Articles from prior issues of The Advocate

November/December 2000

Focus on Fibromyalgia
Its Relationship to Depression and Sleep Disturbance
by Eugene Jerry, GLADE

THE NATIONAL ASSOCIATION OF DISABILITY Examiners hosted its National Training Conference for the first time outside of the continental United States in San Juan, Puerto Rico from September 17-22, 2000. The members of the Puerto Rico Association of Disability Examiners worked very hard to make this conference an educational and rewarding experience.

Dr. Jose Ramirez, Rheumatologist, gave an outstanding presentation on "Fibromyalgia: A sleep disorder" on Friday, September 22, 2000. The disorder is part of two other disorders – chronic fatigue syndrome and depression.

Fibromyalgia Historic Considerations

Most of 18th century medicine viewed musculoskeletal impairments as either articular rheumatism or muscular rheumatism (joints vs. muscles). Sir William Govans in 1904 indicated muscular back pain was due to inflammation of “fibrous” elements in muscle; hence the term fibrositis came into use.

E. F. Trout in 1968 described a syndrome of poor sleep, fatigue, general pain and specific tender points. Smyth suggested common criteria and the syndrome first described in McCarthy’s textbook of rheumatology. Modofsky in 1915 demonstrated the central feature, mainly sleep disturbance or sleep disorder, as the standard by which the diagnosis is made as fibromyalgia.

Since it was clear at that time there was no inflammation of the tissue, the name fibrositis was a little misleading. There was a consensus to change the name from fibrositis (Yunus) to fibromyalgia. The consensus was that fibromyalgia retain some of the historic definition of the disorder and recognized it was not inflammation but pain. Fibromyalgia is often unrecognized by physicians and yet it is extremely common. Statistics show fibromyalgia is diagnosed by:

10 percent of all family medicine clinics; 25 percent of all rheumatology clinics; 30-50 percent of all pain clinics; and 50 percent of all psychiatric clinics.

Fibromyalgia Demographics

An overwhelming preponderance of females are diagnosed with Fibromyalgia. Females make up 85 percent or more of most series. The peak incidence of diagnoses occurs between ages 40 to 60, but can range from ages 20 to 80. The mean duration of treatment before diagnosis is 7 years.

Since the age of peak incidence is from 40 to 60 and the overall age range is 20 to 80, there is a tendency to associate this with hormonal changes. One explanation is that the 40 to 60 age peak incidence rate occurs around the age of menopause. There is a subgroup of younger women who develop amenorrhea, so there appears to be a hormonal imbalance associated with this disorder. The patients usually have seen a large number of physicians. The problem is that there is very little objective data to make the diagnosis. What makes the diagnosis accurate is not the nature of the complaint or findings. It is the combination of several complaints that actually defines the classification.

Fibromyalgia Classification

Fibromyalgia is identified as primary, concomitant, or localized. In Primary Fibromyalgia, there is no identifiable concurrent disease with it. Concomitant Fibromyalgia can be found in conjunction with many chronic illnesses such as cancer. Although there are some differences, Localized Fibromyalgia is also occasionally referred to as Myofascial Pain Syndrome. Fibromyalgia has 18 trigger points around nine sites mostly on the back of the patient. Myofascial Pain Syndrome has 1 to 4 tender points.

Fibromyalgia Symptoms

Musculoskeletal: Pain trigger points - 100 percent of patients

Stiffness - 75 percent of patients

General malaise - 64 percent of patients

“Swelling” - 47 percent of patients (The patient will complain of hand or finger swelling. This is not a true edema. If the physician examines the hands, usually there are no objective signs of swelling. It is well established that these patients have a subjective sense of swelling.)

Non Musculoskeletal: Fatigue - 86 percent of patients

Morning fatigue - 76 percent of patients

Paresthesias (sense of burning in the skin) - 54 percent of patients

“Poor sleep” - 75 percent of patients Associated Syndromes

Anxiety occurs in 65 percent of patients. Headaches occur in 59 percent of patients. Dysmenorrhea, pain during periods, occurs in 53 percent of patients. Irritable bowel occurs in 40 percent of patients.

Some report a burning sensation on urination but there is no clinical sign of infection or irritation. It occurs in 12 percent of patients.

Depression occurs in 30-40 percent of patients and dysthymia occurs in 80 percent of patients.

