Fibromyalgia: Latest Research News
By Dr. Jim Tabios, PhD
Fibromyalgia is a widely misunderstood and sometimes misdiagnosed chronic condition, commonly characterized by widespread muscle pain, fatigue, concentration issues, and sleep problems.
According to the National Fibromyalgia Association, it affects an estimated 10 million people, mainly women, in the United States alone.
The severity of fibromyalgia symptoms can vary from one person to the next and may fluctuate even in a single individual, depending on such factors as time of day or the weather.
Because it is a chronic condition, in most cases, fibromyalgia symptoms never disappear entirely. The good news is that fibromyalgia isn’t progressive or life-threatening, and treatments can help alleviate many symptoms.
The symptoms of fibromyalgia and their severity vary widely, although pain and fatigue are nearly always present. Major symptoms of fibromyalgia include:
- Pain. Some fibromyalgia patients report discomfort in one or more specific areas of their body, while others may experience overall pain in their muscles, ligaments, and tendons.
- Certain areas, such as the back of the head, upper back and neck, elbows, hips, and knees may be particularly sensitive and are described clinically as tender points. The degree and type of pain can range from aching, tenderness, and throbbing to sharper shooting and stabbing sensations. Intense burning, numbness, and tingling may also be present.
- Fatigue. If you’ve ever been knocked off your feet by a bad case of the flu, you have a general idea of how tired some people with fibromyalgia can feel. Though some fibromyalgia patients experience only mild fatigue, many report feeling completely drained of energy, both physically and mentally, to the point that exhaustion interferes with all daily activities.
- Memory problems. Difficulty concentrating and remembering are common cognitive symptoms in people with fibromyalgia.
- Sleep disturbances. Research has shown that the deepest stages of sleep in patients with fibromyalgia are constantly interrupted by bursts of brain activity, causing feelings of exhaustion even after a seemingly good night’s rest. Other problems such as sleep apnea and restless legs syndrome are also common among fibromyalgia sufferers.
- Irritable bowel syndrome (IBS). Symptoms of IBS, including diarrhea, constipation, abdominal pain, and bloating, are present in many people with fibromyalgia.
Other common symptoms:
- Headaches, migraines, and facial pain
- Depression, anxiety, or mood changes
- Painful menstrual periods
- Dry mouth, eyes, and skin
- Heightened sensitivity to noise, odors, bright lights, and touch
Fibromyalgia Symptom Triggers
The following factors can worsen the symptoms of fibromyalgia:
- Changes in weather (too cold or too humid)
- Too much or too little exercise
- Too much or too little rest
- Stress and anxiety
- Some patients also report that pain and stiffness are worse in the morning.
Causes of Fibromyalgia
While the exact cause of fibromyalgia remains a mystery, doctors do know that patients with the disorder experience an increased sensation of pain due to a glitch in the central nervous system’s processing of pain information.
Studies have shown that people with fibromyalgia also have certain physiological abnormalities, such as elevated levels of a chemical in the spinal cord that helps transmit pain signals (thus amplifying, or “turning up,” the signals in the brain’s pain-processing areas).
In some cases, an injury or trauma, especially to the spinal region, or a bacterial or viral illness, may precede a diagnosis of fibromyalgia, which has caused researchers to speculate that these infections may be triggers as well.
Fibromyalgia Risk Factors
A number of factors can increase the odds that you may develop fibromyalgia. These include:
- Gender. Fibromyalgia is more common among women than men.
- Age. Symptoms usually appear during middle age, but can also manifest in children and older adults.
- History of rheumatic disease. People who have been diagnosed with a rheumatic disorder — conditions affecting the heart, bones, joints, kidney, skin, and lungs — such as rheumatoid arthritis, osteoarthritis, and lupus are at increased risk of also developing fibromyalgia.
- Family history. Having a relative who suffers from fibromyalgia puts you at increased risk.
- Sleep problems. Doctors aren’t sure whether sleep disturbances are a cause or a symptom of fibromyalgia — but sleep disorders, including restless legs syndrome and sleep apnea have been cited as possible fibromyalgia triggers.
When to Seek Help for Fibromyalgia?
If you experience pain in your muscles that lasts for several months and is accompanied by significant fatigue, see your doctor.
What causes Fibromyalgia?
While there is a lot of ongoing speculation about what triggers fibromyalgia, its causes have yet to be definitively identified and confirmed. Recent research has generally found that fibromyalgia is most likely a result of what scientists call central sensitization, or unusual responses in the nervous system with regard to pain perception.
Fibromyalgia’s Biochemical Triggers
“The [current] consensus is that fibromyalgia is not a problem with the muscles, joints, or tendons, but rather a problem with the central nervous system,” says Dr. Bruce Solitar, clinical associate professor of medicine in the division of rheumatology at NYU Medical Center/Hospital for Joint Diseases in New York.
