Fibromyalgia Flashcards
How was fibromyalgia discovered?
Fibromyalgia was discovered by analysing pattern of symptoms over the years
In 1876, Balfour made a connection between which 2 symptoms, which eventually led to discovery of fibromyalgia?
Balfour 1876: Connection between muscular rheumatism and tender points
In the discovery of fibromyalgia, who initially named it fibrositis and what was their reasoning?
William Gowers 1904: definition needed for inflammation of fibrous tissue, so should follow cellulitis analogy and call it fibrositis
What 2 symptoms of fibromyalgia were discovered in 1977, and by which 2 scientists?
Smythe and Moldofsky 1977: multiple tender points and disturbed sleep
What 2 discoveries did Yunnus make in 1981 regarding fibromyalgia?
Yunnus 1981: found that tender point examination is useful and found common comorbidities
What organisation adopted the term ‘fibromyalgia’ and why, and in what year did this happen?
American College of Rheumatology 1990: ‘Fibromyalgia’ term adopted as it has respectability and causes acceptance of the condition
What is the percentage worldwide prevalence of fibromyalgia?
1-10%
Is the incidence of fibromyalgia equal in men and women?
3x more common in women than men
Is prevalence of fibromyalgia equal at all ages?
Prevalence increases with age to maximum in 60s
What is the definition of fibromyalgia?
Widespread musculoskeletal pain for which no alternative cause can be identified, that is accompanied by fatigue, unrefreshing sleep, memory, mood issues
In the ACR classification criteria 1990 for fibromyalgia, what is the duration of the pain and what 4 body areas must the pain occur in, and what must this be combined with?
Pain for minimum 3 months in left, right, upper, lower body combined with 11/18 tender points
What is meant by a tender point?
Small area near joint that is painful when pressed on
Where are the 18 tender points in the fibromyalgia criteria 1990?
9 bilateral tender points, making 18 in total:
Suboccipital (back of neck)
Lower cervical
Trapezius
Supraspinatus
2nd rib (upper chest under clavicle)
Lateral epicondyle
Gluteal muscle
Greater trochanter
infrapatellar fat pad
Give 3 critiques of the America College of Rheumatology Fibromyalgia classification criteria 1990?
No gold standard pathology as it isn’t grounded in any clear pathological process
Doesn’t consider related clinical features
Fibromyalgia doesn’t encompass all chronic pain as tender points present in other conditions
From 2010-2016, give 3 ways in which the fibromyalgia classification criteria has changed from the 1990 criteria?
doesn’t use tender points
combination of physician/diagnostic and classification criteria
valid irrespective of other diseases
What are the 3 requirements that need to be met in order to fulfil the 2016 fibromyalgia classification criteria and confirm the validity of the diagnosis?
Pain in 4 out of 5 regions, not including jaw, chest, abdomen
WPI > 7 and SSS 5 or more, or WPI 4/5/6 and SSS > 9 or more
Symptoms present for at least 3 months
What is the Widespread Pain Index used to calculate in the 2016 fibromyalgia classification criteria?
Numbers of areas which contain pain for minimum 3 months
Maximum 19 areas which are split into 5 regions
What is the Symptom Severity Score used to calculate in the 2016 fibromyalgia classification criteria?
Total score is calculated, maximum is 12 points
Symptoms experienced in last week are individually rated from 0-3: fatigue, cognitive symptoms, waking up unrefreshed
Symptoms experienced in last 6 months are individually rated from 0-1: abdominal pain/cramps, depression, headache
Describe a later modification to the 2016 fibromyalgia classification criteria?
Fibromyalgia scale and questionnaire that will consider psychological, social, cultural, biological aspects
Is there a main site of pain in fibromyalgia?
No, patient says that pain hurts all over, and that pain can have a focus but shifts
What are the 2 ways in which individuals with fibromyalgia describe the character of the pain?
Burning, gnawing pain
Give 7 associated symptoms of fibromyalgia
Hyperalgesia: abnormally heightened sensitivity to pain
Allodynia: pain due to a stimulus that usually doesn’t provoke pain
Mental and physical fatigue
Sleep disturbance, 8-10 hrs light sleep a night
EMS
Unrefreshed after waking
Psychiatric symptoms such as depression, anxiety
What 2 types of weather conditions exacerbate fibromyalgia?
Cold, damp weather
Describe the severity of pain caused by fibromyalgia, and how it compares to pain caused by RA?
Pain is moderate or severe, worse than RA
Give 3 characteristic findings of fibromyalgia upon physical examination?
Tender points
No synovial inflammation
No muscle weakness
In fibromyalgia, what are the results of the lab investigations typically like?
All lab tests are normal
In fibromyalgia, what is the typical result of an electromyography?
Normal electromyography
Is there a proven association between infection and fibromyalgia?
No sero-epidemiological evidence has been found
Why 2 pieces of data suggest that there could be an association between lyme disease and fibromyalgia incidence?
20% individuals with lyme disease had widespread pain after infection
Antibiotics didn’t relieve widespread pain after lyme disease infection, suggesting that the pain is noninflammatory/noninfectious
What percentage of individuals with mononucleosis infection developed widespread pain, that could be fibromyalgia?
20%
Give 3 examples of trauma that fibromyalgia is associated with?
Leg fracture
Neck trauma
Hypermobility
When an individual has developed fibromyalgia caused by trauma occurrence, what part of their history should you make sure to also check?
Psychiatric history prior to the trauma occurrence
Give 2 ways in which genetics can cause fibromyalgia?
