Fibromyalgia and chronic fatigue syndrome Flashcards
What is the prevalence/gender bias of fibromyalgia?
Prevalence: 0.5-4% (comprises up to 10% of new referrals to rheumatology clinics)
10:1 female:male
What are the risk factors for fibromyalgia?
- Yellow flags
- Femal sex
- Middle age
- Low household income
- Divorced
- Low socioeconomic status
What is meant by a yellow flag?
Psychosocial risk factors for developing persistent chronic pain and long-term disability
What are the yellow flags for developing persistent chronic pain and long-term disability?
- Belief that pain and activity are harmful
- Sickness behaviours such as extended rest
- Social withdrawal
- Emotional problems such as low mood, anxiety or stress
- Problems or dissatisfaction at work
- Problems with claims for compensation or time off work
- Overprotective family or lack of support
- Inappropriate expectations of treatment e.g. low active participation in treatment
What other disorders are associated with fibromyalgia?
Other somatic syndromes:
- Chronic fatigue syndrome
- Irritable bowel syndrome
- Chronic headaches syndrome
Also found in around 25% of patients with RA, AS and SLE
What are the two key features of fibromyalgia?
Allodynia: pain in response to a non-painful stimulus
Hyperaesthesia: exaggerated perception of pain in response to a mildly painful stimulus
How is fibromyalgia diagosed?
- Pain must be chronic (>3 months)
- Pain must be widespread (involving left and right sides, above and below the waist, and the axial skeleton)
- Inflammation must be absent
- There should be pain on palpation of at least 11 out of the 18 ‘tender points’
- Ix are all normal. Other causes of pain and chronic fatigue should be excluded by Ix e.g. RA, PMR, hypothyroidism)
What additional, non-diagnostic, features may also be seen in patients with fibromyalgia?
- Morning stiffness (80-90%)
- Fatigue, often severe (80-90%)
- Poor concentration
- Low mood
- Sleep disturbance (around 70%)
Describe the non-pharmacological management of fibromyalgia
- Education of the patient and their family on developing coping strategies
- N.B. diagnosis of fibromyalgia may be a relief or a disappointment to the patient
- Explain that fibromyalgia is a relapsing remitting condition with no easy cure and that they will continue to have good and bad days
- Reassure them that there is no serious underlying pathology, that their joints are not damaged and that no further tests are necessary, but be sympathetic to the fact that they may have been seeking a physical cause for their symptoms
- Discuss psychosocial issues (yellow flags)
- CBT: helps patient develop coping strategies and set achievable goals e.g. pacing of activity to avoid over-exertion and consequent pain and fatigue
- Long term graded exercise program can improve functional capacity
What pharmacological treatments are available for fibromyalgia?
- Amitriptyline (tricyclic antidepressant) at low dose is first line pharmacological treatment
- Amitriptyline can improve pain (esp combined with tramadol), sleep disturbance and morning stiffness, but effects may not be apparent for up to a month
- High-dose SNRIs e.g. venlafaxine may also be effective
- SSRIs appear to be less useful
N.B. NSAIDs and steroids are of no use in treating fibromyalgia as there is no inflammation. If there is a response to these drugs, consider a different diagnosis
What is the definition of chronic fatigue syndrome?
Persistent, disabling fatigue lasting >6 months, affecting mental and physical function, present >50% of the time + ≥4 of the list of main symptoms
What are the main symptoms of chronic fatigue syndrome, 4 or more of which are diagnostic?
- Myalgia (approx 80%)
- Polyarthralgia
- Reduced memory
- Unrefreshing sleep
- Fatigue after exercise lasting >24 hours
- Persistent sore throat
- Tender cervical/axillary lymph nodes
How is chronic fatigue syndrome managed?
- Principles are similar to fibromyalgia
- CBT and graded exercise are important
- No pharmacological agents have yet been proved effecting for chronic fatigue syndrome
