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May 28, 2023

Fibromyalgia

Updated: May 22




What is it? Is it even real?

How do I know it is serious and should seek care?


Fibromyalgia is a complex and individual condition with no two presentations of the condition being identical. “Syndromes” is a term used to describe a group of conditions where multiple body systems are affected (1). Fibromyalgia is a chronic health condition with hallmark symptoms including widespread muscle pain and stiffness. The pain associated with Fibromyalgia is thought to be caused by sensitisation and the mechanism of pain is nociplastic which is characterized by hypersensitivity of central nervous system neurons. Pain’s main function is similar to an alarm system for real or potential danger. However, for some individuals, this alarm system malfunctions resulting in the alarm being activated without any real or potential danger (2). “The number of neurons involved in pain is < 5%, but, in situations of chronic pain, this number rises to 15–25%.” (3).


Fibromyalgia has received a lot of stigma and it’s ‘realness’ has even been questioned (4). Fibromyalgia was and continues to be (somewhat) poorly understood (5). The information on Fibromyalgia is relatively new and for this reason, some individuals and health care practitioners may not be aware of the existence of the condition or may simply believe that what is not understood can’t be real. Pain is always a subjective personal experience (5) and Fibromyalgia pain is just as real as headaches, pain from surgery, pain from cancer, pain from a paper cut, etc. Similar to other pain conditions such as persistent low back pain and phantom limb pain, Fibromyalgia does not have a biomedical diagnostic test which can confirm its diagnosis. However, many functional MRI scans of the brain have seen alteration in different regions in people with Fibromyalgia and other persistent pain conditions (3, 6, 7). This includes things such as heightened activity in certain brain regions involved in pain processing and decreased activity in natural pain inhibiting processes (7, 8, 9)


What are the symptoms?

As a condition which affects multiple organ systems, the symptoms of FMS are complex and widespread. Symptoms may include but are not limited to:

  • widespread pain

  • fatigue

  • stiffness

  • exacerbated pain responses

  • sleep disturbances

  • cognitive dysfunctions

  • anxiety and depression


What causes it?

Several risk factors exist in the development of FMS, these include (3, 5, 7, 8):

  • Family history of Fibromyalgia. Specifically a first relative, making the development of Fibromyalgia 8 times as likely.

  • Early lifetime adverse events

  • Trauma

  • Psychosocial stressors

  • Certain infections have seen higher rates of Fibromyalgia (eg, Epstein Barr virus, Lyme disease, Q fever, viral hepatitis)

  • Psychiatric conditions (e.g., Depression and Anxiety)


However, Fibromyalgia as of today cannot be prevented (2) and it is impossible to know the exact trigger (6).


How is it diagnosed?

There is no single biomedical test to test for Fibromyalgia (6). Diagnosis of fibromyalgia relies on subjective history (4) and is often also only diagnosed once other medical conditions with similar symptoms are excluded (e.g. rheumatoid arthritis, hyperthyroidism, Lyme disease) (3).

There have been several changes made in the diagnostic criteria over the years (2, 8). The latest criteria was set up in 2019 by a task-force with the aim to specifically address the need for a revision of the diagnostic criteria (8). This task force identified 3 different criteria for the diagnosis of Fibromyalgia:


  1. Pain is to be found in 6 or more sites of the body (see diagram below)

  2. Pain lasting 3 months or longer.

  3. The presence of fatigue and sleep problems, which are 2 core associated features of fibromyalgia


A cluster of features were developed to further support the Fibromyalgia diagnosis. These include tenderness, dyscognition (eg, trouble concentrating, forgetfulness, and disorganized or slow thinking), stiffness (usually worse in the morning) & environmental sensitivity (decreased tolerance to bright lights,loud noises, perfumes & cold).


Common comorbidities of Fibromyalgia include irritable bowel syndrome, chronic pelvic pain, mood disorders, anxiety, sleep disorders and several others.


It is important to note Fibromyalgia can co-exist with other conditions that present similarly (8).