Fibromyalgia Signs On Examination

Normal muscle strength

Normal tendon reflex

Normal joints

Multiple Tender “trigger points”

Generalized Tenderness

Skin Fold Pain - the sensation of pain more concentrated

Routine Tests are normal

May coexist with other rheumatic disorders

Radionuclide studies are negative

Electromyographic studies are negative

Radiographic studies are non specific

It is not a very difficult disease to make a diagnosis. The treating physician has high evidence of suspicion to include a triad of information. The triad is based on: (1) typical sleep pattern disturbance, (2) symmetrical trigger points, and (3) reasonable exclusion of confounding illnesses.

Fibromyalgia Etiology

Sleep Disturbance is common to almost all patients and on sleep studies Alpha wave is seen in slow wave stages (i.e. 3 and 4). The patient has multiple awakenings at night and complains of restless leg syndrome. Although the patient may obtain sleep, it is non-restorative sleep.

Fibromyalgia Sleep Architecture

EEGs are usually obtained to evaluate and monitor sleep patterns for the following: Rapid Eye Movement (REM) sleep, alpha waves, Non-REM sleep, Slow Wave Sleep. Four increasing deep sleep stages occur as a result of increasing muscle and tone relaxation.

Sleep can be also be disturbed by Neuro-Endocrine Disturbances such as blunted dexamethasone suppression. Serotonin levels are low in most patients and when measured, trytophan (5th precursor) levels are increasingly correlated with morning pain. CNS (central nervous system) serotonin is decreased in patients. When administered parachlorphenylalanine (a 5HT blocker), the patient reproduces fibromyalgia like illness. (The serotonin (5-HT) receptor was first described in 1957. Since then, there has been an explosion of knowledge regarding this ubiquitous neurotransmitter system. Despite extensive documentation of a role for the central 5-HT system in regulation of mood, anxiety, feeding, sleep, sexual activity, body temperature, and nociception, the mechanisms by which disorders of these functions are mediated remain unclear. – study by Jeremy D. Coplan, Susan I. Wolk, and Donald F. Klein supported in part by a National Institute of Mental Health Scientist Development Award for Clinicians and a Mental Health Clinical Research grant.)

In the original Modolfsky Study, seven out of 10 patients had alpha wave (REM type wave) intrusion and decreased slow wave sleep. Three out of 10 had no stage 3 or 4 sleep.

A follow-up study revealed that auditory stimuli (induced alpha waves) reproduced fibromyalgia symptoms in healthy subjects.

Affects of Depression on Sleep Disturbance

Non-restorative sleep and early morning awakening are commonly reported. There is shortened or absence of stage 3 or 4 sleep and increased REM sleep and alpha wave recurrence.

Fibromyalgia patients have been treated successful with antidepressants (i.e. Paxil, Elavil, etc.). Benzodiaphazine (i.e., Valium) has shown to have an effect on Sleep Architecture. It has a short and medium half-life. Patients are subject to reduced REM sleep, even while on medication! The longer half-life of benzodiazepines may worsen depression. Zolpidem can also be affective in treatment of fibromyalgia.

Effects of Antidepressants on Fibromyalgia

Two double blind studies have established positive effects of amitriptiline medication. There has also been positive responses from cyclobenzaprine (a related tricyclic compound) as well as anecdotal responses with trazodone and nortryptyline. A study with fluoxetine and NSAID’s (non-steroidal antiinflammatory drugs) were minimally effective. Studies looking at “chronic pain” have shown SSRI’s (selective serotonin receptor inhibitors) to be effective.

General Management of Fibromyalgia

It is important to assure the patient this is not a “psychological disease”. Physicians need to address major depression and anxiety. Patients should be encouraged to increase their physical fitness. Physical Therapy and treatment with a TENS unit has shown some benefits. Acupuncture and moist heat has also demonstrated results. Other options are: psychotropic agents, injection of tender points. Pharmacological Therapy consists primarily of antidepressants (amitriptyline, SSRI’s, e.g. Paxil, Zoloft,) and use of Zolpidem as an adjunct hypnotic, but patients should avoid Benzodiazepines.

Disability Issues

The only long-term study in these patients suggests a high proportion will be fully disabled. The disease severity and issues of chronic illness are difficult to resolve as it is unclear if the severity is due to disease course or lack of therapy. Other Disability Issues

The musculoskeletal impairment criteria is not appropriate for Fibromyalgia, as there are no specific nationally recognized guidelines. The best approximation is to use Depression disability criteria. The issue of reasonable accommodation remains controversial. The subjectivity of findings continues to be problematic.

Lastly, Fibromyalgia as a disability is easy to mimic but not easy to mimic for a long time.