While it’s easy to think that pain felt by someone who has experienced no physical damage to the body might be categorized as purely psychosomatic, the sensations that a fibromyalgia patient experiences are as real as any other pain.
This was clearly demonstrated when researchers did MRI imaging of patients with fibromyalgia. When they pressed on certain areas of the participants’ bodies, they found dramatically increased activity in the pain center of the brain.
One theory attributes this phenomenon to an increased release of Substance P, the chemical that activates nerves when there is a painful stimulus.
In fibromyalgia patients, Substance P is being released even in the absence of a painful stimulus. And there seems to be an amplified release when there is a painful stimulus,” explains Dr. Solitar.
In addition, the brain’s regulatory effect, which sends “down signals” to turn off pain, also appears to be abnormal in people with fibromyalgia — so when a painful stimulus does occur, it gets amplified rather than dampened.
Fibromyalgia’s Physical and Emotional Triggers
So what causes the nervous system to malfunction in such a way? Scientists aren’t sure, but a number of conditions have been linked to the development of fibromyalgia. These include:
- Infection. The Epstein-Barr virus, influenza, and hepatitis B and C have all been implicated in the development of fibromyalgia. “These viruses may have [long-term] effects on the immune system. It’s also possible that viral particles attach to glial cells, which are cells within the brain that affect neurotransmission [and influence the pain response],” says Dr. Solitar.Additionally, there is a well-established connection between Lyme disease and fibromyalgia: Some patients who have been treated for Lyme — and ostensibly recover from it — continue to experience the unusually high frequency of unprovoked pain that characterizes fibromyalgia.
- Trauma. Sometimes the development of fibromyalgia is linked to physical injury, especially in the upper spinal region. In other cases, it’s associated with great emotional stress, like the death of a family member or the loss of a job. The possible link between these unrelated types of trauma is the neurohormonal change that both physical injury and emotional stress can trigger.
- Psychological processes can change — and can be changed by — alterations in the function of hormone-regulating centers like the hypothalamus and the pituitary and adrenal glands, which in turn affect the nervous system.
Fibromyalgia’s Other Common Threads
“Fibromyalgia has been associated with all age groups, though women between the ages of 30 and 50 have a higher incidence of the disease,” says Dr. Solitar. While this increased prevalence among younger females suggests a hormonal connection, he says it’s also possible that it’s related to diagnosis. “Women tend to [naturally] be more tender [or sensitive to pain] than men, so if you base your diagnosis on tender points, you’re likely to diagnose more women with fibromyalgia than men.”
- Genes. Found in approximately 2 percent of the U.S. population (3.4 percent of women and 0.5 percent of men), fibromyalgia often develops in multiple members of the same families, although it’s not clear if this is the result of genetic or environmental effects. “Family members of people with fibromyalgia seem to be more tender than others,” says Dr. Solitar, “but there isn’t a lot of conclusive genetic research out there.”
- Still a mystery. In many cases, why fibromyalgia strikes is still largely unknown. “For a lot of patients, we don’t come up with a good explanation for the development of fibromyalgia,” Dr. Solitar notes. “We all get exposed to stress regularly. And while trauma and infections do seem to be a common [fibromyalgia] theme, there are a lot of people who just slowly develop a sense of feeling poorly.”
Fibromyalgia and Sleep
More than 75 percent of fibromyalgia patients complain of sleep disturbances and fatigue, according to the National Fibromyalgia Research Association. Studies have shown that this is often the result of problems fibromyalgia sufferers have falling asleep and staying asleep.
While some people don’t remember waking up frequently, others do recall these disruptions to a good night’s rest. Either way, these abnormal sleep patterns prevent fibromyalgia sufferers from getting a healthy amount of restful, restorative sleep.
Fibromyalgia’s Connection to Impaired Deep Sleep
There are five stages of sleep, and in the course of a normal night’s rest, a person will normally cycle through various stages, from light to deep to dreaming, every 90 minutes or so. Dreaming occurs during what’s called REM (rapid eye movement) sleep. Interestingly, EEG (brain wave) studies have found that fibromyalgia patients lack the restorative levels of deep, non-REM sleep.
It is during these deepest levels of sleep — also known as stages 3 and 4 — that the body restores and refreshes itself. Stage 3 is characterized by moderately deep sleep and stage 4, the deepest sleep phase, is when certain substances like growth hormones are released for body-tissue repair and replenishment.
Research suggests that people with fibromyalgia are constantly aroused by bursts of “awake” brain activity, which limits the amount of time they spend in these critical deep stages of sleep. “On EEG studies, fibromyalgia patients in deep-sleep stages have been found to have alpha waves, which are signs of arousal or wakening,” says Patrick Wood, MD, chief medical advisor for the National Fibromyalgia Association. One study published in the Journal of Rheumatologyfound that fibromyalgia patients experience at least twice as many arousals per hour as people without the disorder.
