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Fibromyalgia

Fibromyalgia (FM) is a chronic widespread pain disorder, second only to osteoarthritis as the most common condition seen in rheumatology practices (Lesley et al, 2011). FM is unrelenting and often debilitating. It can affect quality of life by impairing a patient's ability to work and participate in everyday activities, and therefore it disturbs relationships with family, friends, and employers. Increasingly more patients with FM are presenting to primary care clinicians for an initial diagnosis and ongoing care (Bennett et al, 2011).

A clinical description of FM has been reported since the mid-1800s but the term "fibromyalgia" was first coined in 1976 in an American Rheumatism Association editorial. Derived from both Latin (fibra–fiber) and Greek words (myo-muscle and algos–pain), it literally means "pain in the muscle and fibrous tissues" (Firdous et al, 2012).

FM is often regarded as a medically unexplained syndrome due to its lack of objective findings on physical examination, laboratory and imaging modalities. Physicians have been ambivalent about the condition, regularly dismissing it as a psychological, society-driven disorder (Chong et al, 2009) leading to depression and social isolation. For years FM was regarded as a rheumatology specialty owing to the presence of physical pain and body tenderness. In 1990 The American College of Rheumatology (ACR) criteria for the classification of FM was completed (Wolfe et al, 1990) and the World Health Organisation provided FM with its own International Statistical Classification of Diseases (ICD) diagnostic code, to be used by all health practitioners to label the syndrome.

Risk factors
The exact cause of FM is unknown, but recent advances have helped to unpick some of the ambiguity associated with this syndrome and FM studies continue to gather momentum.

Firstly, there may be a genetic link to FM and first-degree relatives of people with FM are at a higher risk (NHS, 2012).

Environmental factors, including physical trauma to the body's tissues, psychological trauma (an incident provoking emotional damage, such as abuse), viral infections (e.g. AIDS, HIV, Hepatitis B, Hepatitis C and Lyme disease) and other stressors (e.g. work, family, life-changing events, depression) all increase the risk of FM.

Gender is another risk factor, with women diagnosed approximately 7 times more often than men, ranging in age from 25 to 60 years (http://www.merckmanuals.com). FM also occurs in men, teenagers and children.

Disturbed pain messages (the way that pain messages are carried and received in your body) are another likely cause of FM. The central nervous system (brain and spinal cord) transmits information throughout the body, but in people with FM the transmission of these pain messages is disturbed. This may explain why FM results in constant feelings of pain and extreme sensitivity to pain (NHS, 2012).

Low levels of the hormones serotonin, noradrenaline (norepinephrine) and dopamine are detected in people with FM. These hormones are responsible for controlling many of the body's processes, such as regulating mood, appetite and sleep (serotonin), stress response (noradrenaline) and mood/behavior or the way we learn (dopamine).

Disturbed sleep patterns might be a cause of FM as well as a symptom. FM prevents deep sleep, leading to fatigue, but people with FM who sleep badly also feel more pain, suggesting that sleep problems contribute to other FM symptoms in some way.

Symptoms
FM symptoms vary from patient to patient and might fluctuate over time. FM patients will experience a range of the following symptoms (NHS, 2012):

  • Widespread pain - often worse in particular areas or at different times
  • Burning sensations
  • Sharp, stabbing pains
  • Hyperalgesia – inappropriately intense pain from a normally painful stimulus
  • Allodynia - pain from a normally non-painful stimulus
  • Heightened sensitivity to other things such as smoke, foods and bright lights
  • Stiffness
  • Muscle spasm
  • Fatigue
  • Poor sleep - waking up un-refreshed
  • Cognitive problems ('fibro-fog') - such as attention and concentration
  • Slowed, confused speech
  • Migraine or tension headaches
  • Irritable bowel syndrome (IBS) or gastroesophageal reflux disease (GERD)
  • Irregular body temperature - feeling too hot or cold
  • Restless legs syndrome - feeling like you need to move your legs to get some relief
  • Tingling, numbness, prickling, or burning sensations in your hands and feet - paraesthesia
  • Tinnitus - the perception of a noise in one or both ears that comes from inside your body
  • Painful menstrual periods - in women
  • Anxiety, depression
  • Migraine or tension headaches
  • Temporomandibular joint (TMJ) disorder - face or jaw pain, jaw clicking and ringing in the ears

FM symptoms may fluctuate depending on factors such as changes in the weather, stress levels or how physically active a patient is.

