Fibromyalgia

Question 1

Define the term Rheumatic disease

Answer 1

A variety of disorders marked by inflammation, degeneration, or metabolic derangement of connective tissue structures of the body especially joints and related structures

Question 2

List the characteristic clinical manifestations of rheumatic conditions

Answer 2

• Pain
• Stiffness
• Limited ROM

Question 3

Define the term Fibromyalgia

Answer 3

Fibromyalgia is a non-articular rheumatologic condition characterised by spontaneous, wide spread soft tissue pain, sleep disturbance, fatigue and extensively distributed areas of tenderness.
Characterised by achy pain, tenderness and stiffness of mm, tendon insertions and adjacent soft tissues

Question 4

Discuss the prevalence of fibromyalgia

Answer 4

≈5% of all GP patients
2-4% of the general population i.e. 3.4% of ♀ and 0.5% of ♂
≈15-20% of Rheumatology, Physical medicine & Rehab patients!
FM is 2nd only toOA as the most common dx in patients seen by rheumatologists

FM most commonly affects:
Women (4-7 times more common in ♀)
25-40 year age group

Question 5

List the main clinical manifestations of fibromyalgia

Name the areas of the body most commonly affected

Answer 5

Rheumatic ssx
Characterised by achy pain, tenderness and stiffness of mm, tendon insertions and adjacent soft tissues

Common areas affected:
- Occiput, Neck, Shoulders, Thorax, Lower back, Thighs

Question 6

Write brief notes on tender spots

Answer 6

Often FM pain and tenderness occurs
in areas called “tender spots/points”
Tender spots are usually found in the same place on repeated examination
Actual nodules may be palpated in the tender spots

NB: nodules (non-tender) are usually found in normal subjects as well
+ there are tender spot maps (check ppt)

Question 7

Which factors are known to exacerbate FM?

What can alleviate ssx?

Answer 7

• more frequent & prominent in the
  morning or evening
• worse for changes in the weather
• aching is increased by inactivity
• pain is aggravated by straining and overuse
• worse for stress
• worse for insensitive treatment by health practitioners

Light/moderate PA can relieve symptoms of FM

Question 8

list 4 non-rheumatic/non articular ssx of FM

Answer 8

• Headaches, Insomnia, Exhaustion/Fatigue, Anxiety/Depression, Irritable Bowel

% of ssx
Muscular Pain 100%
Fatigue 96%
Insomnia 86%
Joint Pains 72%
Headaches 60%
Restless Legs 56%
Numbness and Tingling 52%
Impaired Memory 46%

Question 9

Which female personality type is characteristic of FM?

Answer 9

• Healthy young female
• Self-driven, striving
• Intense
• Anxious
• Compulsive
• Fervently involved in numerous activities
• Tense
• Very sensitive and responsive to external stimuli such as: cold, heat, humidity, noise
• ± a degree of depression

Question 10

Discuss the diagnosis of FM

Answer 10

It is typical for FM patients to see many doctors for over 5 years before being correctly diagnosed
>50% of patients are misdiagnosed and undergo unnecessary treatments including surgery
FM is diagnosed by considering all the patient’s relevant symptoms
The diagnosis is no longer based just on the number of tender points a patient has

Two diagnostic criteria must be met for a diagnosis of FM to be made
- The necessary information is collated via:
- Typical Hx
- Physical Examination
- Lab tests & procedures (include: bloods, metabolic panel, urinalysis, TSH, Vit D, B12, iron studies, ESR)

Widespread pain index (WPI) >7
and
Symptom severity scale (SS) >5
OR
WPI between 3-6 and SS >9

WPI: the practitioner notes the number of areas in which the patient has had pain over the last week (score between 0-19)
The 19 regions include:
- shoulder girdle L or R
- upper arm L or R
- Hip (buttock trochanter) L/R
- abdomen 
- jaw R/L
- chest 
- upper back 
- lower back 
- neck etc

The SS scale score is the sum of the
severity of the following 3 symptoms:
•fatigue
•waking unrefreshed •cognitive symptoms
PLUS, the extent (severity) of:
The somatic symptoms in general The final score is between 0-12
SS Scale scoring for fatigue, waking
unrefreshed & cognitive symptoms:
0 = no problem
1 = slight or mild problems, generally mild or intermittent
2 = moderate, considerable problems, often present and/or at a moderate level
3 = severe: pervasive, continuous, life- disturbing problems

typical somatic ssx
 muscle pain
• muscle weakness
• constipation
• diarrhea
• upper abdominal
• rash
• sun sensitivity
• itching
• hives/welts
• Raynaud's
phenomenon
• easy bruising
• hair loss
• dry mouth
• oral ulcers
• loss of/change in
taste
• chest pain
• wheezing
• shortness of breath
• headache pain
• numbness/tingling
• dizziness
• seizures
• insomnia
• thinking or memory problem
• depression
• nervousness
• fever
• fatigue/tiredness
• frequent urination
• painful urination
• bladder spasms
• heartburn • abdominal
pain/cramps
• irritable bowel
syndrome
• nausea
• vomiting
etc. 
SS Scale scoring for somatic
symptoms in general:
0 = no symptoms
1 = few symptoms
2 = a moderate number of symptoms 3 = a great deal of symptoms

criterion 2 symptoms have to been present at a similar level for at least 3 months 

criterion 3
the patient does not have a disorder that would otherwise explain the pain

eg on ppt of score sheet

The following are important Red Flags:
• Older age at new symptom onset 
• Weight loss
• Night pain
• Focal pain
• Fever or sweats
• Neurological features • History of malignancy

Question 11

Discuss the Prognosis of FM

Answer 11

FM is not life-threatening,
deforming, or progressive
• The ssx are variable
• Without proper dx & tx, the patient may have the illusion of disease progression because of sleep deprivation and physical deconditioning
≈1/3 of px’s need to modify
their work to keep their jobs eg
•shortened workdays
• shortened workweeks
•change to jobs that are less physically and mentally taxing
•inability to advance in careers or education leading to ↓ed income & ↑ed financial burdens
•a significant -ve impact on the quality of social functions
•>15% of FM sufferers receive disability benefits