Fibromyalgia
Fibromyalgia is a chronic pain syndrome ACR (American College of Rheumatology 1990 ) classification criteria state the presence of widespread pain in combination with 11 or more of 18 specific tender point sites. Widespread pain was defined as 3 out of 4 quadrant pain including left-and right and upper and lower segment pain and axial pain.
Better understanding of disease since initial ACR criteria ( 1990 ) Examination of tender point – found to be barrier in primary care Erroneous impression – that it is a peripheral musculoskeletal disease .Fibromyalgia usually diagnosed in primary care Diagnosis often not considered initially
Pain for at-least three months affecting both sides of the body , both above and below the waist Palpation of tender points not required Body divided into 19 regions and score how many regions are painful
Epidemiology-Common with a prevalence of 2 % Seen in all ethnic and socio-economic groups Prevalence ↑↑ in females Age of onset between 20-60 average age of 35 Diagnosis & management remains a challenge Often takes > 2 yrs to diagnose and an average 3.7 consultations with different physicians
Causes -Not known what exactly causes fibromyalgia – several mechanisms proposed ○ central sensitisation – maladaptive pain response ○ sleep cycle abnormalities ○ psychological and social factors ○ genetic-role of polymorphisms of genes ○ disturbances of serotonin , growth hormone , substance P & cortisol levels
Presentation-Varied and fluctuating symptoms Chronic widespread pain and tenderness ○ may have burning quality suggestive of neuropathic pain ○ not localised to any specific body tissue ○ tends to move from site to site Fatigue Unrefreshed sleep Cognitive dysfunction
Differential diagnosis -Inflammatory arthritis- including spondyloarthropathies Osteoarthritis Iron deficiency anaemia Hypermobility syndromes Chronic fatigue syndrome Polymyalgia rheumatica Polymyositis / dermatomyositis Thyroid dysfunction Multiple sclerosis Neuropathies Osteomalacia Drug related- eg statins
Investigations – ESR / CRP TFT FBC Iron studies Alkaline phosphatase Rheumatoid factor- if inflammatory cause suspected ( many false +ves ) Anti-CCP antibody – also many false + ves ANA -r/o SLE Vitamin D and B12
Diagnosis –Establish diagnosis and inform educate the patient / carers – inform that fibromylagia is a real disease Diagnosis does not require specialist eg Rheumatology confirmation Inform and educate- see information under links and resources Discuss treatment options and local availability Advice patients to expect exacerbation and remissions to vary over time Despite treatment with non-pharmacological measures and treatment with maximum dose of a single pharmacological agent , many patients still continue to be symptomatic – consider using combination drug therapy in such cases Consider referral to rheumatology , psychiatry , physiatrist ( physical medicine and rehabilitation physicians ) if troublesome symptoms continue despite optimum measures
Factors associated with a poor prognosis include –long duration of illness high stress levels co-morbidities like depression or anxiety which have not been treated adequately long standing avoidance of work alcohol or drug dependence moderate or severe functional impairment
Pharmacological management
Amitriptyline –Often first-line inexpensive and can improve sleep Studies have shown patients more likely to achieve 30 % pain reduction ie evidence of efficacy
Gabapentinoids –Pregabalin is licensed for use Gabapentin has shown similar efficacy Likely 30 % pain reduction and small effect on fatigue and sleep
SSRIs –Recent review of medium quality seven trials and reported a moderate effect on pain , sleep and no effect on fatigue- total available evidence is of low quality ( currently not approved for fibromyalgia by international drug agencies )
SNRIs- duloxetine Good choice for patients associated depression or fatigue -low to moderate quality evidence of efficacy
NSAIDs and Tramadol –Effective for acute pain and in chronic nocioceptive pain states and widely used -No evidence that they are effective alone in fibromyalgia
Combination –For example Tricyclics + SNRIs ( BMJ Best Practice ) Small risk serotonin syndrome but seen rarely in clinical practice
Non-pharmacological management
Acupuncture –Acupuncture significantly improved pain and symptoms of FM. although sham effect was important , real acupuncture treatment seems to be effective in treatment of FM ( Cochrane 2017 )
Exercise –Aerobic exercise was associated with improvements in pain and physical function. Evidence consistent for aerobic and strengthening exercises – less evidence to suggest superiority of one over another ( Cochrane ) BMJ Best Practice suggests that nearly any kind of exercise can be helpful with some evidence that aquatic exercise may be a good way to begin
Cognitive behaviour therapy-Cochrane review suggests that CBT in part via reductions in catastrophizing , help to normalize pain-related brain responses in FM (Clin J Pain 2017 Mar)
Biofeedback-Cochrane review from 2007 mentions – Biofeedback as a treatment modality reduces pain in patients with FM along with improvements in FIQ ( fibromyalgia impact questionnaire ) , SMWT ( 6 min walk test ) and the number of tender points – Indian J Med Sci 2007
LINKS AND RESOURCES
