Fibromyalgia

• clinical syndrome of chronic widespread non-inflammatory musculoskeletal pain 
• accompanied by variety of typical symptoms including fatigue, sleep disturbance, impaired concentration, cognitive clouding, depression, GI (irritable bowel) and urogenital (irritable bladder) dysfunction.

• poorly understood pathophysiology, believed to be central sensitization
• Women account for more than 75-85% of Fibromyalgia patients
  • Peak Incidence: ages 20 to 60 years old
  • Incidence increases with age
• Most common rheumatic cause of chronic diffuse pain
  • Most common cause of Chronic Pain in women ages 20 to 55 years old
• Incidence
  • Rheumatology patients: 15%
  • Only Osteoarthritis is more common in rheumatology practice
  • General medical patients: 5%
  • General female population: 2-3%

Epidemiology

• F:M >3:1
• Primarily ages 25-45 
• Prevalence of 2-5% in the general population
• Overlaps with chronic fatigue syndrome
• Strong association with psychiatric illness

Symptoms

• Widespread aching, stiffness and reproducible tender points
• Fatigue
• Symptoms aggravated by physical activity, poor sleep, emotional stress
• Patient feels that joints are diffusely swollen although joint examination is normal
• Non-restorative sleep, difficulty falling asleep, frequent wakening
• Neurologic symptoms of hyperalgesia, paresthesias
• Associated with IBS, migraines, tension headaches, obesity, depression and anxiety

Associated Conditions: Symptoms

• Severe Fatigue (81%)
• Morning stiffness longer than 15 minutes (77%)
• Sleep Disorder (75%)
  • Non-restorative sleep (alpha-delta sleep)
  • Sleep Apnea
  • Nocturnal Myoclonus
  • Restless Leg Syndrome
• Atypical Paresthesias (63%)
• Anxiety (48%)
• Dry Mouth (36%)
• Recurrent Headaches (53%)
• Dysmenorrhea (41%)
• Past History of Major Depression (31%)
• Irritable Bowel Syndrome (30-70%)
• Urinary urgency (26%)
• Cold sensitivity or Raynaud’s Phenomenon (17%)
• Exacerbating Factors
  • Post-exertional increase in muscle pain
  • Emotional Stress or Abuse

Diagnosis:

Fibromyalgia is a diagnosis of exclusion

1. Widespread musculoskeletal pain (“I hurt all over”)
2. Regional: Each of 4 body quadrants involved
   1. Pain on left and right side of body
   2. Pain above and below waist
3. Axial skeleton pain present
   1. Cervical Spine
   2. Anterior chest
   3. Thoracic Spine
   4. Low back
4. Pain worse in the morning and at the end of the day
5. Symptoms persist at least 3 months
6. Pain in 11/18 trigger points with approximate force of 4kg
7. Associated symptoms such as:
   • Fatigue: A pervasive sense of tiredness or lack of energy that does not improve with rest.
   • Sleep Disturbances: Non-restorative sleep or difficulty falling/staying asleep.
   • Cognitive Symptoms: Often referred to as “fibro fog,” including problems with memory, concentration, and cognitive functions.
   • Somatic Symptoms: Headaches, irritable bowel syndrome, urinary symptoms, and other widespread somatic complaints.

American College of Rheumatology

1990 Critera

• Widespread Pain: Pain must be present in all four quadrants of the body (both sides and above and below the waist) and must have been present for at least three months.
• Tender Points: The presence of tenderness in at least 11 out of 18 specific anatomical sites (tender points) upon palpation with approximately 4 kg of pressure. These tender points include locations such as the base of the skull, neck, shoulders, chest, lower back, hips, and knees.

