Calming the Fire of Fibromyalgia
Examining Symptoms and Strategies
By Sally M. Marlowe, BSPA, RN, CS, ARNP
“I feel as if a lion were pulling the meat away from my bones! It is tearing, searing pain that travels throughout my body!”
–Susan Heisler, fibromyalgia patient
“My body punishes me for EVERYTHING I do!”
–Cheryl Moore, fibromyalgia patient
Recently a patient told me, “The only common thing about myself and any other patient with fibromyalgia is the name!”
How true. Fibromyalgia occurs in such dramatic variations that no two patients are alike. That’s why I tell my patients with this disorder: “Remember that you cannot compare yourself to anyone else with fibromyalgia. You are unique, you are your own textbook. Do not look at another and expect that her problems are going to become yours and vice versa. What may work for someone else may not work for you at all.”
The uniqueness of fibromyalgia is its lack of form or standard course. There are no objective tests to substantiate subjective complaints or findings. There are no universal treatment guidelines. There are few answers and a multitude of questions.
Because of these gray areas, the term fibromyalgia may be viewed as a “wastebasket” term by providers who doubt a patient’s sincerity because she may not appear “sick.” Family members may misconstrue complaints of pain and fatigue as excuses for not carrying out family duties or obligations. So prevalent are the misconceptions that it is not uncommon for a newly diagnosed patient to exclaim, “Thank goodness! I knew this couldn’t all be in my mind! I’ve gone through so many tests and was told, so often, that there was nothing wrong with me.”
Definition and Background
The Primer on the Rheumatic Diseases1 defines fibromyalgia as a recurring condition in which pain is widespread throughout the body and particularly painful at specific tender points. The diagnostic criteria for fibromyalgia were established in 1990 by the American College of Rheumatology (Table 1).
Experts estimate that 3 million to 6 million U.S. residents are affected by fibromyalgia. Upwards of 88% are thought to be women, primarily between the ages of 20 and 50.2 Anecdotally, rheumatologists report that fibromyalgia is the third most frequent new-patient condition they see (degenerative joint diseases and rheumatoid arthritis are first and second, respectively).
Fibromyalgia pain, which patients often describe as “traveling,” most frequently presents in a subtle manner over a period of time. It is characterized by stiffness (especially in the morning), nonrestorative sleep, overt fatigue, headaches, hypersensitivity to temperature (especially air conditioners), loss of grip strength, and a feeling that the hands, arms or body are “puffy.” Irritable bowel and bladder symptoms may develop.
In about 20% of patients with fibromyalgia, depression is present.3 The low-grade depression often seems to relate to the patient’s continuing pain and the lack of diagnostic confirmation or resolution of complaints. In many cases, the patient may exhibit deficits in short-term memory and attention.4 A recent study examined a cohort of 68 couples in which the wives had fibromyalgia with no co-existing disease. The researchers found that only 22% of the participants reported having satisfying sexual activity. Fifty-six percent stated that their sexual problems were related to fibromyalgia.5
A Guide to the Physical Exam
These drawings illustrate the anatomic locations of tender points identified in the American College of Rheumatology’s diagnostic criteria for fibromyalgia.
Fibromyalgia may be called primary when the patient has no secondary diagnosis. The pain associated with primary fibromyalgia may date back to when the patient was a child or teenager. Or, the discomfort may surface after severe bouts of premenstrual syndrome, after the birth of a child or following physical or emotional trauma. In most cases, the patient recalls no predisposing factor.
Secondary fibromyalgia has a probable cause. It may be the result of a trauma, such as a car crash, or an overlay of a mechanical or skeletal malalignment. It may present after some years of living with lupus or rheumatoid arthritis. In some cases, symptoms develop after a diagnosis of Lyme disease, a silicone implant, exposure to toxic chemicals or working in a “sick” building. Repetitive motion–inherent in jobs that require assembly line work, running a switchboard or using computers–has been implicated.
The symptoms of secondary fibromyalgia are consistent with the complaints of primary fibromyalgia, making differentiation a moot point. Fibromyalgia is fibromyalgia, no matter what the causative factor. In cases in which there is no evidence of attending symptoms prior to a physically traumatic event, the probable onset must be considered. An in-depth history and thorough documentation are necessary after the most benign appearing trauma.
Unexplained physical phenomena seem to bring forth the shout of “somatization” until the causal key is found.6,7 Fibromyalgia is an outstanding example of this concern. Although scientists have not identified cause, the pain is real.
Use the American College of Rheu-matology criteria to guide your history and physical exam. Ask the patient about her primary symptoms and when the symptoms began. Perform a full systems review and include questions about fatigue, physical limitations, stress factors, depression, coping skills, family and work histories, tobacco and alcohol use, sexual problems, etc. Pay particular attention to complaints of disrupted sleep, gastrointestinal discomfort, bladder problems, musculoskeletal pain or hormonal imbalances.