Diagram from Arnold et al., (2019).



Why is movement important?

Firstly, we need movement! Without it we will become disabled and our general health will deteriorate. Remember motion is lotion! Muscles, tendons, ligaments, cartilage, bones, discs need movement to stay healthy and function optimally.


In addition to general movement, exercise, a structured, repetitive and goal orientated sub-category of movement is a highly recommended and effective therapeutic treatment for Fibromyalgia in both the short and long-term (2, 10, 18). Both aerobic (sometimes known as cardiovascular) and strength training have been shown to improve function and quality of life for individuals with Fibromyalgia (2, 5, 10, 11). Hydrotherapy has shown to be especially promising (18). Exercise can also assist in improving sleep quality, mood and anxiety (10, 18) and pain (16, 18).


Role of psychology

Acceptance is a very important psychological factor which can lead the person to improve their quality of lives. In a study that looked at patients that recovered from Fibromyalgia found acceptance of the conditions to be a significant factor (12). CBT (cognitive-behavioural therapy) and ACT (acceptance and commitment therapy) have both been shown to be effective in treating Fibromyalgia (2, 5). These therapies also give you skills and strategies for the long-term. In addition relaxation strategies and stress reduction techniques can also be used (5).


Medication

Medications are commonly used to manage pain. These medications should be targeting the mechanism of the pain (sensitisation and nociplastic pain). Medications that target these areas are anticonvulsants (Lyrica) and antidepressants (Nuloxetine/Cymbalta and Milancepran/Jonica) (2). Other medications that may be explored by your doctor or pain specialist include muscle relaxants (cyclobenzaprine/Flexeril & tizanidine/Zanaflex) and Quatiapine/Apotex.


However, it is important to know that as with the majority of medications, adverse effects do exist. To minimize these side effects your doctor may use a slow dose titration approach (start at a low dose then slowly increase when and if needed) (2). Another important note is that these medications do not always work for everyone with Fibromyalgia.


With the exception of tramadol, opioids are usually ineffective in the treatment of Fibromyalgia. This is possibly due to a reduced number of opioid receptors (sites that the drugs attach to) in individuals with fibromyalgia (2, 3, 15). Other traditional analgesics such as NSAIDs (e.g., nurofen, celebrex) and paracetamol are not found to be effective in Fibromyalgia. Cannabis has also gained interest however, the effects have not yet been convincing.


Other interventions

Nutritional modifications have also shown to play a positive role in the management of Fibromyalgia. However, there is no high quality information to recommend any specific dietary advice (10).


Other therapies that can be explored as an add-on strategy (due to limited quality evidence) include:

  • Stimulation techniques

  • Tai-chi

  • Mindfulness

  • Hypnosis

  • Acupuncture


It is important to note that the above interventions are designed to get control of your pain and not let the pain control you. Although quite uncommon, there are stories of full recovery from Fibromyalgia (12,14). The main common theme in these recovery stories is a very active approach in their management.


Working with Fibromyalgia

It is quite common for people with Fibromyalgia to become unemployed (2). In the very short term not working may have some benefits (e.g., time to rehab, reduced pain, reduced stress). However, in the long-term there are little benefits (e.g., loss of income, challenges in relationships with others, poor health, worsening of pain) (15). There are many potential barriers to return to work (e.g., poor work environment, stigma/pressure from managers/colleagues, inability to modify work, etc.)(16) however, help does exist. Rehab consultants, occupational therapists and other professionals can assist in creating a return to work plan. Additionally, psychological interventions can assist in creating coping skills and helping you life better with pain. Movement therapy (by physio/EP) can also assist in improving physical function.


What we can do at Adapt Movement to help?

At Adapt Movement, we acknowledge the complexity and unique presentation of Fibromyalgia. We understand the negative effects this condition can have on a person. Therefore, we use a holistic personalized approach to rehabilitation.


