Fibromyalgia


Article Author:
Juhi Bhargava


Article Editor:
John Hurley


Editors In Chief:
Sisira Reddy
Joseph Nahas
Chokkalingam Siva


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
5/1/2019 7:47:23 AM

Introduction

Fibromyalgia (FM) is a condition characterized by chronic widespread musculoskeletal pain. Fatigue, cognitive disturbance, psychiatric and multiple somatic symptoms often accompany the disorder. Fibromyalgia has an unknown etiology and uncertain pathophysiology.[1][2] There is no evidence of tissue inflammation despite symptoms of soft tissue pain. Fibromyalgia is a pain regulation disorder as suggested by ongoing research and often classifies as a form of central sensitization syndrome.[3]

Etiology

Fibromyalgia is a chronic pain disorder with unknown etiology.[4][5] There is no evidence of any single event cause of this condition; instead, it is triggered or aggravated by multiple physical and/or emotional stressors which include infections as well as emotional and physical trauma.

Fibromyalgia is considered a disorder of pain regulation often classified under central sensitization.[6] Some studies have shown a genetic predisposition for fibromyalgia though there is no documentation of a definitive candidate gene.[7] Pain and sensory processing alterations in the central nervous system present in fibromyalgia.[8] Patients perceive noxious stimuli as being painful at lower levels of physical stimulation compared to healthy controls.[9] With rapidly repetitive short noxious stimuli to fibromyalgia patients, they experience higher than normal increases in the perceived intensity of pain. There appears to be a deficiency in the endogenous analgesic systems in patients with fibromyalgia. There has been a demonstration of differences in activation of areas of the brain which are pain-sensitive areas by functional neuroimaging techniques.

Epidemiology

Fibromyalgia is more common in women compared to men, and its prevalence is 2 to 3% in the USA and other countries. It increases with age.[10][11] Between the ages of 20 to 55 years, the cause of generalized, musculoskeletal pain in most women is fibromyalgia. The prevalence in adolescents has been found to be similar to those in adults in many studies. Amongst the patients referred to a tertiary care pain clinic, more than 40% met the criteria for fibromyalgia.[12] The risk for fibromyalgia is higher if you have an existent rheumatic disease.

History and Physical

Widespread musculoskeletal pain and fatigue are the characteristics of fibromyalgia and are often accompanied by cognitive and psychiatric disturbances.[13]

Symptoms

  1. Widespread musculoskeletal pain – The chief complaint of a patient with fibromyalgia is widespread musculoskeletal pain which is bilateral and involves both upper and lower parts of the body. The pain may be localized initially, commonly in the neck and shoulders. The predominant description of the pain is as muscle pain, but the patients may complain of joint pain as well.[14]
  2. Fatigue – The other cardinal symptom of fibromyalgia is fatigue.[15] Especially when waking up from sleep, but is also in the mid-afternoon. Minor activities may aggravate the pain and fatigue, though inactivity for a prolonged period also increases the symptoms. There is stiffness on waking up in the morning. Patients complain of sleeping lightly with frequent awakenings during the early morning. They feel unrefreshed in the morning even if they complete 8 to 10 hours of sleep.
  3. Cognitive disturbances – Often referenced as "fibro fog,"; patients have difficulty with attention and doing tasks that require rapid changes in thought.
  4. Other symptoms -  30 to 50 percent of patients have anxiety and/or depression at the time of diagnosis.[16] More than 50 percent of the patients have headaches which include migraine and tension types.[17] Patients often complain of paresthesias, particularly in both arms and both legs. A detailed neurologic evaluation is usually unremarkable. Among gastrointestinal syndrome, IBS commonly correlates with fibromyalgia. Gastroesophageal reflux disease (GERD) occurs more commonly in patients with fibromyalgia compared to the general population.[18] Patients may complain of dry eyes, dyspnea, dysphagia, and palpitations.