Assess pain locations during the physical exam. Start at the base of the spine, moving up the paraspinal muscles while applying gentle but firm pressure (to 4 kg). Watch and listen for the patient’s response. Move over the scapulae, up over the shoulders, and palpate the occipital insertions. Palpate as many soft tissue areas as possible, always covering the appropriate diagnostic tender points (Figure 1). Do not confine your physical exam to points identified by the patient.
Order laboratory tests to rule out immune system-mediated disease. These should include CBC, SMAC, urinalysis, sedimentation rate (Westergren), antinuclear, rheumatoid factor and thyroid profile. If the patient complains of significant muscular weakness, obtain creatine phosphokinase and aldolase. If the patient has fibromyalgia alone, all of these values will be within normal parameters. X-rays, MRI and nerve conduction studies will also be negative if the patient has fibromyalgia. There is no need to obtain the latter studies unless you suspect another condition.
Because the cause of fibromyalgia is not known, treatment is aimed at managing its symptoms. Options include antidepressants, muscle relaxants, analgesics, low-dose cortisone (5 mg to 10 mg depomedrol with 2% xylocaine) or anesthetic injections (Marcaine 0.25%) at tender points, topical pain relievers and various sleep aids. Aquatic exercise, massage, stretching, exercise, diet control and behavioral modification to manage physical and emotional stress are other options to consider as part of overall treatment.
Antidepressants, specifically the serotonin reuptake inhibitors (Zoloft, Paxil, Prozac), may assist in the amelioration of discomfort and, in some cases, reduce fatigue while treating depression. These may be given in combination with other antidepressants by utilizing the SSRIs in the morning. Be sure to prescribe at low doses. Antidepressants should not be limited to patients who show signs of depression, since they promote pain relief and help reduce fatigue.
Anti-inflammatory drugs have not received high marks in anecdotal and research studies of fibromyalgia. This disorder is not an inflammatory process. Therefore, analgesics such as acetaminophen (Tylenol), tramadol (Ultram) or the new drug bromfenac (Duract) may provide temporary relief. If features of arthritis or bursitis are present, NSAIDs might be a logical option. But irritable bowel syndrome is a common feature and must always be borne in mind.
Restorative sleep, especially the fourth stage, is essential to therapy. Medications that can be assistive include amitriptyline (Elavil), nortriptyline (Pamelor), dosepin (Sinequan) and trazodone (Desyrel). My own clinical experience has shown trimipramine (Surmontil) to be particularly effective. Many patients are reluctant to take these medications because they are antidepressants. Point out that the sought-after results are those of restful sleep. The muscle relaxant cyclobenzaprine (Flexeril) may also be considered, but it would not be wise to combine it with any of the mentioned antidepressants without due consideration.
Exercise can be an important tool in fibromyalgia pain management. But the patient may be reluctant to participate due to exacerbations of aches and fatigue.8 Remember that overexertion–even with the most minimal activity–may exacerbate the patient’s “muscle spasm” and pain.
The patient with fibromyalgia tends to complain of sensitivities to odors, noise, temperature change and medication. You must get to know the patient before recommending a specific therapeutic program.
Many people try alternative treatments, such as herbal remedies, acupuncture, chiropractic, Tai Chi, stretching and biofeedback. Occasionally, a patient is helped by one or more of these techniques. Nutraceuticals, which are nontoxic foods or food parts that provide health benefits including disease prevention and treatment, are being scientifically evaluated and may be a more viable option for therapy.9
Due to the chronicity and sensitivity of fibromyalgia, initiate any therapy at the lowest dose or least amount of physical stress. This caveat applies to medications, topical pain relievers, massage, physical therapy and aquatics.
Amidst these treatment interventions, the foremost assist to coping with fibromyalgia is education. Learning options for patients include support groups, materials such as Clark and Bennett’s “Stretching” video,10 the Taking Charge of Fibromyalgia Patient Handbook,11 and texts such as Devin Starlanyl and Mary Ellen Copeland’s Fibromyalgia & Chronic Myofascial Pain Syndrome.12 Encouragement is the key! Not everyone who develops this condition needs to make drastic lifestyle changes.
Remember to explain to the patient that response to therapy may be slow. It takes time to find the appropriate medication or combination of therapies that will provide relief. It is important for the patient–and the NP–to not become discouraged.
In my practice, which specializes in treating adults with rheumatologic and pain complaints, 98% of patients with fibromyalgia are determined to recover their full productivity–including activities of daily living. To achieve this, I recommend pacing of activities: one day for washing clothes, another for cleaning bedrooms, another for paying bills. I also encourage patients to take naps–more than one a day if necessary. Professionals such as occupational or physical therapists can show fibromyalgia patients how to conserve energy by modifying how they perform certain activities.
