Synonyms: FM, fibromyalgia syndrome (FMS)
Fibromyalgia is a chronic pain disorder. The pain can be widespread throughout the body with tender points at specific anatomical sites. There is a reduced pain threshold, hyperalgesia (amplification of pain from painful stimuli that are expected to be painful) and allodynia (pain with stimuli that should not normally cause pain). There can be associated fatigue, depression and other somatic symptoms. These symptoms occur in the absence of other identifiable disease. The European League against Rheumatism (EULAR) published guidelines in 2007 providing evidence-based recommendations for the management of fibromyalgia.
- It is thought that the condition is common and underdiagnosed.
- The estimated prevalence in North America and Europe is as high as 5.8%.
- Women are 10 times more commonly affected than men.
- Usual age of presentation is 20-50 years but it has been diagnosed in children, adolescents and older people.
- There is a link to failing to complete education, low income, female sex and being divorced.
- The exact pathophysiology is not known. Hypotheses include:
- The nociceptive system has links with the stress regulating, immune and sleep systems which may explain some of the clinical features.
- Genetic and environmental factors may play a role in fibromyalgia as it is more common in the relatives of affected patients.
- The patient may complain of:
- Pain at multiple sites (low back pain with/without radiation to the buttocks and legs and pain in the neck and across the shoulders are common complaints; patients may complain of "pain all over").
- Sleep disturbance (sleep may exacerbate symptoms and contribute to depression).
- Morning stiffness.
- Feeling of swollen joints (with no objective swelling).
- Problems with cognition (eg memory disturbance, difficulty with word finding).
- Headaches (may be migrainous).
- Light-headedness or dizziness.
- Fluctuations in weight.
- Anxiety and depression.
- Symptoms are generally reported as worse in cold, humid weather and under times of stress.
- This is clinical. The American College of Rheumatology has produced classification criteria for fibromyalgia. However, these criteria are not meant to be used for diagnosis. Features include:
- Widespread pain involving both sides of the body, above and below the waist as well as the axial skeletal system, for at least three months; AND
- The presence of 11 tender points among the nine pairs of specified sites (18 points) as shown in the diagram.
- Digital palpation using the thumb should be carried out to assess tenderness at these sites. The pressure applied should be just enough to blanch the examiner's thumbnail (approximately 4 kg/cm2). In someone without fibromyalgia, this would not be enough pressure to cause pain.
- Routine blood testing can help to exclude other differential diagnoses: eg ESR, TFTs, antinuclear antibodies. However, be careful not to over-investigate.
- The Fibromyalgia Impact Questionnaire can be used to assess function (see link in Internet and further reading section, below). It also has a role in review and assessment of treatment interventions.
- A full social, personal, family and psychological history should be taken. There may be an interplay with stress, psychosocial experiences, the psychosocial situation and sociocultural factors.
- Irritable bowel syndrome.
- Irritable bladder.
- Premenstrual syndrome.
- Restless leg syndrome.
- Non-cardiac chest pain.
- Temporomandibular joint pain.
- Raynaud's phenomenon.
- Sicca syndrome.
- Rheumatoid arthritis: approximately 25% of patients with rheumatoid arthritis also have fibromyalgia.
- Systemic lupus erythematosus (SLE): approximately 50% of patients with SLE also have fibromyalgia.
- Chronic fatigue syndrome.
- Polymyalgia rheumatica.
- Inflammatory and metabolic myopathies.
The following advice for the management of fibromyalgia is based on the European League against Rheumatism (EULAR) guidelines. 
- Pain and function should be assessed in a psychosocial context.
- A multidisciplinary approach to treatment should be used. GPs, rheumatologists, physicians experienced in dealing with chronic pain, psychologists, psychiatrists, physiotherapists, etc. may all need to be involved.
- Treatments should be discussed with the patient and tailored to their individual needs, including pain levels, function and associated features such as depression, fatigue and sleep disturbance.
- Balneotherapy (heated pool treatment) has been shown to be an effective treatment. It can improve pain and function. Exercise treatment can also be carried during balneotherapy.
- Exercise programmes including aerobic exercise and strength training may help some patients with fibromyalgia. The programmes should be tailored to the individual. (This recommendation is mostly based on expert opinion in the EULAR guidelines due to poor-quality trials.) The Ottawa Panel also recommends aerobic fitness and strengthening exercise for the management of fibromyalgia. A Cochrane review reports 'gold-level evidence' that moderate-intensity supervised aerobic exercise improves overall wellbeing and physical function in fibromyalgia. From a practical point of view, they recommend:
- Slowly increasing the intensity of exercise.
- If symptoms worsen, cutting back on exercise until symptoms improve.
- Cognitive behavioural therapy may help some patients with fibromyalgia. (This recommendation is mostly based on expert opinion in the EULAR guidelines, due to limited and poor-quality trials.)
- Therapies including relaxation, rehabilitation, physiotherapy and psychological support, which may help some people with fibromyalgia.
- Paracetamol, weak opioids and tramadol can be used for the management of pain. However, care should be taken with tramadol because of possible opiate withdrawal symptoms and the potential for abuse and dependance.
- Corticosteroids and strong opioids are not recommended. This is due to the lack of evidence from clinical trials and the long-term side-effects.
- Antidepressants can help to reduce pain and improve function. A meta-analysis in 2009 reported strong evidence for the effectiveness of antidepressants for pain, depressed mood, sleep disturbance and 'quality of life' scores in mainly short-term studies. The tricyclics were best for pain and selective serotonin reuptake inhibitors (SSRIs) for low mood. Although the evidence is strong, the effect of antidepressants is quite small. There was no effect on fatigue. The studies did not allow definitive advice on the superiority of one class of drugs over another. Antidepressants recommended include:
- Tropisetron (discontinued), pramipexole and pregabalin have been shown in studies to reduce pain and should be considered in the treatment of fibromyalgia. The EULAR guidelines suggest further research into these promising drugs.
