Fibromyalgia and Pain Management Explained

'I feel so tired, all the time. And the pain… sometimes I have pain in my leg that is so bad I can’t walk and just to touch it… it feels like someone has slammed into it with a hammer. I have trouble sleeping, I have trouble concentrating… and did I mention the tiredness? When I’m stressed the pain becomes worse, and it’s not only in my leg, sometimes it feels like I have it everywhere, but the leg is always the worst.'

– Quoted from Ms X

You are probably wondering what has happened to Ms X. What is the cause of this pain?

Is the pain causing the fatigue and difficulty concentrating, or is the fatigue making the pain worse?

Why is the pain worse when she is stressed?

And why is it widespread and not just affecting her leg?

For people with fibromyalgia, a condition that often severely impacts quality of life, these questions can not always be answered.

What is Fibromyalgia?

Fibromyalgia is a musculoskeletal pain syndrome with no clearly identified cause. Due to this, treatment tends to be difficult. Fibromyalgia is estimated to affect 2-5% of the population and is more common in women than men (Healthdirect 2018).

The most debilitating symptom of this condition is chronic and widespread pain. Fibromyalgia may also cause a neurological symptom called allodynia, which affects the body’s perception of pain. This means the brain will interpret harmless stimuli as painful, leading to increased sensitivity that causes the slightest touch to feel extremely painful (Agency for Healthcare Research and Quality 2015; Dellwo 2019).

Other symptoms may include:

• Chronic fatigue;
• Sleep disorders;
• Concentration and memory issues;
• Anxiety, depression or emotional distress;
• Irritable bowel syndrome and other functional gastrointestinal tract disorders;
• Headaches;
• Numbness and tingling in arms and legs;
• Endometriosis; and
• Painful bladder syndrome.

(Healthdirect 2018; Watson & Higuera 2019)

Fibromyalgia commonly coexists with other chronic pain conditions such as rheumatoid arthritis, lupus and osteoarthritis, with between 10-30% of people with rheumatic disorders also meeting the criteria for fibromyalgia (Clauw 2015).

Diagnosis of Fibromyalgia

The diagnostic criteria for fibromyalgia state that symptoms must have been present for a minimum of three months and can not be attributed to any other disorder (Agency for Healthcare Research 2015).

The criteria also take into account the other range of symptoms associated with fibromyalgia including fatigue, sleep problems and cognitive disturbances. Additionally, it recognises that symptoms will fluctuate over time (Guymer & Littlejohn 2013).

Treatment of Fibromyalgia

Unfortunately, there is no specific cure for fibromyalgia. Treatment focuses on symptom control and pain management.

Treatment is based on therapies that alleviate the symptoms and improve the level of functioning of the individual. These therapies are generally focused on decreasing musculoskeletal pain, improving both physical and cognitive function, managing any co-morbidities such as depression and increasing independence (Agency for Healthcare Research and Quality 2015).

Treatment will often take a multimodal approach and incorporate strategies such as pharmacological management, exercise programs, patient education and cognitive behavioural therapies (Agency for Healthcare Research and Quality 2015).

Pain Management for Fibromyalgia

The pain experienced from fibromyalgia is often difficult to manage, partially because it is understood to originate from the brain rather than the muscles and bones (Healthdirect 2018).

One theory is that people with fibromyalgia have experienced a change in the way their central nervous system processes pain, causing increased sensitivity. Fibromyalgia may also be associated with abnormally low levels of serotonin, noradrenaline and dopamine in the brain (NHS 2019).

Pharmacological pain management can include centrally-acting antidepressants and anticonvulsants. However, these medicines can also cause a number of side effects for the individual. These include:

• Nausea;
• Dry mouth;
• Drowsiness;
• Agitation;
• Anxiety;
• Weight gain; and
• Constipation.

(Hauser et al. 2014; NHS 2019)

Muscle relaxant medications can also be used for muscle stiffness or spasms associated with fibromyalgia. These medications can help with sleeping difficulties and further assist with other symptoms that may have been exacerbated due to fatigue (NHS 2019).

Individuals can also participate in non-pharmacological pain management techniques such as relaxation, exercise, hydrotherapy and cognitive behavioural therapy (NHS 2019).

