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MarkkuMali

Fibromyalgia

Essentials

  • Fibromyalgia is a combination of individually varying symptoms and findings of various causes; its severity and symptoms vary in different individuals and periods.
  • Fibromyalgia should be suspected if the patient suffers from long-standing, widespread pain (aches, pains, tenderness to touch) stemming from the musculoskeletal system and not sufficiently explained by injury, damage or inflammation.
  • Practical diagnostic criteria based on a patient questionnaire have been suggested for fibromyalgia (see Pain symptom questionnaire Pain Symptom Questionnaire).
  • Many unnecessary examinations and treatments can be avoided by sufficiently early diagnosis.
  • Patient guidance and self care methods form the mainstay of treatment. Regular physical exercise and increasing muscle strength and endurance fitness reduce the symptoms of fibromyalgia .
  • Pharmacotherapy is mainly symptomatic and used to support self care.

Pathogenesis

  • Fibromyalgia is a classic example of so-called centralized i.e. nociplastic pain, with dysfunctional shaping and sensitization of pain systems.
  • The mechanisms and patophysiology involved in fibromyalgia and other chronic pain disorders are largely alike. Therefore the recommendations for treating chronic pain and the main principles of treating fibromyalgia are similar.
  • Sensitization and disturbance of the mechanisms regulating the nociceptive nervous system, and imbalance in the autonomic nervous system are responsible not only for painfulness but also for other typical symptoms of fibromyalgia, such as fatigue, mental symptoms ("fibro fog") and sleep disturbances.
  • Changes also in the peripheral nervous systems have been found; for example small fibre neuropathy has in studies occurred in about 40% of the patients.
  • Genetic differences in the regulation of neurotransmitters regulating pain, in molecules that break down such transmitters or in mediators of inflammation may explain the multifactorial heredity and phenotype.

Aetiology

  • About 4% of the population have fibromyalgia syndrome, and the risk of developing the syndrome is genetic in about one half of the cases. In people with inflammatory rheumatic disorders, migraine or chronic back pain, the prevalence is even up to 10-30%. Fibromyalgia-like symptoms and nociplastic pain occur generally also in other regional chronic pain conditions.
  • The factors most commonly making a person susceptible to fibromyalgia are:
    • peripheral regional pain and pain syndromes
    • insufficient or unrefreshing sleep and rest
    • obesity
    • physical inactivity
    • mental stress or hopelessness.
  • In addition, predisposing and triggering factors include the following:
    • accidents and surgical procedures
    • infections
    • autoimmune diseases
    • hormonal changes, such as hypothyroidism or the menopause.

Symptoms

  • General tenderness to touch (a kind of disturbance in the regulation of the "pain thermostat" in the brain), wide-ranging rest pain.
  • Lethargy and fatigue
  • Unrefreshing sleep (usually broken sleep)
  • Functional symptoms and pain syndromes involving various organ systems (e.g. irritable bowel syndrome Functional Bowel Disorders and the Irritable Bowel Syndrome (IBS), cardiac symptoms, gynaecological problems and pains Lower Abdominal Pain of Gynaecological Origin, headaches Headache, neck and shoulder pain Neck and Shoulder Pain, painful occlusion problems Bruxism, irritated bladder, chronic back pain Low Back Pain or restless legs Restless Legs and Akathisia)
  • Neurological symptoms (numbness, tingling, vertigo, headaches)
  • Mental disorders (depression, anxiety; severe depression is rare)
  • Mental problems (inability to concentrate, memory defects, difficulties in learning new things and in expression)
  • Symptoms vary and their severity fluctuates at different times depending on physical and psychological stress factors.

