Fibromyalgia

Introduction

Fibromyalgia can be broken down into fibro, meaning fibrous tissues, “my” which refers to muscle, and “algia” meaning pain. This makes perfect sense because fibromyalgia describes a well-defined syndrome of chronic widespread soft-tissue pain that is non-inflammatory in nature. It is often accompanied by a variety of typical symptoms including fatigue, sleep disturbance and cognitive clouding.

Although the pathogenesis of fibromyalgia remains poorly understood, we think it’s because of central sensitization. This is when the central nervous system amplifies pain signals resulting in pain hypersensitivity.

This theory suggests the primary 'pathology' is actually in the brain and spinal cord rather than an abnormality confined to the region of the body where the person is currently experiencing pain.

This theory is supported by the presence of altered levels of neurotransmitters in the cerebrospinal fluid as well as various abnormalities on functional imaging studies performed on people with the condition.

Risk factors include female sex, with FM being 5 times more common in women than men, a family history of FM, rheumatological conditions and age between 20- and 60-year-old.

The management of fibromyalgia requires a patient specific approach with thorough patient education, lifestyle optimisation and pharmacological interventions. Referrals to specialists should be considered for both assessment and management to ensure a correct diagnosis.

Key parts of education include reassuring the patient that their pain is real but is not caused by tissue damage, that it’s not a progressive or deforming disease, symptoms might fluctuate, and that chronic pain can obviously affect the way patients feel but doesn’t necessarily suggest a psychiatric condition. Importantly, the overarching goal of management is not to achieve a pain-free state but rather to enable the patient to manage their pain so that it does not limit their function.

Lifestyle management includes healthy habits and supportive care. Encourage regular graded aerobic exercise which is realistic and achievable, a balanced diet and good sleep hygiene.

Helping patients to reduce situational stresses is key. Cognitive behavioural therapy (CBT) may improve pain and function and support groups might also have a serious benefit.

Pharmacological management in FM is limited and might only yield small results but is important to consider, nevertheless. Several drugs often must be trialled and can have adverse side-effects which must be balanced with symptomatic and functional benefit. Agents that have shown to reduce pain in FM include tricyclic antidepressants, gabapentinoids, and some serotonin and noradrenaline reuptake inhibitors.

Don’t forget management requires all three components to be as effective as possible.

The clinical features of this disease includes widespread body pain which is almost always accompanied by comorbid symptoms.

Pain is typically widespread and may be experienced in both soft tissues and joints. Typically, at least six sites are involved with particularly sensitive spots. Patients exhibit diffuse tenderness to palpation on physical examination. Moreover, allodynia, or pain induced by normal touch is common and can be screened for if excessive pain is induced by inflation of a blood pressure cuff. There should be no evidence for a systemic disease process causing inflammation because the primary pathology is probably in the CNS.

Comorbid symptoms often include persistent fatigue and sleep disturbances. Patients with FM characteristically sleep "lightly," waking frequently during the early morning and have difficulty getting back to sleep. They’re often stiff in the morning and feel unrefreshed, even if they’ve slept 8 to 10 hours.

Cognitive clouding, known as “fibrofog” is present in the majority of patients. Typically, people describe problems with attention and difficulty doing tasks that require rapid thought changes. It’s not known if this is related to poor sleep or a primary manifestation of FM.

Another key feature is psychiatric symptoms with depression and/or anxiety present in 30 to 50 percent of patients at the time of diagnosis. Other common symptoms include headaches, paresthesias and comorbid conditions like irritable bowel syndrome and gastroesophageal reflux disease.

Its important to recognise and ask about all the symptoms a patient might experience, because no two individuals are the same.

The FIBRO system is an evidence-based rapid strategy for assessment to screen for fibromyalgia. It’s a great mnemonic which helps you remember key symptoms.

F stands for fibrofog, I for insomnia and waking unrefreshed, B for blues including depression and anxiety symptoms, R for rigidity or stiffness and O for 'Ow! ' or generalised pain.