Fibromyalgia: symptoms, causes, therapies

It is a form of extra-articular rheumatism that causes chronic pain and can significantly interfere with patients’ quality of life.

Fibromyalgia, a syndrome that involves a sense of constant fatigue and widespread musculoskeletal pain, has been heard a lot in recent times, thanks to a pop star who said she was affected in a disabling way.

However, it is a condition that for a long time has been “misunderstood”, although it was included by the WHO already in 2010 in the International Statistical Classification of Diseases, Injuries and Causes of Death.

In Italy it is estimated that approximately 1.5-2 million people are affected, 80% of whom, for unclear reasons, are female. The disease begins mostly in adulthood, around 30/40 years, but can also be diagnosed in adolescence or older.

From the etymological point of view, the term fibromyalgia means pain in the muscles and fibrous connective structures, that is, tendons and ligaments.

Symptoms of fibromyalgia

The main symptom of the disease is chronic pain: widespread, constant, extended to various parts of the body, in some cases very intense and described as “burning”. Sometimes it can start in a localized location, such as the cervical and shoulder area, and then spread. However, the pain is felt especially at the level of the muscles and their insertion points on the bones.

Fibromyalgia is not an inflammatory disease, but a form of extra-articular rheumatism with important repercussions on the psycho-physical state, such as to significantly interfere with the quality of life during the day and with the quality of sleep during the night.

In fact, most patients complain of sleep disorders, which manifest themselves with light sleep, not restorative, with repeated awakenings and the feeling, in the morning, of not having rested. Sometimes this picture is also associated with disorders such as sleep apnea or the “restless legs syndrome“.

Other symptoms are muscle stiffness, especially in the morning, and the feeling of swelling in the hands.

A typical feature of the disease is also the feeling of tiredness, a deep asthenia that leads to poor resistance to fatigue. Sometimes fibromyalgia overlaps with chronic fatigue syndrome (CFS), so some fibromyalgia patients have symptoms of this syndrome and vice versa, so much so that it can be difficult to distinguish the two conditions.

The disease also coexists with rheumatoid arthritis: it is estimated that 20-30% of patients with rheumatoid arthritis are also affected by fibromyalgia.

A common symptom in fibromyalgia patients is headache, especially of the muscle-tension type. Disorders related to irritable bowel syndrome are also frequent, such as alternating constipation and diarrhea. Sometimes the patient reports contractions at the bladder level resulting in an increase in the frequency of urination, in some cases accompanied by burning.

The central nervous system is also affected by this condition: manifestations of anxiety and depression and disorders involving difficulty maintaining concentration, distraction, headaches, memory loss may appear. Symptoms may worsen due to cold, humidity, lack of sleep and hormonal mutations in the pre-menstrual period.

What are the causes of fibromyalgia?

The precise causes have not been identified. However, it is believed that, on the basis of a genetic predisposition, this syndrome depends on a reduced pain tolerance threshold due to an alteration of the modes of perception at the level of the central nervous system. That’s why in the fibromyalgia patient even a handshake or a very small trauma can cause very strong pain.

Recent studies have shown that in these patients there is an alteration of some neurotransmitters involved in the transmission of pain and that the areas of the brain where it is processed are more activated.

Possible triggers include chronic diseases such as osteoarthritis or lupus, physical or mental trauma, traffic accidents, infectious diseases, bereavement and serious family situations, central nervous system disorders and stressful events.

Stress, in particular, is identified as a factor common to all people who have been diagnosed with fibromyalgia. However, it is difficult to say that fibromyalgia is due to a single cause; In fact, patients themselves very often fail to identify a specific factor or event that may have triggered the onset of symptoms.

How is the diagnosis made?

The diagnosis is not simple and depends a lot on the doctor-patient relationship. In fact, the disease does not give obvious external signs and is not detectable either through instrumental diagnostic tests or through laboratory tests.

Unlike other rheumatic diseases, such as rheumatoid arthritis, the manifestations of fibromyalgia are in fact in no way visible through swelling or deformity of the joints.

For this reason, it is quite common for several years to pass before reaching the diagnosis, during which the patient has consulted several doctors and specialists, without reaching a conclusion.

