Widespread pain all over the body for more than three months
Fibromyalgia syndrome (FMS) is a clinically recognisable condition, which is characterised by chronic musculoskeletal pain and tender points at multiple sites. The condition causes significant disability and it has been reported that it is prevalent in 2% of the population in the USA and Canada. NHS Direct states that it affects 4% of the population in the UK and 14700 new cases manifest each year.
The American College of Rheumatology has identified eighteen test sites (tender points), of which 11 must be painful on digital palpation with a pressure of 4kg to give a positive diagnostic of fibromyalgia. Moreover, pain must have been present for at least three months.
Because no objective marker (such as evidence on X-Ray, blood test or muscle biopsies) has yet been discovered for fibromyalgia, diagnosis is based only on the aforementioned symptoms. It appears therefore that musculoskeletal pain experienced in widespread locations is the predominant characteristic of fibromyalgia.
The tender points below are the cardinal feature of fibromyalgia:
- Occiput: bilateral, at the suboccipital muscle insertion
- 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 the midpoint of the upper border
- Second rib: bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces
- Lateral epicondyle: bilateral, two centimetres distal to the epicondyles
- Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle
- Greater trochanter: bilateral, posterior to the trochanteric prominence
- Knee: bilateral, at the medial fat pad proximal to the joint line
Beside chronic musculoskeletal pain, patients also experience
- Stiffness
- 'Hurt all over' (note: this expression is used by Yunus and Inanici)
- Swollen feeling in soft tissues
Non musculoskeletal symptoms
- Tiredness most time of the day
- Poor sleep
- Paraesthesia (a sensation of tingling)
Fibromyalgia is however an enigma for rheumatology. Although it 'hurts so much', there is no progressive degeneration, deterioration or inflammation.
Women are more affected
It appears that nine out of ten of people suffering from fibromyalgia are women. In addition, fibromyalgia most commonly occurs in the 40 to 60 age group although it can manifest at any age.
History
Historic writings suggest that what is now called fibromyalgia has been experienced for centuries by human beings. Guillaume de Baillou (1538-1616) grouped what is now known as fibromyalgia with other "myofascial trigger point syndromes" under the name of muscular rheumatism. The English neurologist Sir William R. Gowers coined the term fibrositis in 1904 to encapsulate the symptoms of fibromyalgia. It was thought at the time that the pain was caused by inflammation of the fibrous tissues.
Smythe & Modofsky drew attention to FMS in 1977 but called it fibrositis syndrome. The term fibrositis implying inflammation (itis) of fibrous (fibros) tissues was abandoned in 1981 and re-named fibromyalgia. This is the official name of the disease in the 10th revision of the International Classification of Diseases of the World Health Organisation (WHO, 2006).
Martinez-Lavin suggests that the illness which plagued the life of the Mexican painter Frida Kahlo (1907-1954) is likely to have been posttraumatic fibromyalgia.
Treatment using western medicine
Goldenberg refers to FMS as "pain that won't go away" and prognosis does not seem optimistic. Wallace reported that only 2% of patients are cured after treatment. As the causes are not known, treatment concentrates on symptoms.
Kumar & Clark implies that the use of low doses of sedative antidepressant drugs such as amitriptyline or dosulepine to increase the level of serotonin could be useful. Research suggests that fluoxetine (Prozac), an antidepressant, is effective for managing the symptoms of fibromyalgia. It has been noted that most patients with fibromyalgia also suffer from non-restorative sleep and feel tired even after a long night's sleep. Goldenberg suggests that tricyclic antidepressants such as amitriptyline would be effective in helping people suffering from fibromyalgia because they help restore stage 4 sleep (deep sleep without dream). This is confirmed by Ozerbil who reports that they can also help patients suffering with fibromyalgia. However, side effects of amitriptyline include weight gain, which may be undesirable. Clark asserts that non-steroidal anti-inflammatory drugs (NSAIDs) are also used by 91% of patients with FMS even though they did not work. NHS Direct in the UK also disapproves the use of NSAIDs in the treatment of fibromyalgia unless there is evidence of inflammation. Clark concludes that medications for fibromyalgia are for the most part ineffective because most of them do not provide more benefits than a placebo after six months.
Other treatments
The American Council of Rheumatology suggests that therapeutic massage and myofascial release could be useful for patients with FMS although they acknowledge that these treatments have not yet been well tested. Acupuncture is suggested by NHS Direct in the UK along with massage, aromatherapy, chiropractic and osteopathy as modalities used by patients to ease fatigue and pain resulting from FMS. The use of Complementary and Alternative Medicine (CAM) is common with patients affected with fibromyalgia because there is no cure available. It appears that more than 90% of patients with fibromyalgia have tried complementary techniques such as dietary techniques and herbal supplements. The efficiency of "Rhus Tox", a homeopathic remedy, in controlling some of the symptoms of fibromyalgia is demonstrated by Bell et al. (2004).
Among these alternative and complementary therapies suggested for the management of fibromyalgia, acupuncture will be the next topic to explore and the question will be, can acupuncture help in the management of fibromyalgia.
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