Fibromyalgia Latest Facts: Etiology, Causes, Risk Factors, Diagnosis and Treatment

What is fibromyalgia?

Fibromyalgia is a chronic, often misdiagnosed, neurologic disorder with a predilection for women. It is a common problem that causes extensive pain and tenderness. Fibromyalgia has been associated with rheumatic diseases and can develop at any age, although it commonly starts in middle age. It can rarely start in teenage or old age. Although associated with rheumatic diseases, it is important to note that fibromyalgia is not an inflammatory or autoimmune disorder.

Fibromyalgia Tender Points

Recent studies described Fibromyalgia as a Central Pain Amplification disorder (CAPD), as they believe that fibromyalgia is a result of over sensitization of nerves. Nerves are believed to overreact to pain signals and produce exaggerated responses.

What Causes Fibromyalgia?

The exact etiology of fibromyalgia is not known. However, several theories have been proposed explaining its development and progression. Recent studies have shown that fibromyalgia might be due to multiple-hit theory involving genetic predisposition, and triggers/sets of triggers such as infections, stress, and so on.

The characteristic pain in affected individuals can be due to many reasons, like;

• Increase in excitatory neurotransmitters (Substance p, glutamate)
• Decrease in inhibitory neurotransmitters (serotonin, norepinephrine)
• Dopamine dysregulation
• Pain threshold being lowered

The increase in substance p and a decrease in serotonin act together to increase the sensitivity of pain in the body. This hypersensitization seen in fibromyalgia is being studied further, to give a better explanation of abnormal central processing of pain.

Substance P levels in CSF of patients with fibromyalgia were almost 2 to 3 times higher than normal, indicating that it plays a vital role in the pathophysiology of the disease. However, some researchers believe that substance p alone cannot be responsible for the development of fibromyalgia. According to them, CAPD is a result of dual action of serotonin and substance p level dysregulation

Furthermore, recent studies found a dysfunctional hypothalamic-pituitary-adrenal axis in fibromyalgia-affected patients. HPA axis is responsible for stress adaptation via the release of the stress hormone, cortisol. Patients with fibromyalgia were found to have lower levels of cortisol, proving the dysfunctional HPA axis theory.  Decreased activity of the HPA axis may lead to a further decrease of serotonin, which can elevate substance p and sensitivity to pain as mentioned above.

Fibromyalgia runs in families and researchers have found some genetic mutations explaining its hereditary characteristics, however, no conclusive results have been achieved. Infections like flu, pneumonia, Shigella, and Salmonella-associated GI infections and EBV can all worsen fibromyalgia in affected individuals.

Fibromyalgia has also been related to PTSD, as it can develop after severe physical or emotional trauma. More recently, neuroinflammation along with systemic inflammation has been demonstrated in patients with fibromyalgia.  Bäckryd et al in 2017 found raised markers of inflammation including IL-7, SIRT2, and CD40 in the CSF and serum in fibromyalgia patients in comparison to healthy participants. 

What are the risk factors for Fibromyalgia?

As mentioned above, infections, stress, and trauma can cause a fibromyalgia attack. Some other risk factors are as follows:

• Having Lupus: Fibromyalgia is not an autoimmune disorder but the presence of autoimmune disorders like SLE may increase the chances of developing fibromyalgia.
• Age: It is usually diagnosed around 35 to 45 years of age
• Family history
• Gender: It is more common in women than in men. Apart from the difference in the number of affected individuals, the characteristic features of fibromyalgia are also different in both genders. Males usually tend to experience milder symptoms than females.

What are the symptoms of Fibromyalgia?

Fibromyalgia has regions of pain and trigger points, which are useful for diagnosis and a better understanding of the patient’s pain and other symptoms. These two regions may overlap. Some of the other symptoms of fibromyalgia include:

• Fatigue
• Trouble sleeping
• Sleeping for long periods of time without feeling rested (nonrestorative sleep)
• Headaches
• Depression
• Anxiety
• Trouble focusing or paying attention
• A dull ache in the lower abdomen
• Dry eyes
• Bladder problems

Cognitive dysfunction in fibromyalgia may manifest as difficulty focusing, memory lapses, and concentration deficits which have been termed, ‘fibromyalgia fog’ or ‘brain fog’.

Fibromyalgia presents itself differently in men and women. In women, fibromyalgia is usually IBS-associated and more painful. Females affected by fibromyalgia may also present with dysmenorrhea or painful menopause with exaggerated signs of menopause.