The 1990 ACR fibromyalgia classification criteria included tenderness at least 11 of 18 defined tender points

  • Suboccipital muscle insertion bilaterally
  • The anterior aspect of C5 to C7 intertransverse spaces bilaterally
  • Mid-upper border of trapezius bilaterally
  • Origin of supraspinatus muscle bilaterally
  • Second costochondral junctions bilaterally
  • 2cm distal to the lateral epicondyles bilaterally
  • Upper outer quadrants of buttocks bilaterally
  • Greater trochanteric prominence bilaterally
  • Medial fat pad of the knees bilaterally

The pressure appropriate for detecting these tender points should be equal 4 kg/cm^2,  enough to whiten the nail bed of the fingertip of the examiner.

However, given many limitations of the tender point examination, the 2010 diagnostic criteria eliminated these findings. The criteria are mentioned below under evaluation.

Evaluation

No abnormalities are seen in fibromyalgia in routine clinical laboratory testing or imaging. However, in research studies, functional MRI and other specialized imaging have revealed certain abnormalities in patients of fibromyalgia compared to control subjects.

Diagnosis

1990 ACR classification criteria — It was used in many clinical and therapeutic trials but has not been useful in diagnosing fibromyalgia in clinical practice

The 1990 ACR fibromyalgia classification criteria included:

  • Symptoms of widespread pain, present on both sides of the body and both above and below the waist
  • Physical findings of at minimum 11 of 18 defined tender points
  1. Suboccipital muscle insertion bilaterally
  2. Anterior aspect of C5 to C7 intertransverse spaces bilaterally
  3. Mid upper border of trapezius bilaterally
  4. Origin of supraspinatus muscle bilaterally
  5. Second costochondral junctions bilaterally
  6. 2cm distal to the lateral epicondyles bilaterally
  7. Upper outer quadrants of buttocks bilaterally
  8. Greater trochanteric prominence bilaterally
  9. Medial fat pad of the knees bilaterally

The pressure appropriate for detecting these tender points should be equal 4 kg/cm^2,  enough to whiten the nail bed of the fingertip of the examiner.

For the purposes of classification, the patient is said to have fibromyalgia if both criteria are met.

2010 ACR preliminary diagnostic criteria

There were a number of limitations of the 1990 diagnostic criteria which include the following.

  1. Physicians not knowing how to examine tender points, performing the exam incorrectly or simply refusing to do so.
  2. A number of symptoms which were previously not considered were increasingly appreciated as key symptoms of fibromyalgia
  3. The criteria set the bar so high that it left little room for variation among fibromyalgia patients. Also, the patient whose symptoms improved failed to satisfy the 1990 criteria.

There was 2011 modification of the 2010 ACR preliminary criteria (2011 modified criteria), followed by 2016 modification.

American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity

A patient fulfills the diagnostic criteria for fibromyalgia if the following three conditions are met:

  1. Widespread pain index (WPI) is 7 and symptom severity (SS) scale score is 5, or WPI equals 3 to 6 and SS scale score of 9.
  2. Symptomatology has been present at a similar level for at least 3 months.
  3. The patient does not demonstrate any other disorder that would otherwise explain the pain.

Ascertainment

  1. WPI: note the number of areas where and in how many areas the patient has had pain during the prior week. The score will be between 0 and 19. Shoulder girdle, left hip (buttock, trochanter), left jaw, left upper back shoulder girdle, right hip (buttock, trochanter), right jaw, right lower back upper arm, left upper leg, left chest neck upper arm, right upper leg, right abdomen lower arm, left lower leg, left lower arm, right lower leg, right
  2. SS scale score: Fatigue, waking unrefreshed, and cognitive symptoms. For the each of the three symptoms above, indicate the severity level over the past week utilizing the following scale: 0 no problem; 1 slight or mild problems, generally mild or intermittent ; 2 moderate, considerable problems, often present and/or at a moderate level; 3 severe: pervasive, continuous, life-disturbing problems. Considering somatic symptoms in general, indicate whether the patient has: 0 for no symptoms, 1 a few symptoms, 2 a moderate number of symptoms; 3 for many symptoms. The SS scale score sums the severity of the 3 symptoms (fatigue, waking unrefreshed, cognitive symptoms) plus the severit) of general somatic symptoms. The final score is between 0 and 12.