Research activity may eventually yield answers to the mystery of fibromyalgia. Highlights of current research include:
* Jon Russell, MD, and colleagues at the University of Texas Health Science Centers in San Antonio are evaluating neurohormonal and biochemical abnormalities in fibromyalgia, including Substance P.13
* Don Goldenberg, MD, in Boston, directs numerous research projects while writing supportive guidance materials.14 He has studied the influence of medication on fibromyalgia and the possible relationship between viral illness and immune abnormalities in fibromyalgia.
* Thomas Romano, MD, PhD, in Wheeling, W.Va., continues to investigate and document the existence of post-traumatic (secondary) fibromyalgia. M.J. Pellegrino has also documented the disability caused by this problem.15
What NPs Can Offer
Nurse practitioners can play an important role in treating patients with fibromyalgia. We possess the listening and support skills, along with the medical knowledge, to ensure that these patients obtain the appropriate interventions and reach their functional potential.
Diagnostic Criteria for Fibromyalgia1
(As defined by the American College of Rheumatology)
To meet the diagnostic criteria for fibromyalgia, a patient must have a history of widespread pain in specific anatomic areas and must exhibit this pain during an examination of tender points.
HISTORY: Patient presents with a history of widespread pain. Pain is considered widespread when all of the following are present:
* pain in the left side of the body
* pain in the right side of the body
* pain above the waist
* pain below the waist
* axial skeletal pain (cervical spine, anterior chest,
thoracic spine or low back)
Shoulder and buttock pain is considered pain for each involved side. Low back pain is considered lower segment pain.
PAIN: Exists in 11 of 18 tender point sites on digital palpation. These tender point sites (or trigger points) include:
* Occiput: bilateral, at the suboccipital muscle insertions
* Low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7
* Trapezius: bilateral, at the midpoint of the upper border
* Supraspinatus: bilateral, at origins above the scapula spine near the medial border
* Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions
on upper surfaces
* Lateral epicondyle: bilateral, 2 cm distal to the epicondyles
* Gluteal: bilateral, in upper quadrants of buttocks in anterior fold of muscle
* Greater trocanter: bilateral, posterior to the trocanteric prominence
* Knee: bilateral, at the medial fat pad proximal to the joint line.
Digital palpation should be performed with an approximate force of 4 kg. For a tender point to be considered “positive,” the subject must state that the palpation was painful. “Tender” is not to be considered “painful.”
For classification purposes, patients are said to have fibromyalgia if both the history and pain criteria are satisfied. Widespread pain must have been present at least 3 months. The presence of a second clinical disorder does not exclude the diagnosis of fibromyalgia.
1. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Primer on the Rheumatic Diseases. (10th ed.) Atlanta: Arthritis Foundation; 1993.
2. Bennett, RM. Coping successfully with fibromyalgia. Patient Care. 1995;29:42.
3. Mufson MM, Regestin QR. The spectrum of fibromyalgia disorders. Arthritis and Rheumatism. 1993;36(5):647-649.
4. Slotkoff AT, Clauw DJ. Fibromyalgia: when thinking is impaired. The Journal of Musculoskeletal Medicine. 1996;13(9):32-36.
5. Marlowe SM, Bishop D, Gionta D. Psychosocial effects of fibromyalgia on couples. Abstract. American College of Rheumatology. 11/97. Washington, DC.
6. Croft P, Burt J. Schollum J, et al. More pain, more tender points; is fibromyalgia just one end of a continuous spectrum? Annals of Rheumatic Diseases. 1996;55:482-485.
7. Katon W, Lin E, Von Korff M. Somatization: a spectrum of severity. American Journal of Psychiatry. 1991;148:34-40.
8. Clark SR. Prescribing exercise for fibromyalgia patients. Arthritis Care and Research. 1994;7(4):221-224.
9. Dykman KD, Tone CM, Dykman RA. Analysis of retrospective survey on the effects of nutritional supplements on chronic fatigue syndrome and/or fibromyalgia. The Journal of the American Nutraceutical Association. 1997, Supplement 1, pp. 28-31.
10. Clark S, Bennett R. Fibromyalgia exercise video: “Stretching.” Salem, Ore: National Fibromyalgia Research Association; 1996.
11. Kelly J, Devonshire R. Taking charge of fibromyalgia. Wayzata, Minn.: Fibromyalgia Educational Systems Inc.; 1995.
12. Starlanyl D, Copeland ME. Fibromyalgia & Chronic Myofascial Pain Syndrome. Oakland, Calif.: New Harbinger Publications Inc.; 1996.
13. Russell IU (ed). Peripheral mechanisms of muscle nociception and local muscle pain. Journal of Musculoskeletal Pain. 1993;1:1.
14. Goldenberg DL. Chronic Illness and Uncertainty. Newton Lower Falls, Mass.: Dorset Press; 1997.
15. Pellegrino, MJ. Understanding Post Traumatic Fibromyalgia. Columbus, Ohio: Anadem Publishing; 1996.
Sally Marlowe is a nurse practitioner who is director of the Arthritis/Pain Treatment Center in Clearwater, Fla.