PATIENT INFORMATION
Arthritis Research booklet on fibromyalgia – https://www.versusarthritis.org/media/1251/fibromyalgia-information-booklet.pdf
FMAUK org information page on fibromyalgia http://www.fmauk.org/information-packs-mainmenu-58/booklet-mainmenu-135/490-patient-booklet
NRS Healthcare – info about fibromyalgia ( has a disability aid shop ) https://www.nrshealthcare.co.uk/articles/condition/fibromyalgia
Fibromyalgia Awareness Association ( Spain ) has a beginners guide which patients can download https://fibro.info/en/
UK Fibromyalgia com https://ukfibromyalgia.com/index.php
Pain relief foundation booklet on Fibromylagia https://painrelieffoundation.org.uk/wp-content/uploads/2019/11/DEALING-WITH-PAINFIBRO.pdf
Excellent work from HSE Ireland https://www.hse.ie/eng/health/az/f/fibromyalgia/treating-fibromyalgia.html
A questionnaire from Fibromyalgia network can be printed for the patient to fill https://neuro.memorialhermann.org/uploadedFiles/_Library_Files/MNII/NewFibroCriteriaSurvey.pdf
This is an online calculator from The SOAP Note project which stands for subjective objective assessment plan by Mark Morgan in 2013 ( I am unsure about the validity of this questionnaire but incorporates the current ACR-FDC diagnostic criteria ) https://www.soapnote.org/musculoskeletal/fibromyalgia-calculator/
American College of Physicians on fibromyalgia 1 page ( double sided ) https://www.acponline.org/system/files/documents/patients_families/products/facts/fibromyalgia.pdf
NHS Inform Scot https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/conditions/fibromyalgia
For patients in the USA https://fibroandpain.org/
American College of Rheumatology fast facts about fibromyalgia https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia
INFORMATION FOR CLINICIANS
European League Against Rheumatism guideline , et al EULAR revised recommendations for the management of fibromyalgia
Another useful article Boomershine CS. A comprehensive evaluation of standardized assessment tools in the diagnosis of fibromyalgia and in the assessment of fibromyalgia severity. Pain Res Treat. 2012;2012:653714. doi:10.1155/2012/653714 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200128/
Polish Archives of Internal Medicine Management of fibromyalgia: practical guides from recent evidence-based guidelines Winfried Häuser, Jacob Ablin, Serge Perrot, Mary-Ann Fitzcharles DOI: 10.20452/pamw.3877 Published online: January 04, 2017
Canadian guideline on fibromyalgia management Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain Res Manag. 2013;18(3):119–126. doi:10.1155/2013/918216 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3673928/
Practical pain management – Fibromyalgia what clinicians need to know by Gary W Jay MD https://www.practicalpainmanagement.com/pain/myofascial/fibromyalgia/fibromyalgia-what-clinicians-need-know
2016 ACR Diagnostic criteria of fibromyalgia https://people.clarkson.edu/~lrussek/2016FMS.pdf
References
- Fibromyalgia syndrome : management in primary care by Peter Glennon GP Stafford, Arthritis Research UK Reports on the Rheumatic Diseases Series 6 Autumn 2010 Hands on No 7
-
EULAR revised recommendations for the management of fibromyalgia
- Fibromyalgia: A Clinical Update June 2010 (Volume 18, Issue 4)
Claudia Sommer https://s3.amazonaws.com/rdcms-iasp/files/production/public/Content/ContentFolders/Publications2/PainClinicalUpdates/Archives/PCU_2010_June_2_FINAL_1390261185357_5.pdf - Fibromylagia Clinical Review BMJ 2014 ; 348 :g1224
- Medscape CME Fibromyalgia : Diagnostic and Treatment Strategies for the Family Physicians
- BMJ Best Practice Fibromyalgia https://bestpractice.bmj.com/topics/en-gb/187
- Fibromyalgia in Primary Care : Incorporating Patient Insights into Patient Care https://www.fmaware.org/wp-content/uploads/2015/06/CME-Needs-Assessment.pdf
- Angry patient with fibromyalgia: Diagnosis and
management in primary care Teoh Soo Huat, MD1,2
1 Department of Family Medicine, Hospital University Science Malaysia, Kubang Kerian, Kelantan, 2 Klinik Kesihatan Bakar Arang, Sungai Petani, Kedah Med J Malaysia Vol 71 No 6 December 2016 http://www.e-mjm.org/2016/v71n6/fibromyalgia.pdf - Fitzcharles, M. A., Ste-Marie, P. A., Goldenberg, D. L., Pereira, J. X., Abbey, S., Choinière, M., Ko, G., Moulin, D. E., Panopalis, P., Proulx, J., Shir, Y., & National Fibromyalgia Guideline Advisory Panel (2013). 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome: executive summary. Pain research & management, 18(3), 119–126. https://doi.org/10.1155/2013/918216
- Australian Family Physician Fibromyalgia Emma Guymer
Geoffrey Littlejohn Volume 42 , No 10 , October 2013 https://www.racgp.org.au/download/Documents/AFP/2013/Oct/201310guymer.pdf -
New and Modified Fibromyalgia Diagnostic Criteria Neha Garg and Atul Deodhar February 9, 2012 http://www.rheumatologynetwork.com/fibromyalgia/new-and-modified-fibromyalgia-diagnostic-criteria Neha Garg, MD
- The effects of acupuncture versus sham
acupuncture in the treatment of fibromyalgia:
a randomized controlled clinical trial
Uğurlu FG1 , Sezer N1 , Aktekin L1 , Fidan F1 , Tok F2 , Akkuş S1 Acta Reumatol Port. 2017 Jan-Mar;42(1):32-37. https://www.ncbi.nlm.nih.gov/pubmed/28371571 - Bhargava J, Hurley JA. Fibromyalgia. [Updated 2019 Nov 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK540974/
