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The Patient With Fibromyalgia
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A 32-year-old woman was diagnosed with fibromyalgia 9 months ago. After being provided with education about the condition, she was placed on a program of regular aerobic exercise and was prescribed pregabalin. This program was stopped due to persistent dizziness and somnolence. Currently, she is not taking any medication and complains of generalized pain, easy fatigability and difficulty staying asleep.
For the past 4 months she has become increasingly depressed and frustrated by her lack of progress. Her physical examination reveals tenderness and pain in the upper arms and legs bilaterally. Her Widespread Pain Index is an 8, Symptom Severity Score is a 5. Thyroid stimulating hormone, C-reactive protein, sedimentation rate, complete blood count, transaminases and renal function tests are normal.
Key Supporting Information
Fibromyalgia is an enhanced pain sensitivity syndrome associated with chronic, widespread pain and tenderness. Abnormalities of sensory processing within the central nervous system interact with neuroendocrine pathways and peripheral pain receptors to generate the broad spectrum hyperalgesia and allodynia associated with this condition. This disorder affects approximately 2% of the U.S. population and typically presents in young or middle-aged women, but also can affect patients of either gender, demonstrating a steady increase with aging.
Both psychosocial and neurobiological factors have been shown to play an important role in causation. The role of proinflammatory cytokines and chronic pain states is being explored. Elevated interleukin (IL)-1 in inflammatory pain (rheumatoid arthritis) and elevated IL-8 in dysfunctional pain (fibromyalgia) have been reported. Patients with fibromyalgia have also been reported to have higher concentrations of colony-stimulating factor IL-8, IL-1Ra, IL-4, and IL-10 than patients with rheumatoid arthritis. In addition, anti-68/48 kD antibodies have been associated and found in patients with fibromyalgia and chronic fatigue syndrome, as well as higher levels of antithyroid peroxidase. Other reports have demonstrated slightly higher antipolymer antibody levels than healthy persons, with 30% of fibromyalgia patients testing positive for antinuclear antibody with a 75% speckled pattern preponderance. Other studies have shown fibromyalgia can generate higher serum levels of soluble factors released in response to substance P.
Compared with healthy individuals, higher levels of IL-10, IL-8, IL-6, and tumor necrosis factor-alpha also have been found in fibromyalgia patients than in healthy persons. Normally, IL-8 promotes sympathetic pain while IL-6 induces depression, fatigue and hyperalgesia or increased pain perception.
Patients may present clinically with a history of persistent (more than 3 months) diffuse pain, fatigue, headaches, dyspnea, gastrointestinal distress, depression, cognitive difficulties and dysfunctional sleep. The pain is usually described as a constant, dull ache worsened by physical activity and may be perceived as coming from the muscle or even the joints. However, there is usually no evidence of muscle enzyme elevations or arthritis. An increase in somatosensory potentials has been demonstrated in some patients with temporal summation occurring when unmyelinated C fibers are repeatedly stimulated every 2 seconds to 3 seconds with an electrical or thermal impulse. Reduced thalamic blood flow also has been demonstrated in patients with fibromyalgia, in keeping with loss of tonic inhibition associated with chronic pain syndromes. Easy fatigability can result from psychological stressors, as well as mental or physical exertion, with many similarities to patients with chronic fatigue syndrome.
Many patients have concomitant depression, usually related to the chronicity and symptom severity of the condition. Cognitive dysfunction manifests itself with difficulties in short-term memory, motivation, logical thought, verbal fluency and concentration. These patients may manifest nonrestorative sleep patterns, awaking tired despite having slept for 8 hours to 10 hours, with many failing to achieve stages 3 and 4 nonrapid eye movement sleep. This disordered sleep usually aggravates symptoms the next day. Various psychometric tests can be utilized for a more comprehensive mental status assessment, including the Multidimensional Pain Inventory, Social Support Questionnaire, Sickness Impact Profile and the Minnesota Multiphasic Personality Inventory.
Many patients give a history of an antecedent injury, stress, infection, toxin exposure or repetitive workload as a key inciting event. Familial prevalence can be variable, which may suggest that some individuals may be genetically predisposed or have previous experiences or events that may trigger its subsequent development.
This disorder has been associated with other pain syndromes, including: temporomandibular joint pain, vulvodynia, pelvic pain, irritable bladder and irritable bowel syndrome. The patient should be thoroughly evaluated for other medical illnesses to explain symptomatology, including: polymyalgia rheumatica, hypothyroidism, collagen vascular disease, autoimmune disorders and cardiac disease. Although it is not considered a hormone deficiency disease, the sympatho-adrenal stress and hypothalamic-pituitary axes may be impaired, with some patients demonstrating neurally mediated hypotension.
The American College of Rheumatology (ACR) 1990 classification criteria previously emphasized tender points and widespread pain as the key features of fibromyalgia, requiring the eliciting of pain in 11 of 18 tender point sites on digital palpation, including: occiput, low cervical, trapezius, supraspinatus, second costochondral junction, lateral epicondyle, gluteal, greater trochanter and knee. In 2010, the ACR proposed preliminary diagnostic criteria for fibromyalgia that relinquished the tender point count, placing increased emphasis on patient symptoms. A later modification of the ACR 2010 criteria for use in surveys utilized the Fibromyalgia Survey Questionnaire as a self-reporting vehicle to assess patient symptoms.
Learning Objectives:
Upon successful completion of this educational activity, participants should be better able to diagnose and treat fibromyalgia.
Overview
Author(s)/Faculty: Ronald A. Codario, MD, FACP, FNLA, RPVI, CCMEP
Source: Healio Rheumatology Education Lab
Type: Monograph
Articles/Items: 7
Release Date: 3/15/2016
Expiration Date: 3/15/2017
Credit Type: CME
Number of Credits: 1
Cost: Free
Provider: Vindico Medical Education
CME Information
Provider Statement: This continuing medical education activity is provided by Vindico Medical Information.
Support Statement: No commercial support for this activity.
Target Audience: This activity is designed for this activity is rheumatologists and other health care professionals involved in the treatment of patients with rheumatological disorders.