In the past, moreover, the disease, also due to the lack of objective tests attesting to its presence, was often attributed to psychological causes or considered a manifestation of a depressive state. Today, however, depression tends to be attributed to the consequences of prolonged malaise caused by chronic pain and fatigue. In subjects with fibromyalgia, lower levels of serotonin, a neurotransmitter that regulates mood and which also seems to be involved in the perception of pain, have been identified.

For the purposes of diagnosis it is very important that the doctor listens to the patient’s history, to identify the events that may have triggered the process. Today, however, something has changed and the rheumatologist, the specialist who usually takes care of the patient, can make use of more certain tools.

The American College of Rheumatology has established diagnostic criteria for fibromyalgia. 18 points (called tender points) have been identified scattered throughout the body which, if stimulated appropriately, by means of pressure, cause pain. When at least 11 of these points are painful then the diagnosis of fibromyalgia is preferred. In fact, the guidelines established that the painful reactivity in tender points is typical only of patients with fibromyalgia and not of other rheumatic patients or healthy individuals.

For this pathology it is also important the differential diagnosis, both with respect to multiple sclerosis, and to exclude other rheumatic diseases such as polymyalgia. It is an inflammatory rheumatic disease that mainly affects the elderly and manifests itself with rigidity and continuous pain in the neck, shoulders and legs area. It often begins suddenly as a result of infectious episodes or stressful events and causes limitation in movements such as turning or getting out of bed. Other conditions that must be ruled out are lupus and hypothyroidism.

Below is a summary table of the pathologies with respect to which to make the differential diagnosis, indicating the symptoms to pay more attention to
.

Pathology	Symptoms not present in fibromyalgia
Rheumatoid arthritis	Swelling of the joints High ESR and PCR values
Systemic lupus erythematosus	Skin rash Systemic symptoms (fever, involvement of kidneys, heart, lungs and brain)
Polymyalgia rheumatica	Severe muscle stiffness in the morning and in periods of sedentary lifestyle High ESR and CRP values
Polymyositis	Muscle weakness Elevated CPK values Electromyographic abnormalities
Spondyloarthritis	Swelling of peripheral joints Low back pain Reduced mobility of the spine Elevated ESR or PCR values
Hypothyroidism	Abnormalities in thyroid function values
Hyperparathyroidism	Hypercalcaemia
Neuropathy	Sensory or motor deficits Electrophysiological test abnormalities

How is fibromyalgia treated?

There is no specific cure. The treatment of fibromyalgia is based on a multidisciplinary approach that integrates:

• education of the patient to change his lifestyle
• Drug therapies
• psychological therapies
• physical activity.

It is also useful to distinguish patients according to the prevailing manifestations: if the psycho-affective sphere is the most affected, psychiatric therapy is useful to reduce somatizations, while musculoskeletal symptoms are prevalent, analgesic therapies are preferable.

In fibromyalgia, anti-inflammatories have little effect and are not recommended, unless an inflammatory disease such as arthritis is also present.

Pain medications are used in the most acute phases; opiates are also useful in this sense, but they must be prescribed by specialized centers and calibrated on the individual case. To facilitate rest, tricyclic antidepressants and selective serotonin reuptake inhibitors are prescribed, as well as drugs with muscle relaxant action, usually at reduced doses.

However, a recent systematic review has identified aerobic exercise as the most effective therapy that can reduce pain and improve movement skills. Low-impact activities such as walking, cycling, swimming or doing exercises in the water are the most suitable exercises for patients with fibromyalgia. Strengthening exercises are also indicated, which improve stability and the ability to move, often limited due to pain. These should be followed by stretching sessions and joint mobilization. In addition, a real rehabilitation program, conducted by a professional, can help to improve body flexibility and posture.

Regarding lifestyle changes, it is essential to act on sleep, which limits pain, trying to establish a routine. It is useful to keep constant schedules, avoid naps during the day, avoid smoking (nicotine has an exciting effect) and consume drinks such as tea and coffee especially in the evening and engage in relaxing activities after dinner.

More recent research has also indicated a positive role for some complementary therapies, such as the practice of meditation, yoga and tai-chi, although the evidence in this regard is still limited.

As far as nutrition is concerned, it is essential to take care of intestinal regularity (through a varied diet rich in vegetables and good hydration) to prevent the mucous membranes from becoming irritated. Protracted irritation in fact leads to inflammation; This facilitates the entry into circulation of substances that can in turn feed adverse reactions affecting the joints and the nervous system itself, increase the autoimmune response and alter the production of serotonin, important in pain control.