What is Fibromyalgia?

Fibromyalgia (FM) is a common illness that affects ~ 2% of the general population, of which the majority are female. The illness may be triggered by physical or emotional trauma. FM is characterized by chronic widespread pain, by sleeping problems, and by profound fatigue that does not improve after resting. There is significant overlap between FM and chronic fatigue syndrome. Patients with FM frequently have other symptoms such as headaches, nocturnal jaw tightness, morning stiffness, tingling and numbness of arms and legs, irritable bowel, urinary urgency, dryness in the mouth and eyes, cold swollen hands, anxiety and/or depression. Another characteristic of FM is tenderness at palpation in defined points at the neck and lower back areas.

Is fibromyalgia easy to recognize ?

The answer is no - for several reasons:

· Many physicians are unaware of the existence of this syndrome.

· The patients are sometimes labeled as hypochondriacs or hysterics because lab tests do not show evidence of disease.

· It may be confused with other rheumatic illnesses such as polymyalgia rheumatica, ankylosing spondylitis or rheumatoid arthritis (because of the generalized muscle and joint pain), with lupus or Sjogren's syndrome (because of its perplexing symptoms). However, an important point of differentiation is the lack of any tissue damage or sign of inflammation in FM.

· Several other diseases may also produce chronic profound fatigue such as the hormonal disturbances of the thyroid or adrenal glands. It is recommended that individuals with FM-like symptoms consult a Rheumatologist, who will be able to distinguish among these different rheumatic entities.
 

As a consequence of this difficult diagnosis, patients with FM may at times end up being mistreated, and possibly even subjected to unnecessary surgical procedures by physicians who are unaware of FM's existence.

What causes fibromyalgia ?

There have been substantial advances in the understanding of the mechanisms that lead to FM. Using a cybernetic technique called heart rate variability analysis, our team has focused on disregulation of the autonomic (sympathetic) nervous system as the cause of FM.
 

What is the autonomic nervous system ?

The autonomic nervous system works below the level of consciousness to maintain the body's equilibrium. It regulates blood pressure, pulse and breathing rates among many other variables. It assures the normal function of all of our internal organs. The autonomic nervous system also responds instantaneously to any type of stress. (stress should be understood as any physical or emotional stimuli that threatens the balance of our body). There are close connections between the autonomic nervous system and the endocrine system that regulates hormone secretion.

In clinical practice, the function of the autonomic nervous system was difficult to assess up to the introduction in recent years of heart rate variability analysis
 

What is heart rate variability analysis ?

Heart rate variability analysis is based on the fact that the heart rate is not constant, but varies continuously by a few milliseconds. The periodic components of this heart rate variation are dictated by the input of the two branches of the autonomic nervous system: the sympathetic nervous system and the parasympathetic nervous systems. These two branches have antagonistic effects on most bodily functions. Time and frequency domain analyses are able to estimate the relative effect of each branch on the periodic variations of the heart rate. The elegance of this new method resides in the fact that all measurements are derived from electrocardiograms, so patients are not subjected to any discomfort.
 

Our research on fibromyalgia

We studied a group of patients with fibromyalgia and compared them with healthy controls. By means of portable recorders, we registered the subjects' heartbeat for 24 hours while they followed their routine daily activities. We found that patients with fibromyalgia have relentless hyperactivity of the sympathetic nervous system. This abnormality was also evident during sleeping hours. In a different study, we subjected patients with fibromyalgia to a simple stress test (to stand up). We observed a paradoxical derangement of the sympathetic nervous system response to the upright posture. Such findings have been confirmed by other groups of investigators.
 

The results of these studies suggest that a fundamental alteration of fibromyalgia is a disordered function of the autonomic nervous system. Patients with fibromyalgia lose the normal day/night cycles (circadian rhythms)  and have a relentless sympathetic hyperactivity throughout 24 hours. This may explain the sleeping problems that the patients have. At the same time, such individuals have sympathetic hypo-reactivity to stress, which could explain the profound fatigue, morning stiffness and other complaints associated to low blood pressure. This autonomic nervous system dysfunction could induce other symptoms of fibromyalgia such as irritable bowel, urinary discomfort, limb numbness, anxiety and dryness of the eyes and mouth. 

Fibromyalgia’s defining features (chronic widespread pain and tenderness to palpation) could be explained by the mechanism known as “sympathetically maintained pain”. After a triggering event (physical/emotional trauma, infections) relentless sympathetic hyperactivity may develop in susceptible individuals. This hyperactivity induces excessive norepinephrine (also known as noradrenaline) secretion, that could in turn sensitize central and peripheral pain receptors and thus induce widespread pain and widespread tenderness. Exquisite tenderness at palpation (its medical term is allodynia) is a typical sympathetically maintained pain feature. This mechanism of pain is supported by our finding that norepinephrine (noradrenaline) injections induce pain in fibromyalgia patients.

