Lady Gaga (born Stefani Joanne Angelina Germanotta) has been getting rave reviews for her leading role in the latest remake of A Star is Born, directed by and co-starring Bradley Cooper. Although she seems healthy now as she promotes the film, earlier in this year she had to cut short her European tour because of fibromyalgia pain.
Lady Gaga was originally diagnosed with fibromyalgia several years ago. She blames her illness on physical and mental components: PTSD (caused by a sexual assault by a music producer at the age of nineteen) and breaking her hip in 2013, 10 months into her Born This Way world tour. Since that time, Gaga says she intermittently deals with “global and mental pain.” Much of this is shown in the Netflix documentary Gaga: Five Foot Two. The film is a glimpse of her tumultuous life during the period when she was writing her Joanne album while preparing for the halftime show at the 2016 Super Bowl. Throughout the film, Gaga is seen suffering with what she calls “full-body spasms.” She is often covered with ice packs while massage therapists try to relieve some of the spasms. During one such episode she wonders:
“I just think about other people who have maybe something like this, that are struggling to figure out what it is, and they don’t have the money to have somebody to help them. I don’t know what I’d (expletive) do if I didn’t have everyone here to help me. What the hell would I do?”
Gaga is also filmed at her doctor’s office where she receives trigger-point injections (a combination of local anesthetic with or without corticosteroids). Her physician also plans the next phase of her treatment, which will involve platelet-rich plasma therapy (presumably into her previously injured hip).
In an interview for the October 2018 issue of Vogue, Lady Gaga explained why she wanted the cameras to document her suffering:
“I get so irritated with people who don’t believe fibromyalgia is real. For me, and I think for many others, it’s really a cyclone of anxiety, depression, PTSD, trauma, and panic disorder, all of which sends the nervous system into overdrive, and then you have nerve pain as a result. People need to be more compassionate. Chronic pain is no joke. And it’s every day waking up not knowing how you’re going to feel.”
Fortunately, Lady Gaga is in an up phase these days: “It’s getting better every day,” she says, “because now I have fantastic doctors who take care of me and are getting me show-ready.”
What is Fibromyalgia?
Fibromyalgia syndrome (FM) is a common and chronic disorder characterized by widespread pain, diffuse tenderness, and other symptoms. The word “fibromyalgia” comes from the Latin term for fibrous tissue (fibro) and the Greek ones for muscle (myo) and pain (algia).
According to the National Fibromyalgia Association, fibromyalgia is one of the most common chronic pain conditions. The disorder affects an estimated 10 million people in the U.S. and an estimated 3-6% of the world population. While it is most prevalent in women — 75-90 % of the people who have FM are women — it also occurs in men and children of all ethnic groups.
Although fibromyalgia is often considered an arthritis-related condition, it is not truly a form of arthritis. This is because it does not cause inflammation or damage to the joints, muscles, or other tissues. Like arthritis, however, fibromyalgia can cause significant pain and fatigue, and it can interfere with a person’s ability to carry on activities of daily living. Also, like arthritis, fibromyalgia is considered a rheumatic condition, a medical condition that impairs the joints and/or soft tissues and causes chronic pain.
What are the Symptoms?
In addition to pain and fatigue, people who have fibromyalgia may experience a variety of other symptoms including:
- cognitive and memory problems (sometimes referred to as “fibro fog”)
- sleep disturbances, including sleep apnea
- morning stiffness
- irritable bowel syndrome
- painful menstrual periods
- numbness or tingling of the extremities
- restless leg syndrome
- temperature sensitivity/sensitivity to loud noises or bright lights (otalgia/photophobia)
A person may have two or more coexisting chronic pain conditions. Such conditions can include chronic fatigue syndrome, endometriosis, fibromyalgia, inflammatory bowel disease, interstitial cystitis, temporomandibular joint dysfunction, and vulvodynia. It is not known whether these disorders share a common cause.
What is the Pathogenesis of FM?
At the current time, the etiology and pathophysiology of FM are unclear, although scientists are starting to put some of the pieces together. There is no evidence that a single event “causes” FM but is more likely a combination of many physical and emotional stressors that can trigger or aggravate symptoms. These events can include infections, mental health conditions, and emotional or physical trauma.
FM is a disorder of pain regulation (classified under the term “central sensitization”) rather than a primary muscle disease. Controlled studies have found no significant biochemical or pathologic abnormalities in the muscles of patients with FM. Any muscular changes present may be secondary to inactivity caused by pain.
