A Family Doctor's Tale - FIBROMYALGIA

DOC I HAVE FIBROMYALGIA

Fibromyalgia is a common nonspecific group of syndrome characterized by diffuse chronic pain, felt in and over muscle masses with focal trigger points or tender points in muscles, joints, tendons and ligaments.


1.genetically predisposed.


2.more females than males, with a ratio of 9:1


3.individuals between the ages of 20 and 50


4.Increased psychosocial stress


5.Excessive physical exertion


6.Lack of slow-wave sleep


7.Changes in humidity and barometric pressure


8.Lack of normal energy


The exact cause of fibromyalgia is unknown.


Fibromyalgia is almost always a combination of several disorders:


1.Genetic predisposition
There is a polygenic predisposition to Fibromyalgia with high aggregation of Fibromyalgia in families


2. Stress
Stress can affect cortisol levels in the body leading to widespread pain.


3.Sleep disturbance
People with fibromyalgia has short wave sleep that do not reach stage four sleep .


4.Dopamine abnormality
Dopamine is a catecholamine neurotransmitter which can cause schizophrenia, Parkinson's disease and addiction.


Abnormality in dopamine cause increased pain perception and analgesia.


5.Serotonin
Serotonin is a neurotransmitter important in regulating sleep patterns, mood, feelings of well-being, concentration and descending inhibition of pain.


Poor uptake of serotonin can cause pain and poor sleep.


6. Human growth hormone
Stress-induced problems in the hypothalamus may lead to reduced sleep and reduced production of human growth hormone during slow-wave sleep.


People with fibromyalgia has low levels of HGH.


Treatment with exogenous HGH or growth hormone secretagogue reduces fibromyalgia related pain and restores slow wave sleep.


7.Chronic fatigue syndrome patients has been known to develop fibromyalgia between onset and the second year of illness


8.Irritable bowel syndrome is found at high frequency in fibromyalgia.


9.Deposition disease
Fibromyalgia is an inherited disorder which cause gradual phosphate build-up in cells but can be accelerated by trauma or illness.


10.Other causes:
a.viral causes such as the Epstein-Barr Virus,


b.disease affecting the hypothalamus gland,


c.immune response to intestinal bacteria


d.neurotransmitter disruptions in the central nervous system


Symptoms can have a slow onset


Many patients have mild symptoms beginning in childhood.

Pain:
1.Onset of pain may be sudden


2.chronic, widespread pain and tenderness to light touch


3.muscle aches(especially lower back, gluteal, neck, chest wall)


4.prolonged muscle spasms,


5.nerve pain,


6.needle-like tingling of the skin,


Fatigue:
7.moderate to severe fatigue,


8.weakness in the limbs,


Psychosomatic disturbances:
9.functional bowel disorders


10.chronic sleep disturbances.


11.cognitive dysfunction


12.impaired concentration,


13.impaired speed of performance,


14.inability to multi-task,


15.diminished attention span


16.anxiety and depressive symptoms


Eye:
17.eye pain,


18.sensitivity to light


19.blurred vision,


20.fluctuating visual clarity,


These criteria are needed for diagnosis of Fibromyalgia:

1.history of widespread pain lasting more than three months-affecting all four quadrants of the body, i.e., both sides, and above and below the waist.


2.Tender points-there are 18 designated tender or trigger points
During diagnosis, four kilograms-force is exerted at each of the 18 points

The patient must feel pain at 11 or more of these points for fibromyalgia to be diagnosed.


3.fibromyalgia patients show sensitivity to pressure, heat, cold, electrical and chemical stimulation.


4.hyperactivity of the sympathetic nervous system

lower heart rate variability,
sympathetic hyperactivity,


5.laboratory blood testing appears normal


6.Cerebrospinal fluid abnormalities
a.cerebrospinal fluid levels of substance P, a neurotransmitter, is raised.


b.Metabolites for  monoamine neurotransmitters serotonin, norepinephrine, and dopamine are lower,


c.Nerve growth factor, a substance known to participate in structural and functional plasticity of nociceptive pathways within the dorsal root ganglia and spinal cord, is higher


d.Excitatory amino acid release within cerebrospinal fluid is higher


7.Brain imaging studies
Abnormal brain involvement in fibromyalgia has been provided via functional neuroimaging
decreased blood flow within the thalamus and elements of the basal ganglia and mid-brain.