Familial clustering, as fibromyalgia tends to run in families
Pain behaviour is learnt from family, which can cause dysfunctional beliefs and mood changes in response to fibromyalgia
Can individuals with fibromyalgia be HLA positive, if so why might this not be linked to fibromyalgia itself?
HLA positive suggests that there is presence of inflammatory disease, which means that patient could have another condition apart from fibromyalgia
What is the association between catechol-O-methyltransferase (COMT) gene mutation and fibromyalgia?
COMT regulates nociceptive processing and inflammation, when a COMT gene mutation occurs this can cause increased pain sensitivity
What is the association between serotonin transporter promotor gene and fibromyalgia?
Serotonin transporter gene polymorphism produces variants
Higher frequency of one variant was found in patients with fibromyalgia, and this group exhibited higher levels of depression and psychological distress
Is muscle abnormality a cause of fibromyalgia?
Intrinsic muscle abnormality detected, but this is secondary cause to inactivity/pain
So muscle abnormality doesn’t directly cause fibromyalgia
How can slow wave distribution in sleep abnormality trigger fibromyalgia?
Slow wave sleep is deep and restorative rest, so produces refreshed feeling upon waking
Alterations in slow wave sleep distribution means that individual will have less restorative rest so will wake up still feeling unrefreshed
What percentage of fibromyalgia cases show EEG non-restorative sleep patterns?
75%
How do EEG results correlate with symptom severity of fibromyalgia?
The more severe the symptoms the more unstable sleep patterns are shown on EEG
Give 2 hormone levels that are increased due to CRH response to stress, which can cause fibromyalgia?
CRH responds to stress by increasing prolactin and stress hormone ACTH
How can increased prolactin levels correlate with fibromyalgia symptoms?
Increased prolactin level correlates with more severe fibromyalgia symptoms
How does 5HT/serotonin level change to cause fibromyalgia, and what 3 symptoms are caused?
Reduced 5HT/serotonin level leads to pain, depression, anxiety
How does growth hormone level change to cause fibromyalgia, and what 4 symptoms are caused?
Reduced growth hormone level leads to impaired cognition, cold intolerance, low energy, reduced exercise capacity
What does physiological testing of tender points in fibromyalgia show?
Detected altered pain threshold, implying CNS sensitisation
How does the level of CSF Substance P change to cause fibromyalgia symptoms?
Elevated CSF Substance P levels, so more SP is released from nociceptors which increases pain sensitivity
How can blood flow in brain regions cause fibromyalgia symptoms?
Brain regional blood flow abnormalities in areas related to pain processing
What is temporal summation of pain, and how can it lead to fibromyalgia symptoms?
Abnormal temporal summation of pain (repeated noxious stimuli at specific frequency overall increases pain sensitivity)
Is fibromyalgia more common in individuals with active psychological illness than without?
Yes, 1.5x more common in individuals with active psychological illness
Does fibromyalgia arise from a specific personality type, and does it cause a specific personality type?
No specific personality type causes fibromylagia, but it causes healthcare seeking behaviour to arise
Is history of abuse associated with fibromyalgia?
Fibromyalgia can arise from psychological/emotional/physical stress, which could be caused by abuse
History of abuse tends to correlate with severity of symptoms
What is the most plausible cause of fibromyalgia?
Disorder of sensory processing of non-nociceptive input
Is a specific treatment available to manage fibromyalgia?
No current highly effective therapy, so clinicians and patients should be willing to try different modalities
What is the most important aspect of managing fibromyalgia?
Patient education
According to the EULAR 2017 recommendations, what is the only strong management option for fibromyalgia?
Exercise
What 4 fibromyalgia management aspects are the EULAR 2017 recommendations based on, and how was it developed amongst clinicians?
pharmacology
multimodal rehabilitation
education
nonpharmacological therapies
Developed by shared decision making
According to the EULAR 2017 recommendations, what 3 factors need to be assessed to make a prompt diagnosis of fibromyalgia?
pain, function, psychological context
According to the EULAR 2017 recommendations, in the multidisciplinary graduated approach to fibromyalgia, what kind of modality is used initially?
Initially non pharmacological and then pharmacological modalities
According to EULAR 2017 recommendations, are non pharmacological or pharmacological modalities stronger for fibromyalgia management?
Non pharmacological modalities are strongest, pharmacological are weakest
According to EULAR 2017 recommendations, give 4 examples of non-pharmacological therapies for fibromyalgia management?
Aerobic, strengthening exercise
Cognitive behavioural therapy
Physiotherapy such as acupuncture
Meditative therapy such as yoga
Give an 2 examples of antidepressant medications that can be prescribed for fibromyalgia management, and describe their drug classes?
Low-dose Amitriptyline: tricyclic
Duloxetine: Serotonin-Noradrenaline Reuptake Inhibitor (SNRI)
What drug classes does tramadol belong to, and how long can it be administered for, in treatment of fibromyalgia?
Tramadol is an opiate analgesic and SRNI that is used for moderate-severe pain relief
Prescribed for short period of time as it can lead to opioid addiction
What is pregabalin used for in fibromyalgia management?
Pregabalin is antiepileptic, anxiolytic (reduces anxiety) medication that is used to manage pain and anxiety symptoms of fibromyalgia
What is cyclobenzaprine used for in fibromyalgia treatment?
Cyclobenzaprine is a muscle relaxant drug that works by acting as a depressant in CNS (blocking nerve impulses sent to brain) and reducing muscle hyperactivity