Treatment / Management

The approach to patients with fibromyalgia includes educating patients regarding the disease and treatment approaches, exercise regimen and drug therapy for patients not responding to non-pharmacologic measures.

Patient Education

It is important that patients with fibromyalgia understand their illness before the prescription of any medications.[2][19][20] The key elements of patient education include:

  1. Reassuring the patient that fibromyalgia is a real disease.
  2. There is a role of stress and mood disturbances and the patients with fibromyalgia should be encouraged to learn relaxation techniques as well as be a part of formal stress reduction programs. About 30% of patients with fibromyalgia have major depression at the time of diagnosis and the lifetime prevalence is 74%. The lifetime prevalence of anxiety disorder is 60%. These patients should be encouraged to get treatment.
  3. Good sleep hygiene is an essential part of the management of fibromyalgia and recognizing and obtaining treatment of sleep disorders which may contribute to symptoms of fibromyalgia is equally important.

Exercise

Cardiovascular fitness training is recommended for patients as it helps with pain and improves sleep.[21][22] Recommended optimal cardiovascular fitness training constitutes a minimum of 30 minutes of aerobic exercise three times a week with the heart rate near the target range.

Medications

It is recommended to continue nonpharmacologic measures along with the use of medications for most patients with fibromyalgia. Some patients, may, however, respond adequately to nonpharmacologic measures alone. The medications that have been well studied and consistently effective are certain antidepressants and anticonvulsants. The antidepressants include tricyclic medications, like amitriptyline and other selective serotonin reuptake inhibitors (SSRIs) and norepinephrine reuptake inhibitors (SNRIs) including duloxetine and milnacipran. Cyclobenzaprine, a tricyclic medication, has also been found to be effective in patients with fibromyalgia. The beneficial anticonvulsants include gabapentin and pregabalin. The three drugs for the treatment of fibromyalgia, approved by the US Food and Drug Administration (FDA) are pregabalin, duloxetine, and milnacipran. Therapy most often initiates with tricyclic antidepressants. An SNRI or one of the anticonvulsants is an option in patients with inadequate response or intolerance to tricyclic antidepressants. However, in a patient with more severe fatigue, depression or severe sleep disturbance, an SNRI or an anticonvulsant is recommended.

Treatment for persistent symptoms

Despite the initial treatment with nonpharmacologic measures and single pharmacologic agents at maximum tolerated dose, many patients continue to be symptomatic. In those patients, the following are the current recommendations.

It is recommended to use a combination drug therapy in patients not responsive to monotherapy

Encouraging participation in a supervised physical exercise program for patients who have difficulty reaching a sufficient level of low-impact aerobic exercise. Referral to a physiatrist and/or a physical therapist would be helpful in these patients. Water-based exercises and yoga have also been found to be useful in a few studies.

Psychosocial interventions like cognitive behavioral therapy can be beneficial in patients with inadequate response to initial treatments.

Specialty consultations which include consultations for rheumatologists, physiatrists and psychiatrists are recommended in patients not responding adequately to initial therapies. Treatment should be multidisciplinary and individualized with close attention to the patient’s symptoms.[23]

There is limited evidence for analgesics and anti-inflammatory drugs as well as complementary and alternative therapies like tai chi, yoga, and acupuncture

Some studies have shown benefits with neuromodulation techniques like transcranial stimulation, occipital and C2 nerve stimulation and transcutaneous electrical nerve stimulation.

