Fibromyalgia (Fibrositis)

Synonyms: fibromyalgia (FM), fibrositis, fibromyalgia syndrome (FMS)

Fibromyalgia is a chronic pain syndrome. 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)¹ and allodynia (pain with stimuli that should not normally cause pain).¹ 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.²

• It is thought that the condition is common and underdiagnosed.³
• Women are 10 times more commonly affected than men.⁴
• Usual age of presentation is 20-50 years but has been diagnosed in children, adolescents and older people.³
• There is a link to failing to complete education, low income, female sex and being divorced.³

• The exact pathophysiology is not known. Hypotheses include:
  • Peripheral and central hyperexcitability at spinal or brainstem level^5,6,7
  • Altered pain perception⁸
  • Somatisation^9,10
• The nociceptive system has links with the stress regulating, immune and sleep systems which may explain some of the clinical features.²
• Genetic and environmental factors may play a role in fibromyalgia as it is more common in the relatives of affected patients.^11,12

• The patient may complain of:
  • Pain at multiple sites (low back pain with/without radiation to buttocks and legs and pain in neck and across shoulders are common complaints;³ patients may complain of "pain all over".¹)
  • Fatigue
  • Sleep disturbance (sleep may exacerbate symptoms and contribute to depression)¹³
  • Morning stiffness
  • Paraesthesiae
  • Feeling of swollen joints (with no objective swelling)
  • Problems with cognition (e.g. memory disturbance, difficulty word finding)
  • Headaches (may be migrainous)
  • Lightheadedness or dizziness
  • Fluctuations in weight
  • Anxiety and depression
• Symptoms are generally reported as worse in cold, humid weather and under times of stress.³

• This is clinical. The American College of Rheumatology have produced classification criteria for fibromyalgia. However, these criteria are not meant to be used for diagnosis. Features include:³
  • 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 examiners thumbnail (approximately 4kg/cm²¹). In someone without fibromyalgia, this would not be enough pressure to cause pain.³
• Routine blood testing can help to exclude other differential diagnoses: e.g. ESR, thyroid function tests, 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).¹⁴ It also has a role in review and assessment of treatment interventions. The questionnaire can be found using the link below.
• A full social, personal, family and psychological history should be taken. There may be an interplay with stress, psychosocial experiences, psychosocial situation and sociocultural factors.

• Anxiety
• Depression
• Irritable bowel syndrome
• Irritable bladder
• Dysmenorrhoea
• 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 fibromyalgia¹
• Systemic lupus erythematosus (SLE): approximately 50% of patients with SLE also have fibromyalgia¹

• Chronic fatigue syndrome
• Hypothyroidism
• Polymyalgia rheumatica
• Inflammatory and metabolic myopathies
• Polymyositis

The following advice for the management of fibromyalgia are based on the EULAR guidelines.

General points

• 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.

Non-drug treatments

• Balneotherapy (heated pool treatment) has been shown to be an effective treatment.^15,16 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 recommend aerobic fitness and strengthening exercise for the management of fibromyalgia.^17,18
• Cognitive behavioural therapy may help some patients with fibromyalgia.¹⁹ (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 may help some people with fibromyalgia.

Drug treatment

• 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.²⁰
• 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.²¹ Those recommended include:
  • Amitriptyline
  • Fluoxetine
  • Duloxetine
  • Milnacipran
  • Moclobemide
  • Pirlindole
  The evidence is strongest for amitriptyline or other tricyclics.
• Tropisetron, 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.²²
• Patient education is also thought to be important.²³

• 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.