Haven't Heard of such a thing ever!

I am sure that you have never heard of this term called FIBROMYALGIA. In fact a good lot of Doctors haven’t ever heard of the disorder and obviously majority of cases henceforth goes undiagnosed. Since, it is under the domain of Rheumatology, I find it comfortable to compose a few simple words regarding fibromyalgia in a FAQ format.So it goes like this

1. What is this FIBROMYALGIA?

In fact the question should have been set in the reverse format. Such as,

“I am a person who was once quite active and energetic but since last few years I feel tired, fatigued, lethargic along with unbearable aches and pains all over my body especially over the mid and lower back, the arms and legs and lower abdominal pain. I feel quite down all the day and my sleep is not at all refreshing. I feel like sinking day by day and lack any form of initiative for doing day to day work. Even ample amount of rest do not provide any relief. Doctor, tell me what I am suffering from? Is it Vitamin D Deficiency, like other doctors have said or should I talk to a psychiatrist?”

Well, the answer is, you are suffering from a condition where the pain threshold of your body is very low. That is even small non painful stimulus can elicit pain in your body. You are actually a pain sensitive person and there is no psychological issue with it, nor has Vitamin D got any business with it.This is called FIBROMYLAGIA, a condition where the entire human body system is perfect except the sensitivity towards pain.

These people tend be too fragile to any form of stimulus which may in normal persons be non painful. Thus they tend to complain of aches and pain all over the body all throughout the day. Even episodes of anxiety and depression occurring in societal circumstances can evoke symptoms of disabling aches and pain.

Since, the problem lies in the central pain processing mechanism of the nervous system, rests do not provide adequate relief. In fact one the classical feature of FIBROMYALGIA is unrefreshed sleep . Even after a good sleep at night , these people do not feel fresh after waking up in the morning and a sense of fatigue and lack of energy persists throughout the day.If the condition is unattended then it may gradually proceed to social withdrawal, mental depression, suicidal ideation and frank psychiatric disorders.

2. Oh God! So the life seems to be doomed. Do we have any treatment or not? Am I supposed to be on lifelong medicines or it is a curable stuff??

Mmmmm. Curable? I am sorry to say that your entire biology is built up to handle pain painfully. This sensitivity pattern is actually not completely acquired genetically. Scientists have proven that serious adverse life events, environmental factors and social factors together in varying proportions may cumulatively result in this disorder. Hence, cure is not there but indeed you can jump back to the peak of your life with proper management.

So far as the medicines are concerned… well YES… I prescribe medicines so that people can ignore their aches and pains and sense of refreshment return back to their life along with added energy and vigour, but there are alternatives to medicines too.

3. Wow… So How can you help me without any pills?

Treatment without any medicines is called non-pharmacological therapy. Researchers after evaluating results of non-pharmacological manoeuvres over last 10 years have found that non-pharmacological therapy indeed outscores pharmacological [treatment by pills] therapy in many aspects. Non-pharmacological therapy has been categorised into three parts

.i. Education

ii. Psychological and

iii. Exercise

We will try to discuss in brief about these techniques in the following paragraph. Elaborate discussion is beyond the scope of this article.

Educational Therapy

Educational therapy is very simple modality of therapy. It consists of educating the patient regarding the disorder just the way I have detailed above. The sufferers need to know that the disorder lies in the pain sensitivity pattern and with appropriate treatment they can overcome the problems quite easily. In a word there should be plenty of positive thinking. Also, this is to be instilled in the mind of the sufferers that exercise do not aggravate the disorder if done in a scientific manner

Psychological

The major psychological therapy that has shown good results is the Cognitive Behavioural Therapy. Once again it has two parts.

The Cognitive therapy consists of voluntary control of thoughts of a person so that the person starts thinking in a positive direction. An example of negative thought is “My pain is awful and there is nothing I can do about it” which by the help of cognitive therapy should be converted into” As bad as my pain might get, there are things I can do to make it at least a little better.” So this is an example of reinforcing the thought from a negative side to a more optimistic direction. This helps a lot in handling the pain problems and work excellent in tandem with medicines. Therefore, errors in thinking such as over generalizing, magnifying negatives, minimizing positives and catastrophizing are challenged and replaced with more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behaviour.