However, men face milder physical symptoms of fibromyalgia but it can leave a mark on their emotional health. Due to fibromyalgia incorrectly being known as ‘women’s disease’, there is a stigma around men being diagnosed with it. Most men prefer not to visit their doctors when symptoms initiate to save themselves from the embarrassment associated with it.

Pain is the characteristic feature of fibromyalgia. It is usually described to be a dull, achy sensation but it can range anywhere between this and extreme, unbearable pain.

How is Fibromyalgia diagnosed?

After a physician suspects fibromyalgia, based on the presence of widespread pain (pain on both sides of the body, and both above and below the waist) for more than three months. A physician must then perform an extremely thorough physical exam to rule out other conditions with similar symptoms.

Physicians may order CBC count and differential count, along with basic metabolic panel and urinalysis. CBC may show elevated ESR, indicating the origin of pain to be an inflammatory disorder and not fibromyalgia. It is normal in fibromyalgia.

Certain laboratory tests like thyroid function tests, Vitamin D, and Vitamin B12 levels, iron studies, and magnesium levels may be performed to further exclude other diagnoses.

Diagnosis of Fibromyalgia can be made using these criteria:

1. Symptoms last at least 3 months or more
2. No other disease explains the symptoms and all diagnoses have been excluded.
3. Characteristic symptoms and constitutional symptoms, plus pain for the past week. Furthermore, the location and severity of pain also need to be taken into consideration for an accurate diagnosis.

How to treat fibromyalgia?

Unfortunately, there is no cure for fibromyalgia. However, pain management is possible with either nondrug or medication-based interventions. According to European League Against Rheumatism (EULAR) 2016, initial management of fibromyalgia should be focused on patient education and non-drug treatments.

Non-Drug Treatment

1. Physical Exercise: Low-impact exercise can alleviate pain and help with fibromyalgia symptoms. Physical exercises like yoga must usually be done in combination with the medical treatment of fibromyalgia.
2. Cognitive Behaviour Therapy (CBT): It aims to help with the cognitive dysfunction or fibromyalgia fog many patients suffer from. Along with mindfulness, these techniques can alleviate stress and improve the general condition of the patients.
3. Chiropractic and Massage therapy & Acupuncture may also help relieve the symptoms of fibromyalgia
4. Therapists and psychiatric help for those suffering from anxiety, depression, or PTSD, all of which are related to fibromyalgia attacks, can be very beneficial

Medical Treatment

1. Pregabalin (Lyrica): This drug, along with gabapentin, blocks overactivity of nerves which has been hypothesized as one of the etiologies of fibromyalgia. This drug has been FDA approved for the treatment of fibromyalgia and causes dizziness as a side-effect.
2. Duloxetine (Cymbalta): This drug, a Selective Serotonin and Norepinephrine Reuptake Inhibitor (SSNRI) is usually used to treat depressive episodes in anxiety disorders and fibromyalgia.
3. Milnacipran (Savella): Also, an SSNRI, it is FDA approved for the treatment of fibromyalgia
   Only these three drugs are FDA approved for the treatment of fibromyalgia. The use of opioid narcotics as pain management therapy should be avoided, according to the FDA. This is because they can cause more sensitivity to pain and worsen the patient’s overall condition.

Also, over-the-counter NSAIDs are not beneficial in the treatment of fibromyalgia pain, however, they can be used in patients with arthritis and fibromyalgia. They may be beneficial in such patients.

Furthermore, sleep disorders can be treated with the above-mentioned three drugs. The use of benzodiazepines for the treatment of sleep disorders is contraindicated.

Patients with fibromyalgia should also be encouraged to make lifestyle changes, along with dietary changes. These changes may be very beneficial and prevent bouts of fibromyalgia flare-ups.

My opinion

The pathophysiology of fibromyalgia is still not completely understood. New studies are being conducted to understand the various hypothesized theories in relation to decreased pain threshold and overall increased sensitivity to pain. Recent studies have shown increased activation of glial cells in the brain, indicating their role in neuroinflammation that was recently shown in fibromyalgia patients. Furthermore, the role of substance p has already been established in fibromyalgia. But new research has been focusing on nerve growth factors, which can enhance the levels of substance p. In the CSF of fibromyalgia-affected subjects, NGF was increased by 3-4 times the normal amount.

References

https://www.niams.nih.gov/health-topics/fibromyalgia

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