Chronic MSK Pain

Question 1

What is the 1990 classification of fibromyalgia?

Answer 1

Pain for at least 3 months - the upper and lower body, right and left sides, axial skeleton
11/18 tender points

Question 2

What are the 18 tender points ?

Answer 2

1. Suboccipital
2. Lower cervical
3. Trapezius
4. Supraspinatus
5. 2nd rib
6. Lateral epicondyle
7. Gluteal
8. Greater trochanter
9. Knee

Question 3

Characteristic features of fibromyalgia (10)

Answer 3

Fatigue
Sleep disturbance
Stiffness
Paraethesiae
Headaches
Irritable bowel
Cold hands
Depression anxiety
Daytime restless leg

Question 4

Criticism of 1990 criteria

Answer 4

Compromise
No gold standard pathology
No grounded in any clear pathological process
Fibromyalgia may be just one end of the spectrum of chronic pain
Does not take into account related clinical features

Question 5

Evolved fibromyalgia classification (2010/2016)

Answer 5

Tender points abandoned
Defines in terms of -widespread pain index, pain regions (to distinguish from localised pain), symptom severity score
Combined diagnostic and classification criteria
Valid irrespective of other diagnosis

Question 6

What is the widespread pain index?

Answer 6

Numbers of areas in which there is pain
Max 19
For at least 3 months

Question 7

What is the symptom severity score?

Answer 7

In the last week:
Fatigue (0,1,2,3)
Waking unrefreshed (0,1,2,3)
Cognitive symptoms (0,1,2,3)
+
In the last 6 months
Headaches (0,1)
Pain or cramps in abdomen (0,1)
Depression (0,1)

Add up, max 12 points

Question 8

What are the pain regions?

Answer 8

Region 1 - left jaw, left shoulder, left upper arm, left lower arm
Region 2 - right jaw, right shoulder, right upper rm, right lower arm
Region 3 - left hip, left upper leg, left lower leg
Region 4 - right hip, right upper leg, right lower leg
Region 5 - neck, upper back, lower back, chest, abdomen

Question 9

2016 classification of fibromyalgia

Answer 9

WPI >=7 and SSS>=5
Or
WPI=4,5or6 and SSS>=9

4 out of 5 regions
(Not incl jaw, chest, abdomen)

Symptoms for over 3 months

Valid irrespective of other diagnosis

Question 10

What is the pain in fibromyalgia like?

Answer 10

‘It hurts all over’
May have a focus but shifts
Burning, radiating, gnawing
Moderate or severe
Worse than that of RA
Cold damp weather
Exhibit hyperalgesia and allodynia

Question 11

What is hyperalgesia?

Answer 11

Touch them firmly but have severe pain response

Question 12

What is allodynia?

Answer 12

Light touch = pain response

Question 13

What is the fatigue like in fibromyalgia?

Answer 13

Light sleep 8-10 hrs a night
Unrefrehed
Morning stiffness
Fatiguability - mental + physical

Question 14

What is fibromyalgia like on examination?

Answer 14

Tender points only reliable physical finding
No muscle weakness
No synovial inflammation

Question 15

What are results of investigations in fibromyalgia ?

Answer 15

Normal
No inflammatory markers
No metabolic or endocrine abnormalities
Muscle enzymes and EMG normal

Question 16

What diseases overlap with fibromyalgia?

Answer 16

Chronic fatigue
Myofascial pain syndromes (whiplash, writers cramp, telegraphist cramp, repetitive strain)
Irritable bowel syndrome
Migraine
Irritable bladder
Post-traumatic syndrome

Question 17

What diseases is fibromyalgia associated with?

Answer 17

Inflammatory rheumatic diseases (30%)
Inflammatory myosotis and myopathies
Hypothyroidism
Multiple sclerosis
Myasthenia gravis

Question 18

Epidemiology of fibromyalgia

Answer 18

Prevalence - 1-10%
3X more common in women then men
Rises with age, peaks in 60s then declines
Disability levels comparable to RA

Question 19

Causes of fibromyalgia

Answer 19

Infection ? E.g. covid
Association occurring after trauma
Psychiatric history prior to trauma is related
Genetics - HLA associations, cat echo-O-Meryl transferase,
HOWEVER pain behaviours is learned in families
Muscle abnormalities have been detected BUT likely to be 2ary to inactivity or pain
No physiological abnormalities
Sleep abnormalities
Reduced growth hormone, prolactin and 5HT
CNS/autonomic - altered pain threshold, increased heart rate variability, CSF substance P levels increased, brain regional blood flow abnormalities in areas related to pain processing, abnormal temporal summation of pain, all implies state of CNS sensitisation
CONSENSUS - disorder of sensory processing of non-nociceptive input is the most plausible current explanation for condition

Question 20

Management of fibromyalgia

Answer 20

No highly defective therapy
Pt education is cornerstone
Exercise
Nonpharmacological therapies
Tailored pharmacology - avoiding opioids
Multimodal rehabilitation
Shared decision making

Question 21

Prognosis of fibromyalgia

Answer 21

Conflicting
Little change over a decade
Community studies show max 25% remit after 2 years
Better outcome = young age, lower pain score