From Fibromyalgia: a general malaise. The Back Letter, Nov 1993
Full Text Skol Corporation 1993.


Fibromyalgia is best defined by its symptoms, and even those are still being refined. A series of new studies examines those symptoms, but also implies that a non-symptom -- overall quality of life -- may be the real key in helping patients recover from their disease.

One group of researchers calls fibromyalgia a "non-articular rheumatic condition characterized by diffuse aching, pain, or stiffness in muscles. The symptoms are associated with multiple muscukoskeletal tender points on examination, and they are often modified by factors such as physical activity level, weather, temperature, and stress." (See the Journal of Rheumatology, Vol. 20, No. 5, 1993.)

The authors, Soren Jacobsen, MD, et al., point out that physical activity tends to be low in patients with fibromyalgia, which in turn accelerates the loss of bone. These patients may thus have a greater risk of osteoporosis.

A study conducted by the same group of researchers, however, finds no differences in bone density, serum levels of alkaline phosphatase, osteocalcin, ionized calcium, and phosphate between 12 premenopausal women with fibromyalgia and 12 healthy controls.

While the fibromyalgia patients had lower levels of urinary creatinine excretion, this was related to the lower levels of physical activity. "We conclude that bone mass and turnover are generally not affected in premenoupausal women with fibromyalgia," write Jacobsen et al.

The pain of fibromyalgia may be a reaction of ischemia, several researchers have hypothesized. When these patients exercise, maximum oxygen uptake is less than normal -- which could be due to abnormal physiology or to poor cardiovascular conditioning.

One study conducted by Kathy E. Sietsema, MD, and colleagues from Harbor-UCLA Medical Center in Los Angeles showed that patients with fibromyalgia had no abnormality in the overall rate and utilization of oxygen during muscular exercise. (See the Journal of Rheumatology, Vol. 20, No. 5, 1993.)

However, other researchers, Eduard N. Griep, MD, et al., were able to document adrenal insufficiency in patients with fibromyalgia, which might explain reduced aerobic capacity and impaired muscle performance. (See the Journal of Rheumatology, Vol. 20, No. 3, 1993.)

Fibromyalgia patients often report depression, tiredness, and insomnia as well as muscular symptoms. Some of these complaints may relate to sleep fragmentation, writes Poul Jennum, MD, et al. Their analysis of 40 patients with fibromyalgia and 10 healthy controls indicates that patients with fibromyalgia showed a higher arousal index than controls, which was mostly caused by sleep apnea. (See the Journal of Rheumatology, Vol. 20, NO. 10, 1993.)

The Quality of Life

With such a diffuse litany of symptoms and complaints, and so little clue as to the etilogy of these symptoms, what can be done to help these patients in the clinic? Clearly the syndrome relates more to quality of life than to any identifiable pathological entity, point out Carol S. Burckhardt, PhD, and colleagues from Oregon Health Sciences University. (See the Journal of Rheumatology, Vol. 20, No. 3, 1993.)

Quality of life has become an umbrella term for satisfaction in various domains, including environmental and economic realms, human relationships, work, and leisure time. In two studies of more than 300 patients with various rheumatic and non-rheumatic chronic diseases, it was found that patients defined quality of life in terms of relationships with others, recreational activities, a sense of security, and the feeling that there is meaning in life. With the exception of those with chronic lung disease, patients seldom mentioned specific symptoms as being related to the quality of their lives.

Apparently fibromyalgia has a depressing effect on overall quality of life. When Burckhardt, et al., surveyed 280 women with fibromyalgia, rheumatoid arthritis, osteoarthritis, ostomies, chronic obstructive pulmonary disease, insulin-dependent diabetes, and healthy controls, the women with fibromyalgia consistently scored among the lowest of all. Disease duration wasn't related to quality of life.

Instead, the women in the sample wre concerned with their inability to participate in activities that required physical endurance, such as work or recreational activities. They were also dissatisfied with themselves and with the level of material comfort in their lives.

"These findings suggest that far-reaching negative feelings and dissatisfactions permeate almost all aspects of the lives of patients with fibromyalgia syndrome and that dissatisfaction is not entirely explained by physical health status, psychological distress, or demographic variables," write Burckhardt, et al.

It is possible, they surmise, that patients with a "well-established and socially acceptable disease" may come to some resolution about their condition -- a sense of acceptance which eludes those who gradually progress from a healthy condition to ill-defined syndrome, Burkhardt and colleagues say.

Clinicians who wish to help their fibromyalgia patients may want to investigate psychological factors as well as organic processes such as muscle pain, fatigue, and nonrestorative sleep.

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