FibromyalgiaDr. Md Rashedul Islam

FCPS, MRCP(UK)Registrar, Neurology, BIRDEM

Definition

Fibromyalgia (FM) is characterized by chronic widespread musculoskeletal pain and tenderness. Although it is defined primarily as a pain syndrome.

FM patients also commonly complain of associated neuropsychological symptoms of fatigue, unrefreshing sleep, cognitive dysfunction, anxiety, and depression.

Epidemiology

FM is far more common in women than in men, with a ratio of about 9:1.

In population-based studies worldwide, there is general agreement that the prevalence rate is approximately 2–3%, with rates of closer to 5–10% in primary care practices.

Pathophysiology

A number of abnormalities in pain processing have been demonstrated in fibromyalgia. Among them are the following:

Excess excitatory (pronociceptive) neurotransmitters (eg, substance P, glutamate levels in the insula)

Low levels of inhibitory neurotransmitters (eg, serotonin and norepinephrine) in descending antinociceptive pathways in the spinal cord

Maintained enhancement of temporal summation of second pain

Genetics and Physiology

Catechol-O-methyltransferase, which controls the synaptic levels of norepinephrine and dopamine, has been associated with FM.

Polymorphisms of the -adrenergic receptor and dopamine receptor are also associated with FM

Genes associated with metabolism, transport, and receptors of serotonin and other monoamines have also been implicated in FM and overlapping conditions.

Etiology

Engel's biopsychosocial model of chronic illness (ie, health status and outcomes in chronic illness are influenced by the interaction of biologic, psychological, and sociologic factors) provides a useful way to conceptualize fibromyalgia.The model is pictured in the image below.

Clinical Manifestations

Clinical Manifestations The most common presenting complaint of a patient with

FM is "pain all over." Patients with FM have pain that is typically above and

below the waist on both sides of the body and involves the axial skeleton (neck, back, or chest).

The pain attributable to FM is poorly localized, difficult to ignore, severe in its intensity, and associated with a reduced functional capacity.

Pain should have been present most of the day on most days for at least 3 months.

DIAGNOSTIC CRITERIA The clinical pain of FM is associated with increased

evoked pain sensitivity. In clinical practice, this is determined by a tender point

examination in which the examiner uses the thumbnail to exert pressure of approximately 4 kg/m2, or the pressure leading to blanching of the tip of the thumbnail, on well-defined musculotendinous sites.

American College of Rheumatology classification criteria previously required that 11 of 18 sites be perceived as painful for a diagnosis of FM.

Neuropsychological Symptoms

FM patients typically complain of fatigue, stiffness, sleep disturbance, cognitive dysfunction, anxiety, and depression.

Pain, stiffness, and fatigue often are worsened by exercise or unaccustomed activity (postexertional malaise).

Sleep complaints include difficulty falling asleep, difficulty staying asleep, and early-morning awakening.

Neuropsychological Symptoms

Cognitive complaints are characterized as slowness in processing, difficulties with attention or concentration, problems with word retrieval, and short-term memory loss.

Symptoms of anxiety and depression are common, and the lifetime prevalence of mood disorders in patients with FM approaches 80%.

Overlapping Syndromes

Headaches, facial/jaw pain, Regional myofascial pain particularly involving

the neck or back, and arthritis. Visceral pain complaints involving the

gastrointestinal tract, bladder, and pelvic or perineal region are also often present.

Comorbid Conditions

FM is often co morbid with chronic musculoskeletal, infectious, metabolic, or psychiatric conditions.

it occurs in 20% or more of patients with degenerative or inflammatory rheumatic disorders,

Psychosocial Considerations

Understanding current psychosocial stressors will aid in patient management as many factors that exacerbate symptoms cannot be addressed by using pharmacologic approaches.

There is a high prevalence of exposure to previous interpersonal and other forms of violence in patients with FM and related conditions.

If posttraumatic stress disorder is an issue, the clinician should be aware of it and consider treatment options.

Functional Impairment It is crucial to evaluate the impact of FM

symptoms on function and role fulfillment. In defining the success of a management

strategy, improved function is a key measure. Understanding where role functioning falls

short will assist in establishing treatment goals.

Differential Diagnosis Inflammatory 

Polymyalgia rheumatica

Inflammatory arthritis: rheumatoid arthritis,

spondyloarthritides

Connective tissues diseases: systemic lupus

erythematosus, Sjögren's syndrome Infectious 

Lyme disease

Parvovirus B19

Epstein-Barr virus

Differential Diagnosis Noninflammatory 

Degenerative joint/spine/disk disease

Bursitis, tendinitis, repetitive strain injuries Endocrine 

Hypo- or hyperthyroidism

Hyperparathyroidism Neurologic diseases 

Neuropathic pain syndromes Psychiatric disease  Major depressive disorder Drugs  Statins, Aromatase inhibitors

Laboratory or Radiographic Testing

Routine  Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) Complete blood count (CBC) Complete metabolic panel Thyroid-stimulating hormone (TSH)

Guided by history and physical examination  Antinuclear antibody (ANA) Anti-SSA (anti-Sjögren's syndrome A) and anti-SSB Rheumatoid factor and anticyclic citrullinated peptide (anti-CCP) Creatine phosphokinase (CPK) Viral and bacterial serologies Spine and joint radiographs

Treatment: Fibromyalgia

Nonpharmacologic Treatment Providing explanation of the genetics, triggers, and

physiology of FM can be an important patients must be educated regarding the

expectations for treatment. The physician should focus on improved function and quality of life rather than elimination of pain.

Nonpharmacologic Treatment

Physical conditioning, with encouragement to begin at low levels of aerobic exercise with slow but consistent advancement.

Supervised or water-based programs to start. Relaxation, such as yoga and Tai Chi. Strength training may be recommended after a patient

has reached his or her aerobic goals. Exercise programs Cognitive-behavioral strategies to improve sleep hygiene

Pharmacologic Approaches Antidepressants: balanced

serotonin:norepinephrine reuptake inhibition

Amitryptiline

Duloxetinea

Milnaciprana Anticonvulsants: ligands of the alpha-2-delta

subunit of voltage-gated calcium channels

Gabapentin

Pregabalina

Prognosis

Fibromyalgia is a chronic relapsing condition. In academic medical centers, long-term follow-up care of

patients with fibromyalgia reportedly averages 10 outpatient visits per year and 1 hospitalization every 3 years.

Chronic pain and fatigue in fibromyalgia increases the risk for metabolic syndrome.

Prognosis

Three distinct subsets of patients with varying prognoses

have been termed

Adaptive copers, Interpersonally distressed Dysfunctional.

Prognosis Adaptive copers, who often do not seek care for their

symptoms, do well with respect to pain, sleep, and fatigue.

Interpersonally distressed patients may respond to resolution of life stressors and interdisciplinary therapeutic approaches, including counseling.

Dysfunctional patients have high levels of pain and anxiety, major impairment in daily functioning, and, quite often, opioid dependence. These patients have a very poor prognosis.