, it does not cause swelling in the joints. The severity of fibromyalgia symptoms varies from person to person. For some people, pain or other symptoms can be so intense that they interfere with daily activities. For others, symptoms may cause discomfort, but are not incapacitating.

Light, unrefreshing sleep is one of the hallmarks of FS. Sufferers often have restless sleep, and may experience restless-legs syndrome during the day. The problem isn't with quantity - they may get 8-10 hours of sleep, but not enough of a form of deep sleep called alpha EEG (the name comes from the brain wave pattern produced in an electroencephalogram).

Lack of deep sleep makes people with or without FS feel achy, tired and less able to concentrate. Sleep problems could therefore not only be a symptom of FS, but also an underlying cause of many of the symptoms.

The following are classic FS symptoms, and are in addition to the pain, sleeping difficulty and fatigue experienced by most fibromyalgia sufferers:

• Stiffness, particularly in the early morning, after prolonged sitting or standing, or with changes in temperature or relative humidity
• Increased headaches or facial pain, including frequent migraine tension, vascular headaches or pain behind the eyes
• Abdominal discomfort, often referred to as irritable bowel syndrome, which can include abdominal pain, bloating, constipation and/or diarrhoea (some of this discomfort may be due to bacterial overgrowth)
• Irritable bladder symptoms with frequency or urgency of urination
• Sensitivity to the cold, especially in the hands and feet, often accompanied by colour changes; this condition is known as Raynaud's phenomenon
• Parenthesia - a numbness or tingling - often in the hands or feet
• Skin problems, including blotchy or itchy skin; also, a sensation of swelling, particularly in the extremities - such as a ring suddenly not fitting - is a common symptom
• Sensitivity to sound and light

Of course, many of these symptoms can apply to a variety of diseases. To resolve the ambiguities, the American College of Rheumatology developed two specific criteria for diagnosing FS in 1990:

• Chronic, widespread, musculoskeletal pain of longer than three months duration in all four quadrants of the body
• Multiple tender points throughout the body -18 have been identified by the ACR and a patient must have 11 of the 18 for a diagnosis of fibromyalgia to be considered (a tender point is found by palpation - pressing the area with the fingers)

• FS may arise following an injury or trauma to the central nervous system -some whiplash victims develop FS
• An infectious agent may trigger FS in susceptible people. Lyme disease is under study as one such trigger in the US - a study found 10-25 per cent of patients with Lyme disease develop fibromyalgia. Another study found a link between small-intestinal bacterial overgrowth and fibromyalgia, with about 78 per cent of patients with fibromyalgia and intestinal symptoms having such an infection. Patients whose infection was completely eradicated with antibiotics experienced an improvement in FS symptoms.
• FS is also associated with autoimmune disorders such as systemic lupus erythematosus. However, women with fibromyalgia who develop Raynaud's phenomenon, characterised by extreme sensitivity to cold in the extremities, may be misdiagnosed as having lupus or scleroderma.
• There are especially strong links between irritable bowel syndrome and fibromyalgia, and between chronic fatigue syndrome and fibromyalgia. More than half of women with IBS or CFS also have fibromyalgia symptoms.

Treatment
Treatment of fibromyalgia requires a comprehensive approach. Studies have shown that aerobic exercise, such as swimming and walking, improves muscle fitness and reduces muscle pain and tenderness. Heat and massage may also give short-term relief. Anti-depressant medications may help elevate mood, improve quality of sleep and relax muscles. It is important to find the best combination of exercise, medication, physiotherapy and relaxation.

Cognitive therapy
Changing your attitude can also help to improve your physical health. Several studies have shown the benefits of cognitive therapy for women with fibromyalgia. The three major research findings are:

• Negative thoughts are not just responses to stress - they add to stress
• Thoughts affect the emotional perception of pain
• Learning to control negative catastrophic thoughts can have a major effect on symptoms

Strategies for dealing with negative thoughts include the following:

• Alternative interpretation. You might start with a fairly neutral thought such as 'I'm tired today'. From there, it's easy to 'go negative' such as 'I feel bad so I won't get anything done today'. An alternative, non-negative interpretation is 'I should investigate strategies for achieving deeper sleep so I won't be so tired.'
• Coping statements. Try telling yourself you can handle the symptoms and reminding yourself of strategies you've used in the past to cope with or alleviate symptoms.
• Label shifting. The way we describe things influences our overall mood and physical sense of well being. You might describe someone who double-checks her work as either obsessive-compulsive (negative) or as thorough and diligent (neutral/positive). Discarding a habit of negative labelling can boost your mood. Changing the way you think is, of course, easier said then done. A cognitive therapist can guide the transition to a less-negative outlook.

Medication
The drugs usually prescribed for muscular pain - nonsteroidal anti-inflammatory drugs (NSAIDs), such aspirin, ibuprofen and naproxen - are not as effective at treating fibromyalgia. Newer medications include tramdol (Ultram), a centrally acting analgesic, and neurontin (Gabapentin), a seizure medication that acts centrally on the brain. Occasionally, injections of anaesthetics or corticosteroids (synthetic hormones with anti-inflammatory properties) are used to relieve acute tender-point pain.

When FS flares, your doctor may recommend a low-dose tricyclic antidepressant (such as amitriptyline), which may temporarily improve sleep and reduce pain. But the effects can wear off after a month, and these drugs have side effects, such as grogginess and dry mouth. They are not usually a long-term treatment for FS.

Common sleeping aids are not effective for FS because they do not induce deeper sleep, or eliminate pain and fatigue. Instead, it's important to develop a daily schedule and stick to it, avoiding caffeine and other stimulants that might interfere with sleeping. Exercise during the day can also pay off with better sleep at night. Other approaches to managing FS pain include physiotherapy, massage and relaxation.

Treatment of fibromyalgia centres on managing its symptoms, as there is currently no cure. Since symptoms vary, so will treatment. Treatment without medications - such as exercise and improved sleep habits - may be as effective as drug-based strategies. Responses to medications vary and may diminish over time.

Helpful organisations
Fibromyalgia Association UK
P.O. Box 206
Stourbridge
DY9 8YL
Tel: 01384 820052
www.ukfibromyalgia.com

The Arthritis Research Campaign
PO Box 177,
Chesterfield,
Derbyshire
S41 7TQ