Fibromyalgia / hyper mobility

Question 1

Fibromyalgia - history

Answer 1

Generalised musculoskeletal pains

Tired all the time and poor sleep

Fatigue and poor concentration

Associated with facial pain, irritable bowel syndrome, tension headaches

History of stressful life events often dating back to childhood.

Question 2

Fibromyalgia - examination

Answer 2

Tender spots - Multiple on palpation, also typical on anterior trunk

Question 3

Fibromyalgia - investigations

Answer 3

Routine bloods (normal)

Anti-CCP antibodies (negative)

X-rays /other imaging unhelpful except to exclude other diseases.

Question 4

What is fibromyalgia?

Answer 4

7% in women aged over 70

F>M; 10:1

RF

• Life events - (unresolved) psychosocial distress relating to previous abuse, marital disharmony, alcoholism or illness in family, poor sleep health, previous injury/assault, low income
• FHx fibromyalgia
• Rheumatological conditions
• Age – 20-60 years

Pathophysiology
Poorly understood but 2 abnormalities common:
- Disturbed, non-restorative sleep
- Pain sensitisation (probs caused by abnormal central pain processing)

Question 5

Fibromyalgia - clinical features

Answer 5

Chronic pain syndrome – at least 3 months and tenderness in at least 11 of 19 tender points

Widespread pain – often worse in neck and back

• Diffuse and non-responsive to analgesics and NSAIDs
• Physio – often makes pain worse

Fatigue – worse in morning

Memory difficulties, sleep and mood difficulties

Often can dress/feed/wash but unable to perform daily tasks like shopping/house work

Exam: unremarkable – but have hyperalgesia on moderate digital pressure (enough just to whiten nail) over multiple sites

Question 6

Fibromyalgia - investigations

Answer 6

No abnormalities on routine blood tests/imaging – but important to screen for other conditions that may be causing symptoms

• FBC, liver and renal function tests – general disease indicators
• ESR, CRP, serum amyloid A, immunoglobulins – inflammatory disease
• Thyroid function
• Calcium, albumin, phosphate, ALP, PTH, 25-hydroxyvitD, serum ACE – hyperparathyroidism, osteomalacia, sarcoid
• Antinuclear antibodies, ENA, RF, ACCP, Complement C3 and C4, lupus anticoagulant, anti-cardiolipin antibodies, streptococcal antibodies – anti-inflammatory and autoimmune diseases

Bone scintigraphy – useful as negative test

Question 7

Fibromyalgia - treatment

Answer 7

Treatment = symptomatic. Associated depression may also require treatment

Education

• Explain it’s a condition where the perception of pain is abnormal -> Cause of FM not fully understood, but widespread pain does not reflect inflammation, tissue damage, or disease
• No cure but treatments available to help control pain.
• Importance of pacing activities
• Should include spouse, family or carer

Pain control
All patients should probably be tried on 1 or 2 TCAs first (inexpensive, when work improve sleep, visceral motility, pain).
SNRI – good if have depression or fatigue
Gabapentinoid – if experiencing significant comorbid sleep issues

• Analgesics and NSAIDs seldom helpful
• Amitriptylene (TCAs): Low dose – 10-75mg at night; May help by encouraging delta sleep and reducing spinal cord wind-up
• Gabapentin
• Nortryptilene (TCAs)
• Fluoxetine (SSRI)

Sleep disturbance
- General advice on sleep hygiene

Physiotherapy
- Graded exercise programme

Clinical psychology

• Cognitive behaviour therapy -> relaxation techniques
• Address unresolved psychological issues

Question 8

Hypermobility

• what is it?
• history
• examination
• referral
• management

Answer 8

Hypermobility can be associated with widespread musculoskeletal pains although many people with hypermobile joints do not have musculoskeletal pain.

Hypermobility is also known as Ehler’s Danlos Syndrome (Type III).

History
Generalised joint pain
Back pain
Dislocations (uncommon)

Examination
Hypermobility can be diagnosed clinically by testing mobility of the hands, knees, elbows, back and wrists and calculating the modified Beighton Score.

Referral
Not necessary to refer patients with hypermobility to the rheumatology service unless you are unsure about the diagnosis. Referral to the pain clinic may be appropriate if the patient’s symptoms don’t respond to the measures outlined below.

Management
Treatment is symptomatic.

Education
Explain that they have hypermobile joints and that sometimes this is associated with joint pain due to laxity of the ligaments and soft tissues.
Explain that there is no cure but some treatments can help control pain.

Drugs
Analgesics 
NSAIDs 
Gabapentin
Amytriptylene
Fluoxitene

Physiotherapy
Referral to physiotherapy help through muscle strengthening exercises to improve joint stability