FIBROMYALGIA 1994 - more pieces of the jigsaw

CLINICAL

Patients with larger numbers of tender points tend to have greater problems with sleep, fatigue and depression[1]. Although only pressure is routinely tested, the general sensitivity to other painful stimuli (cold[2] and heat) is also increased, and, for electrical pain, just at tender points[3].

MECHANISM

Fibromyalgia patients not only complain of sleep disturbance but they have increased amounts of alpha-wave non-Rapid Eye Movement (non-dreaming) sleep, and their sleep-cycle is disorganised[4]. There is a 3-fold increase in the cerebrospinal fluid levels of substance P, which links the nervous system and the immune system[5]. The body's production of stress hormones is reduced[6]. Painful stimulation causes larger brainwaves (evoked potentials)[3]. In one view, Fibromyalgia arises from difficulties in coping with various types of environmental stress. Sleep disturbances, fatigue, a low level of physical activity and poor physical fitness result, making patients susceptible to muscle pain[7].

TREATMENT

In the short-term, the antidepressant Amitryptiline was more effective than Cyclobenzaprine, but by 6 months there was no significant advantage over sugar-pills[8]. Sleeping-pills were also effective[9]. The antidepressant Fluoxetine (Prozac) increased the benefit of Cyclobenzapine[10], but was ineffective alone[11]. Self-management education programmes enhanced self-esteem and quality of life[12], but strenuous physical training had a longer-lasting benefit[13]. Aerobic walking for 20 minutes thrice weekly had doubtful benefit[14].

OUTCOME

With no specific intervention, 1 in 4 patients had overall improvement by 5 years, but a half were worse, and for the majority continuing symptoms severely limited everyday life activities[15]. Over years, physical treatments tended to be discarded, but more than a half were using over-the-counter painkillers, over a third were on antidepressants, and the vast majority continued to have significant symptoms and clinical evidence of Fibromyalgia[16]. Conversely, years after a management programme, nearly half no longer fulfilled diagnostic criteria for Fibromyalgia, and a quarter were judged to be in remission[17]. Regular physical exercise showed the strongest effect[18].