Fibromyalgia
Jill C. Cash and Julie Barnes
Definition
Fibromyalgia syndrome is a clinical condition characterized by generalized aching and stiffness, associated with the finding of numerous tender points in characteristic locations.
A.The most current guidelines for diagnosis are presented by the American College of Rheumatology (ACR; Wolfe et al., 2010). The criteria for diagnosis include characteristic symptoms of pain at specific trigger point locations that are displayed by the patient for the past 3 months when there is no other reason or explanation for the associated pain. According to ACR 2016 revisions, the trigger points of 19 body areas are no longer required for the diagnosis of fibromyalgia; diagnosis is based on the patient’s significant symptoms.
B.Trigger point locations are found primarily in the back, neck, jaw, shoulders, chest, abdomen, arms, hips, and legs.
C.Somatic symptoms are also assessed for and present with fibromyalgia. Somatic complaints may include cognitive problems, sleeping difficulties, fatigue, headaches, and other associated symptoms. These criteria can be found at the ACR website: www.rheumatology.org.
Areas palpated are considered positive if the patient verbalized the area as being painful
when palpated.
Incidence
A.Fibromyalgia affects females more than males at a ratio of 10:1 and patients with an average age of 47 years; 5% of the population is affected with fibromyalgia. Usual onset is between 20 and 50 years; however, it has also been diagnosed in the young as well as the elderly. Often patients have symptoms for longer than 5 years before finally being diagnosed. The prevalence of fibromyalgia in rheumatology practice is 20%.
Pathogenesis
A.The cause is unclear. Studies of sleep physiology, neurohormonal function, muscular function, and psychological factors support a central mechanism for the disorder linked to depression. Other research suggests a pathophysiologic and psychological disorder.
Predisposing Factors
A.Life stress.
B.Depression.
C.Female gender.
D.Age: Mid-30s and older.
Common Complaints
A.Common complaints are multifocal pain present longer than 3 months; moderate to extreme fatigue; morning stiffness; nonrestorative sleep; difficulty with concentration and pain worsening with stress; exposure to cold; inactivity or overactivity; sensitivity to touch, light, and sound; cognitive difficulties; and changes in barometric pressure.
Other Signs and Symptoms
A.Numbness.
B.Swelling.
C.Reactive hyperemia of skin.
D.Raynaud’s phenomenon.
E.Irritable bowel syndrome (IBS) and bladder symptoms.
F.Headaches.
G.Restless legs syndrome (RLS).
H.Anxiety/depression.
Subjective Data
A.Determine onset, duration, and course of complaints.
B.Does fatigue interfere with the patient’s daily activity?
C.Note sleep quality. Does the patient feel rested after sleeping?
D.Do exacerbations of discomfort occur with stress, activity, and cold?
E.Has the patient experienced stress and/or depression in the past?
F.Does the patient have a family history of rheumatoid disease?
G.Has the patient ever been diagnosed with chronic fatigue syndrome, Lyme disease, or thyroid disease?
Physical Examination
A.Check temperature if indicated, pulse, and Blood pressure (BP).
B.Inspect:
1.Observe overall appearance, gait, and posture.
2.Observe the nails, skin, mucous membranes, eyes, joints, and spine. If clubbing is noted and tender points are minimal, consider hypertrophic osteoarthropathy.
3.Check joints for swelling, deformities, erythema; if clubbing is noted and tender points are minimal, consider hypertrophic osteoarthropathy.
C.Palpate the muscles as outlined in the aforementioned criteria for classification of fibromyalgia. Note the following when palpating for tender points:
1.Pressure should be insufficient to produce pain in normal patients or at uninvolved sites in affected patients.
2.Pain on digital palpation must be present in at least 11 of 18 tender point sites.
3.Positive pain reaction
is related to the patient stating that palpation causes pain. Tenderness is not to be considered as pain.
4.Painful points must be differentiated from trigger points of myofascial syndrome, which produce referred pain on compression.
5.Control areas not expected to be tender in fibromyalgia, such as middle of the forehead and fingertips, should be examined to exclude psychological pain or malingering.
D.Auscultate:
1.Heart.
2.Lungs.
Diagnostic Tests
A.Laboratory studies are normal with fibromyalgia.
B.Testing to consider assessing for other conditions includes:
1.Complete blood count (CBC).
2.Erythrocyte sedimentation rate (ESR).
3.C-reactive protein (CRP).
C.If the history and physical suggest some type of inflammatory, rheumatic condition, also order:
1.Antinuclear antibody (ANA).
2.Rheumatoid factor (RF).
