Fibromyalgia -- a Knotty Problem

In the past decade, fibromyalgia has become recognized as a common and refractory disease which is also known by perhaps a dozen different names including fibrositis, psychogenic rheumatism, etc. A differential diagnosis must be made among a number of other illnesses such as inflammatory diseases of the spine, spondyloarthropathy, rheumatoid arthritis, polymyositis, polymyalgia rheumatica, as well as other entities such as entrapment neuropathy, hypothyroidism, myofascitis, and multiple trigger points.

The fibromyalgic syndrome is a consistent entity and its diagnostic criteria have become identified and codified. Many of these patients find their way into the offices of the chiropractor, osteopath, neurologist, orthopedist, physiatrist, physiotherapist, and rheumatologist. The diagnosis should be entertained in any patient with unexplained widespread pain.

Most patients are women, age 25 to 50, and most patients complain of associative fatigue and interrupted sleep. They usually fall asleep quite easily, but their sleep is fitful with frequent awaking at night and often a feeling of being more tired in the morning than they were before going to bed. A crucial finding in the diagnosis is the presence of tender points at the bony insertion of tendons and bellies of certain muscles. Patients are often unable to continue in certain kinds of work capacity due to intractable pain sensations including burning, gnawing, etc. There is an increased frequency in feeling unrefreshed when arising in the morning and a feeling that, "I never recover my energy."

Although the diagnosis of fibromyalgia is often made from the history and detailed musculoskeletal examination, the absence of certain symptoms and signs is just as important as the presence of certain characteristics. The age factor, especially in women, is extremely important. Approximately 50 percent of the patients remember a specific triggering event associated with an abrupt onset of symptoms. These events more often include physical or emotional trauma or an illness or a virus syndrome. The pain may begin in a localized area, often in the neck and shoulders, and then spread over a period of time to other parts. In more than 80 percent of patients, the neck and shoulders, mid and lower back are involved, and eventually complaint of weakness after minimal activity or exercise. Profound fatigue is especially part of the diagnosis with frequent arousals during the night. Gastrointestinal symptoms or irritable bowel syndrome are reported in 50 to 80 percent of the patients. Muscular or tension headaches are common. Some patients report a history of migraine headaches.

These patients characteristically consult many physicians without much benefit. Many of them find their way to the acupuncturist with little or no relief. It actually requires very little training on the part of the physician to recognize and detect multiple tender points following a pain chart where these points are located. The diagnostic criteria require at least 11 out of 18 of these points as the criteria for the diagnosis of fibromyalgia. The points eventually become bilateral, with nine on each side of the body as follows:

1. Insertion of the suboccipital muscle.
2. Anterior aspect of C5-6 at the sternocleidomastoid (SCM) muscle attachment.
3. In the belly of the trapezius muscle in the region over the transverse process of T1.
4. Origin of the supraspinatus muscle at the medial upper border of the scapula, also the levator angular scapulae attachment (this is often an early sign of the disease).
5. In the anterior chest about one inch lateral to the sternum over the second rib, costochondral junction.
6. About one inch distal to the lateral epicondyle of the elbow.
7. About two inches below the crest of the ilium in the region of the gluteus medius.
8. Directly over the greater trochanter of the hip.
9. In the anterior knee, medial to the patella, at the medial fat pad.

Some of the tender points of fibromyalgia are at the same sites, commonly found to be tender in such conditions as tennis elbow, trochanteric bursitis, anserine bursitis and muscles attached to spinal subluxations. Because of the similarity of symptoms with a number of other localized pain disorders, rheumatologists often refer to fibromyalgia as a great imitator. For example, in addition to the entities previously mentioned, there are mimicries such as shoulder bursitis, frozen shoulder, costochondritis, thoracic outlet syndrome, illiopectineal bursitis, anserine bursitis, neck and shoulder myalgia, etc.

No single pathophysiologic mechanism seems to be outstanding in fibromyalgia. The disease overlaps with many other poorly understood syndromes. It is highly suspect when the syndrome presents with chronic fatigue, irritable bowel, idiopathic low back pain, chronic tension headache, and in many patients who complain they "hurt all over." There are no laboratory findings which are found to be abnormal; x-rays are not remarkable. Patients do not respond to anti-inflammatory drugs, either steroid or nonsteroid. Complete remission occurs in 25 percent of the patients, but relapses are frequent and functional disability occurs over prolonged periods of time.

The physician should be prepared to spend an adequate amount of time informing the patient that essentially this is not a degenerative disease. It is very disabling at times and may have many remissions and exacerbations of symptoms. The physician should be willing to provide at least limited guidance and reassurance. The team approach is required in the most difficult cases including a physical medicine aspect along with psychologic, ergonomic, nutritional and even medical/legal aspects. Such things as the adjustment of the height of a desk or chair or back support or head support can be extremely helpful. The physician may want to go into the work place and examine conditions that apply to ergonomic stress. Exercise should be low impact such as fast walking, stretching and gradual muscle strengthening. An exercise program should be initiated for almost every patient unless there is some major contraindication.

Since sleep disturbance is prominent in these patients, it may indicate a central etiologic mechanism which medication might improve. The first investigation was L-Tryptophan which proved to be disappointing in that even doses of five grams did not improve the brain wave pattern. Normally, alpha wave bursts occur during sleep at frequent intervals, but in these patients there is an intrusion or disruption of this pattern. Alpha wave activity during sleep is also referred to as rapid eye movement (REM) sleep. In most instances, the studies have been placebo controlled and found that such medications as Amitriptyline of low dosage, such as 25 mg at bedtime, have been very effective in many patients in improving their alpha pattern REM sleep. Other medications include tricyclic antidepressants, etc. In depression and anxiety, psychiatric referral is necessary. The use of Dramamine before bedtime has been reported as improving the REM sleep of the patient, although this has not been subject to research study. It is important to monitor the patient's sleep improvement and associated reduction in chronic fatigue and low energy which is an extremely common characteristic of this disorder.

Unless fibromyalgia is recognized as a complex syndrome, a chiropractic physician will find that prolonged treatment will not produce the expected results. Especially where insurance reimbursement is involved, the question of medical necessity may frequently arise. The physician will usually be in an uncomfortable and defensive position in attempting to explain prolonged care and poor results to the insurance carrier. Many physicians are quite frustrated and disappointed in their results in these cases because a differential diagnosis was not made. It is wise to look for all the major characteristics of fibromyalgia and then discuss it with the patient in terms of the overall planning and management.