As described above movement and exercise are important in the management of Fibromyalgia in the long-term. However, initially this may seem unachievable and daunting. Our team of exercise physiologists and physiotherapists provide a psychologically informed personalized plan to ease your way into being more active.


Are you worried about not being able to make an appointment due to pain, fatigue, mood or other symptoms? Adapt Movement can provide either Telehealth consults or home-visits as we understand how disabling these symptoms can be and how these can fluctuate day-to-day.


Additional tips:

1. Progress in Fibromyalgia and chronic pain conditions in general is usually very slow and often non-linear.


2. An active approach to healing is essential in recovering and/or living well with Fibromyalgia (4). The person with the condition is the only one that can make any meaningful improvements (4). Recovery becomes a personal process of exploring and negotiating one’s own possibilities and limits, navigating between wishes and reality (12). However, there are people to assist in this journey. For example, health care professionals with a special interest in chronic pain can be very valuable.


3. Pacing activities is crucial and at the same time very challenging. These are the words from a lady living with (and eventually recovering from) Fibromyalgia:

When I had good days, I was aware that I should save my energy, even though it was extremely difficult. When it is 12 o’clock in the evening, and you feel awake and at the top [of your energy], and you want to clear the garage . . . You are completely awake. To go to bed then, after doing nothing for three weeks? But the next day, I am ill again and cannot do anything. I think this is what many are struggling with. Having a more balanced and steadier curve of activity, not these highs and lows! So, I tried to keep the activity more balanced and not overdo it when I had a lot of energy.


4. Fibromyalgia like all persistent pain conditions is determined by biopsychosocial factors. Pain triggers may not always be physical. Think about stressors from work, caring for children, financial stressors, etc. what is triggering your pain? Can this trigger then be modified? Adjusted?




Resources






References



  1. Varol, U., Úbeda-D'Ocasar, E., Cigarán-Méndez, M., Arias-Buría, J. L., Fernández-de-Las-Peñas, C., Gallego-Sendarrubias, G. M., & Valera-Calero, J. A. (2023). Understanding the Psychophysiological and Sensitization Mechanisms Behind Fibromyalgia Syndrome: A Network Analysis Approach. Pain medicine (Malden, Mass.), 24(3), 275–284. https://doi.org/10.1093/pm/pnac121 

  2. Sarzi-Puttini, P., Giorgi, V., Marotto, D., & Atzeni, F. (2020). Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nature reviews. Rheumatology, 16(11), 645–660. https://doi.org/10.1038/s41584-020-00506-w 

  3. Maugars, Y., Berthelot, J. M., Le Goff, B., & Darrieutort-Laffite, C. (2021). Fibromyalgia and Associated Disorders: From Pain to Chronic Suffering, From Subjective Hypersensitivity to Hypersensitivity Syndrome. Frontiers in medicine, 8, 666914. https://doi.org/10.3389/fmed.2021.666914 

  4. Mengshoel, A. M., Skarbø, Å., Hasselknippe, E., Petterson, T., Brandsar, N. L., Askmann, E., Ildstad, R., Løseth, L., & Sallinen, M. H. (2021). Enabling personal recovery from fibromyalgia - theoretical rationale, content and meaning of a person-centred, recovery-oriented programme. BMC health services research, 21(1), 339. https://doi.org/10.1186/s12913-021-06295-6 

  5. Turk, D. C., & Adams, L. M. (2016). Using a biopsychosocial perspective in the treatment of fibromyalgia patients. Pain management, 6(4), 357–369. https://doi.org/10.2217/pmt-2016-0003

  6. Arnold, L. M., Choy, E., Clauw, D. J., Goldenberg, D. L., Harris, R. E., Helfenstein, M., Jr, Jensen, T. S., Noguchi, K., Silverman, S. L., Ushida, T., & Wang, G. (2016). Fibromyalgia and Chronic Pain Syndromes: A White Paper Detailing Current Challenges in the Field. The Clinical journal of pain, 32(9), 737–746. https://doi.org/10.1097/AJP.0000000000000354 

