On Fibromyalgia …

“I hurts all over and I feel tired the whole day!”


By: Dr. Rami Rustim – August, 2010

This is the usual statement heard from any patient suffering from fibromyalgia.

Fibromyalgia is a chronic condition characterized by widespread pain in the muscles, ligaments and tendons, as well as fatigue and multiple tender points.

The disease affects about3% of the population in the United States. Women are much more likely to develop the disorder than are men, and the risk of fibromyalgia increases with age. Fibromyalgia symptoms often begin after a physical or emotional trauma, but in many cases there appears to be no triggering event.

* Symptoms – Signs and symptoms of fibromyalgia can vary, depending on the weather, stress, physical activity or even the time of day. The whole mark of the disease is: Widespread pain and tender points.

The pain associated with fibromyalgia is described as a constant dull ache, typically arising from muscles. To be considered widespread, the pain must occur on both sides of your body and above and below your waist.

Fibromyalgia is characterized by additional pain when firm pressure is applied to specific areas of your body, called tender points. Tender point locations include:

* Back of the head

* Between shoulder blades

* Top of shoulders

* Front sides of neck

* Upper chest

* Outer elbows

* Upper hips

* Sides of hips

* Inner knees

Fatigue and sleep disturbances

People with fibromyalgia often awaken tired, even though they seem to get plenty of sleep. Experts believe that these people rarely reach the deep restorative stage of sleep. Sleep disorders that have been linked to fibromyalgia include restless legs syndrome and sleep apnea.

Co-existing conditions

Many people who have fibromyalgia also may have:

* Chronic fatigue syndrome

* Depression

* Endometriosis

* Headaches

* Irritable bowel syndrome (IBS)

* Lupus

* Osteoarthritis

* Post-traumatic stress disorder

* Restless legs syndrome

* Rheumatoid arthritis

Tender Points as frequently identified in Fibromyalgia

* Causes of Fibromyalgia

There is no known or proven reason in fibromyalgia, but it most likely involves a variety of factors working together. These may include:

* Genetics. Because fibromyalgia tends to run in families, there may be certain genetic mutations that may make you more susceptible to developing the disorder.

* Infections. Some illnesses appear to trigger or aggravate fibromyalgia.

* Physical or emotional trauma. Post-traumatic stress disorder has been linked to fibromyalgia.

* Risk Factors

Risk factors for fibromyalgia include:

* Your sex. Fibromyalgia occurs more often in women than in men.

* Age. Fibromyalgia tends to develop during early and middle adulthood. But it can also occur in children and older adults.

* Disturbed sleep patterns. It’s unclear whether sleeping difficulties are a cause or a result of fibromyalgia. But people with sleep disorders — such as nighttime muscle spasms in the legs, restless legs syndrome or sleep apnea — often have fibromyalgia.

* Family history. You may be more likely to develop fibromyalgia if a relative also has the condition.

* Rheumatic disease. If you have a rheumatic disease, such as rheumatoid arthritis or lupus, you may be more likely to develop fibromyalgia.

* Tests and diagnosis

The diagnosis of Fibromyalgia is usually made from the history of the pain in addition to performing detailed clinical exam. No lab work or x-rays imaging is needed.

* Treatment

In general, treatments for fibromyalgia include both medication and self-care. The emphasis is on minimizing symptoms and improving general health.

Since the symptoms of fibromyalgia are diverse and vary among patients, treatment programs must be individualized for each patient. Treatment programs are most effective when they combine patient education, stress reduction, regular exercise, and medications. Recent studies have verified that the best outcome for each patient results from a combination of approaches that involves the patient in customization of the treatment plan.

Patient education

Patient education is an important first step in helping patients understand and cope with the diverse symptoms. Unfortunately, not all physicians are intimately acquainted with the vagaries of this illness. Therefore, community hospital support groups and the local chapters of the Arthritis Foundation have become important educational resources for patients and their doctors. Arthritis Foundation is a national voluntary health organization that provides community education through their many local chapters. Community hospital support groups also provide an arena for patients to share their experiences and treatment successes and failures.

