Fibromyalgia

Question 1

What is Fibromyalgia?

Answer 1

A syndrome of chronic, widespread musculoskeletal pain & tenderness
“Centralised Pain Syndrome” or
“Central Sensitivity Syndrome”

Question 2

What is the epidemiology of Fibromyalgia?

Answer 2

2-8% of the population
F:M = 7-9:1
most commonly diagnosed between 20 - 50

Question 3

What are the clinical features?

Answer 3

> 3 months of chronic, widespread body pains
other central sensitivity symptoms:
• Fatigue
• Stiffness
• Unrefreshing sleep
-  disruption of stage 4 nREM sleep
• Cognitive disturbances
-  memory & attention impairment
• Emotional distress
• Paraesthesiae / dysaesthesiae 
Autonomic dysfunction

Question 4

What conditions are associated with Fibromyalgia?

Answer 4

• Depression
• Anxiety
• Headache
• Irritable bowel
• Irritable bladder
• Interstitial cystitis
• TMJ disorder
• Chronic sinus pain
• Multiple chemical sensitivities
• Pelvic pain
• Vulvodynia
• Restless legs syndrome

Question 5

What are the diagnostic criteria according to the ACR 2010/2011?

Answer 5

Chronic widespread musculoskeletal pain
– Measured by the Widespread Pain Index (WPI)
• Central Sensitivity Symptoms
– Measured by the Symptom Severity Score (SSS)

• note that the 11/18 tender points is no longer included

Question 6

What is the pathophysiology behind fibromyalgia?

Answer 6

dysfunction of the normal descending inhibitory tone due to central 5HT and NA dysfunction

• this normally dampens down nociception so that not all sensations are perceived as painful
• this results in allodynia (perception of non-panful sensations as pain)
• pain pathway signals are influenced by emotional and cognitive centres

- results in amplified sensations causing:
• Pain
• Dysaesthesia / paraesthesia
• Tinnitus
• Bowel and bladder sensations • Dizziness & palpitations
• Noise / light / odours
• Sensitivities to chemicals
• Side effects with drugs

there is evidence of HPA axis dysfunction

• hyper secretion of ACTH with poor cortisol response to stress
• reduced levels of IGF-1, fT3,GH, oestrogen & urinary cortisol

Question 7

What other conditions is fibromyalgia seen in?

Answer 7

RA - 40%
SLE - 22%
30-40% with autoimmune thyroid disease
18% with T2DM

Question 8

Non-pharmacological management of fibromyalgia

Answer 8

Education: not a dangerous or degenerative disease
- explanation of disease

Exercise - graded, aerobic exercise
CBT - best with tailored programme
- helps patients to manage their pain and develop coping strategies
Massage
Tai-chi
Acupuncture
Stress and relationship management

Question 9

Pharmacological management?

Answer 9

start low, go slow
at best may achieve partial response

Simple analgesia
Serotonin and NA modulators
- SSRIs, SNRIs, TCAs
- Tramadol 
Membrane stabilisers
- Gabapentin, pregabalin