  7. Schmidt-Wilcke, T., & Clauw, D. J. (2011). Fibromyalgia: from pathophysiology to therapy. Nature reviews. Rheumatology, 7(9), 518–527. https://doi.org/10.1038/nrrheum.2011.98 

  8. Arnold, L. M., Bennett, R. M., Crofford, L. J., Dean, L. E., Clauw, D. J., Goldenberg, D. L., Fitzcharles, M. A., Paiva, E. S., Staud, R., Sarzi-Puttini, P., Buskila, D., & Macfarlane, G. J. (2019). AAPT Diagnostic Criteria for Fibromyalgia. The journal of pain, 20(6), 611–628. https://doi.org/10.1016/j.jpain.2018.10.008 

  9. Sarzi-Puttini, P., Giorgi, V., Marotto, D., & Atzeni, F. (2020). Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nature reviews. Rheumatology, 16(11), 645–660. https://doi.org/10.1038/s41584-020-00506-w 

  10. Majdoub, F., Ben Nessib, D., Ferjani, H. L., Kaffel, D., Triki, W., Maatallah, K., & Hamdi, W. (2023). Non-pharmacological therapies in Fibromyalgia: New horizons for physicians, new hopes for patients. Musculoskeletal care, 10.1002/msc.1741. Advance online publication. https://doi.org/10.1002/msc.1741 

  11. Bidonde, J., Busch, A. J., Schachter, C. L., Webber, S. C., Musselman, K. E., Overend, T. J., Góes, S. M., Dal Bello-Haas, V., & Boden, C. (2019). Mixed exercise training for adults with fibromyalgia. The Cochrane database of systematic reviews, 5(5), CD013340. https://doi.org/10.1002/14651858.CD013340 

  12. Eik, H., Kirkevold, M., Solbrække, K. N., & Mengshoel, A. M. (2022). Rebuilding a tolerable life: narratives of women recovered from fibromyalgia. Physiotherapy theory and practice, 38(9), 1188–1197. https://doi.org/10.1080/09593985.2020.1830454 

  13. Spaeth, M., & Briley, M. (2009). Fibromyalgia: a complex syndrome requiring a multidisciplinary approach. Human psychopharmacology, 24 Suppl 1, S3–S10. https://doi.org/10.1002/hup.1030 

  14. Grape, H. E., Solbrække, K. N., Kirkevold, M., & Mengshoel, A. M. (2017). Tiredness and fatigue during processes of illness and recovery: A qualitative study of women recovered from fibromyalgia syndrome. Physiotherapy theory and practice, 33(1), 31–40. https://doi.org/10.1080/09593985.2016.1247933 

  15. Sullivan MJL, Hyman MH (2014) Return to Work as a Treatment Objective for Patients with Chronic Pain? J Pain Relief 3:130. https:/doi:10.4172/2167-0846.100013  

  16. Grant, M., Rees, S., Underwood, M., & Froud, R. (2019). Obstacles to returning to work with chronic pain: in-depth interviews with people who are off work due to chronic pain and employers. BMC musculoskeletal disorders, 20(1), 486. https://doi.org/10.1186/s12891-019-2877-5 

  17. Rodríguez-Domínguez, Á. J., Rebollo-Salas, M., Chillón-Martínez, R., Rosales-Tristancho, A., & Jiménez-Rejano, J. J. (2024). Clinical relevance of resistance training in women with fibromyalgia: A systematic review and meta-analysis. European journal of pain (London, England), 28(1), 21–36. https://doi.org/10.1002/ejp.2161

  18. Rivas Neira, S., Pasqual Marques, A., Fernández Cervantes, R., Seoane Pillado, M. T., & Vivas Costa, J. (2024). Efficacy of aquatic vs land-based therapy for pain management in women with fibromyalgia: a randomised controlled trial. Physiotherapy, 123, 91–101. https://doi.org/10.1016/j.physio.2024.02.005



This blog was written by Samuel Bulten


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