One of the commonest complaints to family doctors is that of muscular pain. Up to 30 per cent of visits to a typical practice will be from patients complaining of chronic widespread aching which waxes and wanes and which is often accompanied by fatigue.
Until recently, doctors have been at a loss to explain the cause of these symptoms in many of their patients. The usual tests for arthritis and other conditions prove negative. Now , however, the diagnostic criteria for fibromyalgia syndrome (FM) have been described. (See table).
The incidence of fibromyalgia in Ireland is unknown, although studies in the US suggest it affects five per cent of the population there. At least 90 per cent of patients are women, with a peak incidence at around 35 years of age.
According to Dr Geraldine McCarthy, Consultant Rheumatologist at the Mater Hospital in Dublin, the typical patient with fibromyalgia will complain of widespread aching and stiffness, which is often temporarily relieved by a hot shower. Morning stiffness may last several hours. Patients report poor quality sleep, often waking unrefreshed. They also experience profound fatigue. "In many ways, fibromyalgia could be considered the musculo-skeletal equivalent of the irritable bowel syndrome," she says.
The multiple tender points are characteristic of the condition. When firm pressure is applied to certain parts of the body, they are found to be symmetrically tender. These spots include the back of the head, the neck, the buttocks and the area over the hip, knee and elbow joints.
There are no blood tests, x-rays or biopsies which can confirm the disease. It is what doctors refer to as a clinical diagnosis; one made purely on the basis of the patient's history and the doctor's examination.
The symptoms of FM will come and go over many years. Flare ups are triggered by fatigue, emotional tension or stress and exposure to cold. Both excessive exercise and immobility can cause a worsening of the disease.
FM's relationship with sleep disturbance has been demonstrated by research which showed that tender points could be induced in normal volunteers after deprivation of the non-rapid eye movement pattern of sleep. These subjects also developed muscular aches and stiffness and reported that the sleep they got was not refreshing.
One of the most important aspects of treatment is a full and detailed explanation of what FM is and, in particular, a reassurance that the condition does not lead to joint or muscle damage.
Exercise is a key element of treatment. A gradual increase in aerobic exercise over months rather than weeks to the point where it lasts for 20 minutes past the point of sweating is the aim. An exercise bike or treadmill is ideal, although it may be necessary to start off with brisk walking. However, patients will often feel worse before they feel better.
Dr McCarthy says that the exercise programme is one of the few situations in medicine where she advises patients "if it hurts, do it anyway. The benefits are worth it".
While waiting for the benefits of exercise treatment , Dr McCarthy prescribes a drug called amitryptalline in low doses. It has a dual effect, acting as painkiller as well as improving sleep quality. Amitryptalline is taken an hour before bedtime.
A new topical treatment helps to reduce the tenderness of FM. Capsaicin cream is applied three times daily to the sore spots. Patients report a definite benefit from this derivative of the pepper plant. If you would like to know more about fibromyalgia, Michael C Kelly has written an excellent book called Fibromyalgia - Fatigue and You (Kelmed Publications; ISBN 095 3307107).
Contact Dr Houston at mhouston@irish-times.ie or leave messages on tel 01- 6707711, ext 8511.