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My thoughts on Fibromyalgia

Derek Jennings - 10 May 2003

My thoughts on Fibromyalgia Syndrome (FMS) are from a personal perspective and my ideas and experiences will not be shared by all, or even the majority, of those who have been diagnosed under the FMS banner.

Before we can cure FMS we must first understand its aetiology. Today, we are far from this but until we understand its aetiology treatments will, inevitably, produce only marginal improvements. FMS is characterized by chronic, widespread musculoskeletal pain. There is a view that suffers are hyper sensitised to pain [1], which may indeed be the case, but hypersensitivity to pain is not the root cause and attacking FMS at this level is too low down the causal chain to yield effective results.

Pain is the body's warning system. So when we feel pain the most likely cause is that our body is suffering, or has suffered, trauma, however caused. It is incorrect to conclude that trauma does not exist simply because we cannot see any physical signs, such as inflammation. We do not yet know what to look for, or even how to look for it, in a FMS sufferer's painful muscles [2] and, of equal importance, although an area which appears to be currently overlooked, the connective tissues. There are diagnosable physical problems at this level. I am certain of this (at least for my type of FMS) because if I use my painful feet, when they are warning me not to, they will protest further and swell. If I'm careless and bend too quickly then physical damage will, and has, been caused to my back. The level of stress I'm talking about here is not a level that would cause any damage to a healthy body. The simple act of brushing one's teeth can be more than enough to severely trouble a fibromyalgic's back. Feet are meant to be walked on and backs are meant to bend.

Although I may feel pain more keenly than a healthy person, I have an extremely high pain threshold and can withstand pain that might cause an average person to pass out. I have objective evidence for this. Pursuing FMS at the level of pain processing may well produce results that will alleviate suffering but it will never cure the problem. It is worth noting that Bengtsson [2] concludes, "There probably is a peripheral component in fibromyalgia". He is right.

The type of FMS I suffer from is of very slow onset, over a period of at least 25 years with an acceleration of symptoms in the last 5 years. I have taken regular exercise and have had a good diet all my adult life. I work from home, as and when I choose, have no financial worries and have an excellent family life. Although, due to its severity, some FMS suffers develop psychological problems I have no doubt that those who seek to understand this disease from a psychological angle would profit more by directing their valuable research funds elsewhere. Research that pursues this line can be safely dismissed as a serious contender for a solution, since it studies effects rather than causes [3].

Some view FMS as a sleep dysfunction. This view probably has some merit, but I suspect this is only one branch of the causal chain. Partial success has been achieved by treating patients with low dosage tricyclic antidepressants, such as amitriptyline (works by blocking the reuptake of chemical messengers noradrenaline and serotonin), in conjunction with selective serotonin reuptake inhibitors, such as fluoxetine. The theory here is that the tricyclic antidepressants relax muscles, reduce pain and thus help restore sleep stages 3 and 4: non-REM phases of sleep that many FMS suffers are thought to have difficulty achieving. The hormone serotonin is believed to play a role in sleep. The addition of the selective reuptake inhibitors causes the nervous system to reduce its uptake of serotonin and thus, hopefully, further promote deep sleep. We must ask the question: what processes are we restoring by promoting deep sleep? After all, sleep stages 3 and 4 are only labels we associate with certain sleep phases during which many processes take place.

It has been known for some time that FMS patients have abnormal sleep patterns [4]. As growth hormone (GH) is secreted predominantly during sleep stages 3 and 4, it seems reasonable to hypothesize that FMS patients may have impaired GH secretion. I know of only one controlled study (GH is expensive) [5], and it did yield some positive results, though not great. It is possible that a solution lies in this direction, but given our current level of understanding it is perhaps better to induce the body to produce GH naturally (and the rest, whatever that may be) by restoring sleep, as our own body's products may be more effective than what we can manufacture. I believe this difficult line of enquiry is worth pursuing. However, I should add that I do not have and have never had sleep problems.

A good diet and an appropriate level of exercise are beneficial to almost all maladies, so it is not surprising that the same is true for FMS [6, 7]. I would urge all FMS suffers to experiment with exercise, though be careful not to overdo things. Too much can be as bad as too little.

In conclusion, where does the answer lie? I favour the view that FMS is caused by a dysfunction of the neuroendocrine system (the complex interactions between our brain, nervous system and endocrine glands) [8] in conjunction with its interaction with the immune system, which manifests itself in genetically predisposed individuals. Yes, it's no wonder we don't understand FMS.

Seemingly complex systems can often have an underlying simplicity. It may be wishful thinking, but I see no good reason why FMS might not yet turn out to have a straightforward and effective solution. Not nearly enough money, research and brain power has been thrown at FMS to rule this out and much of what little has been done has not been beneficial. I do not believe this problem will be solved in the next twenty years, and it may take a great deal longer than that, not because it's difficult (it may be, but from the quality of the research I've seen I remain unconvinced on the intractability of the problem) but because the will to find a solution and, importantly, the funding are absent.

References:

[1] Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Gracely RH, Petzke F, Wolf JM, Clauw DJ.
Arthritis Rheum 2002 May; 46(5):1333-43

[2] The muscle in fibromyalgia. Bengtsson A.
Rheumatology (Oxford) 2002 Jul; 41(7):721-4

[3] The use of contemporary MMPI norms in the study of chronic pain patients.
Ahles TA, Yunus MB, Gaulier B, et al.
Pain 1986, 24; 159-163

[4] Musculosketal symptoms and non-REM sleep disturbance in patients with "fibrositis syndrome" and healthy subjects.
Moldofsky H, Scarisbrick P, England R, Smythe H.
Psychosom Med 1975, 37:341-351

[5] A randomized, double-blind, placebo-controlled study of growth hormone in the treatment of fibromyalgia.
Bennett RM, Clark SR, Walczyk J.
Am.J Med 1998, 104:227-231

[6] Exercise for treating fibromyalgia syndrome (Cochrane Review).
Busch A, Schachter CL, Peloso PM, et al.
Cochrane Database Syst Rev 2002, ( 3): CD003786

[7] Prescribed exercise in people with fibromyalgia: parallel group randomised controlled trial.
Richards SC, Scott DL.
BMJ 2002, 325:185

[8] Neuroendocrine abnormalities in fibromyalgia.
Adler GK, Manfredsdottir VF, Creskoff KW.
Curr Pain Headache Rep 2002 Aug; 6(4):289-98



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Derek Jennings.