2010 Criteria

Recognizing the limitations of the 1990 criteria, the ACR revised the diagnostic criteria in 2010 to include a more comprehensive assessment of fibromyalgia symptoms. The new criteria focus on both the presence of widespread pain and the severity of associated symptoms:

• Widespread Pain Index (WPI): A score based on the number of areas in which the patient has had pain in the last week, out of a possible 19 areas. These areas include regions such as the shoulders, upper and lower back, hips, and extremities.
• Symptom Severity Scale (SSS): A scale that evaluates the severity of three key symptoms (fatigue, waking unrefreshed, and cognitive symptoms) and the presence of other somatic symptoms. Each of the three key symptoms is scored from 0 to 3 (0 = no problem, 3 = severe, pervasive problem). Additional somatic symptoms are scored from 0 to 3, leading to a total possible SSS score of 12.
• Diagnosis Criteria: A diagnosis of fibromyalgia can be made if:
  • WPI score is 7 or more and SSS score is 5 or more, or
  • WPI score is between 3 and 6 and SSS score is 9 or more.
• Duration: Symptoms must have been present at a similar level for at least three months.
• Exclusion of Other Disorders: There should be no other disorder that would otherwise explain the pain.

Differential Diagnosis

Because fibromyalgia shares symptoms with many other conditions, it’s crucial to perform a thorough evaluation to rule out other potential causes:

• Rheumatoid Arthritis: Check for joint inflammation, morning stiffness, and autoantibodies like rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPAs).
• Systemic Lupus Erythematosus: Look for systemic signs such as a butterfly rash, photosensitivity, and presence of antinuclear antibodies (ANA).
• Hypothyroidism: Evaluate thyroid function tests to rule out thyroid dysfunction.
• Chronic Fatigue Syndrome: Overlaps significantly with fibromyalgia but often emphasizes profound fatigue more than pain.
• Sleep Disorders: Such as obstructive sleep apnea, which can cause fatigue and non-restorative sleep.

Red flags

• Older age at new symptom onset
• Weight loss
• Night pain
• Focal pain
• Fever or sweats
• Neurological features
• History of malignancy

Yellow Flags

Psychological Factors

1. Catastrophizing: Exaggerated negative thoughts and feelings about pain and its impact on life.
2. Depression and Anxiety: High levels of emotional distress can exacerbate symptoms and reduce coping ability.
3. Fear-Avoidance Beliefs: Fear that activity or movement will worsen pain, leading to avoidance behaviors.
4. Low Self-Efficacy: Lack of confidence in the ability to manage pain and perform daily activities.
5. Stress: High levels of stress can trigger or exacerbate fibromyalgia symptoms.

Social Factors

1. Social Isolation: Limited social support or relationships can contribute to feelings of loneliness and worsen symptoms.
2. Unstable Home Environment: Family or relationship problems can increase stress and negatively impact health.
3. Occupational Stress: High job stress or dissatisfaction can contribute to symptom flare-ups.

Behavioral Factors

1. Poor Coping Strategies: Ineffective ways of dealing with pain, such as over-reliance on medications or inactivity.
2. Sleep Disturbances: Chronic sleep problems can worsen pain and fatigue, creating a vicious cycle.
3. Inactivity: Lack of regular physical activity can lead to deconditioning, increasing pain and disability.

Cognitive Factors

1. Negative Beliefs about Pain: Beliefs that pain is uncontrollable or that it signifies serious damage can worsen symptoms.
2. Unrealistic Expectations: Expecting quick or complete relief from treatments can lead to disappointment and frustration.

Key Questions to Identify Yellow Flags

To identify these yellow flags in patients with fibromyalgia, consider asking the following questions during clinical assessment:

1. How do you feel about your ability to manage your pain?
2. Do you believe that physical activity will make your pain worse?
3. How much support do you feel you have from family and friends?
4. Have you been feeling down or anxious lately?
5. How well are you sleeping, and do you feel rested when you wake up?
6. How do you typically cope with your pain and stress?
7. Are there any major stressors in your life right now?
8. How do you perceive your pain impacting your life and future?

