FIBROMYALGIA

Fibromyalgia is a complex multi faceted disorder. It is poorly understood not only by the common people but sadly a vast majority of the medical fraternity are also are pretty oblivious to it’s course, diagnosis and management. Fibromyalgia ,if left untreated for a long time can have a considerably debilitating effect on the quality of one’s life. It was only in 1990 that the American College of Rheumatology defined Fibromyalgia and published their research which has now become the cornerstone in diagnosing Fibromyalgia.

The quartet of Unexplained pain, easy fatigability, frequent mood disturbances and loss of function are the major components in Cornerstone in diagnosing Fibromylagia (FM). There are four main components in FM: Pain, fatigue, mood, and function. The incidence of FM is seven times more in women than men. Incidence has been seen to be more in women of the childbearing age. More often than not fibromyalgia presents in association with other somatic disturbances like chronic fatigue syndrome, temper mandibular joint dysfunction, Irritable Bowel Syndrome .[3]As of today, a patient centric multidisciplinary approach to tackle fibromyalgia has been the most widely accepted methodology by clinicians all over.

ETIOPATHOGENESIS

  • Throughout the first half of the 20th century FM was widely referred to as fibrositis. The term fibromyalgia came into existence and gained popularity owing to the concomitant pain symptoms seen in people suffering with FM.
  • A lot of theories attempting to explain the etiology of FM have sprung up. While some of them have been thwarted by research, some of them have enjoyed partial acceptance in the medical fraternity.
  • Damage to soft tissues including muscles was thought to be a main causative factor but absence of damage seen in muscle biopsies strongly refuted this theory.
  • It has been considered that there might be disturbances in the serotonin and epinephrine pathways with may prevent the relative muting of afferent pain. This results in a stronger perception of pain
  • Increase in the concentration of Substance P was considered to increase the peripheral sensitivity to pain in patients suffering with FM but future studies failed to show a correlation between the level of Substance P and the degree of pain present.
  • Studies on sleep patterns of patients with FM have shown increased alpha activity and reduced delta activity on Sleep Electroencephalogram indicating sleep disturbances might find a place in the complex etiology of FM.
  • Impairment of the hypothalamic- pituitary axis has also been considered ads a cause of FM.
  • Trauma, infection or surgery may precipitate some of the biological changes leading to the onset of symptoms.

CLINICAL PRESENTATION

FM is characterised by widespread pain present all throughout. Bilateral involvement of body parts is seen. Pain also occurs in the axial structures like the cervical spine, thoracic spine, lumbar spine or the chest wall. The following 18 musculoskeletal structures have been identifies as the commonest trigger or tender points in FM. A patient exhibiting tenderness palpation in 11 out these 18 points may strongly favour the diagnosis of fibromyalgia.

Occiput or suboccipital muscle insertions.

Low cervical or anterior aspects of the intertransverse spaces at C5–C7

Trapezius or midpoint of the upper border

Supraspinatus or origins above the scapula spine near the medial border

Second rib or upper lateral to the second costochondral junction

Lateral epicondyle or at 2cm distal to the epicondyles

Gluteal or in upper, outer quadrants of buttocks in anterior fold of muscle

Greater trochanter or posterior to the trochanteric prominence

Knee or at the medial fat pad proximal to the joint line.

FIBROMYALGIA-011

Other than tender points the other features of Fibromyalgia are as follows

DIAGNOSIS

The Fibromyalgia Impact Questionnaire is a questionnaire for the patient comprising of 20 questions. This helps to quantify the impact of Fibromyalgia on the patient. Scoring ranges from 0-100 with majority of the FM patients scoring over 50

FIBROMYALGIA SURVEY QUESTIONNAIRE

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Please help us improve our products/services by completing this questionnaire.

Using the following scale, indicate for each item the level of severity over the past week by checking the appropriate box. 

0: No problem
1: Slight or mild problems; generally mild or intermittent
2: Moderate; considerable problems; often present and/or at a moderate level
3: Severe; continuous, life-disturbing problems

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Fatigue*

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Trouble thinking or remembering*

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Waking up tired*

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During the past 6 months have you had any of the following symptoms? Pain or cramps in lower abdomen.

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Depression*

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Headache*

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Joint/ Body pain

Please indicate below if you have had pain or tenderness over the past 7 days in each of the areas listed below. Please make an X in the box if you have had pain or tenderness. Be sure to mark both right side and left side separately.

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Enter Your Name*

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Enter Your Email ID*

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TREATMENT

Non Pharmacological Treatment- Living with Fibromyalgia is a big challenge
when compared to some of the other chronic conditions.