Fibromyalgia’s Constant “Fog” and Fatigue
The lack of uninterrupted deep sleep may be the reason why people with fibromyalgia are also plagued by extreme daytime fatigue. In today’s world, many people complain of feeling tired, but the exhaustion associated with fibromyalgia is much more severe. Fibromyalgia patients report feeling as if their bodies have been completely drained of energy, which can lead to limited physical and mental functioning.
It’s also common for people with fibromyalgia to have problems with concentration, thinking, and memory, a condition known as “fibro fog.” A recent University of Michigan study found that people with fibromyalgia exhibit memory impairments on tests that can mimic 20 years of aging. One possible reason: Memories are processed during sleep stages 3 and 4.
Brain Chemicals: The Root of the Problem?
While the causes of sleep problems in those with fibromyalgia are not yet completely understood, new findings are uncovering possible links. One theory is that brain chemicals may be out of whack. “There’s very good evidence that fibromyalgia is associated with abnormal amounts of dopamine, which is an energy-related neurotransmitter, or brain chemical,” says Dr. Wood.
“During these two stages of sleep, the brain sorts through information accumulated during the day, taking it out of short-term memory and putting it into long-term memory,” says Dr. Wood. When the amount of deep sleep is reduced, experts speculate that the body may have a limited ability to repair and replenish the brain’s functioning, affecting memory as well as energy.
Norepinephrine, another energizing neurotransmitter, and cortisol, a hormone associated with stress, have also been found to be abnormal in fibromyalgia patients. In addition to interfering with restful sleep, neurochemical and hormonal imbalances may exacerbate the pain associated with fibromyalgia, in the opinion of some experts. Others researchers believe that it’s the constant pain that triggers deep-sleep abnormalities.
More studies are currently underway that may help uncover more definitive causes of sleep difficulties associated with this painful, life-altering condition. It is hoped that in the next five years or so scientists will have more answers about the connection between fibromyalgia and disordered sleep.
The fibromyalgia symptoms your doctor will look for…
Diagnosing fibromyalgia can be challenging for the physician and frustrating for the patient. This is because fibromyalgia symptoms vary from person to person and can be similar to those of many other common conditions. Fibromyalgia’s classic chronic pain symptoms, for instance, can mimic those related to arthritis, depression, and even multiple sclerosis.
In addition, there is no specific diagnostic laboratory test for fibromyalgia. In fact, blood tests and X-rays are often normal. This means that a diagnosis has to be based on a patient’s report of his or her symptoms and on a physician’s physical exam. Because so many complicating factors are involved, it often takes a specialist, usually a rheumatologist, to make a firm diagnosis.
Diagnosing Fibromyalgia: Who Is at Risk?
Fibromyalgia affects 2 to 4 percent of the U.S. population, and it predominantly affects women. “Fibromyalgia affects three times as many women as men,” says Dr. Jacob Teitelbaum, medical director of the Fibromyalgia and Fatigue Centers of America and the author of From Fatigued to Fantastic! (Avery) although some studies suggest that this number may be closer to ten times as many women, most of whom are diagnosed between the ages of 20 and 50. But the condition can also affect men, and it can occur in people of all ages.
Other risk factors for fibromyalgia include having a family history of the condition, having a sleep disorder such as restless legs syndrome or sleep apnea, and suffering from a rheumatic disease such as lupus or rheumatoid arthritis.
Diagnosing Fibromyalgia: Common Symptoms
“Fatigue, aches, brain fog (meaning difficulty with short-term memory, word finding, and word substitution), and insomnia sum up the hallmark symptoms of fibromyalgia,” says Dr. Teitelbaum. “If you can’t sleep, even though you’re exhausted, and you have widespread chronic muscle pain lasting longer than three months, you may have fibromyalgia.”
Complicating the diagnosis further, many fibromyalgia sufferers also have a related condition called chronic fatigue syndrome, which is considered a separate disorder, according to Dr. Teitelbaum. Between 50 and 70 percent of people with fibromyalgia fit the criteria for chronic fatigue syndrome, and vice versa. The pain patients experience in fibromyalgia is also similar to the joint pain of arthritis, though fibromyalgia does not cause actual joint damage like arthritis.
Sufferers often say that the muscular aches and pains of fibromyalgia are similar to the body aches associated with the flu. The pain — variously described as throbbing, shooting, stabbing, and aching — and the stiffness may be worse in the morning.
To determine whether you have fibromyalgia, your doctor will ask you questions regarding the degree to which you experience the following symptoms.
Pain: In fibromyalgia, muscle pain encompasses the entire body — above and below the waist, and on both the right and left sides of the body. Muscles used repeatedly tend to hurt more. Patients feel stiff and find it difficult and painful to move. Although their joints are not visibly swollen, patients often report a sensation of swelling in their joints along with joint pain.