Treatment

• Education – disease is benign, non-deforming, does not progress
  • pain is real but not caused by tissue damage
  • not a progressive or deforming disease
  • expect frustration because symptoms fluctuate
  • goal is not to achieve a pain-free state, but to enable pain management for optimal functioning

• Exercise program – Choose low impact Exercise
  • Water aerobics
  • Swimming
  • Bicycling
  • Fast walking

• Phyisotherapy
  • tailored exercise program that addresses specific symptoms and improves strength and flexibilit
• Diet and Nutrition
  • Some people with fibromyalgia find that certain foods exacerbate their symptoms.
  • A balanced diet, possibly with guidance from a dietician, can help identify and eliminate potential food triggers.
• Support back and neck
  • neck support during sleep, strengthen abdominal muscles
• Stress reduction
  • mindfulness
  • meditation
  • deep-breathing exercises
  • relaxation therapies
  • CBT = focus on changing negative thought patterns and behaviors to improve pain management and quality of life.
• Support Groups:
  • Joining a fibromyalgia support group can provide emotional support and practical advice from others who understand the condition.
• Keep patient employed
  • Job modifications and improved ergonomic
  • Work hour reductions may be needed
  • Encourage walking and Stretching every 2-3 hours
  • Education of work supervisors may be needed
  • Consider “Return to Work” Centers
    • Assess ergonomics and teach body mechanics
    • Work hardening program

PHARMACOLOGICAL THERAPIES

• target functional improvement, not pain control
• Analgesics:
  • Paracetamol: Often used as first-line treatment, though its effectiveness in fibromyalgia is based on expert opinion rather than robust evidence.
  • Tramadol: May provide pain relief due to its serotonin-norepinephrine reuptake inhibition properties.
  • NSAIDs: Commonly used but lack strong evidence for efficacy in fibromyalgia.
• Antidepressants:
  • Amitriptyline:
    • A tricyclic antidepressant effective in reducing pain and improving sleep.
    • effective in low doses (10–75 mg/day)
  • Duloxetine
    • effectiveness in doses of 60 mg/day and 120 mg/day in reducing pain, improving quality of life, and alleviating depressive symptoms.
    • The analgesic effect is largely independent of its antidepressant action
  • Milnacipran: Serotonin-norepinephrine reuptake inhibitors (SNRIs) that are effective for pain relief and improving mood and function.
• Anticonvulsants:
  • Pregabalin and Gabapentin: These medications stabilize nerve membranes and reduce pain by decreasing neurotransmitter release.
• Low-Dose Naltrexone:
  • This medication, typically used for opioid addiction, has shown promise in treating Fibromyalgia symptoms. Although more research is needed, low-dose naltrexone has demonstrated potential benefits in pain management for Fibromyalgia patients [(Wulz, 2019)]

Prognosis of Fibromyalgia

• Chronic Pain and Fatigue: Most patients continue to experience these symptoms long-term.
• Tertiary Referral Centers vs. Primary Care: Patients treated in tertiary centers often show poorer outcomes compared to those managed in primary care settings.
• Demographic and Psychosocial Factors: Prognosis is significantly affected by:
  • Female gender
  • Low socioeconomic status
  • Unemployment
  • Obesity
  • Depression
  • History of abuse

Factors Associated with Poor Prognosis

• Long Duration of Disease: Prolonged suffering from fibromyalgia is linked to worse outcomes.
• High Stress Levels: Persistent stress exacerbates symptoms and hinders improvement.
• Untreated Depression or Anxiety: Mental health conditions not managed effectively can worsen prognosis.
• Long-Standing Work Avoidance: Avoidance of work due to pain or other symptoms contributes to poorer outcomes.
• Alcohol or Drug Dependence: Substance abuse complicates management and prognosis.
• Moderate to Severe Functional Impairment: Greater levels of disability are associated with a worse prognosis.

Complications

• Fibro Fog: Cognitive issues, including difficulty concentrating and memory problems.
• Increased Hospitalization Risk: Patients with fibromyalgia are more likely to be hospitalized compared to the general population.’

Myofascial Trigger Points

Definition

• Described by Travell and Rinzler in 1952. (as per Murtag)
• Characterized by:
  • Local tenderness in a muscle.
  • Muscle twitching upon stimulation.
  • Referred pain when subjected to pressure.

Reliability

• Under blinded conditions, there is little consistency in reliably identifying trigger points.

Treatment

• Injection:
  • Identify the maximal point of pain.
  • Inject 5–8 mL of local anaesthetic (e.g., lignocaine/lidocaine 1%) into the painful point.
  • Do not use corticosteroids.
• Post-Injection Care:
  • Perform post-injection massage.
  • Engage in exercises to maintain relief.