If you think it's arthritis, but it's not, then it just might be fibromyalgia syndrome (FMS). FMS mimics arthritis, but differs in that it is not an inflammation of the joint spaces. Rather, it is a painful condition with tenderness in the soft tissues that connect our joints, including ligaments, tendons and muscles. Commonly associated symptoms also include fatigue, sleeplessness, and trouble concentrating. There may be associated symptoms of anxiety or depression.

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The major physical findings in FMS are what we call tender points. These are hypersensitive spots that cause significant pain sensation for the patient when only mild to moderate pressure is applied by the physician. There are 18 classical tender points described on the body, including areas around the neck, back, shoulders, elbows, chest, hips and knees. These areas appear normal with no definite redness, swelling nor other physical abnormalities found, other than the marked tenderness. The examination also shows a lack of evidence of arthritis or other physical findings. There may be some fatiguing of muscles or weakness because of the pain, but generally there is no loss of muscle mass. The joints themselves on examination show no evidence of swelling, warmth, redness or limitation of motion. This is the key finding that differentiates FMS from an arthritic disorder.

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One of the most frustrating situations in FMS for patients, their relatives, and for their physicians is the complete normality of all diagnostic tests performed. All routine blood testing and x-ray testing is remarkably normal, unless there is another disease producing the FMS. Certainly thyroid testing and a general complete workup of the patient is in order, so as not to miss any other potential disease states. Sometimes, in uncertain cases, a bone scan might be in order to exclude other conditions since it allows a physician to detect very subtle early inflammatory arthritis in joints. It would also detect any other possible bone lesions, including cancer.

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The classical diagnosis of primary FMS includes documenting at least 11 out of the 18 characterized tender points over the body. When the symptoms of widespread pain, weakness, and fatigue exist with these classic tender points, in the face of completely normal blood tests and x-rays, then this fulfills the diagnosis of primary FMS. There is no specific known cause of primary fibromyalgia. Many types of insults to the body could occur that might trigger FMS. These could include abnormal responses secondary to an infection, an environmental agent, severe stress, or even trauma. In the case of the latter, it has recently been shown that some trauma cases, especially whiplash automobile injuries, have led to a mechanical problem called Arnold-Chiari malformation. This is a mechanical pressure on the brain stem due to herniation into the top of the cervical spinal canal. When such cases are surgically corrected, FMS symptoms have improved. There also are cases of "secondary" fibromyalgia. In these cases, there is an underlying medical disease, such as inflammatory arthritis, thyroid disorder or other medical illnesses which certainly would need to be diagnosed and treated in order for FMS symptoms to improve.

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The treatment of FMS requires what we call a "full court press." The areas that need to be addressed in treatment include pain control, sleep, serotonin levels, therapeutic exercise and fitness, and generalized supportive care and avoidance of strain. There is no cure for FMS. The goal in treatment is to educate the patient and get on a proper regimen that helps control symptoms enough so that the quality of life is improved and they are able to function in their daily work and activities. The specific cause of primary fibromyalgia syndrome is not definitely known which makes treatment more difficult. Something triggers abnormal levels of substances called neurotransmitters, which are meant to help regulate the electrical system and facilitate function of all of our nerve fibers. One neurotransmitter, called substance P is significantly increased in FMS. Another neurotransmitter, serotonin, is decreased. The resultant situation is that the patient will note a hypersensitivity to pain, and it may seem that pain is amplified. These abnormal findings of the spinal fluid have been documented at certain research centers around the country, but this type of testing is not something that can just be ordered by your physician. Since the problem lies in the spinal fluid, it is easy to understand how there can be so many varied symptoms and associated findings in FMS - not only the common symptoms of widespread pain and aching and fatigue, but also trouble with mental functions, headaches, bowel dysfunction and generalized irritability. The main abnormality of the spinal fluid, substance P elevation, is not currently treatable. There is ongoing research to find an agent that would help block this elevation of substance P. At this time we rely on medications which help raise serotonin levels, since it is the next most important abnormality in the spinal fluid in FMS. There is no actual pill of serotonin itself, so we tend to use a group of agents that block serotonin re-uptake by the cells. By blocking this uptake into the cell, there is more serotonin free in the spinal fluid which helps regulate our neuromuscular functions. The main medications that block serotonin re-uptake are antidepressants including Prozac, Zoloft, Paxil, Effexor, and Celexa. It takes these medications up to six weeks to build up levels of serotonin, so one must not expect immediate results with these agents. Fitness and stretching exercises are quite important in FMS. Although it may initially be painful to exercise, it is better in the long run to faithfully get on a well-planned exercise program. It is very important to start exceedingly slowly when trying to exercise, so as not to cause a flare of the FMS. Warm water aquatic exercise seems to be well tolerated and generally liked by FMS patients, but many other types of mild aerobic and fitness exercise can be equally effective. One should discuss exercise and fitness with their physician and physical therapist. Another important point in treating FMS is to learn how to "slow down." The body of a patient with FMS does not tolerate the usual physical and emotional stress and strains of everyday life. Pacing one's activity is very important. Getting deep sleep is also very important in FMS, and indeed poor quality of sleep on a prolonged basis may even be a contributing factor in FMS. With the use of serotonin re-uptake inhibitors, participation in fitness programs, and avoidance of emotional upset, sleep patterns may improve. It is often necessary, however, to add sleep medications for FMS patients, at least initially. Ambien is one of the most commonly used and best tolerated agents. The muscle relaxer Flexeril has also been useful at bedtime in allowing deep muscle relaxation and facilitating sleep, and helps improve FMS symptoms. The tricyclic antidepressants, such as Elavil, have also been used in the evening to help with deeper sleep and in raising serotonin levels leading to improvement in FMS symptoms. Elavil in low doses can be effective in some patients, but higher doses may lead to more adverse side-effects over time, including dry mouth, constipation and weight gain. Medication for pain is also quite important early on in fibromyalgia, while waiting for the benefits of other treatments to take effect. Since true inflammation cannot be found when the muscles have been biopsied and studied, anti-inflammatory and mild analgesic agents offer very little help in controlling the pain. It is often necessary to use stronger agents including Ultram, Darvocet, or Vicodin or possibly even long-acting narcotics for those with the most severe chronic pain syndromes. It is important that the patient understands that the goal of treatment is to take the edge off of the severe pain rather than to relieve it totally, since addiction is certainly a potential problem. Local injections of lidocaine or a small amount of steroid with lidocaine (trigger point or tender point injections) can also be quite helpful in certain severe tender points. Combining some of these injections with physical therapy and neuromuscular techniques of deep massage are often quite beneficial. Even though there is no cure for fibromyalgia, all is not lost. The prognosis for a patient placed on a complete treatment regimen is good and allows patients to take care of their usual daily activities and work. Half the battle is learning to cope with a chronic condition that has so many adverse symptoms. When a patient is educated about their condition and learns to pace their activities and slow down, things usually improve. There are also numerous support groups present around the country which specifically address fibromyalgia and its treatment. These are quite beneficial for patients and their families. It is important to know that FMS does not lead to any type of crippling or permanent deformities, but rather often just seems to make life miserable. So patients should take the time to be well-informed about their condition and to work closely with a knowledgeable physician such as a rheumatologist or a physical therapist familiar with FMS in order to obtain maximum relief.

Joel Rutstein M.D.
Gerald T. Rosenberg, M.D.