Fibromyalgia has neuropathic pain features since it is a stimulus-independent pain state accompanied by hypersensitivity to palpation (its medical term is allodynia), and abnormal sensations such as tingling, burning, or electric-shocks. There are important similarities between fibromyalgia and the localized painful syndrome named reflex sympathetic dystrophy. As matter of fact we propose that fibromyalgia is a generalized form of reflex sympathetic dystrophy.
 

What is the treatment of fibromyalgia ?

The realization of autonomic nervous system dysfunction in fibromyalgia demands a scientifically holistic approach for its treatment. A correct diagnosis is very helpful to the patient; many patients are relieved to at last find a coherent explanation for all of their complaints. This in turn avoids the costly and constant battery of laboratory tests that many individuals undergo. It is clear that fibromyalgia patients greatly differ from each other, therefore treatment should be individualized and always be supervised by a health care provider.

Useful methods that improve autonomic nervous balance are graded aerobic exercises and mind-body relaxation techniques. Liberal intake of mineral water may help symptoms associated to low blood pressure (fatigue, dizziness, faintness). Avoidance of substances with adrenaline-like effects (nicotine, caffeine containing soft drinks and coffee) is recommended.

For this chronic illness with multiple manifestations it is important to refrain from excessive use of medications. Patients should understand that there is no “magic pill” that will cure all their symptoms. Medications should be directed to improve sleep and autonomic balance. The main fibromyalgia symptom, widespread pain should be ease with centrally acting analgesics. Anti-inflammatory drugs have little beneficial effect. It is prudent to reiterate that responses to treatment vary and that specific prescriptions through internet are clearly unethical.

The proposal that fibromyalgia is a sympathetically maintained neuropathic pain opens new perspectives for its treatment. Diverse anti-neuropathic compounds are in the development period. The intense research that is taking place in different parts of the world will very likely yield more effective treatments in the near future.

References and links:

1. Martinez-Lavin M, Hermosillo AG, Mendoza C, et al. Orthostatic sympathetic derangement in individuals with fibromyalgia. J Rheumatol 1997;24:714
2. Martinez-Lavin M, Hermosillo AG, Rosas M, Soto ME. Circadian studies of autonomic nervous balance in patients with fibromyalgia. A heart rate variability analysis. Arthritis Rheum 1998;41:1966
3. Martinez-Lavin M, Leon A, Hermosillo AG, Pineda C, Amigo MC. The dysautonomia of fibromyalgia may simulate lupus. J Clin Rheumatol 1999;5:332
4. Martinez-Lavin M, Hermosillo AG. Autonomic nervous system dysfunction may explain the multi-system features of fibromyalgia. Semin Arthritis Rheum 2000; 29: 197
5. Martinez-Lavin M, Amigo MC, Coindreau J, Canoso J. Fibromyalgia in Frida Kahlo's life and art. Arthritis Rheum 2000;43:708  http://www.myalgia.com/Frida article by Lavin.html
6. Martinez-Lavin M. Is fibromyalgia a generalized reflex sympathetic dystrophy ?. Clin Exp Rheumatol 2001;19:1-3
7. Martinez-Lavin M. Overlap of fibromyalgia with other medical conditions. Curr Pain Headache Rep 2001;5:347-50
8. Martinez-Lavin M, Vidal M, Barbosa RE, Pineda C, Casanova JM, Nava A. Norepinephrine-evoked pain in fibromyalgia. A randomised pilot study (ISCRTN 70707830). BMC Musculoskel Disord 2002;3:2 (www.biomedcentral.com/1471-2474/3/2).
9. Martínez-Lavín M, Hermosillo AG. La fibromialgia y el sistema nervioso autónomo. Gac Med Mex 2002;138:55-56
10. Martinez-Lavin M. Autonomic nervous system in fibromyalgia. J Musculoskel Pain 2002 10:221-228
11. Martinez-Lavin M. Management of dysautonomia in fibromyalgia. Rheum Dis Clin North Am 2002 28:379-87
12.  Martínez-Lavín M. A novel holistic explanation for the fibromyalgia enigma. Autonomic nervous system dysfunction. Fibromyalgia Frontiers 2002;10;3-6   ( http://www.fmpartnership.org/Lavin%20article.htm )
13. Martínez-Lavín M, López S, Medina M, Nava A. The use of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) questionnaire in patients with fibromyalgia. Semin Arthritis Rheum 2003.
14. Kooh M, Martínez-Lavín M, Meza S, Martín-del-Campo A, Hermosillo Ag, Pineda C, Nava A, Amigo MC, Drucker-Colín R. Concurrent heart rate variability and polysomnography analyses in patients with fibromyalgia. Clin Exp Rheumatol 2003

Manuel Martínez-Lavín MD.
Internist and Rheumatologist

doctor@martinez-lavin.com