Fibromyalgia is a term used to describe diffuse musculoskeletal pain and tender points with no other definable cause, where a tender point is an area of heightened superficial tenderness on palpation. Fatigue is often also prominent. Characteristic tender points exist; however, other areas can be involved. Clinical examination should otherwise be normal.

 

Features of fibromyalgia

 

Cardinal features*

• Chronic (> 3 months) widespread pain

• Tender points

 

Other characteristic features

• Fatigue

• Sleep disturbance

• Stiffness

• Symptoms resembling those of Raynaud’s syndrome

• Headache

• Paresthesias

• Anxiety

• Depression

• Irritable bowel syndrome

 

Adapted from criteria of the American College of Rheumatology 1990.

*Symptoms must have been present for a minimum of 3 months and should have involved the upper and lower body bilaterally as well as the axial skeleton; pain should have been experienced in at least 11 of 18 characteristic tender points.

 

The terms fibrositis and psychogenic rheumatism have been used in

the past to describe the same syndrome. Whether fibromyalgia is simply a continuum of pain and fatigue or a distinct disease entity remains controversial. Although an association with selective disturbance of alpha–delta sleep has been described, a relentless search for underlying pathology affecting muscles, the microcirculation, the nervous system and neuroendocrine mechanisms has failed to reveal any convincing evidence of a clear cause. However, the concept of fibromyalgia as a syndrome of generalised heightened sensitivity to pain, possibly as a result, at least in part, of a deranged sleep pattern, is useful when considering approaches to management of the disorder.

 

Up to 90% of patients with fibromyalgia are women, mostly aged

30–60 years. The prevalence of the disorder varies geographically, with Caucasians most commonly affected. The variation between nations is also associated, in part, with differences in the recognition of the disorder as a distinct entity. In the USA, the overall prevalence is 2%, with an increasing prevalence with age.

 

Investigations aim primarily to exclude other conditions with a similar clinical picture. These include blood tests and possibly nerve and/or muscle studies, and xrays.

 

Management. Approaches to the management of fibromyalgia include education about the disorder, pain control, sleep modulation and physical conditioning.

 

It is important that all sufferers of fibromyalgia have a clear understanding of the disorder. .

 

Exercise. Exercise is recognised to be the mainstay of therapy for fibromyalgia. Aerobic exercise programs have been shown to reduce tender point counts and physician global assessment scores. Counselling, encouragement and supervision are necessary for such programs to succeed, as most patients initially feel that exercise will worsen their symptoms. Although with initial exercise this is the case, the longer term effects of exercise are beneficial.

 

Pain control and sleep modulation can often be achieved with the use of tricyclic agents, such as dothiepin/doselupin or amitryptiline, usually in a single dose at bedtime. Several weeks may elapse before an effect is noted. There are potential side effects, such as sedation in the morning, tremor, dizziness, dry mouth, weight gain and constipation. Note that morning sedation is common in the first few days but dose reduction may be necessary if it continues.

 

Other approaches to pain control, including the use of non-steroidal anti-inflammatory drugs, offer no clinical benefit compared with that of simple painkillers. The use of opioids is generally discouraged.

 

Acupuncture is usually unsuccessful in fibromyalgia and may exacerbate the problem. Other non-pharmacological approaches to pain control including cognitive–behavioral therapy may be helpful.