Fibromyalgia Diagnosis
When making a diagnosis of
fibromyalgia, a practitioner would take into consideration the patients case
history and the exclusion of other conditions such as endocrine disorders,
arthritis, and polymyalgia rheumatica. There are also two criteria established
by the American College of Rheumatology for diagnosis:
- A history of widespread pain lasting more than three
months. Widespread, as in all four quadrants of the body, i.e., both sides,
and above and below the waist.
- Tender points. There are eighteen designated possible
tender points (although a person with the fibromyalgia syndrome may feel pain in other
areas as well). During diagnosis, four kilograms of pressure is exerted at
each of the eighteen points; the patient must feel pain at eleven or more of
these points for fibromyalgia to be considered. This technique was developed
by the American College of Rheumatology as a means of confirming the diagnosis
for clinical studies. It is also used in the United Kingdom. Unfortunately,
while the vast majority of fibromyalgia
patients express pain when these points are pressed, a few patients with a
high pain tolerance may not feel exceptional pain during the test.
Since fibromyalgia is a somewhat
ill-defined syndrome, with no single cause, causal agent or mechanism, blind
tests have been done with people who were suspected to have fibromyalgia,
to rule out the possibility that people were faking having the syndrome. Thanks
to these tests, fibromyalgia and the tender points diagnostic procedure
have now been accepted by official medical associations worldwide.
Living with Fibromyalgia
Fibromyalgia can affect every aspect of a
person's life. While it cannot cause death in itself, the chronic pain and
depression associated with
Fibromyalgia puts its sufferers at risk for suicide, although it is unclear
whether there is an increased risk. However it can severely curtail social
activity and recreation, and many people with fibromyalgia are unable to
maintain a full-time job.
In the United States, those affected by
fibromyalgia may qualify under programs for those whose work is adversely
affected by disabilities. Employed Americans may apply for coverage under the
Americans with Disabilities Act. Children and college students may be granted
more time to take tests, changes in physical education requirements, and college
housing closer to class locations. In the United Kingdom, the Department for
Work and Pensions recognizes fibromyalgia as a condition for the purpose of
claiming benefits and assistance.
History of Fibromyalgia
Fibromyalgia has been studied since the early
1800s and referred to by a variety of former names, including muscular
rheumatism, neurasthenia and fibrositis. The term fibromyalgia was coined in
1976 to more accurately describe the symptoms, from the Greek my-, meaning
muscle, and algia, meaning pain.
Fibromyalgia was once considered an
autoimmune disorder, but laboratory
results reveal no disturbance of the immune
system. It was also once classified as a psychosomatic disorder, although
few specialists currently would classify it as such. Because the understanding
of this disorder has grown so rapidly in the 1990s and 2000s, many texts on the
subject are out of date.
Theories on the Cause of
Fibromyalgia
The cause of fibromyalgia is currently
unknown. Over the past few decades many theories have been presented, and the
understanding of the disorder has changed dramatically. Most current theories
explain only a few symptoms of the disorder and are thus incomplete.
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Transfer Factor. Sleep
Disturbance Theory
The sleep disturbance theory postulates that
fibromyalgia is related to sleep quality. Electroencephalography (EEG)
studies have shown that people with fibromyalgia lose deep sleep. Circumstances
that interfere with "stage 4" deep sleep (such as drug use, pain, or anxiety)
appear to be able to cause or worsen the condition.
According to the sleep disturbance theory, an
event such as a trauma or illness causes sleep disturbance and, possibly, some
sort of initial chronic pain. These initiate the disorder. The theory supposes
that "stage 4" sleep is critical to the function of the nervous system, as it is
during that stage that certain neurochemical processes in the body "reset". In
particular, pain causes the release of the neuropeptide substance P in the
spinal cord, and substance P has the effect of amplifying pain and causing
nerves near the initiating ones to become more sensitive to pain. Under normal
circumstances this just causes the area around a wound to become more sensitive
to pain, but if pain becomes chronic and body-wide then this process can run out
of control. The sleep disturbance theory holds that deep sleep is critical to
reset the substance P mechanism and prevent this out-of-control effect.
