Fibromyalgia (Fibrositis)

Fibrositis, fibromyalgia syndrome, FM, FMS

The term fibromyalgia is preferred to fibrositis that was coined by Gowers in 1904 as the latter infers an inflammatory condition. History and examination tends to be rather variable and only recently have strict diagnostic criteria been established. There is no characteristic laboratory test or x-ray and even histology from specimens taken by biopsy or postmortem fails to show any distinctive lesion. It is also associated with a wide range of other conditions that may co-exist. All this means that over the years it has often been rejected as non-existent or the symptoms have been attributed to a psychiatric disorder, hysteria or malingering. The previous lack of clear diagnostic criteria has also hampered research. All this should now be changed with firm diagnostic criteria and recognition by the WHO that it is a real entity.

Some abnormalities of carbohydrate metabolism have been noted¹ as well as a level of substance P in the CSF that is about 3 times normal² and these findings have been confirmed by subsequent investigators. Nevertheless, the condition is described as being of unknown aetiology.³

Lack of widespread recognition makes it difficult to assess frequency with confidence. Figures from experts may be unduly high as they see an abnormal population. It is estimated that it may affect between 0.5 and 5% of the general population.⁴

• Symptoms usually arise between the ages of 25 and 55 but it can occur in children, most often presenting between 13 and 15.
• In adults it is 7 times more common in women. In children it is also more common in girls but the preponderance may be less marked.
• There is a tendency for it to cluster in families but that does not necessarily imply a genetic basis.⁵

A thorough and detailed history is required. The diagnosis may well have been missed in the past and the patient may even have had inappropriate surgery. Indeed, the average patient has been complaining of symptoms for 5 years and seen several doctors before the diagnosis is made. The pain may be at a single point, flitting or there may be complaints of pain all over. It is very easy to dismiss such complaints as purely functional.

• Identify the main complaint but note the spectrum of complaints. There may be a change in symptoms from day to day, which does not reflect the global nature of the disease.
• Ask further about the pain. Ask about the distribution of the pain including if it is regional or more general. Ask about the duration and onset of the pain. Was it sudden or gradual in onset? Note aggravating and relieving factors. Note other characteristics such as whether the pain is migratory, burning, tender, sore, aching, sharp or radiates.
• Ask about sleep. Does it take a long time to fall asleep and is there waking in the night? If there is snoring or kicking in the sleep this may be answered by a companion. Patients often awake feeling unrefreshed in the morning. They may not volunteer a history of disturbed sleep and it is necessary to make specific enquiry. Sleep is unrefreshing in 65% with morning fatigue in 80%. Fatigue is often worse in the early morning and early evening. It is best late morning and aggravated by poor sleep and exercise.
• Some suggest questions about diet, especially caffeine and carbohydrate intake and exercise.
• Note medications and other existing conditions.
• There may be complaints of swelling or numbness of the extremities, especially the arms but there is no objective neurological loss.

Important diagnostic features about the pain are:

• It is widespread
• It is on both right and left sides of the body
• It is both above and below the waist
• It is along the axial skeleton
• There is always pain
• It has been present for at least 3 months

History and examination are important not just to confirm the diagnosis but to consider other possibilities too. The patient may look fatigued and agitated but not unwell. Beware of an aura of neurosis. Having chronic pain that is undiagnosed despite having seen a number of doctors, many of whom may have been rather dismissive, may result in neurosis rather than being caused by it.

Before 1990 there were no clear guidelines for diagnosis but the work of the American College of Rheumatology in 1990⁶ was updated in 1992 by the Second World Congress on Myofascial Pain and Fibromyalgia which expanded and refined the diagnostic criteria. The presence of other clinical disorders does not exclude a diagnosis of fibromyalgia too. There are 2 basic components:

• There is pain in all 4 quadrants of the body, as well as in the axial skeleton on an almost continuous basis for at least 3 months. The pain is often described as widespread or global.
• There are at least 11 of 18 specific anatomical tender points. A tender point hurts only at the area where very firm pressure is applied, and pain is not referred. The pressure is 4kg, i.e. enough to cause the examiner's nail bed to blanch. An instrument called a dolorimeter can be used to apply exactly 4 kg of pressure over the tender points for the examination.
• The are 18 possible tender points. On the picture, 3 appear to be in the midline but they are really pairs of points just lateral to the midline. The link to the Doctor's Medical Pack from the Fibromyalgia Association UK gives an alternative picture.
• Tender points may be found in any palpable muscle but there are 15 sites that have been found to be present consistently in patients with fibromyalgia and are used for the diagnosis.
• The pressure should elicit pain and not just tenderness.

• On the anterior surface
  • Anterior aspects from the 5th to the 7th intertransverse spaces of the cervical spine
  • In the pectoral muscle at the 2nd costochondral junction
  • About 2cm below the lateral epicondyle
  • Medial fat pad of knee just proximal to the joint line
• On the posterior surface
  • The base of the cranium at the insertion of the nuchal muscles
  • The upper border of the shoulder in the trapezius muscle midway from the neck to the shoulder joint
  • Muscle attachment to upper medial border of scapula at the origin of the supraspinatus
  • The upper outer quadrant of the gluteus medius
  • Just posterior to the prominence of the greater trochanter at the piriformis insertion

It has also been suggested that points to test may include the forehead, distal middle third of the right forearm and the nail of the left thumb. These are not usually tender in fibromyalgia but are used as control points to test the patient's response.