Hippocampal disruption is shown by reduced brain metabolite ratios


Normal age-related brain atrophy occur with areas of reduced gray matter located in the cingulate cortex, insula and parahippocampal gyrus.


Dopamine synthesis in the brain stem is reduced.


There is no cure for fibromyalgia,


A.Medical treatment:

1.corticosteroid seems to help especially to those with adrenal dysfunction and low blood pressure.


Injection of steroids with local anethestics at trigger points or nodules can help relieve pain.


2.Analgesics are able to relieve pain:

a.NSAID medications


b.COX-2 inhibitors,


c.tramadol


3.Muscle relaxants
Muscle relaxants, such as cyclobenzaprine  or tizanidine  to treat the muscle pain associated with the disorder.


4.Tricyclic antidepressants
Low doses of sedating antidepressants (e.g. amitriptyline and trazodone) help to reduce the sleep disturbances associated with fibromyalgia


Amitriptyline is often favored as it can also have the effect of providing relief from neuralgenic or neuropathic pain.


5.Anti-seizure medication
Anti-seizure drugs are also sometimes used, such as gabapentin and pregabalin


Pregabalin for the nerve pain suffered by diabetics has been allowed for treatment of fibromyalgia.


6.Dopamine agonists
Dopamine agonists (e.g. pramipexole (Mirapex) and ropinirole(ReQuip)) have been studied for use in the treatment of fibromyalgia with good results


7.Combination therapy
A combination of amitriptyline and fluoxetine appeared to be more effective in relieving pain.


8.Central nervous system stimulants
Cognitive dysfunction in fibromyalgia may be treated with low doses of central nervous system (CNS) stimulants such as modafinil, adderall or methylphenidate.


Stimulants has the tendency to cause habit forming tendencies in patients and also other serious side effects


9. Cannabis and cannabinoids
Cannabis is used therapeutically to treat symptoms of the disorder.

Cannabinoid agonists can also help in the treatment of chronic pain conditions


B.Non-drug treatment

1. regular flotation tank sessions substantially improves sleep patterns leaving users more optimistic and with reduced nervousness, tension and pain.


Relaxing in a weightless state in the silent warmth of a flotation tank activates the body's own system for recuperation and healing


2.Whirlpool therapy is very beneficial.


C.Psychological therapies

1.Cognitive behavioral therapy has help to improve quality of life


2.Neurofeedback has also shown to provide temporary and long-term relief


3.Biofeedback and self-management techniques such as stress management can help,


D. Healthy lifestyle

1. Stop smoking in smokers.


2. Reduce weight in the obese


3. Exercise to improve blood flow can improve symptoms(sleep , pain and fatigue)


4. heat to painful areas.


5. physical therapy, massage, or acupuncture


6. reduce intake of monosodium glutamate


E Surgical treatment:

Surgery is only indicated in severe cases with
a.limb-threatening ischemia


b.lifestyle-limiting claudication.


F.Experimental treatments
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a.Milnacipran a serotonin-norepinephrine reuptake inhibitor(SNRI) has helped patients in Europe.


b.Dextromethorphan is a cough medicine which acts as an NMDA receptor antagonist.




Fibromyalgia is not degenerative or fatal,


the chronic pain associated with fibromyalgia is pervasive and persistent.


Fibromyalgia can severely curtail social activity and recreation,


Some with fibromyalgia are unable to maintain full-time employment.


It rarely affects activities of daily living.


1.Stop smoking


2.Reduce weight


3.Exercise


4.Aviod monosodium glutamate in diet


5.Avoid stress and depression


6.Live a healthy lifestyle