You don’t know what you don’t know

The other day I was asked to assess a patient’s mental state, a patient who also had a diagnosis of Fibromyalgia. I knew little about this condition other than it’s main symptom was pain before I saw the patient so I decided to find out a bit more about it. What I discovered intrigued me and brought together a number of the patients symptoms.

Before I looked up Fibromyalgia on Wikapaedia and the NHS website I had a vague idea that it was a condition connected with “Fibroyds” which results in severe and enduring pain. Well I got the last bit right. Actually it is associated with the sympathetic and central nervous system and is characterised by widespread pain and tactile allodynia or tenderness to light touch. A diagnosis is made by eliciting a pain response by applying pressure to 18 pressure points on the body (see above).

Other symptoms include sleep disturbance, fatigue, cognitive dysfunction (known as brain fog) characterised by poor concentration and problems with short term memory, dermatological disorders, headaches, myoclonic twitches and symptomatic hypoglycaemia. Although the main symptom is widespread pain, pain can also be localised in the shoulders, hips, lower back or other areas. It is thought that there may be a link between Fibromyalgia and Chronic fatigue syndrome.

Recognizing that Fibromyalgia has a number of discrete symptoms has resulted in it being sometimes referred to as Fybromyalgia syndrome (FMS). Although the cause of the condition is unknown a number of factors are known to exacerbate symptoms such as

• Stress
• Excessive physical activity
• Poor sleep
• Changes in humidity and air pressure

Although the cause is unknown it is thought that some people may have a genetic predisposition to developing the condition and while stress is known to make the condition worse stress is also thought to be a major precipitating factor in the development of FMS. Studies have shown that up to 49 % of PTSD sufferers also develop FMS as a co morbid condition.

Sleep disorder is a major and distressing symptom of FMS but studies have shown that sleep disturbance may in fact be a cause of the condition. Electroencephalography studies have shown that people with FMS lack slow wave sleep and conditions (such as pain, stress, depression, anxiety) which interfere with stage 4 sleep may cause or worsen the condition. The hypothesis suggests that stage 4 sleep is crucial to the correct functioning of the nervous system because it is during this period of deep sleep that the bodies systems “reset” themselves. In particular pain causes the release of a neuropeptide substance P in the spinal cord which has the effect of amplifying pain sensations and causing nerves to become more sensitive at wound sites. If pain becomes widespread and chronic resulting in disturbances to sleep patterns this system is never reset and ends up running away with it’s self. The disturbed sleep hypothesis suggests that deep sleep is critical to resetting the substances P mechanism preventing this out of control effect.

Dopamine and Serotonin abnormalities are also possibly linked with FMS. Restless leg syndrome associated with Parkinson’s disease is a frequent co morbid condition in patients with FMS and dopamine is known to play a role in the perception of pain; it is also a natural analgesia. In support of the dopamine hypothesis a study using positron emission tomography (PET) has demonstrated a reduction in dopamine synthesis in patients with FMS. Serotonin is known to regulate sleeping patterns, mood, and concentration as well as inhibiting pain. Accordingly it has been suggested that FMS may be due to disturbed serotonin levels. However the use of SSRI medication has met with little success in treating FMS but SNRI’s have been more successful.

Other suggestions include the deposition of intercellular phosphate and calcium which eventually rise to a level where it interferes with cellular metabolism, possibly caused by a kidney defect or a missing enzyme that prevents the removal of excess phosphates from the blood stream. The Epstein-Barr virus has been suggested as another possible cause as have human growth hormone deficiencies related to an underlying auto immune disease affecting the hypothalamus gland or an aberrant immune response to intestinal bacteria. FMS has even been linked to the leaking of silicone gel breast implants in women. Reducing monosodium glutamate is also thought to have some benefit.

Patients with FMS benefit from a scheduled life style. Eating regularly, going to bed at the same time and taking regular but not excessive exercise also helps. Living in a warmer, dryer climate can also reduce symptoms. The pain can be treated symptomatically either with NSAID’s or in more chronic cases opiates such as Tramadol are used. Low doses of sedating tricyclic antidepressants such as Amitriptyline and Trazadone have been used to help relieve the sleep disturbances associated with FMS which also have the benefit of raising mood.

Patients suffering with FMS often report that cannabis relieves their core symptom of chronic pain. A study in Germany which gave doses of 2.5 – 15mg of THC to sufferers with FMS over a 3 month period reported significantly reduced levels of daily recorded pain as well as a reduced response to electrically induced pain.

So there you are Fibromyalgia suffers my prescription is move to the Caribbean, soak up some rays, listen to the reggae, get an early night, smoke a joint and Reeelaaaaxx.