Fibromyalgia

Question 1

What is fibromyalgia

Answer 1

Fibromyalgia is a chronic pain syndrome characterised by the presence of widespread body pain.

Question 2

Epidemiology

Answer 2

• 0.5-4% prevalence
• F>M
• Affects people mainly in middle age

Question 3

RFs

Answer 3

• Female sex
• Middle age
• Genetic association
• Environmental e.g. child abuse, low household income, divorced, low educational status, emotional problems, social withdrawal

Question 4

Pathophysiology

Answer 4

Mechanism not well understood - there seems to be a problem with how the brain receives pain signals.

individuals have low levels of serotonin, which is involved in inhibiting pain signals, and elevated levels of substance P, and nerve growth factor, which are involved in propagating pain signals.

thought to play a role in the hypersensitivity to pain, which hints that fibromyalgiamight be a condition of central sensitization. In other words, they would perceive more pain compared to other people

Question 5

What can central sensitisation mean

Answer 5

Nervous system becomes more responsive to pain stimuli or even non painful stimuli

Question 6

Key presentations

Answer 6

• Allodynia - pain in response to non-painful stimulus
• Hyperaesthesia - exaggerated perception of pain to mildly painful stimulus

Question 7

Symptoms

Answer 7

• Widespread pain
  
  • Aggravated by stress, cold and activity
• Extreme tenderness
• Sleep disturbance
• Fatigue - extreme and present after minimal exertion
• Fibro fog
• ## Paraesthesiae - abnormal sensation in skin

Question 8

Investigations

Answer 8

Investigations are all normal!

Diagnosis of fibromyalgiais based on clinical features:

Question 9

Clinical features

Answer 9

• Chronic pain that has been present for at least 3 months
• Widespread pain - involved left and right sides, above and below waist, and the axial skeleton.
• Palpate tender point sites - severe pain in 3 to 6 different areas of your body, or you have milder pain in 7 or more different areas
• No other reason for symptoms has been found

Question 10

Investigations to exclude other conditions

Answer 10

• Thyroid function test (to exclude hypothyroidism)
• ANA’s and DsDNA (to exclude SLE)
• ESR & CRP (to exclude PMR)
• Ca2+ and electrolytes (to exclude high calcium)
• Vit D (to exclude low vitamin D)
• Examine patient and CRP (to exclude inflammatory arthritis)

Question 11

Differential? diagnoses

Answer 11

• Rheumatoid arthritis
• Chronic fatigue syndrome
• Hypothyroidism
• SLE
• Polymyalgia rheumatica (PMR)
• High calcium
• Low vitamin D
• Inflammatory arthritis

Question 12

Non pharmacological treatment

Answer 12

• Regular exercise like cardiovascular fitness training which includes fast walking, biking, swimming, or water aerobics can help by reducing pain and fatigue. Grading of exercise is important to avoid over-exertion and fatigue.
• Relaxation techniques and good sleep hygiene can also help.
• Physiotherapy and rehabilitation
• CBT

Question 13

Pharmacological treatment

Answer 13

• Amitriptyline - tricyclic antidepressant
• Serotonin-norepinephrinereuptake inhibitors (SNRIs) e.g. duloxetine

Help by elevating serotonin and norepinephrine levels.

• Anticonvulsants like pregabalin and gabapentinwhich slow nerve impulses can help with sleep problems.

Question 14

Prognosis

Answer 14

• With good adherence to exercise, sleep, and behavioural therapy, most patients will improve over time.The goal of treatment is to decrease physical and mental symptoms and to increase functioning, not to cure.