Clinicians need to excercise a lot of patience with these patients. One of the key elements to non pharmacological approach is to encourage the patients to become SELF MANAGERS through counselling and training. Patient education is focussed on improving pain, sleep, fatigue and function. Out of the non- pharmacological approaches excercise and psychoeducational approaches have shown be highly beneficial in curbing the symptoms of FM. High intensity aerobic excercises And Aquatherapy are very helpful in some patients.[11,12]] Other tools which might have a positive impact on the quality of life are meditation, stress management and relaxation techniques.

Pharmacological Intervention- Antidepressants- Tricyclic Antidepressants in low doses of 25-50mg/d have been found to be effective for bringing about improvement of fatigue, sleep, pain and depressive symptoms of fibromyalgia.[13]. Amitryptyline has found itself as the first line drug in the management of fibromyalgia in many practices. It has to be carefully monitored as patients on it will have a tendency towards weight gain and developing tolerance. Serotonin Noradrenaline Reuptake Inhibitors are also used in treating FM as levels of serotonin and noradrenaline has been found to be lower in certain subgroups.Duloxetine at 60mg dosage has been tried but with only marginal effects on patients with FM.Milnacipran which inhibits the reuptake of serotonin and noradrenaline (norepinephrine), has found itself approved in Australia for the treatment of FM. It is generally administered with a dosage of 100 mg which is given daily in divided doses.

Antiepileptic drugs- The neurotransmitters Substance P and glutamate are found in increased levels in patients suffering with Fibromyalgia. These constitute the targets of pregabalin and gabapentin, which help in promoting sleep, alleviating anxiety and modulate pain.

Antiepileptic drugs- The neurotransmitters Substance P and glutamate are found in increased levels in patients suffering with Fibromyalgia. These constitute the targets of pregabalin and gabapentin, which help in promoting sleep, alleviating anxiety and
modulate pain. Other drugs that are commonly used in the management of fibromyalgia areTramadol[14], Pramipexole[15] and Memantine[16]. There is weak supporting evidence for use of anti inflammatory medications and hardly any so for paracetamol. Opioid induced hyperalgesia and poor clinical response have put drugs like codeine, fentanyl and oxycodone as contraindications

Intravenous Infusions- Myer’s Cocktail, named after John Myers MD is a well known form of infusion treatment in the medical circles attending to FM. It’s constituents are as follows

  • 5 milliliters (mL) magnesium chloride hexahydrate
  • 3 mL calcium gluconate
  • 1 mL hydroxocobalamin
  • 1 mL pyridoxine hydrochloride
  • 1 mL dexpanthenol
  • 1 mL B-complex (thiamine, riboflavin, niacinamide) vitamins
  • 5 mL vitamin C

Think a cocktail might help you better manage your fibromyalgia symptoms? We’re not talking about a fruity drink with a cherry and an umbrella. Many people who are living with fibromyalgia swear by the Myers cocktail, an intensive vitamin and mineral dose delivered once a week intravenously. Both patients and practitioners report that this infusion – named for John Myers, MD, the Baltimore doctor who first experimented with a vitamin and mineral mix of magnesium, calcium, B vitamins, and vitamin C – helps ease fibromyalgia pain and other symptoms, such as profound fatigue.

According to fibromyalgia researcher David Katz, MD, founding director of the Prevention Research Center at Yale University in Derby, Conn, about 12,000 people across the United States are treated with the Myers cocktail, and about four out of five say the treatment helps ease fibromyalgia symptoms. The treatment is considered to be a form of complementary and alternative medicine (CAM), not traditional treatment, which includes prescribed medications. However, people often are willing to try novel approaches because living with fibromyalgia is often challenging and fibromyalgia symptoms can be so persistent. Myers Cocktail 101

 

The Myers cocktail contains a variety of nutrients:

  • milliliters (mL) magnesium chloride hexahydrate
  • 3 mL calcium gluconate
  • 1 mL hydroxocobalamin
  • 1 mL pyridoxine hydrochloride
  • 1 mL dexpanthenol
  • 1 mL B-complex (thiamine, riboflavin, niacinamide) vitamins
  • 5 mL vitamin C

Proposed Mechanism of action- Proposed Mechanism of action- Though the exact mechanism of action remains unclear, groups of patients receiving Myer’s Cocktails have experienced reduction in pain and fatigue.B Vitamins are essential for maintaining the health of nerve cells and hence probably stabilisation of the nerve cells by the influx of B Vitamins maybe helpful in reducing the pain. The fatigue of FM has been compared to the fatigue experienced after rigorous excercise, which can build up lactic acid in the oxygen deprived muscles. The Magnesium and Calcium help in dilating the blood vessels so that they can carry more oxygen and help muscles relax.

