“Doctor, I have this pain all over my body since the last 5 years. It is crippling me. Painkillers don’t seem to help. I tried to do some exercises and walk a bit. But that only worsens the pain. I feel tired and stiff all the time even when I wake up in the morning. It takes ages for me to get out of bed and get ready. My energy levels are very low and I am unable to do even mundane tasks. I even had to give up my job, as I just couldn’t cope with it. My sleep is also very disturbed. Of late I have noticed that I am having difficulty in concentrating on a task and even listening to people. I am also getting to be very forgetful and can’t even remember the name of movies that I saw recently. Nobody seems to understand me as I have so many problems. Some even say that it is all in my head and this upset me even more. I feel so low and depressed and have mood swings. Sometimes I cry without any rhyme or reason”.
These were the complaints of a very distraught 30 year old girl who had a degree in business management. Besides pain, she also gave a history of stomach upsets on and off, frequent headaches, allergic reactions and repeated pelvic infections. When she was 23 years old, while playing basketball, she had a fractured her ankle and she had to undergo repeated surgeries to set it right. Since she was doing her business management course at that time and was looking forward to a promising career, this incident had left her feeling very stressed and upset as she felt that this had caused a road block in her career trajectory. However, after a break of 1 year, she got back to her studies and completed her course. She had consulted various specialists for her numerous problems, which included neurologists, gastroenterologists, gynaecologists, rheumatologists and skin specialists. She even met psychologists and psychiatrists. But despite trying out various treatments, there was no respite in her symptoms. She continued to suffer both physically and mentally. After 5 years of visiting various specialists, she was diagnosed to have a condition called Fibromyalgia.
These are some of the FAQs regarding fibromyalgia.
What is fibromyalgia? Is it a disorder of muscles, nerves or joints?
Why are there so many unrelated conditions associated with fibromyalgia?
What causes fibromyalgia? Is there a test for diagnosing fibromyalgia?
Fibromyalgia is a condition in which a person has pain, tenderness and stiffness all over the body along with increased fatigability, and depression. It is also frequently associated with sleep disturbances and cognitive problems as well. Cognitive problems are to do with thinking, memory, alertness and concentration. This has also been termed, ‘brain fog’ or, ‘fibro-fog’. Fibromyalgia has been found to be more common in women. Since there may be other associated problems, they would have usually done the round of various specialists before they are finally diagnosed as fibromyalgia.
The mechanism of pain in fibromyalgia is complex and still not well understood. Researchers have found that fibromyalgia is not a disorder of muscles, bones, joints or even nerves, as this cannot explain all the problems seen in patients with fibromyalgia. In fact, it does not originate in the peripheral nerves, but in the central nervous system, which includes the brain and spinal cord. In this condition, the brain & spinal cord are very sensitive to even minor stimuli, which may not actually be painful. In other words, the spinal cord and brain are amplifying signals not only from the periphery but also from the various organs of the body. This is perceived as pain associated with disturbance in the functioning of these organ systems. As a result along with widespread pain, these patients often have frequent gastro-intestinal upsets (irritable bowel syndrome), allergic disorders, pelvic infections, urinary problems and frequent headaches among other conditions.
One factor that could predispose to a person developing fibromyalgia is injury or trauma in the past. The injury may be physical or psychological. This young lady gave a past history of hospitalization and repeated surgeries for a fractured leg (physical trauma). In the process she was extremely stressed out as it interrupted her studies. This could have had a psychological impact on her as well (psychological trauma). This event, which had caused her both physical and psychological trauma, could well have been a precipitating factor for her to develop fibromyalgia.
Fibromyalgia is a diagnosis based solely on history and examination of the patient and there are no laboratory or radiological investigation that can actually confirm the clinical diagnosis.
So, is there a cure for fibromyalgia? Can these patients lead a normal life, in which they can pursue their career?
There is no cure for fibromyalgia.
It is a condition that is difficult to treat and the outcomes are also not very promising. The goal of treatment has to be realistic and this has to be explained upfront to the patient as well as the relatives. It is of utmost importance to have a good rapport between the physician and patient based on trust and empathy and acknowledging the fact that the pain the patient is experiencing is real. It is not unusual for the physician and even the relatives of the patient dismissing the pain as, “It is all in your head”. This can not only be demeaning but it also lowers the already low morale of these patients.
A three-fold approach for the optimal management of fibromyalgia, which can relieve their symptoms are described very briefly.
a. Medications. These include drugs that decrease pain and depression and improve sleep. Anti-depressant medications work by increasing the levels of ‘good’ neurochemicals (serotonin and norepinephrine). Besides this, certain drugs that calm the nerves (anticonvulsants) are also recommended. Some commonly used drugs to treat fibromyalgia include analgesics, pregabalin, duloxetine, gabapentin, amitriptyline and sedatives.
b. Treating the body. Focusing on good sleep, walking, exercises and nutrition is very important. But it should be kept in mind that both exercises & walking have to be started very cautiously and in a graded manner. Being over-enthusiastic with physical activity can only worsen the pain and taken them a step backwards. The dictum is, ‘start slow and go slow’. Heated pool exercises have found to be very useful in patients with fibromyalgia.
Since these patients very often have sleep disturbances and do not feel refreshed in the morning, medications should include sedatives too as lack of sleep lowers the pain threshold and patients tend to experience more pain.
Trigger point injections, dry needling, acupuncture, myofascial release and chiropractic manipulation have also been found to be beneficial to treat the tender points in their body.
c. Treating the mind. Very often these patients tend to have depression and other psychological problems. Psychological counseling and behavioral therapy have been found to be useful in these patients. Relaxation therapies help in relaxing the tense muscles and mind and cognitive behavior therapy helps improve positive thinking. Other mind-body therapies recommended in fibromyalgia include yoga and Tai Chi. Having understanding relatives and colleagues also helps a great deal in improving the morale of these patients as they invariably have a low self-esteem and are frequently depressed.
The treatment of fibromyalgia is thus not clear-cut and simple and it requires the help of a multi-disciplinary team, which includes pain physicians, physiotherapists and psychologists. However, by following these guidelines, it is possible to control symptoms related to the body as well as the mind over a period of time, improve the quality of lives of these patients and enable them to pursue a normal life and career.