Associated Conditions
There are several conditions that can lead to FM (secondary FM) including the following (NHS, 2012):

Musculoskeletal:
Carpal tunnel syndrome
Chronic fatigue syndrome
Hypermobility syndrome
Myofascial pain syndrome
Osteoarthritis (OA)
Restless legs syndrome
Rheumatoid arthritis (RA)
Sjögren syndrome
Systemic lupus erythematosus (SLE)
TMJ dysfunction
Myofascial trigger points

 

 

 

Genitourinary:
Dysmenorrhea
Female urethral syndrome
Interstitial cystitis
Premenstrual syndrome
Vulvar vestibulitis
Vulvodynia

 

 

 

 

Gastrointestinal:
Esophageal dysmotility
Irritable bowel syndrome (IBS)

Miscellaneous:
Allergy
Anxiety disorders
Mitral valve prolapsed
Ocular disturbances
Tension / migraine headaches
Vestibular disorders

 

Diagnosis
The Fibromyalgia Impact Questionnaire (FIQ) was developed in the late 1980s, first published in 1991 and has had various revisions made to it since then. For a long time it was regarded as one of the most frequently used tools in the evaluation of FM, but several weaknesses have since been highlighted in relation to a bulky scoring algorithm acting as a barrier to widespread clinical use (Bennett et al, 2009).

In 1990 the American College of Rheumatology (ACR) published its classification criteria of FM. Patients fulfilling these criteria need to have had widespread pain for at least 3-months and pain in at least 11 of 18 tender points on physical examination (Chong et al, 2009). These tender points (see list below) should hurt only at the area where pressure (enough to cause the examiner's nail bed to whiten or approximately 4 kg per unit area of force) is applied, and there is no referred pain (Jahan et al, 2012):

  • Occiput: Sub-occipital muscle insertions (2)
  • Low cervical: Anterior aspects of the intertransverse spaces at C5-7 (2)
  • Trapezius: Midpoint of the upper border (2)
  • Supraspinatus: Above the medial border of the scapular spine (2)
  • Second rib: Second costochondral junctions (2)
  • Lateral epicondyle: 2cm distal to the epicondyles (2)
  • Gluteal: Upper outer quadrants of the buttocks (2)
  • Greater trochanter: Posterior to the trochanteric prominence (2)
  • Knee: Medial fat pad proximal to the joint line (2)

 fibromyalgia TRPTs

Whilst the ACR criteria provided an 88% sensitivity and 81% specificity in the diagnosis of FM (Jahan et al, 2012), other causes of chronic musculoskeletal pain which can mimic FM (e.g. hypothyroidism, SLE and malignancies) still require further investigation.

More recently, the ACR has outlined an updated set of diagnostic criteria for FM, including common symptoms such as fatigue, sleep disturbance and cognitive problems in addition to widespread pain. The original tender point test has been replaced with a widespread pain index (WPI) and symptom severity (SS) score in a one-page symptom checklist format, more suitable for use in primary-care settings. Firstly, a full physical examination is required, along with other diagnostic tests to exclude other potential causes for a patient's symptoms. Patients highlight 19 body areas in which pain has been experienced during the past week. One point is given for each area, allowing a possible maximum WPI score of 19. Secondly, the patient ranks on a scale of 0-3, specific symptoms including fatigue, waking un-refreshed, cognitive symptoms, physical symptoms such as headache, weakness, bowel problems, nausea, dizziness, numbness/tingling and hair loss. The numbers assigned to each are added up, allowing a possible maximum SS score of 12. FM diagnosis is based on a (a) a WPI score of >7 and SS score of >5 or (b) a WPI of 3-6 and SS of >9 (Jahan et al, 2012).