Diagnosis

  • The diagnosis is made clinically based on patient interview and careful examination of the patient's general status and joints.
  • The American College of Rheumatology (ACR) criteria for the classification of fibromyalgia published in 1990 and based on the detection of tender points (11/18 tender points) fail to take various degrees of severity or concomitant symptoms into consideration.
  • Instead, a patient-filled questionnaire on the extent of pain and the occurrence and severity of symptoms will help to identify and monitor typical symptoms of fibromyalgia (printable pain symptom questionnaire: Pain Symptom Questionnaire).
  • The presence of any, more specifically treatable or previously undiagnosed concomitant diseases, such as inflammatory rheumatic disorders, anaemia, hypothyroidism, hyperparathyroidism or menopausal symptoms should be considered.
  • According to current definitions, fibromyalgia diagnosis holds irrespective of other diagnoses and it does not exclude the existence of other diagnoses.
  • Symptoms and pains of other comorbidities that are very common in patients with fibromyalgia (e.g. osteoarthritis and back problems, rheumatic and connective tissue disorders, depression and anxiety disorders, migraine and chronic headaches) should be treated as effectively as possible - doing so reduces often also the symptoms of fibromyalgia.

Treatment

  • Early diagnosis, a trusting doctor-patient relationship, listening to the patient, a biopsychosocial approach and avoidance of an inappropriate cycle of investigations are the cornerstones of management.
  • Try to correct the patient's false preconceptions about the causes of the pain and fatigue and any fears about their effects on the person's functional ability.
  • Negative thoughts, such as fears and beliefs associated with pain, avoidance and catastrophic thinking should be actively avoided.
  • Patients should be helped to learn to shift their thoughts away from the pain and to see the positive side of things (cognitive behavioural therapy).
  • Non-pharmacological self care methods improve the patient's functional ability and quality of life.
    • Physical training reduces symptoms . Physical exercise aims at improving aerobic capacity and muscle strength: regular walking, cycling, cross-country skiing, swimming, muscle exercises .
    • Commonly recommended health-enhancing physical activity is suitable but patients should start exercising carefully and gradually, listening to their bodies ("start low, go slow"). The body should also be given sufficient rest and time to recover.
    • Sleep should be improved by eliminating disturbing factors (coffee, alcoholic beverages, noise, and stress) and by careful choice of bed and pillow.
  • The aim of pharmacological therapy Carisoprodol, Paracetamol and Caffeine in the Treatment of Fibromyalgia is to relieve symptoms and to support pain self-management methods.
    • Amitriptyline at a dose of 10-50 mg taken early in the evening Amitriptyline for Fibromyalgia. Any adverse effects appear instantly and are often alleviated with time, so the patient should be encouraged to continue with the medication because its effect will only appear in 1-2 weeks.
    • Duloxetine (30-60 mg/day) and milnacipran (50-100 mg/day) , inhibitors of reuptake of both serotonin and noradrenaline, and pregabalin (25-300 mg/day) have been licensed by the FDA for the treatment of fibromyalgia.
    • Gabapentin (300-1 200 mg/day) Gabapentin for Fibromyalgia may also be effective for symptoms of fibromyalgia.
  • Patients with fibromyalgia are often sensitized also to drug effects, and consequently therapy should be started carefully. Pharmacotherapy with doses higher than the aforementioned ones is usually not successful unless the patient has severe neuropathic pain in addition to fibromyalgia.
  • Anti-inflammatory drugs (NSAIDs), analgesics, muscle relaxants and antidepressants based on selective inhibition of serotonin reuptake or inhibition of monoamine oxidase are not effective for fibromyalgia pain. Nociceptic pain is often also involved, such as osteoarthritis or inflammatory pain. An NSAID or paracetamol may be helpful for these pains.
  • Opioids are not recommended for fibromyalgia pain (they have little effect on functional pain and, additionally, they are highly addictive and may, paradoxically, increase hyperalgesia).
  • In the most problematic cases best results are achieved using a comprehensive multidisciplinary rehabilitation programme .

    References

    • Clauw DJ. Fibromyalgia: a clinical review. JAMA 2014;311(15):1547-55. [PubMed]