MSK - Widespread Pain and Fatigue Flashcards
Who is more likely to be affected by fibromyalgia, women or men?
Women - 5 times more likely
What age range is common for fibromyalgia?
30-50 years old
What are the common features of fibromyalgia?
Fibromyalgia is not inflammatory, it is due to abnormal sensory processing in the CNS
Features:
- Chronic pain - characterised by widespread pain with tender points at multiple sites (sometimes feel like ‘pain all over’) - pain is often:
- On both sides of body
- Above and below waist
- Involve axial spine
- Lethargy / fatigue
- Cognitive impairment - so called ‘fibro fog’ e.g.
- Poor concentration
- Poor memory
- Sleep disturbance e.g. insomnia
- Headaches, dizziness and low mood are common
How is fibromyalgia diagnosed?
Clinical judgement
- Other disorders which would explain symptoms must be eliminated
- Symptoms must be present for > 3 months
- 18 tender point scale (argued to be out of date) - if pt is tender in at least 11/18 = fibromyalgia likely
- New method = combination of Widespread Pain Index (WPI) + Symptom Severity (SS score) is used:
- WPI - ask patient if they have felt pain in the last week for each of the 19 identified areas
-
SS score - score from 0-3 the severity/impact of the following:
- Fatigue
- Waking unrefreshed
- Cognitive symptoms
- SS score cont - then tally from a list of symptoms how many the pt experiences
https://neuro.memorialhermann.org/uploadedFiles/_Library_Files/MNII/NewFibroCriteriaSurvey.pdf
How is fibromyalgia managed / treated?
- Explanation and education
- Aerobic exercise (has strongest evidence base)
- CBT
- Acupuncture
- Hydrotherapy
- Screen for anxiety / depression –> treat
- Medication:
- Pregabalin - 150-300mg/12h PO
- Duloxetine (SNRI - serotonin + noradrenaline reuptake inhibitor) or a SSRI with comorbid anxiety / depression
- Amitriptyline (low dose) - 10-20mg nocte for pain + improve sleep
- Fibromyalgia does NOT respond to NSAIDs or steroids
You are the FY2 at a GP practice and are asked to see Ms Fiona May, a 48 year old secretary who has come in with a nine month history of widespread pain and fatigue.
Name some differentials that could be considered relating to fatigue?
- Anaemia
- Malignancy
- Hypothyroidism
- Fibromyalgia
- Addison’s disease
- Hepatitis C
- HIV
- Vit D deficiency
What is polymyalgia rheumatica?
Polymyalgia rheumatica has some overlap with temporal arteritis (histology shows giant cells vasculitis, but with ‘skips’ in the affected artery) - but it is not true vasculitis and its pathogenesis is unknown.
What are the common features of polymyalgia rheumatica?
Features:
- Typical patient > 60 years old
- Often rapid onset (e.g. < 1 month)
- Bilateral aching, morning stiffness in proximal limb muscles (weakness is not a feature)
- Mild polyarthralgia
- Low-grade fever
- Lethargy
- Depression
- Anorexia
- Night sweats
What are some important investigations for polymalgia rheumatica?
- ↑ CRP
- ESR > 40 mm/hr
- ↓ CD8+ T cells
- ↑ ALP (in 30% of cases)
- Creatinine kinase = normal (helps distinguish from myositis / myopathies)
- EMG (electromyography) = normal
How is polymyalgia rheumatica managed?
Prednisolone
- 15 mg/d PO
- Expect dramatic improvement in 1-2 weeks –> if not, reconsider diagnosis
- ↓ dose slowly e.g. by 1 mg/month
- Most need steroids for > 2yrs –> hence need bone protection e.g. Alendronic acid (bisphosphonate to prevent osteoporosis)
What are the 18 points in the standard tender point count?
How much pressure should be applied when testing each area?
18 points / 9 pairs:
- 2 x neck
- 2 x upper chest
- 2 x elbows
- 2 x knees
- 2 x hip
- 2 x upper buttock
- 2 x lower shoulder
- 2 x upper shoulder
- 2 x back of head / neck
Enough pressure should be applied to blanch your nail (turn white)
What are the 2010 ACR criteria for the diagnosis of fibromyalgia according using WPI and SS score?
- No other disorders that would explain the pain
- Symptoms present at at a similar level of intensity for > 3 months
- Fibromyalgia pain, as evidenced by a Widespread Pain Index (WPI)” score of 7 and “symptom severity (SS)” scale score of 5
- OR WPI of 3 to 6 and SS scale score of 9
Fibromyalgia doesn’t have characteristic abnormalities on routine lab + imaging studies - but they are important to rule out differentials.
Thus what investigations might you do?
- TSH:
- Hypothyroidism shares many clinical features with fibromyalgia, especially diffuse muscle pain + fatigue
- 25-Hydroxy vitamin D level:
- Low levels can cause muscle pain + tenderness
- Vitamin B-12:
- Very low levels can cause pain + fatigue
- Iron studies: iron, total iron binding capacity, percent saturation, and serum ferritin:
- Low levels can cause fatigue + poor sleep + depressive symptoms
- Mg2+:
- Low levels can lead to muscle spasms, which are common in fibromyalgia patients
- ESR / CRP:
- Normal in fibromyalgia but raised in other inflammatory arthritis
How would you describe fibromyalgia to a patient?
- Fibromyalgia is a pain condition, it is not related to inflammation but may be due to chemical changes in the body’s pain pathways.
- As well as pain, patients often have problems with sleep as well as other features such as reduced concentration
- The focus of treatment is to manage the symptoms
- Provide leaflet from ARUK (Arthritis research UK)
The prognosis of fibromyalgia depends on various ‘yellow flags’, these are bio-psycho-social indicators suggesting increased risk of progression to long-term disability + pain.
What are some examples of each biomedical, psychological and social ‘yellow flags’?
Biomedical:
- severe pain or increased disability at presentation, previous significant pain episodes, multiple site pain
Psychological:
- Belief that pain indicates harm, expecting that passive treatment > active treatment, fear avoidance behaviour, catastrophic thinking, passive coping strategies, atypical health beliefs, psychosomatic perceptions, high levels of distress
Social:
- Low expectation of return to work, ↓ confidence in performing work activities, ↓ control over rate of work, poor work relationships, social dysfunction, medico-legal issues
What is the difference between hyperalgesia and allodynia?
- Hyperalgesia = indidivual has ↑ sensitivity to pain stimuli i.e. a lower strength painful stimulus elicits a greater pain sensation, relative to the norm
- Allodynia = central pain sensitization in which normally non-painful stimuli elicit a painful sensation
