Special Fibromyalgia Clinic

What is fibromyalgia?

Fibromyalgia is a syndrome characterized by diffuse musculoskeletal pain and diffuse sensitivity and other general symptoms such as sleep and affective disorders and chronic fatigue. The word is fibro- (fibrous tissue) and -myalgia (muscle pain).
It is characterized as a syndrome and not as a disease. A disease is a medical condition with a specific cause or causes and recognizable signs and symptoms. In contrast, a syndrome is described by symptoms and signs and medical problems that occur together but do not have a specific identifiable cause. Although it is associated with rheumatic diseases, it is not purely arthritis because there is no inflammation or damage to the joints. However, it can cause severe pain and fatigue and disrupt a person’s daily life.

What are the symptoms of Fibromyalgia?

• Diffuse pain is the main symptom. At the same time, many patients experience fatigue, hypersensitivity to touch, light and sound, and memory disorders.
• Fibromyalgia pain is described as persistent, deep muscle pain. It is observed all over the body, left and right, above and below the waist. The pain and stiffness are more intense in the morning after waking up. In addition, there may be neurological symptoms, such as ”stings”, numbness, and ”pins and needles”, that aggravate the feeling of discomfort. There is additional pain when pressure is applied to specific body areas, the so-called “tender points”. These are typically described in the figure below.
• Fatigue. It is much more intense than the fatigue of a busy day or after a night without sleep. Fibromyalgia fatigue is experienced as “devastating” that can affect work, social, personal or educational activities. At the same time, there is diminished “natural energy”.
• Sleep Disorders. Sleep is neither deep nor refreshing, and people complain that they do not rest even if they get enough sleep. Various studies have identified disorders in stage 4 of deep sleep. Sleep is constantly interrupted by sounds or “thoughts”, significantly limiting its duration.
• Symptoms from various systems. In fibromyalgia, there are the following: muscle pain, irritable bowel syndrome, fatigue, thinking or anger problem, muscle weakness, headache, abdominal pain or cramps, numbness, tingling, dizziness, insomnia, depression, constipation, pain in the upper abdomen, nausea, nervousness, chest pain, blurred vision, fever, diarrhea, dry mouth, wheezing, Raynaud’s effect, itching, vomiting, heartburn, mouth ulcers, loss or change of taste, seizures, dry eyes, shortness of breath, loss of appetite, rash, photosensitivity, loss or difficulty of hearing, frequent urination, painful urination and bladder spasms.

What causes Fibromyalgia?

The causes are ambiguous and undefined. There is a scientific bias from the pain specialists’ view. The etiology in fibromyalgia is undeniably multifactorial and does not obey a linear model. A physical or mental trauma, stress, or even an illness (Rheumatoid arthritis, Systemic lupus erythematosus, Covid infection, Breast cancer) can trigger this disorder. Several researchers suggest a genetic cause due to finding people with fibromyalgia in the same family. Neurologists, anesthesiologists and rheumatologists tend to define fibromyalgia syndrome in the context of central sensitization, and the increased response of the brain to physiological stimuli, i.e. fibromyalgia is neuropathic pain or neuroplastic pain via repetitive pathophysiology that becomes autonomous. Psychiatrists perceive fibromyalgia as a form of emotional disorder. Psychotherapists treat fibromyalgia as a disorder of physical symptoms where the symptom is the result of a conflict within the mental apparatus. These disagreements transferred to the field of patients, and there is an exact number of patients who share the pure organic origin of pain. The proponents of the psychodynamic theory hold the complete opposite view, who firmly believe that chronic pain is due to unmet emotional needs during patients’ childhood on the part of guardians and caregivers. It is preferable to approach the possible causes of fibromyalgia, pathogenetic mechanisms, and risk factors rather than the causality itself for all these reasons.

Most researchers, however, agree that the pathophysiology of fibromyalgia involves metabolic, immunoregulatory, neurophysiological, and genetic disorders. These briefly include the dysfunction of the ascending pain pathways and of descending inhibitory pathways of the CNS, the disturbance of the hypothalamic-pituitary-adrenal axis, the increase of pro-inflammatory cytokines (IL-1β, IL-6, TNF-α), disturbance of sleep neurophysiology, dysautonomia of the sympathetic nervous system, the dysfunction of neurotransmitters(increase of substance P, glutamate & decrease of serotonin, norepinephrine, dopamine, GABA), small fiber neuropathy, and genetically predetermined perception of pain. These mechanisms interact and are involved in low-intensity stimuli to the skin, or deep muscles, causing high levels of pain signals in the brain and the perception of pain. As a result, patients with fibromyalgia suffer more intensely, more often, and greater than healthy individuals.

How is Fibromyalgia diagnosed?

