Fibromyalgia

Original article by Tom Leach | Last updated on 18/5/2014
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Introudction

Fibromyalgia is a non-specific muscular disorder of unknown origin. It primarily affects insertions of tendons and associated soft tissues and presents with dull aching pains. It is much more common in women.
 

Epidemiology and Aetiology

  • Cause is unknown
  • Affects muscles rather than joints – although can often feel like joint pain
  • Peak age of onset: 40-50 years
  • M:F ratio 1:9

 

Pathology

Unknown. There is some speculation that disruption of sleep patterns and emotional stress are trigger factors. Can be precipitated by systemic disease or infection – for example, Lyme Disease
 

Signs and Symptoms

  • Pain worse with stress, cold weather, activity
  • Morning stiffness (usually <1hr)
  • Pins and needles in hands and feet
  • Simple analgesia / NSAIDs ineffective – some patients say may make pain worse
  • Poor sleep. Patient often complain of being tired all the time and having poor concentration during the day
  • Associated with anxiety / depression – you could try a PHQ9 (or similar) score
  • Examination findings usually unremarkable
  • Other vague symptoms including headache, urinary frequency, vague abdominal symptoms similar to IBS

 

Diagnostic criteria

  • Widespread joint pains, on both sides of the body, and above and below the hips. Not necessarily symmetrical, also often includes axial (shoulders / spine) pain

PLUS

  • Pain in >11 out of 18 sites on palpation of sites

 
The 18 sites are (bilaterally):

  • Insertion of nuchal muscles into occiput
  • Upper border of trapezius
  • Muscle attachments to medial border of scapula
  • Anterior aspects of C5-C7 intertransverse spaces
  • 2nd rib space 3cm lateral to sterna border
  • Muscle attachments at lateral epicondyle of elbow
  • Upper out quadrant of gluteal muscles
  • Muscle attachments posterior to greater trochanter
  • Medial fat pad of knee, proximal to joint line

Investigations

It’s probably sensible to do bloods to exclude other disorders for example, hypothyroidism, inflammatory disorders, and hepatitis C. Example Blood tests iclude: U+Es, FBC, TFTs, LFTs, CRP / ESR, Rheumatoid factor, Ca2+, ANA, immunoglobulins.

Management

  • Reassure patients there is no serious pathology
  • Manage pain – pain is often resistant to traditional analgesia – some find amitriptyline (25-75mg at night) useful – can help with sleep and pain. SSRIs are useful if there and sleep problems and low mood. Give a month’s trial and stop if no improvement – but remember SSRI’s can take 2-3 weeks to reach full effect, and patients may feel worse during the first week or so. Avoid Opioids
  • Improve sleep
  • Exercise
  • Local heat application
  • May require MDT approach from Rheumatology clinic

Differentials