3.Cyclic citrullinated peptide (CCP) test.
D.If there are concerns regarding a possible thyroid or muscle condition, also order:
1.Thyroid-stimulating hormone (TSH).
2.Creatinine phosphokinase.
E.Assessment for a sleep disorder should include ordering a sleep study.
Differential Diagnoses
A.Fibromyalgia.
B.Rheumatoid arthritis (RA).
C.Osteoarthritis (OA).
D.Polymyalgia rheumatica (PMR).
E.AS.
F.Myositis.
G.Systemic lupus erythematosus.
H.Hypothyroidism.
I.Chronic fatigue syndrome.
J.Obstructive sleep apnea.
Plan
A.General interventions:
1.Routine follow-up is recommended. Multiple therapies may be beneficial for controlling symptoms.
2.Stress importance of daily exercises and therapy to control pain.
3.Support groups are beneficial for patients and families.
B.
See Section III: Patient Teaching Guide Fibromyalgia.
Teach the patient that fibromyalgia is a recognizable syndrome that does not progress or cripple and does not warrant further testing. Patients can be assured it is not all in their head
:
1.Exercise: Encourage the patient to exercise daily, including stretching programs along with walking, low-impact cardiovascular conditioning such as cycling, and low-impact aerobics. Initially, pain may increase with the first 2 weeks of exercise; then it improves with a routine exercise program.
2.Pain control: Pain may improve with exercise, hot baths, heating pads, warm weather, and stress reduction.
C.Pharmaceutical therapy:
1.Amitriptyline 10 to 50 mg at bedtime for sleep.
2.Cyclobenzaprine 10 to 40 mg daily or other muscle relaxants.
3.Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 200 to 600 mg every 4 to 6 hours. Maximum dose is 1.2 g/d.
4.Analgesics such as acetaminophen (Tylenol) as needed.
5.Selective serotonin reuptake inhibitors (SSRIs) if depression is present.
6.Pregabalin (Lyrica) 75 mg twice a day to 150 mg twice a day; maximum dose of 450 mg/d.
7.Duloxetine Hcl (Cymbalta) 30 to 60 mg once a day. Give precautions of nausea with medication. If nausea is severe, consider prescribing Zofran 8 mg 30 minutes prior to Cymbalta dose. Advise patient that nausea will resolve after 3 to 4 weeks.
8.Milnacipran (Savella) titrated dose 12.5 mg on day 1, 12.5 mg twice a day for 2 days, 25 mg twice a day from days 4 to 7, then 50 mg twice a day (recommended dose). Maximum dose is 100 mg twice a day. Withdraw gradually. Precautions with renal impairment.
9.Current guidelines suggest guarded use of opioids chronically in nonmalignant pain. Opioids have not been studied in randomized controlled trials and should be considered only after all other medicinal therapies have been exhausted. Tramadol, a centrally acting analgesic with atypical opioid and antidepressant-like activity, is moderately effective in treating fibromyalgia pain.
10.Neurontin (Gabapentin) is approved for use in the treatment of neuropathic pain but not for fibromyalgia. Neurontin 300 mg orally three times a day should be the starting dose, with titrations upward as tolerated.
Follow-Up
A.Schedule regular visits in initial 2 to 4 weeks to evaluate how therapy is helping. Educate the patient each visit, and stress positive reinforcement and supervision of treatment regimen. Visits may then be scheduled every 3 months to monitor progress.
Consultation/Referral
A.Consult with a physician if the patient has abnormal laboratory results.
B.Consult or refer the patient to a physician if depression is suspected and current medication therapy is unsuccessful.
Individual Considerations
A.Geriatrics:
1.Fibromyalgia is common in the elderly and can be more painful for this population because of other coexisting conditions such as OA.
2.Fibromyalgia prevalence has accelerated in the geriatric population that is vulnerable to mobility reductions, sleep deprivation and chronic pain. Studies indicated that older adults suffering with fibromyalgia are more depressed and less physically active than those who are not diagnosed with fibromyalgia. One treatment method is dual-acting antidepressants titrated according to Beers guidelines rather than prescribing chronic use of steroids/NSAIDs.
3.Fibromyalgia syndrome is associated with increased risk of falls and fractures. However, studies indicate that high doses of vitamin D (60,000 IU D3/mo to achieve 25(OH)D level of 30 ng/mL) increased falls 15% and fractures 26% secondary to a negative effect with balance. Recommendations for patients ≥70 years of age are 24,000 IU of vitamin D3 per month, which has no effect with lower extremity function/balance.