Fibromyalgia / Chronic persistent pain (CWP)

Question 1

Define fibromyalgia.

Answer 1

Widespread musculoskeletal pain AFTER other diseases have been excluded.
Is also known as chronic persistent pain (CWP).
Fibro = soft tissue & myalgia = muscle pain.

Question 2

What is the diagnostic criteria for fibromyalgia?

Answer 2

1. Chronic widespread pain lasting for >3 months with other causes excluded.
2. Pain at 11 of 18 tender point sites on digital palpation (with enough pressure, so that the thumb blanches)

Question 3

How long must symptoms have lasted for to diagnose a patient with fibromyalgia?

Answer 3

Over 3 months

Question 4

Give 5 symptoms of fibromyalgia.

Answer 4

1. Neck and back pain.
2. Pain is aggravated by stress, cold and activity.
3. Generalised morning stiffness.
4. Subjective swelling of extremities.
5. Frequent waking during the night.
6. Waking unrefreshed.
7. Low mood, irritable, weepy.
8. Headache and IBS common.

Question 5

Give 5 triggers of fibromyalgia.

Answer 5

1. Physical trauma.
2. Distress.
3. Hormonal alterations e.g. hypothyroid.
4. Infections.
5. Certain catastrophic events e.g. wars.

Question 6

Give 3 factors that increase the volume of pain.

Answer 6

1. Substance P (high levels).
2. Glutamate.
3. Serotonin (low levels).

Question 7

Give 3 factors that decrease the volume of pain.

Answer 7

1. Opioids.
2. GABA.
3. Cannabanoids.

Question 8

What is the pain like in fibromyalgia? What pattern of joints are affected?

Answer 8

Widespread
Symmetrical
Above and below the waist
Morning stiffness

Question 9

Give 4 areas where the pain might focus on.

Answer 9

Areas that pain focuses on:
1. Lower neck in front
2. Base of the skull
3. Upper edge of breast
4. Neck and shoulder
5. Upper inner shoulder
6. Below side bone at allow
7. Upper outer buttock
8. Hip bone
9. Just above knee on inside

Question 10

Name 4 diseases that fibromyalgia is commonly associated with.

Answer 10

1. Depression.
2. Chronic fatigue.
3. Chronic headache.
4. IBS.
5. Myofascial pain syndrome.

Question 11

What method is used in the investigation of a patient to dianose fibromyalgia?

Answer 11

Diagnosis of exclusion.

Question 12

What tests would you do to exclude other causes to diagnose fibromyalgia?

Answer 12

1. TFTs (to exclude hypothyroidism)
2. ANAs + DsDNA (to exclude SLE)
3. ESR & CRP (to exclude PMR)
4. Ca2+ and electrolytes (to exclude high calcium)
5. Vit D (to exclude low vitamin D)
6. Examine patient and CRP (to exclude inflammatory arthritis)

Question 13

Investigation: what must be observed in terms of the pain to diagnose fibromyalgia?

Answer 13

Pain at 11 of 18 tender point sites on digital palpation

Question 14

Describe the management for fibromyalgia.

Answer 14

1. Educate the patient and family.
2. ‘Reset the pain thermostat’.
3. Low-dose antidepressants and anticonvulsants
   - Induce muscle relaxation & make normal sleeping patterns
   - Low dose amitriptyline can help with sleep.
4. Graded aerobic exercise.
5. Acupuncture.

Question 15

Management of fibromyalgia: describe the ‘reset the pain thermostat’ method.

Answer 15

Reset pain thermostat:
* Correct non-restorative sleep
* Improve aerobic fitness - to tire them so sleeping will be easier

Question 16

What 2 things are essential in the management of fibromyalgia?

Answer 16

1. Explaining that sleep disturbance is central to what they’re feeling.
2. Emphasising the importance of exercise and fitness.

Question 17

What medications have been shown to NOT work in managing fibromyalgia?

Answer 17

Steroids or NSAIDs:
- rarely work in fibromyalgia

Question 18

Give 3 diseases might be included in the differential diagnosis for fibromyalgia.

Answer 18

1. Hypothyroidism.
2. SLE.
3. Low vitamin D.
4. Polymyalgia rheumatica (PMR)
5. High calcium
6. Inflammatory arthritis

Question 19

How can you differentiate between polymyalgia rheumatica (PMR) and fibromyalgia?

Answer 19

PMR will show raised inflammatory markers.