Fibromyalgia

Question 1

risk factors for fibromyalgia

Answer 1

low household income 
lack of further education
female
FH 
having been through a traumatic event e.g. car crash
having certain conditions e.g. RA

Question 2

differentials for wide spread muscle pain and fatigue

Answer 2

fibromyalgia
endocrine - addisons, hyperparathyroid, hyopothyroid myopathy, vitamin D deficiency
infection - Hep C, HIV
rheumatology - SLE, RA, polymyalgia rheumatic
malignancy - lymphoma

Question 3

features and diagnosis criteria for fibromyalgia

Answer 3

chronic widespread pain
must be >3 months in duration
found on both sides of the body - left and right also above and below the waist and along the axial sign

difficulty sleeping and poor concentration/memory also typical features

no other disorders to explain the pain

wide spread pain index score of 7 and symptom severity scale score of 5 or WPI of 3-6 and SS scale of 9

Question 4

examination in suspected fibromyalgia

Answer 4

18 tender points that must be palpated, pain in 11+ is in keeping with a diagnosis of fibromyalgia

e.g. supraspinatus, gluteal, trapezius

Question 5

investigations in wide spread muscle pain and fatigue

Answer 5

patients with fibromyalgia don’t have consistent abnormalities on lab testing
done to exclude other causes

TFTs - hypothyroid
vitamin D - low levels can cause muscle pain and fatigue
B12 - same as above
Iron studies
magnesium - low levels can lead to muscle spasms
ESR/CPR - IA
other tests if suspected by history - features of IA or CTD include ANA, RF, anti CCP

Question 6

management of fibromyalgia

Answer 6

patient education

move down numbers if insufficient effect of previous step, use level 3 where necessary

1) EXERCISE
2) acupuncture, hydrotherapy, sedative movement, mindfulness
3) CBT
3) screen and treat for anxiety and depression where appropriate
3) amitriptyline OD in the evening to help sleep and pain if needed. Other meds: duloxetine, pregablin, tramadol
3) multimodal rehab programme for those with severe disability and sick leave

Question 7

how to predict poor prognosis in a patient with chronic disease

Answer 7

yellow flags - suggest increased risk of progression to long term distress, disability and pain

Biomedical yellow flags: severe pain or increased disability at presentation, previous significant pain episodes, multiple site pain, non-organic signs, iatrogenic factors

Psychological yellow flags: belief that pain indicates harm, activity is harmful, an exception that passive rather than active treatments are most helpful, fear avoidance behaviour, catastrophic thinking, poor problem solving ability, passive coping strategies, atypical health beliefs, psychosomatic perceptions, high levels of distress

Social yellow flags: low expectation of return to work, lack of confidence in performing work activities, heavier work, low levels of control over rate of work, poor work relationships, social dysfunction, medico-legal issues