Lidocaine Infusions- Lidocaine infusions are becoming pretty popular amongst some patients and practitioners alike. Some patients have reported a significant reduction of the symptoms of FM.

Ketamine Infusions- Ketamine works by blocking the NMDA receptors. In doing so, it can reboot the pain receptors which have been altered in patients of FM. In the long term ketamine may also help in decreasing Neuro inflammation which might play a role in neuropathic pain.

AT ALLEVIATE,We go a step further and after the inflammation settles down following the steroid injection, we couple it up with successive sessions of Platelet Rich Plasma with Prolotherapy to strengthen the integrity of the cervical spine and the associated soft tissue structures. This is coupled with a structured physical therapy program and inputs from Clinical Nutrition and Clinical Psychology as and when necessary.

FAQs - FIBROMYALGIA

Fibromyalgia is the second most common disease that affects bones and muscles.
Research and studies show that there is aren’t a particular cause of fibromyalgia. Several reasons cause body pains. But, it is often triggered due to stressful event that includes physical stress or psychological stress.
• Another possible reason is arthritis or an infection that indicates higher chances of getting fibromyalgia.
• Trauma, infection, or surgery may also be linked to fibromyalgia in some people.
• Impairment of the hypothalamic-pituitary axis has also led to fibromyalgia.
Fibromyalgia is a chronic disease and is often seems to be a lifelong condition. But the disease will get worsen over time.
Fibromyalgia pain is generally widespread, involving the bilateral movement of body parts involving the neck, shoulders, arms, buttocks, hip bone, knee, and chest wall. Pain can also occur in axial structures such as the cervical spine, thoracic spine, lumbar spine, or chest wall. There are around 18 musculoskeletal structures that have been identified as the tender points in fibromyalgia. A person is diagnosed with fibromyalgia exhibiting 11 out of 18 tender or trigger points.
Other than tender points, the symptoms associated with fibromyalgia may involve:
• Fatigue
• Headaches
• Joint Pain
• Headaches
• Insomnia
• Restless legs
• Depression
• Associated tingling or numbness
• Nervousness
• Impaired Memory
• Jaw Pain
• Anxiety
• Fibromyalgia
If you are having any of the above symptoms, you need to immediately consult for diagnosis. Your doctor will first ask the questions related to commonly known fibromyalgia symptoms. Treatment will begin once the symptoms of fibromyalgia are determined.
Treatments involving fibromyalgia condition may have one or more several options. The non-pharmacological approach is also a part of the treatment procedure to encourage patients that help in reducing pain, have a balanced sleep, reduce insomnia, eliminate fatigue, and improve functional movements.
Pharmacological intervention is the prescribed medication used by doctors to improve fatigue, sleep, pain and assist in withdrawing depressive symptoms of fibromyalgia.
• Antidepressants - Tricyclic Antidepressants with low doses are prescribed by doctors.
• Amitryptyline is the first-line drug that helps in many practices of fibromyalgia.
• Serotonin Noradrenaline Reuptake Inhibitors are also used in treating fibromyalgia.
Dosage of these medications is prescribed after a detailed examination of the patient.
Pain management specialist doctors and physicians recommend the following treatments for fibromyalgia symptoms:
• Pharmacological Intervention
• Antiepileptic drugs
• Intravenous Infusions
• Proposed Mechanism of action
• Lidocaine Infusions
• Ketamine Infusions
Antiepileptic medications help in different ways of the patients suffering from fibromyalgia. It aids in promoting sleeping, alleviating anxiety, and modulating pain.
Intravenous Infusions or IV therapy constitutes B vitamins, magnesium, vitamin C, hydroxocobalamin, pyridoxine hydrochloride, dexpanthenol, and calcium gluconate, all of these are important for nerves cells and muscles to function. And the treatment is considered to be a form of complementary and alternative medicine.
It is the pharmacological term. A Proposed Mechanism of action helps in reducing pain and fatigue. It helps in stabilizing the nerve cells through B Vitamins. Magnesium and Calcium are essentials in dilating the blood vessels that help in muscle relaxation.
Many practitioners use Lidocaine infusions for fibromyalgia as it significantly provides relief from pain and reduces other common symptoms of fibromyalgia.
Ketamine is a mechanism that helps in blocking the NMDA receptors and reboots the pain receptor, which is altered in fibromyalgia patients. It also helps in decreasing Neuro inflammation in the longer run.

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References

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