I come across numerous patients who have had body aches for years. They have had many visits to the doctor, to find out what causes tiredness, lack of sleep, headaches, depression, forgetfulness, painful muscles and joints. Arthritis has been ruled out in many cases, so what actually is the reason for all these symptoms? Fibromyalgia might explain all of the above.

Fibromyalgia is a condition that mainly affects the muscles and sometimes the joints. It’s a collection of various symptoms, and is a diagnosis made after ruling out more obvious reasons for joint pain like arthritis. Fibromyalgia might lead to significant problems in the workplace and is commoner in women.

It is a common disorder affecting almost one in every twenty-five adults.
How does fibromyalgia start?
The exact trigger for fibromyalgia is unknown. We think that it’s a combination of neurological, psychological and sometimes external factors that initiate the symptoms. Pain is a defensive response to any form of injury. It makes any living form withdraw from the stimuli. When we feel pain we try to get away from the harmful source and this itself protects our body from further damage. In fibromyalgia, there is no visible cause for the pain. The patients just feel pain without any reason. Some research show that patients who have fibromyalgia are more sensitive to pain than others. In a healthy person when the body repairs the damaged organ/part, pain tends to diminish or disappear. But in fibromyalgia, as there is no exact cause for pain, it tends to last longer.

Sleep disturbance is also associated with this condition and we believe that the patients never achieve deep sleep. This could be because of the continuous pain. Feeling unrefreshed upon awakening is a result of this haphazard sleep pattern.

Depression is associated with pain in any healthy person. As the pain tends to last longer, patients with fibromyalgia become more depressed. This could in turn affect sleep and vice versa. Normal pressure over healthy muscles/joints/parts of the body can cause severe pain and this was earlier used as a test to diagnose the condition. Unlike in arthritis when we examine the joints we do not find features of wear and tear or inflammation (red, hot, swollen joints).

Most patients with fibromyalgia feel very tired. As this is again a longstanding complaint we call it chronic (long standing) fatigue (undue tiredness). Healthy people get tired after physically demanding tasks but fibromyalgia patients feel tired even after periods of rest. There is a different condition called chronic fatigue syndrome which usually happens after a viral infection. This should not be confused with fibromyalgia.
A condition where the bowel habits become irregular with constipation and diarrhoea is called irritable bowel syndrome(IBS). Irritable bowel syndrome can be associated with fibromyalgia.

Common conditions that could mimic fibromyalgia
Certain diseases need to be ruled out before diagnosing fibromyalgia. For example lack of blood particles (haemoglobin) can cause a condition called anaemia. Anaemia leads to breathlessness, tiredness, difficulty in concentrating etc. Treatment for anaemia is with iron or nutrients. Lack of thyroid hormones can cause lethargy, slowness, hoarse voice, weight gain, muscle aches, joint pain and constipation. This “Hypothyroidism” requires hormone supplements.

Arthritis is the commonest cause for joint pains. Some patients who have arthritis have muscle involvement with swelling. This could cause severe muscle pain and tenderness (pain when being pressed upon). Treatment for arthritis differs from the meds given for fibromyalgia.
What is the outlook?

Fibromyalgia does not actually cause any damage to either bones, muscles or joints but it does cause severe mental agony as this is a long lasting condition. Fibromyalgia affects different patients in different ways. In some it is just a body ache which one could cope with but in others it leads to failure in life events and work. So as specialists we need to identify how severely this affects the individual patient and individualise the treatment.

How to diagnose
Earlier we used to diagnose fibromyalgia using 18 different areas of the patient’s body. Pressure applied over those areas, leading to severe pain, lead to a diagnosis of fibromyalgia. Now the method of diagnosis is different. Patients with fibromyalgia should have widespread pain lasting three months or more, fatigue, waking up feeling unrefreshed and problems with thought processes like memory and understanding (cognitive symptoms).

The widespread pain is checked over 19 areas of the body. And then a score is given between zero to nineteen. Fatigue, waking unrefreshed and cognitive symptoms are again given a score between zero to four. This is based on how bad things are. Somatic symptoms are considered next and given a score between zero to four. Some examples for somatic symptoms are headache, pain/cramps in the abdomen, numbness/tingling, dizziness, insomnia, depression and constipation.

After the scores are obtained we figure out whether the patient has fibromyalgia or not. The most important task is to exclude serious underlying illnesses. There is no blood test or scan to diagnose fibromyalgia so it is a challenge diagnosis to make sometimes.

Treatment of fibromyalgia
I prefer to simply divide the treatment strategies to ones involving medication and therapies that do not introduce meds. To provide the best benefits to the patient it is strongly advised to combine both methods.

There are various drugs used for fibromyalgia of which antidepressants take centre stage. Usually antidepressants are given to treat low mood but in fibromyalgia these are proven to help reduce the pain. Sometimes patients need to take these for longer durations to achieve best results. Some common examples of antidepressants used are amitriptyline and duloxetine.

Another category of drugs used are gabapentin and pregablin. These are also called neuropathic drugs and change the way we perceive pain. We start these at very low dosage and gradually observe how the symptoms subside. A common side effect of these drugs is drowsiness. But as most fibromyalgia patients suffer from insomnia, this side effect is sometimes considered as an advantage.

Tablets which have a mixture of paracetamol and codeine are sometimes useful but usually the normal pain killers and ointments are ineffective in treating fibromyalgia. If we consider alternative therapies, exercise is one of the best remedies for fibromyalgia. Brisk walking for about twenty minutes a day, climbing a staircase rapidly are also good forms of exercise that might be very soothing to the body. There are also stretching exercises that could be done without mobilising yourself too much.

Sometimes referral to physiotherapy and occupational therapy is beneficial in fibromyalgia. In the UK we used to refer patients to a pain clinic attended by physiotherapists and psychologists. One might wonder what a psychologist has to offer in fibromyalgia. I would say a lot, considering all the emotional aspects of pain and its consequences. Relaxation techniques are also proven to be useful in fibromyalgia.

In Sri Lanka some patients have found yoga as a useful remedy for pain relief. The same principles apply in a martial arts form named Tai Chi. In China I have witnessed this common sight before office hours or even at parks, where groups of individuals practise Tai Chi to bring down the stress levels. Both Yoga and Tai Chi involve gradual movement of limbs in a methodical manner.

I always advise patients with fibromyalgia to practise good sleep hygiene techniques. Sleep hygiene is not just maintaining cleanliness but various other factors such as food, beverages, natural light, ventilation etc. which have a collective effect in improving sleep.
(The writer is a specialist in Joint Disease and Rehabilitation)

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