Children tend to experience fewer tender points but more sleep disturbance than adults.

Red Flags

Red flags suggesting other disease include:

• Involvement of joints
• Malaise, especially with weight loss
• Evidence of thyroid disease
• Note sinister causes of back pain

Investigations are helpful only to confirm or exclude other diagnoses. They should include FBC, ESR, LFTs, hepatitis C antibody, calcium and TFTs.³

There are a number of other conditions that frequently coexist with fibromyalgia or can be part of the syndrome but suggest an alternative diagnosis. This multiple symptomatology may increase the risk of being labelled as psychosomatic.

• The sleep disturbance is reminiscent of depression and there may be enough features for diagnosis
• Pain in the neck or lower spine may suggest cervical spondylosis or lumbar back pain
• About 20% also have restless legs syndrome
• Approximately 40% of patients with fibromyalgia describe alternating diarrhoea and constipation, bloating, cramping, and an increased urge to defecate as in irritable bowel syndrome
• Urinary symptoms that include urgency, frequency, and a sense of incomplete voiding
• Pelvic pain and dysmenorrhoea may be present
• Chest pain, shortness of breath, and palpitations are common and may be due to mitral valve prolapse
• There is also considerable clinical overlap with chronic fatigue syndrome or CFS, previously called ME (myalgic encephalitis).⁷

This list is by no means exhaustive

There is no cure but the patient will be much reassured to know that a firm diagnosis has been made and that she is not being dismissed as neurotic.

Whilst not offering cure, management should offer benefit.

Non-drug

• Rehabilitation and physiotherapy must be carefully monitored as it can aggravate the situation. It may need modification as goals are met and symptoms change. Daily aerobic exercise of at least 3 times a week and flexibility training can be most useful. The goal is to exercise safely and without increased pain. The target is to exercise 4 or 5 times a week for at least 20 to 30 minutes, but it may take months to achieve. Some never achieve this. Some gain more benefit from aquatic training. Much of the aim of exercise is to reverse the process of deconditioning as a result of the disease. A Cochrane review⁸ concluded that supervised aerobic exercise training has beneficial effects on physical capacity and symptoms. Strength training may also have benefits on some symptoms. Further studies on muscle strengthening and flexibility are needed. Even if pain is no better, mood is improved.⁹ Exercise can reduce the consumption of medication.¹⁰
• Cognitive behavioural therapy, relaxation training, group therapy, biofeedback, and stress management are some of the most useful options but more research is needed.¹¹
• Some people advise a gradual reduction in caffeine intake. Sudden reduction may cause headache. Some advocate avoidance of alcohol for a few months and avoidance of foods that give fast absorption of glucose. Vitamin, mineral and other supplements may help. There is some evidence of biochemical abnormalities that suggest a problem with glycolysis¹ but dietary manipulation has not been subjected to rigorous testing.

Drugs and Physical Interventions

• Trigger point injection causes mechanical disruption of the trigger point. It leads to less pain and more mobility and exercise tolerance. Dry needling also seems beneficial. Long-term outcomes are best when trigger point injections are used in conjunction with physical therapy, massage therapy, or home stretching exercises. 1% lignocaine is usually used, without adrenaline and without steroid. A large area is often injected, needing 2 to 10ml or more of injection. Injection of trigger points is beneficial but patients should be warned that benefit is delayed and there may be significant pain after injection.¹²
• Patients with fibromyalgia tend to be very sensitive to medication and so the lower range of dose is usually indicated. Steroids do not help. Relatively few interventions, including pharmacological ones, have been rigorously tested in RCTs, but pharmacological therapies have been reviewed.¹³
• Both sleep and depression are best treated with antidepressants to avoid long term use of benzodiazepines. Tricyclics antidepressants (TCAs) are advised over SSRIs and may be better at helping sleep but a change to a SSRI may be useful if the TCA is inadequate.
• Pain should be treated with NSAIDs or COX-2 inhibitors. Avoid opiates. Muscle relaxants such as carisoprodol may be beneficial and if there are spasms, baclofen may help. Analgesia may be augmented by TCAs.
• Tiagabine and gabapentin may also help both sleep and pain, possibly augmenting another analgesic.
• Manipulation, massage and acupuncture may possibly be of value but tend to be poorly researched.
• Herbal remedies should be treated with caution as they do have pharmacological actions but they have not received the level of investigation required of the pharmaceutical industry and potency may be variable.

Young People

Fibromyalgia can affect children and adolescents. They need to have a programme of graded exercise as with older people and to work to realistic goals. It is important to be reassuring that this is not a crippling degenerative disorder. CBT can be useful.¹⁴ It is probably better to rely less on drugs in young people and be especially wary about the use of SSRIs.

• Fibromyalgia is not a life-threatening, deforming, or progressive disease. The symptoms are variable.
• Without diagnosis and treatment, the disease may appear to progress due to sleep deprivation and physical deconditioning.
• Active management should improve function.
• The prognosis in children may be more favourable than in adults.¹⁵

The reader cannot fail to be impressed at how many aspects of this disease can lead the patient to be dismissed as purely neurotic. The disease is real but it requires a most meticulous and conscientious doctor to diagnose and to treat it.

Fibromyalgia has a Latin etymology from Fibro meaning fibrous tissue, my from muscles, al means pain, and gia is condition of.

The condition was described in the medical literature of the early 17th century but it is only in recent years that it has gained recognition.