The diagnostic evaluation of FM can take time, but this should not be a barrier in primary care settings. No laboratory or radiologic testing is required to diagnose FM unless clinically indicated to evaluate other potential diagnoses, including conditions that mimic FM (Arnold et al, 2011). Similarly, specialist referral is usually not necessary to confirm the diagnosis of FM. The patient should be referred for specialist evaluation if uncertainty remains about the diagnosis because of unusual symptoms or signs, laboratory findings or other concerns. Referral should also occur when the patient has abnormal laboratory results that suggest another condition requiring specialty care, including mood/anxiety and sleep disorders (Arnold et al, 2011).

Management
Most FM patients have been evaluated by different specialists and undergone multiple tests. The best management approach is to establish a correct FM diagnosis, to exclude differential diagnoses and to explain the implications of the FM diagnosis to patients (Chong et al, 2009).

It is important that patients are autonomous in the development of their FM management plan as it will help them to assume control of their lives and focus on positive lifestyle changes rather than chronic dysfunction (Jahan et al, 2012).

  • Non-Pharmacological Treatments

FM patients must try to avoid exacerbating factors by limiting anxiety, stress and feelings of depression through lifestyle modifications. Cognitive behavioral therapy (CBT) can help through relaxation training and group feedback. Physical exercise is another good way of responding to stress, allowing the expulsion of negative energy anticipated by the body. Alternative therapies such as Chinese herbal medications, herbal teas and Tai-chi require further research in relation to their effects on FM patients, but it is suggested that Traditional Chinese Medicine (TCM) acupuncture successfully triggers the release of endorphins into the blood stream and are body's natural pain relievers (Chong et al, 2009).

  • Pharmacological Treatments

A range of pharmacological therapeutics, such as non-steroidal anti-inflammatories, opioids, muscle relaxants, anti-depressants, sedatives and anti-epileptics have been used to treat FM by attempting to combat fatigue, rigidity, insomnia and poor sleep. Updated understanding of FM neurophysiology has intensified the development of FM drugs to effect changes in central nervous system (CNS) pain pathways.

  • Manual Therapy

Manual therapists such as Osteopaths, Chiropractors or Physiotherapists assist patients with FM in the relief of deep muscle pain and joint stiffness. Treatment sessions assist with the strength and conditioning of the musculoskeletal system, improving tone and range of range of movement. Therapists educate people with FM on how to make sensible decisions about daily activities that will prevent painful flare-ups.

Contributing Author:
Nikki Harris MOst. MA APNT Dip. Cert Acup. 

References
Arnold, L.M., Clauw, D.J. & McCarberg, B.H. (2011). Improving the Recognition and Diagnosis of Fibromyalgia. Mayo Clin. Proc. 2011 May; 86(5): pp.457–464

Bennett, R.M., Friend, R., Jones, K.D., Ward, R., Han, B.K. & Ross, R.L. (2009). The Revised Fibromyalgia Impact Questionnaire (FIQR): validation and psychometric properties. Arthritis Res. Ther. 2009; 11(4): pp.120

Bennett, R.M. & Goldenberg, D.L. (2011). Fibromyalgia, myofascial pain, tender points and trigger points: splitting or lumping? Arthritis Res. Ther. 2011; 13(3): pp.117

Chong, Y.Y. & Ng, B.Y. (2009). Clinical aspects and management of fibromyalgia syndrome. Ann. Acad. Med. Singapore. 2009 Nov; 38(11): pp.967-73

Jahan, F., Nanji, K., Qidwai, W. & Qasim, R. Fibromyalgia Syndrome: An Overview of Pathophysiology, Diagnosis and Management. Oman Med. J. 2012 May; 27(3): pp.192–195

Rodero, B., Benigno, B.R., Luciano, J.V., Gili, M., Serrano-Blanco, A. & García-Campayo, J. (2011). Relationship between behavioural coping strategies and acceptance in patients with fibromyalgia syndrome: Elucidating targets of interventions. BMC Musculoskelet. Disord. 2011; 12: pp.143

http://www.merckmanuals.com [Accessed 14 February 2013]

http://www.nhs.uk [Accessed 14 February 2013]