- Fatigue: Symptoms of fatigue can range from mild to incapacitating in patients with fibromyalgia; many report feeling “drained” of energy. Brain fog and an inability to concentrate often go hand in hand with the fatigue.
- Sleep disruptions: Fibromyalgia sufferers often fall asleep normally but wake up frequently during the night. And even when they get plenty of sleep, people with fibromyalgia report waking up exhausted.
- Digestive problems: Irritable bowel syndrome, constipation, diarrhea, nausea, and abdominal pain occur in 40 to 70 percent of fibromyalgia patients, along with gastroesophageal reflux disease (GERD), or acid reflux.
- Weight gain: Many people with fibromyalgia experience weight gain because of metabolic changes that occur as a result of the disease. “We’ve found an average weight gain of 32.5 pounds among fibromyalgia sufferers, which may happen within six months or over the course of several years,” says Dr. Teitelbaum.
- Decreased physical functioning: This important feature of fibromyalgia can be measured with the Fibromyalgia Impact Questionnaire (FIQ), developed by clinicians at Oregon Health & Science University.
- Other changes in health: Many patients with fibromyalgia experience light-headedness or dizziness, anxiety, and depression. Irritable bladder, noncardiac chest pain, and migraine headaches may also occur and can become more severe during times of stress, in cold or drafty environments, or when infections, allergies, hormonal fluctuations, depression, or anxiety are present.
Diagnosing Fibromyalgia: What Your Doctor Will Look For
Since no diagnostic lab test for fibromyalgia currently exists, your doctor’s physical exam plays a key role in determining whether you have the condition. Your doctor will probably start by taking a health history.
Blood tests and X-rays may then be ordered to help rule out other possibilities, such as rheumatoid arthritis, lupus, and multiple sclerosis, whose symptoms can be similar to those of fibromyalgia. “Testing may also include hormonal tests (thyroid, adrenal, estrogen, testosterone, and so on), tests for immune function and for dietary deficiencies (most often iron and B12),” says Dr. Teitelbaum.
According to guidelines created by the American College of Rheumatology in 1991, a diagnosis of fibromyalgia requires that you have experienced widespread, aching pain for at least three months and have a minimum of 11 locations on your body that are abnormally sensitive to pain when touched with relatively mild but firm pressure.
Called tender points, these spots are found in 18 specific places on the head, upper body, and certain joints. People with fibromyalgia have very strong reactions to even mild pressure on these tender points; your physician may also use the same level of pressure on nontender points (called control points) to compare your reaction.
Linking Fibromyalgia to Depression and Anxiety
Chronic, widespread muscular pain and tenderness, sleep problems and fatigue, morning stiffness and headaches, concentration and digestive irregularities: All these symptoms can make daily functioning very difficult for those with fibromyalgia.
But equally challenging are the depression and anxiety that often accompany the disorder. Each occurs in approximately 8 percent of those with fibromyalgia, according to Jacob Teitelbaum, M.D., medical director of The Fibromyalgia & Fatigue Centers, Inc. In people with fibromyalgia, he says, anxiety often manifests itself as rapid shallow breathing (hyperventilation), and depression (as a decrease in normal interests).
While it is not unexpected to have an emotional or psychological response to a chronic illness, there may be other physiological reasons that explain why anxiety and depression occur in fibromyalgia patients consistently enough that they are listed as symptoms of the condition. “Biochemically, depression is very different in [people with] fibromyalgia than otherwise,” says Dr. Teitelbaum. “In fibromyalgia, it is often associated with an underactive adrenal function [a low cortisol level], whereas depression [in a non-fibromyalgia population] is associated with a high cortisol level.”
According to some doctors who routinely treat fibromyalgia, there are a number of factors that appear to increase the likelihood of developing anxiety and/or depression if you have this condition. These include:
Dr. Smith says that low cortisol levels related to stress often do not show up on standard blood tests, and she has found they are best measured by saliva testing. “Many physicians only measure cortisol levels as related to Addison’s Disease or Cushing’s disease. They do not look at what happens when the body makes only enough cortisol to stay alive but not to function well (adrenal fatigue),” she explains. Cortisol levels can be normalized by reducing stress. She says, adding, “it may take one to two years to fully normalize the body’s stress system.”
As cortisol levels are restored, fibromyalgia-related anxiety and depression generally lessen.
Dr. Jim Tabios, PhD is a PhD Bay Area (CA) Resident specializing in Biomedical Sciences. Dr. Tabios is currently working on a virtual anatomy portal to examine the human body through the use collaborative data from universities and medical imaging databases. Dr. Tabios is also Vice President of the Knowl Project and MENSA International Member since 2007.
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