Fibromyalgia

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Exercise for Special Populations
February 17, 2012

Fibromyalgia Syndrome (FMS) is a debilitating neurological disorder characterized by chronic widespread pain and fatigue. It affects approximately 2% of the population, and is more common in women than in men. Central nervous system sensitization affects the entire body, leading to many secondary symptoms. This paper will cover the history, symptoms, and causes of FMS as well as known treatments and exercise prescription for the syndrome. Fibromyalgia has been described as a full-body migraine. Another common explanation is to compare everyday life with FMS as being similar to the aches and pains associated with a severe case of the flu. FMS patients experience intermittent flares, which are episodes of increased symptoms. Flares usually occur in response to physical or emotional stress, a schedule change, an illness or injury, a new job, the birth of a child, etc. While fibromyalgia is not considered a degenerative disorder, its symptoms usually become more severe if the patient also has a degenerative disorder such as arthritis. First, a patient must have experienced continuous pain in all four quadrants of the body for at least three months (Wolfe et al., 1990). Doctors will usually order many tests in order to rule out other conditions that might be confused with fibromyalgia.
The key diagnostic tool for FMS is the tender point exam. No more than 4kg/1.54km2 of pressure is applied to 18 spe­cific points (see Table 1). If there is significant pain in at least 11 of the 18 points, the patient may be diagnosed with fibromyalgia.
Table 1: Ten­der Point Sites (Wolfe et al., 1990)

|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 the upper surfaces. |
|Lateral epicondyle: bilateral, 2 cm 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. |

There are so many common secondary symptoms that it is not unusual for a patient to be treated by multiple specialists for those symptoms over a period of years before they are diagnosed with FMS. Secondary symptoms need not be present for diagnosis, and will vary from one patient to the next.
Table 2: Secondary Symptoms

|Migraine or tension-type headaches |Temperomandibular joint disorder |
|Irritable bowel disorder |Gastroesophageal reflux |
|Impaired memory and concentration |Peripheral neuropathy |
|Restless leg syndrome and other sleep disorders |Sjogren’s syndrome |
|Raynaud’s phenomena |Periodic muscle spasms and cramps |
|Myofascial pain syndrome |Impaired coordination |
|Intermittent hearing loss or ringing noises |Skin sensitivity, itching, burning |
|Insomnia |Interstitial cystitis |
|Dizziness |Chemical sensitivity |
|Sensitivity to light, smells and sounds |Fatigue |
|Costochondritis |Diffuse pelvic pain |
|Nausea |Dyspareunia |
|Rashes |Dermatographia |
|Chronic sinusitis/post-nasal drip |Eye irritation, burning or dryness |

