Cooling Painful Hot Spots in Fibromyalgia
Most people try to steer clear of pain if they can. But for people with fibromyalgia, pain is unavoidable. This syndrome, like other chronic pain syndromes such as chronic fatigue syndrome or irritable bowel syndrome, lowers people's pain thresholds, so that they have severe pain when others might not even feel discomfort.
"There is almost universal agreement that these illnesses occur because of some disturbance in the way that the central nervous system is processing pain," says Daniel Clauw, MD, director of the University of Michigan Chronic Pain and Fatigue Research Center and a spokesperson for the American Academy of Rheumatology. "It's almost as if the volume control is turned up too loud on the nerves in the body."
The American Academy of Rheumatology estimates that between 3 and 6 million Americans suffer from fibromyalgia. The pain, fatigue and anxiety these people suffer from can drive them from doctor to doctor in search of a diagnosis, and prevent them from participating in life as fully as they would like to.
While fibromyalgia was once dismissed by most doctors, hundreds of studies have looked at the diagnosis and treatment of this condition over the past 25 years. Even though the precise cause is still unclear, a review published recently in the New England Journal of Medicine confirms that many people with fibromyalgia will find relief if they try a combination of medication and non-drug therapies.
Figuring Out Fibromyalgia
Fibromyalgia, which is much more common in women than men, cannot be diagnosed with standard lab tests. So doctors will first need to rule out other conditions that cause pain and/or fatigue such as rheumatoid arthritis or hypothyroidism. A diagnosis is then based on whether someone has pain throughout their body and whether they feel tenderness when pressure is applied to 11 to 18 hot spots in the body where muscle and tendons meet, such as certain areas on the neck and shoulders. Complicating matters, fibromyalgia can also involve related conditions, such as tension headaches and irritable bowel syndrome.
Another confusing point is that fibromyalgia shares many symptoms with chronic fatigue syndrome (CFS), which causes persistent fatigue and muscle and joint pain. Fortunately, chronic fatigue syndrome and fibromyalgia tend to respond to the same treatments.
Why do certain people become so sensitive to pain? Some doctors suggest that, as odd as it sounds, fibromyalgia is a self-protective measure on the part of the body.
"In your home you have a fuse box, and if you plug too many things in, you blow a fuse that will protect your home from harm," explains Jacob Teitelbaum, MD, director of the Annapolis Center for Effective CFS/Fibromyalgia in Maryland. "Similarly, the hypothalamus in the brain is a major control center for sleep, blood pressure and blood flow and other factors. It's energy dependant, so if you overdraw your energy, then it's the area that goes offline first."
When the hypothalamus goes offline, Dr. Teitelbaum says, the body loses energy and the muscles become short and stiff, causing pain that ultimately leads to pain in other parts of the body as you try to compensate for the discomfort. In other words, the hypothalamus is forcing the body to shut down.
Stress is believed to trigger the blown fuse in many cases. That stress can be emotional, such job or relationship stress, or physical, such as trauma from an infection or from sleep deprivation. Both types of stress lead to the "fight or flight" reaction in the brain that involves the release of certain chemicals and hormones.
"There are two ways that stress seems to be involved in this illness," Dr. Clauw says. "One is that certain types of stress, such as a motor vehicle accident or mononucleosis, seem to be capable of triggering this illness. The other thing that stress can do is exacerbate symptoms if someone already has this condition."
Besides minimizing their exposure to stress, there are a number of treatments available to people with fibromyalgia. Some people, however, may opt not to treat their fibromyalgia. According to Dr. Clauw, these men and women just "want to make sure there is nothing 'bad' going on."
Most patients, however, will opt for treatment. And according to the New England Journal of Medicine review, the ideal approach involves a combination of therapies that in some way or another get the brain chemistry charged.
Manipulating Pain Centers with Medication
While the Food and Drug Administration (FDA) has not approved any drugs specifically for fibromyalgia, tricyclic antidepressants such as Elavil (amitriptyline), and muscle relaxants such as Flexeril (cyclobenzaprine), have been well studied. Other, newer forms of antidepressants, including dual serotonin and norepinephrine reuptake inhibitors (SNRIs) such as Effexor (venlafaxine) and a drug that's awaiting FDA approval for fibromyalgia called milnacipran, have also been shown to be helpful.
Exorcizing Pain with Exercise
Exercise, particularly aerobic exercise such as biking, dance or walking, can also improve pain and energy levels, as well as sleep. Dr. Clauw explains that exercise raises levels of serotonin and norpinephrine just as medication does, "so the way I explain the value of exercise to my patient is that exercise is, in fact, a drug that you get your body to produce."
"Just like with drugs," he continues, " I tell people to start at a low dose and go up slowly." But patients shouldn't worry that exercise will simply cause more pain. A study conducted by Dr. Clauw that was published in January in Arthritis and Rheumatism showed that increased physical activity in people with fibromyalgia was not necessarily associated with more pain.
According to Dr. Clauw, about 15 to 25 minutes of exercise every day is probably more valuable to people with fibromyalgia than 45-minute periods of exercise three days a week.
Controlling Pain with Cognitive Behavioral Therapy
Studies have shown that cognitive behavioral therapy, which involves psychological and behavioral therapy, can also be used to lessen pain and improve function. Such techniques can help people feel like they are have more control over their illness and help them how to cope with pain by teaching relaxation skills, distraction strategies, better scheduling and goal setting. People can get cognitive therapy through a trained counselor, and research groups are working on developing Web-based programs so people can work on these techniques on their own time.
You Don't Have to Feel Sick
Other approaches, including meditation, acupuncture, hypnotherapy, better sleep habits, improved nutrition and better regulation of hormone levels may also help improve symptoms.
If you think you may have fibromyalgia, it's best to find a physician who is familiar with its treatment. That doctor may be an internist or family physician or a rheumatologist, though Dr. Teitelbaum recommends seeking out a pain specialist through the American Academy of Pain Specialists.
"If you are exhausted and you hurt all over, the good news is that fibromyalgia is a very treatable disease," Dr. Teitelbaum says. "You don't have to feel sick anymore."