Stress reduction – It is extremely difficult to measure stress levels in different patients. For some people, spilling milk on the table can represent a significant tragedy! Stress reduction might include simple stress modification at home or work, biofeedback, relaxation tapes, psychological counseling, and/or support among family members, friends, and doctors. Sometimes, changes in environmental factors (such as noise, temperature, and weather exposure) can exacerbate the symptoms of fibromyalgia, and these factors need to be modified.

Exercise – Low-impact aerobic exercises, such as swimming, cycling, walking and stationary cross-country ski machines can be effective treatments for fibromyalgia. Exercise regimens are most beneficial when performed on an every-other-day basis, in the morning. How exercise benefits fibromyalgia is unknown. Exercise may exert its beneficial effect by promoting a deep level of sleep (non-REM sleep). Similarly, avoiding alcohol and caffeine before bedtime can also help promote a more restful sleep. While these diet changes may not apply to everyone, they can be very helpful for some. There is no specific fibromyalgia diet or food supplements that are recommended for all patients.

Medications – Traditionally, the most effective medications in the treatment of fibromyalgia have been the tricyclic antidepressants, medications traditionally used in treating depression. In treating fibromyalgia, tricyclic antidepressants are taken at bedtime in doses that are a fraction of those used for treating depression. Tricyclic antidepressants appear to reduce fatigue, relieve muscle pain and spasm, and promote deep, restorative sleep in patients with fibromyalgia. Scientists believe that tricyclics work by interfering with a nerve transmitter chemical in the brain called “serotonin.” Examples of tricyclic antidepressants commonly used in treating fibromyalgia include Amitriptyline (Elavil) and Doxepin (Sinequan).

Studies have shown that adding Fluoxetine (Prozac), or related medications, to low-dose Elavil further reduces muscle pain, anxiety, and depression in patients with fibromyalgia. The combination is also more effective in promoting restful sleep and improving an overall sense of well-being. These two medications also tend to cancel out certain side effects each can have. Tricyclic medications can cause tiredness and fatigue while Prozac can make patients more cheerful and awake. Even more recently, study of patients with resistant fibromyalgia found that Lorazepam (Ativan) was helpful in relieving symptoms. Prozac has also been shown to be effective when used alone for some patients with fibromyalgia.

In 2007, Pregabalin (Lyrica) became the first medication approved specifically for treating fibromyalgia. Lyrica has advantages of flexible dosing that can be adjusted according to persisting symptoms.

Other treatments – Local injections of analgesics and/or cortisone medication into the trigger-point areas can also be helpful in relieving painful soft tissues, while breaking cycles of pain and muscle spasm. Some studies indicate that the pain reliever Tramadol (Ultram) and tramadol/acetaminophen (Ultracet) may be helpful for the treatment of fibromyalgia pains. The muscle relaxant Cyclobenzaprine (Flexeril) has been helpful for reducing pain symptoms and improving sleep.

The nonsteroidal anti-inflammatory drugs (NSAIDs), while very helpful in treating other rheumatic conditions, have only a limited value in treating fibromyalgia pain. Narcotic pain relievers and cortisone medications have not been shown to be beneficial in this condition. Narcotics and cortisone medications are avoided because they have not been shown to be beneficial and they have potential adverse side effects, including dependency, when used long-term.

Both biofeedback and electroacupuncture have been used for relief of symptoms with some success. Standard acupuncture was recently reported to be effective in treating some patients with fibromyalgia.

While you are dealing with this problem it is good to know that you are not alone.

Organizations such as the Arthritis Foundation and the American Chronic Pain Association provide educational classes and support groups. These groups can often provide a level of help and advice that you might not find anywhere else. They can also help put you in touch with others who have had similar experiences and can understand what you’re going through.


1- American Pain Society

2- Mayo clinic website

3- National Fibromyalgia Association

4- Medicinenet.com


Dr. Rami Rustim
Dr. Rami Rustim

Rami R. Rustum, M.D. is the Director of Merrimack Pain Associates at 50 Prospect St. in Lawrence. For any questions or concerns, please email Dr. Rustum at: ramirustum@comcast.net