After almost two centuries of study, the etiology of fibromyalgia is still a matter of much debate. There are no lab tests for FMS. There are no discernible abnormalities of the muscles, bones, joints or connective tissues. It is known to involve central nervous system changes (Starlanyl and Copeland, 2001), but those changes may be caused by or be the cause of the disorder. Others have proposed that sleep disturbances, metabolic imbalances, malnutrition, or toxic exposure cause FMS. For the last 25 years, most practitioners have treated FMS as an autoimmune disorder, similar to arthritis. Levels of anti­nuclear antibodies are used to diagnose autoimmune disorders, but the presence of those antibodies is similar in most FMS patients and healthy controls (Starlanyl & Copeland, 2001). Travell and Simons believed that untreated myofascial trigger points caused fibromyalgia (1999, as cited in Davies, 2001). Trigger points, though, refer pain to different parts of the body. Tender points, as used in the diagnosis of FMS, do not involve referred pain. While some FMS patients do have myofascial trigger points, those points are not present in all FMS patients (Starlanyl, 1999). Some doctors persist in believing that FMS is a psychiatric disorder, but researchers have been unable to distinguish between FMS, rheumatoid arthritis and other patients who experience chronic pain using psychiatric techniques (Starlanyl & Copeland, 2001). Some physicians have reclassified fibromyalgia as a “functional somatic syndrome,” claiming that it is characterized more by disability than medical explanation, suggesting behavioral and psychiatric treatment rather than any other therapies (Barsky & Borus, 1999). While the incidence of psychiatric disorders such as depression is no higher in patients with FMS than in those with other chronic pain disorders, the number of fibromyalgia patients who have experienced acute or long-term trauma or abuse is far higher than that of the general population (Romans et al., 2002 and Van Houden­hove et al, 2004). Most treatment of FMS is limited to management of symptoms. Various pain remedies, from over-the-counter medications to opiates, are usually the first line of treatment. Muscle relaxants, physical therapy, and massage help some patients. Trigger point therapy and injections are another possibility. Many FMS patients experience difficulties in achieving restful sleep, so physicians commonly prescribe sedatives and tranquilizers. Low doses of anti-seizure medications and atypical antipsychotics, such as Requip and Seroquel, have been found to be effective in helping some fibromyalgia patients to achieve restorative sleep. Selective serotonin reup­take inhibitors (SSRIs), tri­cyclic antidepressants and other medications that affect neurotransmitters help some fibromyalgia patients (Marek, 2003). Cymbalta, a new med­ica­tion which inhibits both sero­tonin and norepinephrine reuptake, seems to improve pain and reduce the number of tender points in FMS patients (Arnold et al., 2004). Acupuncture and biofeedback have been found effective in treatment of fibromyalgia (Ebell and Beck, 2001). Gentle, non-aerobic exercise such as Tai Chi and some forms of yoga may help patients, as well. Stress reduction is one of the most important factors in improving the quality of life for fibromyalgia patients (Williamson, 1998). Regardless of whether the disorder is caused by stress or not, it is aggravated by stress. While it is impossible for any person to completely avoid stress, it is possible to reduce exposure to known stressors and learn to better cope with those that must be endured. Mindfulness-based stress reduction (MBSR) programs are relatively new in the treatment of fibromyalgia in the US. The theory is that mindfulness can allow patients to reduce their reactions to stress, improving their ability to cope with stressors. “In developing the capacity to step back and observe the flow of consciousness, mindfulness can short circuit the fight or flight reaction characteristic of the sympathetic nervous system, allowing individuals to respond to the situ­ation at hand, instead of automatically reacting to it on the basis of past experiences.” (Proulx, 3002, p. 201) MBSR programs typically last from 8 to 12 weeks and include instruction in meditation, breathing techniques, physical awareness, and yoga. They often utilize journaling and group discussions regarding attitudes and positive thinking. While MBSR participation does not necessarily lead to improvement of the physical symptoms of fibromyalgia, it can lead to improved quality of life for the fibromyalgia patient. Medically recommended fibromyalgia exercise programs often include strength training, aerobics, flexibility, stretching and balance components. Warm-water aquatics sessions provide low-impact movement and stretching in a buoyant environment. Continued exercise helps reduce muscle tension and stiffness, and improves sleep quality. Serotonin and endorphin levels also increase, which can contribute to a reduction in fibromyalgia pain. Low-impact exercises are best for fibromyalgia sufferers. Examples include walking or riding a stationary bicycle. It is crucial to start off small with 20 to 40 minutes of exercise three times per week, and then increase the time increments or the frequency of the exercise. Resistance-training can help reduce the muscle deconditioning effects fibromyalgia sufferers often experience. They should not lift heavy weights, but instead use light weights and focus on being able to complete the range of motion involved in the exercise.

References

American College of Sports Medicine. (2003). ACSM's exercise management for persons with chronic diseases and disabilities. Champaign, Ill: Human Kinetics.

Arnold, L. M., Crofford, L. J., Wohlreich, M., Detke, M. j., Iyengar, S., & Goldstein, D. J. (2004, Sep). A DoubleBlind, Multicenter Trial Comparing Duloxetine With Placebo in the Treatment of Fibromyalgia Patients With or Without Major Depressive Disorder. Arthritis and Rheumatism, 50(9), 2974–2984.

Barsky, A., & Borus, J. (1999, 1 Jun). Functional Somatic Syndromes. Annals of Internal Medicine, 130.

Ebell, M., & Beck, E. (2001, May). How effective are complementary/alternative medicine (CAM) therapies for fibromyalgia? Journal of Family Practice, 50(5), 400–402.

Star­lanyl, D., & Copeland, M. E. (2001/1996). Fibromyalgia & Chronic Myofascial Pain: A Survival Manual (2nd ed.). Oakland, CA: New Harbinger Publications, Inc.

Williamson, M. E. (1998). The Fibromyalgia Relief Book.US: Walter Publishing Company, Inc.

Wolfe, F., Ross, K., Ander­son, J., Rus­sell, I., & Hebert L. (1995, Jan). The prevalence and characteristics of fibromyalgia in the general population. Arthritis and Rheumatism, 38(1), 18–28.

Wolfe, F., Smythe, H. A., Yunus, M. o. B., Ben­nett, R. M., Bom­bardier, C., Gold­en­berg, D. L. et al. (1990). Criteria for the classification of fibromyalgia: Report of the multi center criteria committee. Arthritis and Rheumatism, 33(2), 160–72.