Often treatment will be holistic and involve a variety of interventions to ensure the patient is cared for in all aspects of their health, as fibromyalgia can affect all areas of an individual’s life.

Considerations When Designing Exercise Programs for Patients With Fibromyalgia

Helping patients with fibromyalgia keep active is one of the most useful ways to manage their symptoms. When designing a program for individuals with fibromyalgia, it is useful to first consider some of the more common issues that arise with this population.

• Fatigue

  For a patient with fibromyalgia, fatigue, like pain, is a constant concern. Individuals who act as weekend warriors and give their all during therapy may end up unable to participate in daily life post-exercise.

• Depression and Social Isolation

  Fibromyalgia has a significant impact on social interaction and mood. Individualised sessions of one-to-one therapy may not address the root of this concern: the need for peers who understand and can commiserate with each other. Consider enrolling patients in group classes instead of one-to-one therapy; this is especially useful if the group class has a strong social component.

• Need for Predictability

  Individuals with fibromyalgia can become dependent on ritualised behaviours to the extent of presenting with anxiety when these rituals are disturbed. Therapists who routinely add novelty to treatment sessions may engender a sense of quiet desperation in patients who simply long for a reliable level of training intensity.

• Hypersensitivity to Pain

  Patients with fibromyalgia often present with strong pain sensitivities and they may over-react to the sensory overload present during exercise sessions.

Patients with fibromyalgia need to exercise and they need to do so consistently. Aquatic exercise in warm water is often suggested as the perfect solution for this population. Because an aquatic environment makes it possible for individuals to move easily without being bombarded with pain, patients may be willing to move in ways they would never (and should never) attempt on land.

With exercise, a cycle of movement freedom can be birthed and then reared into something sustainable.

Conclusion

Every person with fibromyalgia will have different symptoms and different treatment goals, so treatment is individualised.

As nurses, we may find our role is to provide support to the individual, as well as focus on pain management.

It is also important to remember that fibromyalgia isn’t only about pain management – there are many other symptoms the patient will be experiencing, and all of these symptoms will be impacting on their quality of life.

Additional Resources

• Arthritis Australia, Fibromyalgia
• The Royal Australian College of General Practitioners, Fibromyalgia

References

• Agency for Healthcare Research and Quality 2015, Treatments for Fibromyalgia in Adult Subgroups, Agency for Healthcare Research and Quality, viewed 4 June 2020, https://www.ncbi.nlm.nih.gov/books/NBK274474/pdf/Bookshelf_NBK274474.pdf
• Clauw, D J 2015, ‘Fibromyalgia and Related Conditions’, PlumX Metrics, vol. 90 no. 5, viewed 4 June 2020, https://www.mayoclinicproceedings.org/article/S0025-6196(15)00243-8/fulltext#sec1.2
• Dellwo, A 2019, Fibromyalgia and Tactile Allodynia, Verywell Health, viewed 4 June 2020, https://www.verywellhealth.com/painful-to-touch-fibromyalgia-tactile-allodynia-3972954#:~:text=Tactile%20allodynia%20is%20one%20of,harmless%20physical%20(tactile)%20stimuli.
• Guymer, E & Littlejohn, G 2013, ‘Fibromyalgia’, Australian Family Physician, vol. 42 no. 10, viewed 4 June 2020, https://www.racgp.org.au/afp/2013/october/fibromylagia/
• Hauser, W, Walitt, B, Fitzcharles, M & Sommer, C 2014, ‘Review of Pharmacological Therapies in Fibromyalgia Syndrome’, Arthritis Research & Therapy, viewed 4 June 2020, https://arthritis-research.biomedcentral.com/articles/10.1186/ar4441
• Healthdirect 2018, Fibromyalgia, Healthdirect, viewed 4 June 2020, https://www.healthdirect.gov.au/fibromyalgia
• NHS, Fibromyalgia, NHS, viewed 4 June 2020, https://www.nhs.uk/conditions/fibromyalgia/
• Watson, S & Higuera, V 2019, How Does Fibromyalgia Affect Women Differently?, Healthline, viewed 4 June 2020, https://www.healthline.com/health/fibromyalgia/symptoms-women#periods