Differential Diagnosis

Fibromyalgia may mimic other conditions due to multiple nonspecific symptoms. The differentials include polymyalgia rheumatica, spondyloarthritis, inflammatory myopathy, systemic inflammatory arthropathies, and hypothyroidism. The limited laboratory findings along with history and physical examination can help differentiate fibromyalgia from other differentials.

Prognosis

Most longitudinal long term studies have shown that most of the patients continue to have chronic pain and fatigue, but the majority of these studies have been from tertiary referral centers. In contrast, patients treated by primary care physicians in the community have a much better prognosis. Many demographic and psychosocial factors significantly impact the prognosis and outcome in patients with fibromyalgia. Female gender, low socioeconomic status, unemployment, obesity, depression, and history of abuse had adverse effects on the outcome.

Complications

Some patients with fibromyalgia experience mental fog, often known as fibro fog which includes cognitive issues and lasting memory problems that interfere with their ability to concentrate. Also, patients with fibromyalgia are more likely to be hospitalized for any reason compared to the general population.

Consultations

Specialty consultations which include consultations for rheumatologists, physiatrists and psychiatrists are recommended in patients not responding adequately to initial therapies. Treatment should be multidisciplinary and individualized with close attention to the patient’s symptoms.

Deterrence and Patient Education

It is crucial that patients with fibromyalgia understand their illness before the prescription of any medications. The key elements of patient education include:

Reassuring the patient that fibromyalgia is a real disease

There is a role of stress and mood disturbances and the patients with fibromyalgia should be encouraged to learn relaxation techniques as well as be a part of formal stress reduction programs. About 30% of patients with fibromyalgia have major depression at the time of diagnosis and the lifetime prevalence is 74%. The lifetime prevalence of anxiety disorder is 60%. These patients should be encouraged to get treatment.

Good sleep hygiene is an essential part of the management of fibromyalgia and recognizing and obtaining treatment of sleep disorders which may contribute to symptoms of fibromyalgia is equally important.)

Enhancing Healthcare Team Outcomes

A primary care physician, physician assistant, and nurse practitioner play an essential role in early diagnosis and initiating treatment for fibromyalgia. It is equally important that they utilize the resources available in the community like physical exercise programs and relaxation programs. Psychosocial interventions like CBT can be useful in patients with inadequate response. Referral to a physiatrist and/or a physical therapist is helpful in these patients. Specialty consultations which include consultations for rheumatologists and psychiatrists are also recommended in patients not responding adequately to initial therapies.[24][25] [level 1] A coordinated an interprofessional team approach including physicians, mid-level practitioners, nursing staff, and where needed, pharmacists and physical therapists will produce the best results. [Level V]


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Fibromyalgia - Questions

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A 24-year-old female has a history of Lyme disease. Onset was 2 years ago and the patient was treated with doxycycline 100 mg twice a day for 4 weeks. She now complains of diffuse aching and stiffness, worsened by cold weather and stress. Her joints show no tenderness or synovitis, but she is tender over points bilaterally at the occiput, trapezius, lateral epicondyle, gluteals, and knee. What is the most probable diagnosis?



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A 30-year-old female presents to her provider with widespread musculoskeletal pain, which is bilateral and involving both upper and lower parts of the body for the past four months. She has normal laboratory findings, and imaging studies are unremarkable. Which of the following is a first-line medication used to treat this condition?



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A 40-year-old patient presented with fatigue and difficulty concentrating at work for almost a year. She also complains of pain all over her body but mainly in the shoulder and neck. She has had multiple ED visits but all the labs came back within normal limits. What is the best initial therapy for this patient?



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A 40-year-old female presented with fatigue and insomnia for 6 months. She was complaining of feeling pain all over. Her inflammatory markers came back within normal limits. What is the most common age group and gender affected by this condition?



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Which of the following would be appropriate to treat fibromyalgia-induced insomnia in a patient who also has restless leg syndrome?