Other points concerning treatment
- Acupuncture has not been shown to be of benefit in a systematic review.
- Patient education is also thought to be important.
- Awareness surrounding fibromyalgia has risen in recent years.
- It is difficult to predict the prognosis of fibromyalgia, due to the complex interplay of the social and psychological factors in the pathophysiology and symptomology of this condition.
Further reading & references
- Fibromyalgia Impact Questionnaire; a validated questionnaire looking at the impact of fibromyalgia
- Winfield JB; Fibromyalgia, eMedicine, Feb 2011
- Evidence based recommendations for the management of fibromyalgia syndrome, European League Against Rheumatism (July 2007)
- Chakrabarty S, Zoorob R; Fibromyalgia. Am Fam Physician. 2007 Jul 15;76(2):247-54.
- Hauser W, Bernardy K, Uceyler N, et al; Treatment of fibromyalgia syndrome with antidepressants: a meta-analysis. JAMA. 2009 Jan 14;301(2):198-209.
- Wolfe F, Ross K, Anderson J, et al; The prevalence and characteristics of fibromyalgia in the general population. Arthritis Rheum. 1995 Jan;38(1):19-28.
- Henriksson KG; Fibromyalgia--from syndrome to disease. Overview of pathogenetic mechanisms. J Rehabil Med. 2003 May;(41 Suppl):89-94.
- Desmeules JA, Cedraschi C, Rapiti E, et al; Neurophysiologic evidence for a central sensitization in patients with fibromyalgia. Arthritis Rheum. 2003 May;48(5):1420-9.
- Staud R, Cannon RC, Mauderli AP, et al; Temporal summation of pain from mechanical stimulation of muscle tissue in normal controls and subjects with fibromyalgia syndrome. Pain. 2003 Mar;102(1-2):87-95.
- Kosek E, Ekholm J, Hansson P; Sensory dysfunction in fibromyalgia patients with implications for pathogenic mechanisms. Pain. 1996 Dec;68(2-3):375-83.
- McBeth J, Macfarlane GJ, Benjamin S, et al; Features of somatization predict the onset of chronic widespread pain: results of a large population-based study. Arthritis Rheum. 2001 Apr;44(4):940-6.
- Geisser ME, Casey KL, Brucksch CB, et al; Perception of noxious and innocuous heat stimulation among healthy women and women with fibromyalgia: association with mood, somatic focus, and catastrophizing. Pain. 2003 Apr;102(3):243-50.
- Neumann L, Buskila D; Epidemiology of fibromyalgia. Curr Pain Headache Rep. 2003 Oct;7(5):362-8.
- Buskila D, Sarzi-Puttini P; Biology and therapy of fibromyalgia. Genetic aspects of fibromyalgia syndrome. Arthritis Res Ther. 2006;8(5):218.
- Bigatti SM, Hernandez AM, Cronan TA, et al; Sleep disturbances in fibromyalgia syndrome: relationship to pain and depression. Arthritis Rheum. 2008 Jul 15;59(7):961-7.
- Burckhardt CS, Clark SR, Bennett RM; The fibromyalgia impact questionnaire: development and validation. J Rheumatol. 1991 May;18(5):728-33.
- Hauser W, Bernardy K, Arnold B, et al; Efficacy of multicomponent treatment in fibromyalgia syndrome: a meta-analysis of Arthritis Rheum. 2009 Feb 15;61(2):216-24.
- Evcik D, Kizilay B, Gokcen E; The effects of balneotherapy on fibromyalgia patients. Rheumatol Int. 2002 Jun;22(2):56-9. Epub 2002 Mar 29.
- McVeigh JG, McGaughey H, Hall M, et al; The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: a systematic review. Rheumatol Int. 2008 Aug 27.
- Brosseau L, Wells GA, Tugwell P, et al; Ottawa Panel evidence-based clinical practice guidelines for aerobic fitness exercises in the management of fibromyalgia: part 1. Phys Ther. 2008 Jul;88(7):857-71. Epub 2008 May 22.
- Brosseau L, Wells GA, Tugwell P, et al; Ottawa Panel evidence-based clinical practice guidelines for strengthening exercises in the management of fibromyalgia: part 2. Phys Ther. 2008 Jul;88(7):873-86. Epub 2008 May 22.
- Busch AJ, Barber KA, Overend TJ, et al; Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003786.
- Bennett R, Nelson D; Cognitive behavioral therapy for fibromyalgia. Nat Clin Pract Rheumatol. 2006 Aug;2(8):416-24.
- Senay EC, Adams EH, Geller A, et al; Physical dependence on Ultram (tramadol hydrochloride): both opioid-like and atypical withdrawal symptoms occur. Drug Alcohol Depend. 2003 Apr 1;69(3):233-41.
- Uceyler N, Hauser W, Sommer C; A systematic review on the effectiveness of treatment with antidepressants in fibromyalgia syndrome. Arthritis Rheum. 2008 Sep 15;59(9):1279-98.
- Mayhew E, Ernst E; Acupuncture for fibromyalgia--a systematic review of randomized clinical trials. Rheumatology (Oxford). 2007 May;46(5):801-4. Epub 2006 Dec 19.
- Rooks DS, Gautam S, Romeling M, et al; Group exercise, education, and combination self-management in women with fibromyalgia: a randomized trial. Arch Intern Med. 2007 Nov 12;167(20):2192-200.
|Original Author: Dr Michelle Wright||Current Version: Dr Richard Draper|
|Last Checked: 20/04/2011||Document ID: 2149 Version: 23||© EMIS|
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