W12 - Fibromyalgia Flashcards
a) Define the term Rheumatic disease.
b) List the characteristic clinical manifestations of rheumatic conditions.
a) Rheumatic disease is an umbrella term for conditions causing chronic, often intermittent pain affecting the periarticular tissues.
b) Characteristic clinical manifestations:
- Achy pain (diffuse)
- Tenderness
- Stiffness (gelling of fluids within joints)
Locations: Muscles, tendon insertions and adjacent soft tissues
Define the term fibromyalgia.
A non-articular rheumatologic condition characterised by spontaneous, widespread soft tissue pain, sleep disturbance, fatigue and extensively distributed areas of tenderness.
*PAIN is key clinical feature and this can be used to distinguish from Chronic Fatigue (where most significant clinical feature is fatigue)
Discuss the prevalence of fibromyalgia.
- ~5% of all GP patients
- 2-4% of the general population (ie 3.4% of females and 0.5% of males)
- 2nd only to OA as most common diagnosis in patients seen by rheumatologists
- Affects 2-5% of the population in developed countries (equates to 585,000-1,175,000 Australians)
- Most commonly affects women (4-7x more common), 25-40 year age group
List the main clinical manifestations of fibromyalgia.
- Muscular pain (achy) - 100%
- Fatigue - 96%
- Insomnia - 86%
- Joint pains - 72%
- Headaches - 60%
- Restless legs - 56%
- Paraesthesia - 52%
- Leg cramps - 42%
- Cognitive or mental changes (impaired memory and concentration, nervousness and depression)
Name four (4) areas of the body that are frequently affected by fibromyalgia.
Any 4 of the following:
- Occiput
- Neck
- Shoulders
- Thorax
- Lower back
- Thighs
- Often occurs in in areas called “tender points (TPs)” – Usually found in same place on repeated examination, actual nodules may be palpated in the TPs
Write brief notes on tender-spots.
Paired regions of the body that may or may not have nodules that are tender (pressure just enough to make nail beds turn white = ~1kg of pressure)
Often occurs in in areas called “tender points (TPs)”
– Usually found in same place on repeated examination
- actual nodules may be palpated in the TPs
Locations:
- Low Cx (2) – At anterior aspects of intertransverse spaces at C5-C7
- 2nd rib (2) – Upper lateral to second costochondral junction
- Lateral epicondyle (2) – 2cm distal to the epicondyles
- Knee (2) – At the medial fat pad proximal to the joint line
- Occiput (2) – at midpoint of upper border
- Supraspinatus (2) – At origins, above the scapula spine or near the medial border
- Gluteal (2) – In upper outer quadrants of buttocks in anterior fold of muscle
- Greater trochanter (2) – Posterior to the trochanteric prominence
*Diagnosis of fibromyalgia no longer made based on presence of TPs
Which factors are known to exacerbate the manifestations of fibromyalgia?
- More frequent and prominent in morning or evening
- Changes in the weather
- Aching increased by inactivity
- Pain aggravated by straining and overuse
- Stress
- Insensitive treatment by health practitioners
Which factors are known to alleviate the manifestations of fibromyalgia?
- Aching relieved by moderate physical activity
- Better in the middle part of the day – suggest doing physical activity in middle of day
- More relaxed mental state – empathy and advice about stress-inducing factors
- Stretching and breathing exercises – prescribe
- Heat and massage
List four (4) non-rheumatic/non-articular symptoms of fibromyalgia.
- Headaches
- Insomnia
- Exhaustion/Fatigue
- Irritable Bowel Syndrome (IBS) – Maybe because demograph is young, stressed women ?
Which female personality type is characteristic of fibromyalgia?
- Healthy, young female
- Self-driven, striving
- Intense, anxious, compulsive, tense
- Fervently involved in numerous activity
- Very sensitive and responsive to external stimuli such as: cold, heat, humidity, noise
- +/- a degree of depression
Discuss the diagnosis of fibromyalgia
- Typical for FM patients to see many doctors over 5 years before being correctly diagnosed
- > 50% of patients are misdiagnosed and undergo unnecessary treatments including surgery
- Diagnosed by considering all the patients relevant symptoms
- Diagnosis is no longer based just on the number of tender points a patient has
American College of Rheumatology (ACR) criteria for diagnosing FM:
Criterion #1
- Widespread Pain Index (WPI) >7 and Symptom Severity (SS) scale score >5 OR WPI 3-6 & SS >9
- SS = Sum of severity of following 3 symptoms: Fatigue, waking unrefreshed, cognitive symptoms (rated 0-3). Plus severity of the somatic symptoms in general. Final score between 0-12
- WPI = practitioner notes number of areas in which pt. has had pain over the last week (19 regions examined). WPI score between 0-19
Criterion #2 – Symptoms have been present at a similar level for at least 3 months
Criterion #3
– Patient does not have a disorder that would otherwise explain the pain (use diagnostic investigations to exclude)
- DD may include myofascial pain syndrome
Diagnostic investigations:
- Complete blood count
- Basal metabolic panel and urinalysis
- TSH
- Vit D & B12
- Iron studies
- Magnesium levels
Discuss the prognosis of fibromyalgia.
- Not life-threatening, deforming or progressive
- Ssx are variable
- Without proper diagnosis and treatment, patient may have the illusion of disease progression because of sleep deprivation and physical deconditioning
- ~1/3 of patients need to modify their work to keep their jobs (eg shortened workdays or weeks, change to jobs that are less physically and mentally taxing)
- Inability to advance in careers or education leading to decreased income and increased
- A significant negative impact on the quality of social functions
- > 15% of FM sufferers receive disability benefits
- With appropriate treatment and a caring, informed physician, FM patients should be able to improve their function and reduce their pain