The behavioural therapy includes involvement of two persons and it works in a format of forced change in behaviour of the person by the other which can be achieved in form of rewards or punishment. E.g. If you do not stop thinking negative, we are not going for the holiday this time--- an example of punishment. Or… If you stop thinking negative, we will be making this holiday abroad for sure--- an example of reward. In Fibromyalgia, a number of behavioural techniques are applicable including behavioural activation (getting patients moving again), graded exercise (initiating exercise, then slowly increasing activities), activity pacing (not over doing it on days patients feel good and remaining active on days they feel bad), reducing pain behaviours (not reinforcing behaviours associated with secondary gain), sleep hygiene (identifying then changing behaviours know to disrupt sleep), and learning relaxation techniques to lower stress (e.g., breathing, imagery, progressive muscle relaxation).

Exercise

Exercise has overall benefit on global well-being, physical function and pain and is currently recommended as the first step of a multimodal treatment strategy. Exercise may take a number of forms such as aerobic, strengthening, water, home based or group programs. Water exercise, or combined with education, is associated with improvements in both physical and emotional aspects of FM.Tai Chi is an exercise activity that combines both a physical and mental component and is ideally suited to persons with FM, with reports of improved function and quality of life When traditional yoga was compared to yoga combined with a yoga touch technique “Tui Na”, improvement was more sustained in the yoga group only Although FM patients often report poor exercise capacity, reduced cardiorespiratory fitness was similar to controls, suggesting that FM patients overscore their perception of exertion. In the absence of a single exercise program outperforming others, patients should be encouraged to choose an activity either land based or water, that is enjoyable, easy to follow, convenient and within budget in order to improve adherence.

4. Wow… That means a complete change of lifestyle. I am very comfortable with Yoga and Pranayam. Please let me know about medicines. Do they actually help?

That’s right. A complete change of lifestyle, positive thinking, generation of positive energy within and change of thought process and help you achieve more than half the goal. If medicines are supplemented , things may soon turn perfect for you. So lets discuss about the medicines and how they act and further, importantly, their adverse effects.The medicines are used to target the pain pathway. The basic treatment starts with PARACETAMOL and other pain killers commonly called NSAIDs. A few NSAIDs used in practice are Naproxen, Ibuprofen, Aceclofenac etc. PARACETAMOL can be taken at a maximum daily dose of 4Gms i.e. a tablet of 1000mg taken 4 times a day. The drug is practically side effect free drug but definitely it should be used with immense caution in patients who are chronic alcoholic, suffering from Liver disease and are taking medicines that can affect the liver. Otherwise, the medicine is so safe that one take it for an entire year. At low doses PARACETAMOL is used to treat fever and hence at doses of 500mg or 650mg, pain is unlikely to respond. Hence, for a pain killer effect, the dose should be at least 1000mg per day to 4000mg per day.Few patients may not benefit with PARACETAMOL alone in spite of a maximum dose. We often ask them to take NSAIDs for short duration, say 15 to 20 days. But NSAIDs are those pain killers who have their own battery of side effects e.g. gastritis, stomach ulcers, heart attack, kidney failure, cerebral stroke, rise in blood pressure etc. Once again they should be avoided in elderly patients who have got a chance to damage their kidney easily, cardiac patients as a heart attack may precipitate and kidney failure patients as it will worsen the kidney function.

The next group of drugs are called the OPIODs. These medicines act at the central nervous system or in the brain and the pain processing centre at the high spinal cord area to suppress pain. They are safe but have a high risk of addiction. One classical example of OPIOD is Morphine and we are well aware that it comes under the category of NARCOTIC drug. Hence, its availability is a problem and its use is closely supervised. Another such OPIOD is TRAMADOL which is less addicting but shows effective pain relief. Often TRAMADOL is combined with PARACETAMOL in commercial preparations and they do well in quite a good number of patients suffering from Fibromyalgia. Although less, but TRAMADOL has a tendency to cause dependency. The important adverse effect of tramadol is nausea and vomiting and few patients tend to avoid this drug for this side effect.

