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Fibromyalgia

Fibromyalgia is a chronic pain syndrome 

ACR (American College of Rheumatology 1990 ) classification criteria states
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

DiagnosisEstablish 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 fibromyalgiahttps://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 Macfarlane GJKronisch CDean LE, 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 summaryPain 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 Reports on the Rheumatic Diseases Series 6 Autumn 2010 Hands on No 7 EULAR revised recommendations for the management of fibromyalgia Annals of Rheumatic Diseases Volume 76 Issue 2 Fibromyalgia : A Clinical Update International Association for the Study of Pain Vol XVlll Issue 4 Fibromylagia Clinical Review BMJ 2014 ; 348 :g1224 Medscape CME Fibromyalgia : Diagnostic and Treatment Strategies for the Family Physicians BMJ Best Practice Fibromyalgia Fibromyalgia in Primary Care : Incorporating Patient Insights into Patient Care Fibromyalgia in Primary Care ; What You Need to Know Now diagnosis and pharmacological management Angry patient with fibromyalgia ; Diagnosis and management in primary care Med J Malaysia Vol 71 No 6 December 2016 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia syndrome : Executive Summary Pain Res Manag Vol 18 No 3 May/June 2013 Australian Family Physician Fibromyalgia Volume 42 , No 10 , October 2013 http://www.rheumatologynetwork.com/fibromyalgia/new-and-modified-fibromyalgia-diagnostic-criteria The effects of acupuncture versus sham acupuncture in the treatment of fibromyalgia : a randomised controlled clinical trial Actaa Rheumatol Port 2017 ( Abstract ) Fibromyalgia Juhi Bhargava; John A. Hurley Last Update: November 29, 2019.

 

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