Fibromyalgia

Question 1

Define fibromyalgia.

Answer 1

Fibromyalgia is a chronic pain syndrome diagnosed by the presence of widespread body pain with fatigue and memory and sleep difficulties.

Question 2

What is the cause of fibromyalgia?

Answer 2

The cause of fibromyalgia is unknown, but there is some evidence for:

• genetic predisposition,
• abnormalities in the stress response or hypothalamic-pituitary axis,
• and possible triggering events

Pathophysiology may be linked to:

• Somatisation
• Altered pain perception
• Hyperexcitability at spinal or brainstem level

Question 3

Who is most affected by fibromyalgia?

Answer 3

• 2-3% prevalence
• F>M 10:1
• 20-50yo
• There is a link to failing to complete education, low income and being divorced
• More common in those with a rheumatic disease

Question 4

What are the clinical features of fibromyalgia?

Answer 4

• Pain at multiple sites - usually buttocks, legs, neck, shoulders
• Fatigue
• Sleep disturbance (may exacerbate symptoms –> depression)
• Morning stiffness
• Paraesthesiae
• Feeling of swollen joints
• Headaches
• Cognition deficits
• Light-headedness or dizziness
• Fluctuations in weight
• Anxiety and depression

Question 5

What conditions are associated with fibromyalgia?

Answer 5

• GAD
• Depresison
• IBS
• Irritable bladder
• Dysmenorrhoea
• PMS
• Restless legs syndrome
• Rheumatoid arthritis
• SLE

Question 6

What are some differentials for fibromyalgia?

Answer 6

• Chronic fatigue syndrome
• Hypothyroidism
• PMR
• IBD
• Polymyositis

Question 7

What investigations would you do to diagnose fibromyalgia?

Answer 7

Clinical diagnosis if the following criteria are met:

1. Widespread pain index (WPI) is 7 and symptom severity (SS) scale score is 5, or WPI equals 3 to 6 and SS scale score of 9.
2. 3 months duration
3. No other explanation

Investigations to exclude other diagnoses:

• FBC
• ESR and CRP
• Vitamin D
• TFTs
• ANA/RF in history of inflammatory disorder

Question 8

What is the definition of widespread body pain?

Answer 8

Widespread body pain is defined as axial pain plus upper and lower segment plus left- and right-sided pain

Can be myalgia, arthralgia or both usually described with neuropathic descriptors

Question 9

How do you monitor the symptoms of fibromyalgia?

Answer 9

Fibromyalgia Impact Questionnaire - assesses function

Question 10

What is the management of fibromyalgia?

Answer 10

Conservative:

• MDT approach - GPs, rheumatologists, physicians experienced in dealing with chronic pain, psychologists, psychiatrists, physiotherapists etc
• Assess in the context of psychosocial issues

Medical:

• Antidepressant - either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline
• Do not give benzos or opioids

Question 11

Which medications can be used vs avoided in fibromyalgia?

Answer 11

Recommended antidepressants e.g.

• amitriptyline
• citalopram
• duloxetine
• fluoxetine
• paroxetine
• sertraline

Avoid:

• benzodiazepines
• opiates

Question 12

What is the prognosis of fibromyalgia?

Answer 12

It is difficult to predict the prognosis of fibromyalgia, due to the complex interplay of the social and psychological factors in the pathophysiology and symptomology of this condition.

Question 13

What is the difference between allodynia vs hyperalgesia?

Answer 13

Allodynia is pain due to a stimulus that does not normally elicit pain.

Hyperalgesia is increased pain from a stimulus that normally provokes pain