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A 35-year-old female presented with widespread musculoskeletal pain which was bilateral and involved both upper and lower parts of the body. She experienced fatigue, especially when waking up from sleep. She also had tenderness to palpation at bilateral lateral epicondyles, trapezius, the medial fat pad of knee, second costochondral junction and greater trochanter. Labs and radiology tests were unremarkable. Which of the following is used for this condition induced insomnia?



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A 66-year-old woman presents with extreme fatigue and muscle pain that has troubled her for the past 9 months. On examination, she has many tender points on her upper body. Which of the combination of the following medications is helpful in a patient not responding to initial therapy?



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A 40-year-old female with no significant past medical history presented with bilateral widespread musculoskeletal pain which involved both upper and lower parts of the body. She experienced fatigue, especially when waking up from sleep. She had tenderness to palpation at bilateral lateral epicondyles and trapezius. She was finding it difficult to concentrate on tasks at hand. She was also feeling depressed lately. Labs and radiology tests were unremarkable. Which of the following is one of the first line medications given and what mechanism of action is responsible for improvement?



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A 38-year-old female with no significant past family history presented with six months of symptoms of fatigue and depression. She also was diagnosed with irritable bowel syndrome. She has widespread bilateral musculoskeletal pain and stiffness. Her lab studies came back within normal limits, and the radiological findings were insignificant. What percentage of the population is affected by this condition?



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A female patient describes headaches, joint pains, and muscle pains. She complains of paresthesias in a stocking, glove distribution. She also reports insomnia. The patient has seen several different providers over the past five years and has been treated with multiple NSAIDs without relief. Her joints have a full range of motion without effusions, erythema, or deformity. She is tender over the medial knee, distal to the lateral epicondyle of the elbow, at the suboccipital muscle insertions, and the second costochondral junction. Labs are within normal limits. Plain radiographs are negative. What is the prevalence of this condition?



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To ensure compliance and effectiveness in the treatment of fibromyalgia, when is amitriptyline is best administered?



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Which antidepressant been found to effective in the management of fibromyalgia?



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A 32-year-old female presented with bilateral shoulder, hip and back pain. She was also complaining of fatigue and mental fog for six months. TSH, ESR, CRP, ANA, ds DNA came back within normal limits. Mother has a history of Polymyalgia rheumatica. Which non-pharmacological therapy has been well documented to be effective in patients with this condition?



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A 30-year-old female presented with complaints of pain all over her body with fatigue and feeling of hopelessness. Her mother had similar complains as well. Her labs were unremarkable. How long should symptoms be present to make the diagnosis of this condition?



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A young female has just been diagnosed with fibromyalgia. What is the best way to manage her condition with medications?



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A 33-year-old white female presents with body pain. She reports diffuse body pain associated with pain in the shoulder and neck area. She reports stiffness in the whole body in the morning time which gets slightly better in the afternoon but does not resolve. She also reports of increased fatigue and inability to concentrate. She has a history of Sjogren syndrome and uses artificial tear drops and lozenges for dryness of eyes and mouth, respectively. She has a history of migraine since childhood, and she reports worsening of the headache for last one months. She has no visual symptoms. She has a family history significant of polymyalgia rheumatica in her 82 years old grandmother who is doing well on low dose corticosteroid. Her examination reveals tender points with no joint tenderness or muscle weakness. Her CBC, metabolic profile, thyroid stimulating hormone, creatine phosphokinase, and erythrocyte sedimentation rate are within normal range. What further management should be suggested for the patient?



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A 37-year-old lady complains of pain and tenderness in her upper back, bilateral tights, and sometimes on her shoulders for the past 6 months. She states that the pain gets worse with physical activities, and is tender to touch. She says the pain is 7/10 in severity (10 being the worst pain). She is also experiencing insomnia and fatigue. She has tried acetaminophen, but it has not been very effective in relieving her pain. Which of the following best describes the mechanism of action of the medication that could be given for the patient's condition?



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Fibromyalgia - References

References

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