The next category of drugs is bit atypical. They are actually anti epileptics [Drugs used to treat Epilepsy] and Anti Depressants [Drugs that are used to treat low mood, lethargy, fatigue etc]. The most important of the anti-epileptic drugs is PREGABALIN. This medicine is approved for management of FIBROMYALGIA. The doses begin from 75mg once daily to a maximum of 300mg to 450mg in a day in divided doses. Pregabalin has shown excellent response in conjunction with exercise and behavioural therapy for management of FIBROMYAGIA. Although bit slow in onset of its action, Pregabalin can render good pain free life with alleviation of depression too, if the patient can tolerate. Now here lies the crux of the drug. This medicine is not free from side effects.

Patients on PREGABALIN tend to suffer from dizziness, nausea, vomiting, unsteadiness of gait, increased sleep etc. I have seen patients developing these symptoms at doses as low as 75mg once daily but also I have witnessed patients who are comfortable at doses as high as 300mg in divided doses. Hence, there is a need of decision making and doctor patient trust while prescribing this medicine. I always make the patient aware regarding the possible side effects so that patients can identify the culprit drug. Another such anti-epileptic that have shown promising results is GABAPENTIN, which although has got the same bundle of adverse effects but patients seem to tolerate it much better.

Among the anti-depressants the best results are obtained with drugs called AMITRYPTILINE, NORTRYPTILINE, ESCITALOPRAM, FLUOXETINE, MIANSERIN etc. Amtitryptilin is perhaps the most widely used drug and perhaps the most misused drug amongst the medical fraternity. Doctors tend to prescribe 10mg of Amtitryptiline at bed time to patients who often present with vague complains and this practice is actually unyielding in long term.

Amitryptiline is given at a dose of 5mg to 100mg at bedtime depending on the patient’s tolerance and results. Once again, it is not free form side effects. Increased somnolence, dryness of mouth, rise in blood pressure, confusional state, hallucinations, retention of urine, cardiac rhythm problems etc are a few to mention. It is used at bedtime so that patients who do not have a good sleep can enjoy a satisfactory sleep and at the same time there will be quality results in management of depressive symptoms.Anti-depressants with lesser side effects are ESCITALOPRAM, FLUOXETINE , MIANSERIN which have used in variable doses in different patients with good results.

5. Well, Although the discussion was worth a read but a few parts appeared Hebrew to me. Can you just summarise the whole story.

Indeed. To summarise in a few points:

A. Fibromyalgia is a disease of altered pain perception commonly found in middle aged females and is characterised by undue sensitivity to any physical or situational stimulus that manifests as Pain.

B. Pain may be as a generalised body pain or may be localised at particular area such as low back, back of neck, legs, waist etc.

C. It is characterised by sense of fatigue, lethargy, depression, aches and pains all over the body, lack of energy, poor sleep and sense of unrefreshed overnight sleep. There may be disturbing changes in mood and day to day performance in social life is greatly hampered.

D. Patients with Fibromyalgia may sometime also have coexistent Migraine, Irritable Bowel Syndrome, Pain during Menstruation [Dysmenorrhoea] which are also a part of pain perception problem.

E. It has often been noted that there is a history of serious psycho-social traumatic event that precedes the onset of the disease e.g. loss of near and dear ones, financial loss, mental stress, social issues etc.

F. Behavioural Therapy and Positive thinking can help a lot in coping up with the problem of aches and pains

G. Typically there is no definite cure for the disease but medicines can alleviate the symptoms and improve the quality of life

H. PREGABALIN is an anti-epileptic medicine which is approved for treatment for Fibromyalgia. Anti-depressant drugs like Amitryptiline, Fluoxetine etc., work well in treating depressive symptoms of fibromyalgia. Fibromyalgia typically falls under the domain of rheumatology and the patients should consult rheumatologists for better management.