An interesting aspect of the sleep
disturbance/substance P theory is that it explains "tender points" that are
characteristic of fibromyalgia but which are otherwise enigmatic, since
their positions don't correspond to any particular set of nerve junctions or
other obvious body structures. The theory posits that these locations are more
sensitive because the sensory nerves that serve them are positioned in the
spinal cord to be most strongly affected by substance P. This theory does not
explain slow-onset fibromyalgia, fibromyalgia present without tender points, or
patients without heightened pain symptoms. It also does not address the
multitude of non-pain symptoms present in the disorder.
Also of interest is a possible connection between
this theory and the theory that chronic fatigue syndrome and post-polio syndrome
are due, at least in part to damage to the ascending reticular activating system
of the reticular formation. This area of the brain,
in addition apparently controlling the sensation of fatigue, is known to control
sleep behaviors and is also believed to produce some neuropeptides, and thus
injury or imbalance in this area could cause both CFS and sleep-related
fibromyalgia, explaining why the two disorders so often occur together.
The Deposition Disease Theory
Another theory involves phosphate and calcium
accumulation in cells that eventually reaches a level to impede the ATP process,
possibly caused by a kidney defect or missing enzyme that prevents the removal
of excess phosphates from the blood stream. This theory posits that
fibromyalgia is an inherited disorder, and that phosphate build up in cells
is gradual (but can be accelerated by trauma or illness). Calcium is required
for the excess phosphate to enter the cells. The additional phosphate slows down
the ATP process; however the excess calcium prods the cell to continue producing
ATP.
Diagnosis is made with a specialized technique
called mapping that is a gentle palpitation of the muscles to detect lumps and
areas of spasm that are thought to be caused by an excess of calcium in the
cytosol of the cells. This mapping approach is specific to deposition theory,
and is not related to the trigger points of myofascial pain syndrome.
While this theory does not identify the causative
mechanism in the kidneys, it proposes a treatment known as guaifenesin therapy.
This treatment involves administering the drug guaifenesin to a patient's
individual dosage, avoiding salicylic acid in medications or on the skin, and,
if the patient is also hypoglyemic, a diet designed to keep insulin levels low.
The phosphate build-up theory explains many of
the symptoms present in fibromyalgia and proposes an underlying cause.
The guaifenesin treatment, based on this theory, has received mixed reviews,
with some practitioners claiming many near universal success and others
reporting no success. Only one controlled clinical trial has been conducted to
date, and it showed no evidence of the efficacy of this treatment protocol. This
study was criticized for not limiting the salicylic acid exposure in patients,
and for studying the only effectiveness of guaifenesin, not the entire treatment
method. As of 2005, further studies to test the protocol's effectiveness are in
the planning stages, with funding for independent studies largely collected from
groups which advocate the theory.
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Other Theories
Other theories relate to various toxins from the
patient's environment, viral causes, growth hormone deficiencies,
neurotransmitter disruptions in the central nervous system, and erosion of the
protective chemical coating around sensory nerves. Due to the multi-systemic
nature of illnesses such as fibromyalgia and chronic fatigue syndrome (CFS/ME),
an emerging branch of medical science called psychoneuroimmunology (PNI) is
looking into how the various theories fit together.
Comorbid
Diseases
Cutting across several of the above theories is a
theory that proposes that fibromyalgia is almost always a comorbid
disorder, occurring in combination with some other disorder that likely served
to "trigger" the fibromyalgia in the first place. This concept fits especially
well with the sleep disturbance theory.
By this theory, some other disorder (or trauma)
occurs first, and fibromyalgia follows as a result. In some cases the
original disorder abates on its own or is separately treated and cured, but the
fibromyalgia remains. In other cases the two disorders coexist. This theory
would explain why such a wide variety of symptoms are often ascribed to
fibromyalgia, since there are potentially a wide variety of comorbid disorders.
It also helps explain why fibromyalgia is so hard to treat, since the
fibromyalgia is unlikely to abate while the comorbid condition is untreated. |