There are no specific laboratory tests for fibromyalgia. History, symptoms and clinical examination make the diagnosis. Finding the “tender points”, as shown in the figure below, argues in favor of the diagnosis without being necessary. A detailed pathological, rheumatological and psychiatric history is required.
Diagnosis is delayed by five years due to non-specific symptoms and limited familiarity with physicians. However, laboratory tests are usually regular, although the syndrome has recently been linked to low vitamin D levels in the blood.
It often coexists with other diseases, and the existence of fibromyalgia is not a criterion for the exclusion of different conditions and vice versa.
There must be diffuse pain in the body for at least three months to support the diagnosis, and 11 of the 18 points in the picture must be painful on palpation.
There needs to be chronic persistent pain accompanied by fatigue and sleep disturbance for the diagnosis to be possible. At the same time, some features of mental illness coexist, such as generalized anxiety disorder, panic attacks, panic disorder, phobias, obsessive-compulsive disorder, post-traumatic stress disorder, depression, sexual dysfunction and bipolar disorder. Worsening of the mental state worsens the pain and symptoms of fibromyalgia. Slight stimuli cause pain, and the pain endurance is limited.

The treatment of Fibromyalgia

The critical issue is understanding the person with fibromyalgia who needs to change and reconstruct her lifestyle. Unfortunately, many refuse to make radical changes; however, recognizing the problem and trying to change some areas of life can bring significant improvement.
Good communication with the doctor is essential. The doctor who can hear the problem and work with the patient contributes substantially to the treatment.
Traditional treatments (anti-inflammatory, sedatives, painkillers, etc.) are usually ineffective. As a result, patients have often taken a wide variety of such drugs without having satisfactory results. Relaxation techniques, and especially exercise, play an essential role in healing. When it comes to treating pain, anti-inflammatory drugs, painkillers, sedatives, and narcotics are usually insufficient and can make fibromyalgia worse in the long run. However, there are medications for fibromyalgia that affect the central nervous system. The psychiatric drugs that can help fibromyalgia and its symptoms are antidepressants, antiepileptics, and in severe cases, selective atypical antipsychotics.
However, it is crucial to implement an exercise program with stretching that help maintain muscle tone and reduce pain and stiffness. Exercises should be done at regular intervals and can be swimming, treadmill, jogging, elliptical machine, cycling, walking, aqua aerobics, anaerobic (weight lifting, workout machines), and balance exercises. These exercises are not done according to the rules of sports, championships, and physical rehabilitation but with the laws of behavioral therapy. It is also valuable and necessary to cognitively reconstruct the dysfunctional pain beliefs of fibromyalgia patients. In terms of sleep management, in addition to the appropriate psychotropic drugs, the revitalizing sleep that is necessary is achieved by a change in behavior:

– Going to bed early and getting up at a regular time, either every day or on vacation, helps to normalize.
– The environment should be quiet, with a comfortable temperature and a good mattress.
– Sugar, caffeine and alcohol should be dodged at bedtime.
– Exercise should be done by patients earlier in the day – at least 3 hours before bedtime – at regular and constant intervals.
– Sleep with the TV or other electronic devices should be eluded.
– It is good to avoid sleeping during the day. If necessary, it is better not to exceed one hour, and then there should be an exercise program.
Relaxation exercises before bedtime help significantly. Music or a warm bath before bed help with pain and sleep.
Emotional support and communication with family and friends are beneficial. In addition, organized groups or individual therapy may be necessary. A fundamental condition is the knowledge and understanding of the problem and the syndrome by the patient.
We need to organize personal time based on prioritization, problem-solving training, assertiveness training, engaging in pleasure-seeking activities, and a consistent action routine. Procedures must be stable on good and bad days.
Other activities such as hydrotherapy, aerobics with a coach, yoga and tai-chi exercises can be constructive, especially at the beginning of treatment. They combine muscle toning with relaxation and gradually significantly improve pain. The meaningful way to work out in fibromyalgia is graded exercise and exposure to pain.
Progressive muscle relaxation can have an equally positive effect. In addition, mental exercises to deal with cognitive impairment (lack of concentration, memory problems, etc.) are beneficial, such as memory and attention games, puzzles and mental challenges.
In addition to their symptoms, patients have to deal with their inability to understand the circumstances. Therefore, it is necessary for them and their human surroundings to comprehend the nature of their condition.
Finally, patients follow the instructions of the specialists in the team that takes care of them. They take their medication correctly. Get enough sleep. Do the recommended physical exercise, and follow a healthy diet. Maintain average body weight and adjust their way of life and work.
The European Parliament declares around 14 million people in the European Union have fibromyalgia. The latter has been recognized as a disease by the World Health Organization since 1992. Furthermore, it is acknowledged that they visit more specialists, do more tests, receive more sick leaves, causing significant financial burden. So, the European Parliament developed a community strategy for addressing and raising public awareness and developing specific programs.