Genetic Predisposition and Gene Candidates: There appears to be a genetic predisposition for FM. Buskila and Sarzi-Puttini report that there is a high incidence of FM in families of FM patients and that the inheritance, although unknown, it most probably polygenic. Smith et al did a large candidate gene study looking at >350 genes representing three overlapping domains: (i) transmission of pain signals and nociception, (ii) inflammatory responses to tissue injury or psychological stress, and (iii) mood and affective states associated with chronic pain conditions. They found “significant differences in allele frequencies between cases and controls were observed for three genes: GABRB3, TAAR1, and GBP1.”
A number of studies (Park et al, Inanir et al, Desmeules et al, Martinez-Jauand et al) have demonstrated that catechol-O-methyltransferase (COMT) polymorphism affects central pain and that patients with FM have genetic variations associated with low COMT enzyme activity.
Altered Pain Processing: Patients with FM have alterations in the processing of pain and sensory stimuli. They perceive noxious stimuli as being painful at lower levels of physical stimulation than healthy controls. Researchers have found the following possible explanations:
- Decreased endogenous pain inhibition
- Changes in opioid receptors
- Using functional MRI, there is greater activation in FM patients than control in the secondary somatosensory cortex, insula and anterior cingulate cortex
- Patients with FM and comorbid depression have increased cerebral blood flow in the amygdala and anterior insula.
- Using proton magnetic spectroscopy, FM patients had significantly higher levels of glutamine in the right posterior insula compared with controls. This is associated with lower pressure pain thresholds.
Neurohormonal perturbations: Patients with FM demonstrate a hyperactivity of the stress response, marked by abnormalities of the hypothalamic-pituitary-adrenal (HPA) axis.
How Is Fibromyalgia Diagnosed?
People with fibromyalgia typically see many doctors before receiving the diagnosis. One reason for this may be that pain and fatigue, the main symptoms of fibromyalgia, overlap with many other conditions. Therefore, doctors often must rule out other potential causes of these symptoms before making a diagnosis of fibromyalgia. Another reason is that there are currently no diagnostic laboratory tests for fibromyalgia; standard laboratory tests fail to reveal a physiologic reason for pain. Because there is no generally accepted, objective test for fibromyalgia, some doctors, unfortunately, may conclude a patient’s pain is not real, or they may tell the patient there is little they can do.
A doctor familiar with fibromyalgia, however, can make a diagnosis based on criteria established by the American College of Rheumatology (ACR): a history of widespread pain lasting more than 3 months, and other general physical symptoms including fatigue, waking unrefreshed, and cognitive (memory or thought) problems. In making the diagnosis, doctors also consider the number of areas throughout the body in which the patient has had pain in the past week.
How Is Fibromyalgia Treated?
Fibromyalgia can be difficult to treat, and may require a multispecialty approach.
The initial treatment for all patients with FM should include:
- Patient education about the disease, good sleep hygiene, and the importance of treating co-morbid conditions (including mood or sleep disorders)
- An exercise program with aerobic conditioning, stretching and strengthening
- Drug monotherapy as below.
Only three medications, duloxetine, milnacipran, and pregabalin are approved by the U.S. Food and Drug Administration (FDA) for the treatment of fibromyalgia. Duloxetine(Cymbalta) was originally developed for and is still used to treat depression. Milnacipran(Savella) is similar to a drug used to treat depression but is FDA approved only for fibromyalgia. Duloxetine and milnacipran are both serotonin and norepinephrine reuptake inhibitors (SNRIs). Pregabalin (Lyrica) is a medication developed to treat neuropathic pain (chronic pain caused by damage to the nervous system).
Patients who do not respond adequately to initial therapy may require multi-drug regimens, some incorporating a variety of other medications developed and approved for other purposes. There is evidence for combining a low dose of a selective serotonin reuptake inhibitor (SSRI) (such as fluoxetine), or a SNRI in the morning with a low dose of tricyclic antidepressant (such as amitriptyline) in the evening. The combination of SNRI in the morning and a low dose of pregabalin in the evening has also been evaluated with good results.
Many people with fibromyalgia also report varying degrees of success with complementary and alternative therapies, including massage, movement therapies (such as Pilates and the Feldenkrais method), chiropractic treatments, acupuncture, and various herbs and dietary supplements for different fibromyalgia symptoms. Further information about the use of mind-body practices in fibromyalgia may be found here.
Michele R. Berman, MD, and Mark S. Boguski, MD, PhD, are a wife and husband team of physicians who have trained and taught at some of the top medical schools in the country including Harvard, Johns Hopkins, and Washington University in St. Louis. Their mission is both a journalistic and educational one: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.